Supratrochlear Research Articles

Using of transcutaneous supraorbital nerve stimulation in the treatment of chronic tension type headache

BACKGROUND. The clinical study was carried out as part of the scientific work Non-drug treatment methods and optimization of coping strategies for chronic tension type headache.
 AIM. To evaluate the effectiveness of the use of transcutaneous neurostimulation of the supratrochlear and supraorbital nerves in patients with chronic tension type headache.
 MATERIAL AND METHODS. The clinical study was conducted from February to August 2021. In total, 50 patients with chronic tension type headache took part in the study, which were divided into two groups: the main group (40 participants) and the control group (10 participants). In the main group, patients received transcutaneous neurostimulation of the supratrochlear and supraorbital nerves with low-frequency (60 Hz) impulses. In the control group, participants received only drug therapy. One month after the end of the course of treatment, the intensity, frequency of headache, the amount of drugs taken, and the effect of headache on work ability were assessed. Statistical processing was performed in the IBM SPSS program using tests for nonparametric data and tests of signs and Wilcoxon. The results of the data were taken as significant at p 0.05.
 RESULTS. In the main group, there was a statistically significant (p 0.05) decrease in the frequency of headache episodes by 1.8 times, the number of analgesics consumed by 2.8 times, and the intensity of headache by 50%. We also observed a decrease in the effect of headache on the ability to work of patients from 79 to 47.3%. At the same time, there were patients whose headache did not affect their ability to work. In the control group we did not notice significant dynamics in the frequency of episodes and the intensity of headache.
 CONCLUSION. In our opinion, non-invasive percutaneous neurostimulation of the supratrochlear and supraorbital nerves is an additional option for preventive treatment in patients with chronic tension type headache.

Regional Scalp Blockade for Painless Removal ofIntracranial Pressure Bolts: Technical Note and Patient-Reported Outcomes

Elective insertion of intracranial pressure (ICP) monitoring bolts is useful for the diagnosis and treatment of disorders of cerebrospinal fluid dynamics. Patients typically report severe discomfort on bolt removal, which negatively impacts overall patient satisfaction of ICP monitoring. We assessed the efficacy and safety of using supratrochlear and supraorbital nerve block-a commonly used form of scalp anesthesia-alongside oral analgesia before bolt removal. We compared the efficacy and safety of regional scalp block anesthesia alongside oral analgesia versus oral analgesia alone in a cohort of 85 patients undergoing removal of diagnostic ICP bolts between June 2017 and April 2019 using retrospective patient questionnaires, as well as electronic admission documentation. We found that scalp block alongside oral analgesia improved bolt removal experience (4/5 vs. 3/5 on a 1-5 point Likert scale) and that a majority (70.6%) of patients would have preferred local anesthetic before removal in the oral analgesia-only group. Only 2 patients experienced mild and localized side effects: mild bruising and temporary facial and eyelid swelling following regional scalp block. We conclude that regional supraorbital and supratrochlear nerve block is a simple, safe, and effective adjunct to minimizing discomfort during bolt removal and improving overall patient satisfaction of ICP monitoring.

