Temporal Migraine Surgery: Relevance of Local Blood Vessels in Surgical Technique

Over two and a half decades have passed since the popularization of a surgical approach for migraine therapy based on the neurolysis of certain extra-cranial trigger points. In a retrospective review of 314 patients who had undergone forehead rejuvenation, Guyuron et al. [1] observed that, among 39 patients with migraine headaches prior to surgery, 31 experienced either complete resolution or significant improvement in their symptoms postoperatively. The average follow-up period was nearly four years. Since then, hundreds of studies have been published to validate this approach [2-22]. The results obtained in the same studies clearly show the numero us benefits (economic and related to the quality of life of the patients treated) resulting from the high rates of definitive cure resulting fro m surgical therapy.

Among the many trigger points gradually identified and described, the temporal region is one of the most frequently implicated. The purpose of this manuscript is to present our current surgical approach to treating this anatomical region in migraine patients. In detail, unlike the other surgical appro aches currently in use, we have placed particular emphasis o n the treatment o f lo cal arterial and venous vessels, which, in our opinion, should always be coagulated to obtain a complete and lasting result.

The current approach is primarily based on neurolysis or transection, performed either endoscopically or through open techniques, of the auriculotemporal and/or zygomaticotemporal nerves [23-30]. In our experience, involvement of the zygomaticotemporal nerve is rare. Furthermore, compression of the auriculotemporal nerve by adjacent anatomical structures is uncommon and typically does not necessitate an extensive neurolysis. More often, mechanical impingement may occur due to branches of the superficial temporal artery or vein. When this happens, the vessels are often dilated or ectasic (Figure 1). In other cases, the nerves appear completely unencumbered, showing no signs of compression, edema, inflammation, or fibrosis. Conversely, the presence of dilated or even aneurysmal vessels is almost invariably observed (Figure 2) [31]. In any case, vascular involvement is also confirmed by the typical symptoms of these patients, who invariably report throbbing and localized pain. Over the years, our approach in these patients has increasingly focused on coagulating the superficial temporal vessels. Our current technique involves a horizontal skin incision approximately 3 cm long, centered at the intersection of two perpendicular lines [32]: one vertical line passing through the tragus of the ipsilateral ear and one horizontal line tangent to the apex of the auricle. Following adequate tissue dissection, the auriculotemporal nerve is identified, and a complete neurolysis is performed. Then, the various branches of the superficial temporal artery and vein are coagulated. The procedure is completed with a simple suture.

Figure 1: Right tempo ral trig ger po int: right, dilated superficial temporal artery (white arrow) in between two rami of the right auriculotemporal nerve (blue arrow)

Figure 2: Right auriculo temporal nerve (yellow arrow), ectasic superficial temporal artery (blue arrow) and vein (black arrow)

We interviewed 25 patients (22 females, 3 male, ages: 19-71 years) by telephone, all o f who m had undergone surgery fo r migraine at temporal trigger sites, with a follow -up period o f 12 months. Since most of the operated patients we re distributed as residences throughout the country (and therefore at a great distance from the hospital), telephonic follow-ups were opted for. Inclusion criteria were: age >18 years; involvement of temporal trigger point only, no previous migraine surgery procedures. Exclusion criteria were: absence of migraine diagnosis by a Board Certified neurologist, secondary headaches, tension-type headache; cluster headache. Outcomes assessed included pain frequency (days/month), duration (hours/day), intensity (0-10 scale), and patient-reported percentage of pain resolution. A 12 -mo nth follow-up is universally considered correct in evaluating the effectiveness of migraine therapies. At the time of surgical procedures, all patients signed a detailed informed consent.

Preoperative headache frequency was 23 (±7) days/month, with a mean duration of 10 hours and a mean intensity of 8.5. At the 12-month follow-up, the patient-reported resolution of pain averaged 88% (range: 25%-100%), mean pain frequency decreased to 7 (±7) days/month, mean duration to 6 (range: 0-8) hours, and intensity to 3 (range: 0-8).

Our surgical approach does not differ significantly from those previously described and performed in major centers worldwide. However, there are two notable differences:

• We never cut nerves or nerve fibers: This practice allows us to avoid unpleasant sequelae, such as areas of hypoesthesia, or more concerning complications, such as neuroma, without compromising the procedure's success rate.
• Complete coagulation of all superficial temporal vessels: We place particular emphasis on eliminating local vessels based on two main observations:
• The vast majority of patients with temporally localized migraines report a characteristic throbbing pain, strongly suggestive of local vascular involvement.
• These vessels frequently exhibit specific morphological and ultrastructural abnormalities [33-35], strongly indicating their direct role in the pathogenesis of migraines. Additionally, emerging evidence suggests that environmental factors may contribute to vascular remodeling, a key aspect observed in migraine patients [21]. This aligns with our findings, where the presence of dilated and aneurysmal vessels suggests an intrinsic vascular component in the pathophysiology of temporal migraine.

