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Archive for the ‘migraine surgery’ Category

Outcome Assessment of Frontal Migraine Surgery

Wednesday, October 5th, 2016


The treatment of specific types of migraine headaches has been revolutionized by the use of Botox injections and migraine surgery. While not always producing a cure, both types of treatments can produce a significant reduction in symptoms that is sustainable. The basis for migraine surgery is essentially the deactivation of a trigger which for three out of the four established migraine sites involves sensory nerve decompression.

migraine-surgery-indianapolis-dr-barry-eppleyFrontal or forehead migraines can be triggered by compression of the superior divisions of the trigeminal nerve as they exit from the brow bones. The supraorbital and supratrochlear nerves can be compressed by muscle, vessels or the bone as its exits outward. Surgical decompression has been described using a superior endoscopic or an inferior transpalpebral (through the upper eyelid) approaches. Studies have shown that the endoscopic approach may produce better results than that of the transpalpebral technique.

In the September 2016 issue of Plastic and Reconstructive Surgery, an article was published entitled ‘In-Depth Review of Symptoms, Triggers, and Surgical Deactivation of Frontal Migraine Headaches (Site I)’  In this paper 270 patients treated for frontal migraines who had at least one year followup were analyzed. A high percentage of patients (86%) as a successful outcome as determined by a greater than 50% improvement in the frontal-specific Migraine Headache Index. Over half of the patients (57%) reported a cure with complete elimination of their frontal migraines. Other symptoms beyond the headaches improved as well including blurred/double vision and visual auras. The most common complications were numbness of the nerve distribution which occurred in about one-third of the patients.

supraorbital-nerve-anatomy-dr-barry-eppley-indianapolisFrontal migraine surgery is associated with a high rate of symptom relief that is sustained for years after the procedure. It is not a perfect procedure as some patients don’t get complete relief and a few get little to no symptom improvement. One more recent anatomic understanding is the need to look for before whether the supraorbital nerve comes out from a notch in the brow bone or whether it exits through a completely encasing bony foramen. In such cases a foraminotomy is needed to release any potential bony compression on the nerve.

Dr. Barry Eppley

Indianapolis, Indiana

Lateral Approach to Temporal Migraine Surgery

Wednesday, May 18th, 2016

Zygomaticotemporal nerveTemporal headaches are one of the four known regional migraine areas. The etiology is compression of the zygomaticotemporal nerve (second division of the trigeminal nerve), the auriculotemporal nerve (third division of the trigeminal nerve) or both. Decompression or avulsion of these nerves is a known effective treatment in the properly qualified temporal migraine surgery patient.

The surgical approach to the zygomaticotemporal nerve has historically been from an endoscopic technique where the dissection is done from above. This is often combined with supraorbital nerve decompression and explains why a superior approach has been advocated.

In the My 2016 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘ A Novel Surgical Approach to Chronic Temporal Headaches’.  In this report, the authors used a temporal hairline incision to access the zygomaticotemporal and auriculotemporal nerves for decompression or avulsion. Through a small 3.5 cm incision, the zygonaticotemporal nerve located above the deep temporal fascia. If the nerve was healthy, the fascia was opened and the sentinel vein cauterized. If the nerve appeared non-viable it was transected and the cut end buried in the muscle. The auriculotemporal nerve located closer to the incision was treated simlarly. At one year after surgery the Mean Migraine Headache Index dropped from an average of 131 to 52. Almost 90% of the patients experienced a 50% reduction in their headache symptoms. Almost 40% had a complete cure of their migraines. Three patients (roughly15%) had no substantial improvement.

Auriculotemporal Nerve Migraine Trigger Site Dr Barry eppley IndianapolisThe novelty of this temporal migraine approach is that it is closer to where the zygomaticotemporal nerve is located and allows concurrent access to the auriculotemporal nerve as well. It is a perfectly safe approach that stays below the frontal branch of the facial nerve. The more direct approach better allows the treatment option of  decompression or avulsion under better visual access.

