Surgery for migraine headaches is a new and effective option for patients who do not respond well to current headache medications and other neurological treatments. The key to successful surgical relief is rigorous patient selection. Not every patient with chronic headaches is a surgical candidate as there are numerous overlapping headache diagnoses. So it is important that the patient be diagnosed by a neurologist with a true migraine diagnosis and that its severity be quantified by measurement tools such as the Migraine Headache Index.

Surgical migraine candidates are first tested by Botox injections at suspect trigger sites. Migraine patients typically describe pain from the forehead, temple, eye, and occipital (back of the head) areas. The forehead, temple and occipital regions have pinpoint trigger areas that correspond to the path of sensory nerves that can be compressed by muscles. The ‘behind the eye’ (retroocular) migraine has a trigger located in the nose when the septum is deviated and contacts the inferior turbinate bone. This nasal trigger can not be tested by injection therapy. If Botox injections provide significant relief that is sustained (at least 4 weeks) then surgery should be considered. For my out-of-town patients, where Botox injections may not be practical, I perform local anesthetic injections the day before surgery may be scheduled. Intranasal exam or CT scan confirmation of septal deviation is all that is needed for the nasal trigger.

Surgical migraine treatment is done through specific approaches. Frontal migraines are treated by release and partial removal of the corrugators and procerus muscles around the supraorbital and supratrochlear nerves through an upper eyelid incision. Migraines in the temple area is treated endoscopic avulsion of the zygomaticotemporal nerve branch as it passes through the temporalis muscle. In some cases I may combine this with release of the temporalis fascia and ligation of the anterior branch of superficial temporal artery done through a small scalp incision in the temporal hairline. Occipital migraines are decompressed through a small incision at the back of the scalp where the greater occipital nerve passes through the semispinalis capitis muscle. Retroocular migraine triggers are released by septal straightening and inferior turbinate reductions so that the two no longer contact.

How effective is surgical migraine treatments? While insurance companies frequently view this surgery as experimental (and thus fail to cover the procedure), the medical evidence is quite the contrary. Numerous clinical studies have been conducted and published over the past decade. The most compelling, and best conducted, was a prospective five year study published in 2009. In this study, nearly 90 percent of patients had some level of sustained relief up to five years after surgery. Only a very small percent did not experience some permanent relief and a few others required a second surgery as additional trigger points were unmasked as the primary trigger point was cured.

Surgery offers hope for those migraine patients who do not get substantial relief or do not want to continue with multiple drug therapies. But the key to successful migraine surgery is good patient selection.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Migraines are a common and frequently disabling headache condition that can be drug-resistant or responds very poorly to them. Even in those that do respond, there are side effects to all drugs that for some are problematic. Surgical techniques for migraines have been developed that deactivate migraine trigger sites. For some patients, these surgical techniques can be life-changing. But an interesting and very relevant question that I get from my Indianapolis migraine patients who are having this surgery is…how long will the results of this surgery last? Does this offer just short-term relief or are the results more long lasting?

Developed by plastic surgeons, a study published in the February 2011 Plastic and Reconstructive Surgery journal looked at the long-term effectiveness of this type of migraine surgery. Nearly one hundred migraine patients were treated with surgery compared to twenty-five migraine patient volunteers in a prospective treatment study. Patients completed questionnaires before treatment and at one and five year follow-up. Treated patients received Botox to confirm the potential effectiveness of surgery and then went out to surgical deactivation if positive. Control patients received saline injections only. The comparative results were analyzed at one and five years.

Of the surgically treated patients, 88% of them experienced continued improvement in their migraine symptoms after five years. Nearly 30% had complete elimination of any further migraines while nearly 60% noticed a significant decrease. A little over 10% of the patients experienced no significant improvement. A few of the patients (10%) went on to have the release of additional trigger sites.

This landmark study done by the father of modern migraine surgery is significant in the annals of migraine headache therapies. The five year results provide strong evidence that surgical manipulation of one or more migraine trigger sites can either reduce or eliminate the frequency, duration and intensity of these headaches for a prolonged period of time. Given whom it was done by and the scientific analysis in which it was done by adds further credence to the meaning of this study.

This study provides data that allows one to provide good information about the effectiveness of migraine surgery to patients. First, it is not a magic cure-all and not every patient will be improved. But a near 90% level of some degree of symptom relief is reassuring that the surgery is worthwhile. Complete elimination of all migraine symptoms will not occur in most patients and should not be expected. Only about 1/3 of patients will have a near ‘cure’, most will have less frequent migraines that are less severe in intensity. Some patients will require additional trigger releases based on how many are done during the first surgery.

