WILLIAM G. AUSTEN JR., MD

CHIEF, DIVISION OF PLASTIC & RECONSTRUCTIVE SURGERY

CHIEF, DIVISION OF BURN SURGERY

MGH TRUSTEES CHAIR

Massachusetts General Hospital, Harvard Medical School

Deactivating Peripheral Nerve Triggers:

A Surgical Solution to Refractory Headaches

Founder of Cytrellis Biosystems

DISCLOSURES

WE CAN ONLY KNOW THAT WE

KNOW NOTHING

-TOLSTOY

SOCRATIC PARADOX

The Evolution of Ideas in Plastic Surgery

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Fat grafting 1982-2012

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Interest over time

Migraine Surgery Publications

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very early……..

> 40 Articles

> 1000 publications on migraine therapies/ year

1/3 of patients refractory

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Migraine publications

Schulman.,Headache. 2013

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Migraine publications

SHOULD WE THINK ABOUT

ALTERNATIVES ?

Migraine Facts

324.1 million

1 in 4

1. Lipton et al. Neurology 2007; 68: 343-349.

2. SynerMed Communications. Clin Courier 2001; 19: 1-15.

3. World Health Organization. The Global Burden of Disease 2004 Update.

Geneva, Switzerland: World Health Organization: 2004.

Significance

35MILLION Americans

3 : 1

1. Stewart et al. J Clin Epidemiol 1995

2. Stewart et al. Cephalalgia 2008

Pathophysiology-TheoryMigraine = Brain

Olesen et al. Ann Neurol 1990

1.Leaõ et al. J Neurophysiol. 1944

2.Olesen et al. Lancet Neurol. 2009

Why Surgery ?

Observation

Migraine Therapies

Side Effects

Contraindications

NON- Responders

1. Dodick et al. Headache 2005

2. Blumenfeld et al. Headache 2013

New Developments- Late 1990s

Botulinum Toxin for the Treatment of Migraine

2010

FDA approved

Observation- 2000

Dr. Bahman Guyuron

349 brow- lift patients

- 79% migraine improved

? CARPAL TUNNEL SYNDROME OF THE HEAD ?

Pathophysiology

Nerve Irritation

(muscle, fascia, bone, vessels)

Substance P/ Cytokines

Inflammation/Pain

Theory

1. Janis et. al, PRS 2010

2. Janis et. al, PRS 2010

3. Janis et. al, PRS 2012

Frontal

Temporal

Occipital

Nasal

1. Janis et. al, PRS 2010

2. Janis et. al, PRS 2010

3. Janis et. al, PRS 2012

2005

92%>50% reduction of migraine

2009

2005

PLACEBO CONTROLLED TRIAL WITH SHAM SURGERY

83.7% real surgery

57.7% sham surgery

>50% reduction of migraine

2009

2005

PLACEBO CONTROLLED TRIAL WITH SHAM SURGERY

57.1 % real surgery

3.8 % sham surgery

TOTAL ELIMINATION OF

MIGRAINES

2011

88% >50% reduction of migraine

2015

Clinical Data

> 50% improvement between 62- 95%

Oct

2008

Looking back on my own practice…

Gathering a Team

2009

2009

The 1st Year

NEW

CONSULTS

SURGERY1

5

2010NEW

CONSULTS

SURGERY2

7

The 2nd Year

Patient recruitment

Skepticism - Neurology

Patient selection

Insurance coverage

Challenges

Importance of Media

Since 2011 Increased Interest

Media

Patient recruitment

Skepticism - Neurology

Patient selection

Insurance coverage

Challenges

The art of identification

1. Establish diagnosis in refractory patient

1. Identification of specific trigger points

1. Clinical evaluation & diagnostic testing

Patient must HAVE BEEN followed by a NEUROLOGIST

The art of identification

1. Establish diagnosis in refractory patient

1. Identification of specific trigger points

1. Clinical evaluation & diagnostic testing

Patient must HAVE BEEN followed by a NEUROLOGIST

The art of identification

1. Establish diagnosis in refractory patient

1. Identification of specific trigger points

1. Clinical evaluation & diagnostic testing

Patient must HAVE BEEN followed by a NEUROLOGIST

Comparison from a surgeons view

Migraine

• ‘Deep’ undefined pain

• Starting point unclear

Nerve compression headache

• Specific pain points

• Starts at specific location

Frontal trigger site- SON, STN

Frontal trigger-common history

• Pain above the eyebrows

• Tender to touch

• In the afternoon

• Deep frown lines

• Eyelid ptosis common

• Pressure/Compresses help

Frontal Trigger Site

Frontal pain diagram

Abnormal frontal pain diagram

Temporal trigger site- ZT

1.7cm

6mm

Temporal trigger- common history

• Pain starts at temple

• Patients wake up with pain

• Bruxism very common

• Often throbbing pain

• Pressure/ compresses help

Temporal trigger site

Temporal pain diagram

Patients will usually mark with an x or dot in this region.

