Migraine Surgery: An All or Nothing Phenomenon? Prospective Evaluation of Surgical Outcomes

Surgical Management of Headache Disorders - A Systematic Review of the Literature

PURPOSE OF REVIEW

This review article critically evaluates the latest advances in the surgical treatment of headache disorders.

RECENT FINDINGS

Studies have demonstrated the effectiveness of innovative screening tools, such as doppler ultrasound, pain drawings, magnetic resonance neurography, and nerve blocks to help identify candidates for surgery. Machine learning has emerged as a powerful tool to predict surgical outcomes. In addition, advances in surgical techniques, including minimally invasive incisions, fat injections, and novel strategies to treat injured nerves (neuromas) have demonstrated promising results. Lastly, improved patient-reported outcome measures are evolving to provide a framework for comparison of conservative and invasive treatment outcomes. Despite these developments, challenges persist, particularly related to appropriate patient selection, insurance coverage, delays in diagnosis and surgical treatment, and the absence of standardized measures to assess and compare treatment impact. Collaboration between medical/procedural and surgical specialties is required to overcome these obstacles.

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.

The Positive and Negative Predictive Value of Targeted Diagnostic Botox Injection in Nerve Decompression Migraine Surgery

BACKGROUND

Nerve decompression surgery is an effective treatment modality for patients who experience migraines. Botulinum toxin type A (Botox) injections have been traditionally used as a method to identify trigger sites; however, there is a paucity in data regarding its diagnostic efficacy. The goal of this study was to assess the diagnostic capacity of Botox in successfully identifying migraine trigger sites and predicting surgical success.

METHODS

A sensitivity analysis was performed on all patients receiving Botox for migraine trigger site localization followed by a surgical decompression of affected peripheral nerves. Positive and negative predictive values were calculated.

RESULTS

A total of 40 patients met our inclusion criteria and underwent targeted diagnostic Botox injection followed by a peripheral nerve deactivation surgery with at least 3 months' follow-up. Patients with successful Botox injections (defined as at least 50% improvement in Migraine Headache Index scores after injection) had significantly higher average reduction in migraine intensity (56.7% versus 25.8%; P = 0.020), frequency (78.1% versus 46.8%; P = 0.018), and Migraine Headache Index (89.7% versus 49.2%; P = 0.016) postsurgical deactivation. Sensitivity analysis shows that the use of Botox injection as a diagnostic modality for migraine headaches has a sensitivity of 56.7% and a specificity of 80.0%. The positive predictive value is 89.5% and the negative predictive value is 38.1%.

CONCLUSIONS

Diagnostic targeted Botox injections have a very high positive predictive value. It is therefore a useful diagnostic modality that can help identify migraine trigger sites and improve preoperative patient selection.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

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.

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.

The Efficacy of Trigger Site Surgery in the Elimination of Chronic Migraine Headache: An Update in the Rate of Success and Failure

Migraine headache (MH) is a prevalent neurovascular disorder that affects approximately 15% of the global population. They are more common in women and typically affect young and middle-aged individuals. Chronic MH is characterized by headaches occurring on ≥15 days per month for over three months. While only 5% of MHs are refractory, about 20%-50% do not respond to pharmacologic treatments. As a result, surgical interventions have emerged as an alternative method to eliminate MH since 2000 AD. These surgical treatments primarily target the peripheral mechanisms of MH, focusing on common trigger sites. Migraine surgery involves neurolysis of sensory branches of trigeminal and occipital nerves that supply the face and back of the head. Numerous clinical studies conducted between 2000 and 2021 have extensively described surgical interventions and their prognostic outcomes. After surgery, up to 80% of patients reported complete elimination of headaches, while 20%-35% experienced no relief. The failure to achieve complete elimination of MH can be attributed to various factors. The most common reason for a partial clinical response is the failure to identify all trigger sites or inadequate surgery on the trigger sites. In this review, we aim to provide an overview of current surgical interventions for MH at different trigger sites, including recent updates, success and failure rates, and potential causes of failure.

Relative Pain Reduction and Duration of Nerve Block Response Predict Outcomes in Headache Surgery: A Prospective Cohort Study

BACKGROUND

Experts agree that nerve block (NB) response is an important tool in headache surgery screening. However, the predictive value of NBs remains to be proven in a prospective fashion.

METHODS

Pre-NB and post-NB visual analogue pain scores (0 to 10) and duration of NB response were recorded prospectively. Surgical outcomes were recorded prospectively by calculating the Migraine Headache Index (MHI) preoperatively and postoperatively at 3 months, 12 months, and every year thereafter.

RESULTS

The study population included 115 patients. The chance of achieving MHI percentage improvement of 80% or higher was significantly higher in subjects who reported relative pain reduction of greater than 60% following NB versus less than or equal to 60% [63 of 92 (68.5%) versus 10 of 23 (43.5%); P = 0.03]. Patients were more likely to improve their MHI 50% or more with relative pain reduction of greater than 40% versus 40% or less [82 of 104 (78.8%) versus five of 11 (45.5%); P = 0.01]. In subjects with NB response of greater than 15 days, 10 of 13 patients (77.0%) experienced MHI improvement of 80% or greater. Notably, all of these patients (100%) reported MHI improvement of 50% or greater, with mean MHI improvement of 88%. Subjects with a NB response of 24 hours or more achieved significantly better outcomes than patients with a shorter response (72.7% ± 37.0% versus 46.1% ± 39.7%; P = 0.02). However, of 14 patients reporting NB response of less than 24 hours, four patients had MHI improvement of 80% or greater, and seven, of 50% or greater.

