THE IMPACT OF REVASCULARIZATION SURGERY ON HEADACHE IN PATIENTS WITH MOYAMOYA

Abstract

Background and Aims: Significant headache in moyamoya vasculopathy is not uncommon but the pathophysiology is poorly understood. We aimed to investigate if headache in moyamoya patients improves after revascularization surgery and whether this is associated with improvement in cerebrovascular reactivity. Methods: For this single-center retrospective study, adult patients with moyamoya vasculopathy who underwent extracranial-intracranial bypass surgery between January- 2010 and September-2022 were selected from a database with consecutive patients who had MRI with cerebrovascular reactivity studies. Clinical data including a headache history and imaging data were collected through systematic chart review. We assessed the association between headache and cerebrovascular reactivity before and after uni- or bilateral revascularization surgery. Results: Fifty-one patients were included (mean age 4213 years, 37 women (73%)). Thirty- three patients (65%) had bilateral moyamoya vasculopathy and 14 (27.5%) underwent bilateral extracranial-intracranial bypass surgery. Thirty-five patients (69%) reported headache pre-surgery. Features included: episodic headache (96%), preceding aura (12%), predominantly throbbing headache (47%) with nausea/vomiting (39%), and/or photo/phonophobia (11%); 62% of patients lost workdays because of headache. Headache improved in 24/35 (69%) patients after surgery with reduction in pain severity (median VAS from 7 to 3; p <0.01) and sick leave (62% to 19%; p=0.0024). CVR improved in 25/38 (66%) patients who had pre- and post-surgery CVR-MRI, which was associated with headache improvement (OR:13; 95%CI: 1.3-124). Younger age was also associated with headache improvement post-surgery (OR:0.88; 95%CI: 0.81-0.96). Conclusions: Headache in moyamoya vasculopathy improved in most patients after revascularization surgery and was associated with improvement in cerebrovascular reactivity, supporting the hypothesis of a vascular origin of the headache.