Migraine headache trigger site prevalence analysis of 2590 sites in 1010 patients

Active Occipital Motion with Digipressure as Preoperative Screening in Migraine Surgery

Background

Modern surgical therapy of chronic headaches/migraines is essentially based on the release/neurolysis of extracranial nerves, which, when compressed or inflamed, act as trigger points and, as such, trigger headache attacks. The aim of this article was to describe a novel maneuver we use as an aid in the preoperative planning of occipital trigger sites.

Methods

In the period of January 2021-September 2023, we operated on 32 patients (11 men, 21 women, age range: 26-68 years), who underwent migraine surgery for occipital trigger point release. All patients were evaluated using the described preoperative maneuver. In a dedicated card, the levels of tenderness at each point were marked accordingly, differentiating them by intensity as nothing (-), mild (+), medium (++), or high (+++). Patients were then operated on at the points corresponding only to the ++ and +++ signs.

Results

At 6-month follow-up, we observed significant improvement (>50%) in 29 patients (91%), with complete recovery in 25 patients (78%).

Conclusions

In our experience, the maneuver described, in addition to being very simple, has been shown to have good sensitivity and reproducibility. We therefore recommend its use, especially for those surgeons beginning their practice in this particular area of plastic surgery.

Comprehensive Criteria for Differential Diagnosis and a Surgical Management Algorithm for Occipital Neuralgia and Migraine Headaches

The differential diagnoses and nuances of the surgical management of occipital migraine and occipital neuralgia have not been clearly discussed in the available literature. This study aims to highlight additional diagnostic features and offers an algorithm for the surgical treatment of occipital migraine and occipital neuralgia based on the vast experience of the senior author spanning over 23 years. A retrospective cohort study was conducted to review the number and distribution of patients who underwent surgical treatment for occipital migraine headaches and neuralgia and the signs and symptoms observed. Among the 660 patients who underwent surgical treatment for headaches within the territory of the greater occipital nerves, 86 patients underwent isolated deactivation of the greater occipital site (site IV) or combined greater and lesser occipital sites (site IV and site VI surgical). Within the isolated occipital headache group, 43 patients met the criteria for migraine headaches and 43 for occipital neuralgia. Our additional observation on the differences between the occipital neuralgia and migraine groups included that occipital neuralgia is more commonly unilateral, less commonly familial, and more commonly associated with a whiplash-type injury. In addition, the patient with occipital neuralgia can consistently identify the distinct point of pain using the index finger. An ultrasound Doppler signal can also be detected at the pain site and a pulse is often palpable in the site identified by the patient. Occipital neuralgia is also commonly continuous and unrelenting, with occasional spikes of shooting pain, and is less likely to respond to botulinum toxin-A injection. Patients with occipital neuralgia often have a single-site headache while patients with migraine headaches often suffer from headaches in multiple sites. Additional clinical criteria are offered for the differential diagnosis of occipital migraine headaches and occipital neuralgia based on the vast experience of the senior author and the developed surgical management algorithm.

Outcomes of Surgical Treatment of Migraines: A Systematic Review & Meta-Analysis

Background: Migraine surgery at 1 of 6 identified "trigger sites" of a target cranial sensory nerve has rapidly grown in popularity since 2000. This study summarizes the effect of migraine surgery on headache severity, headache frequency, and the migraine headache index score which is derived by multiplying migraine severity, frequency, and duration. Materials and Methods: This is a PRISMA-compliant systematic review of 5 databases searched from inception through May 2020 and is registered under the PROSPERO ID: CRD42020197085. Clinical trials treating headaches with surgery were included. Risk of bias was assessed in randomized controlled trials. Meta-analyses were performed on outcomes using a random effects model to determine the pooled mean change from baseline and when possible, to compare treatment to control. Results: 18 studies met criteria including 6 randomized controlled trials, 1 controlled clinical trial, and 11 uncontrolled clinical trials treated 1143 patients with pathologies including migraine, occipital migraine, frontal migraine, occipital nerve triggered headache, frontal headache, occipital neuralgia, and cervicogenic headache. Migraine surgery reduced headache frequency at 1 year postoperative by 13.0 days per month as compared to baseline (I2 = 0%), reduced headache severity at 8 weeks to 5 years postoperative by 4.16 points on a 0 to 10 scale as compared to baseline (I2 = 53%), and reduced migraine headache index at 1 to 5 years postoperative by 83.1 points as compared to baseline (I2 = 2%). These meta-analyses are limited by a small number of studies that could be analyzed, including studies with high risk of bias. Conclusion: Migraine surgery provided a clinically and statistically significant reduction in headache frequency, severity, and migraine headache index scores. Additional studies, including randomized controlled trials with low risk-of-bias should be performed to improve the precision of the outcome improvements.

