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Reconstructive: Head and Neck: Ideas and Innovations

Use of a Doppler Signal to Confirm Migraine Headache Trigger Sites

Guyuron, Bahman M.D.; Riazi, Hooman M.D.; Long, Tobias M.D.; Wirtz, Emily

Author Information
Plastic and Reconstructive Surgery: April 2015 - Volume 135 - Issue 4 - p 1109-1112
doi: 10.1097/PRS.0000000000001102

Abstract

Published research has continued to show that the elimination of peripheral compression or irritation sites provides relief for patients with migraine headaches.1–6 Many patients have positive outcomes following decompression of frontal, temporal, septal/turbinates, and occipital areas, but occasionally patients have persistent or emergent migraine headaches in less common sites. The auriculotemporal nerve has been identified as one of the potential trigger sites for migraine headaches in some patients.7,8

Successful identification of peripheral nerves as potential trigger sites for the individual patient depends on many factors, with the most important being patient participation by pointing to the sites of intense pain onset.9 The patient’s ability to specifically identify where the pain starts with one fingertip provides key information for detection of the nerve branch involved in the migraine cascade. When the patient identifies the pain site within or close to the hair-bearing temple area, it often involves the anterior branch of the auriculotemporal nerve or the main auriculotemporal or posterior branch of the zygomaticotemporal nerve, rather than the more common main trunk of the zygomaticotemporal branch of the trigeminal nerve. The pain related to the latter nerve is usually centered in a spot approximately 17 mm lateral and 6 mm cephalad to the lateral canthus.10

Our cadaver studies and clinical experience have demonstrated an intertwining of the superficial temporal artery or its branches and the auriculotemporal nerve or its branches, potentially triggering migraine headaches.7 Three distinct compression points have been identified. The first two relate to preauricular fascial bands described in relation to the external auditory meatus. The third potential compression point involves the superficial temporal artery, found in 80 percent of hemifacial cadaver studies. Three nerve-artery relation patterns have been described, including a single site of the artery crossing the nerve, a helical intertwining, and the nerve crossing over the artery.7,8

The superficial temporal artery runs close enough to the skin surface to allow its signal to be readily detected with an ultrasound Doppler signal. Therefore, combining patient participation in identifying the temporal trigger site with the use of ultrasound Doppler provides the surgeon with a precise target for decompression. The goal of this study was to determine the reliability of the ultrasound Doppler signal in determining whether the superficial temporal artery or its branches are involved at the most intense temporal pain site and how it can facilitate locating the culprit vessel.

PATIENTS AND METHODS

After institutional review board approval, a retrospective chart review was conducted to identify patients who underwent auriculotemporal nerve decompression. Preoperatively, the patients were asked to point to the area of intense pain or to the most tender spot using the ipsilateral index finger (Fig. 1). (SeeVideo, Supplemental Digital Content 1, in which the patient is asked to point to the area of most intense pain and, immediately, a Doppler signal is identified by sliding the Doppler probe to the site at which the patent’s index finger is pointing, http://links.lww.com/PRS/B263.) It is interesting that this spot could often be identified by the patients, even in the absence of active migraine headaches. The area was first marked (Fig. 2) (see Video, Supplemental Digital Content 1, http://links.lww.com/PRS/B263), the Doppler signal was identified (Fig. 3) (see Video, Supplemental Digital Content 1, http://links.lww.com/PRS/B263), and photographs were obtained for intraoperative reference in the event of a patient failing to reidentify the site at the time of surgery. On patients who had pain in the suspected site, a nerve block using 0.5 cc of ropivacaine was achieved, which further confirmed the compression/irritation site. The correlation between intraoperative presence of the superficial temporal artery in the most intense pain and the Doppler examination results was tabulated.

Fig. 1
Fig. 1:
Photograph of a patient pointing to the area of most intense pain.
Fig. 2
Fig. 2:
The pain site is marked for intraoperative reference.
Fig. 3
Fig. 3:
An ultrasound Doppler signal is used to detect the arterial signal.
Video
Video:
Supplemental Digital Content 1, in which the patient is asked to point to the area of most intense pain and, immediately, a Doppler signal is identified by sliding the Doppler probe to the site at which the patent’s index finger is pointing, http://links.lww.com/PRS/B263.

RESULTS

A total of 32 patients (26 female and six male patients) ranging in age from 15 to 67 years (mean, 47.68 years) were included in this study. The presence of a positive Doppler signal over the area of most intense temporal pain identified by the patient preoperatively correlated with intraoperative presence of the artery in the suspected site in 100 percent of the patients. A Doppler signal was noted on 34 sites and the artery was found and arterectomy carried out in all 34 sites (Fig. 4).

Fig. 4
Fig. 4:
Intraoperative image demonstrating the superficial artery crossing the auriculotemporal nerve.

DISCUSSION

The data clearly demonstrate that use of an ultrasound Doppler test over the area of most intense pain as identified by the patient allows the surgeon to detect the compression/irritation points between the superficial temporal artery and auriculotemporal nerve with 100 percent accuracy. This information can be further verified with a nerve block, contingent on the patient having pain at the time of examination or during surgery, if it is performed under local anesthesia. Before the discovery of this technique, the authors used only the patient’s guidance to locate the most intense pain site and thus the nerve. However, the patient may not always have pain at the time of surgery. By proper marking of the site, followed by confirmation of the pain site with Doppler imaging, nerve block that results in elimination of the pain, and photographic documentation preoperatively, the surgeon can readily find the nerve irritation site, even if the patient does not have pain at the time of surgery. We have also been successfully using this technique in different migraine trigger sites where a vessel may play a role in producing migraine headaches such as the lesser occipital, supratrochlear, supraorbital, vertex, mid-forehead, and any residual migraine headaches following surgery. This study provides further evidence in support of the role of peripheral mechanisms in commencing the migraine headache cascade without disputing the role of the central mechanisms. Although contact and compression of the nerves by an accompanying vessel is not unique to patients with migraine headaches, we have demonstrated that patients with migraine headaches have a myelin defect, making their nerves more vulnerable.11 Our method of precise location of the vessel reliably reduces the operative time, limits the incision size, and renders this operation simpler and more predictable.

CONCLUSIONS

A simple preoperative Doppler detection of arterial signal is a safe and very reliable method of determining whether the superficial temporal artery or its branches are present in the most intense pain site. This test along with a nerve block can lead to successful identification and faster decompression of the auriculotemporal nerve with minimal dissection under local anesthesia as an office procedure.

PATIENT CONSENT

Patients provided written consent for the use of their images.

REFERENCES

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Supplemental Digital Content

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