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      Trigger Site Inactivation for the Surgical Therapy of Occipital Migraine and Tension-type Headache: Our Experience and Review of the Literature

      research-article
      Author(s): , MD, PhD 1 , , , MD 1
      Publication date (Electronic):
      Journal: Plastic and Reconstructive Surgery Global Open
      Publisher: Wolters Kluwer Health

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          Background:

          Literature from the last decade has shown a correlation between resection of the occipital muscles and vessels and relief from migraine and tension-type headaches.

          Methods:

          The aim of this article was to describe the authors' technique to treat occipital migraine, while comparing our approach with the other currently available surgical options. Relevant anatomical issues and their implications in the surgical treatment of occipital migraine have been reviewed. We undertook a modified version of the currently used method of occipital migraine surgery. Patients completed questionnaires before and after surgery, and results were compared.

          Results:

          To identify all trigger points, we used a constellation of symptoms referred to by the patient rather than injection of botulinum toxin type A. The entire procedure was carried out under local anesthesia. In most of the patients (56) in whom a dilated/aneurysmal occipital artery was found, the procedure was limited to ligation of the occipital artery, with no further undermining of muscles or neurolysis, which reduced the invasiveness of the procedure.

          Conclusions:

          The main differences between our procedure and the currently used method were that (1) extensive undermining and muscular or nerve resection were not necessary and (2) no flap was transposed with the purpose of covering isolated nerves. Hence, our method could improve the currently used method, while minimizing its invasiveness.

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          Most cited references21

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          Corrugator supercilii muscle resection and migraine headaches.

          B Guyuron, A Varghai, B Michelow … (2000)
          This study was conducted to determine whether there is an association between the removal of the corrugator supercilii muscle and the elimination or significant improvement of migraine headaches. Questionnaires were sent to 314 consecutive patients who had undergone corrugator supercilii muscle resection during endoscopic, transpalpebral, or open forehead rejuvenation procedures. The patients were queried as to whether they had a history of migraine headaches and, if so, whether the headaches significantly improved or disappeared after surgery. If the answer was affirmative, then the patients were further questioned about the duration of the improvement or cessation of the headaches and the relationship to the timing of the surgery. After an initial evaluation of the completed questionnaires, a telephone interview was conducted to confirm the initial answers and to obtain further information necessary to ensure that the patients had a proper diagnosis based on the International Headache Society criteria for migraine headaches. The charts of the patients who had migraine headaches were studied to ascertain and classify the type of surgery they had undergone. Patient demographics were reviewed, and the results were statistically analyzed. Of the 314 patients, 265 (84.4 percent) either responded to the questionnaire, were interviewed, or both responded to the questionnaire and were interviewed. Of this group, 16 patients were excluded because of the provision of insufficient information to meet the International Headache Society criteria, the presence of organic problems, and other exclusions mandated by study design. Thirty-nine (15.7 percent) of the remaining 249 patients had migraine headaches that fulfilled the Society criteria. Thirty-one of the 39 (79.5 percent) with preoperative migraine noted elimination or improvement in migraine headaches immediately after surgery (p < 0.0001; McNemar), and the benefits lasted over a mean follow-up period of 47 months. When the respondents with a positive history of migraine headaches were further divided, 16 patients (p < 0.0001; McNemar) noticed improvement over a mean follow-up period of 47 months, and 15 (p < 0.0001; McNemar) experienced total elimination of their migraine headaches over a mean follow-up period of 46.5 months. When divided by migraine headache type, 29 patients (74 percent) had nonaura migraine headaches. Of these patients, the headaches disappeared in 11 patients, improved in 13 patients, and did not change in five patients (p < 0.0001). Ten patients experienced aura-type headaches, which disappeared or improved in seven of the patients and did not change in three of the patients (p < 0.0001). This study proves for the first time that there is indeed a strong correlation between the removal of the corrugator supercilii muscle and the elimination or significant improvement of migraine headaches.
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            Comprehensive surgical treatment of migraine headaches.

