The middle meningeal nerve (nervus spinosus) is a recurrent branch of the mandibular nerve (V3) that re-enters the skull through the foramen spinosum alongside the middle meningeal artery to supply the dura mater of the middle cranial fossa and the mastoid air cells. It provides the principal sensory innervation to the temporal and parietal dura.
The middle meningeal nerve and its branches supplying the temporal and parietal dura are increasingly recognised targets in migraine treatment. CGRP (calcitonin gene-related peptide) released from trigeminal nerve terminals in the dura is the molecular mediator of migraine headache, and the middle meningeal nerve branches are primary sites of this neurogenic inflammation. Middle meningeal artery embolisation for chronic subdural haematoma uses endovascular coils to obliterate the MMA lumen, and incidentally ablates the accompanying middle meningeal nerve fibres. Galcanezumab and other anti-CGRP monoclonal antibodies target this pathway.
Trigeminovascular activation of the middle meningeal nerve branches in the temporal dura releases CGRP and other neuropeptides, producing neurogenic inflammation of the dura perceived as throbbing migraine headache; anti-CGRP antibodies (erenumab, fremanezumab, galcanezumab) targeting this pathway reduce migraine frequency in chronic migraine.
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