Migraine Surgery in Male

Migraines are a debilitating illness experienced by over 30 million Americans with a predilection for females. First-line treatment is medical. Refractory migraines can be amenable to surgical intervention. Thorough evaluation by a neurologist/headache specialist is required before surgical evaluation. Minimally invasive treatments such as botulinum toxin A (BTX-A) is beneficial but if history is indicative of localized trigger sites, surgical intervention is appropriate. Four major trigger sites include: frontal, temporal, occipital, and nasal regions. Fontal trigger site is commonly affected by the supraorbital and supratrochlear nerves irritated by adjacent muscles, vessels, bands over the supra-orbital notch or bony foramen. It is treated by releasing constriction of the nerve and interposing a fat. Temporal trigger site is caused by impingement of the zygomaticotemporal branch of the trigeminal nerve (ZTBTN) as it emerges from deep temporal fascia. It is treated by nerve avulsion/decompression. Occipital trigger site is caused by irritation of the greater occipital nerve through the semispinalis capitis and trapezius fascia as it crosses the occipital artery. It is treated by partial muscle/fascia resection, subcutaneous fat flap, or adjacent artery resection. Rhinogenic triggers are theoretically caused by vascularized nasal mucosa irritation by direct contact or pressure from entrapped air pockets. Rhinogenic treatment included septoplasty, elimination of contact points of the turbinate/nasal side wall and septum, turbinate reduction, or concha bullosa removal. Less common trigger sites, auriculotemporal nerve, lesser occipital nerve, third occipital artery or distal branches of the aforementioned nerves, are irritated by adjacent blood vessels or fascial bands that require release.