Migraine Surgical Interventions


Article Author:
Jitin Bajaj


Article Editor:
Sunil Munakomi


Editors In Chief:
Laura Stanley
Diana Peterson
Chantal Prewitt


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
6/4/2019 10:40:24 AM

Introduction

Migraine is a primary neurologic headache, often accompanied by nausea, vomiting, photophobia, phonophobia, or vertigo, and may present with or without aura.[1] It is prevalent in 11.7% Americans with 17.1% in women, and 5.6% in men.[2] Migraine can be acute or chronic. Treatment of this condition includes beta blockers, anticonvulsants, calcium channel blockers, tricyclic antidepressants, non-steroidal anti-inflammatory drugs, among others.[3] Migraine surgery is indicated when the condition is refractory to medical management.

Anatomy

There are several theories for migraine generation. Previously, vasodilation of the cerebral vasculature was proposed as the mechanism, but it has been refuted by several experiments that showed an absence of a migraine with the vasoactive intestinal peptide that increases the blood flow.[4] Similarly, the drugs precipitating migraine like sildenafil do not cause sustained vascular changes.[5] There is evidence to show cortical and brainstem hyperexcitability in a headache,[6][7] and cortical spreading depression as responsible for the aura.[8] There is evidence that shows trigeminal afferents projecting to meninges and releasing pain mediators like substance P, calcitonin-gene related peptide, and neurokinin A, thus causing a vicious cycle of sterile meningitis.[9] The strongest clinical evidence points toward the peripheral origin of a migraine. This is supported by the beneficial effect of Botulinum toxin and peripheral neurolysis for a chronic migraine, which is detailed in the following paragraphs.

Migraine surgery focuses around the neurolysis of sensory branches of trigeminal and occipital nerves supplying the face and back of the head. These nerves include supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, and greater and lesser occipital nerves. Sometimes, the pain is also due to hypertrophic nasal turbinates or deviated nasal septum irritating branches of trigeminal nerves.

Indications

Migraine surgery is indicated when the disease is not controlled by conservative measures, which include medicines and behavioral therapy.

Contraindications

A confirmed psychiatric disease is a relative contraindication.

Personnel

A neurologist should initially evaluate all cases. 

Preparation

The assessment of migraine severity can be done through several scales, of which most commonly used is the Migraine Disability Assessment Questionnaire (MIDAS).[10] In this, 0 to 5 score is labeled as MIDAS grade I (little or no disability), 6 to 10 as MIDAS grade II (mild disability), 11 to 20 as MIDAS grade III (moderate disability), 21 and higher as MIDAS grade IV (severe disability).

The initial treatment of a migraine is with drugs and behavioral methods, but often, patients develop refractoriness to these therapies.[11][12] ICHD-3 beta has amended the definition of a refractory migraine as along with existent criteria, monthly migraine headaches of at least 8, with 15 or more headache days a month. A flowchart showing management paradigm is shown in Figure 1.

When there is suspicion of a rhinogenic headache, the clinician can order a computed tomography (CT) scan of the nose and paranasal sinuses.

Technique

Botulinum Toxin

Botulinum toxin has to be instilled into pericranial muscles at multiple sites according to pain. The safe and effective dose is 25 units in total after mixing with normal saline. This can be divided into 3 units for temporalis each side (total 6 units), 2.5 units at 4 frontalis sites (5 units unilaterally; 10 units for both sides), 3 units at corrugators on each side (total 6 units), and 3 units for procerus in the midline.[13] For occipital headaches, one can instill about 12.5 to 50 units on each side of midline in the region of greater and lesser occipital nerves. Pain relief for 6 to 12 weeks indicates an appropriate candidate for the surgery.

Peripheral Neurolysis  

Frontal headache: An eyelid incision is used. The orbital septum is retracted caudally and orbicularis is retracted cranially. The corrugator supercilii and depressor supercilii are resected, and the nerves are freed. Both supraorbital and supratrochlear vessels are sacrificed, and the supraorbital foramen is unroofed. The space made is filled with the medial orbital fat and fixed with 6-0 vicryl. The incisions are then closed with 6-0 nylon suture. This can be done bilaterally.[14]

Anterior Temporal headache: The procedure described is cutting of zygomaticotemporal nerve. For a frontotemporal headache, it is combined with the procedure for frontal headaches by making 2 incisions, one in the upper tarsal crease and another at the superior temporal line.[15] These can also be done endoscopically.[14] The zygomaticotemporal nerve is found about 16-mm lateral to the lateral canthus and 6-mm cranial to it. A small incision of size 2 cm is made at this point and dissection is done in between the 2 layers of temporalis fascia. The nerve can be found at the lateral margin of orbit. It is cut and the end is buried deep into the muscle. The closure is done in layers.