Abnormal temporal pain diagram

Occipital trigger site- GON

occipital

protuberance

3cm

1.5cm

Occipital trigger- common history

• Pain starts above GON

• No specific start time for pain

• History of trauma common

• Neck muscles tight

• Worse with exercise/ heavy lifting

Occipital trigger site

Occipital pain diagram

Occipital pain diagram

Abnormal occipital pain diagram

Rhinogenic trigger site

Rhinogenic trigger-common history

• Pain starts behind the eye

• Patients are woken up by pain

• Menstrual cycle/ weather/ allergy can change pain

• Decongestants help

• Rhinorrhea common

• Septal deviation/ concha bullosa/ Haller’s cell common

Rhinogenic pain diagram

The art of identification

1. Establish diagnosis in refractory patient

1. Identification of specific trigger points

1. Clinical evaluation & diagnostic testing

Patient must HAVE BEEN followed by a NEUROLOGIST

Botox/ Nerve blocks?

Doppler Ultrasound

Arterial versus non- arterial trigger

• Especially useful in identification of

minor triggers

• Too early to understand impact

Doppler exam

CT scan

Detection of nasal pathology

Deviated Septum/

Concha Bullosa

Haller Cell

History/ Nerve Block and/or Botox Injection/ Doppler/ Imaging

to identify trigger sites

✔✖

NEUROLOGYPAIN SERVICE ENT

Two Pathways

Posterior triggers GON/LON

Ducic et al. Plast. Recon. Surg. 2009

GREATER OCCIPITAL NERVE6 COMPRESSION POINTS

Ducic et al. Plast. Recon. Surg. 2010

Injection local

Incision

Dissection

Fascia elevation

Fascia elevation

GON exposure

GON

GON exposure

Muscle removal

Muscle removal

Post fascia and muscle removal

OCCIPITAL ARTERY

GON

Adipose fat flap

Complete release

Closure and drain

Frontal Trigger Site-Surgical Approach

Endoscopic Openvs.

Anatomy SON/STN

Liu et al.. Plast Reconstr Surg. 2011.

Removal Upper Eyelid Skin

Dissection to the Orbital Rim

Dissection to the orbital rim

Identification of Nerves

Supraorbital

Nerve

Supratrochlear

Nerve

Frontal Trigger Site- SON/STN

Fascial band versus supraorbital foramen

Falluco, M et al.. Plast Reconstr Surg. 2012.

Foraminectomy

Supraorbital Foramen

Two nerves exiting through foramen

Very high supraorbital foramen

Nerve exiting supraorbital foramen

Frontal - Anatomy

ST SON

Aberrant Nerve

Exposure of Corrugator Supercilii

Removal of Corrugator Supercilii

Exposure/Removal Corrugator

Post-Release

Adipose Flap

Adipose Flap

Zygomaticotemporal nerve

Janis et al.. Plast Reconstr Surg. 2010.

Temporal Trigger Site

Endoscopic

Totonchi et al.. Plast Reconstr Surg. 2005.

Blepheroplasty approach to ZT

Dissection to sentinel Vein

sentinel vein

Identification and removal ZT

sentinel vein

zygomatico-

temporal

nerve

Video ZT release

MGH Experience

Results Migraine Headache Frequency

Preop 18.5

Postop 3.7

p<0.01

Frequency (d)

Results Migraine Headache Duration

Preop 16.8

Postop 4.8

p<0.01

Duration (h)

Results Migraine Headache Intensity

Preop 9.2

Postop 3.3

p<0.01

Pain (0-10)

Results Migraine Headache Index

Migraine headache index =

Frequency (d) Duration (1/24) Severity (0-10)

Preop 99.4

postop 10.1

p<0.01

-90%

Post- Surgical Response Rates

> 50%

< 50%

90.9%

9.3%Migraine

Headache Index

Improvement

Positive Response Distribution

100%

> 80%

50- 80%51.3%

28.2%

20.5%

Migraine

Headache Index

Improvement

PATIENTS DO VERY WELL POST OPERATIVELY

Post-Operative Management

Happy Patients…Happy Doctors!

