Endoscopic Forehead Lift and Migraine Surgery

Approximately 35 million people in the United States, or approximately 17% of women and 6% of men in America suffer from Migraines. Frequent Headache symptoms can last from 4 hours to several days and include: severe pain nausea, aura, light sensitivity, appetite loss, dizziness, and exhaustion. Spontaneous Migraines can radically hinder work, the individual’s ability to concentrate, as well as being present, family events, relationships and virtually every facet of life.

Many Migraine suffers manage Migraine Headaches prescription medication. The yearly cost of these Migraine medications is roughly $1.5 billion. Presently, there is no generally established, permanent cure, and the majority of patients continue to endure symptoms, even with pharmacologic treatment.

Even though the pathophysiology of Migraine Headaches continues to cause controversy, studies have exemplified that trigeminal nerve irritation causes the release of calcitonin gene-related peptide and neurokinin A into the cell bodies of the trigeminal nerve. These proteins cause inflammation and pain in the region surrounding the trigeminal nerve. The hypothesis is that the musculature, vessels, bony foramen, and perhaps the fascia bands surrounding the trigeminal nerve branches in the head and neck inflame the nerves, causing inflammation. Based on this theory, Migraine Surgery has progressed to include removal of various surrounding superficial muscles, fascia, or vessels to decrease irritation, diminishing Migraine Headache occurrence.

Benefits of Surgery for Migraines

It has been proven that Surgery for Migraines has provide relief for 5 years or more, with a 50% reduction in frequency, duration and intensity in more than 80% of patients. Migraine Surgery can be performed at 4 common trigger sites: the frontal site is the most widespread, where the glabellar muscles (depressor supercilii, corrugator supercilii, procerus muscle) and connected vessels, overlying fascia bands and the foramina apply unwanted pressure on the supratrochlear nerve and the supraorbital nerve, causing Migraine Headaches. Additional trigger sites include temporal, septonasal and occipital regions. Accessing the frontal trigger site requires the resection of glabellar muscle group, cauterization of vessels surrounding the nerves, uncovering the supraorbital foramen when present, and, if accessible, release the fibrous band across the supraorbital notch. These surgical techniques alleviate supratrochlear nerve and supraorbital nerve inflammation.

For the past 15 years, endoscopic nerve decompression has been used on patients undergoing concomitant endoscopic treatment of zygomaticotemporal branch of the trigeminal nerve. Endoscopic nerve decompression was not performed on patients with long foreheads (> 8 cm measured from the anterior hairline to the supraorbital ridge) or on patients with considerable forehead curvature, since endoscopic access would have been nearly impossible. Transpalpebral nerve decompression was performed when there was no related endoscopic site surgery, as transpalpebral nerve decompression offered closer access to the glabellar muscle group and did not require endoscopic equipment. Efficacy of transpalpebral nerve decompression was compared to endoscopic nerve decompression in frontal Migraine Headache reduction.

Migraine Surgery Patient Selection

Patients selected by Migraine Doctors in NYC were comprised of individuals who received Frontal Migraine Surgery. A successful surgical outcome resulted in a 50% decrease in Migraine manifestation after 1 year.

Overview of Transpalpebral Nerve Decompression Surgical Technique

An incision was placed in the supratarsal crease, including up to two-thirds of the central limit of the center segment of the conventional upper blepharoplasty incision. The upper eyelid glabellar area and the lower forehead were penetrated 1% Lidocaine containing
1:1000,000 epinephrine and 0.5% ropivacaine HCL. After the incision is completed, a skin-orbicularis oculi muscle flap was elevated above the level of the septum and the orbicularis muscle in a cephalic direction. The dissection was continued to the supraorbital rim. The depressor supercilii muscle was exposed and removed, protecting the supraorbital nerve and supratrochlear nerve. This enabled the unveiling of the corrugator supercilii muscle, which is a darker color and more fragile when compared with the depressor supercilii muscle. The corrugator supercilii muscle was excised with electrocautery, and lateral fibers of the procerus muscle covering the supratrochlear nerve were also removed. Fat was harvested either from the medial fat pad of the upper lid or from a region vast to the deep temporal fascia above the zygomatic arch, if endoscopic tissue removal of the zygomaticotemporal branch of the trigeminal nerve was completed concomitantly, and plated to fill the depression left after removal of the corrugator supercilii muscle and to protect the nerves

