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OBM Neurobiology

(ISSN 2573-4407)

OBM Neurobiology is an international peer-reviewed Open Access journal published quarterly online by LIDSEN Publishing Inc. By design, the scope of OBM Neurobiology is broad, so as to reflect the multidisciplinary nature of the field of Neurobiology that interfaces biology with the fundamental and clinical neurosciences. As such, OBM Neurobiology embraces rigorous multidisciplinary investigations into the form and function of neurons and glia that make up the nervous system, either individually or in ensemble, in health or disease. OBM Neurobiology welcomes original contributions that employ a combination of molecular, cellular, systems and behavioral approaches to report novel neuroanatomical, neuropharmacological, neurophysiological and neurobehavioral findings related to the following aspects of the nervous system: Signal Transduction and Neurotransmission; Neural Circuits and Systems Neurobiology; Nervous System Development and Aging; Neurobiology of Nervous System Diseases (e.g., Developmental Brain Disorders; Neurodegenerative Disorders).

OBM Neurobiology publishes a variety of article types (Original Research, Review, Communication, Opinion, Comment, Conference Report, Technical Note, Book Review, etc.). Although the OBM Neurobiology Editorial Board encourages authors to be succinct, there is no restriction on the length of the papers. Authors should present their results in as much detail as possible, as reviewers are encouraged to emphasize scientific rigor and reproducibility.

Publication Speed (median values for papers published in 2024): Submission to First Decision: 7.6 weeks; Submission to Acceptance: 13.6 weeks; Acceptance to Publication: 6 days (1-2 days of FREE language polishing included)

Current Issue: 2026  Archive: 2025 2024 2023 2022 2021 2020 2019 2018 2017
Open Access Review

Migraine Surgery: Assessment of the Prevalence and Surgical Outcomes of Different Trigger Sites

Elisa Bertulla 1,2,†,*, Ilaria Baldelli 1,2,†, Andrea Antonini 1,2,†, Edoardo Raposio 1,2,†

  1. Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, L.go R. Benzi 10, 16132 Genoa, Italy

  2. Plastic and Reconstructive Surgery Division, IRCCS Azienda Ospedaliera Metropolitana, Genova, Italy

† These authors contributed equally to this work.

* Correspondence: Elisa Bertulla

Academic Editor: Nicola Montemurro

Special Issue: Surgical Therapy for Migraine and Tension-Type Headache

Received: November 14, 2025 | Accepted: February 25, 2026 | Published: February 28, 2026

OBM Neurobiology 2026, Volume 10, Issue 1, doi:10.21926/obm.neurobiol.2601327

Recommended citation: Bertulla E, Baldelli I, Antonini A, Raposio E. Migraine Surgery: Assessment of the Prevalence and Surgical Outcomes of Different Trigger Sites. OBM Neurobiology 2026; 10(1): 327; doi:10.21926/obm.neurobiol.2601327.

© 2026 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

Abstract

Migraine surgery is primarily indicated for patients with chronic migraine who are refractory to conventional pharmacological treatments. The procedure aims to deactivate peripheral trigger sites—anatomical zones where migraines can be triggered by nerve compression and irritation. The most common trigger areas are the frontal, occipital, and temporal. This review seeks to analyse the prevalence of treatment and corresponding success rates for these three main trigger sites. A systematic review was conducted on PubMed, Scopus, and Cochrane in November 2025 using the keyword “Migraine Surgery”. The study followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. After applying exclusion criteria and removing duplicates, 270 records were identified, and 62 full-text articles were assessed. Five retrospective studies published between 2012 and 2024 were included, totaling 2,253 patients. Of these, 907 cases involved frontal migraine, 1,049 occipital migraine, and 1,038 temporal migraine. Reported improvement rates ranged from 87-90% for frontal, 81-95% for occipital, and 86-88% for temporal triggers. Follow-up durations ranged from 3 months to 6 years. Trigger-specific surgical interventions for frontal, occipital, and temporal migraine show consistently high rates of clinical improvement, supporting their role as viable treatment options for selected patients. Although constrained by the retrospective nature of the studies, heterogeneity designs, and variable durations of follow-up, these findings assist in underscoring the potential effectiveness migraine surgery can offer. Further prospective studies with standardized methodologies are warranted to validate these outcomes and optimize patient selection criteria.

