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Eur Arch Otorhinolaryngol (2017) 274:2093–2106 DOI 10.1007/s00405-017-4450-x

REVIEW ARTICLE

Decompression endoscopic surgery for frontal secondary headache attributed to supraorbital and supratrochlear nerve entrapment: a comprehensive review

Boris Filipović1,2,3 · J. Alexander de Ru4 · Rick van de Langenberg2 · Pepijn A. Borggreven2 · Zdravko Lacković3 · Peter J. F. M. Lohuis2 

Received: 8 September 2016 / Accepted: 3 January 2017 / Published online: 25 January 2017 © Springer-Verlag Berlin Heidelberg 2017

perspective decompression surgery for secondary head-ache attributed to supraorbital and supratrochlear nerve entrapment.

Keywords Secondary headache · Migraine · Nerve entrapment · Decompression endoscopic surgery · Migraine surgery · Botulinum toxin type A

Introduction

Headaches form a common, and at the same time hetero-genic group of neurological disorders. According to the World Health Organization, it has been estimated that prev-alence among adults of current headache disorder (symp-tomatic at least once within the last year) is about 50% [1]. Headache patients are primarily seen by primary care physicians, neurologists and anesthesiologists, and treated by pharmacotherapy with different classes of drugs. Occa-sionally, they are also treated by other specialists (physical therapists, dentists, otorhinolaryngologists, head and neck surgeons, neurosurgeons, maxillofacial surgeons, ophthal-mologists) with alternative treatment modalities ranging from massages, acupuncture, and electrical therapy to dif-ferent types of surgery.

A new surgical treatment for headache termed “migraine surgery” has been introduced in the last decennium [2]. This procedure involves decompression of peripheral sensory nerve branches in different head and neck areas (frontal, temporal and occipital), which are believed to be migraine trigger points [3–5]. However, although entrap-ment of sensory nerves is a well-defined pathophysiologi-cal mechanism in different chronic pain conditions [6] and some types of headaches [7], the entrapment mechanism as a trigger in migraine remains controversial [8].

Abstract In the last decade, a new surgical treatment modality was developed for frontal secondary headache, based on the assumption that the trigger of this pain entity is the entrapment of peripheral sensory nerves. The sur-gery entails a procedure, where an endoscopic approach is used to decompress the supraorbital and supratrochlear nerve branches, which are entrapped by the periosteum in the region of the corrugator supercilii muscle. Candidates for the surgery define their headache as moderate to severe persistent daily pressure or tension, localized in the frontal area, sometimes accompanied by symptoms of nausea and photophobia mimicking a primary headache—migraine. We created a step-by-step screening algorithm which is used to differentiate patients that have the highest chance for a successful surgical decompression. Up to now, pub-lished data regarding this type of surgery demonstrate long-lasting successful outcomes while adverse effects are minor. This article reviews and discusses from a surgeon’s

Electronic supplementary material The online version of this article (doi:10.1007/s00405-017-4450-x) contains supplementary material, which is available to authorized users.

* Boris Filipović boris.filipovic@hotmail.com

1 Department of Otorhinolaryngology/Head and Neck Surgery, University Hospital Sveti Duh, Sveti Duh 64, 10000 Zagreb, Croatia

2 Department of Otorhinolaryngology/Head and Neck Surgery, Center for Facial Plastic and Reconstructive Surgery, Diakonessen Hospital, Utrecht, The Netherlands

3 Department of Pharmacology, Laboratory of Molecular Neuropharmacology, University of Zagreb School of Medicine, Zagreb, Croatia

4 Department of Otorhinolaryngology/Head and Neck Surgery, Central Military Hospital, Utrecht, The Netherlands

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The goal of this article is to critically summarize the literature on decompression surgery for frontally localized headache which is triggered by entrapment of supraorbital and especially supratrochlear nerve branches. We will share our personal surgical view and experience and provide data on the effectiveness of this type of surgery based on the available literature.

Surgical treatment for frontal headache: “migraine surgery”

The beginning of surgery for frontal headache was a result of careful clinical observations. Bahman Guyuron was one of the first physicians to note that some of his patients who underwent a brow-lift procedure for esthetic reasons also experienced an unexpected and beneficial effect on their frontal headache. He published his observations in a retro-spective study showing long-term postoperative improve-ment of headache symptoms in 47 patients who preop-eratively fulfilled criteria for migraine [2]. The authors hypothesized that the cause of frontal pain in these patients could be an entrapment of sensory nerves, and coined the procedure with the term “migraine surgery”. This hypoth-esis was based on the fact that the standard maneuver in a brow-lift procedure is a release of the periosteum of the

supraorbital ridge and transection of the corrugator super-cilii muscle through which sensory nerve branches (supra-trochlear—STN and supraorbital—SON) run in well-defined anatomical trajectories [3–5].

