Migraine surgery: a plastic surgery solution for refractory migraine headache

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.

Therapeutic Options for Migraines in the Microsurgical Patient: A Scoping Review

BACKGROUND

There exists an increasing array of treatments proposed to prevent, alleviate, and abort symptoms of a migraine; however, for patients who undergo reconstructive microsurgery, caution must be taken to preserve vascular integrity. This study is the first-to-date scoping review of vascular and bleeding risk of current migraine therapies, with the purpose of identifying potential therapeutic agents for postoperative migraine management appropriate for microsurgical patients.

METHODS

Currently available migraine therapeutics were compiled from the UpToDate software system and the American Academy of Family Physicians. A PubMed literature review was performed for each therapeutic's effect on bleeding or vascular involvement. Data were compiled into tables of abortive, symptom-controlling and prophylactic, and nonpharmacologic treatments. Expert microsurgeons reviewed the data to provide recommendations for optimized patient care.

RESULTS

Triptans and other ergot derivatives demonstrated strong evidence of vasoconstriction and were greatly advised against for immediate postmicrosurgical use. Novel pharmaceutical therapies such as lasmiditan and calcitonin gene-related peptide antagonists have no literature indicating potential for vasoconstriction or hematoma and remain an investigational option for abortive medical treatment. For symptom control, acetaminophen appears the safest option, with clinical judgment and further research needed for use of nonsteroidal antiinflammatory drugs. Alternative treatment techniques may include migraine prophylaxis with botulinum toxin injection or nutraceutical treatment by means of magnesium supplementation or coenzyme Q10 administration, minimizing the need for additional medication in the postoperative setting.

CONCLUSIONS

Patients undergoing reconstructive microsurgery have a unique medical profile limiting the therapeutic options available to treat migraines. This review provides preliminary evidence to be considered as a guide for prescribing therapeutics for migraine in the postoperative setting.

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.

Assessing the Relationship between Obesity and Trigger Point-specific Outcomes after Headache Surgery

Background

Trigger point deactivation surgery is a safe and effective treatment for properly selected patients experiencing migraine, with 68.3%-100% experiencing symptom improvement postoperatively. However, it is still unknown why certain patients do not respond. Obesity has been shown to be associated with worsened migraine symptoms and a decreased response to select pharmacotherapies. This study aimed to determine whether obesity may also be associated with an attenuated response to surgery.

Methods

A retrospective chart review was conducted to identify patients who had undergone trigger point deactivation surgery for migraine. Patients were split into obese and nonobese cohorts. Obesity was classified as a body mass index of 30 or higher per Centers for Disease Control and Prevention guidelines. Outcomes and follow-up periods were determined with respect to individual operations. Outcomes included migraine attack frequency, intensity, duration, and the migraine headache index. Differences in demographics, operative characteristics, and operative outcomes were compared.

Results

A total of 62 patients were included in the study. The obese cohort comprised 31 patients who underwent 45 total operations, and the nonobese cohort comprised 31 patients who underwent 34 operations. Results from multivariable analysis showed no impact of obesity on the odds of achieving a more than 90% reduction in any individual outcome. The overall rates of improvement (≥50% reduction in any outcome) and elimination (100% reduction in all symptoms) across both cohorts were 89.9% and 65.8%, respectively.

Conclusion

Obese patients have outcomes comparable to a nonobese cohort after trigger point deactivation surgery for migraine.

Nonpharmacologic Treatments for Chronic and Episodic Migraine: A Systematic Review and Meta-Analysis

BACKGROUND

Minimally invasive techniques for treatment-resistant migraine have been developed on recent insights into the peripheral pathogenesis of migraines. Although there is a growing body of evidence supporting these techniques, no study has yet compared the effects of these treatments on headache frequency, severity, duration, and cost.

METHODS

PubMed, Embase, and Cochrane Library databases were searched to identify randomized placebo-controlled trials that compared radiofrequency ablation, botulinum toxin type A (BT-A), nerve block, neurostimulation, or migraine surgery to placebo for preventive treatment. Data on changes from baseline to follow-up in headache frequency, severity, duration, and quality of life were analyzed.

