Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

Why Do Nerves Take So Long To Recover?

I hear this question a lot from just about every patient I see, whether for chronic headaches or tarsal tunnel syndrome.  The answers have to do with the technical aspects of the surgical procedure, the physiology of peripheral nerves as well as the wound healing process itself.    As you can imagine, a compressed nerve is usually compressed on all sides because it is a three dimensional structure.  Therefore when decompressing a nerve, it has to be manipulated such that the superficial, deep, medial, lateral, cranial and caudal aspects of the nerve can be examined and released if necessary. In addition, there are often multiple compression points (the GON has up to 6 that have been described and often others that are noted intra-operatively).  Moreover, there are times when there is intra-neural scarring (scarring within the nerve, not just around it) which also requires removal.  Hence, there is a fair bit of manipulation usually required (albeit with microneurosurgical techniques) during any decompression procedure.

 

Axon -mediumAs part of the normal wound healing process, there is swelling.  The more neural manipulation required during the operation, the more swelling of the nerve you’re likely to have post-operatively.  I tell my patients to think of nerves as electrical wires, pure and simple.  All they do is conduct electrical signals back and forth, but it is the brain the interprets these signals as ‘hot’, ‘cold’, ‘painful’, ‘ticklish’ etc.  Therefore, if you think about pouring water into the drywall in your house near the electrical wires, it is likely that the lights will start to flicker on and off until the water dries up because the fluid is interfering with the electrical signals.  In the same way, swelling of the nerve can result in all sorts of “unusual firing” of the nerve and is one reason many patients may experience weird, sometimes painful sensations post-op.  However, if the nerves are going to recover, within a few weeks or months when the swelling has subsided, this “unusual firing” abates and the nerves “calm down”.  Just like with cutaneous scars (which also swell as part of the healing process) the time for swelling to decrease is usually longer than a few days or weeks.

 

Another reason why nerves may take a while to recover has to do with the severity and duration of compression.  I’m sure everyone has fallen asleep on their arm(s) at some point in their lives.  Sometimes, when you wake up, your hand is just a little numb and it takes about 10 seconds of shaking your hand to restore normal sensation.  Other times, however, when you wake up the entire arm seems paralyzed, weak and numb!  In these cases, aside from some transient agita, it takes up to 1-2 minutes of shaking the arm out for function and sensation to return fully.  Phew!  The difference between these two situations is that in the latter, the compression of the nerves to the arm has been present for longer and may have been more severe as compared with the former.  Therefore, it takes longer for sensation (and function) to return.  Now take that phenomenon and stretch the timeline out months and often years - that is how long many peoples’ nerves have been compressed.  Therefore, it can take weeks or months for function to return to “normal”.  Also, since the blood flow to the nerves in the latter scenario has been compromised for a longer period of time, they become more engorged with blood after flow is restored and then that extra blood takes time to return to its baseline levels.  It is for this reason that you often experience that sensation of tingling and pain after you remove pressure from the arm and as blood flow resumes. The same thing happens when blood flow is restored after decompression - (more intra-neural blood flow usually combined with more surgical manipulation).  Finally, since we don’t immobilize our heads after surgery (doing so would just stiffen all the joints), the nerves will glide right away after we do all of these things to them and also likely contributes to the recovery process. The take home message is that as patients and physicians, we have to be patient in assessing whether or not decompression has been successful as the final results may not be apparent for many months (as noted by many here).  After all, the same would true of a facelift or breast augmentation.  For more information, visit www.peledmigrainesurgery.com and call 415-751-0583 or 925-933-5700 to setup your appointment!

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Why Are Plastic Surgeons Doing Nerve Surgery?

There have been several comments recently about how it seems strange that plastic surgeons are the leaders in peripheral nerve surgery, specifically as it relates to chronic headaches. Many have wondered why this type of procedure is not performed by neurosurgeons as would seem intuitive. As with any questions, there are often several components to the answers.

