Where Is The Best Place On The Temporalis Muscle To Do Botox Injections For Migraines?
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