Overview of Endoscopic Nerve Decompression Surgical Technique

A midline incision or two paramedian incisions were marked 1.5 cm long, approximately 3.5 cm apart in the frontal area and 1 or 2 similar incisions in the temple if decompression of the temple trigger site was also indicated. The hair-bearing forehead scalp was infiltrated with 0.5% Lidocaine mixed with 1:2000,000 epinephrine, and the remaining forehead area was infiltrated with a mixture of 0.5% ropivacaine HCL and 1% Lidocaine with 1:1000,000 epinephrine. If this was performed in conjunction with Migraine Trigger Site Surgery, 5 or 6 1 cm incisions were made for access to the glabellar muscle group and the zygomaticotemporal branch of the trigeminal nerve. Migraine Surgery was preformed first, and fat was harvested from beneath the deep temporal fascia above the zygomatic arch medially. To remove the muscles, the incisions were made and endoscopic access devices were used. The dissection was completed caudally and medially in a subperiosteal plane to reveal the glabellar muscle group. The corrugator supercilii muscle and the depressor supercilii muscle were completely removed, along with the lateral fibers of the procerus muscle under direct endoscopic visualization, being careful to protect the supraorbital and supratrochlear nerves

Outcome: Transpalpebral Nerve Decompression vs. Endoscopic Nerve Decompression

The majority of patients received endoscopic nerve decompression; only a select few underwent transpalpebral nerve decompression. Of the transpalpebral nerve decompression patients, 79% experienced a 50% reduction in frontal Migraine occurrence, with 52% no longer experiencing Migraine Headaches. Of the endoscopic nerve decompression patients, 89% experienced 50% reduction in frontal Migraine occurrence, with 67% experiencing complete elimination. Endoscopic Nerve Decompression provided Migraine Headache suffers with slightly more relief than transpalpebral nerve decompression patients received.

Chronic Migraines (CM), or Transformed Migraine, is a complication of periodic Migraines with 2.5% progressing annually from intermittent to full-fledged CM. Symptoms can arise with or without excessive medication use. The pain level is typically mild to moderate and not always associated with photophobia, phonophobia, nausea, or vomiting and may appear to be a blend of Migraine and Tension Headache with sporadic Migraines. Depression is present in 80% of patients. Risk factors that contribute to Chronic Migraines include: medication overuse (particularly opiates taken in conjunction with barbiturates), high caffeine intake, female gender, stressful events, anxiety, baseline high attack frequency, individuals from lower educational and socioeconomic backgrounds, Caucasian parents, previously married individuals, permanent head or neck injuries, obesity, snoring, Arthritis, and Diabetes.

Only 20% of patients with CM are properly diagnosed with Chronic Migraines by healthcare providers and instead are given a constellation of alternate sinus, stress, cervical spine, and allergies. Or they believe their bad Headaches are Migraines and they have other diagnoses for the milder Headaches. Only 33% of patients with CM are using preventive medications.

Although the evidence should be carefully considered, medication rebound can transpire when opiates are used 8 more days per month with effect more obvious in men, triptans in individuals with a high Headache frequency at baseline, or butalbital combinations 5 or more days per month with the effect more prominent in women. Triptans on 10 or more days per month, or OTC analgesics or any combination of triptans and analgesic opioids for 15 or more days per month on a regular basis for more than 3 months without overuse of any particular class can result in Medication-overuse Headache (MOH). Obviously, in addition to inducing medication overuse, constant use of butalbital and opiates can prompt addiction and other unwanted side effects.

Protocol to Treat Medication Overuse

Withdrawal of the overused medication alone, which can be combined with a preventive medication, may lead to a decrease in Headache frequency in most patients. Caffeine should be avoided, as ingestion of as little as 200 mg daily in vulnerable patients can lead to MOH, and some individuals with withdrawal symptoms with even low does of 100 mg daily. Decrease overused medications. For individuals taking high-frequency butalbital combinations, phenobarbital 30 mg twice a day (bid) can be substituted for 2 weeks, followed by 15 mg bid for 2 weeks (sudden withdrawal my cause seizures). For patients taking high doses of opioids, clonidine 0.1-0.2 mg three times daily (tid) increased or decreased based on symptoms or clonidine patch 0.1-0.2 mg 24 hours for 1-2 weeks.

There are various transitional therapy options. Naproxen 500 mg bid for 1-2 weeks may be used alone or in conjunction with tizanidine, starting at 2 mg at bedtime (hs).

Are there Any FDA-Approved Treatments for CM?

Yes, Botox® Cosmetic (onabotulinumtoxinA), approved by the FDA in October 2010, based on the 2 phase 3 research evaluating Migraine Prophylaxis Therapy (PREEMPT) trials. The approved treatment involves administering 155 units in 31 fixed-site, fixed dose injections of 5 units in each of the following muscles: the procerus and bilateral corrugators, frontalis, temporalis, occipitalis, cervical paraspinals, and superior trapezius muscles.

Migraines and Botox

At 24 weeks, 47.1% of patients treated with onabotulinumtoxinA had a >50% decrease from baseline in Headache frequency days compared with 35.1% of placebo-treated patients. Botox treatment for Migraines was as effective in 65.3% of the patients from 2 studies with medication overuse as the total PREEMPT population of 1384 adults with and without medication overuse.

