11.1 Introduction

The origin of temporal migraine headaches (MHs) can be confusing since the headaches can arise from the zygomaticotemporal branch of the trigeminal nerve, from the auriculotemporal nerve, from the terminal branches of these two nerves, or—rarely—from a branch of the zygomaticofacial branch of the trigeminal nerve. Many of the new daily and nummular headaches are related to the auriculotemporal nerve. Some of these MHs arising from the auriculotemporal region can be mistaken for temporomandibular joint conditions. In fact, these two conditions can sometimes coexist. Auriculotemporal MHs may cause headaches anywhere in the temporal region, but they are mostly confined to the hair-bearing portion of the temporal region.

A vessel signal is almost always detected at the most tender site, which can be identified by the patient, using his or her fingertip to point to the area. ¹ The patient will often complain about pain in the temple area with variable consistency in location and severity. The patient may initially point to the entire temporal area using the whole hand. Yet with further persuasion, the patient can find the most tender spot from which the MH begins using his or her index fingertip. This site is immediately marked and explored with a Doppler ultrasound, and often the signal is identified with minimal effort. Sometimes one has to move the Doppler probe around to locate the signal. Ironically, the signal is only heard in a single spot in spite of the linear nature of the offending artery.

A nerve block commonly results in complete elimination of the MH, should the patient experience a headache at the time of examination. This is especially common if the nerve block is attempted close to the onset of the headaches. A negative response to the nerve block does not necessarily predict a surgical failure, especially at a later stage and on a patient who has sensitization of the entire area. At this stage, the inflammation has spread beyond the target zone, and the central sensitization phase of the migraine cascade could be in effect.

Management of these MHs will be very different than those arising from the zygomaticotemporal branch of the trigeminal nerve. A superficial temporal branch arterectomy with auriculotemporal branch neurectomy often crossing the nerve will usually be successful. Otherwise, for those patients who have multiple tender sites with a positive ultrasound Doppler signal, those with recurrent pain along the distribution of this nerve or patients with vague temporal MH within the hair-bearing area, neurectomy of the main auriculotemporal nerve, and arterectomy of the main superficial temporal would be the best choice. However, since the auriculotemporal nerve branches before it reaches the sideburn, neurectomy of the isolated branch would often be the first choice, especially if the identified signal site is anterior to the hairline. ²

Additionally, should the patient have residual headaches at this site following a main auriculotemporal neurectomy, it is likely to be related to the branch of this nerve caudal to the sideburn, the zygomaticofacial branch of the trigeminal nerve, or the zygomaticotemporal branch of the trigeminal nerve. Surgery on the site, identified by the patient and confirmed by the ultrasound Doppler, would still benefit this patient.