Surgical treatment delay in patients with headache disorders and neuralgia correlates with poor postoperative outcome.

INTRODUCTION: Although nerve decompression surgery has proven to be effective in reducing symptoms in patients with head and neck neuralgia and headache disorders, it is currently not part of the treatment algorithms for headache disorders. Therefore, patients wait an average of 20 years from the onset of symptoms to surgery, resulting in high conservative treatment costs ($989,275.65 per patient) and patient morbidity. This study evaluated the clinical impact of treatment delays on surgical outcomes. METHODS: Overall, 282 patients who underwent nerve decompression surgery at Weill Cornell Medicine and Massachusetts General Hospital between September 2012 and January 2024 were enrolled. Information regarding demographics, onset of symptoms, and headache characteristics was collected using patient surveys. The treatment outcome was evaluated by the percentage of symptom reduction in terms of frequency, duration, and pain intensity. An area under the receiver operating characteristic analysis was performed to determine the optimal timepoint to undergo surgery. RESULTS: Postoperative symptom reduction and time between the onset of symptoms and surgery were negatively correlated (r = -0.22; p < 0.001). The most significant difference in outcome was found at 2.9 years from symptom onset; patients who underwent surgery before this timepoint reported an average improvement of 79 ± 23% versus 67 ± 35% in those who were treated after the timepoint (p = 0.021). CONCLUSION: Our results indicate that delays in undergoing nerve decompression surgery beyond 2.9 years from symptom onset leads to less favorable postoperative outcomes, underscoring the need for timely referral to peripheral nerve surgeons when conservative management fails. Nonetheless, even with delays in surgical intervention, patients continued to experience significant symptom reduction.

Preoperative visualization of the greater occipital nerve with magnetic resonance imaging in candidates for occipital nerve decompression for headaches.

Occipital nerve decompression is effective in reducing headache symptoms in select patients with migraine and occipital neuralgia. Eligibility for surgery relies on subjective symptoms and responses to nerve blocks and Onabotulinum toxin A (Botox) injections. No validated objective method exists for detecting occipital headache pathologies. The purpose of the study is to explore the potential of high-resolution Magnetic Resolution Imaging (MRI) in identifying greater occipital nerve (GON) pathologies in chronic headache patients. The MRI protocol included three sequences targeting fat-suppressed fluid-sensitive T2-weighted signals. Visualization of the GON involved generating 2-D image slices with sequential rotation to track the nerve course. Twelve patients underwent pre-surgical MRI assessment. MRI identified four main pathologies that were validated against intra-operative examination: GON entanglement by the occipital artery, increased nerve thickness and hyperintensity suggesting inflammation compared to the non-symptomatic contralateral side, early GON branching with rejoining at a distal point, and a connection between the GON and the lesser occipital nerve. MRI possesses the ability to visualize the GON and identify suspected trigger points associated with headache symptoms. This case series highlights MRI's potential to provide objective evidence of nerve pathology. Further research is warranted to establish MRI as a gold standard for diagnosing extracranial contributors in headaches.

Temporal aneurysms and migraine surgery.

The present study reports two cases of chronic migraines associated with superficial temporal artery aneurysms. The patients received aneurysm's ligation, with no other surgical maneuvers. In the six months following surgery, both patients were disease-free and did not experience any migraine attacks. Evidence-based medicine ranking: Level V.

Minimally invasive nerve and artery sparing surgical approach for temporal migraines.

Background: Temporal migraines (TM) present with throbbing, pulsating headaches in the temporal area. Different surgical techniques ranging from resecting the auriculotemporal nerve (ATN) and or ligating the superficial temporal artery (STA) have shown similar good results to decrease TM symptoms. No conclusive data supports a specific disease of the STA in TM patients. A minimally invasive technique is proposed to preserve both vascular and nerve structures. Methods: Patients with drug resistant TM were selected and treated with two techniques: nerve sparing and nerve and artery sparing. The study included 57 patients with TM, with an average age of 47.5 years. TM improvement was quantified after at least one year of follow up time. STA biopsies were sent for histological analysis. Results: Forty-two patients underwent nerve-sparing decompression, with a therapeutic success rate of 78.6%, corresponding to 22.1 days with migraine per month decreasing to 6.2. Histological analysis of the STA showed varying degrees of endofibrosis in 75% of the samples. Histological results do not correlate with the intensity of symptoms before or after surgery. Fifteen patients underwent nerve and artery sparing arteriolysis, with an overall therapeutic success rate of 86.6% of which 80% had >90% improvement. The average migraine days dropped from 24 to 2.5 days per month in this group. Conclusion: Minimally invasive nerve sparing approaches are an effective and safe treatment to improve drug resistant TM symptoms. Endofibrosis of the STA was present in 75% of the cases, but it was found to be unrelated to pre-operative symptoms and outcome. Results are promising, but the limited numbers of patients treated with artery and nerve sparing technique needs further investigations.

