16 - Surgical management of facial pain, including migraines

Abstract

Migraine headaches are a debilitating neurological condition with associated high medical costs and indirect costs from lost wages. The traditional treatment of migraine headaches involves prophylactic and abortive medications. Some patients with migraine headaches may have compression of peripheral head and neck nerves that can be surgically deactivated to provide symptomatic relief. There are known trigger sites corresponding to specific named nerves with known anatomic points of potential compression: frontal (supraorbital and supratrochlear nerves), temporal (zygomaticotemporal branch of trigeminal nerve and the auriculotemporal nerve), rhinogenic, and occipital (greater occipital nerve, third occipital nerve, and lesser occipital nerve). Nummular headaches are an additional class of headaches and can occur anywhere on the scalp and may also benefit from a surgical approach. The diagnosis of peripheral nerve compression headaches follows a step-wise approach beginning with patient history to obtain the constellation of symptoms surrounding the headache pain, hand-held Doppler to help confirm the presence of possible offending compressive adjacent vasculature, nerve blocks using local anesthetics, injection of botulinum toxin-A, imaging modalities (i.e., CT scan), and pain sketches. Surgical treatment of peripheral nerve compression headaches is based on deactivation of known anatomic points of compression for each nerve. Clinical outcomes have been well studied and documented in the literature – patients receive significant and long-lasting symptomatic relief.