Surgical Treatment of Migraine Headaches byCorrugator Muscle Resection Franz Dirnberger, M.D., and Klaus Becker, M.D.
The authors, a plastic surgeon (Dirnberger) and a neu- The article on the surgical treatment of mi- rologist (Becker), conducted this study after reading the graine headaches by Bahman Guyuron et al.1 article by of Bahman Guyuron et al. in the August 2000 in the August 2000 issue of the Journal gener- issue of Plastic and Reconstructive Surgery (106: 429, 2000).
Sixty patients were operated on between June of 2001 and ated great interest in the senior author (Dirn- June of 2002; postoperative follow-up ranged between 6 berger), as he not only is a plastic surgeon but and 18 months. Patients’ charts were reviewed to confirm also has experienced migraine headaches for the diagnosis of migraine headache according to the cri- the last 20 years. He decided immediately to teria of the International Headache Society. Sixty patients (13 men and 47 women) from Austria and four neigh-boring countries took part in the study. The patients were The operation was performed in February of divided into three groups, based on the severity of their 2001 and the result was striking. His migraine migraines: group A comprised patients with up to 4 days attacks were reduced by about 80 percent in of migraine per month; group B included patients with 5 frequency as well as severity. All side effects, to 14 days of migraine per month; and group C was com- such as nausea and intolerance to noise, disap- posed of patients with more than 15 days of headache permonth (“permanent headache”) or evidence of drug peared completely, and his quality of life had abuse and drug-related headaches. The effectiveness of practically returned to its premigraine era the operation was evaluated using the following factors: percentage reduction of headache days; percentage re- To ensure that the effect of the intervention duction of drugs; percentage reduction of side effects, was a lasting one, an observation period of 6 severity of headaches, and response to drugs; and patientgrade of personal satisfaction, using a scale from 1 to 5 [1 months was allowed to pass before it was de- ϭ excellent (total elimination of migraine headache) to 5 ϭ insufficient or no improvement].
graine patients. Following publication of a From the entire group of 60 patients, 17 (28.3 per- brief report in a newspaper, the interest of cent) reported a total relief from migraine, 24 (40 migraine patients in the new treatment was percent) reported an essential improvement, and 19(31.7 percent) reported minimal or no change. Pa- overwhelming, but it was decided to operate tients with a rather mild form of migraine headache only on patients with a history and symptoms of had a much better chance (almost 90 percent in group migraine correlating to the standards of the A and 75 percent in group B) to experience an im- International Headache Society. The charts of provement or total elimination of migraine than those all patients were reviewed by a neurologist patients (n ϭ 27) from group C with severe migraine,“permanent headaches,” and drug-induced headaches.
(Becker); they were examined for various pa- Contrary to the reports by Guyuron, 11 patients who had a very favorable response immediately and in the firstweeks after the operation experienced a gradual returnof their headaches to preoperative intensity after about 4 postoperative weeks. After 3 months, the results in all Between August of 2001 and July of 2002, 60 patients could be declared permanent. All side effects, patients underwent surgical treatment for mi- such as paraesthesia in the frontal region, disappeared inall patients within 3 to 9 months.
graine headaches. All had symptoms of classic migraine according to the standards of the From the Department of Plastic Surgery, Wilhelminenspital, and the Department of Neurology, Sanatorium Grinzing. Received for publication May 15, 2003; revised September 19, 2003.
DOI: 10.1097/01.PRS.0000131906.27281.17
Vol. 114, No. 3 / CORRUGATOR MUSCLE RESECTION Non spec., nonspecific drugs; Ergot, ergotamine; DA, drug abuse; MFI, migraine-free interval.
* Grade of severity: A, 1 to 4 days of migraine per month; B, 5 to 14 days of migraine per month; C, more than 15 days of migraine per month.
PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2004 International Headache Society. They were in- corrugator and depressor muscles was per- formed that the operation was still experimen- formed, using 4.5 times loupe magnification.
tal, as only one scientific article had been pub- Patients were put under sedo-analgesia by an lished so far.1 The fact that the surgeon anesthesiologist using 0.5% Xylocaine with epi- (Dirnberger) performing the operation had nephrine as local anesthetic. All patients were been operated on himself with great success treated in a day clinic and left the hospital naturally made the patients’ decision much easier, although they knew that about 20 per- In all patients, the corrugator muscle was cent or more of them might not experience removed on both sides, even in patients who declared that they were experiencing theirheadaches strictly on one side. The intent was to prevent a possible later shift of their mi- Patients completed a preoperative question- graine to the other side of the head.
naire that collected data on age, sex, type of Although typical blepharoplasty incision and migraine (aura or nonaura), side effects (nau- skin resection were performed, in no case was the orbital septum opened to remove orbital and/or ocular), age at onset, frequency per fat, for fear of additional bleeding, which may month (in days), inability to work (in days), have caused prolonged postoperative swelling types of drugs used (ergotamine, triptanes, or additional scar formation around the su- nonspecific drugs), amount of drugs used per month, other neurological disorders, history of head trauma, and history of meningitis.
nerves were localized, but no effort was made As the patients came from Austria and four to perform a preparation of the supraorbital neighboring countries, it quickly became clear nerve. As soon as the supratrochlear nerve was that it would be impossible to obtain clear observed, the author switched to a microsurgi- numbers, especially concerning the number of cal technique, using 4.5 times loupe magnifi- days with migraine headaches as well as the cation. Small vessels were coagulated by bipo- type and amount of medicine taken to sup- lar diathermy. Although care was taken not to press the headaches. Patients were therefore hurt the nerve, in seven cases a partial dissec- divided into three groups. Group A comprised tion of the supratrochlear occurred; this was patients with up to 4 days of migraine per mainly due to bleeding that was sometimes month (n ϭ 9). Group B included patients quite heavy, making the preparation difficult.
with 5 to 14 days of migraine per month (n ϭ In all cases, a soft rubber drain was left in place 24). Group C was composed of patients with 15 for a few hours postoperatively. No hematoma or more days of headache per month or “per- was observed in any case. All patients received manent headache,” with extreme drug con- cool wet soaks over their eyes, which they had to change frequently during the first 12 hours; headaches (n ϭ 27, including 18 with drug- thus, postoperative bleeding and swelling were kept to a minimum. The sutures were removed As it appeared to be difficult for many pa- tients to explain whether or not they had an The preoperative evaluation showed that the aura, we decided to drop this question for majority of patients had been having strong migraine headaches for years and had alreadyused practically all kinds of treatment, includ- ing acupuncture, diet programs, and clinical All patients were operated on by the same drug withdrawal. Thirty-four patients stated surgeon (Dirnberger) using the same tech- that they were forced to bed rest and/or sick nique. The corrugator supercilii muscle was leave by their attacks; 13 patients in group C complained of “permanent headaches” and ron through an incision in the upper eyelid.2,3 showed symptoms of drug-related headaches.
In order to remove all muscular structures Ten patients showed signs of classic “ergot- around the supratrochlear nerve and its rami- ism,” which is caused by taking large amounts fications, which appeared to compress the of ergotamine drugs over a period of years.
nerve, total or at least subtotal resection of the One woman had developed a rectovaginal fis- Vol. 114, No. 3 / CORRUGATOR MUSCLE RESECTION tula after practically daily use of ergotamine drug consumption, because as we know, these suppositories (Avamigran suppositories).
data are also highly individual and hardly All 60 patients reported having the typical For some patients, it is of major importance to be able to go to work, even on days ofmigraine headache, albeit in a milder form and without strong side effects and symptoms.
