Surgical Management of Headache Disorders - A Systematic Review of the Literature.

PURPOSE OF REVIEW: This review article critically evaluates the latest advances in the surgical treatment of headache disorders. RECENT FINDINGS: Studies have demonstrated the effectiveness of innovative screening tools, such as doppler ultrasound, pain drawings, magnetic resonance neurography, and nerve blocks to help identify candidates for surgery. Machine learning has emerged as a powerful tool to predict surgical outcomes. In addition, advances in surgical techniques, including minimally invasive incisions, fat injections, and novel strategies to treat injured nerves (neuromas) have demonstrated promising results. Lastly, improved patient-reported outcome measures are evolving to provide a framework for comparison of conservative and invasive treatment outcomes. Despite these developments, challenges persist, particularly related to appropriate patient selection, insurance coverage, delays in diagnosis and surgical treatment, and the absence of standardized measures to assess and compare treatment impact. Collaboration between medical/procedural and surgical specialties is required to overcome these obstacles.

Can Sonography Distinguish a Supraorbital Notch From a Foramen?

Diagnostic tools for evaluating the supraorbital rim in preparation for nerve decompression surgery in patients with chronic headaches are currently limited. We evaluated the use of sonography to diagnose the presence of a supraorbital notch or foramen in 11 cadaver orbits. Sonographic findings were assessed by dissecting cadaver orbits to determine whether a notch or foramen was present. Sonography correctly diagnosed the presence of a supraorbital notch in 7 of 7 cases and correctly diagnosed a supraorbital foramen in 4 of 4 cases. We found that sonography had 100% sensitivity in diagnosing a supraorbital notch and foramen. This tool may therefore be helpful in characterizing the supraorbital rim preoperatively and may influence the decision to use a transpalpebral or endoscopic approach for supraorbital nerve decompression as well as the decision to use local or general anesthesia.

Pearls for Starting a Headache Surgery Practice in Academic and Private Practice.

There has been a growing body of evidence indicative of the effectiveness of headache surgery in treating patients with refractory headache disorders. The American Society of Plastic Surgeons issued a Policy Statement in 2018 stating that peripheral nerve decompression surgery for the treatment of refractory chronic headache disorders in select patients is considered a standard of care treatment. This endorsement sparked the interest of numerous plastic surgeons into initiating their own headache surgery practices. However, establishing a headache surgery clinic introduces challenges and considerations. This report outlines the key pillars for launching a successful headache surgery practice in academic and private practice environments.

Preoperative visualization of the greater occipital nerve with magnetic resonance imaging in candidates for occipital nerve decompression for headaches.

Occipital nerve decompression is effective in reducing headache symptoms in select patients with migraine and occipital neuralgia. Eligibility for surgery relies on subjective symptoms and responses to nerve blocks and Onabotulinum toxin A (Botox) injections. No validated objective method exists for detecting occipital headache pathologies. The purpose of the study is to explore the potential of high-resolution Magnetic Resolution Imaging (MRI) in identifying greater occipital nerve (GON) pathologies in chronic headache patients. The MRI protocol included three sequences targeting fat-suppressed fluid-sensitive T2-weighted signals. Visualization of the GON involved generating 2-D image slices with sequential rotation to track the nerve course. Twelve patients underwent pre-surgical MRI assessment. MRI identified four main pathologies that were validated against intra-operative examination: GON entanglement by the occipital artery, increased nerve thickness and hyperintensity suggesting inflammation compared to the non-symptomatic contralateral side, early GON branching with rejoining at a distal point, and a connection between the GON and the lesser occipital nerve. MRI possesses the ability to visualize the GON and identify suspected trigger points associated with headache symptoms. This case series highlights MRI's potential to provide objective evidence of nerve pathology. Further research is warranted to establish MRI as a gold standard for diagnosing extracranial contributors in headaches.

Treatment Delay in Patients Undergoing Headache Surgery (Nerve Decompression Surgery).

