Your Questions
Your Questions
Q: Dr. Eppley, I am interested in migraine surgery. My migraine history is long. I started having migraines over twenty years ago. I take multiple prophylactic and rescue medications with mixed results. My headaches usually last two to three days and have lasted up to several weeks. The post-dromal lasts up to a week longer than that. I have had as little as a migraine every week or as many as a dozen migraines a month. I have been getting Botox for more than a year. Under normal circumstances I get a migraine a week, usually a 5-7/10 severity, taking the current medications. After the first day or two of rescue medications I stop taking them, I don’t think they do anything if they haven’t worked on the first day or so. I get Botox shots injections every three months.
A: Thank you for providing your detailed history and medication profile for your migraines. While migraines are complex, qualifying those patients that may have a successful outcome from migraine surgery is much simpler. The surgical treatment of migraines is based on identifying those migraine patients that have focal trigger points where the sensory nerves exit from the skull and pass through muscle where they can be entrapped. The three classic areas are the supraorbital, temporal, and greater occipital regions. Good surgical candidates have very specific trigger areas that they can pinpoint precisely, have repeatable symptoms from the same focal areas and usually have positive relief from Botox injections. Since you have had repeatable positive responses to Botox, it would be helpful to know more specifics about those injections. (location and dose)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a lot of orbital bossing of the skull which may be pinching the supraorbital nerves causing daily migraine pain. I guess this surgery would be called forehead reconturing/orbital bony contouring/brow bone reduction of that region. I was hoping to get a surgery that could take care of the functional as well as the aesthetic. I have a 3D Ct scan of that region and was wondering what a rough estimate might be for that surgery. Would insurance cover this procedure? I know that the same incision is made across the hairline for both the migraine surgery and the recontouring of the orbital bony area of the forehead. Listed below are descriptions of the surgery I have in mind. Thanks!
1. Forehead reconstruction or cranioplasty where the glabella bone is taken apart, thinned and re-shaped, and reassembled with small titanium wires or titanium microplates and screws.
2. Or the compression technique in appropriate cases where the wall of bone is first thinned and weakened, and then compressed into place. It then heals in the new position.
A: Certainly orbital rim recontouring by brow bone reduction and decompression of the supraorbital nerves can be done at the same time. Only brow bone reduction uses an open scalp incision. Isolated supraorbital nerve decompression for frontal migraines is usually done by an endoscopic limited incision technique. But the open approach does afford great access to the nerves for the best decompression possible.
Most brow bone reductions are best done by an osteoplastic flap technique where the outer table of the frontal sinus is removed, reshaped and then put back in its reshaped form by either resorbables sutures or very plates and screws.
Neither is aesthetic brow bone reshaping or supraorbital nerve decompression for migraines covered by insurance. Prominent brow bones are not a recognized craniofacial deformity by insurance companies. Nerve decompression for migraines is currently viewed as ‘experimental’ surgery without long-term clinical studies to be currently viewed as an approved medical procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, would the following make me a favorable candidate for migraine surgery? I have a history of chronic migraines for over 15 years. It is well controlled for the past 5 years with Botox injections in four areas (forehead, above ears, back of head, and around eyes) and manual therapy. I have noted a reduction in the effectiveness of Botox injections in the last 18 months.
A: On the surface, a positive response to Botox suggests that migraine surgery can be effective. However it is important to know exactly where the Botox was injected and whether those sites corroborate with the exact anatomic sites of peripheral nerve compression. Where in the forehead and the back of the head exactly? The above the ear and around the eyes are not sites where nerve compression can occur so these may be completely incidental to whatever improvement you may have been seeing to the forehead and back of the head injection sites. (if in fact they were near the course of the nerves) These injections sites sound suspiciously like a very typical ‘wrap around’ the head injection pattern that I have seen done many times by neurologists. Such a random approach is not necessarily indicative that migraine surgery would be effective.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in migraine surgery. I have been suffering from disabling, chronic migraines since 1991. However, I have been suffering from migraines daily since 2011. My neurologist prescribed different types of medicines, but nothing helped. The neurologist also performed several tests including MRIs and CTs but could not find the cause of my migraines. In 2012, I began seeing a headache specialist but that too was unsuccessful. In 2013, I began seeing an acupuncturist/chiropractor. This helped very little in that I still suffer from migraines daily and the pain is even worse during my menstrual cycles. I can no longer depend on pharmaceutical short term fixes that do not and the harm it has done on my body. I’ll try to explain the location of my migraines the best I can. I usually feel my migraines right underneath my eyebrows and between them. During a migraine, I press whatever tissue that is inside my eye sockets (the area closest to the middle of my eyebrows). Doing this can take pressure off but only while I continue to press. Also I can feel a difference in the amount of swelling in the tissues of that area when my migraines are at a ten plus. There are also some rare times when my migraines are in the temple location. I hope I explained in a way that was not confusing to you.