Functional outcomes between headache surgery and targeted botox injections: A prospective multicenter pilot study.

Introduction: Chronic migraine headaches (MH) are a principal cause of disability worldwide. This study evaluated and compared functional outcomes after peripheral trigger point deactivation surgery or botulinum neurotoxin A (BTA) treatment in patients with MH. Methods: A long-term, multicenter, and prospective study was performed. Patients with chronic migraine were recruited at the Ohio State University and Massachusetts General Hospital and included in each treatment group according to their preference (BTA or surgery). Assessment tools including the Migraine Headache Index (MHI), Migraine Disability Assessment Questionnaire (MIDAS) total, MIDAS A, MIDAS B, Migraine Work and Productivity Loss Questionnaire-question 7 (MWPLQ7), and Migraine-Specific Quality of Life Questionnaire (MSQ) version 2.1 were used to evaluate functional outcomes. Patients were evaluated prior to treatment and at 1, 2, and 2.5 years after treatment. Results: A total of 44 patients were included in the study (surgery=33, BTA=11). Patients treated surgically showed statistically significant improvement in headache intensity as measured on MIDAS B (p = 0.0464) and reduced disability as measured on MWPLQ7 (p = 0.0120) compared to those treated with BTA injection. No statistical difference between groups was found for the remaining functional outcomes. Mean scores significantly improved over time independently of treatment for MHI, MIDAS total, MIDAS A, MIDAS B, and MWPLQ 7 (p<0.05). However, no difference in mean scores over time was observed for MSQ. Conclusions: Headache surgery and targeted BTA injections are both effective means of addressing peripheral trigger sites causing headache pain. However, lower pain intensity and work-related disabilities were found in the surgical group.

Nerve blocks for occipital headaches: A systematic review and meta-analysis.

Migraine surgeons have identified six "trigger sites" where cranial nerve compression may trigger a migraine. This study investigates the change in headache severity and frequency following nerve block of the occipital trigger site. This PRISMA-compliant systematic review of five databases searched from database inception through May 2020 is registered under the PROSPERO ID: CRD42020199369. Only randomized controlled trials utilizing injection treatments for headaches with pain or tenderness in the occipital scalp were included. Pain severity was scored from 0 to 10. Headache frequency was reported as days per week. Included were 12 RCTs treating 586 patients of mean ages ranging from 33.7 to 55.8 years. Meta-analyses of pain severity comparing nerve blocks to baseline showed statistically significant reductions of 2.88 points at 5 to 20 min, 3.74 points at 1 to 6 weeks, and 1.07 points at 12 to 24 weeks. Meta-analyses of pain severity of nerve blocks compared with treatment groups of neurolysis, pulsed radiofrequency, and botulinum toxin type A showed similar headache pain severity at 1 to 2 weeks, and inferior improvements compared with the treatment groups after 2 weeks. Meta-analyses of headache frequency showed statistically significant reductions at 1 to 6-week follow-ups as compared with baseline and at 1 to 6 weeks as compared with inactive control injections. The severity and frequency of occipital headaches are reduced following occipital nerve blocks. This improvement is used to predict the success of migraine surgery. Future research should investigate spinous process injections with longer follow-up.

Long-term results of migraine surgery and the relationship between anatomical variations and pain.

BACKGROUND: Migraine headache surgery has been recently reported and supported by studies as management to provide long-term relief in migraine sufferers. This study aimed to monitor the long-term results of patients who underwent migraine surgery in our clinic and determine the relationship between pain and anatomical anomalies. METHODS: A prospective review was conducted of 93 patients who underwent surgery for migraine headaches performed between 2017 and 2021 by the senior author (M.U.) and had at least 12 months of follow-up. Anatomical data were obtained by recording the findings during surgery. Migraine surgery was performed bilaterally in all patients. Anatomical symmetry differences between the right and left sides were recorded. RESULTS: A total of 79 (84.9%) patients experienced at least 50% reduction in migraine headache. Furthermore, 13 (14%) patients reported complete elimination of migraine headache. A significant difference was found before and after surgery in Migraine Disability Assessment score, migraine headache index, frequency, duration, and pain (p < 0.001). Also, 30 (32.3%) of the patients had bilateral headaches and 63 (67.7%) had primarily unilateral headaches. Then, 51 (81%) patients with mostly unilateral headache were anatomically asymmetrical and 12 (12%) were anatomically symmetrical. Patients with mostly unilateral headache were found to be anatomically highly asymmetrical (p < 0.005). CONCLUSIONS: This study shows that surgical treatment is effective and long-term protection and has mild complications that are easily tolerated by the patient. The fact that headache side and anatomical asymmetry were significant in this study supports the peripheral mechanism.

