Surgical Treatment of Migraine Headaches
Migraine headaches affect over 28 million Americans and approximately 324.1 million people worldwide. They commonly interfere with daily function and are the twentieth leading cause of years lost due to disability around the world. They are also the ninth leading cause of disability in women around the globe. The most common treatments available for migraine headaches today include a combination of avoidance of common migraine triggers, prophylactic pharmacologic interventions, acute abortive therapy, and acute analgesic therapy.
The current surgical treatment for migraine headaches was first reported in 2002, in which patients reporting elimination or improvement of their migraines following forehead rejuvenation surgery. Subsequently, several follow-up studies demonstrating similar results have been published. In 2009, a 5-year follow-up study after migraine headache surgery found that 22% of patients reported complete elimination of migraines; 62% noticed a significant decrease in migraines (defined as a ˃50% reduction in intensity, frequency, or duration of migraines), and only 10% experienced no significant change in migraine symptoms following surgery.
Migraine surgery can be performed at four common trigger sites: trigger site I, frontal triggers, where glabellar muscles or vessels accompanying the nerves may irritate the supratrochlear and supraorbital nerves to cause frontal headaches; trigger site II, temporal triggers, where the temporalis muscle or the vessels adjacent to the nerve may cause inflammation of the zygomaticotemporal branch of the trigeminal nerve to induce temporal headaches; trigger site III, rhinogenic triggers, where intranasal abnormality (e.g., deviated septum, spurs, contact between the turbinates and the septum, concha bullosa, septa bullosa) may irritate the trigeminal end branches to cause paranasal and retrobulbar headaches; and trigger site IV, occipital triggers, where the semispinalis capitis muscle or the occipital artery can irritate the occipital nerve to cause occipital headaches.
Localized botulinum toxin type A injections have been used to detect and confirm suspected trigger sites I, II, and IV in migraine headache patients before surgery. The onset of action of botulinum toxin type A begins after 3 to 4 days, and the neuromuscular junction typically regains its full function 3 to 4 months after initial injection. Injections are targeted directly into muscle, where nerve terminals reside, to weaken the musculature. Aside from diagnostic purposes, botulinum toxin type A injections have also been approved by the U.S. Food and Drug Administration for temporary reduction of migraine headaches.
Surgery is performed on one or any combination of trigger sites in the same setting: trigger site I (frontal trigger site), removal of the glabellar muscle group (corrugator supercilii, depressor supercilii, and the lateral portion of procerus muscles) to decompress the supraorbital and supratrochlear nerves; trigger site II (temporal trigger site), avulsion of the zygomaticotemporal branch of the trigeminal nerve; trigger site III (rhinogenic trigger site), septoplasty and turbinectomy; and trigger site IV (occipital trigger site), removal of a small segment of the semispinalis capitis muscle to decompress the greater occipital nerve or remove the occipital artery. All of the above procedures are performed on an outpatient setting.