433 Efficacy and Safety of Surgical Decompression for Migraine: A Systematic Review

INTRODUCTION: Migraine is a common disabling disease with high socioeconomic and personal impacts. Despite various medical options, many patients suffer refractory and chronic migraines. New surgical approaches are gaining traction as viable options to treat migraines. METHODS: The study was conducted in accordance with PRISMA guidelines. An inclusive search of several databases from January 1990 to December 2nd, 2020, was performed. Studies reporting various decompression approaches of peripheral nerves for chronic or refractory migraines were included and analyzed. The risk of bias of individual studies was assessed in accordance with the modified Newcastle-Ottawa Quality Assessment Scale. Only those studies representing their data of migraine with mean frequency and intensity of headache, as well as their complication event rate, were reported. RESULTS: Total, 22 studies comprising 1377 patients with migraines were included. Mean age of patients undergoing surgery was 44.22 (95% CI 42.96 - 45.48) years. Patients underwent surgery for migraine comprising decompression of supraorbital, supratrochlear, zygomaticotemporal, or occipital nerve. Most studies reported recovery from headache with improvement in mean headache frequency (range 4.4 to 16.6 days per month) and mean headache intensity (range 2.80 to 7.30 in visual analog scale). The risk of bias was high, with the bias being high in 10 studies and moderate in 11 studies. Total complication rate was 8.0% (95% CI 4.0%-13.0%) which included paresthesia, wound infection, and hypertrophic scarring in a follow-up duration of 2 to 66 months. Heterogeneity in outcome measures and moderate-to-high risk of bias in the majority of studies precluded for meta-analysis. CONCLUSION: Despite improvement in headache frequency and intensity reported on surgical decompression for migraine, available studies reported used variable outcome measures and had moderate-to-high risk of bias.

Modern capabilities in diagnosis and treatment of neurotrophic keratopathy

In recent years, the problem of diagnosing and treating neurotrophic keratopathy (NK) has become relevant in view of its prevalence reaching 1.6-11.0 per 10000 people. While previously it was associated only with neuroparalytic keratitis, at present the violation of sensitive and trophic innervation of the cornea with the development of characteristic keratopathy is observed in many diseases and injuries of the organ of vision. Diagnosis of NK is based on anamnestic information and assessment of clinical and functional parameters: determination of the stability of the tear film, tear production and assessment of staining of the ocular surface with vital dyes. The main role in the diagnosis of NK belongs to corneal sensitivity determined with the Cochet-Bonnet esthesiometer. Treatment of NK is designed to restore or increase corneal sensitivity and involves tear replacement therapy, instillations of preparations derived from patient's own blood, anti-inflammatory, metabolic and antibacterial therapy. However, instillations of human erve growth factor (NGF) - the drug Cenegermin (registered in Europe in 2017 at a dose of 20 μg/ml under the name Oxervate), a recombinant form of human rhNGF from Escherichia coli bacteria - exhibit the highest pathogenetic orientation. Its «target» is the affected nerve fibers (specific receptors for their growth factor), which makes it possible to eliminate the violation of reparative processes in neural and epithelial cells. A high and long-term clinical efficacy of a course of six (with an interval of 2 hours) instillations of the drug for 8 weeks in the treatment of children and adults with NK has been established. Among the pathogenetically justified methods of surgical treatment, there is the so-called surgical neurotization of the cornea involving the contralateral supraorbital, supratrochlear, great auricular and other nerves, which has a long-term clinical effect.

Anatomical and functional justification of the use of supraorbital and supratrochlear nerves for direct corneal neurotization in patients with combined pathology of the trigeminal and other cranial nerves

<h3>АКТУАЛЬНОСТЬ</h3> Повреждение тройничного нерва сопровождается нарушением чувствительности роговицы и ведет к развитию нейротрофической кератопатии. При сочетанном поражении тройничного и лицевого нервов нарушается защитная функция век и развиваются экспозиционные симптомы, усугубляющие течение заболевания, что может привести к утрате зрительных функций и потере глаза как органа. <h3>ЦЕЛЬ ИССЛЕДОВАНИЯ</h3> Изучить топографо-анатомические особенности донорской зоны и функциональные результаты при проведении прямой невротизации роговицы с использованием надглазничного и надблокового нервов при сочетанном поражении тройничного и других черепно-мозговых нервов. <h3>МАТЕРИАЛ И МЕТОДЫ</h3> Мультидисциплинарной бригадой выполнены 10 прямых невротизаций роговицы с использованием надглазничного и надблокового нервов. Показанием к операции являлось снижение или отсутствие мигательного рефлекса и чувствительности роговицы. Эффективность операции оценивалась по динамике показателей чувствительности и фоторегистрированию роговицы с окрашиванием флуоресцеином и без окрашивания, а донорский ущерб — по динамике кожной чувствительности в области лба и верхнего века на пораженной и донорской сторонах до и после операции. <h3>РЕЗУЛЬТАТЫ И ОБСУЖДЕНИЕ</h3> Использовали 3—5 нервных фасцикул длиной 6—12 см надглазничного и надблокового нервов. Срок наблюдения составил 4—30 мес. При этом на фоне отсутствия рецидивов нейротрофической кератопатии наблюдалось полное восстановление у 6 пациентов и значительное увеличение чувствительности роговицы у 4 пациентов. При фоторегистрировании отмечалось улучшение прозрачности роговицы, сокращение площади и интенсивности помутнений. Однако на донорской стороне, в области верхнего века и лба, отмечено незначительное снижение кожной чувствительности. <h3>ЗАКЛЮЧЕНИЕ</h3> Прямая невротизация роговицы у всех пациентов обеспечила положительную динамику, заключающуюся в восстановлении чувствительности роговицы, сокращении площади и интенсивности бельма, частичном восстановлении чувствительности кожи века на пораженной стороне без существенного донорского ущерба.

