Your Questions
Your Questions
Q: Dr. Eppley, I would like to possibly get temporal zone migraine surgery or Botox injections. I have been diagnosed with chronic daily headache (migraine) and believe this would be beneficial. I have had it for approximately 3 1/2 years and normal medications and treatments do not correct the issue. The issue developed approximately 2 to 3 months after returning home from overseas. I do wear a TMJ mouth guard for bruxism and have daily muscle tension type headaches in both temples and above the ears. Since medications and the mouth guard do not fix the problem I believe that this procedure may provide some more permanent relief. Please feel free to email or send any additional information. Thank you.
A: By your description, it appears you have symptoms that involved both temporal and masseteric muscles. This, to me, more likely suggests myofascial pain syndrome of these muscles and fascia rather than a specific trigeminal nerve compression issue. The first place to start is with Botox injections into either the temporal or masseter muscles or both. Then see what the response is which, in my experience, I have yet to see a patient who does not get some significant reduction in their symptoms. Migraine surgery is reserved for those patients in which a specific peripheral neurovascular trigger can be found rather than overall masticatory muscle pain/headaches. That is the first place to start and is what should be done during the first visit.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had frontal headaches for about 10 years. I don’ t like getting toxins, but a low dose Botox injection cut my usual debilitating headache from a 9/10 to about a 5 for seven weeks and then about a month later last week, I am back to a 9/10 again. Can you do a surgical procedure to get me more permanent relief? If so, do you think insurance will cover it?
A: You may have had more significant migraine relief if the dose of Botox was higher than just ‘low dose’. The wearing off of the Botox effects after three months or so is a fairly standard period of time for the duration of its effects. If Botox is effective in the supraorbital area for migraine reduction, then surgical decompression of the supraorbital and supratrochlear nerves should provide similar (and hopefully greater) and more sustained relief than the injections. The general quoted numbers is 70% of patients will get a noticeable and sustained reduction in the frequency and severity of their headaches with surgical nerve decompression. The remaining 30% is a mixture between ‘cures’ and those with limited to no benefit.
Insurance is very unequivocal about not covering migraine decompression surgery. They have a hardline stance that it is still ‘experimental’ at this time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I got treated with Botox for migraines three months ago and it was not effective. It was done by a neurologist and when I asked why it did not work he said he did it in the “standard FDA” way by a band formation around the head, neck and forehead. This is so disappointing and I paid around $3,000 to have it done.
A: That is certainly disappointing to hear not only because it did not work but because of the way it was done. There is no such thing as a ‘standard FDA’ way to do it. If that statement meant that it was done by using the clinical information and methods that was the basis for what made Botox approved for migraine treatment by the FDA, the ‘wrap around the head ‘ method was not it. Botox works for a select group of migraine patients who have identifiable peripheral trigger points in the frontal, temporal and occipital regions by both examination and history. It is these very specific points which are injected not in a random method. You may benefit by Botox injections if you have these trigger points so your lack of improvement is more likely due to that you are either not a good candidate or the injection approach was flawed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a teenage daughter with nonstop migraine headaches for over a year and I suspect occipital neuralgia. I’d like to know more about what you do for migraines. Thank you.
A: There are some specific non-surgical and surgical treatments for migraines that have identifiable trigger points. Most so-called migraines do not have trigger point, however, Trigger points can be identified by both history and physical examination. Almost all of the patients that I treat for migraines as a plastic surgeon have been through full medical work-ups usually by a neurologist and have failed all conventional medical therapies.
Trigger points are specific areas where sensory cranial nerve branches pass through muscles on their way to supply specific skins areas. The muscles squeeze or pinch the nerves which serves as the trigger point for the migraine. The three most common trigger point areas are the occipital, temporal, and frontal regions. Sometimes only one trigger point exists but it can include two or even three. By far, the occipital trigger point is the most common in my migraine patient experience.
The initial treatment of a suspected ‘trigger point’ migraine is Botox injections. This is both a treatment as well as a diagnostic test. If sufficient relief is obtained, then one can continue with Botox injections or proceed with nerve decompression surgery where the constricting muscle is removed around the nerve.
