Migraine surgery, zone 3 (nasoseptal), zone 4 (greater occipital), and zone 6 (lesser occipital)

Migraine surgery targeting peripheral nerves in the head and neck is a relatively recent treatment option that originated when Dr. Guyuron discovered marked symptomatic improvements in migraine patients undergoing endoscopic forehead and brow lift surgery. Numerous studies have demonstrated that extracranial decompression of specific trigeminal and cervical root branches leads to a marked reduction in migraine headache frequency, intensity, and duration (Guyuron et al., Plast Reconstr Surg 115:1-9, 2005; Guyuron et al., Plasti Reconstr Surg 124:461-468, 2009). The nomenclature of migraine trigger zones and their associated nerves is as follows: zone 1 (frontal-supraorbital and supratrochlear nerves), zone 2 (temporal-zygomaticotemporal nerve), zone 3 (sinonasal-involves nasoseptal deviation with turbinate contacts or concha bullosa, resulting in irritation of the sinonasal nerves and triggering of migraine symptoms), zone 4 (occipital-greater and lesser occipital nerves; often referred as to zone 6), and zone 5 (auriculotemporal nerve) (Behin et al., Cephalalgia 25:439-443, 2005). The recent identification of a fifth trigger zone, the auriculotemporal nerve, where impingement occurs by means of the superficial temporal artery and other proximal fascial compression points, is leading to further technical refinements and overall greater success rates in migraine surgery. Before migraine surgery is considered, it is crucial that an accurate diagnosis was confirmed and that the patient must undergo a detailed history and physical examination with an established neurologist. Identifying the trigger areas based on the constellation of symptoms may suffice in certain patients, but the injection of botulinum toxin, nerve blocks, or both into specific trigger sites is confirmatory and carries a positive-predictive value for the success of surgical treatment. Collaboration with a board-certified neurologist specializing in migraines and chronic headaches is important in identifying patients who may be candidates for surgery, as it is usually reserved for patients who are not adequately controlled with medication or who have significant adverse effects with the medications. The approach to trigger release of zones 3, 4, and 6 will be discussed in this chapter.