Outcomes of Surgical Treatment of Migraines: A Systematic Review & Meta-Analysis.

Background: Migraine surgery at 1 of 6 identified "trigger sites" of a target cranial sensory nerve has rapidly grown in popularity since 2000. This study summarizes the effect of migraine surgery on headache severity, headache frequency, and the migraine headache index score which is derived by multiplying migraine severity, frequency, and duration. Materials and Methods: This is a PRISMA-compliant systematic review of 5 databases searched from inception through May 2020 and is registered under the PROSPERO ID: CRD42020197085. Clinical trials treating headaches with surgery were included. Risk of bias was assessed in randomized controlled trials. Meta-analyses were performed on outcomes using a random effects model to determine the pooled mean change from baseline and when possible, to compare treatment to control. Results: 18 studies met criteria including 6 randomized controlled trials, 1 controlled clinical trial, and 11 uncontrolled clinical trials treated 1143 patients with pathologies including migraine, occipital migraine, frontal migraine, occipital nerve triggered headache, frontal headache, occipital neuralgia, and cervicogenic headache. Migraine surgery reduced headache frequency at 1 year postoperative by 13.0 days per month as compared to baseline (I2 = 0%), reduced headache severity at 8 weeks to 5 years postoperative by 4.16 points on a 0 to 10 scale as compared to baseline (I2 = 53%), and reduced migraine headache index at 1 to 5 years postoperative by 83.1 points as compared to baseline (I2 = 2%). These meta-analyses are limited by a small number of studies that could be analyzed, including studies with high risk of bias. Conclusion: Migraine surgery provided a clinically and statistically significant reduction in headache frequency, severity, and migraine headache index scores. Additional studies, including randomized controlled trials with low risk-of-bias should be performed to improve the precision of the outcome improvements.

Historique: Le traitement de la migraine à l'une des six « zones gâchettes ¼ établies d'un nerf crânien sensoriel cible ont rapidement gagné en popularité depuis 2000. La présente étude résume l'effet du traitement chirurgical de la migraine sur la gravité et la fréquence des céphalées et sur le score de migraine obtenu par la multiplication de la gravité, de la fréquence et de la durée des migraines. Matériel et méthodologie: La présente analyse systématique de cinq bases de données fouillées depuis leur création jusqu'à mai 2020 respecte la liste PRISMA et est enregistrée sous le numéro d'identification CRD42020197085 de PROSPERO. Les chercheurs ont retenu les études cliniques sur le traitement des céphalées par des interventions chirurgicales. Ils ont évalué le risque de biais des études aléatoires et contrôlées. Ils ont également effectué des méta-analyses des résultats au moyen d'un modèle à effets aléatoires pour déterminer le changement moyen regroupé par rapport à l'état de référence et, dans la mesure du possible, pour comparer des sujets traités à des sujets témoins. Résultats: Au total, 18 études respectaient les critères, y compris six études aléatoires et contrôlées, une étude clinique contrôlée, et 11 études non contrôlées auprès de 1 143 patients ayant des pathologies incluant la migraine, la migraine occipitale, la migraine frontale, la céphalée occipitale, la céphalée frontale, la névralgie occipitale et la céphalée cervicogénique. Par rapport à l'état de départ, le traitement chirurgical de la migraine avait réduit la fréquence des céphalées de 13,0 jours par mois (I2 = 0%) un an après l'opération, la gravité des céphalées de 4,16 points sur une échelle de 0 à 10 de huit semaines à cinq ans après l'opération (I2 = 53%) et le score de migraine de 83,1 points de un à cinq ans après l'opération (I2 = 2%). Ces méta-analyses sont limitées par le petit nombre d'études pouvant être analysées, y compris des études comportant de forts risques de biais. Conclusion: Le traitement chirurgical de la migraine assure une diminution cliniquement et statistiquement significative de la fréquence et de la gravité des céphalées, ainsi que des scores de migraine. D'autres études, y compris des études aléatoires et contrôlées comportant un faible risque de biais, devront être exécutées pour mieux préciser les améliorations aux résultats cliniques.