Posterior temporal headache: For this, the auriculotemporal nerve is the culprit. The incision is made at the base of side-burn of a size of 2 cm. The nerve along with the superficial temporal vessels are identified. The vessels are sacrificed. The nerve is isolated for about 1 to 2 cm, is cut and then buried in the temporalis muscle. The incision is closed in layers.

Occipital headache: In case of an occipital migraine, occipital nerve neurolysis from semispinalis capitis muscle can be performed.[16] For diffuse occipital region pain, one should perform greater occipital neurolysis. A midline incision is made from external occipital protuberance to C2 spinous process. The trapezius fascia is cut about 1cm off midline. The trapezius fibers are split in line and dissection is performed below it to find the greater occipital nerve. The semispinalis capitis muscle around the nerve is transected to free the nerve. Similarly, trapezius muscle and fascia over the nerve is removed. The procedure can be repeated on the opposite side also. A pedicled fat is taken from the overlying skin and inserted between the nerve and the muscle and sutured there to be held in place. The incision is then closed with nylon 3-0.

For lateral occipital headache lesser occipital neurolysis or neurectomy can be performed. A 2-cm incision is made about 2-cm medial to the mastoid in the hairline. The thick temporal fascia is incised. The lesser occipital nerve is dissected out along with the vessel. The artery is coagulated and cut. The nerve is dissected out for about 1 to 2 cm, is cut and buried in the muscle. The incision is closed with nylon 3-0.

Occipital neurolysis though has immediate relief but also has high chances of recurrence,[16] and in such cases, alternative options like neuromodulation can be tried.

Rhinogenic headaches: If hypertrophied turbinates or deviated nasal septum is identified as the cause of headaches then turbinectomy or septoplasty is done in the standard manner.

Neuromodulation for Migraine

Neuromodulation is done when there is a failure of medical management, peripheral neurolysis is not feasible or has failed. The foremost option is occipital nerve stimulation (ONS). It is done by placing electrodes around cervical dorsal nerves in the suboccipital region and connecting them first to a trial stimulator, and if successful to a permanently implantable pulse generator. Other options of neuromodulation include sphenopalatine ganglion stimulation,[17] supraorbital nerve stimulation[18][19] and vagus nerve stimulation.[20][21] Though these have proved their beneficial roles in initial studies, large controlled trials are needed.

Complications

Botulinum Toxin

One can have transient hollowness of muscles in which the drug is injected, especially the temporalis muscle. The incidence can be around 23%.[22] Other complications may be transient eyelid ptosis (when injected into the eyebrow muscles), or neck muscle weakness (when injected into the cervical region).

Peripheral Neurolysis/Neurectomy

Patients can have neuroma formation when neurectomy is conducted. This can be prevented by burying the cut nerve end in the muscle. Infection, hemorrhage can be associated, but the incidence is low.

Turbinate Surgery

One can have postoperative epistaxis, sinusitis, or septal deviation.[22]

Neuromodulation

Lead migration can occur if they are not anchored properly. Infection can be associated, these can generally be managed with antibiotics, and rarely require implant removal.

Clinical Significance

A migraine is a common primary headache. A neurologist evaluates clinical features and MIDAS score. Initial treatment is through medicines and behavioral therapy. Botulinum toxin is commonly used as a screening tool to identify the triggers. Peripheral neurolysis/neurectomy is an effective treatment for drug refractory cases.

Enhancing Healthcare Team Outcomes

The migraine patient should be evaluated by an interprofessional team involving a neurologist, psychologist, psychiatrist, surgeon, specialty trained neurology nurse, and allied health professionals. Appropriate case selection is necessary to have a successful outcome of surgery. A pharmacist should be involved in pharmaceutical selection and maintenance. Nurses should assist in patient education before and after surgery. One should follow the methodology as given in the flowchart.

