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For Physicians

The role of the primary care physician and physician extenders is indespensible in the treatment of headache, as often patients rely on them for the majority of their prescriptions. Nearly all patients seen for migraine surgical evaluations have at some point been under the care of a neurologist, though this specialty is not available in all communities. Candidates that should be considered should have been tried on preventative medications in addition to abortive therapy. Those that do not obtain relief, want to avoid undesirable side effects, or those that want to avoid taking too many medications should be considered for consultation.

This criteria usually indicates the possible efficacy of Botox® Therapeutic injections which has recently been done with the 32 injection pattern that was used by Dr. Ninan Mathew in Headache: The Journal of Head and Face Pain. While this technique appears to be better than previous injection techniques used by Neurologists prior to the FDA’s approval (usually “follow the pain” or the “bandana” pattern), it is not purposefully designed to follow the anatomy of the superficial sensory nerves (supraorbital, supratrochlear and zygomaticotemporal branches of the trigeminal nerve (CN5) or the greater occipital nerve).

For Physicians

Still, many more patients are coming after a positive response to Botox® Therapeutic testing than before. When Botox® has not been tried, or there has not been a sufficient response with the 32 injection pattern, retesting is performed in our office using our protocol (demonstrated in our videos – 7 injections). The medication is delivered into the muscles superficial to, or encircling, the above mentioned sensory nerves. The locations were determined through multiple cadaveric landmark studies. A positive response is obtained 70-80% of the time with the vast majority of the nonresponders having a significant element of rhinogenic triggering which can only be managed with surgery.

The injection videos are intended for those that are trained in Botox® injections and are comfortable managing this powerful medication, though the dose used is usually less than 100 units. Special attention should be paid to the dilutions (more dilute for fanned out injections into deeper muscle – temporalis and semispinalis capitis muscles), depth and delivery. It is important not to inject against the lateral orbital rim as this may communicate through to the lateral rectus, causing diplopia. Injection of too much over the midpupillary line makes ptosis more likely. This and more is included in the videos, which I encourage you to watch.Interpretation of the response is logical, but not necessarily intuitive.

Many patients that have not previously improved with standard injection techniques are still candidates for evaluation. A few patients get significant injection-associated migraine which implicates the associated nerve as a likely trigger zone. This may mislead both the patient, who will avoid this at all cost, and the practitioner. Some patients’ pain may move to another area which may be just as severe – implicating a second or third trigger zone that was either not tested, or not adequately injected. Again, this patient may not perceive a benefit and may make the practitioners start scratching their heads. Persistent frontal pain, especially if it follows the rhinogenic pattern, can implicate the anatomy of the nasal septum and or turbinates. This may significantly decrease the apparent response since a second overlapping zone is persistently triggering in the nose.

There are some surgeons that are not performing Botox® Therapeutic testing, despite the prognostic value showing a higher success rate for the surgery. This is arguable since the surgical side effects and complications are so few, making a lower success rate acceptable without this expensive screening process. Other testing modalities using local anesthetic and steroids are used by some surgeons as a less expensive alternative.

Regarding the implantable Occipital Nerve Stimulator

While this may be efficacious for those triggering entirely in zone 3 through the greater occipital nerves at their intersection with the semispinalis capitis muscles, this represents the minority of migraine sufferers. Certainly the idea of a stimulator in this area makes sense in terms of its ability to interrupt the triggering stimulis, but practically-speaking, is illogical. This zone has the highest success rate of any of the zones we treat – near 95%. This is a 60-75 minute operation under sedation with the most common complication being temporary numbness. Contrast this with implanted wires and a large pacemaker-like battery pack in the back or flank that must be surgically maintained on a regular basis.

There are 30 million migraine sufferers in the United States that are currently being almost entirely managed medically. Despite many indispensible and wonderful medication, studies show that over 75% of migraine sufferers feel that their migraines are not adequately treated. This is changing with the emergence of this new surgical field now taught at many top Plastic and Reconstructive Surgical Residencies. Insurance acceptance has increased dramatically over the last 18 months. Lack of awareness appears to be the greatest hurdle to overcome, despite countless local news stories around the country, as well as a few national exposures including CNN and The Doctor’s Show. Surgeons who are interested in learning the surgical technique are encouraged to attend the yearly Migriane Surgery Symposium in Cleveland under the instruction of Dr. Bahman Guyuron. For those that would like more of a one-on-one short mentoring experience, this has been and can be arranged through my office. Once completed (usually a 1 or 2 week program) you will be provided with all of our templates necessary for evaluation, follow up, surgical precertification and billing.