Supraorbital Nerve Decompression for the Treatment of Chronic Refractory Migraine

Background: Chronic migraine is a leading cause of disability worldwide, and many patients remain refractory to pharmacologic and behavioral therapies. Decompression of the supraorbital and supratrochlear branches of the ophthalmic division of the trigeminal nerve—often termed frontal trigger site or site I surgery—has emerged as a potential treatment for selected patients with medically refractory frontal migraine. Methods: We report the case of a 73-year-old man with a 10-year history of chronic refractory migraine localized to the left forehead and periorbital region following remote blunt trauma to the brow. Despite multiple preventive and abortive therapies, his symptoms persisted. A targeted left supraorbital and supratrochlear nerve block produced complete but temporary relief, supporting a peripheral entrapment etiology and referral for surgical evaluation. To contextualize this case, we performed a structured literature review of supraorbital and supratrochlear nerve decompression for chronic headache. Results: The patient underwent decompression of the left supraorbital and supratrochlear nerves. He experienced near-immediate and sustained relief of his frontal pain and near-complete resolution of migraine exacerbations. The literature, including anatomic studies, retrospective cohorts, a randomized sham-controlled trial, multiple long-term follow-up series, and systematic reviews with meta-analysis, demonstrates significant reductions in migraine frequency, intensity, and duration. Reported success rates range from 68% to 100%, with complete symptom elimination in 8% to 86% of patients. Complications are uncommon and generally limited to transient paresthesia and dysesthesia. Conclusions: In appropriately selected patients with chronic intractable migraine with focal frontal trigger sites, positive diagnostic nerve block, and refractory disease, supraorbital and supratrochlear nerve decompression can produce durable and sometimes complete relief of chronic migraine.