Botulinum Toxin

Botulinum toxin (BT) is a toxin produced by Clostridium botulinum. It paralyzes muscles by inhibiting release of acetylcholine from presynaptic terminals. It has 8 subtypes: A through H, of which type A is safe and effective for therapeutic usage.[23] Justinus Kerner discovered the idea of botulinum toxin to be used as a medical therapeutic, which he called botulinum toxin as "sausage poison." He did animal experiments and human experiments, including upon himself.[24] Scott initially used botulinum toxin for strabismus.[23] Thereafter, it was used in focal dystonia like blepharospasm,[25][26] cervical dystonia,[27][28] oromandibular dystonia,[29] laryngeal dystonia,[30] hemifacial spasm,[29][31] writer’s cramp,[32] spasticity, focal hyperhidrosis,[33] and to diagnose and treat trigger factors for migraine.[13] Botulinum toxin reduces migraine frequency and severity by decreasing the irritation of peripheral nerves by paralyzing the triggers, i.e., muscles, and decreasing the inflammatory mediators.[34] Evidence, including double-blinded controlled trials, suggest more than a 50% reduction in frequency and severity of migraines at 3 months, with efficacy lasting 3 to 4 months,[13][35][36] but some other blind trials did not show or show only modest effects of botulinum toxin over placebo.[37][38]

Though botulinum toxin can be used short term as an acute and prophylactic treatment,[13][35] its permanent use is difficult due to development of resistance with time leading to decrease in effect, and side-effects like muscle paralysis, muscle atrophy, and irritation, especially with higher doses.[13][39] Therefore, some recommend only using it as a screening tool before the neurolysis.[40]

Peripheral Neurolysis

The beneficial effect of peripheral neurolysis of supratrochlear and supraorbital nerves on migraine was discovered when Guyuron found that his patients were relieved of a debilitating migraine after brow lift surgery.[41] Subsequently, the group published a prospective study confirming the findings.[14] Neurolysis is performed after identification of trigger sites and when pain relief is more than 50% for at least 6 weeks by injecting BT. One can instill BT in bilateral frontal, temporal, over corrugators, and occipital region (12.5 units each).[14][15] Examination of hypertrophied nasal turbinates irritating the nasal septum should be done.

Neuromodulation

Occipital nerve stimulation (ONS) can have benefit for pain in the distribution of both occipital and trigeminal nerves through the modulatory activity of trigeminocervical complex. This consists of trigeminal nucleus and portions of upper 3 cervical dorsal nerves. It can result in 30% to 50% of patients having more than 50% pain relief.[42][43][44] This procedure has high rates of lead readjustments (around 50%) but that is minimally invasive.[44] ONS can also help in cluster headaches.[45] (Level I and II)


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    Contributed by Jitin Bajaj, MCh
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Migraine Surgical Interventions - Questions

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A 40-year-old female presented with daily hemicranial headaches precipitated by bright light. She has a moderate disability with it. She has to take medicines every time to relieve the pain. In which grade of Migraine Disability Assessment Questionnaire (MIDAS), is this patient?



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A 30-year-old female is experiencing severe migraine attacks over the left frontotemporal region since last one year. She is under treatment of a neurologist who has tried medical and behavioral treatment with no benefit. The patient has been advised to have injection at left frontal and temporal regions. What is the rationale of botulinum toxin injection in her management?



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A 25-year-old girl has refractory migraine attacks for last one year. The pain starts in the left temporal region and spreads to the whole head. Botulinum toxin injection in the left temporal region leads to the cessation of pain. The effect lasted up to 3 months. What is further best management in this patient?



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A 30-year-old businessman has cervical region pain radiating to the whole head since last five years. Medical and behavioral treatment has failed. Botulinum toxin injection given at suboccipital region on both sides lead to a greater than 75% reduction of pain lasting for eight weeks. What is the further line of management?



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A 34-year-old male has a refractory migraine to drugs and behavioral therapy for the last three years. The pain is diffuse and predominates in the back of the head, but also keeps shifting over the vertex, back of the head, and at sides. Botulinum toxin injection applied over the suboccipital region had given a more than 70% pain relief over the occipital region for six weeks, but not in vertex and temporal regions. What is the further best management?



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Migraine Surgical Interventions - References

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