Reduction in severity and frequency of migraines following such forehead rejuvenation procedures has been an unexpected finding, confirmed by both retrospective and prospective studies.

The reason for such outcomes is still being debated. The most popular hypothesis suggests that prolonged contraction of over-active corrugators lead to nerve compartment syndrome of the supratrochlear nerve, a branch of the trigeminal nerve. This in turn causes some degree of nerve ischaemia with consequent release of neuro-peptides from the nerve fibres causing neurogenic inflammation of the nerve and meninges.

The importance of the trigeminal nerve as a component of the pathogenic pathway for migraine headaches, has been studied for many years but its role in migraine genesis has not been identified until recently.

Some clinical researchers advocate surgical intervention for migraine prophylaxis, if the patients have a good response to Botox injections. We follow a strict case-selection protocol for these patients. They are assessed to exclude organic causes for the headaches; usually requiring a neurologist's consultation. The patients are then required to keep a log-book for one month prior to commencing treatment. The log books are used to identify the site, severity and frequency of headaches prior to trial treatment with Botox. Log-book keeping is repeated after the first treatment.

If patients respond well to this then they are offered the option of continuing with Botox or permanently ablating the relevant muscles or nerves. These surgical manoeuvres aim to produce minimal functional or cosmetic morbidity.

Dr Sanjay Parishar offers this surgical migraine service to patients with debilitating migraines that are not controlled with simple analgesia.