Frontal Migraine Surgery: Indications and Results

Suat Morkuzu ¹, Alice Morello ², Giorgio Raposio ², Edoardo Raposio ^2,3,*

1. Department of Anatomy, Faculty of Medicine, Akdeniz University, Antalya, Turkey

2. Plastic Surgery Chair, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Italy

3. Plastic and Reconstructive Surgery Division, IRCCS Ospedale Policlinico San Martino, Genova, Italy

* Correspondence: Edoardo Raposio

Academic Editor: Maurizio Elia

Special Issue: Surgical Therapy for Migraine and Tension-Type Headache

Received: July 18, 2024 | Accepted: November 18, 2024 | Published: November 27, 2024

OBM Neurobiology 2024, Volume 8, Issue 4, doi:10.21926/obm.neurobiol.2404258

Recommended citation: Morkuzu S, Morello A, Raposio G, Raposio E. Frontal Migraine Surgery: Indications and Results. OBM Neurobiology 2024; 8(4): 258; doi:10.21926/obm.neurobiol.2404258.

© 2024 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

Migraine is a prevalent neurological disorder, affecting 20% of women and 8% of men [1]. U.S. population-based studies on migraine prevalence over the past 30 years have reported an overall prevalence ranging from 11.7% to 14.7% [2]. The results indicate that migraine surgery is a safe and effective option, improving patients' quality of life and potentially lowering long-term expenses [3,4,5,6,7,8,9,10,11,12,13]. This suggests that it should be considered for migraine sufferers who haven’t responded to medication, provided they are appropriately selected for the procedure.

Recent studies have identified that certain types of migraines, including frontal migraine headaches (FMH), may be attributed to the irritation of specific extracranial nerves [14,15]. Frontal migraine may result from chronic irritation or compression of some cranial nerves, specifically the supraorbital (SON) and supratrochlear (STN) nerves, as well as other terminal branches of the frontal nerve [8]. The supraorbital (SON) and supratrochlear (STN) nerves are branches of the frontal nerve, the largest branch of the ophthalmic division of the trigeminal nerve. The SON typically divides into a lateral branch, which passes through the supraorbital notch to innervate the forehead skin, and a medial branch, which passes through the frontal notch to innervate the bridge of the nose and medial forehead. Variations in their courses are common, generally dividing into superficial branches over the frontalis muscle and deep branches beneath the corrugator supercilii and frontalis muscles [13]. This anatomical variability highlights two main infraorbital course variants for these nerves. Considering the anatomy of SON and STN and their possible variations, we can identify the most common trigger points: pain starts above the eyebrows and is associated with deep frown lines, corrugator muscle hypertrophy, or eyelid ptosis.

The aim of this systematic review is to comprehensively analyze surgical options for chronic frontal migraine headaches, including their success rates and safety profiles. Also, examine the literature on surgical treatments and techniques for chronic FMH, whether used alone or combined with other invasive therapies.

2. Methods

A literature search was performed using the PubMed database, following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, to provide a systematic review of the literature on the diagnosis and treatment of chronic FMH.

The following searching strategy was used: ((((((frontal migraine [Title/Abstract]) OR (Frontal Headache [Title/Abstract])) OR (Frontal site [Title/Abstract])) OR (Frontal Trigger Site [Title/Abstract])) OR (supraorbital [Title/Abstract])) OR (supratrochlear [Title/Abstract])) AND ((surgery [Title/Abstract]) OR (nerve decompression [Title/Abstract])) Filters: from 2000/1/1 - 2024/10/15. Abstracts were screened to identify eligible articles, and the reference lists of relevant articles were analyzed for additional studies.

2.1 The Selection of the Studies Was Based on the Following Criteria

1. Studies reporting the surgical treatment of Frontal Migraine Headaches (FMH)/peripheral trigger points for migraine: sites I).
2. Registration of post-operative outcomes of frontal trigger site surgery.
3. Full text available.

