Surgical Therapy of Temporal Triggered Migraine Headache

Abstract

Background:The auriculotemporal and zygomaticotemporal nerves are the 2 primary trigger points in the temporal area of migraine headache. Different surgical approaches are described in literature, either open or endoscopic ones.Methods:We described and delineated the currently adopted strategies to treat temporal trigger points in migraine headache. Furthermore, we reported our personal experience in the field.Results:Regardless of the type of approach, outcomes observed were similar and ranged from 89% to 67% elimination / >50% reduction rates. All procedures are minimally invasive and only minor complications are reported, with an incidence ranging from 1% to 5%.Conclusions:Just like upper limb compressive neuropathies, migraine headache is believed to be caused by chronic compression of peripheral nerves (ie, the terminal branches of trigeminal nerve) caused by surrounding structures (eg, muscles, vessels, and fascial bands) the removal of which eventually results in improvement or elimination of migraine attacks. Particular attention should be paid to the close nerve/artery relationship often described in anatomical studies and clinical reports.

Minimally Invasive Surgical Treatment of Migraine

“…From June 2011 until July 2019, we performed MH decompression surgeries in over 269 patients with either frontal, occipital, or temporal migraine trigger sites [2,[13][14][15][16][17][26][27][28].…”

“…The ATN is one of the terminal braches of the mandibular (V1) division of the trigeminal nerve. The ZTN is one of the terminal braches of the maxillary division (V2) of the trigeminal nerve [17][18][19][20][21].…”

“…A handheld Doppler was regularly used to locate the STA, since we observed 100% correlation rate between the trigger point identified and a close ATN-STA relationship (being either a simple crossover or a helical intertwining). Once the incision was made, dissection was taken with the help of blunt tipped scissors to expose and isolate both ATN and STA, which was ligated both proximally and caudally to the area of nerve-artery intersection [17].…”

“…We opened the inferior temporal septum exposing the inferior temporal compartment that contains the ZTN, sentinel vessels, and temporal branches of facial nerve (that must be carefully preserved by incorporating it in the roof of the elevated flap). Then we widened the exit of the ZTN through temporal muscle and fascia, and the sentinel vessels were cauterized only when patients described a pulsating pain in the temporal region [17] (Figure 2).…”

“…Temporary anesthesia occurred in all patients, which lasted 163 days on average [2,[13][14][15][16][17][26][27][28][29]. Minor and transient complications reported in literature are lasting occipital numbness, intense itching after surgery, hypertrophic scar, incisional cellulitis, transient mild incisional alopecia or hair thinning, lasting neck stiffness that have an incidence ranging from 1 to 5% [2,[13][14][15][16][17][26][27][28][29]. As regard our experience, intense itching after surgery was present in 30% of patients, temporary anesthesia in all patients while postoperative infections, seromas, or hematomas were not observed.…”