A: Your migraine history/story is fairly classic from my perspective as patients often seek surgery as the last measure. The place to start is to define a patient’s migraines by location…where do they start and spread to. What makes some migraines improveable by surgery is if they come from a point of peripheral nerve compression. Your description sounds similar to what migraine patient’s experience when they have peripheral nerve compression of the supraorbital/supratrochlear nerves as their trigger point. This strongly suggests that migraine surgery consisting of nerve release/decompression through an open hairline approach could be effective for migraine relief.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, have you ever treated sufferers of migraines caused by (likely) the hard throbbing of the superficial temporal artery. My wife has 5 migraines a week, nearly all of which are in this area. We do not understand the root cause of the pulsations themselves, but it is possible these hard pulsations (lasting hours, or even days on end) are irritating the nerves local to the artery, and becoming interpreted as migraine in the brain. Given that medications (and neurologists and others) offer no relief, and she has suffered for decades, we are exploring procedures. Thank you.
A: While getting to the origin or even finding an effective treatment for migraines is never simple, the simple answer to your question is yes. It is very possible that high flow through the superficial temporal artery (STA) can be a source of migraines. While I would have initially thought it was possible but with a low probability, I recently treated a lady with a 30 year history of refractory migraines of the right temporal region with 2-point ligation of the STA with a dramatic and sustained reduction of her migraines. She felt that the pulsations she was feeling was a major contributor to her migraines and the origins was clearly on the temporal side with very visible pulsations. Given that there is no risk of any downside to STA ligation and it is a minor procedure with no recovery, it seemed like a reasonable thing to do.
While there would be no guarantee that STA ligationswould be effective for your wife’s migraines, and they should always be done from two points to eliminate recurrent pulsations due to retrograde flow, it would be relatively easy to eliminate this potential source.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was treated by a “#1 Migraine Specialist” in my state. I had been seeing this Dr. for 1 yr. and 4 months before he suggested Botox and I finally did the treatment because my insurance paid for it! YAY! I finally did the treatment in November 2012 and it was so painful! There was no spot left untouched. It helped the headache I had then so I was sure it was going to prevent the future ones! And low and behold just days later I get a Migraine and been having them as usual! I never had migraines until I had my stroke on May 10, 2010. When I get them they stay until i have to go to the emergency room for relief. Ten dr.’s later and I still have no relief. I have taken over 50 different types of meds and STILL NO RELIEF! I am so disappointed! I cannot live like this anymore! What can I do???
A: I am so sorry to hear about your terrible migraine history and current condition. Just based on your description I comment on your Botox experience. First, it should not have been that painful. When skillfully done wirth a small 30 gauge needle, it is at best of minimal discomfort. Secondly, when Botox is used for migraines it is not done ‘all over the head’. It needs to be placed specifically into known trigger point areas of which there are three very specific locations. This does not sound like what was done. Whether you have the type of migraine headaches that may be improved by Botox is unknown…as of yet. I would suggest that you have the Botox injections repeated at the identified trigger points based on your headache pattern. This will the tell you if you may be a good candidate for surgical decompression which is what, as a plastic surgeon, I can offer for your potential migraine headache relief.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had occipital neuralgia decompression surgery 5 weeks ago, My doctor also talked about decompressing the auriculotemporal nerve. I was nervous to have them done at the same time, so we were conservative and are waiting to see if it will be necessary after the 3 month mark from surgery. I have never suffered from migraines. I had a whiplash in my neck that had caused my neuralgia. I had mild temple pain on the right side, but my doctor said that could come from the greater occipital as well, so I wanted to wait see if that went away like the nerve pain has. What are your thoughts? I have been reading your website and wanted to get your input. I also wanted to know what the recovery time was for the auriculotemporal nerve. Is it the same as the occipital nerve decompression surgery. Also what are the percentages of success after auriculotemporal decompression.
