Treatment of Frontal Secondary Headache Attributed to Supratrochlear and Supraorbital Nerve Entrapment With Oral Medication or Botulinum Toxin Type A vs Endoscopic Decompression Surgery

Abstract

IMPORTANCE Endoscopic surgical decompression of the supratrochlear nerve (STN) and supraorbital nerve (SON) is a new treatment for patients with frontal chronic headache who are refractory to standard treatment options. OBJECTIVE To evaluate and compare treatment outcomes of oral medication, botulinum toxin type A (BoNT/A) injections, and endoscopic decompression surgery in frontal secondary headache attributed to STN and supraorbital SON entrapment. DESIGN, SETTING, AND PARTICIPANTS Prospective cohort study of 22 patients from a single institution (Diakonessen Hospital Utrecht) with frontal headache of moderate-to-severe intensity (visual analog scale [VAS] score, 7-10), frontally located, experienced more than 15 days per month, and described as pressure or tension that intensifies with pressure on the area of STN and SON. A screening algorithm was used that included examination, questionnaire, computed tomography of the sinus, injections of local anesthetic, and BoNT/A in the corrugator muscle. INTERVENTIONS Different oral medication therapy for headache encountered in the study cohort, as well as BoNT/A injections (15 IU) into the corrugator muscle. Surgical procedures were performed by a single surgeon using an endoscopic surgical approach to release the supraorbital ridge periosteum and to bluntly dissect the glabellar muscle group. MAIN OUTCOMES AND MEASURES Headache VAS intensity after oral medication and BoNT/A injections. Additionally, early postoperative follow-up consisted of a daily headache questionnaire that was evaluated after 1 year. RESULTS In total, 22 patients (mean [SD] age, 42.0 [15.3] years; 7 men and 15 women) were included in this cohort study. Oral medication therapy reduced the headache intensity significantly (mean [standard error of the mean {SEM}] VAS score, 6.45 [0.20] [95% CI, 0.34-3.02; P < .001] compared with mean [SEM] pretreatment VAS score, 8.13 [0.22]). Botulinum toxin type A decreased the mean (SEM) headache intensity VAS scores significantly as well (pretreatment, 8.1 [0.22] vs posttreatment, 2.9 [0.42]; 95% CI, 3.89-6.56; P < .001). The mean (SEM) pretreatment headache intensity VAS score (8.10 [0.22]) decreased significantly after surgery at 3 months (1.30 [0.55]; 95% CI, 5.48-8.16; P < .001) and 12 months (1.09 [0.50]; 95% CI, 5.71-8.38; P < .001). There was a significant decrease of headache intensity VAS score in the surgical group over the BoNT/A group (mean [SEM] VAS score, 2.90 [0.42]) after 3 months (mean [SEM] VAS score, 1.30 [0.55]; 95% CI, 0.25-2.93; P < .001) and 12 months (mean [SEM] VAS score, 1.09 [0.50]; 95% CI, 0.48-3.16; P < .001) after surgery. CONCLUSIONS AND RELEVANCE Endoscopic decompression surgery had a long-lasting successful outcome in this type of frontal secondary headache. Even though BoNT/A had a positive effect, the effect of surgery was significantly higher. LEVEL OF EVIDENCE 3.

Decompression Surgery for Frontal Migraine Headache

“…In our review the most frequently used methods were MHI 7 , 28 , 34 , 36 and the headache questionnaire. 36 – 38 , 40 , 42 Quality of life documentation before and after a migraine surgery is exiguous, mirroring the literature regarding trigger site decompression surgery. In our opinion, to improve the migraine surgery effect reporting, future investigations should spotlight what is the most complete evaluation method to universalize outcome measurements.…”

“…From the 16 selected studies, 6 were retrospective studies, 7 , 32 – 34 , 37 , 39 11 were prospective studies, 28 – 31 , 35 , 36 , 38 , 40 – 42 of which 1 was a blinded randomized cohort study, 41 1 was a double-blind, sham surgery, controlled clinical trial, 30 and 1 was a cross sectional study. 40 A total of 628 patients were included in the review, and the sample size of each study ranged from 10 to 132 patients.…”

“…Concerning surgical techniques, 2 different approaches were mentioned. Seven studies reported a transpalpebral approach 28 – 30 , 39 , 40 , 43 , 44 : 6 studies reported an endoscopic approach 31 , 35 – 38 , 42 and 5 studies reported both. 27 , 31 – 34 , 41 Studies further mentioned that among endoscopic techniques from 1 single incision (1.5 cm) to 5 incisions, all were positioned behind the hairline.…”

“…With respect to outcome measurements, the most frequently used methods were migraine headache index (MHI) 32 , 33 , 38 , 41 and the headache questionnaire. 36 – 39 , 42 …”

“…Seven of 16 studies mentioned postoperative complications. 27 – 31 , 39 , 42 The most common complication reported in 6 studies 27 – 29 , 31 , 39 , 42 was transient paresthesia, followed by pruritus reported in 2 studies, 30 , 39 and eyebrow asymmetry or uneven movement, 27 , 30 frontal muscle paralysis, 27 eyelid ptosis 39 and hematoma formation reported in one patient. 31 Many authors suggest wearing a compressive bandage for 24–48 hours after surgery.…”