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Posts Tagged ‘temporal migraine surgery’

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

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

Surgery for Temporal Migraine Sufferers – Potential Hope with Vascular Decompression

Tuesday, November 2nd, 2010

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

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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