A cosmetic complication after supraorbital/supratrochlear nerve block.

In this article, a cosmetic complication case secondary to bilateral supraorbital and supratrochlear nerve block with low dose local anesthetic and dexamethasone combination is presented.

Evaluating the Anatomic Spread of Selective Nerve Scalp Blocks Using Methylene Blue: A Cadaveric Analysis.

The modern scalp block consists of local anesthesia injections that target the supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, and greater and lesser occipital nerves. Limited data exist on the local anesthetic spread that occurs with this technique. This study examines the extent of the spread of a scalp block using methylene blue in a cadaveric model. A traditional landmark-based scalp block was performed on 6 unembalmed human cadavers using 25-G, 1.5-inch needles to inject 1 to 2 mL of methylene blue 0.1% at each nerve bilaterally; a total volume of 20 mL was injected. The cadavers were then dissected, and the spread of injectate was measured and recorded. All the nerves required for analgesic coverage were appropriately stained by the injections, except for in 2 specimens where the lesser occipital nerve could not be identified. The zygomatic (stained in 2 of 8 specimens) and temporal (stained in 5 of 8 specimens) branches of the facial nerve were stained as a result of the zygomaticotemporal and/or auriculotemporal injections. Tracking from the zygomatic injection site was noted as far inferior as the temporalis muscle attachments on the mandible. This cadaveric study confirms that the landmark-based technique for scalp blocks consistently stained all 6 nerves involved in scalp innervation. There was significant unintentional spread to the branches of the facial nerve when using the landmark technique.

Determination of Current Flow Induced by Transcutaneous Electrical Nerve Stimulation for the Treatment of Migraine: Potential for Optimization.

Introduction: Transcutaneous electrical nerve stimulation (TENS) for migraine involves the application of pulsatile stimulation through electrodes placed on the forehead to target the underlying trigeminal nerves. It is a simple, safe modality and has secured clinical approval in several markets including the European Union and the United States. Despite nearing almost 7 years of use (postclinical approval), the exact mechanism of action is not fully known. Guided by the need to stimulate the trigeminal nerves bilaterally, electrode dimensions are simply required to extend enough to cover the underlying nerves. The goal of this study is to examine induced current flow [magnitude and spatial distribution of electric field (EF)] and another driver of stimulation [activating function (AF)] due to TENS therapy for migraine for the first time. We further consider the effect of changing the electrode dimension and shape and propose a design modification to deliver optimal flow.Methods: We developed the first ultra-high-resolution finite element (FE) model of TENS for migraine incorporating the target supratrochlear (ST) and the supraorbital (SO) nerves. We first simulated the clinically approved V-shaped geometry. We then considered three additional designs: extended V-shaped, idealized pill-shaped, and finally an extended V-shaped but with greater contact spacing (extended V-shaped +CS).Results: Our findings revealed that the clinically approved electrode design delivered substantially higher mean current flow to the ST nerve in comparison with the SO nerves (Medial: 53% and Lateral: 194%). Consideration of an extended design (~10 mm longer and ~ 4 mm shorter) and a pill-like design had negligible impact on the induced current flow pattern. The extended V-shaped +CS montage delivered relatively comparable current flow to each of the three target nerves. The EF induced in the ST nerve was 49 and 141% higher in the Medial and Lateral SO nerve, respectively. When considering maximum induced values, the delivery of comparable stimulation was further apparent. Given the existing electrode design's established efficacy, our results imply that preferential targeting of the ST nerve is related to the mechanism of action. Additionally, if comparable targeting of all three nerves continues to hold promise, the extended V-shaped +CS montage presents an optimized configuration to explore in clinical studies.