A: Given that the origin of your head pain was from a whiplash injury and not a ‘traditional’ migraine trigger, I don’t think anyone can answer your question as to the success of auriculotemporal nerve decompression in your case. For refractory temporal pain it is also important to identify where the potential nerve source involved is the auriculotemporal or the zygomaticotemporal nerves. They are in different locations on the temple with one being in the hairline and the other between the hairline and the brow. If the pain location is between the hairline and the brow (the zygomaticotemporal nerve), this should first be tested by Botox injections which can predict the success of surgical nerve decompression/avulsion. There is no test for the auroiculotemporal nerve and whether its decompression will be successful.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, have had surgery for migranes the first one was 2012 all four trigger points and deviated septum. about 4 months later I developed a very suttle yet painfull pressure pain in my right temple. It was relentless. feb 2013 the surgeon went back in and removed an artery. for a week I was sure it was better then it came back again. since then I have had steroid injection and anestetic injected in the temple.. no help then botox injected.for two days after I felt great accually thought I might have a life. then the pain came back and remains and it sometimes triggers a full blown migrane, yesterday I got a shot for a migrane I was given demerol toradol and benadryl and phenigan. It helped in all areas but not in the area in the temple I still had the pain.. I cant live like this. the surgeron removed a portion of the zygomatic nerve.
A: Based on your description it sounds like you have had every migraine surgery approach for your right temporal migraines. The zygomaticotemporal nerve has been avulsed and the anterior branch of the temporal artery has been ligated/removed. Short of a temporalis fasciectomy, there are not other surgical options that I know. The fact that Botox had little to no sustained effect does not bode well that any further surgical manipulation would have a high chance of being effective.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis,Indiana
Q: Dr. Eppley, why does electronic stimulus or surgery eliminate the headache associated with migraines? I noticed when I apply pressure with my forefinger the headache is relieved. Why is that accomplished? Is there any guaranteed method to relieve headaches caused from supraorbital nerve dysfunction?
A: Compressing the area of the focal headache is known to provide some temporary relief and many people do it to try and get some very temporary headache reduction. It is not known precisely why this works although the most logical explanation is similar to what happens when you burn your fingers or hit your thumbs with a hammer…you instinctively shake your the hand which does help to relieve some of the pain. This works because other sensory fibers than those carrying pain in the nerve supplying the area are stimulated. (such as pressure and movement sensations) This cuts the number of nerve fibers that can carry pain, thus one feels less pain. (competitive stimulation so to speak) Otherwise, there are no guaranteed methods for migraine headache relief. In properly selected patients surgical decompression has a high rate of success in the majority of patients with reduced frequency and duration of headaches that is sustained.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been very pleased with the surgery you performed on me this past May. By the end of 2011, I started have chronic migraines (pulsing in temples). It was really debilitating and interfered with my work, going out with my friends and husband, and everyday activities like working out. After the surgery, I am no longer in constant pain and I feel like I am getting my life back! I still have some minor pulsing in my temples. I am working with a local Neurologist to try to alleviate the pulsing. But even if we never resolve the pulsing, I feel like I will be able to live a normal life. Since the surgery, I have started having some pain in my forehead (right between my eyebrows and right above the eyebrows). It not nearly as extreme or painful as what I had experienced in the temples. It does not occur every day. The Neurologist has prescribed a low dose of Baclofen to take when I feel the forehead tension and that works well. But I was curious whether it would not just be better treated surgically? I had read that patients sometimes develop secondary trigger spots after having the primary trigger spot operated on. I was wondering if you thought that it might worth having a second operation done. What exactly would the procedure be, are the muscles removed?
