Migraine Surgery, Zone 1 (Frontal), Zone 2 (Zygomaticotemporal), and Zone 5 (Auriculotemporal)

Abstract

Migraine surgery targeting peripheral nerves in the head and neck is a relatively recent treatment option. It originated when Dr. Bahman Guyuron discovered marked symptomatic improvements in migraine patients undergoing endoscopic forehead and brow lift surgery. Numerous studies have demonstrated that extracranial decompression of specific trigeminal and cervical root branches leads to a marked reduction in migraine headache frequency, intensity, and duration (Guyuron et al., Plast Reconstr Surg 115:1–9, 2005; Guyuron et al., Plast Reconstr Surg 124:461–468, 2009).

Nomenclature of migraine trigger zones and their associated nerves are as follows: zone 1 (frontal, supraorbital and supratrochlear nerves), zone 2 (temporal, zygomaticotemporal nerve), zone 3 (sinonasal, involves nasoseptal deviation with turbinate contacts and concha bullosa resulting in irritation of the sinonasal nerves and triggering of migraine symptoms), zone 4 (occipital, greater and lesser occipital nerves [often referred to as zone 6]), and zone 5 (auriculotemporal nerve) (Behin et al., Cephalalgia 25:439–443, 2004). Recent identification of a fifth trigger zone, the auriculotemporal nerve, where impingement occurs by means of the superficial temporal artery and other proximal fascial compression points, leads to further technical refinements and overall greater success rates in migraine surgery.

Before migraine surgery is considered, it is crucial that migraine is accurately diagnosed. Patient must undergo a detailed history and physical examination with an established neurologist. Identifying the trigger areas based on constellation of symptoms may be sufficed in certain patients. Injection of botulinum toxin, nerve blocks, or both into specific trigger sites is confirmatory and carries a positive predictive value for success of surgical treatment. Collaboration with a board-certified neurologist specializing in migraines and chronic headaches is important in identifying patients who may be candidates for surgery, as it is usually reserved for patients whose symptoms are not adequately controlled with medication or those who have significant adverse effects with the medications.

Open and endoscopic approaches to trigger release of zones 1, 2, and 5 will be discussed in this chapter.