Morphologic vascular anomalies detected during migraine surgery.

Although there is increasing evidence of migraine headaches having extracranial origins, the exact mechanisms underlying the pathogenesis of surgically treated migraines continue to be poorly investigated and described. We studied the microscopic and ultrastructural characteristics of superficial temporal artery (STA) and occipital (OA) artery in the auriculotemporal and great occipital trigger points of migraine patients to determine their possible role in migraine etiopathogenesis. Fifteen biopsies, 10 of STA and 5 from OAs, were collected intraoperatively during migraine surgery and immediately processed for optical and ultramicroscopic analysis. We detected the following anomalies in all the specimens: (a) endothelial damage with internal elastic lamina fragmentation and intimal thickening; (b) marked irregularity in the shape and metachromasia of the vascular smooth muscle cells (VSMCs), separation of cells by abundant extracellular matrix and vacuoles. The electron microscopy analysis confirmed that presumed VSMCs infiltrated the intima layer revealing a consistent shift of VSMCs from contractile to synthetically active phenotypes, endosome-like organelles, multilamellar structures, abundant extracellular vacuoles filled with fine granular material and membranes, and extracellular vesicles in the matrix space surrounding synthetically active cells. Our study revealed specific alterations in the vasculature at the neurovascular bundles of the temporal and occipital trigger sites. These findings are indicative of an active involvement of the arteries in the auriculotemporal and great occipital trigger sites in evoking migraine.

Quality of online information about migraine headache surgery.

Migraine headache is a debilitating disease that can lead to severe functional limitations and is the most common primary headache. In more than 30% of cases conservative therapies do not allow the control of symptoms or cause side effects. Peripheral nerve surgery should be considered in non-responsive chronic migraine or suspected peripheral origin. Nowadays Web has become one of the most important sources of knowledge for patients: the information available on the web is not subject to a control of the sources reliability but can influence the patient. The aim of the study is to evaluate the quality of information accessible on the Web about the surgical treatment of migraine headache. "Headache OR migraine treatment", "headache OR migraine surgery" were the keywords used on two main search engines (Google and Yahoo). Among the first 50 websites, 26 were suitable and we divided them into five groups (practitioners, hospitals, healthcare portals, professional societies, encyclopedias). We applied the expanded EQIP (Ensuring Quality Information for Patients) scale: the EQIP scale consists of 36 questions with three sections (content, identification data and structure). Although the overall average score was relatively high (22 out of 36), many lacks information were highlighted: overall, readability was not satisfactory in communicating information regarding migraine and its surgical treatment. Readability should be tested before medical online publication, in order to provide for its correct use by the patient and improving migraine knowledge.

Single midline incision approach for decompression of greater, lesser and third occipital nerves in migraine surgery.

BACKGROUND: The traditional approach for occipital migraine surgery encompasses three separate surgical incisions in the posterior neck to decompress the greater occipital nerves (GON), lesser occipital nerves (LON), and third occipital nerves (TON). Other incisions have been investigated, including singular transverse incisions. We sought to evaluate a single, vertical midline incision approach for decompression of all six occipital nerves. METHODS: Using 10 cadaveric hemi-sides (5 fresh cadaver head and necks). Anatomic landmarks and the location of the bilateral GON, LON, and TON were marked according to previous anatomic studies. A single, midline 9-cm incision was made, and lateral skin flaps were raised to decompress or avulse all six nerves. RESULTS: Through the midline incision, the GON and TON were identified at 3.5 and 6.2 cm, respectively, inferior to a line bisecting the external auditory canal (EAC) and 1.5 cm lateral to the midline. The LON was identified as 6-cm inferior and 6.5-cm medial to a line bisecting the EAC in the plane just above the investing layer of the deep cervical fascia until the posterior border of the sternocleidomastoid was encountered. The LON had the greatest amount of variation but was identified lateral to the posterior border of the SCM. CONCLUSIONS: A single midline incision approach allows for successful identification and decompression of all six occipital nerves in migraine surgery.

Letter to the Editor: Insights into migraine surgery - An ACS-NSQIP data analysis over a 13- year period.

We demonstrate the safety of MS based on big data database research and outline the clinical relevance of white female migraineurs affected by menstrual migraines.

Letter to the Editor: The Case for Publicly Funded Headache Surgery in Germany.

