Macromastia is a symptomatic breast enlargement linked to musculoskeletal and neurological symptoms such as sleep disturbance, radicular pain, headache, dyspnea, back and neck pain. Clinical assessment is complicated by breast composition, obesity, and variability in breast size, all of which may increase the risk of headache and exacerbate pain. Up to 89% of affected women report the headaches prior to reduction mammoplasty surgery; however, characteristics of headache are poorly defined and standardized international classification of headache disorders, 3rd edition (ICHD-3) diagnoses are rarely used. Proposed mechanisms include sleep disruption, nerve sensitization, mechanical strain, hormonal influences, and inflammatory factors, but the pathophysiology remains unclear. A recent pilot study published in Cephalalgia Reports aimed to characterize preoperative headache features, determine migraine prevalence, and assess postoperative changes following breast reduction surgery.
In this single-center prospective cohort study, adults aged ≥18 years with more than 4 headache days/month, body mass index (BMI) of <39 kg/m2, insurance-approved for reduction mammoplasty were enrolled. Participants were excluded if they had a history of breast malignancy, high-dose estrogen therapy, and spinal or brain surgery. All participants completed baseline (one day to 3 months preoperatively) and two postoperative surveys (12-16 weeks and 19-28 months) through REDCap. The primary endpoint was change in identification of migraine (ID-migraine). Secondary endpoints were Berlin obstructive sleep apnea (OSA) questionnaire, allodynia symptom checklist–12 (ASC-12), structured interviews, and modified migraine disability assessment (mMIDAS). Secondary endpoints were assessed changes in OSA risk, headache intensity, disability, surgical satisfaction, headache frequency, and allodynia. Exploratory endpoints were postoperative changes in mood/sleep/exercise. Mixed-effects models analyzed longitudinal changes.
A total of 34 patients (mean age = 34.9±11.4 years, mean BMI = 30.9±3.7 kg/m², White = 62% [21/34]) were included in this study. At baseline, participants reported a mean MIDAS score of 48.2±42.4, mean headache frequency of 13.4±8.9 days/month, and mean pain intensity of 6.1±1.8. Prior diagnoses included 18% of tension-type headache and 44% of migraine, with 38% had prior neurologic evaluation.
Occipital neuralgiform pain occurred in 38%, and 48% had allodynia with mean ASC-12 of 3.4±3.4. OSA risk was detected in 77%, with 73% high risk. Daily over-the-counter (OTC) use occurred in 15% and 44% used OTCs 2-3 days/week. Approximately 90% (31/34) of participants screened positive for migraine, in which 58% had episodic migraine, whereas 42% chronic migraine. OTC medication overuse was reported in 38% of chronic migraine women.
There were significant improvements observed from baseline to postoperative time in OSA risk, disability, headache intensity, allodynia, and headache frequency. At 12-16 weeks, 79% achieved ≥50% reduction in headache days and increasing up to 89% at 19-28 months. Mean BMI decreased from 30.9±4.1 kg/m² to 28.7±4.6 kg/m² at long-term follow-up with p<0.001. Neck pain improved in 88% at baseline and 89% at late follow-up period.
Post-hoc analysis demonstrated that highest mean BMI was observed in responders compared to non-responders at postop-1 period (31.7 kg/m2 vs 27.9 kg/m²; p = 0.028). Most participants reported marked global improvement in headaches (79% scoring ≥5 points). Moreover, surgical satisfaction was reported in 91% of participants at postop 1 and 100% at postop 2. Exploratory outcomes like exercise, sleep, and mood improved among 70-86% of women. Mild complications like excessive pain, skin dimpling, stitches not dissolved properly, and rash occurred in 24% (n = 8) of patients.
This study’s limitations include non-randomized study design, recall-based MIDAS use, small sample size, absence of control group, and possible expectancy/placebo effects. Recruitment of surgical participants limits generalizability and causality cannot be established.
In conclusion, this study highlights that among 34 females, 91% screened positive for migraine. Postoperatively, OSA risk, headache burden, and allodynia improved up to 28 months, however, mechanisms remain unclear. This pilot study does not support mammoplasty surgery as a primary head treatment and underscores the need for randomized longitudinal clinical trials.
Reference:
Pocock KS, Rigdon J, Laikhter E, et al. Understanding headache in the context of macromastia: An observational pilot study of headache profiles and postoperative changes. Cephalalgia Reports. 2026;9:25158163261416853. doi:10.1177/25158163261416853