RESULTS

A total of 30 randomized controlled trials and 2680 patients were included. Compared with placebo, there was a significant decrease in headache frequency in patients with nerve block ( P = 0.04) and surgery ( P < 0.001). Headache severity decreased in all treatments. Duration of headaches was significantly reduced in the BT-A ( P < 0.001) and surgery cohorts ( P = 0.01). Quality of life improved significantly in patients with BT-A, nerve stimulator, and migraine surgery. Migraine surgery had the longest lasting effects (11.5 months) compared with nerve ablation (6 months), BT-A (3.2 months), and nerve block (11.9 days).

CONCLUSIONS

Migraine surgery is a cost-effective, long-term treatment to reduce headache frequency, severity, and duration without significant risk of complication. BT-A reduces headache severity and duration, but it is short-lasting and associated with greater adverse events and lifetime cost. Although efficacious, radiofrequency ablation and implanted nerve stimulators have high risks of adverse events and explantation, whereas benefits of nerve blocks are short in duration.

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 areas nerve decompression for refractory chronic migraine

BACKGROUND

Chronic migraine refractory to medical treatment represents a common debilitating primary neurovascular disorder associated with great disability, high financial costs, reduced rates of productivity and impaired health-related quality of life.

OBJECTIVE

To demonstrate the feasibility of scalp (trigger areas) nerve decompression as a treatment alternative in the management of refractory CM patients METHODS: From January 2005 to January 2020, we retrospectively collected data of 154 patients diagnosed with chronic migraine that underwent trigger site nerve decompression. These trigger areas were divided according the nerve compromise as frontal (supraorbital nerve), temporal (auriculotemporal nerve), occipital (greater occipital nerve). Following extensive clinical evaluation, the surgical treatment was performed after under local anesthesia and required the release of the affected nerve from surrounding connective tissue adhesions, and vascular conflicts.

RESULTS

Of the total amount of patients, 91 (59.09%) patients underwent auriculotemporal nerve decompression, 27 (13.63%) cases supraorbital nerve decompression, 15 (9.74%) patients greater occipital nerve decompression, and the remaining 21 (13.63%) patients had more than one procedure of nerve decompression. At 1-year follow or latest follow-up, 96 (62.2%) patients were considered as cured, 29 cases (18.83%) reported improvement of their symptoms, 21 (13.64%) patients considered only a partial symptomatic remission and 5 (3.25%) patients reported no change or failed surgical treatment.

CONCLUSION

Nerve decompression of trigger site areas (frontal, temporal, occipital) by removal of tissue, muscles and vessels in patients with medically refractory CM is a feasible alternative treatment modality with a high success of up to 80.5.

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.

Population-Based Health Utility Assessment of Migraine Headache Symptoms before and after Surgical Intervention

BACKGROUND

Approximately 30 million Americans suffer from migraine headaches. The primary goals of this study are to (1) use Migraine-Specific Symptoms and Disability criteria and Migraine Headache Index to describe the symptomatic improvement following decompressive surgery for refractory migraines, and (2) use the average Migraine Headache Index preoperatively and postoperatively for health utility assessment from a healthy patient's perspective.

METHODS

The Migraine-Specific Symptoms and Disability criteria and the Migraine Headache Index were used to characterize migraine symptoms in the authors' patient population before and after decompressive surgery. Healthy individuals were randomized to a scenario in which they assumed either the preoperative or postoperative average patient symptom profile described by the authors' migraine patients. Health utility assessments were used to quantify the evaluation of health states the authors' patients experienced before and after surgical migraine therapy.

RESULTS

Twenty-five patients underwent surgery for migraine headaches. The Migraine-Specific Symptoms and Disability questionnaire showed a significant decrease in both frequency of headaches per month (p < 0.0001) and overall pain score (p = 0.007). The Migraine Headache Index demonstrated a statistically significant improvement (p = 0.03). Healthy individuals in the preoperative group had significantly lower utility scores compared with the postoperative group in all of the health utility assessments completed for migraine symptoms.

