The surgical procedure can vary depending on the patient’s trigger sites, and only the identified trigger sites (up to 4, but usually 2-3) are surgically addressed. The goal of the procedure is to eliminate triggering stimuli (muscle impingement or airway turbulence and vibration).

Generally, the operation will be done as an outpatient procedure under sedation or general anesthesia. Affected nerves are decompressed from enveloping muscle and wrapped with fatty (noncontracting) tissue. When performed on the brow, the surgery is similar to a cosmetic brow lift. In back of the neck, the greater occipital nerve is treated similarly through a hidden incision in the scalp. Nasal airway surgery is a variation of the commonly performed procedure for deviated septum and difficulty breathing. Incisions are small and hidden in the nose.

How Are Patients Selected?
Pre-surgery Information
Post-surgery Information
Frequently Asked Questions

How Are Patients Selected?
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Patients must have been seen by a neurologist and have a diagnosis of migraine disease or neuralgia to be evaluated. Depending on the character and location of the disease and radiological findings, we will determine which of the four currently known trigger sites will be evaluated. Three of these sites—brow, temple, and the back of the neck—can be evaluated with injections of Botox Æ. The fourth site is the nasal passage, and can be tested with nasal sprays, in addition to physical and x-ray findings.

Pre-Surgery Information
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How long is the selection process?
The initial visit is an evaluation for testing candidacy. Testing is usually done at the time of the initial visit. Once all the trigger sites are identified—usually 2-3—outpatient surgery becomes an option. For for those that have already undergone trigger point testing by another physician, surgery can often be scheduled.

How does Botox Æ affect migraine headaches?
Current theory holds that Botox Æ results in the temporary weakening of the muscles that impinge on the nerves. Some do believe the Botox Æ acts inside the nerves themselves. These nerve branches have been pinpointed as some of the trigger areas that cause migraine headaches.

How do I know if I am a candidate for surgical treatment?
Botox Æ has proven to be an extremely reliable prognosticator. Of the 60 to 80% of patients who respond favorably to the injection of Botox Æ, 90% of those benefit from migraine surgery.

Post-Surgery Information
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Common complaints after surgery:
• Incisional tenderness and temporary numbness of forehead and scalp.
• Forehead itchiness.

What is recovery like?
The procedure is day surgery and patients can go home following the procedure. Patients are out of work for one to two weeks. Exercise and lifting (more than the equivalent of a gallon of milk) is prohibited for these two weeks. Headaches are common during this time, which can be managed with appropriate pain medications.

Are there scars?
Yes, however, all are small and hidden in the hair or at the hairline. Nasal airway incisions are inside the nose.

When do I see Results?
Improvements usually begin two to four weeks post surgery.

Frequently Asked Questions
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Q: What is Botox Æ?
A: Botox Æ is a small dose of Type A Botulinum Toxin that is injected to temporarily weaken the target muscles. Dr. Guyuron first introduced this treatment to plastic surgeons for the purpose of aesthetic facial improvement over 20 years ago.

Q: What are the chances that the injection for Botox Æ will help my migraine headaches?
A: Botox Æ has proven to be an extremely reliable prognosticator. Over 90% of the patients who respond favorably to the injection of Botox Æ benefit from migraine surgery. Studies have shown that 60-80% of the patients who have undergone injection with Botox Æ, with proper landmarks and techniques, experience elimination or significant improvement of their migraine headaches.

Q: What is the surgical procedure?
A: The surgical procedure can vary depending on the patients trigger site. With injection of Botox Æ, we can identify where the trigger site is and eliminate the offending stimulation. The trigger site can either be a muscle or a deviated septum. Generally, the operation will be done as an outpatient procedure under sedation or general anesthesia. The muscles that commonly cause migraine headaches include the frowning muscles in the forehead and a muscle or nerve branch in the temple area. A muscle in the back of the head may also cause migraine headaches. A small segment of muscle over the nerves is removed through small, hidden incisions. This procedure often results in improvement of forehead lines and eyebrow position.

A septoplasty, if indicated, is combined with another minor procedure called a partial turbinectomy. This typically results in an improvement in breathing along with elimination or improvement of the headaches.

Q: How does Botox Æ affect migraine headaches?
A: The hypothesis is that Botox Æ results in temporary weakening of the muscles that impinge on the nerves. These nerve branches have been pinpointed as some of the trigger areas that cause migraine headaches.

Q: How long does Botox Æ last?
A: The effect of a Botox Æ injection may last from 3 to 5 months in the muscles. However, migraine headaches may disappear only for 1 to 3 months.

Q: Are there any side effects?
A: Side effects may include a more youthful appearing brow, and, in those requiring septoplasty and/or turbinectomy, oftentimes improved nasal breathing. Temporary numbness is almost always present, but generally resolves within two to six months. Generally, this numbness is not severe enough to cause complaints.

Q: What are the possible complications of Botox Æ injection or migraine surgery?
A: Any procedure involving incisions, regardless of the professionalism and skill of the performing surgeon, contains the possibility of complication. In addition to the general risks associated with incisions other complications, though rare, may include:

• Discomfort at the injection sites
• Mild bruising or swelling lasting a few days.
• Temporary droopy upper eyelids from Botox Æ testing
• Temporary hair loss (rare)
• Temporary (and rarely permanent) numbness in the forehead and scalp
• Infection and/or bleeding
• Nasal whistling, crusting, occasional bleeding, numbness of the upper teeth
(if septoplasty is done)
• Dryness inside the nose, if turbinectomy is done
• Change in brow appearance and movement
• No change in symptoms
• Worsening of symptoms

Q: What are the financial implications of this procedure?
A: While we cannot comment on or guarantee your own individual experience following the procedure, it has been shown that migraine surgery patients experience, on average, a health care savings of over $6,000 a year.

Consider this excerpt from http://www.myplasticsurgeonusa.com/scott-mosser/san-francisco-plastic-surgery-news.htm?art=344 an article written by Dr. Scott Mosser, MD,</a>a San Francisco-based plastic surgeon who also trained with Dr. Guyuron. Dr. Mosser also attended as an expert presenter at the first Migraine Surgery Symposium in Cleveland, Ohio:

“After the use of BotoxÆ for migraine therapy was initiated in 2001, protocols for Surgery for Migraine Headaches were developed by Dr. B. Guyuron, with whom I trained extensively. During my training, I had the opportunity to participate in groundbreaking research, which is now leading to pain relief for migraine sufferers around the nation.

I’m excited by the results we’ve achieved. In one study it was demonstrated that after surgery performed by a surgeon trained specifically in these particular techniques, 92% of the patients (82 of the 89 participants) in the treatment group who completed the study demonstrated at least a 50% reduction in migraine headache frequency, duration, or intensity compared with the baseline data. A full 35% (31 of the participants) reported complete elimination of migraine headaches, and 57% (51 patients) experienced improvement over a mean follow-up period of 396 days.

A comparison of the costs of migraine headache control therapy was also recorded in the above study. The mean annualized cost of migraine care for the treatment group ($925) was reduced significantly compared with the baseline expense ($7612) and the control group ($5530). The mean monthly number of days lost from work for the treatment group (1.2) was reduced significantly compared with the baseline data (4.41) and the control group (4.4).“

Q: Will my insurance cover Botox Æ injections or the surgical procedure?
A: At this time, some insurance companies cover the injection of Botox Æ; however, most insurance companies in Maine do not cover the surgery. This has changed with insurance companies in other states. It is no longer covered by Anthem BC/BS of Maine. Often an insurance company can be lobbied into approving the surgery or Botox Æ expense, especially if medical costs have been high.