This is a general migraine treatment overview. The use of Botox and decompressive surgery are rare in adolescents for migraines but, in the properly qualified patient, would be acceptable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have migraines which are predominantly left sided. A few weeks ago I received injections to both the left corrugator and temporalis muscles. There has been a reduction in migraine attack intensity but no reduction in attack frequency. But there is a definite change in pain pattern as the forehead and cheek are considerably less involved but the temporal headache persists. Would you consider this to be indication of the injected sides being trigger points or just a part of a pain pattern, triggered elsewhere? What would be your next step in the diagnostic process in my case? Local anesthetics into the pain site or a botox injection to the occipital area?
Do you find the local anesthetic nerve block to be a good predictor of a successful vascular decompression?
A: The identification of potential loci for migraines can be difficult. While Botox injections can identify trigger points, they are technique-dependent. The corrugators is fairly easy to inject because it is a small area of muscle that is discretely located. The temporalis, however, is a very broad muscle and there is no well-defined injection point. Not knowing where your tenporalis muscle was injected or with what dose, it is impossible to say whether that area has been properly tested. It must be injected around the zygomaticotemporal nerve lateral to the orbit or in the temporal hairline near the area of the course of the auriculotemporal nerve. Until that area is adequately injected, I would not proceed to the occipital site unless it is a very specific pain site that can be definitely palpated. While local anesthetics can be a limited substitute for Botox, it is not helpful at all to determine any potential role of vascular compression.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, In early June I had Botox injections for migraines through my neurologist. I’ve suffered with migraines for over 20 years and tried just about everything protocol. The neurologist did a lot of injections in the forehead and temples and then a bunch in the back of my head/hair and at the base of my skull and a few along my shoulders. I was migraine free for a week for the first time in I don’t know how long. After a week, my neck became progressively weaker until it was like a bowling ball on my shoulders and I could no longer hold it up for simple things like looking down, brushing teeth, vacuuming, simple picking up the house, etc. It’s been almost two months now and while it’s not as bad as it was a month ago, my neck is not recovered to its former strength, and gets tired very easily. My neurologist has stated that we can do a lower strength and a different pattern in the future. I am leery of ever doing this again based on my reaction and unsure. Have you ever heard of this reaction?
A: I think you are merely experiencing the effects of Botox in the neck muscles which has resulted in some temporary muscle weakness. This is not a reaction but an expected response based on the muscles that were injected. In the treatment of migraines with Botox, the key is to inject the potential trigger points that are where the sensory nerves come through the muscle. In the back of the head, this is a very specific location that relates to the path of the greater occipital nerve. This is at the base of the occipital skull and can be precisely palpated. While this does involve injecting into the upper end of the splenius capitus muscles, this will not cause any neck muscle weakness. It sounds like neck muscle was injected below this point which is not helpful in determining the location of a trigger point and can cause some neck muscle weakness, particularly if a high number of units was injected. The good thing is that in another month or so your neck muscle problem will be self-solving as the Botox wears off.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am interested in exploring the option of using Botox to help with my migraines. I have had them since I was a teenager and am now on Topomax twice a day and rotate with Treximet, Imitrex, and Maxalt. I am 42 now. Is there any chance insurance would pay to try this?
A: Botox can be quite effective in the relief of migraine headaches, provided it is the right type of migraine. Specifically, one must have a migraine history and head and neck location that can be specifically linked to one of the peripheral triggers. This means that where it starts can be pointed to exactly one of these sites. This includes the occipital region (base of the skull), temporal region (side of the head), supraorbital (brow) and the septal (nose region) If you can specifically point your finger on the origin and location, then a Botox injection into the trigger area can serve both as a treatment and a surgical predictor. If you get good relief with Botox, then you can continue with these injections every 4 months or so as an effective treatment. Or one can go on to surgical decompression of these sites, of which three are directly related to sensory cranial nerves.
While Botox is FDA-approved for the treatment of migraines, my Indianapolis plastic surgery practice does not process insurance for these treatments. The typical cost would be around $300 to $350 for two or three injections sites.
Dr. Barry Eppley
Indianapolis, Indiana