CONCLUSION

This is the first study to use health utility assessments to attest the efficacy of decompressive therapy by demonstrating the population perspective, which perceived a significant improvement in quality of life following the surgical treatment of migraines in the authors' patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

A Surgical Approach to Treat Painful Neuromas of the Supraorbital and Supratrochlear Nerves with Implantation of the Proximal Stump into the Orbit

Frontal neuralgia causally related to trauma to the supraorbital and supratrochlear nerves remains a difficult problem to resolve. A peripheral nerve approach to this problem would involve neuroma resection and relocation of the proximal nerve stump to a location away from the vulnerable supraorbital ridge. A retrospective chart review was done to identify patients with frontal pain related to supraorbital trauma who underwent operative interventions to solve this problem by neuroma resection and relocation of the proximal stumps into the orbit. Eight patients were identified for inclusion in this study. At a mean of 16 months after surgery, there was a significant change in the visual analog score from a mean of 9.4 to 2.8 ( p  < 0.05), with 88% of the patients reporting a >50% reduction in pain postoperatively. There was one treatment failure. There were no postoperative complications. The strategy of relocating the proximal end of the supraorbital and supratrochlear nerves into the posterior orbit after resecting the painful neuromas can successfully manage posttraumatic craniofacial pain related to these injured nerves.

Can Functional Nasal Surgery Treat Chronic Headaches? A Systematic Review

BACKGROUND

Nasal surgery is one of the most common operations performed by plastic surgeons. The link between functional nasal surgery and improvement in nasal breathing is well established, but there are other metrics that have been shown to improve as a result of anatomical correction of the nose. Current literature suggests that surgery to remove nasal mucosal contact points can reduce symptoms in chronic headache patients. The authors conducted a systematic literature review to determine the validity of this hypothesis.

METHODS

A systematic search of the literature was performed using the terms "headache," "rhinogenic headache," "contact point," "migraine," and "surgery/endoscopy."

RESULTS

The authors identified 39 articles encompassing a total of 1577 patients who underwent surgery to treat mucosal contact point headaches. Septoplasty and turbinate reduction were the most commonly performed procedures, often in combination with endoscopic sinus surgery. Analysis of the combined data demonstrated improvement in the reported severity of patient symptoms, with 1289 patients (85 percent) reporting partial or complete resolution of headaches postoperatively. Average visual analogue scale scores and number of headache days in patients undergoing nasal surgery were reduced from 7.4 ± 0.9 to 2.6 ± 1.2 (p < 0.001) and 22 ± 4.3 days to 6.4 ± 4.2 days (p = 0.016), respectively. Improvement in headache symptoms was significantly associated with a positive response to preoperative anesthetic testing, and with inclusion of endoscopic sinus surgery as part of the surgery.

CONCLUSION

Functional nasal surgery is a viable option to improve headache symptoms in appropriately selected patients.

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.

The supraorbital region revisited: An anatomic exploration of the neuro-vascular bundle with regard to frontal migraine headache

BACKGROUND

Recent findings on the pathogenesis of frontal migraine headache support, besides a central vasogenic cause, an alternative peripheral mechanism involving compressed craniofacial nerves. This is further supported by the efficiency of botulinum toxin injections as a new treatment option in frontal migraine headache patients.

METHODS

The supraorbital regions of 22 alcohol-glycerine-embalmed facial halves of both sexes were dissected. Both the supratrochlear and supraorbital nerves (STN and SON, respectively) were identified, and their relationship with the corrugator supercilii muscle (CSM) was investigated by dissection and ultrasound. The course of both nerves was defined, and the interaction between the supraorbital artery (SOA) and SON was determined.

RESULTS

We discovered a new possible compression point of the STN passing through the orbital septum and verified previously described compression points of both STN and SON. Osteofibrous channels used by the STN and SON were found constantly. We described the varying topography of the STN and CSM, the SON and CSM, and the SON and SOA. Further, we provide an algorithm for the ultrasound visualization of the supraorbital neurovascular bundle.

CONCLUSION

Our data support the hypothesis of a peripheral mechanism for frontal migraine headache because of following potential irritation points: first, the CSM is constantly perforated by the SON and frequently by the STN; second, the topographic proximity between SOA and SON and the osteofibrous channels is used by the SON and STN; and third, the STN passes through the orbital septum.

Venous Thoracic Outlet Syndrome as a Cause of Intractable Migraines

Thoracic outlet syndrome (TOS) refers to the compression of the neurovascular bundle within the thoracic outlet. Cases are classified by primary etiology-arterial, neurogenic, or venous. In addition to the typical symptoms of arm swelling and paresthesias, headaches have been reported as a potential symptom of TOS. In this report, we describe a patient with debilitating migraines, which were consistently preceded by unilateral arm swelling. Resolution of symptoms occurred only after thoracic outlet decompression. Patients with migraines and concomitant swelling and/or paresthesias, especially related to provocative arm maneuvers, should be considered a possible atypical presentation of TOS and evaluated in more detail.