The deactivation of migraine trigger sites continues to prove that it can be effective at providing some patients a treatment that surpasses conventional drug therapy. Because of its relatively new development, there are many patients who would benefit from such migraine surgery that are unaware or uncertain of its effectiveness. Studies like this one provide clinical proof of what the early adopters of migraine surgery techniques are experiencing. 

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana    

Background: Migraine headaches are a common and potentially debilitating disorder. Affecting both men as well as women, they account for a significant amount of lost productivity and a hampered lifestyle for those severely affected. Why migraines occur is still largely unknown. Treatment of migraines is largely done by drug therapies which focus on either prevention or the cessation of an active attack. Unfortunately the effectiveness of many of these drugs is modest at best and they all are not without their side effects.

Despite a longheld belief that the cause of migraines emanates from inside the brain, an alternative cause of some migraines has been proposed and studied in the past decade. This theory advocates that the cause is more peripheral or outside the brain. Peripheral triggers caused by the compression of specific cranial nerves as they exit the skull can be the migraine source for some patients. This discovery was initially made by plastic surgeons who observed that  endoscopic browlift patients, who also had pre-existing migraines, were significantly improved due to the surgical dissection of the supraorbital and supratrochlear nerves. This muscular compression theory was concurrently corroborated by the now known and FDA-approved use of Botox injections as an important new migraine treatment.

A specific set of peripheral nerve triggers for migraines have been identified. These include the supraorbital and supratrochlear nerves for frontal migraines, the zygomaticotemporal nerve for temporal migraines and the greater occipital nerve for occipital migraines. A fourth trigger  is the nasal septum if there is a contact point between it and the inferior turbinate creating a retrobulbar or orbital migraine. Surgical deactivation of these triggers is based on muscular decompression of the nerves as they course through the muscle.   

Case Study: A 50 year-old male had a long history of difficult and debilitating migraines. He suffered an average migraine frequency of three to five per month, often lasting for days. He had been completely worked up by multiple neurologists which ruled out any identifiable cause. He had been through numerous drug therapies including beta-blockers, calcium channel blockers, antiepileptics and antidepressants. He had a very specific area of easily identifiable peripheral triggers in the bilateral occipital areas. His migraines always started at the base of his skull and spread out upward across the back of his head.

He was initially treated with Botox injections in the occipital region in the pin point areas that he could specifically put his finger on. Each side received 20 units. He did not have the onset of a migraine until 3 ½ months later. He then underwent a series of three more Botox injections over the next year and near had a full blown migraine. He received Botox when he felt that a migraine may be starting again. This was always between the 3^rd and 4^th month after the previous Botox injection.

Because of his Botox success, he proceeded forward with migraine surgery to seek a more permanent cure and eliminate the expense of the drug. Under general anesthesia, his greater occipital nerves were approached through bilateral incisions located 3 cms below the occipital protuberance and then 1.5 cms on each side. Through these two horizontal incisions, the nerves were located and the semispinalis capitis muscle removed from around them. The margin of muscle release was about a cm around the pathway of the nerve. The incisions were closed with dissolveable sutures. No dressing was applied. The procedure was completed in an hour under general anensthesia as an outpatient. There were no restrictions after surgery.

At one year after surgery, he has not has any migraine episodes. He states he has a few mild headaches but they were infrequent and definitely no migraine in nature. His scalp incisions have healed in a near undetectable manner and remain hidden in his hairline. He has nor received any Botox since surgery.

Case Highlights:

1)      For select patients with occipital-based migraines, the peripheral trigger may be muscle entrapment or compression by the semispinalis muscle of the greater occipital nerve branches.

2)      Surgical decompression of occipital migraines should only be considered after complete neurologic work-up and management and at least one positive treatment with Botox injections.

3)      Surgery for occipital migraines is a relatively easy procedure for patients to go through with little to no after surgery pain or after care needed. The biggest risk of greater occipital nerve decompression is that it may not be successful or long-lasting. There are no other negative side effects known.

Dr. Barry Eppley

Indianapolis, Indiana

The prevalence of migraine headaches, specifically those that are disabling and life-altering, is not rare. When traditional neurologic approaches, such as drugs destined to prevent or abort a migraine, fail to provide relief through a centrally-mediated mechanism then peripheral therapy should be considered. A lot of new information is forthcoming that supports the peripheral theory of certain migraines caused by external trigger points that then migrate centrally to the brain. This has spawned trigger point therapy using an injectable drug or surgery.Through either Botox injections or decompression of the brow (supraorbital) or base of the skull (occipital) nerves as they exit from their muscular beds, significant and sustained relief has been obtained in selected migraine sufferers.