Headache surgery has become a considerable therapeutic option in headache treatment and is of rising interest in the German medical sector. This viewpoint outlines the need for reimbursement of headache surgery in the German healthcare system and demonstrates its cost-effectiveness. Using state-of-the-art patient selection algorithms, the authors found headache surgery to be cost-effective within 7.2 to 6.3 years. Of note, the approach presented is not limited to the German healthcare system.

Surgical Options for Migraine: An Overview.

OBJECTIVE: The goal of this manuscript was to provide a comprehensive review of the surgical treatment for migraine headaches with a focus on trigger points and their clinical presentations, and to emphasize the importance of appropriate patient selection. BACKGROUND: Migraine is a prevalent neurological disease with headache being a disabling component of it. Surgical treatment for migraine headache became available two decades ago, which is based on proper identification and the deactivation of the specific trigger sites in the head and neck area. DESIGN: This manuscript reviews the discovery and evolution of migraine surgery with changes in patients' selection throughout the years. CONCLUSION: Patients with migraine headaches who do not respond or cannot tolerate the medical treatment might benefit from trigger site deactivation surgery. The success of the surgery is closely related to proper identification of trigger point (s) and close collaboration with a neurologist or a headache specialist. This collaboration would enhance patients' positive outcomes and help to rule out other causes of the headache.

The complex relationship between estrogen and migraines: a scoping review.

BACKGROUND: Migraines are a chronic disease for millions worldwide and have been hypothesized to be hormonally mediated due to their higher prevalence in females and menstrual associations. Estrogen has been commonly implicated in migraine pathogenesis, yet its exact role in the pathophysiology of migraines has yet to be fully understood. METHOD: We conducted a scoping review of the literature regarding estrogen's role in migraine pathogenesis and included 19 studies out of an initial 202 in the final review. Two independent reviewers screened and extracted data from included studies based on predetermined inclusions and exclusion criteria. RESULTS: The estrogen withdrawal hypothesis, discussed by 12 of the reviewed studies, is the most discussed theory about estrogen's role in migraine physiology and describes the association of migraine onset with natural declines in estrogen levels, particularly when estrogen levels fall below 45-50 pg/mL after an extended period of priming. Additional findings suggest that women with a history of migraine have an increased sensitivity to physiologic fluctuations in estradiol levels. Several studies suggest that migraines are associated with menstruation. CONCLUSION: It appears that estrogen is very likely to play a key role in migraine pathogenesis, but seems to affect patients in different ways depending on their past medical history, age, and use of hormonal therapy. Further research is warranted to isolate the effects of estrogen in each unique patient population, and we believe that studies comparing menstruating women to postmenopausal women could help shed light in this area.

Migraine Treatment.

Migraine headaches affect more than 35 million Americans and are ranked the third-highest cause of disability worldwide, resulting in decreased quality of life and serious economic consequences. There are 4 types of migraine headaches: frontal, temporal, occipital, and rhinogenic. Each type has a well-described trigger site. Migraines headaches often are refractory to medical therapy and may respond well to botulinum toxin type A. Migraine surgery is another option to release trigger sites. A systematic review of the migraine surgery literature found an average success rate of 90%, with elimination or greater than 50% improvement of migraine headaches after migraine surgery.

Migraña: efectividad del tratamiento quirúrgico: revisión de la literatura / Migraine headache: effectiveness of surgical treatment: review of the literature

Resumen La migraña afecta a un porcentaje importante de la población y los síntomas pueden interferir con calidad de vida de manera importante. A pesar de los avances en el manejo médico, existe una proporción de pacientes que no responden adecuadamente a la intervención farmacológica. En los últimos años, se han planteado nuevos enfoques en el tratamiento de la migraña. Éstos se basan en la teoría que ramas sensoriales extracraneales del trigémino y de los nervios espinales cervicales pueden irritarse, atraparse o comprimirse en algún punto a lo largo de su trayecto, generándose una cascada de eventos fisiológicos que finalmente resulta en la migraña. Se ha demostrado que la inyección diagnóstica y terapéutica de toxina botulínica y la descompresión quirúrgica de estos puntos gatillos reducen o eliminan las migrañas en pacientes que no responden adecuadamente a la intervención farmacológica y siguen sintomáticos. La evidencia que respalda la eficacia y seguridad de la descompresión quirúrgica de los puntos de gatillos periféricos se está acumulando rápidamente, y la tasa de éxito general de la cirugía se acerca a 90%. Este trabajo revisa la evidencia clínica y pretende proporcionar un artículo sobre el estado actual de la técnica en el tratamiento quirúrgico de las migrañas.