First, let me start by saying that I am not a neurosurgeon nor is anything in this post intended to disparage neurosurgeons. Their profession is a difficult and exquisitely complex one, but like many fields within medicine, typically limited to specific areas of focus. While I'm sure that there are neurosurgeons out there who do peripheral nerve work, most those with whom I have interacted and worked focus exclusively on the brain and spinal cord. Indeed, pathology within these two body parts are complex enough and could keep any practitioner busy for the rest of his/her career. Therefore, while nerves exist throughout the body, if you’ve never operated outside of the brain, spinal cord or immediate paraspinal regions repairing a nerve in the forearm would be difficult for a number of reasons. One, the anatomy is foreign and there are many structures which are unfamiliar and can be injured inadvertently resulting in worse pathology. Two, it is well-known that peripheral nerves are distinctly different than nerves within the central nervous system and therefore medical/surgical treatments which may be effective in one area, maybe ineffective in the other. Third, the operation is only a part of the overall treatment of a patient hence a surgeon must be able to manage the expectations of the patient prior to the operation and any complications/issues that might arise post-operatively.  These skills require specific experience with specific procedures (see above).

Second, I should explain why plastic surgeons are uniquely qualified to perform peripheral nerve surgical procedures. Plastic surgeons are known for, among other things, being able to operate on all parts of the body. When we perform reconstructive or aesthetic procedures, we operate everywhere from the head to the feet. As part of our reconstructive training we are taught how to move and mobilize tissue from one part of the body to fill defects created either by surgery or trauma in other parts of the body. We therefore often run into peripheral nerves during these dissections and are familiar with their locations, anatomic variations and surrounding anatomy throughout the body. For example, one main sub-field of plastic surgical training is hand surgery which obviously involves many, very critical nerves. Approximately 50% of all hand surgical procedures performed in this country are performed by plastic surgeons. A few decades ago, several plastic surgeons, a little bit older and far wiser than I, began to ask themselves, ‘If nerves can be manipulated within the upper extremities and hands to relieve pain, provide sensation or restore function, why would it not be possible to perform similar types of procedures in the legs, trunk, head or neck for the same purposes?’ These pioneers adapted the surgical principals they were using in the upper extremities to these other parts of the body and for some it became the focus of their careers. It also soon became apparent that many of the principals that are applied, for example, to release of the median nerve in a patient with carpal tunnel syndrome can be applied to nerves within the foot and ankle in a patient who has tarsal tunnel syndrome. A second-generation of plastic surgeons luckily recognized the potential of these procedures, learned from the prior generation and continued their work. I’d like to also believe that we’ve been able to advance the field by applying established peripheral nerve surgical principles to yet other nerves which were once thought untouchable (e.g. I routinely see patients in my office with meralgia paresthetica who were told they would have to live with their pain forever),  but have now been successfully operated upon.  In addition, we have tools that didn’t exist previously such as biologic nerve allografts and utilize newer techniques such as targeted re-innervation to give amputees relief of pain as well as the potential for use of functional myoelectric prostheses.  In short, peripheral nerve surgery is an exciting and burgeoning field within the larger realm of plastic surgery which will hopefully continue to grow and develop. While other surgeons may be able to perform such procedures, plastic surgeons have been and continue to be some of the pioneers in the field for the reasons noted above.

For more information on how we can help with your nerve related issues, please call us at (415) 751-0583 in San Francisco and (925) 933-5700 to set up an appointment, and visit www.peledmigrainesurgery.com today to read more about us!

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What Are The Long-Term Effects Of Botox?

My name is Dr Ziv Peled. Welcome to the blog for my practice, Peled Migraine Surgery. My work as a Plastic Surgeon at Peled Migraine Surgery.has given me the experience needed to treat nerve and migraine issues here in San Francisco.
Several people have recently asked about the long-term effects of Botox treatment.  Happily or unhappily (depending on your perspective) this will be a relatively short post as very little is known about the long-term effects of repeated Botox injections.  There are likely a number of reasons for this fact. First, keep in mind that Botox is used for many different clinical conditions such as chronic headaches, blepharospasm (spams of the eyelid - the condition for which Botox was first developed and studied), spastic paresis in cerebral palsy and of course for cosmetic reasons. Secondly and because of the first reason, Botox is used in many different doses, places and frequencies making its long-term effects hard to study.  Even for chronic migraines, there are many different treatment algorithms (i.e. dosages and patterns of injection) amongst clinicians using Botox. Third, there are now three FDA approved versions of botulinum toxin type A (Botox® made by Allergan, Dysport® made by Ipsen, and Xeomin® made by Merz) each with slightly different formulations and hence clinical properties.