A comparison of outcome of medical and surgical treatment of migraine headache: In 1 year follow-up

BACKGROUND

This study was designed to compare the efficacy of the medical treatment versus the surgical treatment approach to decompression of trigger point nerves in patients with migraine headaches.

MATERIALS AND METHODS

Fifty volunteers were randomly assigned to the medical treatment group (n = 25) or the surgical treatment group (n = 25) after examination by the team neurologist to ensure a diagnosis of migraine headache. All patients received botulinum toxin type A to confirm the trigger sites. The surgical treatment group underwent surgical deactivation of the trigger site(s). The medical treatment group underwent prophylactic pharmacologic interventions by the neurologist. Pretreatment and 12-month posttreatment migraine headache frequency, duration, and intensity were analyzed and compared to determine the success of the treatments.

RESULTS

Nineteen of the 25 patients (76%) in the surgical treatment group and 10 of the 25 patients (40%) in the medical treatment group experienced a successful outcome (at least a 50% decrease in migraine frequency, duration, or intensity) after 1 year from surgery. Surgical treatment had a significantly higher success rate than medical treatment (P < 0.001). Nine patients (36%) in the surgical treatment group and one patient (4%) in the medical treatment group experienced cessation of migraine headaches. The elimination rate was significantly higher in the surgical treatment group than in the medical treatment group (P < 0.001).

CONCLUSIONS

Based on the 1-year follow-up data, there is strong evidence that surgical manipulation of one or more migraine trigger sites can successfully eliminate or reduce the frequency, duration, and intensity of migraine headaches in a lasting manner.

Anatomic and Compression Topography of the Lesser Occipital Nerve

Background:

The surgical treatment of occipital headaches focuses on the greater, lesser, and third occipital nerves. The lesser occipital nerve (LON) is usually transected with relatively limited available information regarding the compression topography thereof and how such knowledge may impact surgical treatment.

Methods:

Eight fresh frozen cadavers were dissected focusing on the LON in relation to 3 clinically relevant compression zones. The x axis was a line drawn through the occipital protuberance (OP) and the y axis, the posterior midline (PM). In addition, a prospectively collected cohort of 36 patients who underwent decompression of the LON is presented with their clinical results, including migraine headache index scores.

Results:

The LON was found in compression zone 1, with a mean of 7.8 cm caudal to the OP and 6.3 cm lateral to the PM. The LON was found at the midpoint of compression zone 2, with an average of 5.5 cm caudal to the OP and 6.2 cm lateral to the PM. At compression zone 3, the medial-most LON branch was located approximately 1 cm caudal to the OP and 5.35 cm lateral to the PM, whereas the lateral-most branch was identified 1 cm caudal to the OP and 6.5 cm lateral to the PM. Of the 36 decompression patients analyzed, only 5 (14%) required neurectomy as the remainder achieved statistically significant improvements in migraine headache index scores postoperatively.

Conclusion:

The knowledge of LON anatomy can aid in nerve dissection and preservation, thereby leading to successful outcomes without requiring neurectomy.

Episodic and chronic migraine headache: breaking down barriers to optimal treatment and prevention

Migraine is a common disabling primary headache disorder that affects an estimated 36 million Americans. Migraine headaches often occur over many years or over an individual's lifetime. By definition, episodic migraine is characterized by headaches that occur on fewer than 15 days per month. According to the recent International Classification of Headache Disorders (third revision) beta diagnostic criteria, chronic migraine is defined as "headaches on at least 15 days per month for at least 3 months, with the features of migraine on at least 8 days per month." However, diagnostic criteria distinguishing episodic from chronic migraine continue to evolve. Persons with episodic migraine can remit, not change, or progress to high-frequency episodic or chronic migraine over time. Chronic migraine is associated with a substantially greater personal and societal burden, more frequent comorbidities, and possibly with persistent and progressive brain abnormalities. Many patients are poorly responsive to, or noncompliant with, conventional preventive therapies. The primary goals of migraine treatment include relieving pain, restoring function, and reducing headache frequency; an additional goal may be preventing progression to chronic migraine. Although all migraineurs require abortive treatment, and all patients with chronic migraine require preventive treatment, there are no definitive guidelines delineating which persons with episodic migraine would benefit from preventive therapy. Five US Food and Drug Association strategies are approved for preventing episodic migraine, but only injections with onabotulinumtoxinA are approved for preventing chronic migraine. Identifying persons who require migraine prophylaxis and selecting and initiating the most appropriate treatment strategy may prevent progression from episodic to chronic migraine and alleviate the pain and suffering associated with frequent migraine.