But not every migraine responds to these peripheral muscular decompression treatments norc an certain migraines even be explained by such approaches. One specific type of migraine emanates from pain high in the temple (temporal) region. The image of someone holding their temples while in pain is a classic one for migraines. Some patients will tell you that they can make it actually feel better, experience less pain, if they press in on their temple area. Whether this maneuver works is unknown but some patients feel that it helps. Migraines in the temple region do not appear to have a muscular trigger point as there is no specific cranial nerve in the temple area that passes out through the muscle like that in the brow or at the back of the heads.

One potential explanation is that the trigger in the temporal area may be medicated by a vascular origin and not muscle. The auriculotemporal nerve passes through the temple area, largely being on top of the muscle. Its pathway is located fairly close to where most temporal migraine sufferers can put their finger on as the most intense areas of pain. This type of pain location is where both the  auriculotemporal nerve) and the superficial temporal artery are in close association.

Recent published anatomic studies by plastic surgeons has shown that up to one-third of cadaver head dissected showed a direct relationship  between the artery and the nerve where they crossed each other or became actually intertwined. This could be a source of nerve irritation and a potential trigger for temporal-based headaches. As the nerve and artery are located  in the superficial fascia of the temple, they both are easily accessible through very limited incisions inside the temporal hairline.

Auriculotemporal nerve decompression can be done through an inch or two vertical incision about one inch back from the hairline. The superficial temporal artery (STA) splits about 5 cms above the back of the zygomatic arch so this should be where the incision is made. The bifurcation can easily be found. Some patients will show the nerve in proximity to the anterior branch of the STA while others will not. The artery can be ligated from where it branches from the main trunk of the STS up as far as one can go. There is usually a specific point that one can put their finger on which is the area of maximal pain. The anterior branch of the STA will almost always pass right into that area. There is where the upper end of the ligation is done. I also take a window of fascia over and around the point of maximal spot pain. Whether this is beneficial or not is unknown but it is simple to do and may help provide some relief from ‘muscle decompression’. Should the nerve and artery be in close proximity, it is always preserved.

The field of migraine surgery through muscle or vascular decompression is new and continues to evolve. Less studies have been done on temporal migraine decompression but vascular ligation/separation seems like a plausible theory. There are virtually no downsides to this procedure other than it may not work. It is simple enough that it can be done under local anesthesia if it is the only trigger point being decompressed. Diagnostic testing of the temple region as a potential culprit can not be done by Botox to prove the vascular trigger point theory or that the surgery may be effective. Local anesthetic injection would seem to more reliable as a nerve block test but one has to be careful to not puncture the underlying artery. The correlation between a positive local anesthetic nerve block and the success of vascular decompression, however, has not been proven and further studies are needed.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

The treatment of migraine headaches has undergone new insights in the past decade through the use of surgical decompression of specific peripheral nerves in the head and neck. Through either the use of injectable Botox or muscle resection of the supraorbital or occipital nerves as they exit out from their cranial bone sites, significant and sustained relief has been obtained in selected migraine sufferers. But some migraine headaches are not responsive to treatment at these cranial nerve sites.

One specific migraine patient suffers from pain high in the temple region. This type of pain location suggests that there may be a vascular-mediated peripheral trigger site as there is where there is not only a branch of the trigeminal nerve (auriculotemporal nerve) but also the superficial temporal artery. These two anatomic structures are in close proximity. Could the intersection of the superficial temporal artery and the auriculotemporal nerve be an inciting point for a migraine headache?

This anatomic relationship was investigated and reported in the May 2010 issue of Plastic and Reconstructive Surgery by Drs. Janis and others. Using fresh cadaver heads, the superficial temporal arteries and  auriculotemporal nerves  were dissected out and a topographic map of their relationships was created. In 34% of the cranial heads studied, there was a direct relationship  between the artery and the nerve where they crossed each other or became actually intertwined.

Because the superficial temporal artery lies against or is intertwined with the auriculotemporal nerve is some cases, it certainly could cause irritation of the nerve. As the nerve and artery are located  in the superficial fascia of the temple, it is easily accessible through small incisions within the temple hairline. The artery could be simply tied  above and below the crossing point of the two. This could be a new procedure for the treatment of migraines that have been shown to have a trigger point high in the temporal area.