Botox InjectionOne of the few truly long-term follow-up studies I have found regarding botulinum toxin type A (in this case Botox®) was out of Jordan, Turkey and the University of Cincinnati.  In this study, chart reviews were performed on 32 patients who were being treated for hemi-facial spasm and blepharospasm and had had at least one Botox injection annually for at least 10 years (some patients had been treated for 20 years).  The findings demonstrated a need for a slightly higher dose of Botox to be effective over time and a decrease in the number of adverse effects (i.e. complications) over time. No life-threatening or systemic complications were reported, only localized ones likely relating to the function of the drug at the site of injection. Several other studies with follow-up between 6-15 years have found similar results.  The latter finding is likely a function of greater experience treating patients after many years and improved injection techniques.  The former finding can be related to a number of potential causes.

Prolonged treatment with botulinum toxin type A has been shown to result in the development of neutralizing antibodies which are thought to decrease the efficacy of the toxin.  Risk factors for the development of such antibodies are the formulation of the toxin, the frequency and dosage of the injections and the conditions for which the injections are being used.  Decreased efficacy (and hence the need for higher doses) may also be a reflection of the progressive nature of the disease being treated.  In other words, if the nerves are progressively injured by the disease process, they may require higher doses of Botox for clinical effectiveness. The take home message would be that Botox appears to be relatively safe and effective in long-term use although very few studies have been done to test this concept formally and none with occipital neuralgia.  Therefore, in my hands botulinum toxin type A remains a diagnostic test which, if effective, means that no more botulinum toxin type A needs to be injected - the patient is a candidate for decompression.  After all, in ON we are talking about a mechanical compression of the nerve(s) by a physical structure (muscle, fascia, blood vessels) and no amount of medicine will make that go away.

For more information on the effects of Botox, and how Migraine Surgery can help relieve Migraine symptoms and pain, visit www.peledmigrainesurgery.com today, and call (415) 751-0583 for an appointment.  Contact the author at This email address is being protected from spambots. You need JavaScript enabled to view it..

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WHAT’S THIS TRIGEMINAL NEURALGIA THING?

Several people have recently asked about trigeminal neuralgia (TN) and how it may relate to chronic headaches.  Trigeminal neuralgia is classically thought of as being caused by compression of the trigeminal nerve (root) near the pons (a part of the brain) or the trigeminal sensory ganglion (its sensory component) in the middle cranial fossa (another part of the inner skull) near another part of the brain.  The primary cause of TN is thought to be compression of the trigeminal nerve by an abnormal blood vessel inside the skull.  There is sometimes another term used, trigeminal neuropathy, which usually relates to TN caused by issues other than blood vessel compression such as herpes zoster, post-traumatic pain, or other space occupying lesions such as brain tumors, benign or malignant. Hence this problem is typically thought of as a central nervous system issue.  Again, the central nervous system to doctors simply means brain or spinal cord.

The symptoms of trigeminal neuralgia are very narrowly defined and include severe, unilateral, paroxysmal, electric or stabbing attacks that last a few seconds to a few minutes, in the distribution of one or more divisions of the trigeminal nerve and in the absence of other identifiable neurologic disorders.  In this regard, TN is very much like occipital neuralgia whose symptoms are defined in extremely specific ways.  These two disorders thus stand in sharp contradistinction to other headache disorders like migraines, cluster headaches and tension headaches whose symptoms are often generic, quite varied and hence overlap significantly.  It is for this reason among others that I feel ON and TN are extremely misunderstood and underdiagnosed.

So how does TN relate to headaches?  Well, the trigeminal nerve is the primary sensory nerve to the face, forehead and temporal scalp.  Therefore, injury to this nerve can cause facial pain, or frontal/temporal pain, the latter often perceived as forehead or temporal headaches. The supraorbital, supratrochlear, auriculotemporal and zygomaticotemporal nerves are all branches of the trigeminal nerve. The first two are responsible for sensation to the forehead and above/between the eyes and the latter two for sensation to the anterior and posterior temporal scalp.  Hence compression or irritation of these sensory nerve branches can cause pain in their distributions.  For example, as I have posted before (photos included), the auriculotemporal nerve is often compressed by the adjacent superficial temporal artery.