A new aesthetic pretrichial approach for upper third-facial fractures and pathologies: The “Crown incision”

The coronal incision represents the cornerstone for the treatment of upper-third maxillofacial pathologies. However, this approach leaves long scars that in numerous patients, it can cause extensive surrounding alopecia and sensory skin deficits. This clinical evidence prompted the authors to propose a full pretrichial incision, the crown incision, in order to overcome these drawbacks. A retrospective study was performed to investigate and report the aesthetic and functional outcomes of 15 patients treated with this new approach. In the postoperative period, no major or minor complications were detected. The aesthetic evaluation of the scar by the operator and the patient showed overlapping results. The overall rating was 2.93 for the patient and 2.87 for the surgeon, on a scale from 0 (as normal skin) to 10 (very different from normal skin). The recovery of sensitivity in the innervation territories of the supratrochlear and supraorbital nerves was found to be complete in 14 patients. In one case, the sharp/blunt discriminative sensitivity was absent in all three points assessed. This study showed the crown incision to be a safe approach with an optimal recovery of scalp sensitivity and excellent aesthetic results even in bald patients. Therefore, it can be considered a valid aesthetic and effective alternative to the classic coronal approach and should form part of the craniomaxillofacial surgical armamentarium.

Corneal neurotisation for neurotrophic keratopathy with a sural nerve autograft: a case report

Neurotrophic keratopathy is a corneal disease characterised by reduced corneal sensation. Corneal neurotization is the transfer of healthy donor nerve tissue to the cornea to restore sensation. An 11-year-old male presented with reduced Mackie Stage 1 neurotrophic keratopathy from de-bulking of a cerebellopontine angle arachnoid cyst. He underwent minimally invasive indirect corneal neurotization with a sural nerve autograft to ipsilateral supratrochlear nerve and cornea. Close and objective post-operative monitoring of donor sites, the cornea, visual acuity, and tear production clearly demonstrate the efficacy of this technique, and the timeline of clinical improvement.

966 Implementation of Regional Scalp Blockade for Painless Removal of ICP Bolts: A Quality Improvement Project

Abstract Introduction Intracranial pressure (ICP) monitoring through insertion of a bolt is a common neurosurgical procedure for diagnosing cerebrospinal fluid disorders. The first step of our quality improvement project identified ICP bolt removal the most painful part of the procedure. We implemented and tested the efficacy of a scalp nerve block for bolt removal. Method Two groups were identified: (A) receiving oral analgesia only and (B) receiving ipsilateral supraorbital and supratrochlear nerve blocks. We then retrospectively compared satisfaction ratings of insertion versus removal process for the two bolt types using a telephonic questionnaire Results Eighty-five patients had ICP bolts (32M:53F, mean age 42.7±16.0 SD). Fifty-four were removed with oral analgesia (A) and 31 with oral and regional anaesthesia (B). Removal experience was reported as worse for group A than for group B (p &amp;lt; 0.01). Most patients (66%) reported would have preferred local anesthetic during removal. No complications occurred from the block. Conclusions Regional nerve blocks are a safe and effective adjuvant for the painless removal of frontal ICP monitoring bolts. The final stage of the project was to implement nerve blocks as standard practice for bolt removal, to improve patient experience.