CONCLUSIONS

Relative pain reduction and duration of NB response are predictors of MHI improvement after headache surgery. NBs are a valuable tool to identify patients who will benefit from surgery.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Neurovascular Compression-Induced Intracranial Allodynia May Be the True Nature of Migraine Headache: an Interpretative Review

PURPOSE OF REVIEW

Surgical deactivation of migraine trigger sites by extracranial neurovascular decompression has produced encouraging results and challenged previous understanding of primary headaches. However, there is a lack of in-depth discussions on the pathophysiological basis of migraine surgery. This narrative review provides interpretation of relevant literature from the perspective of compressive neuropathic etiology, pathogenesis, and pathophysiology of migraine.

RECENT FINDINGS

Vasodilation, which can be asymptomatic in healthy subjects, may produce compression of cranial nerves in migraineurs at both extracranial and intracranial entrapment-prone sites. This may be predetermined by inherited and acquired anatomical factors and may include double crush-type lesions. Neurovascular compression can lead to sensitization of the trigeminal pathways and resultant cephalic hypersensitivity. While descending (central) trigeminal activation is possible, symptomatic intracranial sensitization can probably only occur in subjects who develop neurovascular entrapment of cranial nerves, which can explain why migraine does not invariably afflict everyone. Nerve compression-induced focal neuroinflammation and sensitization of any cranial nerve may neurogenically spread to other cranial nerves, which can explain the clinical complexity of migraine. Trigger dose-dependent alternating intensity of sensitization and its synchrony with cyclic central neural activities, including asymmetric nasal vasomotor oscillations, may explain the laterality and phasic nature of migraine pain. Intracranial allodynia, i.e., pain sensation upon non-painful stimulation, may better explain migraine pain than merely nociceptive mechanisms, because migraine cannot be associated with considerable intracranial structural changes and consequent painful stimuli. Understanding migraine as an intracranial allodynia could stimulate research aimed at elucidating the possible neuropathic compressive etiology of migraine and other primary headaches.

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.

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.

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.

Artificial Intelligence-Enabled Evaluation of Pain Sketches to Predict Outcomes in Headache Surgery

BACKGROUND

Recent evidence has shown that patient drawings of pain can predict poor outcomes in headache surgery. Given that interpretation of pain drawings requires some clinical experience, the authors developed a machine learning framework capable of automatically interpreting pain drawings to predict surgical outcomes. This platform will allow surgeons with less clinical experience, neurologists, primary care practitioners, and even patients to better understand candidacy for headache surgery.

METHODS

A random forest machine learning algorithm was trained on 131 pain drawings provided prospectively by headache surgery patients before undergoing trigger-site deactivation surgery. Twenty-four features were used to describe the anatomical distribution of pain on each drawing for interpretation by the machine learning algorithm. Surgical outcome was measured by calculating percentage improvement in Migraine Headache Index at least 3 months after surgery. Artificial intelligence predictions were compared with clinician predictions of surgical outcome to determine artificial intelligence performance.

RESULTS

Evaluation of the data test set demonstrated that the algorithm was consistently more accurate (94%) than trained clinical evaluators. Artificial intelligence weighted diffuse pain, facial pain, and pain at the vertex as strong predictors of poor surgical outcome.

CONCLUSIONS

This study indicates that structured algorithmic analysis is able to correlate pain patterns drawn by patients to Migraine Headache Index percentage improvement with good accuracy (94%). Further studies on larger data sets and inclusion of other significant clinical screening variables are required to improve outcome predictions in headache surgery and apply this tool to clinical practice.

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.

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.

Letter to the Editor: The Case for Publicly Funded Headache Surgery in Germany

Headache surgery has become a considerable therapeutic option in headache treatment and is of rising interest in the German medical sector. This viewpoint outlines the need for reimbursement of headache surgery in the German healthcare system and demonstrates its cost-effectiveness. Using state-of-the-art patient selection algorithms, the authors found headache surgery to be cost-effective within 7.2 to 6.3 years. Of note, the approach presented is not limited to the German healthcare system.

A Correlation between Upper Extremity Compressive Neuropathy and Nerve Compression Headache

BACKGROUND

Compressive neuropathies of the head/neck that trigger headaches and entrapment neuropathies of the extremities have traditionally been perceived as separate clinical entities. Given significant overlap in clinical presentation, treatment, and anatomical abnormality, the authors aimed to elucidate the relationship between nerve compression headaches and carpal tunnel syndrome, and other upper extremity compression neuropathies.

METHODS

One hundred thirty-seven patients with nerve compression headaches who underwent surgical nerve deactivation were included. A retrospective chart review was conducted and the prevalence of carpal tunnel syndrome, thoracic outlet syndrome, and cubital tunnel syndrome was recorded. Patients with carpal tunnel syndrome, cubital tunnel syndrome, and thoracic outlet syndrome who had a history of surgery and/or positive imaging findings in addition to confirmed diagnosis were included. Patients with subjective report of carpal tunnel syndrome/thoracic outlet syndrome/cubital tunnel syndrome were excluded. Prevalence was compared to general population data.

RESULTS

The cumulative prevalence of upper extremity neuropathies in patients undergoing surgery for nerve compression headaches was 16.7 percent. The prevalence of carpal tunnel syndrome was 10.2 percent, which is 1.8- to 3.8-fold more common than in the general population. Thoracic outlet syndrome prevalence was 3.6 percent, with no available general population data for comparison. Cubital tunnel syndrome prevalence was comparable between groups.

CONCLUSIONS

The degree of overlap between nerve compression syndromes of the head/neck and upper extremity suggests that peripheral nerve surgeons should be aware of this correlation and screen affected patients comprehensively. Similar patient presentation, treatment, and anatomical basis of nerve compression make either amenable to treatment by nerve surgeons, and treatment of both entities should be an integral part of a formal peripheral nerve surgery curriculum.

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.

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.

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.