Migraine surgery is a surgical operation undertaken with the goal of reducing or preventing migraines. Migraine surgery most often refers to surgical decompression of one or several nerves in the head and neck which have been shown to trigger migraine symptoms in many migraine sufferers. Following the development of nerve decompression techniques for the relief of migraine pain in the year 2000, these procedures have been extensively studied and shown to be effective in appropriate candidates. The nerves that are most often addressed in migraine surgery are found outside of the skull, in the face and neck, and include the supra-orbital and supra-trochlear nerves in the forehead, the

zygomaticotemporal nerve The zygomaticotemporal nerve (zygomaticotemporal branch, temporal branch) is a small nerve of the face. It is derived from the zygomatic nerve, a branch of the maxillary nerve (CN V2). It is distributed to the skin of the side of the forehead. It ...

and

auriculotemporal nerve The auriculotemporal nerve is a branch of the mandibular nerve (CN V3) that runs with the superficial temporal artery and vein, and provides sensory innervation to various regions on the side of the head. Structure Origin The auriculotempor ...

s in the temple region, and the

greater occipital The greater occipital nerve is a nerve of the head. It is a spinal nerve, specifically the medial branch of the dorsal primary ramus of cervical spinal nerve 2. It arises from between the first and second cervical vertebrae, ascends, and then ...

, lesser occipital, and

third occipital nerve While under the Trapezius The trapezius is a large paired trapezoid-shaped surface muscle that extends longitudinally from the occipital bone to the lower thoracic vertebrae of the spine and laterally to the spine of the scapula. It moves ...

s in the back of the neck. Nerve impingement in the nasal cavity has additionally been shown to be a trigger of migraine symptoms.

Indications and patient selection

Migraine surgery is usually reserved for migraine patients who fail more conservative therapy or who cannot tolerate the side effects of drugs used to treat their migraines. Appropriate patients are screened using injections of

local anesthesia Local anesthesia is any technique to induce the absence of sensation in a specific part of the body, generally for the aim of inducing local analgesia, that is, local insensitivity to pain, although other local senses may be affected as well. It ...

to provide a temporary nerve block. In some cases,

Botox Botulinum toxin, or botulinum neurotoxin (BoNT), is a neurotoxic protein produced by the bacterium '' Clostridium botulinum'' and related species. It prevents the release of the neurotransmitter acetylcholine from axon endings at the neuromus ...

may be used to provide temporary decompression of the nerve. Patients who respond to nerve blocks often see an immediate though temporary reduction in their pain by "shutting off" the nerve that is triggering the migraine, while pain relief following Botox injections is provided by relaxation of nearby muscle tissue that may be compressing the nerve. Patients who respond well to these screening procedures are felt to be excellent candidates for migraine surgery.

Surgical procedures

Migraine surgery is an outpatient procedure which addresses peripheral nerves through limited incisions. Depending on the symptoms of the patient and the screening results following nerve blocks or Botox, different areas of the head and neck may be addressed to treat the nerves found to be the migraine trigger in a given patient. Migraine surgery is always individualized to each patient's symptoms and anatomy.

Anterior nerves

Nerves found in the forehead ( supra-orbital and supra-trochlear nerves) are either addressed using

endoscopic surgery An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are inser ...

or by using an incision in the crease of the upper eyelid. Structures that are found pressing on the nerves here are released and may include

bone A bone is a rigid organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red and white blood cells, store minerals, provide structure and support for the body, ...

at the upper orbit, fascia,

blood vessel The blood vessels are the components of the circulatory system that transport blood throughout the human body. These vessels transport blood cells, nutrients, and oxygen to the tissues of the body. They also take waste and carbon dioxide away ...

s, or muscle tissue. The supra-orbital and supra-trochlear nerves travel through the

corrugator supercilii muscle The corrugator supercilii muscle is a small, narrow, pyramidal muscle close to the eye. It arises from the medial end of the superciliary arch, and inserts into the deep surface of the skin of the eyebrow. It draws the eyebrow downward and medi ...

which enables frowning of the brow. These nerves are released from these muscles so they may lie free of pressure from these muscle structures. Small blood vessels which travel with these nerves may be divided to prevent pressure as well. In the bony notch where these nerves exit the eye socket, small pieces of bone or connective tissue may be removed so undue pressure is not placed on the nerves in this region.

Nerves of the temple region

The

and

s are found in areas between the top of the ear and the lateral portion of the eye, in different areas of the temple. These nerves can also be addressed by endoscopic techniques, or well hidden small incisions. Blood vessels next to or crossing these nerves are often found to be the source of compression, and these blood vessels may be divided to prevent irritation of these nerves. Associated

temporal muscle In anatomy, the temporalis muscle, also known as the temporal muscle, is one of the muscles of mastication (chewing). It is a broad, fan-shaped convergent muscle on each side of the head that fills the temporal fossa, superior to the zygomat ...

release in the region of these nerves may also be indicated. Because these nerves are very small and provide feeling to small regions of the scalp, they are often cut or avulsed, allowing the ends to retract into muscle tissue to prevent

neuroma A neuroma (; plural: neuromata or neuromas) is a growth or tumor of nerve tissue. Neuromas tend to be benign (i.e. not cancerous); many nerve tumors, including those that are commonly malignant, are nowadays referred to by other terms. Neuroma ...

formation.

Posterior nerves

Chronic irritation of the occipital nerves is called

occipital neuralgia Occipital neuralgia (ON) is a painful condition affecting the posterior head in the distributions of the greater occipital nerve (GON), lesser occipital nerve (LON), third occipital nerve (TON), or a combination of the three. It is paroxysmal, la ...

and is frequently the cause of migraine symptoms. The

and

s are addressed through an incision at the base of the scalp in the upper neck by either a vertical or transverse incision. Incisions are usually placed within the hairline. The

greater occipital nerve The greater occipital nerve is a nerve of the head. It is a spinal nerve, specifically the medial branch of the dorsal primary ramus of cervical spinal nerve 2. It arises from between the first and second cervical vertebrae, ascends, and then p ...

travels through several muscle layers (including the

trapezius muscle The trapezius is a large paired trapezoid-shaped surface muscle that extends longitudinally from the occipital bone to the lower thoracic vertebrae of the spine and laterally to the spine of the scapula. It moves the scapula and supports the ...

and

splenius capitis muscle The splenius capitis () () is a broad, straplike muscle in the back of the neck. It pulls on the base of the skull from the vertebrae in the neck and upper thorax. It is involved in movements such as shaking the head. Structure It arises from t ...

) where it is often compressed, and therefore surgery for this nerve involves releasing it from tight muscle and fascia in the upper neck. Blood vessels found crossing the nerve such as the

occipital artery The occipital artery arises from the external carotid artery opposite the facial artery. Its path is below the posterior belly of digastric to the occipital region. This artery supplies blood to the back of the scalp and sternocleidomastoid musc ...

may be divided in order to avoid chronic pressure and irritation of the

. The

is a small nerve that travels near the greater occipital nerve and may treated similarly in order to alleviate chronic irritation. The

lesser occipital nerve The lesser occipital nerve or small occipital nerve is a cutaneous spinal nerve. It arises from second cervical (spinal) nerve (along with the greater occipital nerve). It innervates the scalp in the lateral area of the head posterior to the ...

is a small nerve that has additionally been found to be associated with migraine pain. This nerve is found near the

sternocleidomastoid muscle The sternocleidomastoid muscle is one of the largest and most superficial cervical muscles. The primary actions of the muscle are rotation of the head to the opposite side and flexion of the neck. The sternocleidomastoid is innervated by the access ...

and may be decompressed or divided here through a small incision. As this small nerve provides feeling for a small region of the scalp, the minimal numbness resulting from the division of this nerve often goes un-noticed.

Nerves of the nose

The nerves of the nasal lining may be impinged by structures in the nose such as the

nasal septum The nasal septum () separates the left and right airways of the nasal cavity, dividing the two nostrils. It is depressed by the depressor septi nasi muscle. Structure The fleshy external end of the nasal septum is called the columella or co ...

and

turbinates In anatomy, a nasal concha (), plural conchae (), also called a nasal turbinate or turbinal, is a long, narrow, curled shelf of bone that protrudes into the breathing passage of the nose in humans and various animals. The conchae are shaped like ...

. Nasal surgery to decompress these regions may include

septoplasty Septoplasty �sɛp.toˌplæ.sti(Etymology: L, saeptum, septum; Gk, πλάσσειν plassein – to shape), or alternatively submucous septal resection and septal reconstruction, is a corrective surgical procedure done to straighten a deviated ...

turbinectomy A turbinectomy or turbinoplasty (preserving the mucosal layer) is a surgical procedure, that removes tissue, and sometimes bone, of the turbinates in the nasal passage, particularly the inferior nasal concha. The procedure is usually performed t ...

, or other

rhinoplasty Rhinoplasty ( grc, ῥίς, rhī́s, nose + grc, πλάσσειν, plássein, to shape), commonly called nose job, medically called nasal reconstruction is a plastic surgery procedure for altering and reconstructing the nose. There are two typ ...

procedures.

Surgical outcomes

Though initially thought to be experimental surgery, the benefits of migraine surgery have now been well documented. Followup data has shown that 88% of migraine surgery patients experienced a positive response to the procedure after 5 years. 29% of patients have been shown to achieve complete elimination of their migraine disease, while an additional 59% of patients reported a significant decrease in their pain and symptoms 5 years following their migraine surgery. 12% of patients undergoing migraine surgery reported no change in their symptoms after 5 years. Migraine surgery has additionally been studied in a

socioeconomic Socioeconomics (also known as social economics) is the social science that studies how economic activity affects and is shaped by social processes. In general it analyzes how modern societies progress, stagnate, or regress because of their l ...

context and has been shown to reduce both direct and indirect costs associated with migraine disease. Such costs after migraine surgery have been shown to be reduced by a median of $3,949 per patient per year.

References

{{DEFAULTSORT:Migraine Surgery Migraine Neurosurgery