An Association between Carpal Tunnel Syndrome and Migraine Headaches-National Health Interview Survey, 2010

Background:

Migraine headaches have not historically been considered a compression neuropathy. Recent studies suggest that some migraines are successfully treated by targeted peripheral nerve decompression. Other compression neuropathies have previously been associated with one another. The goal of this study is to evaluate whether an association exists between migraines and carpal tunnel syndrome (CTS), the most common compression neuropathy.

Methods:

Data from 25,880 respondents of the cross-sectional 2010 National Health Interview Survey were used to calculate nationally representative prevalence estimates and 95% confidence intervals (95% CIs) of CTS and migraine headaches. Logistic regression was used to calculate adjusted odds ratios (aORs) and 95% CI for the degree of association between migraines and CTS after controlling for known demographic and health-related factors.

Results:

CTS was associated with older age, female gender, obesity, diabetes, and smoking. CTS was less common in Hispanics and Asians. Migraine was associated with younger age, female gender, obesity, diabetes, and current smoking. Migraine was less common in Asians. Migraine prevalence was 34% in those with CTS compared with 16% in those without CTS (aOR, 2.60; 95% CI, 2.16–3.13). CTS prevalence in patients with migraine headache was 8% compared with 3% in those without migraine headache (aOR, 2.67; 95% CI, 2.22–3.22).

Conclusions:

This study is the first to demonstrate an association between CTS and migraine headache. Longitudinal and genetic studies with physician verification of migraine headaches and CTS are needed to further define this association.

A systematic review of peripheral nerve interventional treatments for chronic headaches

OBJECTIVE

This study aimed to systematically compare the outcomes of different types of interventional procedures offered for the treatment of headaches and targeted toward peripheral nerves based on available published literature.

BACKGROUND

Multiple procedural modalities targeted at peripheral nerves are being offered to patients for the treatment of chronic headaches. However, few resources exist to compare the effectiveness of these modalities. The objective of this study was to systematically review the literature to compare the published outcomes and effectiveness of peripheral nerve surgery, radiofrequency (RF) therapy, and peripheral nerve stimulators for chronic headaches, migraines, and occipital neuralgia.

METHODS

A broad literature search of the MEDLINE and CENTRAL (Cochrane) databases was undertaken. Relevant studies were selected by 2 independent reviewers and these results were narrowed further by the application of predetermined inclusion and exclusion criteria. Studies were assessed for quality, and data were extracted regarding study characteristics (study type, level of evidence, type of intervention, and number of patients) and objective outcomes (success rate, length of follow-up, and complications). Pooled analysis was performed to compare success rates and complications between modality types.

RESULTS

Of an initial 250 search results, 26 studies met the inclusion criteria. Of these, 14 articles studied nerve decompression, 9 studied peripheral nerve stimulation, and 3 studied RF intervention. When study populations and results were pooled, a total of 1253 patients had undergone nerve decompression with an 86% success rate, 184 patients were treated by nerve stimulation with a 68% success rate, and 131 patients were treated by RF with a 55% success rate. When compared to one another, these success rates were all statistically significantly different. Neither nerve decompression nor RF reported complications requiring a return to the operating room, whereas implantable nerve stimulators had a 31.5% rate of such complications. Minor complication rates were similar among all 3 procedures.

CONCLUSIONS

Of the 3 most commonly encountered interventional procedures for chronic headaches, peripheral nerve surgery via decompression of involved peripheral nerves has been the best-studied modality in terms of total number of studies, level of evidence of published studies, and length of follow-up. Reported success rates for nerve decompression or excision tend to be higher than those for peripheral nerve stimulation or for RF, although poor study quantity and quality prohibit an accurate comparative analysis. Of the 3 procedures, peripheral nerve stimulator implantation was associated with the greatest number of complications. Although peripheral nerve surgery seems to be the interventional treatment modality that is currently best supported by the literature, better controlled and normalized high-quality studies will help to better define the specific roles for each type of intervention.