Following the same philosophy and surgical principles, other authors conducted prospective clinical studies and reported similar beneficial effect of the surgery on fron-tally localized pain [9–13] (Table  1). Other possible trig-ger areas of headache caused by neural entrapment such as temporal [14] and occipital [15] were the focus of further studies. However, the surgical procedures related to these regions are out of the scope of this review.

Is “migraine surgery” the right term for frontal decompression surgery

Before we go into the details regarding the surgery and its possible effects, we have to know exactly which headache disorder we intend to treat. Because headaches comprise such a heterogenic group of disorders, it is advisable to adhere closely to the International Classification of Head-ache Disorders (ICHD 3-Beta is the most up to date). The ICHD 3-Beta classifies headaches into major groups, types, subtypes and subforms following explicit diagnostic criteria

Table 1 Clinical studies on decompression surgery for frontal headache

Success rate indicates the percentage of patients who experienced late postoperative reduction of headache of 50% or more on a visual analog scale (0–10)CM chronic migraine, CTTH chronic tension-type headache, CDH chronic daily headache, B botulinum toxin type A, E-decompression endo-scopic approach, T-decompression transpalpebral approach

Study/Ref. number Year Num-ber of patients

Headache type Pharma-cological screening

Surgical approach

Follow-up/months Success rate/% Adverse effect

Guyuron et al. [2] 2000 39 CM Not used E, T 46.5 79.5 Paresthesia of the scalp, forehead asymmetry, paraly-sis of m. frontalis, eyebrow asymmetry

Dirnberger and Becker [9]

2004 60 CDH Not used T 6 68.3 Transient surgery site paresthesia

Bearden and Ander-son [10]

2005 12 CM, CTTH Not used T 6–19 92 Transient surgery site paresthesia

de Ru et al. [11] 2011 10 CDH B E 30 90 Numbness in three patients, paresthesia and hematoma for-mation in one case

Chepla et al. [31] 2012 86 CM Not used E 12 100 Not reportedLiu et al. [29] 2012 253 CM Not used E, T 12–126 T 79, E 89 Paresthesia of the

scalp, forehead asymmetry, paraly-sis of m. frontalis, eyebrow asymmetry

Edoardo and Giorgia [13]

2015 15 CDH Not used E 24 93 Not reported

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[16]. A list of specific diagnostic criteria (ICHD 3-Beta) for each of the major headache groups is shown in Table 2.

In our practice, candidates for decompression sur-gery suffer from frequently occurring frontal headache (>15  days per month), with severe pain (visual analog score 7–10), described as a frontally localized pressure or tension, which is often accompanied by photophobia and sometimes by nausea. If we adhere to the ICHD 3-Beta, these frontal headaches should be classified as secondary headaches as we anticipate the underlying cause to be the entrapment of the supraorbital and supratrochlear nerves. When we further evaluate the headache symptoms of our patients they often seem to mimic chronic migraine or chronic tension-type headache.

It is our opinion, when referring to the criteria of ICHD 3-Beta, that “migraine surgery” is not the ideal term as it implicates that surgery would alleviate the cause of a primary headache—migraine. This creates unnecessary disagreement between neurologists and surgeons because by following diagnostic criteria (Table  2) per definition the specific underlying cause in primary headaches can-not be determined. In a review by Mathew  (2014) it was argued that frontal headaches successfully treated with

decompression surgery should be classified as cranial neu-ralgias (supraorbital and supratrochlear), based on the fact that they are caused by nerve entrapment [8]. However, patient with neuralgia have completely different symptoma-tology (shooting or jabbing pain that may feel like an elec-tric shock) compared to the type of headache (pressure or tension in the frontal area) of those patients that we con-sider suitable for decompression surgery.