For other patients, their expenses for triptanes dropped significantly; the costs for these drugs The patients were asked to keep a postoper- can become quite a burden for a patient with ative migraine diary for 4 weeks. After 6 severe migraine, so this economic effect will months, a postoperative questionnaire was sent show up as a good grade of individual satisfac- to them for an in-depth evaluation of the post- tion. Because migraine affects the daily lives of the patients within their families, among their During our evaluation of the questionnaire friends, and at their jobs so tremendously, even responses, we realized that it was frequently a rather moderate reduction of pain and the difficult for the patients to grade their postop- associated complaints is highly appreciated.
erative results, as most of them were accus-tomed to pain that was even severe and discom- Relationship between Patient Age and Postoperative fort that had lasted for years. Even a moderate reduction of accompanying symptoms such as The result of the operation was measured by nausea or a slight reduction of the severity of comparing patient age with individual satisfac- the headaches with the ability to work was tion. The results show that there is a slightly highly appreciated. Patients naturally rated smaller chance of 5 percent that older people these improvements with a higher grade of might not benefit from the operation to the same extent as patients under the age of 60 years. Nevertheless, two out of three patients percent reduction in the number of headache (67 percent) experienced a substantial or total days and/or a 30 percent reduction in the relief of their headaches (Table III).
amount of medicine taken, at a minimum, wasconsidered a successful outcome of the opera- Relationship between Severity of Migraine and tion. We also dropped the grade 4 level of minimal patient satisfaction and included Patients in group A (mild form of migraine) these responses with the unsuccessful cases had an almost 90 percent chance of getting total or at least essential relief; this chance Because of the difficulty inherent in any “ob- dropped markedly with the severity of the mi- jective grading” of pain, we decided to give graine. In group B, 75 percent had a realistic individual patient ratings preference over the hope of experiencing this result, while group C strictly “objective data” of headache days and patients had a worse chance by far— onlyslightly more than half of them (55.6 percent) 1. Did you experience a sudden, a gradual, or no relief of profited from the operation. [The biostatistical 2. Did side effects/symptoms such as nausea, vomiting, control (two chi-square tests) showed that the irritability, and so on change, disappear, or not change? results for patient age and postoperative satis- 3. Did the migraine headaches change in frequency and/or 4. Number of headache days per month, percent reduction in results for severity of migraine and postopera- tive satisfaction are not significant, but the p 6. Personal satisfaction with the result of the operation as a grade of quality of life (comparable to school-grades): 1 ϭ excellent (total elimination of migraine headaches) 2 ϭ good3 ϭ fair (considerable improvement) Other Factors and Observations Related to the 7. Postoperative numbness or dysesthesia in the frontal region 8. Complications or undesirable side effects erative workup it became apparent that in 11 FIG. 1. Postoperative questionnaire.
patients who had reported a total cessation or PLASTIC AND RECONSTRUCTIVE SURGERY, September 1, 2004 Reduction of headache days after 6 months, % Reduction of medication after 6 months, % Personal satisfaction after 6 months, no.* * Grade 1, total relief; grade 2–3, considerable improvement; grade 4, minimal; grade 5, no improvement.
an essential improvement of their headaches one has to wait at least 3 months postopera- during the first month postoperatively, this fa- tively before one can call the result permanent.
vorable result unfortunately did not last. For the Difference in the grade of satisfaction between the 1 first time in years, they had experienced a mi- graine-free period that had lasted between 4 percent of patients showed a successful re- and 12 weeks postoperatively. Naturally, their sponse to the operation. This initial favorable disappointment was extreme when their com- response dropped to the final result of 68.3 plaints gradually returned, in the majority of percent with a successful operation (Table IV).