            Bahman Guyuron, Jennifer Kriegler, Janine Davis … (2005)
            The purpose of this study was to investigate the efficacy of surgical deactivation of migraine headache trigger sites. Of 125 patients diagnosed with migraine headaches, 100 were randomly assigned to the treatment group and 25 served as controls, with 4:1 allocation. Patients in the treatment group were injected with botulinum toxin A for identification of trigger sites. Eighty-nine patients who noted improvement in their migraine headaches for 4 weeks underwent surgery. Eighty-two of the 89 patients (92 percent) in the treatment group who completed the study demonstrated at least 50 percent reduction in migraine headache frequency, duration, or intensity compared with the baseline data; 31 (35 percent) reported elimination and 51 (57 percent) experienced improvement over a mean follow-up period of 396 days. In comparison, three of 19 control patients (15.8 percent) recorded reduction in migraine headaches during the 1-year follow-up (p < 0.001), and no patients observed elimination. All variables for the treatment group improved significantly when compared with the baseline data and the control group, including the Migraine-Specific Questionnaire, the Migraine Disability Assessment score, and the Short Form-36 Health Survey. The mean annualized cost of migraine care for the treatment group (925 dollars) was reduced significantly compared with the baseline expense (7612 dollars) and the control group (5530 dollars) (p < 0.001). The mean monthly number of days lost from work for the treatment group (1.2) was reduced significantly compared with the baseline data (4.41) and the control group (4.4) (p = 0.003). The common adverse effects related to injection of botulinum toxin A included discomfort at the injection site in 27 patients after 227 injections (12 percent), temple hollowing in 19 of 82 patients (23 percent), neck weakness in 15 of 55 patients (27 percent), and eyelid ptosis in nine patients (10 percent). The common complications of surgical treatment were temporary dryness of the nose in 12 of 62 patients who underwent septum and turbinate surgery (19.4 percent), rhinorrhea in 11 (17.7 percent), intense scalp itching in seven of 80 patients who underwent forehead surgery (8.8 percent), and minor hair loss in five (6.3 percent). Surgical deactivation of migraine trigger sites can eliminate or significantly reduce migraine symptoms. Additional studies are necessary to clarify the mechanism of action and to determine the long-term results.
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              A review of current evidence in the surgical treatment of migraine headaches.

              Jeffrey E. Janis, Jenny Barker, Chris Javadi … (2014)
              Migraines affect 18% of women and 6% of men and result in an estimated $1 billion in medical costs and $16 billion productivity loss in the United States annually. Migraine headaches persist as a problem of this scale because pharmacologic treatments for migraines are frequently incompletely effective, resulting in a population of patients with significant residual disability. In the last decade, novel approaches to the treatment of migraines have been developed based on the theory that extracranial sensory branches of the trigeminal and cervical spinal nerves can be irritated, entrapped, or compressed at points throughout their anatomic course, ultimately leading to the cascade of physiologic events that results in migraine. Botulinum toxin (Botox) injection and surgical decompression of these trigger points have been shown to reduce or eliminate migraines in patients who are incompletely treated by traditional medical management. Despite the recent advances made with Botox, this treatment strategy most commonly results in only temporary migraine prevention. However, the evidence supporting the efficacy and safety of permanent surgical decompression of peripheral trigger points is accumulating rapidly, and the overall success rate of surgery has approached 90%. In addition, an abundance of literature investigating the precise anatomical dissections associated with trigger points has been published concurrently. This article reviews the most up-to-date clinical and anatomic evidence available and seeks to provide a comprehensive, concise resource for the current state of the art in the surgical treatment of migraine headaches.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Plast Reconstr Surg Glob Open
                Journal ID (iso-abbrev): Plast Reconstr Surg Glob Open
                Journal ID (publisher-id): GOX
                Title: Plastic and Reconstructive Surgery Global Open
                Publisher: Wolters Kluwer Health
                ISSN (Electronic): 2169-7574
                Publication date Collection: November 2019
                Publication date (Electronic): 12 November 2019
                Volume: 7
                Issue: 11
                Electronic Location Identifier: e2507
                Affiliations
                [1]From the Plastic Surgery Unit, Department of Medicine and Surgery, University of Parma, Italy.
                Author notes
                Edoardo Raposio, MD, PhD, Plastic Surgery Unit, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126, Parma, Italy, E-mail: edoardo.raposio@ 123456unipr.it
                Article
                Accession ID: 00022
                DOI: 10.1097/GOX.0000000000002507
                PMC ID: 6908332
                PubMed ID: 31942299
                SO-VID: af2ab898-a120-4731-ac9c-aab9f845248a
                Copyright © Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
                License:

                This is an open access article distributed under the Creative Commons Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 13 August 2018
                Date accepted : 28 August 2019
                Categories
                Subject: Special Topic
                Custom metadata
                OPEN-ACCESS TRUE

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