Hence there can be compression both in the central nervous system as noted above and in the peripheral nervous system as in the example just cited, but both involving the trigeminal nerve.  The former requires a neurosurgeon because in order to access the compressive element (blood vessel or tumor) near the brain, the skull must be cut and the compressive element removed.  This compression usually involves the entire trigeminal nerve or a large part thereof. The latter doesn’t require anything be done to the skull and is performed on the tissues (e.g. nerves, blood vessels, connective tissue) external to it, addressing one or more trigeminal nerve branches. Therefore, I believe the more precise term for compression/irritation of these peripheral nerves should be trigeminal branch neuralgia and it is these compression syndromes that I and Drs. Guyuron, Ducic, Hagan, Janis, etc. treat with our decompression procedures.

One last point: several people have wondered whether these peripheral nerve decompression procedures are “minimally invasive” and the answer is, “It’s all relative”.  I guess compared with using a saw to remove part of the skull and exposing the brain and other nerve roots, the answer is yes. That type of procedure is done in a hospital and often requires a multi-day hospital stay.  However, even though the peripheral nerve decompression procedures noted above are outpatient cases and are performed at accredited surgery centers, they are real operations and are not to be taken lightly.  They require skill and experience as the nerves are quite small peripherally.  They require general anesthesia because the patient must be positioned carefully and be perfectly still because the nerves are so small. And they require incisions, so compared with an MRI or trigger point injection, they are invasive.  Having said that, like the procedures for ON, they can be very effective with relatively low complication rates and risks.

For more information about peripheral nerve surgery, and migraine surgery in San Francisco, CA, visit www.peledmigrainesurgery.com today, and call 415-751-0583 to schedule an appointment.

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When Migraines Strike In San Francisco, Can Outpatient Surgery Help?

My name is Dr Ziv Peled. Welcome to the blog for my practice, Peled Migraine Surgery. I live in San Francisco, CA and work as an Plastic Surgeon at Peled Migraine Surgery. Contact the author at This email address is being protected from spambots. You need JavaScript enabled to view it.

When migraines strike, the first thought in many San Francisco residents' minds is "ouch".  After that, they think "medication".  But is medication really the answer to severe headache pain?  While some medication can help alleviate the pain of a migraine in some patients, sometimes they don’t work, they often require chronic use, and sometimes they only work for a short time and then stop working altogether.  When conservative modalities have failed, as they do for many, there is another option.  Peripheral nerve surgery has been clinically proven, when performed by a board-certified plastic surgeon with experience in such procedures, to reduce pain and change people's lives, potentially permanently.  

Axon -mediumLiving with chronic, severe headache pain can be a nightmare, and peripheral nerve surgery can help.  But what is a "peripheral nerve"?  A peripheral nerve simply refers to a nerve outside of the brain and spinal cord.  These nerves, and the surrounding tissue, can become inflamed, causing intense pain.  Such pain is not that different from the pain experienced by someone who steps on a tack with their big toe.  The nerves in the toe become activated and send pain signals back to the brain. If a peripheral nerve in the head/neck is activated because of compression or inflammation those same pain signals may develop and can be a source of migraines.  When it is determined that this is the issue, the problem can be alleviated with a surgical procedure that decompresses the nerve in the hopes of reducing those signals. Recent research has demonstrated that just like at the wrist, there are nerves within the head and neck that are compressed and that decompressing them, can produce significant or even complete relief that can be permanent.

I have been performing peripheral nerve surgery all over the body in San Francisco for a number of years.   My practice now includes many former chronic headache patients who suffered from nerve compression very similar to that which I had been treating for years in the trunk, arms and legs.  I have operated on several hundred nerves in the head/neck and my very positive results with these patients has validated my choice to help people stricken with migraines and other forms of chronic headaches.  I firmly believe that peripheral nerve surgery can help people living with this condition live a more normal life, with significantly reduced or possibly no headache pain.  The gratitude expressed by these patients is the reason that I became a physician in the first place, and I hope that every physician feels the same way I do every day when I come into the office.

For more information about peripheral nerve surgery, and migraine surgery in San Francisco, CA, visit www.peledmigrainesurgery.com today, and call 415-751-0583 to schedule an appointment.

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Whiplash and Occipital Neuralgia: What’s The CONNECTION?