We have never observed sequelae related to this maneuver, such as skin necrosis or localized alopecia. While further studies are certainly required to evaluate the specific contribution of each surgical maneuver to the final outcome, we strongly support the approach described.

A clear weakness o f the study was that its s mall sample size reduced generalizability. Future, larger, multicenter studies are needed , with inclusion of patient satisfaction and quality of life measures, as well as long-term fo llow-ups studies to assess sustainability of outcomes, mo re ro bust co st-effectiveness analysis.

Further studies would also be desirable to compare the described technique with other migraine treatment appro aches.

1. Guyuron, Bahman, et al. “Corrugator supercilii muscle resection and migraine headaches.” Plastic and Reconstructive Surgery, 106, no. 2, August 2000, pp. 429-434. http://dx.doi.org/10.1097/00006534-200008000-00030.

2. Knoedler, Samuel, et al. “Neural interconnections of extracranial nerves in headache surgery: Anatomical landmarks and clinical implications: A review of the literature.” Plastic and Reconstructive Surgery, 155, no. 1, April 2024, pp. 183e-192e. http://dx.doi.org/10.1097/prs.0000000000011504.

3. Caruana, Giorgia, et al. “Endoscopic forehead surgery for migraine therapy Personal technique”. Ann Ital Chir. vol. 85, November 2014, pp. 583-586.

4. Lee, Seok Joon, et al. “Case series and literature review of up-to-date surgical management of occipital neuralgia.” Archives of Plastic Surgery, 51, no. 06, July 2024, pp. 556-560. http://dx.doi.org/10.1055/a-2364-5564.

5. Polotto, Susanna, et al. “Surgical treatment of frontal and occipital migraines.” Plastic and Reconstructive Surgery-Global Open, 4, no. 3, March 2016, pp. e653-0. http://dx.doi.org/10.1097/gox.0000000000000631.

6. Caruana, Giorgia, et al. “Endoscopic forehead muscle resection for nerve decompression.” Plastic and Reconstructive Surgery- Global Open, 3, no. 3, March 2015. http://dx.doi.org/10.1097/gox.0000000000000308.

7. Evans, Adam G., et al. “Outcomes of surgical treatment of migraines: A systematic review and meta-analysis.” Plastic Surgery, 31, no. 2, December 2021, pp. 192-205. http://dx.doi.org/10.1177/22925503211036701.

8. Bertozzi, Nicolò, et al. “Surgical therapy of temporal triggered migraine ” Plastic and Reconstructive Surgery - Global Open, vol. 6, no. 12, December 2018. http://dx.doi.org/10. 1097/gox.0000000000001980.

9. Gfrerer, Lisa, et al. “Surgical treatment of migraine headache: Back to the ” Plastic and Reconstructive Surgery, vol. 142, no. 4, October 2018, pp. 1036-1045. http://dx. doi.org/10.1097/prs.0000000000004795.

10. Raposio, Edoardo, and Giorgia Caruana. “Tips for the surgical treatment of occipital nerve-triggered headaches.” European Journal of Plastic Surgery, 40, no. 3, October 2016, pp. 177-182. http://dx.doi.org/10.1007/s00238-016-1249-8.

11. Huayllani, Maria T. and Jeffrey Janis. “Migraine surgery and determination of success over time by trigger site: A systematic review of the literature”. Plastic and Reconstructive Surgery, vol. 51, no. 1, October 2022, pp. 120e-135e. http://dx.doi.org/10.1097/prs.0000000000009775.

12. Henriques, Sara, et al. “Current evidence in migraine surgery.” Annals of Plastic Surgery, 89, no. 1, October 2021, pp. 113-120. http://dx.doi.org/10.1097/sap.0000000000002989.

13. “Practical approach and safety of hyaluronic acid fillers: Erratum.” Plastic and Reconstructive Surgery-Global Open, vol. 7, no. 12, December 2019. http://dx.doi.org/10. 1097/gox.0000000000002507.

14. Mangialardi, Maria Lucia, et al. “Decompression surgery for frontal migraine ” Plastic and Reconstructive Surgery-Global Open, vol. 8, no. 10, October 2020. http://dx.doi.org/10.1097/gox.0000000000003084.

15. Chung, Michael, et al. “The greater occipital nerve and its dynamic compression points: Implications in migraine surgery.” Plastic and Reconstructive Surgery, 149, no. 6, April 2022, pp. 1321-1324. http://dx.doi.org/10.1097/prs.0000000000009094.

16. Raposio, Giorgio, and Edoardo Raposio. “Surgical therapy of occipital (arnold) neuralgia: A case series.” Annals of Medicine and Surgery, 80, August 2022. http://dx.doi.org/10.1016/j.amsu.2022.104237.

17. Ps, Yesantharao et al. “A Markov analysis of surgical versus medical management of chronic migraines”. Plast Reconstr Surg., vol 149, no. 5, 2022 May 1, pp.1187-1196.