A: It is well known that the successful treatment of one trigger point for migraines can potentially unmask or uncover another more minor but contributing source. For the temporal-based migraines, the unmasked trigger point is the suprarobital-supratrochlear region located in the inner brow area. Unlike the temporal region, this migraine trigger site is treated differently. It is approached using an endoscopic technique from two small incisions behind the frontal hairline. Through the endoscope, the muscles are removed from around the nerves as much as possible and, in some cases, the bony foramen where the nerves emerge from the brow bone are opened up to decompress the nerve completely. This takes the same amount of time to complete, around one hour, as the temporal migraine surgery.
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, Since you are experienced in migraine surgery, would you mind answering a few questions? 1) How does surgery for migraines work? 2) How many people undergo the surgery? 3) How often does it work? 4) What are the costs? 5) Is it covered by insurance? 6) What should people try before undergoing the surgery? 7) Why are you the only doctor in Indiana who performs this surgery?
A: In answer to your questions:
1) Migraine surgery works on the principle of sensory nerve decompression by removing the constructing muscles around the nerves, known as trigger points. I would recommend you go to www.eppleymigrainesurgery.com to learn more or go to www.exploreplasticsurgery.com and search under migraine surgery where the details of surgery are discussed in multiple blogs in detail.
2) Migraine surgery is for those patients who have very specific types of migraines that have been fully worked up and treated by a neurologist and have received either no or little relief. Surgical candidates are chosen either based on their response to Botox injections or by their migraine history.
3) The one and five year results show that over 70% of people experience significant and sustained relief. About 30% of patients are cured and subsequently experience no or few migraines again. About 10% of patients experience only temporary relief and long-term do not show significant improvement.
4) Costs are based on how many migraine trigger sites are released and the time to do the surgery. Costs could range from $3500 to $8,000.
5) It is usually not covered by insurance. Insurance companies, despite the overwheling evdience, feel that it is still ‘experimental surgery’.
6) As per #2 above.
7) Migraine surgery is usually done by plastic surgeons who express an interest to treat this medical condition. The surgical techniques used are common to board-certified plastic surgeons and come from procedures learned from cosmetic and craniofacial surgery, microsurgery and hand surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read your explanation of the temporal migraine with a vascular component rather than a muscular one caught my attention. Are there any research into the effectiveness of this kind of surgery or do you have a personal experience with it´s alleviation of migraines? Do you have a personal experience of local anesthetic as a diagnostic test? I am currently undergoing Botox injections into triggers points to determine how best to help my migraines.
A: I wrote that migraine surgery blog based on my clinical experience in doing it. While temporal migraines can usually be relieved by avulsion of the zygomaticotemporal nerve just outside the lateral orbit, it is not always completely effective. That is why I often will ligate/decompress the anterior branch of the superficial temporal artery as it courses along with the auriculotemporal nerve in the scalp portion of the temporal region. Through a single vertical temporal incision both procedures can be done simultaneously. Since there is no harm is eliminating this vascular element, it is often a part of my temporal migraine surgical approach. The use of local anesthetics would not be effective in determing if there is a vascular component to your temporal migraines. Like Botox, local anesthetics only provide insight into a muscular compression source of a migraine.
Dr. Barry Eppley
Indianapolis, Indiana
Over 30 million people in the United States have some degree of migraine headaches. While there are drug therapies that are very effective, some patients either get little to no relief or have other problems related to side effects from taking the drugs. For a small number of migraine sufferers it is very disabling and little benefit is obtained despite the best neurologic care.
Plastic surgeons have developed new procedures to “deactivate” migraine headaches…and it was learned from results seen from cosmetic treatments. Usually cosmetic surgery benefits from what is learned in reconstructive surgery but this is one of the rare instances where the reverse has occurred. Based on Botox injections and browlift surgery, both which temporarily paralyze or remove certain brow muscles, significant improvements or actual cures occur in migraines that start in the forehead. This has led to understanding the cause of migraines in some patients known as the peripheral trigger.