My name is Dr Ziv Peled. Welcome to the blog for my practice, Peled Migraine Surgery. I live in San Francisco, CA and work as an Plastic Surgeon at Peled Migraine Surgery.
I have been asked recently about the relationship between whiplash and occipital neuralgia.  First of all, what is whiplash?  Simply put, it is a sudden jerking of the head, usually in a backward/forward direction or sometimes side to side.  Common causes of whiplash include motor vehicle accidents, sports related injuries and any other violent motions such a shaking a baby too hard or even a big roller coaster ride.  Motor vehicle accidents are by far the most common cause with an estimated incidence of over 1,000,000/year although the true number is hard to gauge since many cases of whiplash are not reported. In 2008, the total estimated cost to the healthcare system of whiplash injury was over 40 billion dollars!

 

headache - mediumOne of the most common sequelae (consequences) of whiplash is chronic neck pain/headaches. Why do these symptoms occur?  Likely, because the nuchal muscles will suddenly tighten as the head is rocked violently and the soft structures that pass through and around these muscles are affected. Nerves are like wet noodles - they are soft and pliable, but the neck muscles and fascia that covers these muscles is tough and tight to begin with to allow stabilization and efficient mobilization of those bowling balls we call our heads. If you think about the force it would take to tear a wet noodle, you get a sense for how easy it could be to injure an occipital nerve.

However, as many out there can attest the work up of these patients is often negative.  Why is that?  The answer lies in what I believe to be the underlying cause of this chronic pain/headache which is a traction (i.e. stretch) injury to the occipital nerves.  Even with high resolution MRIs (see previous post on why the MRI may be negative), the relatively small occipital nerves (greater, lesser and third) are hard to image accurately.  Therefore, a negative MRI may rule out an injury to the nuchal ligaments, bones, and/or muscles, but it cannot rule out a small tear to already tiny nerve(s).  Moreover, since the above-mentioned occipital nerves are purely sensory (i.e. they don’t move any muscles, only provide sensation to the scalp and back of the ears), the primary symptoms tend to be pain which cannot be objectively measured with a CT scan/MRI or blood test.  Since many practitioners don’t recognize the impact of a traction injury to these sensory nerves, management is often empirical.

For these reasons and others, patients are often treated with a combination of pharmacologic agents, PT, chiropractic manipulation, cervical collars, etc.  Certainly many patients do get better with these conservative modalities, but given the sheer numbers we are talking about, many thousands do not.  However, if you believe as I do that the issue may be a tear within a small nerve causing intra-neural scarring, or a small tear within a muscle surrounding that nerve that causes subsequent scarring and narrowing of the canals through which these nerves usually pass (hence compression), then the above-mentioned modalities will not work for obvious reasons.  If there is mechanical compression on a nerve, that compression must be physically and precisely removed or permanent damage may occur.  The take home message is that when all other potential causes of chronic neck pain/headaches post-whiplash have been ruled out, think of occipital neuralgia as a possible cause.  A consultation with an experienced peripheral nerve surgeon should then follow and ON ruled out as a possible cause.  The good news is that if ON is felt to be the culprit, there are safe and effective procedures that can provide significant relief.

For more straight talk about how surgery can help you, contact Peled Migraine Surgery at 415-751-0583 and visit www.peledmigrainesurgery.com today.  Reach the author at This email address is being protected from spambots. You need JavaScript enabled to view it.

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WHAT TO LOOK FOR WHEN CHOOSING A “HEADACHE SURGEON”

My name is Dr Ziv Peled. Welcome to the home page for my practice, Peled Migraine Surgery.: www.peledmigrainesurgery.com I live in San Francisco, CA and work as an Plastic Surgeon at Peled Migraine Surgery.

1. One of the first things to assess is whether your surgeon has significant and specific training in peripheral nerve surgery. Since the operations for chronic headaches/neuralgia potentially involve many nerves within the peripheral nervous system, the person performing such operations should have had focused training on the workup, evaluation and management of patients with any number of peripheral nerve problems (chronic headaches included). Because peripheral nerve surgery is performed on all parts of the body (e.g. arms, legs, trunk and head), your surgeon should ideally have experience and training with many of these types of nerve procedures because they provide the procedural foundation now employed in the operations designed for chronic headaches. A sample question that a patient might ask is what percentage of the surgeon’s practice is focused on peripheral nerve surgery. Dr. Peled has operated upon numerous patients involving many nerves in the forehead, temple and occipital regions with great success. Approximately 60% of his practice is devoted solely to peripheral nerve surgery.

