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Surgical Treatment of Migraine Headaches
Migraine headaches affect an estimated 10% of the worldwide population annually, and cause significant loss of workdays and billions of dollars in productivity. It is well documented that migraine headaches cause significant disability, and reduce of quality of life that is as dire, if not worse than, debilitating chronic diseases. There have been major pharmacological advances for the treatment of migraine headaches, yet patients must still endure migraine headache symptoms until the medications take effect. Furthermore, often times they still experience a poor quality of life despite an aggressive regimen of pharmacotherapy. Recently, innovative surgical techniques have been developed to help patients with migraine headaches. Elimination of trigger sites (TS) which was introduced to the public after successful clinical trials has been revolutionary in providing  significant improvement and/or long lasting relief from symptoms in appropriate candidates.

Trigger Site Release
The proposed theory is that trigger sites exist where sensory nerves are being stimulated by surrounding muscle or specific contact points. As a consequence of irritation of these nerves, a cascade of events is initiated which lead to inflammation of meningeal layers and migraine headaches. Four trigger areas have been identified so far. Three of these are in locations which the nerve passes through a muscle .The fourth trigger point, however, has been identified in the nose of patients who have significant septal deviation with enlargement of the turbinates. The contact between these structures causes the irritation of the trigeminal nerve end branches and thus triggers migraine headaches. Several large series of studies have been conducted to evaluate the efficacy of surgical obliteration of trigger points. Almost all demonstrated more than 90% response, with at least 50% improvement to complete resolution of migraine pain symptoms.

Ohio Plastic Surgeon Dr. Bahman Guyuron Chair of Plastic Surgery at Case Western Reserve University, was the first to explore and describe trigger site surgery to relieve migraines. His serendipitous discovery followed revelation by several of his patients that their migraines had disappeared following cosmetic brow lifts. This prompted a series of retrospective and prospective studies with gratifying results by Dr Guyuron and others. However, this type of migraine surgery is not offered as a first line of treatment, rather it is used after extensive evaluation and failure of medical treatment. This surgery is currently offered by the American Migraine Center through the Department of Plastic Surgery at University Hospitals of Cleveland and several centers around the United States and worldwide. Trials are still ongoing to standardize the procedures of choice for definitive management of migraine headaches, but there have been successful guidelines for surgical therapy described by Dr. Guyuron, which are being used by several migraine surgery specialists around the globe. Currently this treatment has institutional approval for adults, and trials for the pediatric population are ongoing at Rainbow Babies and Children’s Hospital in Cleveland, Ohio.

Details of the procedure:

Patients have to be screened preoperatively with a full neurological examination, and subsequent Botox injection and/or nasal endoscopy. A positive response to Botox predicts a favorable outcome of surgery. Single or multiple TS could exist and after proper identification, the surgical approach is planed. Migraine headaches can start in one area depending on their corresponding trigger site and spread to the rest of the forehead. It is important to identify the initial trigger sites rather than address all the areas of pain, after the inflammation involves the entire trigeminal tree. The following migraine headaches corresponds to their four separate trigger sites and are addressed individually either with multiple surgeries or more commonly on a single setting. Sometime alleviation of one trigger site results in unmasking a second site.

1) Forehead Migraine Headaches: In the glabellar area the supra-orbital and supra-trochlear nerves are skeletonized by resecting the corrugator and depressor supercilii muscle using an endoscopic approach similar that of used for cosmetic forehead lift.

2) Temporal Migraine Headaches: The temporal area,  where the zygomaticotemporal branch of trigeminal nerve passes through the temporalis muscle, is addressed using a similar endoscopic approach but involves removing a segment of the nerve rather than transecting the muscle. The residual sensory defect on the temporal skin area is minimal because of cross innervation from other sensory nerves.

3) Rhinogenic Migraine Headaches: The nasal trigger points where enlarged turbinates are in contact with the nasal septum are addressed with spetoplasty and turbinectomy.

4) Occipital Migraine Headaches: The posterior neck area where the greater occipital nerve passes through the semispinals capitis muscle is addressed with an open surgical approach with resection of a small segment of the semispinalis muscle and shielding the nerves with a subcutaneous adipose flap.

Other Surgical and invasive approaches in consideration
A) Surgical Ligation of scalp vessels has shown some promis in the treatment of migraine headaches. Ligation of temporal vessels was first descidebed by Al-Zahrawi (936 - 1013 AD)( Link to Al-Zahrawi page in wikipedia page), a Moorish physician. Historically it is reported that Abroise Pare (1510-1590 AD) father of modern medicine ligated his own temporal vessels for relief of his migraines. This technique however has not been popularized thus far. There are no scientifically valid studies that have been offered to substantiate efficacy of such techniques.

B) Patent Foramen Ovale (PFO) Correction: Several clinical trials are currently under way in an effort to determine the existence of a causal linkage between PFO and migraine. It has been shown that migraines are reduced in frequency if the foramen is closed.

C) Botulinum Toxin A: Various headache specialists report encouraging results for chronic migraines using injection of botulinum toxin A. This treatment is effective in suppressing the trigger site without invasive surgery. However, repeated injections are required to keep the headaches under control and they do not address the headaches which are triggered from the septum and turbinates.

D) Spinal Cord Stimulators: These are medical implant stimulators in the region of the spinal cord. They are sometimes used in cases of severe migraine headache on patients who tend to have multiple attacks in a month.