The treatment of migraine headache patients by Botox injections has been shown to be effective in specific patients who have identifiable triggers of the supraorbital and supratrochlear, zygomaticotemporal, greater occipital, and septal trigeminal nerves. The temporary relief from Botox has led to the concept that relieving pressure on the nerves by muscle resection (surgical decompression) can subsequently be effective and may provide a more long-term solution to the migraine problem. Since Botox relaxes muscles around the nerve, the concept of nerve decompression through muscle resection is a logical transition. The use of Botox then becomes a qualifier to determine if nerve decompression is likely to be successful.
Surgical decompression of migraines, pioneered by plastic surgeon Dr. Guyuron in Cleveland, has shown that a high percentage of carefully-chosen patients may benefit. (> 90%) The key here is...careful patient selection. One must work with a neurologist who refers the patient based on their trigger points for their migraine and their success with Botox injections. On average, most migraine patients experienced improvement at one year follow-up, needing less medications for management. While some patients do experience a 'cure', this is not the majority of migraine sufferers. A recent publication in the July 2008 issue of Plastic and Reconstructive Surgery by Dr. Poggi of Wichita confirms these results in their own reported experience. One of the most interesting findings of their study was that two-thirds of the patients felt that surgery offered better relief than Botox injections and, even in those patients who had results no better than Botox, stated that they would go through surgery again..
Surgical decompression involves removing muscle that intertwines or lays against the nerve. In the frontal area, this can be done endoscopically (like an endoscopic brow lift) from a remote scalp location or directly through an upper eyelid incision. As of now, this is a surgeon's choice and the evidence that one method is superior over the other remains to be conclusively proven. Going through the eyelid approach probably allows better control of the amount of muscle removed and the potential for inadvertent nerve transection or avulsion. For the zygomaticotemporal, greater occipital and septal trigeminal nerves, a direct open approach is used as this is done in the hairline or inside the nose.
For those patients whose migraine headaches are of sufficient frequency and are not well controlled by medication, surgical decompression of trigger points offers potential for improving their lives.
Dr Barry Eppley is a board-certified plastic surgeon in private practice in Indianapolis, Indiana at Clarian Health Systems. ( http://www.eppleyplasticsurgery.com ) He writes a daily blog on plastic surgery, spa therapies, and medical skin care at http://www.exploreplasticsurgery.com
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