 

2. Another important thing to ask your surgeon is how many of these procedures they have performed. In addition to the specific number of cases s/he has performed, the surgeon should also have experience with the wide breadth of peripheral nerves that are known to be potential causes of chronic, severe headaches. These include nerves within the forehead, temple and occipital regions.

3. Is your surgeon a member of the American Society for Peripheral Nerve (ASPN)? This society is the leading academic society for peripheral nerve surgeons. Its mission is to stimulate and encourage study and research in the field of neural regeneration, to provide a forum for the presentation of the latest research and relevant clinical information and to serve as a unifying authority on all areas of neural regeneration and restorative neuroscience. In order to become a member there are a number of qualifications that a surgeon must meet.  For example, a candidate has to be nominated by two of their peripheral nerve surgical peers and have published at least one scholarly, peer-reviewed paper on some aspect of peripheral nerve surgery. Looking for ASPN membership can serve as an objective vetting factor in deciding between several surgeons.  It also demonstrates a true commitment to the study of peripheral nerve problems and a genuine interest in advancing the field. Look for the ASPN logo on your surgeon’s website or communication forms. Dr. Peled has been a member of this Society for several years and has published several papers about various aspects of peripheral nerve surgery.  He is also currently involved in additional studies to advance the field which will hopefully be published in the near future.

4. Your surgeon should also be able to provide you with references for the type of procedure(s) he or she is recommending.  Not only does this give you the chance to speak with someone who has gone through what you will likely experience, it demonstrates that the surgeon has actually performed the procedure at least once before.

5. Finally, you should choose a surgeon with whom you have the best rapport.  This is the hardest concept to describe or discern.  While there are so few of us who perform these operations, realize that there still may be several qualified surgeons technically capable of performing the right operation for the correct indications.  However, just like every patient is different, so too is every surgeon.  Is their office staff professional and pleasant?  Does the doctor answer your questions in a manner that you can understand and make you feel at ease that they understand your particular situation?  Do they spend time actually listening to you and your symptoms?  Are they realistic in setting your expectations for what will happen before, during and after your procedure?  These factors can make the difference between simply a good outcome and a good outcome with a good experience along the way.

For more straight talk about how surgery can help you, contact Peled Migraine Surgery at 415-751-0583 and visit www.peledmigrainesurgery.com today.

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WHY DOES IT HURT SO MUCH AFTER THE INJECTION?!?

WHY DOES IT HURT SO MUCH AFTER THE INJECTION?!?

I’ve heard from so many people over the years who consistently tell me that they had worse pain AFTER their injections - whether it is Botox, a local anesthetic (such as is used in nerve blocks) and/or steroids. Remarkably, despite numerous queries to their treating clinicians, their physicians have never had a good answer for them as to why this problem happens. Actually, the answers are quite simple. Worse pain after injections such as those done to diagnose ON can occur for several reasons.

One reason is that the injections done for ON are performed within muscle. Injections into muscle cause a little muscle inflammation/swelling no matter what you inject (even saline) and this inflammation causes discomfort. Anyone who has ever had a tetanus shot into the shoulder muscle (deltoid) knows exactly what I’m talking about. Their shoulder can be sore for 7-10 days afterwards. Fortunately, the discomfort is temporary and only lasts a few hours or days as the inflammation/swelling subsides.

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Neuroma 101

Neuroma 101

First of all, what is a neuroma? A neuroma can be defined in one of two ways. One, as a tumor composed of nerve tissue such as an acoustic neuroma. Almost overwhelmingly, these tumors are benign. The more common usage of the term neuroma means a mass of nerve tissue consisting of regenerating nerve fibers that have been previously severed or injured somehow. When a nerve is injured, it tries to re-grow - that’s what nerves do. If that nerve re-grows into the scar at the skin, it can cause exquisite pain even with light touch in the area. This situation would be akin to having a cavity (which hurts because the nerve at the root of the tooth is exposed) and eating ice cream - ouch! So if a nerve is severed or injured in some other way, how do you prevent a neuroma from occurring?