Anatomic studies of this type continue to show that specific sensory cranial nerves can be  a cause of migraine headaches. Decompression through either muscle resection or vascular ligation can be a welcome relief for properly selected patients for plastic surgeons. Diagnostic testing of the temple region as a potential culprit could be done by a 24 hour local anesthetic to determine potential effectiveness of a vascular ligation procedure. While Botox is used for supraorbital and occipital nerve testing, that will not work for temple migraine testing as it is a vascular and not a muscular problem.    

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

Migraines are difficult treatment problems that are resistant to many standard drug therapies. Few migraine sufferers have one treatment approach that works consistently. Migraines that have a single or predominant trigger site, while is just a subset of migraine sufferers, have been undergoing novel non-surgical (Botox) and surgical (nerve decompression) treatments in some centers with fairly high rates of relief.

In a recent paper in the August 2009 issue of Plastic and Reconstructive Surgery, the Departments of Plastic Surgery (Dr. Bahman Guyuron) and Neurology of the Cleveland Clinic report on their experience with the surgical treatment of migraine headaches. Seventy-five (75) patients with moderate to severe headaches were studied who had a prior positive response to Botox injection therapy. Frontal, temporal and occipital trigger sites were identified and the patients were assigned  to receive either  actual or sham surgery on their predominant trigger site. Of the 75 patients, 58% in the sham group and 84% in the actual surgery group experienced at least 50% reduction in their migraine headaches. In the surgery group, 57% reported complete elimination of their migraine pain compared to just 4% in the sham group.

This reported study is one of, if not the most significant, clinical study ever performed in evaluating the relatively new surgical decompression techniques of external migraine trigger points. Being actually able to perform sham surgery on patients seems like a throwback from years ago and is a credit to the authors to having gotten this through their institutional IRB. Because of this study’s design, the outcomes are fairly convincing that surgical deactivation of peripheral migraine trigger sites works….even if the mechanism of its effects is not completely understood yet. While there was a significant response rate in the sham group,  few complete migraine eliminations were recorded unlike the actual surgery group.

No one knows exactly why migraines occur and many theories have been proposed. Surgical decompression of external migraine trigger points that course through cervicofacial muscles is based on the premise that peripheral nerve activation results in central brain sensitization. For some migraine patients, this published work and their previously reported studies provide solid evidence that this concept has merit.

Any potential patient reading this study should not necessarily assume that they are good candidates for these procedures. Patients should be thoroughly evaluated by a neurologist and have other causes for their migraines evaluated. Their migraine headache should be classified and, if appropriate, the effects of Botox on the trigger points should be done. Only if Botox injections produce significant relief should surgical nerve decompression of the trigger point be considered.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Pain coming from the occipital nerve (occipital neuralgia) is a very disabling disorder that is marked by fairly severe headaches coming from the back of the head forward. I personally know several very good physicians with this problem and they often have to miss work and take a lot of pain and headache medications for intermittent partial relief.
 

The diagnosis of occipital neuralgia can be confirmed by point tenderness over the occipital nerves and complete elimination of headaches by either a local anesthetic injection (24 hour relief) or Botox (several months relief). While many different treatments have been tried and used, none has proven to have a high degree of pain relief that is sustained.

Surgical decompression of the occipital nerve (neurolysis) has been a promising treatment that is directed toward muscular resection around the emerging greater occipital nerves. In the May 2009 issue of Plastic and Reconstructive Surgery, Ducic , Hartmann and Larson from Georgetown University have published the largest series ever reported of the outcomes of this approach. In 206 consecutive patients, they analyzed the effects of greater and/or lesser occipital nerve neurolysis. The authors found that 80% of patients experienced at least 50% pain relief and 43% of patients experienced complete relief of all headaches at one year or greater after surgery. They only experienced two minor wound infection complications.

These substantial data support the concept that neurolysis of the greater occipital nerves can provides a safe, effective, and sustainable method of pain relief for those patients crippled with chronic headaches coming from this nerve source. Patients should first be evauated by a neurologist to rule out any other source for the headaches and have been through 6 months of non-surgical treatments to ensure that other approaches are not effective. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Headaches or migraines coming from the occipital region (back of the head) is a chronic pain issue for some people that comes from numerous pathologies. The common origin is nerve inflammation (neuritis) and one potential cause is nerve compression from the surrounding muscle. This has now been identified as one potentially treatable occipital migraine cause through surgical decompression.

In my Indianapolis plastic surgery practice, I have found that Botox injections and surgical decompression by the select removal of muscle around the occipiptal nerve to be effective for a specific subset of migraine patients. When other potential sources of the pain have been worked up and managed by a neurologist and have failed, surgical decompression may be of benefit if the physical examination has a positive finding. This finding is very straightforward to determine by touching the area and watching how the patient responds. Point tenderness and or a shooting nerve sensation up the scalp are definitive signs. Much like carpal tunnel syndrome, compression of the occipital nerve where it comes through the muscle can be the source of migraine pain and attacks.