Patient outcomes, satisfaction, and improvement in headaches after endoscopic brow-lift

IMPORTANCE

To improve preoperative counseling for patients considering endoscopic brow-lift (EBL).

OBJECTIVES

To understand patient-reported outcomes, satisfaction, and recovery after EBL surgery to improve preoperative counseling.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective telephone survey of 57 patients who had EBL or EBL with concurrent rhytidectomy to assess cosmetic and functional outcomes using 47 questions.

MAIN OUTCOME AND MEASURE

Questions evaluated outcomes, satisfaction, and recovery.

RESULTS

Fifty-three patients (93%) reported the procedure was successful, and 55 patients (96%) would recommend undergoing this procedure. Forty-two (74%) were incidentally told they looked younger; 37 patients (65%) were told they looked less tired. Forty-two patients (74%) reported increased confidence. Fifty-one patients (89%) required analgesics for less than 1 week, 44 patients (77%) reported scars as unnoticeable, 54 patients (95%) reported postoperative edema lasting less than 2 weeks, 16 patients (28%) reported alopecia at an incision site, and 36 patients (63%) had some numbness. In the 16 patients who reported headaches before surgery, 8 patients (50%) reported an improvement in either frequency or intensity. Patients who underwent rhytidectomy were significantly more likely to take 2 weeks or longer to return to normal activities. No differences were noted between rhytidectomy with EBL compared with EBL alone in analgesic use, edema, numbness, alopecia, and satisfaction.

CONCLUSIONS AND RELEVANCE

Endoscopic brow-lift is well tolerated and most patients are happy with the outcome. Relying on patient-reported information helps us to better understand the surgical experience and to improve preoperative counseling.

LEVEL OF EVIDENCE

4.

Chronic daily headaches secondary to greater auricular and lesser occipital neuromas following endolymphatic shunt surgery

In head and neck surgery, peripheral sensory nerves are at risk for traumatic injury. These injuries are known to be peripheral triggers of chronic headaches if left untreated or unrecognised. We report the case of a patient that presented with a severe headache, nausea and emesis of 2 years duration following endolymphatic shunt placement for Meniere's disease. Nerve blockade suggested a peripheral trigger, and surgical exploration of the incision site revealed traumatic neuromas of the greater auricular and lesser occipital nerves. Subsequent nerve resection yielded complete symptomatic relief. This is the first case report of a peripherally triggered migraine headache due to the development of neuromas of the greater auricular and lesser occipital nerves, also representing a previously unreported complication of endolymphatic shunt placement. It is recommended that in patients presenting with intractable migraines and a history of head and neck surgery, diagnostic nerve blockage be used to assess for neuromas.

Clinical outcomes following supraorbital foraminotomy for treatment of frontal migraine headache

BACKGROUND

Although 92 percent of patients who undergo surgical decompression of the supraorbital nerve for treatment of frontal migraine headaches through resection of the glabellar muscle group achieve at least 50 percent improvement, only two-thirds demonstrate complete resolution of symptoms. The authors investigated the role of additional decompression methods by comparing surgery outcomes between patients who underwent glabellar myectomy alone and patients who also underwent supraorbital foraminotomy.

METHODS

Outcome measures including migraine headache frequency, severity, and duration; Migraine Headache Index score; and forehead pain were reviewed retrospectively and analyzed statistically for 43 age-matched control patients who underwent glabellar myectomy for release of the supraorbital nerve and 43 patients who underwent glabellar myectomy with supraorbital foraminotomy from 2002 to 2010.

RESULTS

The myectomy group statistically matched the myectomy with foraminotomy group for age, number of surgical sites, and preoperative headache characteristics (p > 0.05). For the myectomy and myectomy with foraminotomy groups, postoperative migraine frequency was 7.8 per month versus 4.1 per month, severity was 5.6 versus 4.4, Migraine Headache Index score was 26.5 versus 11.1, and persistent forehead pain was 48.8 percent versus 25.6 percent, respectively. These differences were all statistically significant (p < 0.05). Duration of headache was unchanged (p = 0.17).

CONCLUSIONS

The supraorbital foramen is a potential site of supraorbital nerve compression that can trigger frontal migraine headache. If it is present, the authors strongly recommend foraminotomy to ensure complete release of the supraorbital nerve to optimize outcomes. Their results also support consideration of release of any fibrous bands across the supraorbital notch.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.