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