PURPOSE The objectives of this research project were to identify the trigger sites for subjects with moderate to severe migraine headaches (MH) and deactivate these sites surgically. Over 50 percent of the 28,000,000 Americans with MH may benefit from this new treatment.

METHODS AND PATIENTS The diagnosis of MH was confirmed for all patients by the research team neurologists and the internal nose was examined by the plastic surgeon. Two separate IRB approvals were obtained for this project. All patients completed health-related, SF-36, Migraine Disability Assessment (MIDAS), and Migraine Specific Quality of Life (MSQ) questionnaires before treatment and one year after surgery. The first 50 of 125 patients were randomized and 25 patients underwent injection of botulinum toxin (Botox®) to detect the trigger sites using an algorithm developed by the research group. Another 25 patients received injection of 0.5 cc of placebo and served as a control group, primarly to compare the impact of surgery on socioeconomic and quality of life parameters. The remaining 75 patients also received injection of Botox®. If injection of Botox® identified one or several trigger sites, evidenced by complete elimination or significant improvement (50% reduction in severity or frequency) of MH, the patient was considered a candidate for surgery. If the injection of Botox® failed to eliminate MH, and sufficient evidence of rhinogenic migraine headaches and a deviated septum and enlarged turbinates were present, septoplasty and turbinectomy were carried out. Surgery included any one of the following as a single procedure or in combination; removal of the corrugator supercilii muscle group (including depressor supercilli and procerus muscles), detachment of the zygomaticotemporal branch of the trigeminal nerve, partial removal of the semispinalis capitis muscle to release the greater occiptal nerve, septoplasty and turbinectomy. All patients kept an accurate record of their headaches. The results were statistically analyzed.

Results Of the 100 patients in the study group, 91 patients underwent injection of Botox® to identify their trigger sites and 90 were subjected to surgery. Nine patients failed to complete the study. Only one trigger site was detected on 10 patients, 21 patients had two trigger sites, 38 patients had three trigger sites, and 19 patients had four trigger sites. Of the 88 patients (82 female, 6 male) with at least one month follow-up after surgery, 83 (94%) benefited from surgery, 26 (29.5%) patients noted complete elimination of their headaches, and 57 (65%) observed improvement over an average follow-up period of 172 days. When the response to surgery was analyzed based on trigger sites, of the 76 patients with glabellar trigger site, 75 (98.5%) responded favorably, 51 (67%) patients observed elimination and 24 (31.5%) patients had improvement. Temporal surgery was done on 70 patients resulting in a positive response in 68 (97%) patients, 43 (61%) experienced elimination and 25 (36%) patients had improvement. Surgery in the occipital trigger site produced a positive response rate in 33 patients: 22 (67%) patients had elimination and 11 (33.3%) patients reported improvement. Finally, septoplasty and turbinectomy was performed on 60 patients yielding a favorable response in 56 (93%) patients, 23 (38%) patients had elimination and 33 (55%) patients had improvement. The details of the results with at least one year average follow-up will be shared with the audience, along with an enormous amount of new information, including previously unreported procedures.

Conclusion Based on the preliminary results of this study and our previous studies (1 and 2), it is our conclusion that migraine surgery has a prodigious role in treatment of migraine headache.