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Posts Tagged ‘migraine surgery’

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.

Highlights:

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

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.

Consent for Plastic Surgery: Migraine Surgery

Saturday, March 2nd, 2013

 

Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of the various migraine surgery procedures. The following is what Dr. Eppley discusses with his patients for this procedure. This list includes many, but not all,of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.

ALTERNATIVES

The alternatives to migraine surgery include oral and injectable medications, local anesthetic and Botox injections, acupuncture and other non-medical stress/headache therapies.

GOALS

The goal of migraine surgery is to reduce the frequency and severity of one’s migraine headaches. Some few patients may get a complete cure but this would not be common.

LIMITATIONS

The limitations of nerve decompression migraine surgery is the degree to which one’s headache may be reduced or eliminated.

EXPECTED OUTCOME

Expected recipient site outcomes include the following: temporary swelling and bruising of the eyes (supraorbital and zygomaticotemporal nerve decompression), temporary neck stiffness/soreness (occipital nerve decompression), small permanent scars in the scalp, and up to 3 months to see the final result.

RISKS

Significant complications from migraine surgery have not occurred. More likely risks include infection, scar widening, increased headaches due to nerve irritation (stretching) and scar tissue formation, failure of any headache improvement at all, and return of presurgical migraine symptoms even if initial improvement of them is seen. Any of these risks may require revisional surgery for improvement.

ADDITIONAL SURGERY

Should additional surgery be required for further migraine relief or any complications, this will generate additional costs.

Patient Testimonials: Migraine Surgery

Wednesday, January 9th, 2013

 

 

Dr. Eppley,

I really want to thank you for changing my life. I can not express my appreciation for what a difference you have made. I was in such pain every day and after spending 25 years in school it is quite disheartening not to be able to rely on your brain. I know that some people think that I was a little extreme to have a nerve decompression. But I have NO regrets about the procedure and I feel like it saved my life. Although I still have some pulsing, it is minor compared to the pain that I was experiencing prior to having the nerve decompression. I am extremely grateful for your help.

I also wanted to tell you that I am extremely impressed with you as a doctor. And I wish that more doctors were like you. You have always been responsive to my questions – even six months after having the surgery. You are a kind and empathetic person to deal with in person. And I love you are always up on the most recent research. It makes me have a tremendous amount of respect and confidence in your ability as a surgeon.

Beth E.

Columbus, IN

Comment:

Migraine surgery in the properly selected patient can be literally life changing. Almost all patients who undergo nerve decompression for migraines have a long history of both disabling symptoms and having received a wide array of migraine treatments. They are almost always on numerous medications with very incomplete headache symptom reduction. Many are so affected that it affects both their personal and work lives. If their migraines have a very specific focus in origin (supraorbital, temporal, or occipital) and respond positively to Botox injections, there is a very high likelihood that nerve decompression will be successful. A successful surgical  result is one in which patients experience a very noticeable reduction in both frequency and duration of their migraines. A smaller number of patients will have a near complete cure of their migraines. Long-term studies show that after five years many of these results are maintained.

While one should not be cavalier about undergoing nerve decompression, it is a procedure that has very few side effects. The most significant side effect and risk of migraine surgery is that it may not always work or may reveal another nerve trigger after surgery that may require an additional procedure for further symptom reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Auriculotemporal Nerve Decompression for the Treatment of Temporal Migraines

Saturday, September 1st, 2012

 

The trigger point mechanism for migraine headaches has been revolutionary in helping some patients achieve partial or complete relief of their headaches. It is based on identifying one or more of the four peripheral triggers points, frontal (supraorbital/supratrochlear nerves), occipital (greater occipital nerves), temporal (zygomaticotemporal nerve) and nasal (septum/turbinates), for injectable Botox or surgical decompression therapy.  (migraine surgery) With good trigger point identification and isolation, successful treatment outcomes will occur in the majority of treated cases.

But migraine trigger point therapy is not always universally effective and some patients will have persistent pain. This has led to the identification of minor peripheral trigger points such as the lesser occipital and the auriculotemporal nerves. The auriculotemporal nerve is particularly interesting because it is near the site of temporal-based migraines. Most patients with this trigger point will press directly over a skin area between the eyebrow and the temporal hairline, the exact location of the coursing of the zygomaticotemporal nerve. But decompression of this nerve does not always relieve the migraines. The close association of the auriculotemporal nerve in the more posterior hair-bearing temporal scalp raises the question of its contribution to migraine pain.

In the August 2012 issue of Plastic and Reconstructive Surgery, a study entitled ‘The Auriculotemporal Nerve in Etiology of Migraine Headaches: Compression Points and Anatomical Variations’ was published. From an anatomical study out of Cleveland (the home of modern-day migraine surgery), a cadaver study was done to evaluate the course of the auriculotemporal nerve and to locate potential compression points along its course. Their studies showed three potential compression points; two located above the ear due to fascial bands and a third point due to being wrapped into and overlaid by the superficial temporal artery.

Having done a fair amount of surgery in the temporal region (temporal implants, temporal artery ligation, facelifts) I have always been impressed with the intricate anatomy and pathways of the arteries, veins and nerves in this area. For most of the traditional surgeries performed in this area, these neurovascular structures are a nuisance and are merely pushed to the side and/or tied off. But from a migraine standpoint, these anatomy could well be the source of a syndrome known as auriculotemporal neuralgia. This is a well known neurologic entity in which the patient experiences attacks of pain in the preauricular area that spreads upward to the temples.

For those patients who have failed zygomaticotemporal nerve decompression or have persistent preauricular pain/headaches, treatment of the auriculotemporal nerve may be beneficial. Because the compression on this sensory nerve branch is not due to muscular contraction, Botox injections will not be helpful for either diagnosis or treatment. Surgical decompression is very straightforward through a small vertical temporal incision. Releasing the fascial bands and/or separating the nerve from the artery through its upward course could be curative.

Dr. Barry Eppley

Indianapolis, Indiana

The Importance Of Patient Selection in Migraine Surgery

Sunday, May 22nd, 2011

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

Indianapolis, Indiana


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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