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.

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.

Background: One source of forehead migraine pain is compression of the supraorbital nerve. Squeezing of the nerve as it comes out of the supraorbital foramen or notch by the enveloping muscles is a well recognized source of migraines that is treatable by decompression either through Botox injections or surgical removal of muscle tissue. (migraine surgery) The effectiveness of supraorbital nerve decompression on migraine relief is now well documented.

But the supraorbital nerve can become compressed by other means although much less commonly. Examples include bone fractures that involve the frontal sinus that go through the nerve foramen or notch or lacerations of the brow that may entrap nerve branches in scar tissue. Tumor or masses can also cause nerve compression as they expand.

One common but benign forehead soft tissue tumor is the lipoma. Lipomas are encapsulated collections of abnormal fat cell growth that present as subcutaneous masses or nodules. They grow slowly and are often not noticed until they are seen as a visible lump through the skin. They can occur anywhere on the body and the forehead and scalp are no exceptions. It is conceivable that a lipoma located near the supraorbital nerve can cause painful compression.

Case Study: This 48 year-old male had noticed a lump that appeared above his left brow over the past year. As the lump appeared so did persistent and increasing headaches on that side of the forehead. The lump felt firm, immobile, and down at the bone level. It was felt that it was either a lipoma or an osteoma so no diagnostic s-rays were done.

Under local anesthesia, a 2 cm incision was made in a horizontal forehead crease directly over the lump. Dissection through the subcutaneous tissue revealed a 1 x 1 cm lipoma with multiple supraorbital nerve branches running on top and around it. The lipoma extended down and was attached to the periosteum of the forehead/brow bone.

The nerves were separated from the lipoma and it was then removed in its entirety leaving all nerve branches intact. The incision was closed in layers with resorbable subcuticular suturing. The patient reported a complete elimination of his left-sided forehead headaches when seen a week later.

Lipomas are a rare cause of supraorbital pain/headaches but the mass compression effect is easy to understand. Fortunately, the lipoma is straightforward to remove using a direct forehead incision in a patient that has existing wrinkles. In females without wrinkles it may need to be removed through an endoscopic technique to eliminate visible scarring if no forehead wrinkles exist.

Case Highlights:

1)      Pressure on the supraorbital nerve of the forehead is a known source of headache pain.

2)      Lipomas can occur on the forehead and may rarely put pressure on branches of the supraorbital nerve causing pain.

3)      Excision of a forehead lipoma can be a source of relief of headache pain through its decompressive effects.

Dr. Barry Eppley

Indianapolis, Indiana

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

The treatment of frontal-based migraines by supraorbital and supratrochlear nerve decompression (stripping the muscle away from the nerves) has made a significant contribution to improved results for well qualified patients. (positive Botox responders)While it does not always cure every patient, numerous studies support that migraine headache frequency and severity are decreased in the majority of patients by this approach.

While the supraorbital and supratrochlear nerves course through muscle on their way up through the forehead tissues, there is a bony exit or foramen where it exits the brow bone of the frontal skull. As the nerve comes out of the bone,  it is well known that there is a variety of shapes including an encircled complete bony foramen, a notch at the lower edge of the brow bone or some combination of both.  This is also a potential source of nerve compression as a non-muscular trigger and is worthy of additional evaluation.

In the December 2012 issue of Plastic and Reconstructive Surgery, this relationship is studied in the article ‘The Anatomical Morphology of the Supraorbital Notch: Clinical Relevance to the Surgical Treatment of Migraine Headaches’. The bilateral supraorbital nerve exits in 30 cadaver heads were studied. In just over ¼ of the nerves, it came out through a foramen above the edge of the brow bone. In the majority (83%), the nerve was associated with a notch. Only 10% had a combination of a foramen and a notch.  Interestingly, some nerves showed differences (foramen vs notch) between the two sides in the same head. When a notch was present, there was a fascial band that encircled the bottom part of the nerve most of the time. (86%) The authors identified four types of supraorbital notch bands based on their fascial and bony compositions.

This study is extremely relevant for the treatment of frontal migraines as it has identified for the first time in detail potential proximal compression points at the supraorbital nerve exit.  This suggests that when there is a supraorbital notch present (which can even be identified prior to surgery by palpation) its complete release should be done or at least considered. The best way to ensure complete notch release is the ability to move the nerve away from the  notch in both right and left directions.  Whether such fascial releases are truly beneficial seems logical as that is part a fundamental component of decompressions of numerous other nerve surgeries for chronic pain and sensory dysfunction.

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Indianapolis, Indiana