18. Simonacci, Francesco, et al. “Surgical deactivation of occipital migraine trigger site.” Chirurgia, vol. 33, no. 3, May 2020, pp. 143-149. http://dx.doi.org/10.23736/s0394-9508.19.05027-7.

19. Raposio, Edoardo, and Giorgio Raposio. “Surgical therapy of migraine: A 12-year single-center experience.” European Journal of Plastic Surgery, vol. 46, no. 5, April 2023, pp. 699-705. http://dx.doi.org/10.1007/s00238-023-02065-1.

20. Baldelli, Ilaria, et al. “Site v surgery for temporal migraine headaches.” Plastic and Reconstructive Surgery-Global Open, vol. 8, no. 6, June 2020. http://dx.doi.org/10.1097/gox.0000000000002886.

21. Poli, Venkataramanaiah, and Srinivasulu Reddy Motireddy. “The impact of di-2-ethylhexyl phthalate (DEHP) in focus on the reproductive system and toxicity in rat or mammalian model.” American Journal of Pharmacology and Toxicology, vol. 19, no. 1, January 2024, pp. 1-26. http://dx.doi.org/10.3844/ajptsp.2024.1.26.

22. Raposio, Giorgio, and Edoardo Raposio. “Temporal surgery for chronic migraine treatment: A minimally-invasive perspective.” Annals of Medicine and Surgery, vol. 76, April 2022. http://dx.doi.org/10.1016/j.amsu.2022.103578.

23. Pietramaggiori, Giorgio et al. “Minimally invasive nerve and artery sparing surgical approach for temporal migraines”. JPRAS Open., vol. 39. pp. 32-41, 2023 Nov 24, pp. 32-41.

24. Peled, Ziv M., et al. “Anatomic anomalies of the nerves treated during headache surgery.” Plastic and Reconstructive Surgery -Global Open, vol. 11, no. 11, November 2023. http://dx.doi.org/10.1097/ gox.0000000000005439.

25. Choi, You-Jin, and Hee-Jin Kim. “New anatomical insights of the superficial branch of the zygomaticotemporal nerve for treating temporal migraines: An anatomical study.” Clinical Anatomy, vol. 36, no. 3, October 2022, pp. 406-413. http://dx.doi.org/10.1002/ca.23962.

26. Chen, Guiwen, et al. “Trigger areas nerve decompression for refractory chronic migraine.” Clinical Neurology and Neurosurgery, vol. 206, July 2021. http://dx.doi.org/10.1016/j.clineuro.2021.106699.

27. Vincent, Arnaud J.P.E., et al. “Extracranial trigger site surgery for migraine: A systematic review with meta-analysis on elimination of headache symptoms.” Frontiers in Neurology, vol. 10, February 2019. http://dx.doi.org/10.3389/fneur.2019.00089.

28. Olla, Danielle, et al. “Migraine treatment.” Clinics in Plastic Surgery, vol. 47, no. 2, April 2020, pp. 295-303. http://dx.doi.org/10. 1016/j.cps.2020.01.003.

29. Peled, Ziv M. “A novel surgical approach to chronic temporal headaches.” Plastic Reconstructive Surgery, vol. 137, no. 5, May 2016, pp. 1597-1600. http://dx.doi.org/10.1097/prs.0000000000002051.

30. Sanniec, Kyle, et al. “Decompression–avulsion of the auriculotemporal nerve for treatment of migraines and chronic headaches.” Plastic and Reconstructive Surgery-Global Open, vol. 4, no. 4, April 2016. http://dx.doi.org/10.1097/gox.0000000000000663.

31. Raposio, Giorgio, et al. “An easy and reliable way to preoperatively identify the auriculo-temporal nerve in migraine surgery.” Journal of Plastic, Reconstructive and Aesthetic Surgery, vol. 75, no. 7, July 2022, pp. 2387-2440. http://dx.doi.org/10.1016/j.bjps.2022.04.029.

32. Cortese, Katia, et al. “Ultrastructural imaging reveals vascular remodeling in migraine patients.” Histochemistry and Cell Biology, vol. 157, no. 4, January 2022, pp. 459-465. http://dx.doi.org/10.1007/s00418-021-02066-w.

33. Raposio, Giorgio, and Edoardo Raposio. “Temporal aneurysms and migraine surgery.” JPRAS Open, vol. 41, September 2024, pp. 9-13. http://dx.doi.org/10.1016/j.jpra.2024.05.001.

34. Raposio, Edoardo, et al. “Morphologic vascular anomalies detected during migraine surgery.” Journal of Plastic, Reconstructive and Aesthetic Surgery, vol. 75, no. 11, November 2022, pp. 4069-4073. http://dx.doi.org/10.1016/j.bjps.2022.08.036.

35. Raposio, Edoardo, et al. “Proteomic vascular anomalies detected during migraine surgery.” European Journal of Plastic Surgery, vol. 47, no. 1, December 2024. http://dx.doi.org/10.1007/s00238-024-02256-4.