Dr. Barry Eppley

Indianapolis, Indiana

Arterial Ligation in Temporal Migraine Surgery

Wednesday, October 28th, 2015


While everyone knows what a migraine headache is, determining its exact cause in many patients is not so obvious. Recent advances in migraine care have been to determine if there is a specific extracranial cause that triggers the migraine. The focus has been on nerve compression of certain sensory nerves where they exit from the skull. These trigger sites include the frontal, occipital, temporal and nasal areas.

Temporal Migraine Surgery Dr Barry Eppley IndianapolisThe temporal migraine trigger site is the most perplexing due to a close association of vessels (anterior temporal branch), nerves (auriculotemporal and zygomaticotemporal) and the temporalis muscle and enveloping fascia. Many patients point to the temporal area as the origin of their migraines and often can pin point one very specific area.

temporal artery anatomy 2In the October 2015 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘The Current Means for Detection of Migraine Headache Trigger Sites’. In this paper the most interesting aspect of it was the section devoted to Doppler Signals. Since some of the sensory nerves can intersect or become intertwined with an artery, the migraine headache may be described as a throbbing type headache. This seems to be particularly true in the temporal area in my experience. Physical examination may demonstrate a pulsatile vessel and a hand held doppler unit can be useful to pick up the arterial signal at the site of the pain. This cause of some temporal headaches may be due to the anterior branch of the superficial temporal artery intersecting with the auriculotemporal nerve. But the doppler is also useful for isolating pulsatile flow in temporal areas that may not be considered traditional migraine trigger sites.

Doppler Probe in Temporal Migraines Dr Barry Eppley IndianapolisThe use of digital palpation combined with the doppler in the temporal region correlates with what I have seen in the aesthetic treatment of prominent temporal vessels.With ligation of some of the peripheral anterior branches of the superficial temporal artery, some patients will experience relief of their temporal headaches. While this arterial correlation may be more obvious due to the enlarged sizes of the artery, reduction of pulsatile flow works nonetheless.

Spot ligation of small temporal arterial branches is a part of temporal migraine surgery and can be an effective strategy for reducing certain types of pulsatile migraine headaches in temporal region.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Temporal Muscle Reduction Migraine Surgery

Sunday, July 19th, 2015


Background: There are a wide variety of types of headaches of which migraines make up some of the most disabling. While the exact cause of many migraine headaches is not precisely known, certain types of migraines are known to occur from peripheral compression of certain cranial nerves. This has led to a variety of injectable Botox and surgical decompression surgeries to treat these very specific types of migraines.

One the of peripherally-based type of migraine headache occurs in the temporal region or the side of the head. Because the temporalis muscle is a chewing muscle such headaches often occur in people who grind their teeth due to stress. The zygomatico-temporal nerve branch (ZTBTN) comes through the temporalis muscle near the eye and can often be a source of temporal migraines. Treatment with Botox injections (diagnostic test for surgical treatment or simple avulsion of the nerve can produce noticeable improvement in the frequency and duration of these type of temporal migraine headaches.

Temporalis Muscle Reduction and Augmentation Dr Barry Eppley IndianapolisBut a false Botox test of the ZTBTN nerve or failure to produce a very pronounced reduction in the migraine headaches indicates that the compression of this small sensory nerve is not the true source of the problem.  The overall size of the temporalis muscle and/or its repetitive contraction could then be more likely the headache source. This can be confirmed by a clinical examination of clenching of the teeth, feeling the expansion of the muscle and palpating for the location of the painful stimulus.

Case Study: This 56 year-old female had a long history of temporal headaches that had been refractory to every conceivable treatment. She knew that it came from clenching her teeth and was persistent on the side of her head. Dental splints, drugs and ZTBTN Botox injections did not provide relief. Botox placed all over the temporalis muscle provided some improvement but the dose requirement (50 units per side) was high and only temporary. (less than three months)

Temporal Reduction Dr Barry Eppley IndianapolisUnder general anesthesia, the posterior portion of her temporalis muscle was removed through a small vertical incision. Both the fascia and the muscle were removed anteriorly to about 3 cms behind the temporal hairline.