Moreover, it was recently shown that the entrapment of trigeminal nerve branches could induce intracranial sensiti-zation of dural nociceptors, which is one of the main gen-erators of pain and hallmarks in primary headaches [17]. These findings elucidated how secondary headaches which have an extracranial origin (entrapment of the sensory nerve) can mimic chronic migraine or chronic tension-type headache. In line with these findings we would, therefore, tentatively like to propose a new subclass: frontal second-ary headache attributed to supraorbital and supratrochlear nerves entrapment. In addition, we believe that a more appropriate term for the surgical procedures related to this type of headache would be: “decompression surgery for frontal secondary headache attributed to supraorbital and supratrochlear nerve entrapment”.

Table 2 International classification of headache disorders 3-Beta16

Major headache groups (ICHD 3-Beta) Diagnostic criteria Major headache types

Primary headaches Each headache type has specific symptomatology Migraine Migraine with aura Chronic migraine Complications of migraine Probable migraine Episodic syndromes migraine associated

Underlying specific organic disorder cannot be determined

Tension-type headache

Cluster headache and Trigeminal autonomic cephalalgias

Other primary headachesSecondary headaches (attributed to*) Based on the underlying cause of headache Head and/or neck trauma*

Cranial or cervical vascular disorders*Non-vascular intracranial disorders*A substance or its withdrawal*

Symptomatology can mimic any type of primary headaches

Infection*

Disorder of homostasis*Disorder of the cranium, neck, eyes, ears, nose,

teeth, mouth or other facial or cervical structure*Psychiatric disorder*

Cranial neuralgias, central and primary facial pain and other headaches

Pain originates from irritation of different cranial nerves

Cranial neuralgias and central causes of facial pain

Specific symptomatologyConditions that fulfill all but one criterion Other headache, cranial neuralgia, central or

primary facial pain

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Multidisciplinary approach in the treatment of headaches

The majority of headache patients are treated by primary care physicians, sometimes in collaboration with a neurolo-gist or an anesthesiologist. In this patient group pharma-cotherapeutic recommendations are given for most types of headaches, but in a relatively large number of patients treatment outcome remains insufficient, whereas also drug intolerability or adverse effects further can limit the use of medication [18–20].

For certain types of headaches other specialists (physical therapists, dentists, otorhinolaryngologists, head and neck surgeons, ophthalmologists, neurosurgeons, maxillofacial surgeons) are consulted to explore alternative treatment options (Fig. 1).

Decompression surgery for frontal secondary headache can be considered such an alternative treatment modality and should be discussed with the patient as an attractive alternative, waging a low morbidity procedure versus the possibility of a successful postoperative outcome. Patients with frontally localized headache and a long history of insufficient drug treatment are nowadays the most likely candidates for decompression surgery. Ideally this option is provided by a specialized multidisciplinary team which comprises a specialist with experience in headache disor-ders (neurologist and/or anesthesiologist) as well as a sur-geon (otorhinolaryngologist, head and neck surgeon, facial plastic surgeon).

In daily practice, the physicians who are treating head-ache should have sufficient information about the alterna-tive treatment options and who is providing them (Fig. 2a), to avoid that some patients are referred to the wrong spe-cialist and remain untreated (Fig. 2b).

Screening algorithm: which patients with frontal headache are good candidates for decompression surgery?

A screening algorithm was developed by our group (Fig. 3) to help identify those patients with frontal secondary head-aches that have the highest chance for a successful surgical treatment outcome. Similar algorithms have been described by other authors [21, 22]. Some authors reported that also simple clinical signs (applied pressure in the area of the nerves inducing higher pain intensity) could be used to identify patients suitable for surgery [23, 24]. In some clin-ics, questionnaires facilitate the screening process [11].

Our screening algorithm includes both clinical (1 and 2) and pharmacological (3) elements. To properly identify the patients for surgery each step in the algorithm is to be com-pleted in the following order (Fig. 3).

Table 3 Entrapment points of the supratrochlear and supraorbital nerve and their anatomical landmarks

Trigger point region

Nerve involved Entrapment points Anatomical landmarks Study/Ref. number Surgical procedure involves

Frontal Supraorbital nerve Corrugator supercilli muscle

From nasion most medial inserion at 2.9 ± 1.0 mm / lateral inserion 14.0 ± 2.8 mm (Four types of supraorbital nerve branching patterns)

Janis et al. [3, 4] Resection of corrugator supercilii muscle

Supraorbital foramen or notch

83% of the time notch with fascial band (4 common variations band types)

