Surgical Migraine Treatment
Each of our patients is unique, and the operation or set of operations that we offer you will be bespoke and tailored to you based on the specific trigger sites that we have identified.
Our surgical migraine treatment focuses principally on three anatomical sites. The following sections explain the surgery for these main trigger sites in greater detail.
1. Frontal site (the forehead)
Here, we are targeting the supra-orbital and supra-trochlear nerves. These are sensory nerves that emerge from the skull at the top of the orbit (eye socket) to give sensation to the skin of the forehead and scalp. The nerves can be compressed by tight bands of fascia (connective tissue) or by blood vessels as they emerge from the orbital rim. These nerves then travel through the corrugator supercilii muscle – a frowning muscle – and contraction of these muscles compresses and pulls on these nerves. Patients in whom these nerves contribute to their migraines often have deep frown lines between the eyebrows. They often find that the migraine pain frequently starts around the eyebrows, and they commonly massage this area to lessen the pain during migraine attacks.
Surgery to the frontal trigger site involves making a small incision in the eyelid to decompress the nerves where they emerge from the orbit, and in some cases to remove part of the corrugator supercilii muscle. For this operation, we use the same incision that is used in cosmetic eyelid surgery (blepharoplasty), which is hidden in the eyelid crease and barely visible once fully healed.
2. Temporal site (the temple)
There are two potential sensory nerves involved here – the auriculotemporal nerve, and the zygomaticotemporal nerve. In most patients with a temporal trigger site, there is irritation of the auriculotemporal nerve from a blood vessel called the superficial temporal artery, which travels in front of the ear. The nerve is often found intertwined within the blood vessel and its branches, and the blood vessel is frequently thickened and inflamed. Patients with a temporal trigger site might often find themselves pressing their temples during a migraine attack to relieve the pain – what they are doing here is temporarily closing off the superficial temporal artery.
Surgery to the temple involves making a small vertical incision in front of the ear, carefully identifying and freeing up the branches of the auriculotemporal nerve, and permanently closing the blood vessel. The scar is very discreet and can usually be hidden in the hairline or in a natural crease.
3. Occipital site (the back of the head)
For patients with an occipital trigger site, their headaches often start at the back of the head, and will frequently radiate to the forehead or behind the eye. There is often neck pain, neck tightness, and there may be a history of whiplash. Patients are typically tender at the top of the nape of the neck, on either side of the midline, and may subconsciously massage these areas during a migraine attack. The trigger site is the point at which the greater occipital nerve emerges from a muscle called semispinalis, and travels under the aponeurosis (a tight, fibrous, connective tissue band) of another muscle called the trapezius. This area is known as the ‘trapezius tunnel’. It is here where contraction of the trapezius muscle causes the sharp edge of the aponeurosis to compress and apply traction on the nerve, and this is why Botox to temporarily paralyse that muscle results in symptomatic relief in patients with a greater occipital nerve trigger site. There is a strong overlap with another condition called occipital neuralgia, which often overlaps with (or can be mistaken for) migraine headaches.
Surgery to decompress this trigger site is performed through a midline incision at the back of the head, which is mostly hidden within the hairline. About 2-3cm of the incision will be visible below the hairline. We identify the greater occipital nerve at its emergence from the semispinalis muscle, and follow its course, releasing all constricting fibrous bands and the compressing fibres of the trapezius tunnel. There are frequently blood vessels that cross or intertwine with the nerve that contribute to the compression, and these are surgically ablated.
4. Additional sites
There are other less common but recognised ‘minor’ migraine trigger sites, such as the lesser occipital nerve, the third occipital nerve, or ‘nummular’ sites (smaller, unnamed nerves under the skin that cause a very focal pain). If we identify these trigger sites when examining you, we will discuss treating these sites in addition to the three major trigger sites.
