11Surgical Treatment of Auriculotemporal Migraine Headaches (Site V)
Bahman Guyuron
Salient Points
• Migraine headaches arising from the temporal region could be triggered from the zygomaticotemporal, auriculotemporal, or zygomaticofacial branches of the trigeminal nerve.
• Some of these migraine headaches arising from the auriculotemporal region can be mistaken for temporomandibular joint disorders.
• An ultrasound Doppler vessel signal is almost always detectable at the most tender site identified by the patient using only one fingertip to identify the discomfort.
• A nerve block commonly results in complete elimination of the migraine headache as long as the patient reports a headache at the time of examination, especially if the block is done soon after the onset of the headache.
• A superficial temporal arterectomy, with or without a neurectomy of the small branch often crossing the nerve, will often result in elimination or significant improvement of the headache.
• For those patients who have multiple tender sites with positive Doppler signal, those with recurrent pain along the distribution of this nerve, or patients with vague temporal migraine headaches within the hair-bearing area, neurectomy of the main auriculotemporal nerve and main superficial temporal artery would be the best choice.
• This trigger site can always be treated under local anesthesia if it is an isolated site or even if it is combined with the lesser occipital or other localized trigger sites and nummular headaches.
• After injection of the area with lidocaine containing 1:100,000 epinephrine, a 6- to 10-mm incision is made over the Doppler signal site, or a 10- to 15-mm incision is made over the base of the sideburn, if the main auriculotemporal nerve and the main superficial temporal artery are the target of the surgery.
• The main superficial temporal artery or the branch of the superficial artery that was detected preoperatively is dissected with a mosquito hemostat and gently cauterized.
• If the main superficial temporal artery is the target of the surgery, it is isolated, ligated, and transected.
• The nerve branches and the vessels entangled with the arterial branches are removed.
• When the main nerve is large enough, it should be buried in the temporalis muscle.
• The incision is closed using 6-0 Monocryl and 6-0 fast-absorbing catgut.
11.1 Introduction
The origin of temporal migraine headaches (MHs) can be confusing since the headaches can arise from the zygomaticotemporal branch of the trigeminal nerve, from the auriculotemporal nerve, from the terminal branches of these two nerves, or—rarely—from a branch of the zygomaticofacial branch of the trigeminal nerve. Many of the new daily and nummular headaches are related to the auriculotemporal nerve. Some of these MHs arising from the auriculotemporal region can be mistaken for temporomandibular joint conditions. In fact, these two conditions can sometimes coexist. Auriculotemporal MHs may cause headaches anywhere in the temporal region, but they are mostly confined to the hair-bearing portion of the temporal region.
A vessel signal is almost always detected at the most tender site, which can be identified by the patient, using his or her fingertip to point to the area.1 The patient will often complain about pain in the temple area with variable consistency in location and severity. The patient may initially point to the entire temporal area using the whole hand. Yet with further persuasion, the patient can find the most tender spot from which the MH begins using his or her index fingertip. This site is immediately marked and explored with a Doppler ultrasound, and often the signal is identified with minimal effort. Sometimes one has to move the Doppler probe around to locate the signal. Ironically, the signal is only heard in a single spot in spite of the linear nature of the offending artery.
A nerve block commonly results in complete elimination of the MH, should the patient experience a headache at the time of examination. This is especially common if the nerve block is attempted close to the onset of the headaches. A negative response to the nerve block does not necessarily predict a surgical failure, especially at a later stage and on a patient who has sensitization of the entire area. At this stage, the inflammation has spread beyond the target zone, and the central sensitization phase of the migraine cascade could be in effect.
Management of these MHs will be very different than those arising from the zygomaticotemporal branch of the trigeminal nerve. A superficial temporal branch arterectomy with auriculotemporal branch neurectomy often crossing the nerve will usually be successful. Otherwise, for those patients who have multiple tender sites with a positive ultrasound Doppler signal, those with recurrent pain along the distribution of this nerve or patients with vague temporal MH within the hair-bearing area, neurectomy of the main auriculotemporal nerve, and arterectomy of the main superficial temporal would be the best choice. However, since the auriculotemporal nerve branches before it reaches the sideburn, neurectomy of the isolated branch would often be the first choice, especially if the identified signal site is anterior to the hairline.2
Additionally, should the patient have residual headaches at this site following a main auriculotemporal neurectomy, it is likely to be related to the branch of this nerve caudal to the sideburn, the zygomaticofacial branch of the trigeminal nerve, or the zygomaticotemporal branch of the trigeminal nerve. Surgery on the site, identified by the patient and confirmed by the ultrasound Doppler, would still benefit this patient.
11.2 Surgical Technique
This trigger site can always be treated under local anesthesia if it is an isolated site or even if it is combined with the lesser occipital site or multiple small localized sites and nummular headaches. However, general anesthesia will be preferred if this site is being operated on in conjunction with sites I (frontal), II (temporal), III (intranasal), or IV (occipital).
For surgical treatment of auriculotemporal nerve-related headaches, a small amount of hair is shaved over the area identified by the patient and confirmed by the Doppler. The area is then prepped and draped. The site is infiltrated with Xylocaine containing 1:100,000 epinephrine. For the main auriculotemporal surgery, a 10- to 15-mm incision is made within the hair-bearing scalp at the base of the sideburn (►Fig 11.1).
