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Anatomy of the Supratrochlear Nerve: Implications for the Surgical Treatment of Migraine Headaches

Janis, Jeffrey E. M.D.; Hatef, Daniel A. M.D.; Hagan, Robert M.D.; Schaub, Timothy M.D.; Liu, Jerome H. M.D., M.S.H.S.; Thakar, Hema M.D.; Bolden, Kelly M. M.D.; Heller, Justin B. M.D.; Kurkjian, T. Jonathan M.D.

Plastic & Reconstructive Surgery: April 2013 - Volume 131 - Issue 4 - p 743–750
doi: 10.1097/PRS.0b013e3182818b0c
Reconstructive: Head and Neck: Original Articles

Background: Migraine headaches have been linked to compression, irritation, or entrapment of peripheral nerves in the head and neck at muscular, fascial, and vascular sites. The frontal region is a trigger for many patients' symptoms, and the possibility for compression of the supratrochlear nerve by the corrugator muscle has been indirectly implied. To further delineate their relationship, a fresh tissue anatomical study was designed.

Methods: Dissection of the brow region was undertaken in 25 fresh cadaveric heads. The corrugator muscle was identified on both sides, and its relationship with the supratrochlear nerve was investigated.

Results: The supratrochlear nerve was found in all 50 hemifaces. Three potential points of compression were uncovered in this investigation: the nerve entrance into the brow through the frontal notch or foramen, the entrance of the nerve into the corrugator muscle, and the exit of the nerve from the corrugator muscle. The nerve generally bifurcates within the retro–orbicularis oculi fat pad, and these branches enter into one of four relationships with the corrugator muscle: both branches enter the muscle, one branch enters the muscle and one remains deep, both branches remain deep, and the branches further branch into ever smaller filaments that cannot be identified cranially.

Conclusions: Some patients are nonresponders to migraine decompression techniques that address the supraorbital nerve. The supratrochlear nerve may be compressed in these patients. A standard corrugator resection that comes more medially within 1.8 cm of the midline may be beneficial. The morphology of the frontal notch/foramen must be examined and addressed if necessary.

Dallas and Houston, Texas; St. Louis, Mo.; Scottsdale, Ariz.; Baltimore, Md.; Mountain View and Los Angeles, Calif.; and Portland, Ore.

From the Department of Plastic Surgery, University of Texas Southwestern Medical Center; the Department of Plastic Surgery, Baylor College of Medicine; private practice; the Department of Plastic Surgery, Oregon Health Sciences University; and the California Skin Institute.

Received for publication December 19, 2011; accepted October 15, 2012.

Presented at the Fourth Annual Surgical Treatment of Migraine Headaches Symposium, at Case Western Reserve University, Cleveland, Ohio, October 30 through 31, 2010; the American Society of Peripheral Nerve Annual Meeting, in Cancun, Mexico, January 16, 2011; Division of Plastic Surgery, University of Minnesota, in Minneapolis, Minnesota, February 8, 2011; Division of Plastic Surgery, Loyola University, in Chicago, Illinois, March 16, 2011; Texas Society of Plastic Surgeons Annual Meeting, in San Antonio, Texas, October 16, 2011 (awarded “Best Paper,” Young Plastic Surgeons Section); Fifth Annual Surgical Treatment of Migraine Headaches Symposium, at Case Western Reserve University, in Cleveland, Ohio, October 22, 2011; Illinois Society of Plastic Surgeons, in Chicago, Illinois, November 17, 2011; and the Sixth Annual Surgical Treatment of Migraine Headaches Symposium, at Case Western Reserve University, in Cleveland, Ohio, October 6, 2012.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

Jeffrey E. Janis, M.D.; Department of Plastic Surgery, University of Texas Southwestern Medical Center, 1801 Inwood Road, Dallas, Texas 75390-9132, jeffrey.jenis@utsouthwestern.edu

©2013American Society of Plastic Surgeons