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Medication Overuse Headache (MOH) or ‘Rebound Headaches”

Medication Overuse Headache (MOH) or ‘Rebound Headaches”

I have been asked recently to write a little something about so-called “rebound headaches”.  This topic can be quite confusing, and as you will read, is not very well understood.  The precise medical term for this disorder is Medication Overuse Headache (MOH) or analgesic rebound headache.  The prevalence of this problem is about 1% in the general population and as with many types of headaches, is higher in women than in men.  The underlying mechanisms for MOH are unknown, but as with many medical problems, are oftentimes multifactorial.  It is known that there can be a genetic predisposition to MOH.   In addition, long-term exposure to opiates is known to cause changes in the nervous system through increased expression of specific cytokines (chemicals, e.g. Calcitonin Gene-Related Peptide) and increased activity of certain neural pathways felt to modulate the sensation of pain.  Some people also feel that addictive personality disorders are associated with MOH. Interestingly, migraines are the thought to be the most common “primary headache disorder” that has been linked to MOH. The bad news is that just about any medication used to treat chronic headaches has the potential to lead to MOH.

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BLOCKS & STIMULATORS & DECOMPRESSION, OH MY?!?

BLOCKS & STIMULATORS & DECOMPRESSION, OH MY?!?

I’ve noted that there has been some confusion lately over the roles of nerve blocks, nerve stimulators and nerve decompression in the treatment of chronic headaches. To be sure, there will be variations in how each clinician may use these modalities, if only because each patient presents a unique clinical dilemma.  While I certainly can't speak to the ways in which others utilize these modalities, I can offer general guidelines as to how I use them in my practice.  Hopefully this information will also provide some insight into the advantages and disadvantages of each.

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HOW MANY HEADACHES IS TOO MANY?

HOW MANY HEADACHES IS TOO MANY?

Over the past year or so, I’ve noticed that many patients are being told by their other treating “headache doctors” that they shouldn’t consider surgery for their problem because their headaches are “not bad enough”.   Patients are often so struck by these remarks that many wonder whether this statement represents actual medical fact and repeat it to me as if it were empirically true. They then ask me if I agree with that concept.  My answer is always the same, “The only person who can say whether the pain you’re having is too much, is YOU.”

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What If I Still Have Headaches?

What If I Still Have Headaches?

Over the years, as I have operated on more and more patients with chronic headaches, my impression of this problem has changed somewhat. Time and again, I would see patients who had severe, frequent, long-lasting headaches who underwent surgery with me and did extremely well. Their headache frequency, severity and duration decreased significantly after their procedure and they were extremely happy.  However, many patients still experienced severe headaches from time to time and the question that was posed to be on many occasions was, "What does it mean that I still have some severe headaches after surgery?" As I have talked with numerous such patients on many occasions and drilled down on their remaining symptoms and their treatment of these symptoms, an interesting observation occurred to me.

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Restoring Anatomy and Nerve Regeneration

As awareness of “migraine surgery” increases, I have often been confronted by the question of whether the nerves that are involved need to be cut for the procedure to be effective. The answer to this question is “sometimes”, but let me elaborate in the next few sentences. There generally seems to be two perspectives on how to deal with "smaller" sensory nerves, in other words those with relatively small areas of sensory distribution. One approach would postulate that cutting the nerve oftentimes leaves a small area of numbness which is easily tolerated or is not even appreciated by the patient and therefore is a relatively good trade-off for relief of pain. Another perspective is that if the nerve is viable as noted during surgery, then leaving it intact will hopefully allow good relief of pain and preservation of sensation. Each of these approaches has its advantages and its disadvantages. Cutting the nerve can lead to immediate relief, but often leaves a noticeable area of numbness. Leaving the nerve intact requires the nerve to heal, recover and/or regenerate from the compression/irritation which was present as the cause for the surgical procedure. This process often requires several months depending on the longevity and severity of the compression/irritation, but if successful should lead to decreased pain and a preservation of some degree of sensitivity. Both procedures carry a small risk that nerve recovery will not occur and pain may persist. In the case of a cut nerve, the proximal (upstream) nerve end may remain persistently sensitive thus leading to a "phantom limb" type of sensation despite numbness in the former area of distribution. In the case of a decompressed nerve, the nerve may not regenerate again leading to persistent discomfort. Moreover, both procedures carry a small risk of neuroma formation although I personally believe that this risk is slightly less when nerves are left intact as compared to when they are cut.

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Peled Migraine Surgery Helps Eliminate Walnut Creek Migraines!