Migraine headaches affect a significant percentage of the population and the symptoms can interfere with quality of life in an important way. Despite advances in medical management, there is a proportion of patients who do not respond adequately to the pharmacological intervention. In recent years, new approaches have been proposed in the treatment of migraine. These are based on the theory that extracranial sensory branches of the trigeminal and cervical spinal nerves can become irritated, trapped or compressed at some point along their path, generating a cascade of physiological events that ultimately results in migraine. It has been shown that the diagnostic and therapeutic injection of botulinum toxin and the surgical decompression of these trigger points reduce or eliminate migraines in patients who do not respond adequately to the pharmacological intervention and remain symptomatic. The evidence supporting the efficacy and safety of surgical decompression of peripheral trigger points is rapidly accumulating, and the overall success rate of surgery approaches 90%. This paper reviews the clinical evidence and aims to provide an article on the current state of the art in the surgical treatment of migraines.

Surgical intervention for chronic migraine headache: A systematic review.

AIMS: Migraine is a global phenomenon, affecting more than 10% of the world's population. It is characterized by unilateral headache that may be accompanied by vomiting, nausea, photophobia and phonophobia. Some patients with chronic migraine respond to extra-cranial botulinum toxin type A injection, although the benefits observed are temporary. The rationale for surgical trigger site deactivation is to achieve lasting symptomatic improvement or permanent relief from migraine. METHODS: We performed a PRISMA-compliant systematic review of clinical studies evaluating surgical intervention for migraine by searching Ovid MEDLINE and EMBASE databases from inception to June 2017. Studies were independently screened by two authors. Data were extracted on study characteristics, migraine outcomes, adverse events and recurrence. The quality of evidence was assessed using the GRADE approach. The review protocol was prospectively registered on the PROSPERO database (CRD42017068577). RESULTS: The search strategy identified 789 articles; of them, 18 studies (4 RCTs and 14 case series) were eligible for analysis. Surgical interventions were heterogeneous and variably involved peripheral nerve decompression by myectomy or foraminotomy, nerve excision, artery resection and/or nasal surgery. All studies reported significant reductions in migraine intensity, frequency, duration and composite headache scores following surgery. Study heterogeneity precluded formal meta-analysis. Where reported, adverse event rates varied markedly between studies. The quality of included studies was consistently low or very low. CONCLUSION: There is insufficient evidence to support the effectiveness of any specific surgical intervention for chronic migraine, especially with regard to permanent relief; however, all included studies report improvements in key outcomes following migraine surgery. A definitive, well-powered RCT with objective surgical and patient-reported outcome measures and robust adverse event reporting is required.

The importance of surgical maneuvers during treatment of frontal migraines (site I): A prospective, randomized cohort study evaluating foraminotomy/fasciotomy, myectomy, and arterectomy.

BACKGROUND: The current prospective, blinded, randomized cohort study aims to delineate the relative contribution of different surgical treatments for frontal migraines. METHODS: Patients undergoing migraine surgery in the frontal region (site I) were prospectively enrolled and blindly randomized into one of the following four groups: (1) myectomy alone, (2) myectomy and foraminotomy/fasciotomy, (3) myectomy and arterectomy, and (4) foraminotomy/fasciotomy alone. Pre- and post-surgical migraine headache severity, duration, Migraine Headache Index (MHI) score, and migraine-free days (MFDs) were obtained. RESULTS: Thirteen patients agreed to participate in the study. For all patients, the mean pre- and post-operative MHI scores demonstrated a significant improvement from 52.6 (3.8-85) to 4.7 (0-21.3) (p = 0.0001). Thirty-one percent of patients required a site I revision that included an arterectomy. Patients who had an arterectomy at their initial surgery demonstrated statistically significant improvement in both frequency (12 vs. 6.11; p = 0.02) and MHI scores (51.71 vs. 5.55; p < 0.01). Arterectomy patients also demonstrated a significant improvement in the number of MFDs following surgery, from 18 to 24 MFDs (p = 0.021). Those patients not undergoing arterectomy demonstrated statistically significant improvements in the number of MFDs after their initial surgery (13.25 MFDs, p = 0.01), but the improvement was significantly less when compared to the arterectomy group (13.25 vs. 24 MFDs; p = 0.026). Following revision arterectomy, both groups had statistically equivalent improvement in MFDs (20.75 vs. 24 MFDs; p = 0.178). CONCLUSIONS: These findings suggest that arterectomy is necessary for successful treatment of frontal migraines (site I).