Keywords

Migraine surgery; migraine trigger sites; headache surgery

1. Introduction

Migraine is a common neurological disorder marked by recurrent, often severe headaches and a range of neurological symptoms that affect 14-15% of the global population. It is now recognized as a complex brain network disorder involving genetic, environmental, and neurobiological factors, with pathogenesis rooted in abnormal sensory processing and neural circuit dysfunction [1,2,3,4]. However, the source of the pain remains a subject of debate: the neuronal mechanisms underlying this primary condition are still not fully understood [5]. Microscopic and ultrastructural analyses of arteries at migraine trigger sites (superficial temporal and occipital arteries) consistently reveal: endothelial damage and irregular vascular smooth muscle cells with their infiltration into the intima and a shift from contractile to synthetically active phenotypes. These vascular anomalies support the theory that vascular remodelling and dysfunction are central to migraine pathogenesis and may justify targeted surgical approaches [6,7,8,9].

Migraines are one of the leading causes of disability worldwide, particularly among individuals of working age. It greatly diminishes quality of life and generates substantial costs—both direct healthcare expenses and indirect losses, primarily due to absenteeism [10,11]. A significant proportion of migraine sufferers do not achieve adequate relief from pharmacologic treatments, which has driven interest in surgical interventions, particularly for those with refractory or intractable migraines who have failed multiple medication regimens [12,13,14,15,16,17,18]. The percentage of patients refractory to treatment is unknown due to the lack of unifying diagnostic criteria in the International Classification of Headache Disorders 3rd edition (ICHD-3) [19,20]. Approximately 5% of chronic migraine patients remain refractory to medical treatment [21,22,23].

Multiple research teams worldwide have reported that, in properly selected patients, surgery targeting extracranial trigger sites yields reliably favourable results and carries a low risk of complications [24,25]. Initially, the supraorbital and supratrochlear nerves were recognized as the first trigger site (site I: frontal), where they can be compressed by the corrugator supercilii, depressor supercilii, and procerus muscles [26,27,28]. Later research identified additional major peripheral trigger points, including the temporal region (site II: involving the zygomatic and the auriculo-temporal nerves), the nasal area (site III: terminal branches of the trigeminal nerve), and the occipital region (site IV: the great occipital nerve) [29]. These findings support the role of nerve compression or irritation along their course through the head and neck as a potential mechanism in migraine pathogenesis [30,31] as demonstrated by ultrastructural and proteomic evidence supporting peripheral nerve involvement [32]. They support the idea that surgically decompressing the nerves can help alleviate or even eliminate migraine symptoms [29,33,34], as introduced through the pioneering work of Guyuron [35,36,37,38].

This study aimed to assess the prevalence of treatment for each specific trigger site and the corresponding success rates when available.

2. Materials and Methods

A systematic literature review was performed on the PubMed, Scopus, and Cochrane databases by querying the keywords “Migraine Surgery” in November 2025. No date limits were set. This study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines [39]. It was also registered in the International Prospective Register of Systematic Reviews (PROSPERO ID: CRD420251176314).

Two independent reviewers performed two-stage screening and data extraction.

Studies were selected based on the following inclusion criteria: (1) Studies selectively investigating the prevalence of each migraine trigger site; (2) studies selectively investigating the surgical treatment of each migraine trigger site. (3) registration of outcomes after surgical treatment; (4) full text available in English.

Studies were excluded due to any one of the following criteria: (1) case report; (2) books and chapters; (3) letters; (4) conferences abstracts; (5) editorials; (6) technical reports; (7) comments articles reporting only anatomic data and not surgical outcomes; (8) articles reporting only surgical technique and not surgical outcomes; (9) non-referenced articles; (10) expert opinion (Level V).

Extracted data included the authors’ names, year of publication, number of patients included, surgical strategy, mean follow-up time, and results.

The selection process is shown in the flowchart in Figure 1.

Click to view original image

Figure 1 PRISMA flowchart. PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analysis.

2.1 Ethics Statement

This systematic review was registered on PROSPERO (ID: CRD420251176314) and does not involve any new studies with human participants or animals.

3. Results

After the exclusion of repeated items, 270 articles were identified. All the records were analysed by title and abstract by 2 different reviewers. 63 full-text articles were examined for eligibility, and 6 met the inclusion criteria.

All studies included were retrospective, except for one prospective placebo-controlled trial, and were published between 2009 and 2024. The number of patients enrolled ranged from 14 in the smallest study to 1,010 in the largest, for a total of 2,329 cases.

The findings are presented according to the three main migraine triggers identified: frontal, occipital, and temporal.

Overall, 926 cases involved frontal migraine, 1,060 occipital migraine, and 1,057 temporal migraine.