Even though Migraine treatment with Botox is expensive, the costs can be reduced by less triptan use. Additionally, a retrospective study of 223 patients with CM who were treated with 2 injection cycles found a 39% counterbalance of estimated injection costs by a reduction in Migraine-related emergency department visits, hospitalizations, and urgent care visits.

Effective Migraine Headache Management with Botox

Botox has been used off label since 2000 for Migraine Headache treatment. PREEMPT 1 and 2 trails provide class 1A evidence that treatment with Botox decreases Migraine Headache severity and improves Headache-related quality of life. As a result of these evidence-based statics, the U.S. Food and Drug Administration approved Botox for Chronic Migraine treatment on October 15, 2010. This approval ultimately and to an extent confirms surgical treatment of Migraine Headache because the physiologic device behind Botox treatment and surgical Migraine Headache treatment is in all probability comparable.

Both work to relax peripheral nerves, Botox chemically, while in contrast surgery automatically removes physical anomalies. Indeed, due to this cohesion, Botox has been used time and again as a diagnostic tool in Migraine Surgery trigger site identification. Although a recent study demonstrates that Botox injection may not be required in trigger identification, FDA approval of Botox for Chronic Migraine Headache treatment in increase its use among Migraine patients.

Patient response to Botox varies from no decrease in Migraine Headache to complete Migraine Headache eradication.

The peripheral trigger point for Migraine Headaches can be deactivated either chemically through Botox injection or routinely via surgery. Even though Botox injection is a powerful Migraine trigger point deactivator, Migraine Surgery attains permanent, successful outcome juxtaposed with Botox injection. Patients typically mention exacerbated Migraine Headaches 2.5 to 3 months after injection, which coincides with the recurrence of dynamic muscle contraction. In addition to offering temporary reduction of Migraine Headaches, Botox injections are also integral to Migraine Surgery. Botox can be utilized to determine possible Migraine Surgery trigger sites. A detailed patient history and physical exam is comparable to Botox injection in identifying possible trigger sites.

Most of the patients who require Migraine Surgery have had previous onabotulinumtoxinA injections, for either diagnostic or therapeutic reasons. The figure will only increase, due to the recent approval of onabotulinumtoxinA by the U.S. Food and Drug Administration for therapeutic Migraine treatment. A vast majority of patients (53.3%) have received onabotulinumtoxinA prior to surgery.

Generally, Migraine Surgery yields a more positive outcome in patients who respond favorably to onabotulinumtoxinA injections, regardless of whether the onabotulinumtoxinA injection and surgery are administered in the same region (surgery success rate, 90.3% vs. 73.7%.

The affiliation between onabotulinumtoxinA injection reaction and Migraine Surgery reaction is intensified when patients who have the same onabotulinumtoxinA injection and surgery site were examined.

Are Nerve Blocks an effect treatment?

In an open-label, single treatment arm study of 150 patients suffering from Migraine Headaches with a pronounced cervicogenic component (at least 50% of their most severe Headaches occurred from one side of the base of the skull or both) who received unilateral or bilateral occipital nerve blocks with local anesthetic and steroid, 52% encountered a 50% decrease in Headache days over the month after the procedure, compared with the pretreatment baseline month.

A prospective open-label included 218 patients with intractable CM, without butalbital or opioid medication overuse who received a fixed-dose (0.1 cc of 0.25% Bupivacaine) and a fixed-site (10 at greater and lesser occipital nerves, 5 at auriculotemporal and zygomaticotemporal, 2 at supraorbital and supratrochlear areas bilaterally) pericranial injections every 3 months. After 1 year, 53.2% of patients had a more than 50% decease in frequency of Headache days.

Are there Effective Alternative or Complementary Treatments for CM?

Acupuncture can offer some relive of CM symptoms, with an additional benefit when used in tandem with medical management. Safflower seed acupuncture point injection can be more effective than NS in patients with daily, chronic Headache. In a study of 66 CM patients randomly selected for acupuncture treatment administered during 24 sessions over 12 weeks or topiramate measured to a maximum of 100 mg daily, the average monthly number of moderate/severe Headache days decreased from 20.2 to 9.8 in the acupuncture group, compared to 19.8 to 12.0 in the topiramate group, with benefit observed in patients with medication overuse.

Behavioral sleep modification can be beneficial for Transformed Migraine. Although biofeedback, relaxation therapy and cognitive behavioral therapy have proven efficiency for preventing Episode Migraines, there is limited data for CM treatment. In a study of 91 subjects with Episodic Migraine randomized to treatment groups, physical exercise, relaxation therapy and topiramate were equally effective for CM prevention. Biofeedback-assisted relaxation may supplement prescription medications based on a 3-year follow-up study of chronic daily Headache related to medication overuse.

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