Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Radiologic Evaluation of Exiting Points of Supraorbital Region Neurovascular Bundles in Patients With Migraine Helen Buciog˘lu, MD,  O ¨ zlem Elvan, PhD, y Kaan Esen, MD, z Gu ¨lhan Temel, PhD, § Nevra O ¨ ksu ¨z, MD, ô Gu ¨lcan Go ¨c ¸mez Yilmaz, MD, ô Cengiz O ¨ zcan, MD,  and Mesut Sabri Tezer, MD jj Purpose: To reveal the presence and nature of exiting points of supraorbital region neurovascular structures and determine the distances of those structures to midline with computed tomography images by taking into account gender and sides in patients with migraine. Methods: The study was conducted retrospectively on computed tomography images of 70 migraine and 70 control patients with a mean age of 39.5  13.8 years (range: 18 – 80). Presence and nature (foramen or notch) of exiting points of neurovascular structures in terms of side and gender in both groups, and the distances of these structures to the midline of the face were evaluated. Results: In migraine and control groups, the most commonly seen structure was single notch. Coexistence of foramen and notch was statistically significant in migraine and female migraine groups than control and female control groups (P < 0.05). Bilateral presence of supraorbital structure was 51.4% in migraine group and 64.3% in control group patients. In all cases, foramen-midline distance was statistically significant longer than the notch-midline distance (P < 0.05). In migraine patients, no statistically significant difference was detected regarding distances of foramen and notch to midline in terms of side and gender. Conclusion: Consideration of variable presence and location of the supraorbital notch and foramen, analysis of computed tomography scan might be beneficial in preoperative planning of foraminotomy and fascial band release in adult migraine patients to prevent intraoperative complications. Also, coexistence is more frequent on left side in migraine patients that might cause overlooking those structures during surgery. Key Words: Coexistence, computed tomography, foramen, headache, migraine surgery, notch, supraorbital region (J Craniofac Surg 2019;30: 2198–2201) A ccording to the declaration of International Headache Society in January 2018; primary headaches are classified in 4 groups as migraine, tension type headache, trigeminal autonomic cephal- gia, and other primary headache disorders. Headache is reported as the 3rd most common disorder in the world in 2010 Global Disease Burden study. 1 Migraine, which is thought affect 959 million people in the world, is the most disturbing headache disorder in population levels. 2,3 Migraine headache management and treatment include pharma- cologic and nonpharmacologic approaches. Nonpharmacologic approaches include cognitive behavioral therapy, relaxation tech- niques, and other options such as biofeedback. Pharmacologic approaches are divided into symptomatic and preventative treat- ments. Symptomatic treatment goal is to prevent an attack, whereas prophylactic treatments main objective is to reduce attack fre- quency and severity by modifying the disease. Today, pharmaco- logic options are more commonly used for the treatment of migraines. 4,5 However, in some of the migraine variants, such as chronic migraine, those pharmacologic approaches can be insuffi- cient or the disease can become resistant to therapy. 5 Following some of the surgical esthetic procedures applied on frontal region and Botox injections to pericranial muscles, it has been asserted that migraine symptoms might get resolved 6,7 and migraine attack frequency and severity has significantly reduced. 8–10 When the common ground of those 2 different potential treatment modalities effects was reviewed, it was theorized that glabellar muscle groups might actually cause irritation in supraorbital and supratrochlear nerves. 7 This theory was tested by a prospective pilot study in 2002 which included patients who were diagnosed with migraine by a neurologist that used International Headache Society criteria and responded to botox treatment. 11 Those prospective results confirmed the results of previous retrospective studies and supported the idea of nerve decompression can prevent migraine headache triggering. 6,11–19 A throughout knowledge of supraorbital region neurovascular structure exiting points topography is essential for supraorbital and supratrochlear nerve decompression. 13,17,20,21 If nerves pass through a foramen, foraminotomy is performed whereas if the nerves pass through a notch, fascial bands are released. 6,13,22 Therefore; this study was designed to assess the properties and frequency of supraorbital region neurovascular structure exit points according to gender and side using computerized tomography (CT) for providing detailed and reliable information to guide the sur- geons during supraorbital region surgery in patients with migraine. METHODS The study was conducted retrospectively on computed tomography images of 70 patients with mean age of 42.7  12.5 years (range: 18 – 80) diagnosed with migraine, and 70 patients with mean age of 36.4  14.4 years (range: 18–73) as a control who had cerebral, maxillofacial, and/or temporal bone CT images in Mersin Univer- sity Faculty of Medicine archives. The study was approved by Mersin University Clinical Studies Ethics Committee (2017/290). From the  Department of Otorhinolaryngology, School of Medicine; y School of Health; z Department of Radiology, School of Medicine; § Department of Biostatistics; ô Department of Neurology, School of Medicine, Mersin University, Mersin; and jj Oral and Maxillofacial Surgery Department, Faculty of Medicine, Istanbul University, Istanbul, Turkey. Received March 13, 2019. Accepted for publication May 30, 2019. Address correspondence and reprint requests to O ¨ zlem Elvan, PhD, School of Health, Mersin University, C ¸ iftlikko ¨y Campus, Yenis ¸ehir, 33343 Mersin, Turkey; E-mail: ozlemelvan33@gmail.com Supplemental digital contents are available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jcraniofacialsurgery.com). The authors report no conflicts of interest. Copyright # 2019 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000005751 CLINICAL STUDY 2198 The Journal of Craniofacial Surgery  Volume 30, Number 7, October 2019