2.2 Studies Were Excluded Based on the Following Criteria

1. Studies that did not report surgical outcomes in terms of frontal migraine headache reduction or success rates.
2. Reviews, systematic reviews or meta-analyses of the literature.
3. Cadaver studies. 

2.3 Data Pooling and Data Analysis

Two independent reviewers evaluated the titles and abstracts of the retrieved articles for relevance. Any differences in opinion were addressed through discussion and consensus. The full texts of articles that appeared to be eligible were subsequently reviewed according to established inclusion and exclusion criteria. The data from the selected studies were combined for analysis. A general overview of the studies includes the author, publication year, number of patients, type of surgery, and reported complications. In this review, we analyzed surgical outcomes, considering the type of surgery, techniques employed, and the potential role of medical treatment in achieving post-operative objectives. Due to the heterogeneity of the studies, a quantitative synthesis of the results was not feasible.

3. Results

A total of 756 articles were identified from the PubMed databases. Of all these, only 16 articles met the inclusion criteria (Figure 1). In total, 1004 patients suffering from FMH underwent surgical treatment, encompassing all the established procedures. These patients were studied and followed up to track outcomes (Table 1).

Figure 1 PRISMA 2020 flow diagram for new systematic reviews which included searches of databasesand registers.

Table 1 Main scientific studies analyzed in the research.

Mangialardi et al conducted frontal trigger site surgery involving selective myotomies through either an endoscopic or transpalpebral approach, resulting in 87% of patients showing improvement, with 32% achieving complete recovery [27]. Complications included cutaneous numbness, paresthesia, and itching in the undermined area. In another study, Guyuron et al compared frontal trigger site surgery with sham surgery, finding a 57.1% reduction in migraine frequency, intensity, and duration in the surgical group. However, some patients experienced temporary intense itching and residual muscle function [17].

3.1 Comparison of Surgical Approaches for Nerve Decompression

Liu compared transpalpebral nerve decompression with endoscopic decompression in patients with frontal migraine [24]. The endoscopic group showed a higher success rate (89%) compared to the transpalpebral group (79%) and a significantly higher rate of complete migraine elimination (67% vs. 52%). Raposio also reported on supraorbital and supratrochlear nerve decompression, achieving a 50% or more significant reduction in migraine attacks in 87% of patients, with minimal complications, mainly paresthesia [8].

3.2 Endoscopic and Transpalpebral Decompression Surgeries

Raposio et al reported that endoscopic or transpalpebral decompression of the supraorbital and supratrochlear nerves led to a 94% positive response among patients with frontal trigger site migraine [16,20]. Minor complications included postoperative edema and itching. Hagan et al performed bilateral or unilateral transpalpebral decompression with positive outcomes at both 3 and 12 months, though some patients developed complications like persistent swelling, hematoma, and neuroma [19].

3.3 Foraminotomy and Myectomy

Chepla et al analyzed supraorbital foraminotomy in comparison with traditional resection and found statistically significant improvements in migraine frequency and severity among the foraminotomy group [22]. Persistent forehead pain was less common in this group compared to the traditional resection group. Gatherwright et al examined patients undergoing myectomy alone, myectomy with foraminotomy, and arterectomy, with the arterectomy group showing significantly improved frequency and severity of migraines [15].

3.4 Botulinum Toxin and Myotomy

In studies by Guyuron and Janis, endoscopic forehead surgery combined with botulinum toxin A showed favorable outcomes [17,25]. Guyuron et al observed a 99% positive change, with 64% achieving complete elimination of migraines; minor complications included scalp itching and small hematomas [17]. Janis et al reported that 83.3% of patients experienced an improvement, with significant symptom reduction and no notable complications [25].

3.5 Long-Term Outcomes and Additional Surgical Techniques

Kurlander et al reported on transpalpebral corrugator resection, with 88% of patients achieving positive outcomes [21]. Symptoms such as visual aura and blurred vision resolved postoperatively, though eyelid ptosis occurred in 5.8% of cases. Dirnberger et al reported that 31.7% of patients experienced a 90-100% reduction in headache days, with no significant adverse events noted during follow-up [14].