The peripheral trigger theory of migraines is based on certain sensory nerves being squeezed or compressed by a surrounding muscle or contact point. Due to the nerve being irritated, this leads to a cascade of events that becomes a migraine. To date, four trigger areas have been identified. Three of these are where a nerve passes through a muscle and many with migraines can actually put their finger on these exact spots; the greater occipital nerve in the back of the head, the zygomaticotemporal nerve in the temple area, and the supraorbital nerve at the inner half of the eyebrows. The fourth trigger point has been identified in the nose where a significant septal deviation makes contact with an enlarged turbinate.
Surgical migraine deactivation is done by removing the source of irritation, the muscle from around the nerves or straightening the nasal septum. This is done through small incisions inside the scalp hair or from inside the nose. Studies have now been reported that such surgery produces good results that last, with nearly 90 percent of patients having at least partial relief at five years after surgery. Migraine attacks were less in number, not as severe, and lasted for a shorter period of time. In about one-third of patients studied their migraine headaches were completely eliminated.
While migraine surgery is for just a minority of sufferers, it is not a procedure that is associated with any significant complications or side effects. The procedures are comparatively minor surgery, have quick recovery, results are immediate and no patient yet has reported that they have gotten worse afterwards.
How does one know they may get improvement in their migraines with surgery? Before surgery, one needs to be tested with Botox injections to confirm the correct trigger site. If Botox works to temporarily improve migraine symptoms, then the peripheral trigger is confirmed and surgery will likely be successful. But before one considers Botox injections and even surgery, they should be initially evaluated and treated by a neurologist. Only after failure of traditional medical treatments should one consider this new plastic surgery treatment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have suffered from severe disabling migraines for years. I have seen two different neurologists and none of the medications seem to work or are causing severe side effects. I’ve been doing research and came across the migraine surgery. I am willing to try anything to do away with or at least ease my migraines. As I am a single mother of three small children and it is crippling my income because I miss so much work due to these awful migraines.
A: Certain types of migraines can be cured or significantly improved by migraine surgery. Such surgery is based on release or decompression of sensory cranial nerves as they pass through muscles as they emerge from the bone. This has been shown to be effective for migraines that originate from the occipital, temporal, or supraorbital (brow bone) areas. A physical examination and the history of the migraine headache pattern can determine if one is a potential candidate. The definitive presurgical test is a Botox injection treatment into the identified nerve area. If significant relief occurs with the Botox injection, then this is a very good indicator that surgical decompression will be effective. I have yet to see a positive Botox test in which the patient did not get significant and sustained relief from the surgery.
Long-term studies out to five years has shown that about one-third of patients who undergo migraine surgery are cured. The majority of migraine surgery patients (about half) are not cured but have reduction in the number and severity of their headaches. A small number of patients (about 10%) failed to get benefit from the surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have had severe migraines for years. My migraines start in the back of my head and shoot up into my scalp and down into my shoulders. It usually feels like there is a vise on the back of my head. I have been to a lot of doctors and have tried everything from every drug out there to chiropractors, acupuncturists, massage therapists and even Chinese oriental practitioners. A few things worked for several days or a week but nothing lasts. I went to the local university and saw a neurologist there who did an MRI and other blood tests and came up with nothing. His drugs didn’t work any better. I have read recently on the internet about some type of migraine surgery. While I am desparate to try anything, the thought of going through surgery and then not have it work would be disappointing to say the least. What is the success of this new migraine surgery?
A: Migraine surgery is based on the concept that there is a peripheral trigger or site of nerve compression which is the stimulus for the attack. One of the four recognized trigger zones is at the greater occipital nerve at the back of the head at the base of the skull which causes occipital migraines. Whether surgery would be effective can be predicted beforehand through the use of Botox injections into the area. A positive response to Botox, which includes a significant and sustained relief of the migraines, correlates highly with surgical success. While about 1/3 of patients will have a near complete elimination of their migraines, 2/3 s will have reduced frequency, intensity and duration of attacks. A recent clinical study reported that 90% of patients treated maintained good relief out to five years after surgery which as the time limit of the study.
Dr. Barry Eppley
Indianapolis, Indiana