Migraine headaches have traditionally been thought to begin within the central nervous system (i.e. the brain and/or spinal cord) and then produce symptoms elsewhere such as throbbing in the back of the head, forehead or temples. There are many theories as to what exactly within the central nervous system is causing these chronic and often debilitating headaches. Some of these theories include pathologic blood vessel dilatation and constriction (loosening and tightening), abnormal firing of neurons within the brain, and abnormalities of various biologic substances (e.g. serotonin, calcitonin gene-related peptide). The fact that no one theory has been proven correct is likely one of the many reasons that there are so many different methods for the treatment of chronic headaches like migraines. In fact, from a medication standpoint alone, there are dozens of medications and medication classes used to treat migraines.

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Pain in the Neck - Understanding Occipital Nerve Compression Treatment

As the surgical treatment of migraine headache evolves, plastic surgeons are learning that this modality actually represents a series of procedures designed to relieve pressure on specific peripheral nerves throughout the head and neck.

Occipital neuralgia or cervicalgia relates to occipital-generated headaches that stem from the greater (C2) and least (C3) occipital nerves. The occipital trigger sites are the most common trigger points of headache pain.

All patients presenting with chronic daily headaches should be evaluated by a neurologist or primary care physician who is familiar with International Headache Society guidelines for these disorders. Once this evaluation is complete, a thorough history focused on identifying peripheral nerve compression should be performed. The history should quantify the subjective complaints of pain by using the Migraine Disability Assessment Tool (MIDAS) or other reliable instruments such as the migraine headache index (MHI). Once the severity of disability has been stratified, it is important to ask where the pain consistently starts and radiates, whether there is a history of trauma such as whiplash, and if there are any previous cervical surgery/pathology and/or any other issues specific to the occipital region.

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The Difference Between Cervicogenic Headaches and ON - Is There One?

I recently read a comment from a patient asking a very interesting question - “What is the difference between occipital neuralgia (ON) and cervicogenic headaches (CH)?”

Unfortunately the answer to this question is not a straightforward one. It has been postulated that pain in the head/neck region can be referred from problems in the bony or soft tissues of the neck, but there is still some controversy as to whether cervicogenic headache constitutes a distinct clinical entity. The upper-most cervical nerves and their branches are the most commonly cited sources of CH with the most common source being the C2/C3 levels. The actual definition of cervicogenic headaches is also not firmly established. One accepted way of defining this disorder is by its clinical characteristics. Specifically, it is a unilateral pain of variable severity that is not stabbing and radiates from posterior to anterior. It doesn’t shift from side to side, is brought on by unusual head position or neck motion and may be associated with shoulder or upper extremity pain on the same side. The biggest issue with this definition is that it overlaps with many of the characteristics of other headache disorders such as tension headaches and migraines without aura. Another way of defining CH is by demonstrating a cervical source of pain and confirming that source with a nerve block.

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Is it true that because I’ve had RFA to my occipital nerves, that I’m not a candidate for surgery?

This statement represents a common misconception. First of all, let’s define ‘RFA’ or radiofrequency ablation. Simply put, this treatment modality uses radio waves at a high frequency to ablate a structure, in this case a nerve. The term ‘ablation’ actually means to surgically remove a body part or organ, but since RFA is performed with probes through the skin (i.e. percutaneously) it essentially means to destroy the nerve. The probe tip is hopefully placed close enough to the nerve in one or more places such that when the radio waves are passed through it, the tip heats up and completely destroys the nerve which theoretically should be equivalent to surgically excising the nerve.

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Can Botox Cure My Chronic Headaches?

Can Botox Cure My Chronic Headaches?

Many potential chronic headache patients have asked if they are not surgical candidates because they have not responded to Botox® in the past. The answer is, “Not necessarily.” and the reason is because it depends on how and in what doses the Botox was used. The primary way in which Botox® is used by most neurologists and pain management physicians is based upon the PREEMPT protocol (see attached). It calls for using 155 units over 31 injection sites every three months in an effort to reduce the symptoms associated with chronic migraine headaches. There are several problems with this approach. 

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What To Look For When Choosing A Migraine Surgeon

What To Look For When Choosing A Migraine Surgeon

Dr. Ziv Peled explains how to choose a peripheral nerve surgeon, what qualifications to look for and how to decide who is the best fit for you!

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