Falluco et al. [28] Supraorbital foraminotomy + release of fibrous bands

Supratrochelear nerve Entrance to corrugator supercilli muscle

Nerve generally bifurcates within the retro-orbicu-laris oculi fat pad, and these branches enter into one of four relation-ships with the corrugator muscle

Janis et al. [5] Resection of corrugator supercilii muscle

Exit of the corrugator supercilli muscle

Supratrochlear foramen or notch

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ICHD 3-Beta criteria for secondary headache

Patients with frontally localized headaches are referred by different specialists (primary care physicians, neurolo-gists, anesthesiologists, etc.) to be evaluated by the team member who is a specialist with experience in headache disorders. He takes patient history, performs physical examination, and fills questionnaires (scales and scores) for validation of headache symptoms and characteristics. Pain should be moderate to severe in intensity (VAS score 7–10), frontally located (>15 days per month), described as pressure or tension that intensifies with applied pres-sure on the area of supratrochlear and supraorbital nerves. Candidates for decompression surgery can only be those patients having headache that fulfills the ICHD 3-Beta criteria for frontal secondary headache [16], which mimic chronic migraine or chronic tension-type headache.

CT scan

CT scan of the head and neck should be routinely per-formed in previously selected patients to exclude

secondary pathology (frontal sinusitis, concha bullosa, contact point spine, etc.) that can cause pain sensation in the frontal area.

Pharmacological screening

A: testing with local anesthetic (LA) Pain reduction after application of LA is regarded as evidence of a peripheral origin of the pain. As a first diagnostic tool, a local anes-thetic such as Xylocaine (lidocaine 2%, adrenaline 1:80,000) can be injected around the exit points of the STN and SON at the supraorbital rim. By acting on voltage-gated sodium channels of the entrapped peripheral sensory nerves LA directly decreases peripheral firing, resulting in decreased pain symptoms [25]. Pain should decrease to at least half of the initial VAS headache score.

B: testing with  BoNT/A Patients with pain reduction after LA injections may receive additional BoNT/A (approximately 15 IU Botox®, Allergan, USA) injections into the corrugator muscle on both sides, in at least two sessions [24]. BoNT/A-mediated cleavage of SNAP 25 (complex that is responsible for Ca2+-dependent exocyto-

Fig. 1 Multidisciplinary approach in the treatment of headaches—proposed organization diagram

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sis) in motor nerves leads to prevention of acetylcholine release resulting in a reversible neuromuscular paralysis [26]. This action is only resolving entrapment of STN and SON caused by the constriction of muscles. Pain should decrease to at least half of the initial VAS headache score. With this information, we can suspect the leading cause of headache to be neural entrapment (muscle) in the trigger area [21]. The effect of BoNT/A on headache can last for several months [27], after which it can be repeated if nec-essary. Subsequently patients should be given an option to continue with the BoNT/A therapy or to proceed with the decompression surgery.

In conclusion, according to our algorithm (Fig.  3), patients suitable for decompression surgery are those with a headache that fulfills the ICHD 3-Beta criteria for sec-ondary headache, with high pain scores (VAS 7–10) and refractory to any prior pharmacological treatment. To elu-cidate the cause of frontal secondary headache (supraorbi-tal and supratrochlear nerve entrapment) both CT scan and injections of LA and BoNT/A should be performed.

Anatomy

Anatomical cadaver studies in the frontal region were con-ducted to investigate potential entrapment sources of the STN and SON and their landmarks [3–5, 28] (Table  3). Muscle, periosteum (fascia) and bone were identified as anatomical structures with the potential to cause the entrap-ment, either separately or combined.

Muscular entrapment points related to the corrugator muscle were identified with different branching patterns of the STN and SON, either running underneath the muscle or through the muscle [3–5].

The SON and STN separately exit the orbit (STN more medially) either through bony passages (foramina) or bony-periosteal elevation (notch) structures which are positioned at the supraorbital ridge (Fig. 4) [5, 28]. The supraorbital foramen, a bony opening at the supraorbital ridge, com-pletely circulates the nerve resulting in a higher possibility of a bony entrapment. If a notch is found this also results in a higher chance for periosteal encirclement or entrapment of the nerve since the floor of the notch contains fascial bands (remnants of the periosteum) which are connected to the roof of the notch (supraorbital ridge) (Fig. 4).

Surgical technique: endoscopic approach

Based on the anatomical studies the goal of decompres-sion surgery in the frontal region is to release muscular, periosteal and bony entrapment of the SON and STN. To achieve this goal two surgical approaches where intro-duced: the endoscopic approach [11, 13, 29, 30] and the open-transpalpebral approach [2, 9, 10, 12].

