The Anatomy of a Headache

Nerve Compression Headaches

With the understanding that some of his brow lift patients were reporting headache improvement, Dr. Bahman Guyuron began the investigation of the effect of nerve compression as a factor in migraine headaches. Dr. Guyuron’s further work ushered in the field of surgical nerve decompression for the treatment of migraine headaches. As the nerves above the orbits (eye sockets) were decompressed from the release of tissue here during brow lifts, other nerves have been identified as sources of migraine headaches when constricted. Subsequently surgical approaches to decompress these nerves have been developed, and the honing of these operations have provided migraine relief for thousands of patients. The nerves that we can address in the surgical treatment of migraine headaches include:

• The supra-orbital and supra-trochlear nerves above the eye socket
• The zygomaticotemporal and auriculotemporal nerves in the temple region
• The greater and third occipital nerves at the base of the back of the head and the lessor occipital nerves in the lateral aspect of the back of the neck
• The nerves supplying the lining of the nose

Each of these nerves have been identified as trigger points for migraine headaches. When constricted by surrounding tissue, these nerves become irritated and initiate the headache cascade producing pain and other migraine symptoms. Constriction of these nerves can be caused by several things.

• In the area above the eye socket, muscles called the corregator muscles can push on the supra-orbital and supra-trochlear nerves, creating irritation. At the base of the skull and upper neck, everyday tension and stress can cause the trapezius muscles to tighten around the occipital nerves, causing severe headache symptoms.
• Connective tissue bands around the nerves in the back of the neck are another cause of nerve constriction that can cause irritation of the occipital nerves and subsequent headaches.
• Swelling of the nasal lining can cause compression of the nerves of the nose against other parts of the nasal passage, causing irritation of these small nerve endings and headaches that seem to arise in the sinus region of the mid face.
• Some people are born with small notches in the bone above the eye, called the superior orbit, where the supraorbital and supratrochlear nerves pass in a tension free manner to provide feeling to the forehead and anterior scalp. Other patients have bony tunnels instead of notches, which can be too small for the nerves to comfortably pass and can cause compression and irritation in these areas.
• Any of these nerves can be constricted by blood vessels, though the nerves that are most susceptible to this type of irritation are the three occipital nerves and the two nerves found in the temples. Because it is often an artery that is next to the nerve causing the irritation, patients may experience a “pulsating headache” associated with nerve irritation caused by nearby blood vessels.

Central Headaches

These are headaches that are caused by dysfunction of the chemistry or anatomy of the brain. Because the skull is a hard and fixed encasement of the brain, any swelling of the tissue within the skull can cause pain. Dilation of blood vessels within the skull, or the growth of a lesion may increase the pressure on the brain and cause headache. Other central headaches are thought to be mediated by fluctuations in chemical mediators, such as serotonin which can have profound effects on mood and personality as well. On the whole, headaches that originate from a central source inside the skull are not amenable to this type headache surgery and require evaluation by a neurosurgeon

How does migraine headache surgery address these issues?

By surgically releasing the nerves from the surrounding constricting tissue, the nerves are allowed to conduct their business without the irritation that causes the symptoms of migraine headaches. Surgical release of the nerves listed above is associated with a success rate (defined as complete elimination of migraine symptoms or more than 50% decrease in the symptoms associated with migration headaches) in between 70% and 90% of patients, and complete resolution of headache symptoms in roughly 30% of patients who undergo migraine headache surgery.

The Occipital Nerves

The Supraorbital and Supratrochlear Nerves

The Zygomaticotemporal and Auriculotemporal Nerves