Dayan.MigraineSurgery.Harvard
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A 49-year-old male CEO with chronic migraines underwent surgical decompression of trigeminal and occipital nerves. He had a history of migraines triggered by flights, fatigue and light. Prior treatments including medications and Botox provided some relief but migraines persisted. The patient underwent septoplasty, greater occipital nerve release, and decompression of supraorbital, supratrochlear and zygomaticotemporal nerves. Post-operatively, he had no migraines and was able to fly without triggers. The presentation reviewed the history of migraine surgery, evidence for peripheral trigger sites, and future directions including identifying patients most likely to benefit from surgery.
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Dayan.MigraineSurgery.Harvard
- 1. Migraine Surgery Erez Dayan, MD Harvard Plastic Surgery Interesting Case Presentation October 5, 2016
- 2. Outline I. Case Presentation II. History of Migraine Surgery III. Impact on population IV. Anatomy/Trigger points V. Clinical Evidence/Controversy VI. Future Directions
- 3. Patient B.B. • 49M Biotech CEO • Prior Workup: MRI, PET scan, sleep study, and seizure study. • Medications: lyrica, noratriptyline • Patient has tried botox in supraorbital/glabellar region with improvement • Triggers to migraines flights, fatigue, light.
- 5. CT Scan
- 7. Botox
- 8. Plan 1- Frontal 2- Temporal 3- Nasoseptal 4- Occipital
- 10. Greater occipital nerve release
- 13. Postoperative Course • Uneventful recovery, some minor paresthesias that have improved over posterior scalp and forehead • After septoplasty- able to fly without migraines • Has not experienced any migraines since surgery.
- 14. Evolution of Migraine Surgery 1931 – Walter Dandy Removed cervical and 1st thoracic sympathetic ganglions in 2 patients. Eliminated migraines in both. 1946 – Gardner Resection of greater superficial petrosal nerve. 26 patients underwent surgery, all with migraine headaches improved, 2 recurred within 7-8 months. Problems with lack of tears, corneal ulceration, dryness of nose 1969 – Murillo Resection of superficial temporal artery and auriculotemporal nerve. Eliminated migraines in 30/34 patients. Report did not include length of follow-up, nor was there control group. 1969 – Murphy Occipital neurectomy. Performed in 30 patients, 18-excellent, 7- good, 3-fair, 2- poor. All less than 1 year followup 1982– Maxwell Trigeminal ablation via radiofrequency in 8 patients with moderate to significant relief. 2000– Guyuron Relief of migraines in 2 patients who had endoscopic forehead rejuvenation with resection of corrugators
- 16. 60 patients (1 yr follow-up) • 28% - reported total relief from MH • 40% - significant improvement • 31% - minimal or no change
- 17. Impact • 18% women, 6% men (35 million Americans/yr) • Increasing incidence every year • $1.5 billion medical costs • $16 billion productivity loss • Pharmacologic treatment incompletely effective
- 18. Global Burden of Disease
- 19. Media
- 23. FDA fixed site fixed dose protocol
- 25. Oct 2015: FDA Approval of Botox for Migraines
- 27. Major Trigger Sites 1- Frontal 2- Temporal 3- Nasoseptal 4- Occipital
- 28. I. Frontal Trigger Site 1- Frontal
- 31. Supraorbital Foramen vs Notch
- 35. • 35 patients (43 trigger deactivation procedures) • 90.7% positive response rate – 51.3%: total elimination – 20.5%: >80% resolution – 28.2%: 50-80% resolution – 9.3%: no effect
- 36. II. Temporal Trigger Site 2- Temporal
- 37. Temporal Trigger
- 38. III. Nasoseptal Trigger Site 3- Nasoseptal
- 41. IV: Occipital Trigger Site 4- Occipital
- 45. • Surgical randomized controlled trial (n=75) with sham surgery and 1 year f/u Treatment group •41/49 patients (83.7%) experienced migraine elimination or significant improvement •28 (57.1%) reported complete elimination Sham surgery group •15/26 (57.7% p<0.05) reported improvement with 1 patient reporting migraine elimination (3.8%, p<0.001)
- 46. •69/89 patients were avail for follow-up •61/69 (88%) experienced complete elimination or substantial improvement of migraine headaches.
- 47. Expense of medical management for migraine headaches exceeded up-front cost of surgery shortly after 2 years postop.
- 50. Future Directions • Identify and stratify patients who may not respond to medical management earlier and more accurately • Multidisciplinary collaboration • Prospective data collection • Multicenter studies
- 51. Thank You
Editor's Notes
- Patients with lower midas do better Most patients are off the charts
- During patients first visit he was not experiencing migraine. He returned to office with migraine the next day. Left greater occipital nerve injected with 1.5mL marcaine with epi mixed with 0.5cc kenalog 10. Pain improved from 8/10 to 3/10.
- During patients first visit he was not experiencing migraine. He returned to office with migraine the next day. Left greater occipital nerve injected with 1.5mL marcaine with epi mixed with 0.5cc kenalog 10. Pain improved from 8/10 to 3/10.