Forehead crease-An approach to frontal-naso-orbito-ethmoid fractures

Introduction: Fractures of frontal bone and naso-orbito -ethmoid region are usually associated with facial trauma. These usually present a frontal depression, csfrhinorrhoea, nasal deformity, diplopia, nasal bleeding with physical signs of midrace injury. In our study we had used this transverse forehead crease as an approach. This has provided good surgical exposure for managing these traumatic injuries. By careful dissection and preserving sensory nerves supplying the forehead and scalp, a cosmetically well accepted scar within the crease and normal forehead sensation could be achieve. Material and Methods: The study was conducted from Aug 2007 to august 2011. During this period patients who presented with isolated faciomaxillary injury involving fronto-naso-orbito-ethmoidwere part of the study. A total of 13 patients with these isolated injuries presented. The age of patients ranged from 23 years to 65 yrs. All patients were male. Surgical procedure: All the patients were explained the details of operative procedure pre operatively and informed consent was taken. Skin incision was given along the transverse crease. Subcutaneous dissection was done, followed by dissection of frontal is muscle along verticalplane splitting the fibres in order to avoid trauma to supratrochlear and supraorbital nerves branches. Dissection was then preceded to periosteum. Subperiosteal dissection was carried to expose Fracture segments. The fracture segments were elevated when depressed and reduced. Fracture segments were fixed with mini plates. Results: The age of patient ranged from 23yrs to 65yrs. All patients were male. Depressed isolated frontal bone fracture were present in two casesand in remaining 11 patients this was associated with nasoethmoid fractures. CSF rhinorhea was present in two of these patients. There was no wound over forehead in 10 of our patient. The follow up ranged from 1 month to 48 months. The was nopermanent loss of sensation or motor anesthesia over forehead. All patients were satisfied with surgical procedure. Keywords: Forehead crease, Frontal, Orbital, Ethmoid, Nasal fractures.

The Paramedian Forehead Flap: A Retrospective Clinical Model for Understanding the Connection Between Supraorbital and Supratrochlear Nerve Pathology and Headaches.

In the later stages of a paramedian forehead flap (PMFF) surgery, the supratrochlear (STN) and branches of the supraorbital nerve (SON) are transected during flap inset above the supraorbital rim. This can lead to either a nerve release if the compression point was previously distal to the transection point or a new nerve compression through neuroma or scar tissue formation. We inferred that PMFF could be a model for understanding the correlation between STN/SON pathology and migraines headaches (MH). We hypothesized that patients undergoing PMFF would experience either a change in severity or an onset of a new headache (HA) or MH. One hundred ninety-nine patients who underwent a PMFF at a tertiary medical centre were identified and contacted by phone. Patients were asked about the presence of MH or HA before and after the procedure. If a patient reported a perioperative history of MH/HA, their pre- and postoperative MH/HA characteristics were recorded. Of the 199 patients contacted, 74 reported no perioperative HA/MH history and 14 reported a perioperative history of HA/MH. Of these 14 patients, 5 had stable HA/MH pre- and post-surgery, and 9 reported a change in HA/MH post-surgery. In this subset of 9 patients, 3 reported change in HA/MH quality post-surgery, 1 reported HA/MH resolution post-surgery, and 5 reported new onset HA/MH post-surgery. Sixty-four percent of patients with perioperative HA/MH experienced a change in headache quality following surgery. These results suggest a potential connection between SON and STN pathology and HA/MH pathophysiology; further work is warranted.

Craniofacial neuralgias.

While non-headache, non-oral craniofacial neuralgia is relatively rare in incidence and prevalence, it can result in debilitating pain. Understanding the relevant anatomy of peripheral branches of nerves, natural history, clinical presentation, and management strategies will help the clinician better diagnose and treat craniofacial neuralgias. This article will review the nerves responsible for neuropathic pain in periorbital, periauricular, and occipital regions, distinct from idiopathic trigeminal neuralgia. The infratrochlear, supratrochlear, supraorbital, lacrimal, and infraorbital nerves mediate periorbital neuralgia. Periauricular neuralgia may involve the auriculotemporal nerve, the great auricular nerve, and the nervus intermedius. The greater occipital nerve, lesser occipital nerve, and third occipital nerve transmit occipital neuralgias. A wide range of treatment options exist, from modalities to surgery, and the evidence behind each is reviewed.

Direct Versus Indirect Corneal Neurotization for the Treatment of Neurotrophic Keratopathy: A Multicenter Prospective Comparative Study

To analyze the comparative safety and efficacy of two techniques of corneal neurotization (CN) (direct corneal neurotization [DCN] vs indirect corneal neurotization [ICN]) for the treatment of neurotrophic keratopathy (NK). Multicenter interventional prospective comparative case series. This study took place at ASST Santi Paolo e Carlo University Hospital, Milan; S.Orsola-Malpighi University Hospital, Bologna; and Santa Maria alle Scotte University Hospital, Siena, Italy. The study population consisted of consecutive patients with NK who underwent CN between November 2014 and October 2019. The intervention procedures included DCN, which was was performed by transferring contralateral supraorbital and supratrochlear nerves. ICN was performed using a sural nerve graft. The main outcome measures included NK healing, corneal sensitivity, corneal nerve fiber length (CNFL) measured by invivo confocal microscopy (IVCM), and complication rates. A total of 26 eyes in 25 patients were included: 16 eyes were treated with DCN and 10 with ICN. After surgery, NK was healed in all patients after a mean period of 3.9months without differences between DCN and ICN. Mean corneal sensitivity improved significantly 1 year after surgery (from 3.07 to 22.11mm; P < .001) without differences between the 2 groups. The corneal sub-basal nerve plexus that was absent before surgery in all patients, except 4, become detectable in all cases (mean CNFL: 14.67 ± 7.92mm/mm2 1 year postoperatively). No major complications were recorded in both groups. CN allowed the healing of NK in all patients as well as improvement of corneal sensitivity in most of them thanks to nerve regeneration documented by IVCM. One year postoperatively, DCN and ICN showed comparable outcomes.

Neuromodulation in primary headaches: current evidence and integration into clinical practice.

Neuromodulatory approaches add to our armamentarium of therapeutic tools for the treatment of primary headaches. This review provides a comprehensive overview of current controlled studies on the different neuromodulation techniques and recommendations for clinical practice. Evidence for efficacy of transcutaneous vagal nerve stimulation (tVNS) is limited to acute use in migraine with ambiguous results and episodic cluster headache as well as chronic cluster headache if applied in addition to conventional treatment. Transcutaneous stimulation of the supraorbital and supratrochlear nerve was effective in both acute and preventive stimulation (the latter with ambiguous results) in episodic migraines. Thus, invasive procedures should be reserved for severe and refractory cases only. Occipital nerve stimulation for chronic refractory cluster headache is the only available invasive approach with a Conformité Européenne mark. Neuromodulation can complement conventional therapy, with noninvasive procedures being used preferably. Given the limited number of studies for each modality and the lack of head-to-head studies, it is difficult to place neuromodulation techniques in a conventional treatment algorithm.

Open Eyebrow Correction

The open brow lift is a powerful tool for facial rejuvenation of the upper third of the face which can address rhytids, upper eyelid hooding, and brow ptosis. With a history dating back over a hundred years, a variety of techniques have been described including coronal, pretrichial, mid-forehead, direct supraciliary, and transpalpebral brow lifts. These vary in terms of invasiveness and the ideal approach is determined by patient age, sex, symmetry, and anterior hairline characteristics. While endoscopic techniques became popular in the 1990s based on novelty, smaller incisions, less post-scar numbness, and a perception of less invasive nature, this technique’s popularity has diminished recently and less invasive open approaches have become more popular. Recent years have seen the numbers of all forms of brow lift become less common as neuromodulators, such as botulinum toxin, allow for chemical denervation of brow depressor muscles. This has become a truly non-invasive way to address minor forms of aging of the forehead and brow. However, for advanced cases, open brow lift remains a powerful technique which should remain in the arsenal of the plastic surgeon. This review contains 3 figures, 2 tables, and 39 references. Keywords: cosmetic surgery, facial plastic surgery, facial aging, brow ptosis, rhytids, facial nerve, supraorbital nerve, supratrochlear nerve

The ALblation Technique for Treating Migraine Headache.

This work aims at describing a technique "The ALblation technique" for treating migraine headache. This technique describes radiofrequency ablation for supraorbital, supratrochlear, lesser occipital and greater occipital nerves bilaterally for treating migraine headache. This is a novel procedure that was not described before. Author published some articles on radiofrequency ablation for the pericranial nerves for treating different types of headache with consistent positive outcomes. Success of this procedure depends on identifying the appropriate nerves to treat the headache and associated neuralgia.

Unrecognized challenges of treating status migrainosus: An observational study.

Status migrainosus is a condition with limited epidemiological knowledge, and no evidence-based treatment guideline or rational-driven assessment of successful treatment outcome. To fill this gap, we performed a prospective observational study in which we documented effectiveness of treatment approaches commonly used in a tertiary headache clinic. Patients with episodic and chronic migraine who experienced continuous and prolonged attacks for more than 72 hours were treated with dexamethasone (4 mg orally twice daily for 3 days), ketorolac (60 mg intramuscularly), bilateral nerve blocks (1-2% lidocaine, 0.1-0.2 ml for both supraorbital and supratrochlear nerves, 1 ml for both auriculotemporal nerves, and 1 ml for both greater occipital nerves), or naratriptan (2.5 mg twice daily for 5 days). Hourly (for the first 24 hours) and daily (for first 30 days) change in headache intensity was documented using appropriate headache diaries. Fifty-four patients provided eligible data for 60 treatment attempts. The success rate of rendering patients pain free within 24 hours and maintaining the pain-free status for 48 hours was 4/13 (31%) for dexamethasone, 7/29 (24%) for nerve blocks, 1/9 (11%) for ketorolac and 1/9 (11%) for naratriptan. These success rates depended on time to remission, as the longer we allowed the treatments to begin to work and patients to become pain free (i.e. 2, 12, 24, 48, 72, or 96 hours), the more likely patients were to achieve and maintain a pain-free status for at least 48 hours. These findings suggest that current treatment approaches to terminating status migrainosus are not satisfactory and call attention to the need to develop a more scientific approach to define a treatment response for status migrainosus.

Migraine Surgery at the Frontal Trigger Site: An Analysis of Intraoperative Anatomy.

The development of migraine headaches may involve the entrapment of peripheral craniofacial nerves at specific sites. Cadaveric studies in the general population have confirmed potential compression points of the supraorbital and supratrochlear nerves at the frontal trigger site. The authors' aim was to describe the intraoperative anatomy of the supraorbital and supratrochlear nerves at the level of the supraorbital bony rim in patients undergoing frontal migraine surgery and to investigate associated pain. PATIENTS: scheduled for frontal-site surgery were enrolled prospectively. The senior author (W.G.A.) evaluated intraoperative anatomy and recorded variables using a detailed form and operative report. The resulting data were analyzed. One hundred eighteen sites among 61 patients were included. The supraorbital nerve traversed a notch in 49 percent, a foramen in 41 percent, a notch plus a foramen in 9.3 percent, and neither a notch nor a foramen in one site. The senior author noted macroscopic nerve compression at 74 percent of sites. Reasons included a tight foramen in 24 percent, a notch with a tight band in 34 percent, and supraorbital and supratrochlear nerves emerging by means of the same notch in 7.6 percent or by means of the same foramen in 4.2 percent. Preoperative pain at a site was significantly associated with nerve compression by a foramen. The intraoperative anatomy and cause of nerve compression at the frontal trigger site vary greatly among patients. The authors report a supraorbital nerve foramen prevalence of 50.3 percent, which is greater than in previous cadaver studies of the general population. Lastly, the presence of pain at a specific site is associated with macroscopic nerve compression.