Nowadays, for our group state of the art is the endo-scopic approach as it allows complete release of the peri-osteum at the level of supraorbital ridge while at the same time the entire glabellar muscle group can be dissected. Some authors believe that muscle de-entrapment can only be achieved by complete excision of the glabellar muscle group. By employing endoscopic approach in our practice we found that blunt dissection of the muscles (without exci-sion) in combination with periosteum release is a sufficient maneuver to achieve an adequate level of decompression indicating that the periosteal entrapment is most likely the leading causative factor. Additionally, by blunt dissection of the glabellar muscles the chance of more serious adverse effects of the surgery is decreased.

The open-transpalpebral approach can be regarded as an extension of an upper blepharoplasty procedure. After opening the skin and visualization of the muscles and nerves, decompression is achieved by complete excision of the glabellar muscles while the periosteum and fascial bands of the supraorbital ridge are left intact. In line with that, Liu et al. (2012) showed that an endoscopic approach has better treatment outcomes compared to the transpalpe-bral approach, and it was advocated that it should be used as the approach of first choice whenever it is anatomically feasible [29].

Some authors discussed the need to additionally perform a supraorbital bony foraminotomy in patients with high pain sensation at the supraorbital foramina. The procedure involves percutaneous release of the supraorbital foramina roof using a guarded 2-mm osteotome. In their opinion, this ensures complete bony release of the SON resulting in improved treatment outcome [31]. However, in our prac-tice, we have not found the need to perform this procedure up to now. Adequate release of the supraorbital ridge peri-osteum and blunt dissection of the glabellar muscle group by the endoscopic approach is sufficient in almost all our cases (Fig. 5).

All of our patients are operated under general anesthe-sia. Surgical set used for endoscopic approach is shown in Fig. 6. Prior to the incision the skin is marked and the forehead is injected with xylocaine to minimize the bleed-ing in the operating field (Fig. 7a, b). A pre-hair line skin incision (W shape, 12  mm long) is made in the midline with a 15-blade scalpel all the way to the periosteum which is incised and elevated with the Obwegeser periosteum

Fig. 2 Schematic presentation of referral patterns which are results of different level of information about the alternative headache treat-ments. a Primary care physician refers headache patient to a neu-rologist who later determines that the best treatment option for that patient is provided by the otorhinolaryngologist. b As a result of a lack of knowledge about the different treatment options the headache patient is referred to several different specialists (neurologist, anesthe-siologist, etc.) and remains devoid of the appropriate treatment

◂

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elevator (Fig. 7c, d). Although a second skin incision can be made laterally to the midline to allow an extra surgical instrument, we have not found it necessary in most cases (Fig. 5).

Under direct control of the endoscope the Obwegeser periosteum elevator is used to further elevate skin–mus-cle–periosteum flap in a subperiosteal plane. Dissection is carried caudally in the medial line until the supraorbital rims are visualized at which level the periosteum is incised. We do not remove any of the glabellar muscles. Instead we use the elevator for blunt dissection of the muscles through the periosteal incision, until both STN and SON and accompanying vessels are well visualized (Fig. 8a, b). This procedure is safe and in our hands proved to be efficient to achieve the necessary level of muscle and periosteum

de-entrapment of the SON and STN finally resulting in sat-isfactory postoperative frontal pain relief.

Surgery is finished with homeostasis and stapling of the skin incision (Fig.  9a). Dressings with bandage are placed around the forehead for 1 day (Fig. 9b). Parts of the endoscopic procedure are additionally shown in Online Resource 1.

Surgical outcome

Evidence about efficacy of surgical treatment for frontal secondary headache is accumulating rapidly as different surgical groups are continuously reporting their results. Apparently, the surgery has a long-lasting effect [9–13]. In these studies, outcome was measured by the percentage

Fig. 3 Screening algorithm which is used to identify patients with frontal secondary headache that have the highest chance for a successful surgical treatment outcome

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Fig. 4 Sagittal view through the skull base at the level where the supraorbital nerve exits the orbit: anatomical structural variations of the supraorbital ridge with different nerve entrapment points. a SON exits the orbit through supraorbital foramina—bony opening in the frontal bone. In this case there are three possible entrapment points of the SON—the bony foramina, the periosteum attachments

to the foramina, the corrugator muscle. b SON exits the orbit through supraorbital notch—roof is composed of frontal bone while the floor of the notch is composed of the periosteum attachments. In this case there are two possible entrapment points of the SON—the periosteum attachments and the corrugator muscle