Neuropraxia

Shooting nerve pain/ numbness

Acute migraine attack

Hypertrophic scar

Additional surgery

Low Incidence of Adverse Events

Post-Op pain medication plan

Neurologist and PCP

Pain Specialist

Encourage:

• Patient to contact

Neurologist

• Patient to speak about their

surgery and result

Post-Op Management

From

art…

To

science…

What are the important questions?

Screening?

Evaluate/ communicate results?

Working? How well?

Migraine Q

Screening Evaluation

Questions are a powerful tool

Current Migraine Questionnaires

Migraine Specific Quality of

Life Questionnaire

The migraine work and productivity loss questionnaire

PHQ

9

Screening Tool for doctors

5

Migraine Q

Evaluation Tool for patients Migraine Q

PHQ

2

For Migraine

Prospective questionnaire study

Migraine

Headache

Index

& Chronic Pain

Pain Self Efficacy

Questionnaire

Preliminary Results Questionnaires

mean values; unpublished data

* p<0.01

**

Migraine Headache Frequency (days per month)

*

*

Preliminary Results Questionnaires

mean values; unpublished data

* p<0.01

**

Migraine Headache Duration (hours)

Preliminary Results Questionnaires

mean values; unpublished data

* p<0.01

**

Migraine Headache Severity (0-10)

**

Preliminary Results Questionnaires

mean values; unpublished data

* p<0.01

**

Migraine Headache Index

Frequency (d) Duration (1/24) Severity (0-10)

*

*

-85.7%

-93.5%

Comparison % improvement

8.4%

91.6%

Improvement

90.9%

9.3%

Improvement

prospective retrospective

Comparison positive response distribution

39.4%

18.2%

Improvement

prospective retrospective

Improvement

42.4%

Pain Self Efficacy

Confidence in performing normal activities

low pain self efficacy = POOR outcomes

Kennedy SA et al.,

J Hand Microsurg. (2010)

Vranceanu AM et al., J Hand

Surg Am. 2010

Skidmore JR. at al.,

Clin J Pain. (2015)

Pain Self Efficacy

Treatment Comparison

Jan Paul Briet et al., Phys Ther. (2014) Maughan et. al., Eur Spine J. (2010)

Pre- Treatment Scores

MigraineMigraine

Chronic Back Pain

Carpal Tunnel Syndrome

unpublished

Pain Self Efficacy

Treatment Comparison

Jan Paul Briet et al., Phys Ther. (2014) Maughan et. al., Eur Spine J. (2010)

Post- Treatment Scores

unpublished

Carpal Tunnel Pre

Carpal Tunnel Post

Chronic Back Pain Pre

Chronic Back Pain Post

Migraine Pre

Migraine Post +147%

+13%

+8%

Age of onset mattersMean age at onset 23.9 ± 14.4 (Range 2-61)

Age of onset >40

p<0.05

Duration matters

p<0.05

Mean duration in hours

Predictive Variables

Patients do better… when bothered by…

Predictive Variables Nausea

nausea no nausea

p <0.01

Predictive Variables

Patients do better… when relieved by…

Predictive Variables Hot and Cold Compresses

hot and cold compresses help hot and cold compresses don’t help

p <0.05

What are the important questions?

Pathomechanism

Imaging

…

Migraine Tissue Bank

.. First Migraine Tissue Bank to our knowledge

Pathomechanism

Thermal Imaging

Can we predict nerve compression and

surgery outcomes?

Imaging

Thermal Image

Early days-Thermal Imaging

Pre-operative thermal image

Prediction & intraop

finding

Right- Supraorbital foramen

Left- Notch

WILLIAM G. AUSTEN JR., MD

CHIEF, DIVISION OF PLASTIC & RECONSTRUCTIVE SURGERY

CHIEF, DIVISION OF BURN SURGERY

MGH TRUSTEES CHAIR

Massachusetts General Hospital, Harvard Medical School

Deactivating Peripheral Nerve Triggers:

A Surgical Solution to Refractory Headaches