Understanding headache in the context of macromastia: An observational pilot study of headache profiles and postoperative changes

Background Women with enlarged breast tissue (macromastia) experience many musculoskeletal and neurologic symptoms, including headaches, and may seek breast reduction. These headaches are frequently labeled “tension-type,” though headache features and diagnoses remain poorly defined. Methods This observational study aimed to characterize headache features and ICHD-3 diagnoses in women with macromastia undergoing reduction and assess headache pre- and postoperatively. Validated surveys included migraine screening (ID-Migraine), disability (Migraine Disability Assessment [MIDAS]), allodynia (Allodynia Symptoms Checklist [ASC-12]), and obstructive sleep apnea risk (OSA, Berlin). Results Inclusion criteria: age ≥18 and ≥4 headache-days/month. Exclusion criteria: brain/spine surgery, breast malignancy, or high-dose estrogen use. The primary outcome was migraine identification preoperatively; secondary outcomes included postoperative changes in headache and OSA risk. Among 34 participants (mean age 34.9 [standard deviation (SD) = 11.4] years, BMI 30.9 [4.1] kg/m 2 , 62% White), baseline headaches were frequent and disabling (median 10 [interquartile range (IQR) = 7–19.5] days/month, mean pain intensity 6.2/10 [SD = 1.8], mean MIDAS 49.8 [SD = 42.7]). Allodynia was present in 40%; 56% screened high-risk for OSA. Migraine screening was positive in 91%, though 100% reported red flag features. Postoperatively, significant improvements in headache frequency (incidence rate ratio 0.23 [IQR = 0.18, 0.29]; p < 0.0001), pain intensity (mean −3.0; p < 0.0001), disability (mean −32.9; p < 0.0001), allodynia (mean −2.1; p = 0.0008), and OSA risk (OR = 0.19; p < 0.05) were observed and sustained through 19–28 months postoperatively. Conclusion This pilot study shows that most women with macromastia and headache pursuing reduction screened positive for migraine, challenging the assumption of tension-type headaches. Many exhibited red flag features, suggesting a need for further evaluation. Improvements in headache features and OSA risk were observed following a reduction up to 28 months postoperatively.