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Ask the Doctor 2014 Number 4 (August)

Disclaimer: neither the BEBRF nor members of the BEBRF Medical Advisory Board has examined these patients and are not responsible for any treatment.

Question: I am a pediatrician in Wisconsin who suffers with BEB. I am curious to know if it is possible that compression of the supraorbital nerve could play a role in BEB. I suffer from migraines and BEB and have been reading about the "migraine surgery" (decompression of the supraorbital nerve) being done at University of Wisconsin and other major academic centers and wonder if there is reason to think this type of procedure might also help BEB. Could compression or demyelination of the SO nerve sendoff ectopic spontaneous discharges (much like compression of the facial nerve has been implicated in HFS) causing the trigeminal blink reflex to be stimulated? (or leading to trigeminal sensitization and hyperexcitability)? I ask this question because of the following observations:
  1. Stimulation of the SO nerve is used experimentally to induce reflex blinks.

  2. Irritating the SO nerve causes photophobia and increased blink response Previous experiments have demonstrated that injections of sodium chloride (a nerve irritant) into the frontalis muscle above the supraorbital margin produces photophobia and increased blink response.

  3. Nerve blocks of the SO nerve have been reported to decrease photophobia.

  4. Botox to the brow line improves BEB more than just injecting OO muscle. BEB Patients note that botulinum toxin in the brow line improves their symptoms more than just injection of the OO alone. (could botulinum toxin here be relaxing the muscles that surround the SO nerve as it exits the supraorbital notch in the corrugator supercilii?, or causing release of other factors that decrease SO nerve irritability as has been proposed in use of botox for migraine prophylaxis?)

  5. Migraines and accompanying photophobia improve with decompression of the supraorbital nerve. New developments in pathophysiology of migraine implicates the role for compression of SO nerve in development of migraine, with relief via botox to this area, and more recently "migraine surgery" to relieve compression of the SO nerve via removal of the corrugator supercilii muscle. Patients experience a reduction or elimination in photophobia and headaches. (Both BEB and migraine share the photophobia and trigeminal hyperexcitability as a feature.)

  6. The Borodic pin, to which many patients have had a marked reduction in photophobia and BEB actually involves a "brow lift" that could potentially decompress the supraorbital nerve much like migraine surgery does.

  7. "sensory tricks" that work for some patients often involve pulling or pushing the eyebrow in some way, that could potentially be decompressing the SO nerve (?)

Answer: You have researched and made some interesting observations regarding the supraorbital nerve. Certainly blepharospasm, migraine headaches, "sinus headaches", photophobia, ocular photodynia and other disorders are manifest by pain in this area. I have been operating on blepharospasm patients and studying the disorder since 1976. I developed the "Anderson myectomy" surgery for blepharospasm. Early on in the development of this surgery it became apparent to me that complete and meticulous removal of the corrugator supercilli and depressor supercilliaris muscles were the key to successful myectomy surgery. Removal of only the orbicular oculi muscle was not successful. It also became apparent from blepharospasm patients that removal of these muscles relieved headaches and pain in this area.

I have written many papers on myectomy surgery for blepharospasm as well as migraine and tension headaches over my career. When I began using neurotoxins in 1982, it also became obvious that the strongest muscles requiring the largest doses of neurotoxins were the corrugator supercilli and depressor supercilliaris muscles. This is still the case today with the use of neurotoxins for everything including blepharospasm, migraine headaches and even with cosmetic uses. In virtually all cases where I remove the corrugator supercilli and depressor supercilliaris muscles the patient has supraorbital anesthesia for several months and sometimes permanently. However, I have never seen the blepharospasm recur in over 2,500 myectomy surgeries I have performed because the supraorbital anesthesia resolved. Therefore, I do not believe the supraorbital nerve but rather these strong muscles around it are the issue with blepharospasm.

However, in blepharospasm patients with associated severe headaches in this area and in severe migraine sufferers I feel the relief of headache is not only relieve of the myofascial pain from these squeezing muscles. It may also be improved by the supraorbital anesthesia from the extripation or injury to the supraorbital nerve which causes loss of sensation in this area. I decompress and sometimes intentionally damage the supraorbital nerve rather than trying to preserve it in severe headache cases. I feel that the loss of sensation from "decompressing" the supraorbital nerve rather than the "decompression" itself is the reason for greater improvement in severe headaches. The ephatic transmission of the facial motor nerve that causes hemifacial spasm has not reported with sensory nerves such as the supraorbital nerve which she questioned.

In summary, I congratulate you for your background research and stimulating questions regarding blepharospasm. In blepharospasm and migraine headaches, I feel a key component is eliminating the action of the corrugator supercilli and depressor supercilliaris muscles in this area. In the headache component, I feel eliminating the pain by "decompressing" or causing supraorbital anesthesia may be of value in some cases. In all of these cases, whether blepharospasm or migraine headaches, raising the eyelids and eyebrows surgically is also key to improvement. In blepharospasm, this helps elevate the eyelids and prevent closure. In headaches and blepharospasm, it helps eliminate using the frontalis and occipitalis muscles as well as the neck muscles from trying to raise the droopy brows and eyelids which causes myofascial pain and migraine headaches. Raising the brows and eyelids is paramount for success in myectomy surgery for blepharospasm or migraine headaches. Removal of the squeezing muscles is also required for blepharospasm patients.

Richard L. Anderson, MD, FACS, Medical Director, Center for Facial Appearances Salt Lake City, UT, and Michael W. Worley, MD, Medical Director, Eyelid & Facial Consultants New Orleans, LA

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