Targeting Headaches: Trigger release surgery an option for patients with chronic migraine

Systematic BOTOX injections are used to gauge the likelihood of surgical success. “BOTOX can be used as a test to see if one might respond to surgery,” said Dr. Janis, who uses a strict algorithmic approach to inject BOTOX into the migraine trigger points in the clinic setting. “If the BOTOX works, that’s a good sign the patient may be a good candidate for surgery. If the BOTOX doesn’t work, surgery may not necessarily be the best option,” Dr. Janis said. According to Dr. Guyuron, patients who suffer from nasal contact migraines must have clear findings of contact either via CT scan or physical examination before being approved for surgery.

Surgical Technique

To relieve frontal trigger migraines, surgeons remove the glabellar muscle group, including the corrugator supercilii, depressor supercilii and procerus, through an upper eyelid incision, freeing the supraorbital and supratrochlear nerves. Temporal migraines are treated with the endoscopic removal of approximately three centimeters of the zygomaticotemporal branch of the trigeminal nerve to prevent its compression by the temporalis muscle (Plast Reconstr Surg. 2005;115(1):1-9; Plast Reconstr Surg. 2009;124(2):461-468).

Removal of a small section (approx. 1 cm X 2.5 cm) of the semispinalis capitis muscle is part of the treatment for occipital migraines. Surgeons also create a subcutaneous flap to shield the greater occipital nerve from irritation. “It’s kind of like doing a superficial parotidectomy,” Dr. Stepnick said. “But the nerve in the partotid, the facial nerve, is actually much smaller and has many smaller branches. I actually think it’s easier to do the migraine nerve. It’s easier to find, and the nerve is bigger.”

Intranasal trigger points are treated with septoplasty and turbinate work. “You try to make sure that the turbinate is not touching the septum,” Dr. Stepnick said. “There are different ways to do that, and you choose the way based on the patient. One option is a therapeutic outfracture. You can also do a submucosal resection to take out the bony part of the turbinate.”

A word of caution: The existence of contact points is not an absolute indication for surgery. “The severity of contact points, or even their presence, does not translate to headaches. Minor contact points can induce severe headaches,” said Dr. David Parsons, clinical professor of pediatric otolaryngology at the Universities of North and South Carolina. Any decision to perform intranasal migraine surgery should be based on a patient’s history, not just on the existence of contact points as demonstrated by CT scan, he said.

Complications

To date, surgical complications have been minimal. Three of 69 patients reported some occipital stiffness or weakness at five years; some patients experience hypo- or hypersensitivity along the supraorbital or supratrochlear nerves (Plast Reconstr Surg. 2011;127(2):603-608). “A couple of patients have told us that they have muscle tightness, but I’m not sure if that’s related to the surgery, because muscle tightness is part of what causes occipital migraine headaches anyway,” Dr. Guyuron said. Other possible complications include minor muscle hollowing, eyelid ptosis, scalp itching and minor hair loss. At five years post-surgery, none of the patients examined by Dr. Guyuron’s team reported intense itching or uneven eyebrow movement; 20 of 79 patients experienced very occasional itching (Plast Reconstr Surg. 2011;127(2):603-608).