- Bone on bone contact point on posterior superior aspect of nasal vault with perpendicular plate of ethmoid contacting insertion of middle turbinate. Perpendicular plate of ethmoid was removed via hemitransfixtion incision, relieving contact point.
- In response to his prior 2000 retrospective study, Guyuron et al piloted a prospective cohort study. 22 patients underwent transpalpebral CSM resection or endoscopic CSM resection with concurrent ZTN resection in response to trigger points identified by a preoperative series of Botox. 21/22 (95.5%) experience complete elimination or significant improvement of migraine headaches with 1 yr follow-up
- Single-site surgery- frontal trigger point BTX-A not utilized for patient selection
- Extracranial sensory branches of trigeminal and cervical spinal nerves can be irritated, entrapped, compressed. Vasodilation is consequence of meningeal nociceptor-induced release of calcitonin gene related peptide, substance p, neurokinin A (found in cell bodies of trigeminal neuron. Botox and surgical decompression of trigger points have been shown to reduce/eliminate migraines
- Compare ZTN from patients with migraines vs without (n=15) Migraine patients linear organization, disrupted myelin sheaths, discontinuous neurofilaments that suggested axonal abnormality.
- The discovery of migraine surgery coincided with the PREEMPT 2 trial
- However, it was not until the PREEMPT 1 and 2 trials that class 1A evidence was provided that botulinum toxin type A treatment reduces chronic migraine headache impact and improves headache-related quality of life.9,10 After these evidence-based data, the U.S. Food and Drug Administration approved botuli- num toxin type A for the treatment of chronic migraine headache on October 15, 2010.
- These findings are pertinent for CSM injection and subsequent resection because lower early surgical success rates in some studies were attributed to failing to appreciate the lateral extent of the glabellar complex which resulted in incomplete resection. In the second part of the series, Janis et al32 described 4 branching patterns of the SON in relation to the CSM, with a 78% incidence of nerve/muscle interactions and a 22% incidence of nerve branching cephalad to the CSM, which may have implications on the success of decompression
- In the second part of the series, Janis et al32 described 4 branching patterns of the SON in relation to the CSM, with a 78% incidence of nerve/muscle interactions and a 22% incidence of nerve branching cephalad to the CSM, which may have implications on the success of decompression
- Double hit theory Guyuouron doesn’t take down foramina/notch unless warrented endoscopically
- Midline 0.5 cm, 7, 10 cm from the midline and 1.5–2 cm behind the hairline. These radial incisions are 1.2–1.5 cm in length,
- 253 patients who underwent surgery for frontal migraine headaches were reviewed. These patients underwent either transpalpebral nerve decompression (n 62) or endoscopic nerve decompression (n 191). Preoperative and 12-month or greater postoperative migraine frequency, duration, and intensity were analyzed to determine the success of the surgeries.
- Liu et al (2012) compared success rate of endoscopic verus transpalpebral approaches and found that endoscopic approach ahs higher success rate.
- The zygomaticotemporal branch of the trigeminal nerve traverses a bony canal of the zygomatic bone and terminates in the temporal fossa (Fig. 1). Distal to the foramen, it travels either between the bone and temporal muscle (about 50 percent of cases), within the muscle via a brief course (about 25 percent of cases), or within the muscle via a tortuous course (about 25 percent of cases).3 Finally, it pierces the temporal fascia to innervate skin of the temporal region Irritation of ZTN: temporalis muscle adjacent vessels deep temporal fascia opening where the nerve exits from the fascia Pain in the morning due to grinding or clinching teeth while asleep, TMJ symptoms. Pain 17mm lateral and 6mm cephalad to the lateral canthus Rubbing or pressing the exit point of the ZTN from the deep temporal fascia may stop or reduce the pain in the beginning.
- Patient often complains of pain in the retrobulbar area Failure to respond to diffuse botulinum toxin-A injections Weather changes, menstrual cycle changes, and air travel. History of difficulty breathing through the nose, being a mouth breather, and history of sinus infections and headaches.
- Greater occipital nerve/Third Occipital Nerve: semispinalis capitis muscle Trapezius muscle Occipital artery Fascial bands This point is located approximately 1.5 cm from the midline and 3 cm caudal to the occipital protuberance.
- The high incidence of improvement of symptoms in the sham surgery group is intriguing. Some of this may be attributable to the placebo effect and is similar to what other studies have found.18 However, it is also possible that the incision and the undermining of the tissues may have, to some extent, altered neurosensory function, at least temporarily. In addition, it is possible that some of these patients exaggerated their preoperative symptoms to increase their chance of selection. Nevertheless, when the surgical treatment group as a whole was analyzed and when each surgery site was assessed separately, the surgical treatment group had a statistically significant improvement.
- Mean total cost reduction of $3,949/year $5820/yr spent to migraine treatment preop and declinded to $900/postop Migraine medication expenses reduced by median of $1997.26/year Alternative treatment costs reduced by $450/year Patients missed 8.5 fewer days of work/yr (regained $1525/yr) Average surgery cost $8378