The reported improvement rates for each trigger site, when available, were as follows:

  • Frontal trigger: from 87% to 90%.
  • Occipital trigger: from 81% to 95%.
  • Temporal trigger: from 86% to 88%.

Among the clinical studies included, Guyuron et al. [40] is the only one to conduct a placebo-controlled trial, reporting significant reductions in both headache frequency and severity.

Moreover, the study by Hazewinkel et al. [41] showed that prolonged delays before surgical intervention are associated with significantly poorer postoperative outcomes, with 79% improvement in patients who underwent surgery within 2.9 years, compared to 67% in those who had the procedure after this timeframe.

The follow-up period across studies ranged from 3 months to 6 years.

A summary of the main characteristics and outcomes of each study is provided in Table 1.

Table 1 Summary of the main characteristics and outcomes of each study.

4. Discussion

Migraines are a disease that greatly diminishes the quality of life. Activation of the trigeminovascular pain pathways is thought to mediate several qualities of migraine pain through the release of neuropeptides. Neurogenic inflammation in the “periphery” was initially proposed as a generator of migraine pain [1]. Many forms remain refractory to pharmacological treatments; therefore, surgical interventions have emerged as an adjunctive option for patients who do not achieve adequate disease control with medication alone. The most commonly reported procedures in the literature include decompression of specific extracranial branches of the trigeminal or occipital nerves, as well as cauterization or ligation of extracranial arteries [27,46,47].

Given the positive results achieved over the years, migraine surgery has gained increasing success and wider recognition and is now being performed more frequently. This growing use underscores the need for clear guidelines regarding patient selection and the precise localization of trigger sites. Several methods have been described to accurately identify these sites such as:

  • Pain sketches: Patients were asked to illustrate their pain. Atypical pain sketches can predict poor surgical outcomes [48,49].
  • Doppler ultrasound: Used to detect arterial involvement at suspected trigger sites, especially when patients indicate the most painful area [50,51,52].
  • Nerve blocks: Local anaesthetic blocks at suspected sites can confirm trigger points; a positive response is highly predictive of surgical benefit [38,53,54].
  • Botulinum toxin injections: Diagnostic Botox injections have a high positive predictive value for identifying responsive trigger sites [38,55].
  • Techniques like active occipital motion with digipressure and the scratch collapse test may aid in specific scenarios, though their reliability varies [56,57].

Several trigger sites are thought to be involved in the development of migraine; in this review, only the three most common ones were evaluated: temporal, frontal, and occipital.

The most frequently treated trigger site was the occipital region, followed by the temporal area, while the frontal region was the least commonly addressed.

Surgical interventions targeting frontal, occipital, and temporal migraine trigger sites showed high success rates across included studies, with improvement rates ranging from 81% to 95%, reflecting the overall efficacy of trigger-specific surgical interventions in reducing migraine frequency and intensity.

Studies reported consistent improvement across all trigger sites, with slightly higher success rates for occipital migraine. This may be related to clearer anatomy, making it easier to identify and decompress the nerves [56,57,58,59,60].

However, heterogeneity in study design, follow-up duration, and outcome measures limits direct comparison among studies. Among the included studies, Guyuron et al. [40] is the only prospective placebo-controlled trial, providing high-quality evidence on the efficacy of trigger-site decompression. This study represents a pivotal contribution by highlighting the potential role of peripheral nerves in migraine pathogenesis.

Nevertheless, the majority of studies remain retrospective and involve relatively small sample sizes, which limits the overall strength of the conclusions.

Despite the limitations, the findings support the use of trigger-specific surgical procedures in migraine management. Future prospective studies with standardized outcome measures and longer follow-up periods are needed to confirm these results and refine patient selection criteria.

5. Conclusions

Trigger-specific surgical options for frontal, occipital, and temporal migraine demonstrate high rates of clinical improvement, supporting their role as a therapeutic option for selected patients. Accurate identification of trigger sites remains critical for surgical success. Various methods can help guide patient selection and optimize outcomes. While current evidence is limited to retrospective studies with variable follow-up and outcome measures, these findings highlight the potential efficacy of surgery in migraine management. Future prospective, standardized studies with longer follow-up are warranted to strengthen the evidence base and optimize patient selection.

Author Contributions

E.R.: conceptualization, methodology, review and editing, supervision. I.B.: methodology, data curation, visualization. A.A.: methodology, data curation, visualization. E.B.: methodology, writing-original draft, data curation, visualization. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Competing Interests

The authors declare no conflicts of interest.

Data Availability Statement

All data come from previously published studies.

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