The greater and lesser occipital nerves are major nerves of feeling that come out from the muscles at the back of the scalp and run upward. They provide feeling to the back of the scalp. The greater occipital nerve is the larger one and it comes out of the semispinalis capitis muscle a few cms off of the midline and below the occipital protuberance. The lesser occipital nerve is more to the side and comes into the scalp off of the sternocleidomastoid muscle. Because the greater occipital nerve pierces the muscle, surgical decompression is primarily aimed at its treatment.

Qualified patients are those who have been worked up by a neurologist, have point tenderness over the nerve, and get temporary relief from nerve blocks or Botox. Surgical decompression consists of finding the nerve through a small incision on the back of the scalp and removing muscle around it without injuring the nerve itself. Sometimes there may be small blood vessels around the nerve as well and these can be similarly removed. Opening up the pathway for the greater occipital nerve can provide significant relief for the properly selected patient. Other occipital sensory nerves, such as the lesser and posterior, are also sources of pain that are currently being studied as well.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The treatment of migraine headache patients by Botox injections has been shown to be effective in specific patients who have identifiable triggers of the supraorbital and supratrochlear, zygomaticotemporal, greater occipital, and septal trigeminal nerves. The temporary relief from Botox has led to the concept that relieving pressure on the nerves by muscle resection (surgical decompression) can subsequently be effective and may provide a more long-term solution to the migraine problem.

 
Surgical decompression of migraines, pioneered by plastic surgeon Dr. Guyuron in Cleveland, has shown that a high percentage of carefully-chosen patients may benefit. (> 90%) On average, most migraine patients experienced improvement at one year follow-up, needing less medications for management. While some patients do experience a ‘cure’, this is not the majority. A recent publication in the July 2008 issue of Plastic and Reconstructive Surgery by Dr. Poggi of Wichita confirms these results in their own reported experience. One of the most interesting findings of their study was that two-thirds of the patients felt that surgery offered better relief than Botox injections.
Surgical decompression involves removing muscle that intertwines or lays against the nerve. In the frontal area, this can be done endoscopically (like an endoscopic brow lift) or directly through an upper eyelid incision. As of now, this is a surgeon’s choice and the evidence that one method is superior over the other remains to be conclusively proven. For the zygomaticotemporal, greater occipital and septal trigeminal nerves, a direct open approach is used.

 
For those patients whose migraine headaches are of sufficient frequency and are not well controlled by medication, surgical decompression of trigger points offers potential for improving their lives.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Botox is Effective in the Treatment of Specific Types of Migraine Headaches

Botox is the single greatest non-surgical aesthetic treatment that has been discovered to date. It is a near 1 billion dollar drug in sales because of one simple fact…..it works and it works well. It effectively weakens select facial muscles so that certain undesireable facial expressions, such as frowning, are eliminated. In the process of weakening the facial muscles between the brows, know as the glabellar area, it has been observed that some patients’ migraines were improved or eliminated. I have observed this is in several of my patients here in Indianapolis and it has been observed in plastic surgery for many years.

While Botox is not approved by the FDA for the treatment of migraines, there is little clinical doubt from our experience in plastic surgery that it works. The exact way it works seems to be through relaxation of the forehead muscles that wrap around a sensory (feeling) nerve that comes out of the brow bone. (supraorbital/supratrochlear nerves) This is also a common area that gets Botox for cosmetic purposes. By relaxing the muscles, the nerve is no longer ‘pinched’ and the trigger for the migraine is temporaily removed. This same phenomenon works on migraines that start in the back of the head in the occipital region of the upper neck. In this area, the large occipital nerve (which provides feeling to the scalp on the back of the head) exits from the bone in the back of the skull up through the occipital muscle.

These observations do not mean that every migraine patient will get relief of their headaches with Botox injections. It appears that only a very specific type of migraine patient will get improvement. My belief is that those patients that have a ‘focal’ or specific origin of their migraine headache have a good chance to have a 3 -4 month relief, or as long as the Botox is working. If the migraine begins specifically in the brow region and spreads for there, this is a good sign that Botox will be effective. If Botox is effective, this also indicates that surgical decompression of the nerve (removing muscle from around the nerve) through an endoscopic approach may provide a more permanent cure. Botox, therefore, can be a pharmacologic treatment or a qualifier for possible surgical treatment.

Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis