A Prospective Randomized Outcomes Comparison of Two Temple Migraine Trigger Site Deactivation Techniques:

Comparing Migraine Headache Index versus Monthly Migraine Days after Headache Surgery: A Systematic Review and Meta-Analysis

BACKGROUND

Nerve deactivation surgery for the treatment of migraine has evolved rapidly over the past 2 decades. Studies typically report changes in migraine frequency (attacks/month), attack duration, attack intensity, and their composite score-the Migraine Headache Index-as primary outcomes. However, the neurology literature predominantly reports migraine prophylaxis outcomes as change in monthly migraine days (MMD). The goal of this study was to foster common communication between plastic surgeons and neurologists by assessing the effect of nerve deactivation surgery on MMD and motivating future studies to include MMD in their reported outcomes.

METHODS

An updated literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The National Library of Medicine (PubMed), Scopus, and Embase were systematically searched for relevant articles. Data were extracted and analyzed from studies that met the inclusion criteria.

RESULTS

A total of 19 studies were included. There was a significant overall reduction in MMDs [mean difference (MD), 14.11; 95% CI, 10.95 to 17.27; I 2 = 92%], total migraine attacks per month (MD, 8.65; 95% CI, 7.84 to 9.46; I 2 = 90%), Migraine Headache Index (MD, 76.59; 95% CI, 60.85 to 92.32; I 2 = 98%), migraine attack intensity (MD, 3.84; 95% CI, 3.35 to 4.33; I 2 = 98%), and migraine attack duration (MD, 11.80; 95% CI, 6.44 to 17.16; I 2 = 99%) at follow-up (range, 6 to 38 months).

CONCLUSION

This study demonstrates the efficacy of nerve deactivation surgery on the outcomes used in both the plastic and reconstructive surgery and neurology literature.

Secondary Trigger Point Deactivation Surgery for Nerve Compression Headaches: A Scoping Review

Background

Primary trigger point deactivation surgery has been successful in reducing or eliminating nerve compression headaches between 79% and 90% of the time. The aim of this review article was to discuss the factors that contribute to index trigger point deactivation surgery failure, the importance of reevaluating trigger points following failure, and the options for secondary surgery.

Methods

A literature search was performed using a combination of keywords involving "chronic headache" and "nerve deactivation surgery," in databases until February 2023.

Results

Data of 1071 patients were evaluated and included (11 articles). The failure rate after index trigger point deactivation surgery occurs is approximately 12%, primarily due to incomplete primary trigger point deactivation. Secondary trigger points may not appear until the primary trigger is eliminated, which occurs in 17.8% of patients. Reevaluation of previously diagnosed trigger points as well as uncovered trigger points and additional preoperative testing is indicated to help determine candidacy for further surgical deactivation. To address scarring that could contribute to failure, corticosteroid injection, acellular dermal matrix, adipofascial fat, or expanded polytetrafluoroethylene sleeves have been described with beneficial effects. For neuroma management, regenerative peripheral nerve interface, targeted muscle reinnervation, a combination of both, relocation nerve grafting, or nerve capping have also been described. Neurectomy can be performed when patients prefer anesthesia and/or paresthesia over current pain symptoms.

Conclusion

Secondary trigger point deactivation surgery is indicated when there is suspicion of incomplete deactivation, internal scarring, neuroma, or newly-diagnosed trigger points.

Expanding Our Role in Headache Management: A Systematic Review and Algorithmic Approach to Surgical Management of Postcraniotomy Headache

BACKGROUND

Chronic postcraniotomy headache (PCH) is common and debilitating. Unfortunately, the literature on this topic is sparse without clear management algorithms. Possible etiologies of PCH include nerve injury and/or entrapment, hardware, dural adhesions, or musculoskeletal injury. The purpose of this study was to present the results of both a systematic review of the literature and a single-center case series, both of which informed the development of a novel treatment algorithm that may be applied to this patient population.

METHODS

Using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we performed a systematic review of the literature, identifying articles describing the surgical management of PCH. A retrospective chart review was performed to identify patients who met the criteria for PCH treated at our institution. A patient's history and physical examination determined the etiology and management, and pain severity scores were the primary outcome measured.

RESULTS

Nineteen articles encompassing 131 patients described surgical management techniques for PCH. 83 patients (63.3%) had complete resolution of pain (χ2 = 52.1, P < 0.0001). At our institution, 19 patients underwent surgical management for PCH. A significant reduction in pain scores from 7.57 to 2.16 (P < 0.001) was demonstrated, and 84 percent of patients achieved complete or significant pain reduction.

CONCLUSIONS

Through a literature review and our own case series, we demonstrate that surgical management of PCH can achieve remarkable results. Plastic surgeons, with their expanding role in treating migraine and headaches, are well suited to manage these patients. We present an algorithmic approach to simplify the management of this common and debilitating condition.

Long-term results of migraine surgery and the relationship between anatomical variations and pain

BACKGROUND

Migraine headache surgery has been recently reported and supported by studies as management to provide long-term relief in migraine sufferers. This study aimed to monitor the long-term results of patients who underwent migraine surgery in our clinic and determine the relationship between pain and anatomical anomalies.

METHODS

A prospective review was conducted of 93 patients who underwent surgery for migraine headaches performed between 2017 and 2021 by the senior author (M.U.) and had at least 12 months of follow-up. Anatomical data were obtained by recording the findings during surgery. Migraine surgery was performed bilaterally in all patients. Anatomical symmetry differences between the right and left sides were recorded.

RESULTS

A total of 79 (84.9%) patients experienced at least 50% reduction in migraine headache. Furthermore, 13 (14%) patients reported complete elimination of migraine headache. A significant difference was found before and after surgery in Migraine Disability Assessment score, migraine headache index, frequency, duration, and pain (p < 0.001). Also, 30 (32.3%) of the patients had bilateral headaches and 63 (67.7%) had primarily unilateral headaches. Then, 51 (81%) patients with mostly unilateral headache were anatomically asymmetrical and 12 (12%) were anatomically symmetrical. Patients with mostly unilateral headache were found to be anatomically highly asymmetrical (p < 0.005).

CONCLUSIONS

This study shows that surgical treatment is effective and long-term protection and has mild complications that are easily tolerated by the patient. The fact that headache side and anatomical asymmetry were significant in this study supports the peripheral mechanism.

The Surgical Management of Migraines and Chronic Headaches: A Cross-sectional Review of American Insurance Coverage

BACKGROUND

Migraine headache can be an extremely debilitating condition, with pharmacotherapy for prophylaxis or treatment of acute symptoms being unsuccessful in a large proportion of patients. Surgical management of migraine has recently gained popularity as an alternative to pharmacotherapy for severe disease. However, the novel nature of these procedures may lead to variable insurance coverage, limiting access to care.

METHODS

A cross-sectional analysis of 101 US insurance companies was conducted. Companies were chosen based on greatest market share and enrollment per state. A Web-based search or phone call identified whether each company had a publicly available policy on nonsurgical or surgical management of migraine or headache. For companies with an available policy, coverage was categorized into covered, covered on a case-by-case basis, or never covered, with criteria required for coverage collected and categorized.

RESULTS

Of the 101 evaluated insurers, significantly fewer companies had a policy on surgical treatment for migraine or headache (n = 52 [52%]) compared with nonsurgical treatment (n = 78 [78%]) (P < 0.001). For companies with a policy, the most frequently covered nonsurgical treatments were biofeedback (n = 23 [92%]) and botulism toxin injections (n = 61 [88%]). Headaches were an approved indication for occipital nerve stimulation in 4% (n = 2) of company policies and nerve decompression in 2% (n = 1) of policies. Migraines were never offered preauthorized coverage for surgical procedures.

CONCLUSION

Approximately half of US insurance companies have a publicly available policy on surgical management of migraine or headache. Surgical treatment was seldom covered for the indication of headache and would never receive preauthorized coverage for migraine. Lack of coverage may create challenges in accessing surgical treatment. Additional prospective, controlled studies are necessary to further support the efficacy of surgical treatment.

New anatomical insights of the superficial branch of the zygomaticotemporal nerve for treating temporal migraines: An anatomical study

The zygomaticotemporal nerve is known to contribute to temporal migraines; however, its precise anatomy remains unknown. The potential accessory branches of the zygomaticotemporal nerve may be considered a cause of continued temporal migraines after surgical procedures. In this study, we defined the novel superficial branch of the zygomaticotemporal nerve (sZTN) and investigated its anatomical course, distribution, and clinical implications. Twenty-two hemifaces from 11 fixed Korean cadavers (six males, five females; mean age, 78.3 years) were used in this study. The piercing points of the sZTN through the deep and superficial layers of the deep temporal fascia, and the superficial temporal fascia were defined as P1, P2, and P3, respectively. The distance of each point from the zygomatic tubercle was measured using an image analysis software. The sZTN ascended between the bone and the temporalis after emerging from the zygomaticotemporal foramen. It then pierced the deep temporal fascia without penetrating the temporalis. After then, it pierced the superficial layer of the deep temporal fascia and turned superiorly toward the upper posterior temple. When the sZTN passed through the superficial temporal fascia, it intersected with the superficial temporal artery in every case. The novel findings of the sZTN may help in the treatment of intractable temporal migraines refractory to injection or surgical procedure. Based on our findings, targeting the sZTN may be applied as an alternative treatment strategy for patients who do not show significant improvement with treatment targeted to trigger sites.

Measuring Success in Headache Surgery: A Comparison of Different Outcomes Measures

BACKGROUND

Studies of migraine surgery have relied on quantitative, patient-reported measures like the Migraine Headache Index (MHI) and validated surveys to study the outcomes and impact of headache surgery. It is unclear whether a single metric or a combination of outcomes assessments is best suited to do so.

METHODS

All patients who underwent headache surgery had an MHI calculated and completed the Headache Impact Test, the Migraine Disability Assessment Test, the Migraine-Specific Quality-of-Life Questionnaire, and an institutional ad hoc survey preoperatively and postoperatively.

RESULTS

Twenty-seven patients (79%) experienced greater than or equal to 50% MHI reduction. MHI decreased significantly from a median of 210 preoperatively to 12.5 postoperatively (85%; P < 0.0001). Headache Impact Test scores improved from 67 to 61 (14%; P < 0.0001). Migraine Disability Assessment Test scores improved from 57 to 20 (67%; P = 0.0022). The Migraine-Specific Quality-of-Life Questionnaire demonstrated improvement in quality-of-life scores within all three of its domains ( P < 0.0001). The authors' ad hoc survey demonstrated that participants "strongly agreed" that (1) surgery helped their symptoms, (2) they would choose surgery again, and (3) they would recommend headache surgery to others.

CONCLUSIONS

Regardless of how one measures it, headache surgery is effective. The authors demonstrate that surgery significantly improves patients' quality of life and decreases the effect of headaches on patients' functioning, but headaches can still be present to a substantial degree. The extent of improvement in migraine burden and quality of life in these patients may exceed the amount of improvement demonstrated by current measures.

Migraine Surgery and Determination of Success over Time by Trigger Site: A Systematic Review of the Literature

BACKGROUND

Migraine headache is a debilitating disorder that produces high costs and compromises patient quality of life. This study aimed to evaluate surgery success and the longevity of the surgical benefit by trigger site.

METHODS

A systematic literature review was performed by querying the PubMed, Embase, Scopus, and Web of Science databases. The keywords "surgery," "migraine," "outcomes," "headache index," and synonyms in titles and abstracts were used to perform the search.

RESULTS

A total of 17 articles published between 2009 and 2019 met the inclusion criteria. Six studies were prospective and 11 were retrospective. Most of the studies (77.8%, 77.8%, and 80%, respectively) reported success of migraine surgery at 12-month follow-up for trigger sites I, II, and III, respectively. For trigger site IV, the greatest Migraine Headache Index reduction (93.4%) was observed at 12-month follow-up, and the earliest Migraine Headache Index reductions (80.3% and 74.6%) were observed at 6-month follow-up. All studies that evaluated trigger sites V and VI identified surgery success at 12-month follow-up. Migraine surgery was found to remain beneficial at 22 months for trigger sites I, II, III, and IV.

CONCLUSIONS

The symptomatic improvement may initially be evident at 6 months for trigger site IV and at 12 months for trigger sites I, II, III, V, and VI. Surgical benefit in trigger sites I, II, III, and IV can persist after 22 months. Further studies are required to evaluate results at longer follow-up.

Current Evidence in Migraine Surgery: A Systematic Review

INTRODUCTION

Migraine headache is a widespread neurovascular disorder with an enormous social and economic impact. A subgroup of patients cannot be managed with pharmacological therapy. Although surgical decompression of extracranial sensory nerves has been proposed as a valid alternative treatment option, the medical community remains reluctant to accept it.

MATERIALS AND METHODS

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. An electronic search was performed in September 2020 on PubMed, ScienceDirect, CENTRAL, and Google Scholar databases for original articles reporting outcomes on migraine surgery.

RESULTS

The search strategy revealed a total of 922 studies, of which 52 were included in the review. Significant improvement was reported in 58.3% to 100% and complete elimination in 8.3% to 86.8% of patients across studies. No major complications were reported.

DISCUSSION

This systematic review demonstrates that migraine surgery is an effective and safe procedure, with a positive impact in patients' quality of life and a reduction in long-term costs.

CONCLUSION

There is considerable scientific evidence suggesting extracranial migraine surgery is an effective and safe procedure. This surgery should be considered in properly selected migraineurs refractory to medical treatment.

A Markov Analysis of Surgical versus Medical Management of Chronic Migraines

BACKGROUND

Refractory chronic migraine is a common and debilitating neurologic condition, affecting over 8 million people in the United States. It is associated with billions of dollars in lost productivity annually. Novel medical (anti-calcitonin gene-related peptide antibodies) and surgical treatment modalities have emerged for chronic migraine in recent years. The current study investigated the cost-utility of surgical versus medical management of refractory chronic migraine.

METHODS

A Markov cohort analysis using hybrid Monte Carlo patient simulation was performed to compare surgical decompression versus erenumab for the treatment of refractory chronic migraine in adults. Both societal and payer perspectives were considered. Primary model outcomes included incremental cost-effectiveness ratio, or cost per quality-adjusted life-year gained.

RESULTS

Over a 5-year period, migraine surgery was associated with an increase of 0.2 quality-adjusted life-year per patient when compared to erenumab. In terms of costs, the results demonstrated a $19,337 decrease in direct medical costs and a $491 decrease in indirect costs (productivity lost) for the surgery cohort compared to erenumab. Because surgery improved quality of life and decreased costs compared to erenumab, even when considering revision surgery needs, surgery was the overall dominant treatment in terms of cost-effectiveness. Sensitivity analyses demonstrated that surgery was cost-effective compared to erenumab when patients required therapy for at least 1 year.

CONCLUSIONS

Surgical deactivation of migraine trigger sites may pose a cost-effective approach to treating refractory chronic migraine in adults. This is especially the case when patients are anticipated to require therapy for more than 1 year.

Efficacy and Safety of Migraine Surgery: A Systematic Review and Meta-analysis of Outcomes and Complication Rates

OBJECTIVE

The objectives of this study are to assess the efficacy and safety of peripheral nerve surgery for migraine headaches and to bibliometrically analyze all anatomical studies relevant to migraine surgery.

SUMMARY BACKGROUND DATA

Migraines rank as the second leading cause of disability worldwide. Despite the availability of conservative management options, individuals suffer from refractive migraines which are associated with poor quality of life. Migraine surgery, defined as the peripheral nerve decompression/trigger site deactivation, is a relatively novel treatment strategy for refractory migraines.

METHODS

EMBASE and the National Library of Medicine (PubMed) were systematically searched for relevant articles according to the PRISMA guidelines. Data was extracted from studies which met the inclusion criteria. Pooled analyses were performed to assess complication rates. Meta-analyses were run using the random effects model for overall effects and within subgroup fixed-effect models were used.

RESULTS

A total of 68 studies (38 clinical, 30 anatomical) were included in this review. There was a significant overall reduction in migraine intensity (P < 0.001, SE = 0.22, I2 = 97.9), frequency (P < 0.001, SE = 0.17, I2 = 97.7), duration (P < 0.001, SE = 0.15, I2 = 97), and migraine headache index (MHI, P < 0.001, SE = 0.19, I2 = 97.2) at follow-up. A total of 35 studies reported on migraine improvement (range: 68.3%-100% of participants) and migraine elimination (range: 8.3%-86.5% of participants). 32.1% of participants in the clinical studies reported complications for which the most commonly reported complications being paresthesia and numbness, which was mostly transient, (12.11%) and itching (4.89%).

CONCLUSION

This study demonstrates improved migraine outcomes and an overall decrease in MHI as well as strong evidence for the safety profile and complication rate of migraine surgery.

The Great Auricular Nerve Trigger Site: Anatomy, Compression Point Topography, and Treatment Options for Headache Pain

BACKGROUND

Peripheral nerve decompression surgery can effectively address headache pain caused by compression of peripheral nerves of the head and neck. Despite decompression of known trigger sites, there are a subset of patients with trigger sites centered over the postauricular area coursing. The authors hypothesize that these patients experience primary or residual pain caused by compression of the great auricular nerve.

METHODS

Anatomical dissections were carried out on 16 formalin-fixed cadaveric heads. Possible points of compression along fascia, muscle, and parotid gland were identified. Ultrasound technology was used to confirm these anatomical findings in a living volunteer.

RESULTS

The authors' findings demonstrate that the possible points of compression for the great auricular nerve are at Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle in the dense connective tissue before entry into the parotid gland (point 2), and within its intraparotid course (point 3). The mean topographic measurements were as follows: Erb's point to the mastoid process at 7.32 cm/7.35 (right/left), Erb's point to the angle of the mandible at 6.04 cm/5.89 cm (right/left), and the posterior aspect of the sternocleidomastoid muscle to the mastoid process at 3.88 cm/4.43 cm (right/left). All three possible points of compression could be identified using ultrasound.

CONCLUSIONS

This study identified three possible points of compression of the great auricular nerve that could be decompressed with peripheral nerve decompression surgery: Erb's point (point 1), at the anterior border of the sternocleidomastoid muscle (point 2), and within its intraparotid course (point 3).

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.

Surgical Options for Migraine: An Overview

Objective

The goal of this manuscript was to provide a comprehensive review of the surgical treatment for migraine headaches with a focus on trigger points and their clinical presentations, and to emphasize the importance of appropriate patient selection.

Background

Migraine is a prevalent neurological disease with headache being a disabling component of it. Surgical treatment for migraine headache became available two decades ago, which is based on proper identification and the deactivation of the specific trigger sites in the head and neck area.

Design

This manuscript reviews the discovery and evolution of migraine surgery with changes in patients' selection throughout the years.

Conclusion

Patients with migraine headaches who do not respond or cannot tolerate the medical treatment might benefit from trigger site deactivation surgery. The success of the surgery is closely related to proper identification of trigger point (s) and close collaboration with a neurologist or a headache specialist. This collaboration would enhance patients' positive outcomes and help to rule out other causes of the headache.

Occipital Neuralgia: Advances in the Operative Management

Background

Occipital neuralgia (ON) is a primary headache disorder characterized by sharp, shooting, or electric shock-like pain in the distribution of the greater, lesser, or third occipital nerves.

Aim

To review the existing literature on the management of ON and to describe our technique of an endoscopic-assisted approach to decompress the GON proximally in areas of fibrous and muscular compression, as well as distally by thorough decompression of the occipital artery from the nerve.

Methods

Relevant literature on the medical and surgical management of ON was reviewed. Literature on the anatomical relationships of occipital nerves and their clinical relevance were also reviewed.

Results

While initial treatment of ON is conservative, peripheral nerve blocks and many surgical management approaches are available for patients with pain refractory to the medical treatment. These include greater occipital nerve blocks, occipital nerve stimulation, Botulinum toxin injections locally, pulsed radiofrequency ablation, cryoneuroablation, C-2 ganglionectomy, and endoscopic-assisted ON decompression.

Conclusion

Patients of ON refractory to medical management can be benefitted by surgical approaches and occipital nerve blocks. Endoscopic-assisted ON decompression provides one such approach for the patients with vascular, fibrous or muscular compressions of occipital nerves resulting in intractable ON.

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.

A Comprehensive Review of Surgical Treatment of Migraine Surgery Safety and Efficacy

BACKGROUND

Recent clinical experience with migraine surgery has demonstrated both the safety and the efficacy of operative decompression of the peripheral nerves in the face, head, and neck for the alleviation of migraine symptoms. Because of the perceived novelty of these procedures, and the paranoia surrounding a theoretical loss of clinical territory, neurologists have condemned the field of migraine surgery. The Patient Safety Subcommittee of the American Society of Plastic Surgeons ventured to investigate the published safety track record of migraine surgery in the existing body of literature.

METHODS

A comprehensive review of the relevant published literature was performed. The relevant databases and literature libraries were reviewed from the date of their inception through early 2018. These articles were reviewed and their findings analyzed.

RESULTS

Thirty-nine published articles were found that demonstrated a substantial, extensively replicated body of data that demonstrate a significant reduction in migraine headache symptoms and frequency (even complete elimination of headache pain) following trigger-site surgery.

CONCLUSIONS

Migraine surgery is a valid method of treatment for migraine sufferers when performed by experienced plastic surgeons following a methodical protocol. These operations are associated with a high level of safety. The safety and efficacy of migraine surgery should be recognized by plastic surgeons, insurance companies, and the neurology societies.

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.

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.

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.

Radiologic Evaluation of Exiting Points of Supraorbital Region Neurovascular Bundles in Patients With Migraine

PURPOSE

To reveal the presence and nature of exiting points of supraorbital region neurovascular structures and determine the distances of those structures to midline with computed tomography images by taking into account gender and sides in patients with migraine.

METHODS

The study was conducted retrospectively on computed tomography images of 70 migraine and 70 control patients with a mean age of 39.5 ± 13.8 years (range: 18-80). Presence and nature (foramen or notch) of exiting points of neurovascular structures in terms of side and gender in both groups, and the distances of these structures to the midline of the face were evaluated.

RESULTS

In migraine and control groups, the most commonly seen structure was single notch. Coexistence of foramen and notch was statistically significant in migraine and female migraine groups than control and female control groups (P < 0.05). Bilateral presence of supraorbital structure was 51.4% in migraine group and 64.3% in control group patients. In all cases, foramen-midline distance was statistically significant longer than the notch-midline distance (P < 0.05). In migraine patients, no statistically significant difference was detected regarding distances of foramen and notch to midline in terms of side and gender.

CONCLUSION

Consideration of variable presence and location of the supraorbital notch and foramen, analysis of computed tomography scan might be beneficial in preoperative planning of foraminotomy and fascial band release in adult migraine patients to prevent intraoperative complications. Also, coexistence is more frequent on left side in migraine patients that might cause overlooking those structures during surgery.

Extracranial Trigger Site Surgery for Migraine: A Systematic Review With Meta-Analysis on Elimination of Headache Symptoms

Introduction: The headache phase of migraine could in selected cases potentially be treated by surgical decompression of one or more “trigger sites,” located at frontal, temporal, nasal, and occipital sites. This systematic review with subsequent meta-analysis aims at critically evaluating the currently available evidence for the surgical treatment of migraine headache and to determine the effect size of this treatment in a specific patient population.

Methods: This study was conducted following the PRISMA guidelines. An online database search was performed. Inclusion was based on studies published between 2000 and March 2018, containing a diagnosis of migraine in compliance with the classification of the International Headache Society. The treatment must consist of one or more surgical procedures involving the extracranial nerves and/or arteries with outcome data available at minimum 6 months.

Results: Eight hundred and forty-seven records were identified after duplicates were removed, 44 full text articles were assessed and 14 records were selected for inclusion. A total number of 627 patients were included in the analysis. A proportion of 0.38 of patients (random effects model, 95% CI [0.30–0.46]) experienced elimination of migraine headaches at 6–12 months follow-up. Using data from three randomized controlled trials, the calculated odds ratio for 90–100% elimination of migraine headaches is 21.46 (random effects model, 95% CI [5.64–81.58]) for patients receiving migraine surgery compared to sham or no surgery.

Conclusions: Migraine surgery leads to elimination of migraine headaches in 38% of the migraine patients included in this review. However, more elaborate randomized trials are needed with transparent reporting of patient selection, medication use, and surgical procedures and implementing detailed and longer follow-up times.

Surgical Treatment of Migraine Headache: Back to the Future

Understanding the history and evolution of ideas is key to developing an understanding of complex phenomena and is the foundation for surgical innovation. This historical review on migraine surgery takes us back to the beginnings of interventional management for migraine centuries ago, and reflects on present practices to highlight how far we have come. From Al-Zahrawi and Ambroise Paré to Bahman Guyuron, two common themes of the past and present have emerged in the treatment of migraine headache. Extracranial treatment of both nerves and vessels is being performed and analyzed, with no consensus among current practitioners as to which structure is involved. Knowledge of past theories and new insights will help guide our efforts in the future. One thing is clear: Where we are going, there are no roads. At least not yet.

Surgical intervention for chronic migraine headache: A systematic review

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A focus on sound systematic review methodology to present an unbiased and scientific assessment of the body of knowledge for migraine surgery.

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Comprehensive search strategy included a range of study types to capture all relevant reports of primary clinical research, enabling a global evaluation of the topic.

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A descriptive analysis allowing an overview of the likely effect of a variety of surgical interventions, with a snapshot of the rates of recurrence and adverse events.

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Formalised assessment of methodological quality using the GRADE approach identifies specific flaws affecting the reliability of migraine surgery research to date.

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Limited by a paucity of methodological quality in included studies, heterogeneous interventions, inconsistent outcome reporting and variability in baseline data, intervention data and outcome data.

Aims

Migraine is a global phenomenon, affecting more than 10% of the world's population. It is characterized by unilateral headache that may be accompanied by vomiting, nausea, photophobia and phonophobia. Some patients with chronic migraine respond to extra-cranial botulinum toxin type A injection, although the benefits observed are temporary. The rationale for surgical trigger site deactivation is to achieve lasting symptomatic improvement or permanent relief from migraine.

Methods

We performed a PRISMA-compliant systematic review of clinical studies evaluating surgical intervention for migraine by searching Ovid MEDLINE and EMBASE databases from inception to June 2017. Studies were independently screened by two authors. Data were extracted on study characteristics, migraine outcomes, adverse events and recurrence. The quality of evidence was assessed using the GRADE approach. The review protocol was prospectively registered on the PROSPERO database (CRD42017068577).

Results

The search strategy identified 789 articles; of them, 18 studies (4 RCTs and 14 case series) were eligible for analysis. Surgical interventions were heterogeneous and variably involved peripheral nerve decompression by myectomy or foraminotomy, nerve excision, artery resection and/or nasal surgery. All studies reported significant reductions in migraine intensity, frequency, duration and composite headache scores following surgery. Study heterogeneity precluded formal meta-analysis. Where reported, adverse event rates varied markedly between studies. The quality of included studies was consistently low or very low.

Conclusion

There is insufficient evidence to support the effectiveness of any specific surgical intervention for chronic migraine, especially with regard to permanent relief; however, all included studies report improvements in key outcomes following migraine surgery. A definitive, well-powered RCT with objective surgical and patient-reported outcome measures and robust adverse event reporting is required.

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.

Surgical Therapy of Temporal Triggered Migraine Headache

Background

The auriculotemporal and zygomaticotemporal nerves are the 2 primary trigger points in the temporal area of migraine headache. Different surgical approaches are described in literature, either open or endoscopic ones.

Methods

We described and delineated the currently adopted strategies to treat temporal trigger points in migraine headache. Furthermore, we reported our personal experience in the field.

Results

Regardless of the type of approach, outcomes observed were similar and ranged from 89% to 67% elimination / >50% reduction rates. All procedures are minimally invasive and only minor complications are reported, with an incidence ranging from 1% to 5%.

Conclusions

Just like upper limb compressive neuropathies, migraine headache is believed to be caused by chronic compression of peripheral nerves (ie, the terminal branches of trigeminal nerve) caused by surrounding structures (eg, muscles, vessels, and fascial bands) the removal of which eventually results in improvement or elimination of migraine attacks. Particular attention should be paid to the close nerve/artery relationship often described in anatomical studies and clinical reports.

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 .

Surgical treatment of migraine headaches

The senior author (BG) introduced the modern concept of migraine surgery in 2000. Since then, over 40 articles have been published by eight centers across the US, Europe, and Asia, describing positive outcomes after surgery in 68-95% of cases. Surgeons, neurologists, and patients are increasingly interested in this new treatment method. However, the majority of publications on this topic are found in surgical literature, with few articles presented in neurology journals. This review is an introduction to migraine surgery for neurologists from a surgeons view. It discusses the surgical treatment of migraine headaches based on the discoveries made and articles published by the senior author. It outlines the current history of migraine surgery, presents evidence supporting its effectiveness, and tries to dispel claims that what we are seeing is a placebo effect. It further describes detection of trigger sites and outlines surgical techniques of peripheral nerve decompression. We hope that this review will generate a positive discussion between surgeons and neurologists and lead to more interdisciplinary collaboration for the benefit of the patients in the future.

The surgical management of cephalalgia

PURPOSE OF REVIEW

Management of headache disorders is not part of most craniomaxillofacial surgery practices; however there are certain indications for surgical management of headaches by the craniomaxillofacial surgeon.

RECENT FINDINGS

Migraine headaches are the most amenable to surgical management and while the exact mechanism of migraine is unknown, a central or peripheral trigger such as compressive neuropathy of trigeminal nerve branches leading to neurogenic inflammation has been suggested. The primary management for episodic migraine headache should be lifestyle modification and medication, whereas for chronic migraine (>15 headache days/month) use of medication and botulinum neurotoxin is effective, whereas some patients may choose to explore surgical options. Trigger site decompression for chronic migraine surgically relieves anatomic impingement at various sites and has been shown to reduce by at least 50% the frequency, intensity, and duration of headaches in over 85% and elimination of headaches in almost 60%. Trigger points may also lead to exacerbation of cluster headaches and treatment with botulinum neurotoxin may reduce attacks.

SUMMARY

Trigger site decompression is an effective treatment for chronic migraine, as are botulinum neurotoxin injections in reducing attacks in cluster headaches. The craniomaxillofacial surgeon is uniquely qualified to treat these primary headache disorders.