Background: Although headache surgery has been shown to be an effective treatment option for refractory headache disorders, it has not been included as part of the headache disorder management algorithm by non-surgical providers. This study aims to evaluate the delay in surgical management of patients with headache disorders. In addition, a cost comparison analysis between conservative and operative treatment of headache disorders was performed, and the surgical outcomes of headache surgery were reported. Methods: Among 1112 patients who were screened, 271 (56%) patients underwent headache surgery. Data regarding the onset of headache disorder and pre- and postoperative pain characteristics were prospectively collected. To perform a cost comparison analysis, direct and indirect costs associated with the conservative treatment of headache disorders were calculated. Results: The median duration between onset of headache disorder symptoms and headache surgery was 20 (8.2-32) years. The annual mean cost of conservative treatment of headache disorders was $49,463.78 ($30,933.87-$66,553.70) per patient. Over the 20-year time period before surgery, the mean cost was $989,275.65 ($618,677.31-$1,331,073.99). In comparison, the mean cost of headache surgery was $11,000. The median pain days per month decreased by 16 (0-25) (p<0.001), the median pain intensity reduced by 4 (2-7) (p<0.001), and the median pain duration decreased by 11 hours (0-22) (p<0.001). Conclusion: This study shows that patients experience symptoms of headache disorders for an average of 20 years prior to undergoing headache surgery. Surgical treatment not only significantly improves headache pain but also reduces healthcare costs and should be implemented in the management algorithm of headache disorders.

Quality of online information about migraine headache surgery.

Migraine headache is a debilitating disease that can lead to severe functional limitations and is the most common primary headache. In more than 30% of cases conservative therapies do not allow the control of symptoms or cause side effects. Peripheral nerve surgery should be considered in non-responsive chronic migraine or suspected peripheral origin. Nowadays Web has become one of the most important sources of knowledge for patients: the information available on the web is not subject to a control of the sources reliability but can influence the patient. The aim of the study is to evaluate the quality of information accessible on the Web about the surgical treatment of migraine headache. "Headache OR migraine treatment", "headache OR migraine surgery" were the keywords used on two main search engines (Google and Yahoo). Among the first 50 websites, 26 were suitable and we divided them into five groups (practitioners, hospitals, healthcare portals, professional societies, encyclopedias). We applied the expanded EQIP (Ensuring Quality Information for Patients) scale: the EQIP scale consists of 36 questions with three sections (content, identification data and structure). Although the overall average score was relatively high (22 out of 36), many lacks information were highlighted: overall, readability was not satisfactory in communicating information regarding migraine and its surgical treatment. Readability should be tested before medical online publication, in order to provide for its correct use by the patient and improving migraine knowledge.

Letter to the Editor: Insights into migraine surgery - An ACS-NSQIP data analysis over a 13- year period.

We demonstrate the safety of MS based on big data database research and outline the clinical relevance of white female migraineurs affected by menstrual migraines.

Letter to the Editor: The Case for Publicly Funded Headache Surgery in Germany.

Headache surgery has become a considerable therapeutic option in headache treatment and is of rising interest in the German medical sector. This viewpoint outlines the need for reimbursement of headache surgery in the German healthcare system and demonstrates its cost-effectiveness. Using state-of-the-art patient selection algorithms, the authors found headache surgery to be cost-effective within 7.2 to 6.3 years. Of note, the approach presented is not limited to the German healthcare system.

Computerized tomographic evaluation of supraorbital notches and foramen in patients with frontal migraine headaches and correlation with clinical symptoms.

PURPOSE: To correlate the location and size of supraorbital notches (SON) and foramen (SOF) with migraine headache symptoms in a migraine patient population. METHODS: A retrospective review was performed on consecutive patients who were candidates for frontal migraine surgery with available preoperative computed tomography (CT) images of the face/perinasal sinuses. The supraorbital anatomy from CT images was analyzed and correlated with presenting migraine headache symptoms. To assess for anatomic variations associated with migraine headaches, normative anatomic data were obtained by performing a meta-analysis. RESULTS: Fifty-six patients were included, 95% were female, aged 17-80 (mean = 47) years. Bilateral SON were present in 58.9% patients, combination of SON/SOF in 25%, and bilateral SOF in 16.1%. SOF mean diameter (1.22 mm) was 45% smaller than SON (2.20 mm, p < 0.0001). The mean lateral distance from midline for SOF (2.74 cm) was ~0.5 cm farther than SON (2.25 cm, p < 0.0001). Migraine patients with SOF had 178.6% longer mean migraine headache duration (p = 0.0020), 9.8% higher intensity (p = 0.0052), and 91.4% greater migraine headache index (p = 0.0498) compared to those without SOF. Compared to normative patient data, migraine patients are more likely to have SON/SOF (100% vs. 83%, p = 0.0047) and have mean SON and SOF diameters that are 34.3-41.5% smaller (p < 0.0001). DISCUSSION: Nerve compression at SON and especially SOF contributes significantly to migraine headache symptoms, and these structures (if present) should be released during frontal migraine surgery. Given the variable presence and location of SON/SOF, analysis of available face/perinasal sinus CT images helps preoperative planning for foraminotomy and band release.