4. Discussion

This review synthesizes current literature on the surgical treatment of frontal migraine headaches (FMH), highlighting the efficacy of various surgical techniques and comparing these with non-surgical interventions. Also, the main point is that surgical interventions for migraines demonstrated significant symptom reduction, with response rates ranging from 57% to 94% across techniques.

Pharmacological treatments remain the first line of defense against migraines [28]. However, approximately two-thirds of patients with migraines do not respond adequately to these treatments, necessitating alternative approaches. This review underscores that surgical decompression of the supraorbital (SON) and supratrochlear (STN) nerves has shown promising results in patients with FMH who are refractory to medical treatment. For instance, Guyuron et al. demonstrated substantial reductions in migraine duration, frequency, and severity post-surgery [2]. These findings, along with reports from other literature [29,30,31,32,33,34], indicate that surgical intervention can offer a viable and often superior alternative for patients unresponsive to medication. Similarly, Raposio et al. reported a 94% positive response rate to surgery, with significant improvements or complete relief in most cases [23,35].

Botulinum toxin has been employed as a diagnostic and therapeutic tool in migraine management. It helps identify trigger points and provides temporary relief, which can guide surgical planning. In 30 randomized controlled trials with 2680 patients, nerve block and surgery significantly reduced headache frequency, while all treatments decreased severity [36,37,38]. Migraine surgery had the longest-lasting effects at 11.5 months, compared to nerve ablation (6 months), botulinum toxin (3.2 months), and nerve block (11.9 days).

Both endoscopic and transpalpebral approaches aim to alleviate nerve compression by performing selective myotomies. The endoscopic approach is preferred for its minimally invasive nature and has proven effective in relieving symptoms. However, the transpalpebral approach offers better anatomical exposure, particularly for addressing supraorbital nerve (SON) and supratrochlear nerve (STN) vascular compressions. This may contribute to better outcomes in specific cases.

Detailed anatomical evaluation and tailored surgical interventions are crucial for optimizing patient outcomes. The heterogeneity of techniques and outcome measures across studies makes a quantitative synthesis challenging. Variations in patient selection, surgical approach (e.g., endoscopic vs. transpalpebral), and follow-up duration impact results.

Complication rates reported across studies are generally low and include minor, transient symptoms such as numbness, itching, and occasional swelling. While endoscopic approaches are associated with a favorable safety profile, complications like temporary cutaneous numbness and paresthesia in the operated area are reported in transpalpebral approach procedures (Table 1). Furthermore, more invasive techniques, such as foraminotomy, may have a slightly higher risk of post-surgical numbness or localized discomfort. However, studies like those by Ortiz et al. have shown that these symptoms tend to be resolved without long-term impact [26]. The overall low incidence and mild complications support the safety of these surgical interventions, mainly when performed by experienced surgeons.

4.1 Limitations

Limitations include small sample sizes, lack of randomized controlled trials, varied surgical techniques, short follow-up, subjective outcomes, potential bias, inconsistent complication reporting, and differing diagnostic criteria. These limit generalizability and highlight the need for larger, standardized, long-term studies. One possible limitation of this study is the uncertainty regarding reimbursement for these procedures by national health systems worldwide, which may lead to financial burdens for patients and introduce a conflict of interest not accounted for in the analysis.

5. Conclusion

Different surgical methods for treating frontal trigger site migraines have shown considerable effectiveness, with endoscopic techniques potentially yielding higher success rates. Procedures such as foraminotomy and the use of botulinum toxin A may improve results even further. However, there is a need for multi-center, high-quality, randomized controlled studies to standardize these techniques, evaluate long-term outcomes, and examine the quality of life for patients after surgery.

Author Contributions

SM, AM and GR performed the analysis and wrote the paper, ER supervised the whole project.

Competing Interests

The authors have declared that no competing interests exist.