Nerve blocks for occipital headaches: A systematic review and meta-analysis

Migraine surgeons have identified six "trigger sites" where cranial nerve compression may trigger a migraine. This study investigates the change in headache severity and frequency following nerve block of the occipital trigger site. This PRISMA-compliant systematic review of five databases searched from database inception through May 2020 is registered under the PROSPERO ID: CRD42020199369. Only randomized controlled trials utilizing injection treatments for headaches with pain or tenderness in the occipital scalp were included. Pain severity was scored from 0 to 10. Headache frequency was reported as days per week. Included were 12 RCTs treating 586 patients of mean ages ranging from 33.7 to 55.8 years. Meta-analyses of pain severity comparing nerve blocks to baseline showed statistically significant reductions of 2.88 points at 5 to 20 min, 3.74 points at 1 to 6 weeks, and 1.07 points at 12 to 24 weeks. Meta-analyses of pain severity of nerve blocks compared with treatment groups of neurolysis, pulsed radiofrequency, and botulinum toxin type A showed similar headache pain severity at 1 to 2 weeks, and inferior improvements compared with the treatment groups after 2 weeks. Meta-analyses of headache frequency showed statistically significant reductions at 1 to 6-week follow-ups as compared with baseline and at 1 to 6 weeks as compared with inactive control injections. The severity and frequency of occipital headaches are reduced following occipital nerve blocks. This improvement is used to predict the success of migraine surgery. Future research should investigate spinous process injections with longer follow-up.

Clinical Outcome of Nerve Decompression Surgery for Migraine Improves with Nerve Wrap

Background:

Chronic migraine headaches affect nearly 30 million Americans every year and are responsible for roughly 1.2 million emergency department visits annually. Many of the standard therapies commonly used to treat migraines are often unsuccessful and may furthermore introduce unwanted side effects. The purpose of this study was to identify independent predictors of clinical improvement in patients undergoing surgical nerve decompression for migraine.

Methods:

A retrospective chart review between 2010 and 2020 was conducted. The primary endpoint was clinical improvement at 1-year follow-up, defined as an independence from prescription medications. Patients were stratified into two groups: clinical improvement and treatment failure. Backward multivariable logistic regression was used to examine the associations between migraine improvement and different patient characteristics.

Results:

A total of 153 patients were included. In total, 129 (84.3%) patients improved and 24 (15.7%) did not. Significant associations with clinical improvement at multivariable logistic regression were found with acellular dermal matrix nerve wrap (OR = 10.80, 95%CI: 6.18–16.27), and operation of trigger sites four (OR = 37.96, 95%CI: 2.16–73.10) and five (OR = 159, 95%CI: 10–299).

Conclusion:

The use of acellular dermal matrix nerve wraps in surgery was significantly associated with clinical migraine improvement, as was operation at trigger sites four and five.

Trigger-Site Deactivation Surgery for Nerve Compression Headaches

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Identify patients who are candidates for headache surgery. 2. Counsel the patient preoperatively with regard to success rates, recovery, and complications. 3. Develop a surgical plan for primary and secondary nerve decompression. 4. Understand the surgical anatomy at all trigger sites. 5. Select appropriate International Classification of Diseases, Tenth Revision, and CPT codes.

SUMMARY

Headache surgery encompasses release of extracranial peripheral sensory nerves at seven sites. Keys to successful surgery include correct patient selection, detailed patient counseling, and meticulous surgical technique. This article is a practical step-by-step guide, from preoperative assessment to surgery and postoperative recovery. International Classification of Diseases, Tenth Revision, and CPT codes, in addition to complications and salvage procedures, are discussed. Intraoperative photographs, videos, and screening questionnaires are provided.

The Evolution of Migraine Surgery: Two Decades of Continual Research. My Current Thoughts

SUMMARY

A mere serendipitous finding has culminated in a life-changing development for patients and a colossally fulfilling field for many surgeons. The surgical treatment of migraine headaches has been embraced by many plastic surgeons after numerous investigations ensuring that the risks are minimal and the rewards inestimable. Seldom has a plastic surgery procedure been the subject of such scrutiny. Through retrospective, prospective pilot, prospective randomized, prospective randomized with sham surgery, and 5-year follow-up studies, the safety, efficacy, and longevity of the given operation have been confirmed. Although the first decade of this journey was focused on investigating effectiveness and risk profile, the second decade was largely devoted to improving results, reducing invasiveness, and shortening recovery. Multiple publications in peer-reviewed journals over the past 20 years, several independent studies from reputable surgeons at recognized centers, and over 40 studies from the author's center have established the surgical treatment of headaches as a standard practice.

Decompression Surgery for Frontal Migraine Headache

INTRODUCTION

Migraine headache (MH) is one of the most common diseases worldwide and pharmaceutical treatment is considered the gold standard. Nevertheless, one-third of patients suffering from migraine headaches are unresponsive to medical management and meet the criteria for "refractory migraines" classification. Surgical treatment of MH might represent a supplementary alternative for this category of patients when pharmaceutical treatment does not allow for satisfactory results. The goal of this article is to provide a comprehensive review of the literature regarding surgical treatment for site I migraine management.

METHODS

A literature search using PubMed, Medline, Cochrane and Google Scholar database according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines was conducted using the following MeSH terms: "frontal neuralgia," "frontal trigger site treatment," "frontal migraine surgery" and "frontal headache surgery" (period: 2000 -2020; last search on 12 March 2020).

RESULTS

Eighteen studies published between 2000 and 2019, with a total of 628 patients, were considered eligible. Between 68% and 93% of patients obtained satisfactory postoperative results. Complete migraine elimination rate ranged from 28.3% to 59%, and significant improvement (>50% reduction) rates varied from 26.5% to 60%.

CONCLUSIONS

Our systematic review of the literature suggests that frontal trigger site nerve decompression could possibly be an effective strategy to treat migraine refractory patients, providing significant improvement of symptoms in a considerable percentage of patients.

Site V Surgery for Temporal Migraine Headaches

Background:

Auriculotemporal nerve is demonstrated to contribute to migraine pain in temporal area. In particular, its relationship with the superficial temporal artery in the soft tissues superficial to the temporal parietal fascia has attracted researchers’ attention for many decades. The objective of this review was to explore whether site V nerve surgical decompression is effective for pain relief in temporal area.

Methods:

A literature search, according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, was conducted to evaluate the surgical treatment of auriculotemporal migraine. Inclusion was based on studies written in English, published between 2000 and February 2020, containing a diagnosis of migraine in compliance with the classification of the International Headache Society. The treatment must consist of surgical procedures involving the auriculotemporal nerve and/or arteries in site V, with outcome data available for at least 3 months.

Results:

Three hundred twenty-four records were identified after duplicates were removed, 31 full-text articles were assessed for eligibility, and 2 records were selected for inclusion. A total of 77 patients were included in the review. A direct approach at the anatomical site identified with careful physical examination and confirmed with a handheld Doppler probe is generally performed under local anesthesia. Blunt dissection to the superficial temporal fascia to expose the auriculotemporal nerve and the superficial temporal artery is followed by artery cauterization/ligament and eventual nerve transection/avulsion. Site V surgery results in a success rate from 79% to 97%.

Conclusions:

Despite the recent advances in extracranial trigger site surgery and a success rate (>50% improvement) from 79% to 97%, site V decompression is still poorly described. Elaborate randomized trials are needed with accurate reporting of patient selection, surgical procedure, adverse events, recurrencies or appearance of new trigger points, quality of life outcome, and longer follow-up times.