As all of them had been operated on by the who reported grade 2 or 3 personal satisfaction, same surgeon using the same technique, the this was not only because of a reduction in the question arose, what might be the reason for number of headaches days but also because of the recurrence of their headaches: remaining an essential reduction in the amount of drugs muscle fibers causing pressure on the nerve, or necessary to suppress the migraine. Especially striking was that many of them stated that they did not need triptanes anymore but were able operative revision. A secondary neurolysis of to suppress their headaches with aspirin or low the supratrochlear nerve was attempted, but it proved to be extremely difficult and ended in Analysis of these 24 patients showed that the transection of the nerve at one side. No before the surgery 12 used to take triptanes alone, triptanes in combination with ergota- Analysis of these 11 patients showed that mine, or other nonspecific drugs (patients 2, 7, eight of them were from preoperative group C 12, 15, 23, 26, 27, 28, 31, 36, 39, and 56). Of and had a severe form of migraine or “perma- these 12 patients, seven (patients 2, 26, 27, 28, nent headaches.” Five of them were considered 36, 39, and 56) were free of the need for to be drug addicted. This accentuates our ex- triptanes after the surgery. For these patients, perience that these patients have a far worse this was a substantial improvement in their chance for relief of their headaches and that medical expenses, as one pack of triptanes (sixtablets) in Austria costs about $100. Consider-ing that the average monthly income in Austria is about $1200, one can imagine that a mi- graine patient quite easily may need to spend10 to 20 percent of his or her salary just for Difference in Grade of Satisfaction after 1 and 6 Months * Group A, 1 to 4 days of migraine per month; group B, 5 to 14 days of migraine per month; group C, more than 15 days of migraine per month.
Vol. 114, No. 3 / CORRUGATOR MUSCLE RESECTION Provocation of migraine by trigger compression. but plastic surgeons may become important Two patients reported a remarkable phenom- helpers for those patients who do not get sub- enon: the arousal of an acute migraine attack stantial relief of their headaches after thor- after accidental compression of the trigger ough neurological treatment. We believe that we do have a tool, but we still do not know why course of the supratrochlear nerve by painting and how it works; this naturally leaves some a corresponding line on the skin, to explain it to other patients. As this had been done with a Our observations confirm the opinion that strongly adherent ink, quite heavy pressure the corrugator muscle has a “trigger function,” and rubbing were necessary to remove the line.
and that the compression of the supratrochlear Thus the patient involuntarily massaged the nerve is essential for the provocation of a mi- underlying nerve. The patient, who had been graine attack. Our data show that there is a free of any migraine for 2 months, called about distinct difference in the chance of responding 1 hour later and reported that she experienced positively to the operation: the milder the mi- a severe migraine attack, like those she had graine headaches are, with regard to fre- Another patient told us a similar story. Some- one recommended that he softly massage the scars at the upper eyelid to get them to mature Since the operation has so far not caused any faster, and anytime he did this, he also experi- serious complications or side effects, it can be enced some kind of mild migraine. These re- recommended to patients with severe forms of ports conform the suspicion that compression migraine and symptoms of drug dependency.
of the supratrochlear nerve might play an es- These patients still have a 50 percent chance of sential role in provoking a migraine attack.
responding with partial or even total relief of After the first report by Guyuron et al.,1 our expectations for this new migraine treatment were high. Almost 2 years later and after more than 100 patients have been operated on (the first 60 are included in this report), we are convinced that this operation is of real value and will become an essential tool in the treat- ment of this widespread malady. Because of the large number of people who are affected by 1. Guyuron, B., Varghai, A., Michelow, B. J., Thomas, T., migraines, this treatment has essential social and economic effects. A reduction in the num- and migraine headaches. Plast. Reconstr. Surg. 106: 429, ber of headache days means that people will be able to stay on their jobs and get back their 2. Guyuron, B., Tucker, T., and Davis, J.
pleasure in their private and social lives.
ment of migraine headaches. Plast. Reconstr. Surg. 109:2183, 2002.
We had to realize that it is not easy to con- 3. Guyuron, B., Michelow, B., and Thomas, T.
vince our colleagues, especially neurologists, supercilii muscle resection through blepharoplasty in- that we have “accidentally” found a good cision. Plast. Reconstr. Surg. 95: 691, 1995.
method for the treatment of this malaise. We agree that there is good reason to distrust re- blepharoplasty incision. Plast. Reconstr. Surg. 107: 604,2001.
ports of 80 percent cure rates. We still believe that migraine is a neurological disease and that tor supercilii and procerus muscles. Plast. Reconstr. it needs to be treated primarily by neurologists,


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