Fig. 5 Schematic presentation of the endoscopic approach in decom-pression surgery for frontal secondary headache. Positions of the endoscope (0° with the Full HD camera; Storz®) and surgical instru-ments are schematically shown in relation to the important anatomi-cal structures (glabellar muscle group, STN and SON) during the endoscopic decompression surgery in the frontal area

Fig. 6 Surgical set used for the endoscopic decompression of the supraorbital and supratrochlear nerves

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of patients who experienced late postoperative reduction of headache symptoms of 50% or more on a VAS (0–10). Surgical success rates from the early publication to the lat-est published study have improved from 68.3% [9] to 93.3% [13].

It is important to emphasize, as headache can emerge from other head regions (temporal and occipital) [14, 15] that some authors implicate the need to operate these regions simultaneously with the frontal region to achieve better outcomes [32]. However, the frontal region is the single most frequently operated site with the highest suc-cess rate reported by some studies with a level 2 of clini-cal evidence (Table 1) [9–13]. In addition, in our practice the patients most often have frontally localized headache, while other regions are far less presented. We believe that a potential successful outcome of surgery depends highly on the precise preoperative patient selection using a screening algorithm (Fig. 3).

If we analyze the origin of the study groups, surgical treatment has spread from one institution to many others in the USA, and further to several EU countries [9–13]. This is important as one of the ways to prove efficacy of the pro-cedure is that different institutions, not connected, are con-tinuously showing good results [33].

In our practice, most operated patients experienced an immediate decrease in headache (VAS average from 10 to 7 pre op to 2–0 post op). In many of our patients a form of pain is still present in the first postoperative month, but with a significantly lower intensity and an altered character

(described not as pressure or tension, but a more general feeling of bruising after surgery). Importantly, postopera-tively the patients stopped using pain medication on a daily basis.

Adverse effect

Every treatment modality for headache has adverse effects. Reported adverse effects of decompression surgery in the literature primarily include transient paresthesia of the surgical field, hematoma formation and brow asymmetry (Table 1). In our practice, we find decompression surgery of the frontal region to be one of the safest procedures, while the only observed adverse effects have been tran-sient paresthesia (duration 1–2 months, from the hair line to the orbital rims) and postoperative swelling around the orbit. Although the bleeding in the surgical field is a possi-ble intaoperative complication, occurring especially around the nerves, it can be avoided by blunt dissection and easily resolved with appropriate surgical instruments (Fig. 6). Our patients are routinely discharged from the hospital on their first postoperative day.

Possibility of the placebo effect: sham operation

A surgical treatment outcome is related to the cumulative effect of crucial, placebo and non-specific factors [34, 35]. The crucial factor in surgery provides the “real” thera-peutic effect, the placebo factor is related to the patients’

Fig. 7 Decompression surgery for frontal secondary headache; steps before introduction of the endoscope. a Pre-hair line skin marking (W shape 12 mm long); b forehead injected with xylocaine; c skin incision (15-blade scalpel) is made through skin, frontal muscle and perios-teum; d periosteum is elevated around the incision with the Obwegeser periosteum elevator

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expectations of the surgery, while the non-specific factor is associated with symptom fluctuations, course of disease, report biases, etc. [36, 37]. It was shown that more invasive procedures have a stronger placebo effect [38]. In surgical

procedures in general the placebo effect may be as high as 35% [39].

Sham randomized controlled clinical surgical trials are rare [40] and usually result in an ethical debate regarding

Fig. 8 Decompression surgery for frontal secondary headache; endo-scopic approach. a Surgical field is shown on the screen; patient head position during surgery (tip of the endoscope is under the skin–mus-cle–periosteum flap of the forehead). b Three steps during surgery: A

elevation of the frontal muscle in the subperiosteal plane; B incision of the periosteum with blunt dissection of the glabellar muscles; C decompression of the supraorbital and supratrochlear nerves

Fig. 9 Decompression surgery for frontal secondary headache; skin closure, dressings, band-age. a Stapling of the skin inci-sion; b dressings with bandage are placed around the forehead for 1 day

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their necessity [41]. The benefit of using a sham surgery control group is the possibility of evaluating the pla-cebo factor. Guyuron et  al. (2009) published a sham con-trol study involving decompression surgery for headache in three areas (frontal, temporal, and occipital) with 75 patients (26—sham surgery in their predominant area; 49—actual decompression surgery in the predominant area) [42]. However, decompression surgery in the frontal area was performed using an open/transpalpebral approach in which the crucial factor involved resection of the glabel-lar muscles around the nerves while the periosteum was left intact. The sham group underwent exposure of the glabellar muscles and nerves while the muscles were not cut.

