Temporal Migraine Surgery: Relevance of Local Blood Vessels in Surgical Technique

Over two and a half decades have passed since the popularization of a surgical approach for migraine therapy based on the neurolysis of certain extra-cranial trigger points. In a retrospective review of 314 patients who had undergone forehead rejuvenation, Guyuron et al. [1] observed that, among 39 patients with migraine headaches prior to surgery, 31 experienced either complete resolution or significant improvement in their symptoms postoperatively. The average follow-up period was nearly four years. Since then, hundreds of studies have been published to validate this approach [2-22]. The results obtained in the same studies clearly show the numero us benefits (economic and related to the quality of life of the patients treated) resulting from the high rates of definitive cure resulting fro m surgical therapy.

Among the many trigger points gradually identified and described, the temporal region is one of the most frequently implicated. The purpose of this manuscript is to present our current surgical approach to treating this anatomical region in migraine patients. In detail, unlike the other surgical appro aches currently in use, we have placed particular emphasis o n the treatment o f lo cal arterial and venous vessels, which, in our opinion, should always be coagulated to obtain a complete and lasting result.

The current approach is primarily based on neurolysis or transection, performed either endoscopically or through open techniques, of the auriculotemporal and/or zygomaticotemporal nerves [23-30]. In our experience, involvement of the zygomaticotemporal nerve is rare. Furthermore, compression of the auriculotemporal nerve by adjacent anatomical structures is uncommon and typically does not necessitate an extensive neurolysis. More often, mechanical impingement may occur due to branches of the superficial temporal artery or vein. When this happens, the vessels are often dilated or ectasic (Figure 1). In other cases, the nerves appear completely unencumbered, showing no signs of compression, edema, inflammation, or fibrosis. Conversely, the presence of dilated or even aneurysmal vessels is almost invariably observed (Figure 2) [31]. In any case, vascular involvement is also confirmed by the typical symptoms of these patients, who invariably report throbbing and localized pain. Over the years, our approach in these patients has increasingly focused on coagulating the superficial temporal vessels. Our current technique involves a horizontal skin incision approximately 3 cm long, centered at the intersection of two perpendicular lines [32]: one vertical line passing through the tragus of the ipsilateral ear and one horizontal line tangent to the apex of the auricle. Following adequate tissue dissection, the auriculotemporal nerve is identified, and a complete neurolysis is performed. Then, the various branches of the superficial temporal artery and vein are coagulated. The procedure is completed with a simple suture.