At one year after surgery, she reported a complete elimination of her migraine headaches. She did not have a single headache since the surgery. Her incisions healed inconspicously and she had no short or long-term effects on chewing or mouth opening.

Temporal muscle reduction may seem like a radical solution to the treatment of temporal migraines. But as an end treatment in the refractory migraine headache patient, it is a simple procedure that has no adverse functional effects.


1) Temporal (side of the head) migraines typically responds to Botox injections, ZTBTN nerve avulsion or ligation of the temporal artery.

2) When the source of temporal migraines is related to clenching and large bulging posterior temporal muscles, muscle reduction can be effective for which Botox injections would be the first treatment approach.

3) Temporal muscle reduction of its posterior belly is an end stage migraine treatment that can be effective in the properly selected patient.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Intraoperative Pain Control Techniques in Migraine Surgery

Monday, April 6th, 2015


Treatment of very specific types of migraine headaches can be successfully done by extraforaminal decompression techniques. This is especially true for the migraine trigger site of the supraorbital nerve. By removing all of the muscle from around the neurovascular bundle (and occasionally removing some foraminal bone and ablating the artery) a decrease in the severity and frequency of migraine headaches can be potentially achieved.

But despite the procedure’s ultimate success at migraine reduction, very often migraine surgery creates an immediate postop migraine event. This is not surprising given the trauma that results in and around the nerve from its decompression. While such a migraine ‘reaction’ does not occur in every patient, it certainly is distressing to those in which it does. In the short term it is very much like ‘adding insult to injury’.

Marcaine Injections in Migraine Surgery Dr Barry Eppey IndianapolisSeveral intraoperative techniques can be useful for reducing the risk of an immediate after surgery migraine attack. After the induction of anesthesia, supraorbital nerve blocks are done using a  0.25% Marcaine and epinephrine (1:200,000) solution. (bupivicaine) This will block nerve sensations in the forehead and create a profound but temporary numbness of the supraorbital nerve’s anatomic distribution. These effects will wear off in 24 hours.

Endoscopic Supraorbital nerve decompression with gelfoam spongeAnother intraoperative technique is to treat the base of the supraorbital nerve with steroids after it has been decompressed. This is best done by soaking a dissolveable collagen sponge with Kenalog (triamcinolone) and wrapping it completely around the now visible nerve branches. This will have a calming effect on the nerve that will last well beyond that of the local anesthetic Marcaine.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Doppler Probe in Temporal Migraine Surgery

Sunday, April 5th, 2015


Auriculotemporal Nerve Migraine Trigger Site Dr Barry eppley IndianapolisThe cause of certain migraine headaches is now well known be caused by peripheral compression of cranial sensory nerves usually caused by muscular contraction. This compression causes nerve irritation and serves as the nidus for the initiation of the migraine. In the auriculotemporal nerve migraine trigger area, its close association with the superficial temporal artery also creates the potential for a vascular source of irritation as well.

Doppler Probe in Temporal Migraines Dr Barry Eppley IndianapolisIn the April issue of the journal Plastic and Reconstructive Surgery, a paper was printed entitled ‘Use of a Doppler Signal to Confirm Migraine Headache Trigger Sites’. In patients that were treated with migraines involving the auriculotemporal nerve, the location of the most intense preoperative pain was tested with an external doppler. During surgery the determination was made as to whether there was an artery associated with the trigger site. A positive Doppler signal over the migraine area before surgery correlated with an associated artery 100% of the time. On 34 temporal surgery sites, an associated artery was found each time and an arterectomy carried out for nerve decompression.

Perhaps to no great surprise, a positive doppler signal in the temporal region of greatest migraine pain consistently isolates an offending artery. This is a simple and important technique to ensure optimal reduction of intensity and frequency of temporal migraines. Whether the artery is ligated before the site of nerve compression or removed at the site, the elimination of the pulsations on the nerve is an important part of auriculotemporal nerve decompression.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies in Plastic Surgery – Fat Grafting in Migraine Surgery

Sunday, July 20th, 2014


Contemporary migraine surgery for the treatment of perpheral triggers involves decompression of the involved nerves. The most common involved nerves include the supraorbital, supratrochlear and the greater and lesser occipital nerves. (the zygomaticotemporal and auriculotemporal nerves are avulsed so they are excluded)  The success of nerve decompression depends on adequate release of the enveloping muscle and fascia so any pinching effect on the nerve is eliminated.