Migraine Surgery at the Frontal Trigger Site: An Analysis of Intraoperative Anatomy

BACKGROUND

The development of migraine headaches may involve the entrapment of peripheral craniofacial nerves at specific sites. Cadaveric studies in the general population have confirmed potential compression points of the supraorbital and supratrochlear nerves at the frontal trigger site. The authors' aim was to describe the intraoperative anatomy of the supraorbital and supratrochlear nerves at the level of the supraorbital bony rim in patients undergoing frontal migraine surgery and to investigate associated pain.

METHODS

PATIENTS: scheduled for frontal-site surgery were enrolled prospectively. The senior author (W.G.A.) evaluated intraoperative anatomy and recorded variables using a detailed form and operative report. The resulting data were analyzed.

RESULTS

One hundred eighteen sites among 61 patients were included. The supraorbital nerve traversed a notch in 49 percent, a foramen in 41 percent, a notch plus a foramen in 9.3 percent, and neither a notch nor a foramen in one site. The senior author noted macroscopic nerve compression at 74 percent of sites. Reasons included a tight foramen in 24 percent, a notch with a tight band in 34 percent, and supraorbital and supratrochlear nerves emerging by means of the same notch in 7.6 percent or by means of the same foramen in 4.2 percent. Preoperative pain at a site was significantly associated with nerve compression by a foramen.

CONCLUSIONS

The intraoperative anatomy and cause of nerve compression at the frontal trigger site vary greatly among patients. The authors report a supraorbital nerve foramen prevalence of 50.3 percent, which is greater than in previous cadaver studies of the general population. Lastly, the presence of pain at a specific site is associated with macroscopic nerve compression.

The Cutting Edge of Headache Surgery: A Systematic Review on the Value of Extracranial Surgery in the Treatment of Chronic Headache

BACKGROUND

Migraine is a debilitating neurologic condition, with a large socioeconomic impact. There is a subgroup of patients that does not adequately respond to pharmacologic management and may have underlying neuralgia. Surgical decompression of extracranial sensory nerves has been proposed as an alternative therapy. The aim of this article is to review the evidence for the surgical treatment of neuralgias.

METHODS

A systematic review was conducted to study the efficacy of decompression of extracranial sensory nerves as a treatment for neuralgia. Clinical studies were included that studied patients, aged 18 years or older, diagnosed with any definition of headache and were treated with extracranial nerve decompression surgery. Outcome parameters included intensity (on a 10-point scale), duration (in days), and frequency (of headaches per month).

RESULTS

Thirty-eight articles were found describing extracranial nerve decompression in patients with headaches. Postoperative decrease in headache intensity ranged from 2 to 8.2, reduction of duration ranged from 0.04 to 1.04 days, and reduction in frequency ranged between 4 and 14.8 headaches per month. Total elimination of symptoms was achieved in 8.3 to 83 percent of cases. A detailed summary of the outcome of single-site decompression is described. Statistical pooling and therefore meta-analysis was not possible, because of articles having the same surgeon and an overlapping patient database.

CONCLUSIONS

Nerve decompression surgery is an effective way of treating headaches in a specific population of patients with neuralgia. Although a meta-analysis of the current data was not possible, the extracranial decompression of peripheral head and neck sensory nerves has a high success rate.

Is an "Epigenetic Diet" for Migraines Justified? The Case of Folate and DNA Methylation

Migraines are a common disease with limited treatment options and some dietary factors are recognized to trigger headaches. Although migraine pathogenesis is not completely known, aberrant DNA methylation has been reported to be associated with its occurrence. Folate, an essential micronutrient involved in one-carbon metabolism and DNA methylation, was shown to have beneficial effects on migraines. Moreover, the variability of the methylenetetrahydrofolate reductase gene, important in both folate metabolism and migraine pathogenesis, modulates the beneficial effects of folate for migraines. Therefore, migraine could be targeted by a folate-rich, DNA methylation-directed diet, but there are no data showing that beneficial effects of folate consumption result from its epigenetic action. Furthermore, contrary to epigenetic drugs, epigenetic diets contain many compounds, some yet unidentified, with poorly known or completely unknown potential to interfere with the epigenetic action of the main dietary components. The application of epigenetic diets for migraines and other diseases requires its personalization to the epigenetic profile of a patient, which is largely unknown. Results obtained so far do not warrant the recommendation of any epigenetic diet as effective in migraine prevention and therapy. Further studies including a folate-rich diet fortified with valproic acid, another modifier of epigenetic profile effective in migraine prophylaxis, may help to clarify this issue.

