Could I Have Developed Another Migraine Trigger That Needs Decompression?
Q: Dr. Eppley, I wanted to get your advice about having an additional migraine surgery. I have been very happy with the results from the bilateral zygomaticotemporal nerve decompression procedure. I have continued to have pulsing in my temples. I also feel a pulsing sensation in my ears. Most days, I do not find this pulsing to be painful. This is quite a remarkable improvement given that I was experiencing constant pain prior to seeking treatment with you. Do you think that auriculotemporal nerve decompression might relieve this pulsing sensation? Also, is it possible that I have developed a secondary trigger point in my forehead because I had started to have pain in my forehead. I actually had a sinus infection in my left maxillary and left ethmoid sinuses and had sinus surgery in September. I still have a little bit of pain in my forehead, but I think that this might not be an issue.
A: I am glad to hear that you have continued to have persistent migraine relief, even if it is not completely cured. The pulsing in your temples and ears, and I am assuming this is new since your surgery, strikes me as more vascular then neural. Ligation of the main trunk of the superficial temporal artery as it crosses into the temporal hairline as well as ligation of the posterior superficial temporal branch would seem to be a more logical approach than auricultemporal nerve decompression although that would inadvertently be done at the same time at the same time with the ligations.
It is not uncommon that improvement by decompression of one trigger point unmasks a secondary contributing one. This is most common between the supraorbital and zygomaticotemporal trigger points. Their close association makes a contributing connection between the two anatomically likely. It is hard to know, because of its anatomic proximity, as to whether your recent sinus surgery has a contribution to your frontal/forehead discomfort. The simplest way to find out is to do a few units of Botox around the supraorbital nerve and see what happens to the forehead discomfort. A positive response to Botox would mean that supraorbital nerve decompression may be beneficial and that the sinuses are not making a contribution to your discomfort.
Dr. Barry Eppley