One theory and approach to frontal migraine headaches has been the release of branches of the trigeminal nerve due to muscular and bony impingement. Whether pharmacologically treated by Botox injections or surgically treated by removal of constricting muscle and bone, dramatic and lasting improvements have been seen in properly selected patients.

One such treated area is that of the frontal migraine, commonly presenting as pain at the brow bone, behind the eye and up into the forehead. This is where the supraorbital and supratrochlear nerves exit the brow bone and can be entrapped by a tight bony foramen and/or the multiple muscles of the glabellar region. With adequate deompression, studies have shown that the majority of patients get lasting relief up to five years later with significant reduction in the frequency and intensity of their migraines.

Surgical decompression of the frontal area can be performed by two basic approaches, either coming from above using an endoscope or approaching it from below through an upper eyelid incision. Having done it both ways I have often wondered does one approach produce better results than the other?

In the May 2012 issue of Plastic and Reconstructive Surgery , a study out of Case Western Reserve University in Cleveland Ohio addressed this very issue of surgical approach to frontal migraines. Such a published study is of particular interest since this institution and its senior author may be considered the father of modern-day migraine surgery. Based on retrospective reviews of over 250 patients who underwent frontal migraine surgery, nearly 80% of those that had an eyelid approach had a successful outcome (62 patients) compared to a near 90% successful outcome in those patients who were treated with an endoscopic approach. (191 patients) Slighty over half of the eyelid approach patients had complete elimination of their headaches while two-thirds of the endoscopic group did.

This paper makes the case that endoscopic treatment of frontal migraines is more effective. One reason is that a superior approach is more effective at removing the most amount of muscle in a 360 degree fashion around the nerves. Muscle access from the eyelid approach is partially blocked by the path of the nerves themselves often resulting inadequate resection. The authors also feel that the bony foramen or notch is much better located coming from above and this certainly is true based on my Indianapolis plastic surgery experience with cosmetic endoscopic browlift procedures.

The one limitation to endosocopic frontal migraine surgery is the length and shape of the forehead bone. A long forehead with a hairline that is 8cms or more from the brows make instrument access very difficult if not impossible. A similar limiting factor is if the forehead bone is very curved or prominent, again making instrument manipulation of the tissues around the nerves mechanically restricted.

Dr. Barry Eppley

Indianapolis, Indiana

One of the causes of migraine headaches that emanate in the forehead region is compression of the supraorbital nerve. This trigger point cause of migraines is due to the squeezing or pinching of this nerve by the enveloping muscles. Relief can be obtained through either Botox injections or surgical removal of the muscles (myectomy) around the nerve. Clinical studies have shown that most patients will achieve improvement with about two-thirds having near complete resolution of their migraines long-term.

The supraorbital nerve is a branch of the ophthalmic nerve, which is the first division of the fifth or trigeminal cranial nerve. It supplies feeling primarily to the forehead and the scalp that lies above and behind it. It comes out through a hole in the brow bone known as the supraorbital foramen. In most people this foramen appears on the very edge of the brow bone and is more of a notch. In a minority of patients, it appears as a hole above the brow bone with a thick layer of bone beneath it.

In the surgical treatment of frontal migraines, it is customary to release the muscle around the supraorbital nerve. But could the bone from the supraorbital foramen also be a contributing factor in this nerve’s compression as well? In the April 2012 issue of Plastic and Reconstructive Surgery, this exact issue was studied. Out of Case Western University in Cleveland, a published paper investigated the role of additional decompression of the supraorbital nerve through a foraminotomy procedure. (removal of bone around the nerve) In 86 migraine patients, 43 were treated by muscle resection around the supraorbital nerve alone and another 43 were treated by muscle resection combined with supraorbital foraminotomy.

Based on after surgery migraine frequency, migraine severity, Migraine Headache Index and persistent forehead pain, the foraminotomy patients showed  more improvement and better scores than muscle resection only. This study indicates that the supraorbital foramen is a potential site for nerve compression that can contribute to frontal migraine headaches. When surgically possible the nerve should be released down to its exit from the bone and any adherent bands stripped away.

How much the supraorbital nerve can be released from the bone is highly influenced by the surgical approach. In a superior endoscopic technique, the attachments around the nerve can be partially released but not completely. Visualization on the inferior edge of the nerve is not possible. When done through an upper eyelid approach, a 360 circumferential release can be done including removal of some of the bone around the nerve, creating a true foraminotomy procedure. This has become my preferred approach for frontal migraine surgery due to the more complete release of all nerve attachments including bone.    

Dr. Barry Eppley

Indianapolis, Indiana   

Migraine headaches are a major concern and lifestyle alteration for those afflicted. While some have only occasional or sporadic migraines, others have more frequent and intense bouts that affects many parts of their life and are even disabling. Drug therapy does help many but not all and it is associated with some side effects. Besides ineffectiveness or a limited improvement, some of the side effects of these drugs are not worth the limited benefits in migraine reduction that they provide.

Newer migraine treatments include Botox injections and surgical decompression. Based on the concept that there is a peripheral trigger in certain migraines, nerve decompression by muscle chemorelaxation and then surgical muscle resection from around the involved nerve has been shown to offer long-term improvement. While there has been compelling evidence that such treatments work, new and independently conducted studies are always welcome.

In the July 2011 issue of Plastic and Reconstructive Surgery, a study out of Texas was published based on a retrospective review  of 24 migraine patients. Botox was used to identify frontal, temporal, and occipital trigger points. The nasal trigger point (septal deviation) was identified by examination but is not an injectable area. If a positive response to Botox was seen, surgical decompression was then performed on the trigger points. The success of the procedures was determined and followed by the Migraine Headache Index up to nearly two years after surgery.

Nineteen of the studied patients (80%) were improved by the surgery. While a few (2) had complete elimination of their migraines, most (17) reported significant improvement. Among those patients who responded to surgery, average improvement from baseline was 97%. Among all patients studied, average improvement was 78% from baseline.

While this was a relatively small patient study compared to some prior published reports, it nonetheless shows comparable findings. This study adds to the growing body of medical literature that shows Botox injections and surgical decompression can be tremendously effective in reducing migraines in the properly screened patient. Since the screening procedure for migraine surgery is Botox, it makes the decision and the probability for surgical success easy.

One thing I have not yet seen reported and have observed in my own migraine patients is different levels of success depending on the trigger point location. By far, surgical decompression of the greater occipital nerve (back of the head migraines) seems to work every time and usually quite dramatically. Less dramatic success is seen in some of the frontal trigger points, particularly the temporal location. This may be because there are different levels of compression along the path of the zygomaticotemporal nerve and other regional nerves, such as the auriculotemporal, may also be a contributing cause.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

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