But decompressive migraine surgery does not always produce sustained relief and one of the reasons is recurrent compression due to scar formation. Despite being relieved of constructive muscle fibers, the surrounding tissues do have to heal and the space left behind can be replaced with scar tissue. Such scar tissue formation naturally contracts as it heals, thus potentially replicating the initial nerve compression problem.

Greater Occipital Nerve Decompression Dr Barry Eppley IndianapolisGreater Occipital Nerve Decompression with Fat Graft Dr Barry EppleyOne simple strategy to prevent recurrent nerve compression in migraine surgery is the use of fat grafts. Placing a fat graft over or around the released nerve can have several beneficial effects. Its obvious benefit is that it fills the open space around the nerve from the release and provides a quickly revascularized soft tissue buffer from the surrounding tissues. The other potential benefit is less obvious and unproven but theoretically possible.

Fat tissue is seen today as an active and secreting organ that produces a variety of special proteins. One of these are neurotrophic factors such as nerve growth factor and brain-derived neurotrophic factor. Such factors are known to have a role in stimulating repair of peripheral nerves as well as a regulator of immune and inflammatory responses. Placing a fat graft against a nerve that has been compressed and inflamed may have a healing and reparative effect.

The harvest of a small fat graft is quick and easy and its placement onto the released nerve is similarly so. There is no morbidity in doing so and fat graft placement around the nerve can be done either in an open wound or in an endoscopic approach.

Dr. Barry Eppley

Indianapolis, Indiana

The Success of Temporal Migraine Headache Surgery

Monday, April 21st, 2014


Certain types of migraine headaches have been attributed to compression of the extracranial portions of the trigeminal nerves. One of the four main types of peripheral compression migraines are temporal-based which result from the temporal muscle squeezing the zygomaticotemporal branch of the trigeminal nerve. (there could also be a concomitant effect of a tight fascial opening as well) It is where the nerve passes through the muscle and fascia on its way to supply the overlying skin in the temporal region as to where it is affected. This is at an approximate point in the temporal skin between the corner of the eye and the eyebrow.

Decompression of this affected nerve for temporal migraines is really an avulsion technique. Through an endoscopic approach, the nerve is identified as it comes through the deep temporal fascia, grasped and pulled like a small piece spaghetti. There is no harm in eliminating this nerve as it only supplies a small area of skin with feeling in the temporal region. As the nerve is avulsed, its most proximal end retracts into the temporal muscle under the fascia which is helpful for prevention of potentially painful neuromas. While  this technique is uncomplicated to perform, how success is it in reducing temporal migraines.

In the April 2014 issue of the journal Plastic and Reconstructive Surgery, a study entitled ‘In-Depth Review of Symptoms, Triggers and Treatment of Temporal Migraine Headaches (Site II)’ was published which examines this very question. Over a ten year period, a total of 246 patients who underwent temporal migraine decompression surgery were assessed to determine the success of the procedure. It was determined that 85% of the patients had at least a 50% improvement in their headache symptoms at one year after surgery. Over half (55%) reported a complete elimination of their headache symptoms.

This study supports the benefits of zygomaticotemporal nerve avulsion to reduce the severity and frequency of temporal-triggered migraine headaches.  Despite its relatively high success rates for headache reduction, it does not solve every patient’s symptoms. There may be other contributing factors to migraine headaches such as the auriculotemporal nerve and the anterior branch of the superficial temporal artery. In those patients who have minimal improvement, these sites may be considered for secondary treatment.

The ideal candidates for temporal migraine surgery are those that have very specific symptoms that are be traced to the topographic location of the zygomaticotemporal nerve location. For those that can specifically point to the exact temporal location, the use of preoperative Botox testing can be bypassed.

