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Pinpointing pain

Article-Pinpointing pain

Key iconKey Points

  • Using botulinum toxin to treat migraines has a limited effect
  • However, some surgeons are now using Botox to identify and remove the muscles causing migraines

Dr. Guyuron
CLEVELAND — The use of botulinum toxin to treat migraine headaches is inherently limited by the relatively short longevity of its effect. But some plastic surgeons are taking a new tack on the migraine-Botox relationship, using the toxin not as a treatment, but as a diagnostic tool for pinpointing the specific muscles causing migraines and then excising the culprits.

Dr. Janis
Bahman Guyuron, M.D., professor and chair of plastic surgery at Case Western Reserve University in Cleveland, pioneered the approach after several patients reported improvement of their migraines following brow lift surgery. Dr. Guyuron considered the possibility that the corrugator muscles, removed in the brow lifts, played a role in the migraines. "It was conjectured that these muscles somehow irritated, compressed or entrapped the nerves to set up a cascade of events leading to the migraines," explains Jeffrey E. Janis, M.D., assistant professor of plastic surgery, University of Texas Southwestern Medical Center, and chief of plastic surgery, Parkland Health and Hospital System, who collaborated with Dr. Guyuron. "That led to the idea that if Botox injected in a particular area alleviates headaches, then surgery in that spot would offer longer lasting treatment," Dr. Guyuron tells Cosmetic Surgery Times .

TRIGGER POINTS The surgeons closely evaluated the nerves and muscles in the brow area to devise a precise way to administer the Botox and, ultimately, design a surgery for permanent treatment. Drs. Guyuron and Janis determined a set of trigger points and a methodical Approach: Patients referred with migraines are treated with botox at just one of the trigger points at a time. if after 30 days their migraines don't resolve, another trigger point is injected (if indicated), and so on. When — and if — injection in a particular trigger point results in either resolved or significantly improved migraines, surgery is offered to resect the muscle identified as the trigger point. not only does neurologists' traditional use of botox for migraines offer only a temporary treatment, it doesn't offer trigger point clues. "Most neurologists who treat migraines with Botox typically inject one or two vials in a headband-like pattern around the head," explains Dr. Janis. "While that may temporarily work, it really is kind of a shotgun approach."

SUCCESS RATES Dr. Janis says his success rate with the more targeted surgery is about 90 percent, approximately that reported by Dr. Guyuron and colleagues in one of the more prominent studies on the approach. In it, 125 patients diagnosed with migraine headaches were divided into two groups. The treatment group of 100 patients was injected with Botox to identify trigger sites, and 89 who noted improvement in their migraine headaches from the Botox underwent surgery (Guyuron et al. 2005). A variety of surgeries were conducted based on identified triggers. For patients with a frontal trigger migraine headache, for instance, the glabellar muscle group — including the corrugator supercilii, depressor supercilii, and procerus muscle — was removed to relieve compression of the supraorbital and supratrochlear nerves which traverse those muscles. For patients with temporal migraine headaches, surgeries involved endoscopic removal of 3 cm of the zygomaticotemporal branch of the trigeminal nerve to prevent its compression by the temporalis muscle. "The nerve travels between this muscle and the lateral orbital wall and is commonly transected during craniofacial or aesthetic forehead surgery, with no reported consequence," they wrote.

Patients who experienced both temporal and frontal migraine headache underwent endoscopic removal of the zygomaticotemporal branch of the trigeminal nerve and glabellar muscle group. Results showed that 82 of the 89 patients who completed the study demonstrated at least a 50-percent reduction in migraine frequency, duration or intensity; 31 (35 percent) reported headache elimination and 51 (57 percent) reported improvement over a follow-up period of 396 days.

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