Compared with the sham placebo surgery group, the crucial surgery group demonstrated statistically significant better treatment outcomes (57.7 versus 83.7%—experi-enced at least 50% reduction of headache symptoms; 3.8 versus 57.1%—experienced complete elimination of head-ache symptoms) 1  year postoperatively. In our opinion, exposing the nerves either by blunt dissection or resection of the muscle will result in some nerve decompression in both cases which explains the relatively high outcome after the sham operation. We believe that the most crucial fac-tor of the surgery is the release of the periosteum at the supraorbital ridge. This was not performed in both study groups.

Final comments

In his review, Mathew  (2014) critically evaluated decom-pression surgery and some of his comments have been the focus of this review [8]. For example, Mathew does not consider “migraine surgery” to be a treatment procedure for migraine (especial episodic migraine, lasting <15 days a month). We agree with this comment and tried to bring forward our opinion that only frontal secondary headache (lasting >15 days a month, described as tension or pressure) is eligible for surgical decompression after performing a step-by-step screening algorithm (Fig.  3). Furthermore, Mathew questions the use of LA as a valid preopera-tive screening tool on assumption that LA injections are decreasing pain by the central mechanism of action, thus creating a bias in a patient selection [8]. Yet, it seems more logical that any central effect of LA is merely an outcome of their direct action on voltage-gated sodium channels of the entrapped peripheral sensory nerves [24].

In addition, Mathew questioned the use of BoNT/A as valid preoperative screening tool [8], as it was shown in the recent preclinical studies that toxin antinociceptive activ-ity is of central origin in sensory nerves and is not solely related to the decrease in muscular overactivity [43, 44]. This new information only shows that BoNT/A is also

effective in decreasing pain from not only muscle entrap-ment but also periosteal and bony entrapments. In line with that, in the future, it may be necessary to test another short-lasting muscle relaxant as a potential screening tool to bet-ter differentiate the leading cause of entrapment.

Mathew also remarks decompression surgery as an expensive treatment [8], even though the estimated annual medication cost per chronic migraine patient in the Euro-pean countries is between 319 and 1279  €. When other parameters are included (hospitalization, other procedures, etc.), expenses can rise up to 3718  € depending on the country involved [45]. In contrast, decompression surgery, depending on the European country involved, is estimated to be around 2000–3000 € and might help patient to stop using their medication.

Finally, we cannot agree with the comment from Mathew that decompression surgery is a treatment option with potentially irreversible complications including wors-ening of pain [8]. In our practice, this is one of the safest procedures with the only observed adverse effect being the transient paresthesia and postoperative swelling around the orbit.

Pain as a phenomenon is a highly subjective experience which evaluation in clinical studies is difficult and mainly based on self-reported scores (VAS or questionnaires). In line with that it is important that in future studies the same standardized and validated questionnaires are used by dif-ferent surgery groups to make the validation of end results possible and more accurate.

Conclusion

Pharmacological treatment should be the first option in every headache patient. However, there are patients with frontal headaches and high pain scores which are refrac-tory to pharmacological treatment or have severe drug side effects. Some of these patients suffering from frontal sec-ondary headache caused by the entrapment of the supraor-bital and supratrochlear nerves could benefit from the sur-gical decompression. These patients should be carefully selected using step-by-step screening algorithm. In that case, the success rate of this procedure is high with mini-mal or no adverse effects.

Acknowledgements We are thankful to Mr. Nikola Šudelija and Mr. Ivan Filipović for graphic design and illustration contribution.

Compliance with ethical standards

Funding This is a non-funded study.

Ethical approval All procedures performed in study involving human participants were in accordance with the ethical standards of

2105Eur Arch Otorhinolaryngol (2017) 274:2093–2106

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the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent Informed consent was obtained from all individ-ual participants included in the study.

Conflict of interest The authors declare that they have no conflict of interest.

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