Dr. Barry Eppley

Indianapolis, Indiana

Occipital Nerve Excision in Migraine Surgery

Monday, March 3rd, 2014


The most common surgical treatment today for migraine headaches that are due to peripheral occipital nerve impingement is decompression as the nerve courses through the neck muscles and fascia. While this operation has a significant rate of symptom improvement, not all patients get better and some who get better relapse back after a period of time. What is there to do when decompression surgery fails?

Great Occipital Nerve Decompression Surgery for Migraines Dr Barry Eppley IndianapolisFailed nerve decompression for migraines can be treated by further surgery using a variety of methods. Re-exploration of the nerve site and removal of scar tissue and fat grafting to prevent further scarring around the nerve is an option. It may also be that the nerve has not been decompressed along enough of its length or there may be additional peripheral or ancillary branches that have not yet been treated. There is also complete removal of a segment of the nerve, known as greater occipital nerve excision. (GONE)

In the February 2014 issue of the Annals of Plastic Surgery, a migraine treatment study was published entitled ‘Occipital Nerve Excision for Occipital Neuralgia Refractory to Nerve Decompression’. In this paper, patients who had undergone greater occipital nerve excision (GONE) after failing occipital nerve decompression were evaluated. A total of 71 patients who had an average follow-up of 33 months had their headache severity measured by the migraine headache index (MHI) and disability by the migraine disability assessment. The success rate of surgery was 70% of which 40% of patients showed a 90% or greater decrease in migraine headache symptoms with an average reduction of 63%. The most common adverse effect was bothersome numbness or hypersensitivity of the scalp on the back of head, occurring in up to one-third of the patients.

While the GONE procedure is historic and predates nerve preservation and decompression, it is always an option after failed nerve decompression surgery. This study shows that it is a reasonable option for headache relief in patients with occipital headaches refractory to both medications and surgical decompression. The reason it is not the first surgical procedure used is the risk of problematic numbness or hypersensitivity of the scalp. But that trade-off may be worth it when initial decompression for migraine surgery fails.

Dr. Barry Eppley

Indianapolis, Indiana

Postoperative Instructions: Migraine Surgery

Sunday, March 3rd, 2013


Migraine surgery can be done in the properly selected patient through decompression of what is known as peripheral triggers. These are various locations of large sensory nerves that may be entrapped by muscle and other tissues as they exit the skull bone. Three such peripheral triggers have been identified including the supraorbital nerves for forehead or frontal migraines, the zygomaticotemporal nerve for temporal migraines and the greater occipital nerve for back of the head migraines. Through small scalp incisions the tissue around the nerve is cleared (decompression) removing any pinching effect on it.

The typical postoperative instructions for migraine surgery are as follows:

1. Most cranial nerve decompression procedures have only modest pain after surgery. Patients usually only feel the need to use Tylenol or Ibuprofen for just a few days after the procedure, some patients may need stronger pain medication for a few days. In rare cases the surgery may actually trigger a migraine and you may use your regular migraine medications as needed.

2. You may sleep in any position that feels comfortable. Most find the best comfort to sleep sitting up for the first few days after surgery.

3. There may be a circumferential wrap placed around the head right after surgery. This will be worn overnight and you may remove it the next morning. It does not need to be replaced.

4. You may shower and wash your hair the next day. There is no harm in getting the scalp sutures wet.

5. The sutures used in the scalp incisions will dissolve on their own. There is NO need for suture removal.

6. You may treat any eye bruising with ice or neck stiffness with a warm pad in the first few days after surgery.

7. There will usually be some temporary scalp numbness or periodic itching in the first few weeks after surgery. This is due to the scalp manipulation and will resolve on its own with healing.

8. There are no limitations to any physical activities after migraine surgery. You may feel free to run, workout and do any non-contact sporting activity as soon as you feel comfortable. Wearing of hats or head bands is based on scalp tenderness.

9.There are no restrictions on what you can eat or drink after surgery.

10. If any incisional or scalp redness, increased tenderness or swelling, or drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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