Migraine Surgery

Supplemental Digital Content is available in the text.

This article is a practical and technical guide for plastic surgeons interested in or practicing migraine surgery. It discusses the goals of migraine surgery including selection of appropriate candidates (screening form contained), pertinent anatomy, and surgical techniques with text summary, intraoperative photographs, and videos. In addition, pearls and pitfalls, the most common complications, and current procedural terminology (CPT) coding are detailed.

Entrapment Neuropathy: A Concept for Pathogenesis and Treatment of Headaches-A Narrative Review

Entrapment neuropathy is a known cause of neurological disorders. In the head and neck area, this pathophysiological mechanism could be a trigger for headache. Over the last few decades, injection of botulinum toxin type A in the muscles that are causing the compression as well as surgical decompression have proved to be effective treatment methods worldwide for large numbers of patients with daily headaches. In particular the entrapment of the supraorbital nerves in the glabellar musculature and the occipital nerves in the neck musculature are triggers for headache disorders for which many patients are still seeking an effective treatment. This article reviews the literature and aims to bring the concept of neural entrapment to the attention of a wider audience. By doing so, we hope to give more exposure to an effective and relatively safe headache treatment.

The role of the otolaryngologist in the evaluation and management of headaches

BACKGROUND

Headaches are commonly evaluated in otolaryngology and often represent a diagnostic dilemma. This review addresses rhinogenic headache as well as trigeminal neuralgia and migraine, both of which can masquerade as sinus headache and whose management increasingly involves otolaryngology intervention. Discussion considers diagnostic criteria and novel therapies and derives an algorithm for clinical decision-making.

DATA SOURCES

OVID MEDLINE, Cochrane Library, and Google Scholar databases.

METHODS

A literature search was performed to identify relevant articles published in the past 10 years addressing the diagnosis and management of rhinogenic headache, trigeminal neuralgia and/or migraine.

FINDINGS

Rhinogenic headache: Identification of the specific cause must be achieved before treatment. No studies have mentioned the effect of certain therapies on the amelioration of headache. New techniques of balloon dilation for sinusitis are controversial, and their use remains contingent on surgeon preference. Removal of mucosal contact points has been shown to benefit quality of life in patients with contact point headache. Trigeminal neuralgia: Microvascular decompression is considered the gold standard for treatment, but percutaneous therapies can be effective for achieving pain control. Migraine: Patients who report amelioration of symptoms after targeted botulinum toxin injection may benefit from definitive decompression or nerve avulsion. Patients with mucosal contact points may have less favorable outcomes with migraine surgery if they are not simultaneously addressed.

CONCLUSIONS

A comprehensive understanding of the diagnostic workup and therapeutic options available for common headache etiologies is key to the management of a patient presenting with headache attributed to a rhinogenic cause.

Interface Between Cosmetic and Migraine Surgery

This article describes connections between migraine surgery and cosmetic surgery including technical overlap, benefits for patients, and why every plastic surgeon may consider screening cosmetic surgery patients for migraine headache (MH). Contemporary migraine surgery began by an observation made following forehead rejuvenation, and the connection has continued. The prevalence of MH among females in the USA is 26%, and females account for 91% of cosmetic surgery procedures and 81-91% of migraine surgery procedures, which suggests substantial overlap between both patient populations. At the same time, recent reports show an overall increase in cosmetic facial procedures. Surgical techniques between some of the most commonly performed facial surgeries and migraine surgery overlap, creating opportunity for consolidation. In particular, forehead lift, blepharoplasty, septo-rhinoplasty, and rhytidectomy can easily be part of the migraine surgery, depending on the migraine trigger sites. Patients could benefit from simultaneous improvement in MH symptoms and rejuvenation of the face. Simple tools such as the Migraine Headache Index could be used to screen cosmetic surgery patients for MH. Similarity between patient populations, demand for both facial and MH procedures, and technical overlap suggest great incentive for plastic surgeons to combine both. Level of Evidence V This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .