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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