Peled Migraine Surgery Blog

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 not only dozens of medications used to treat migraines, but dozens of classes of medications such as triptans, anti-depressants, muscle relaxants, blood pressure medications, narcotics, anesthetics, ergotamines, and so on. Fortunately, a different perspective on chronic headaches has produced remarkable results that have been previously unheard of.

This different school of thought suggests that peripheral nerve irritation (i.e. irritation of nerves outside of the brain and spinal cord such as those within the scalp or forehead) can cause irritation within the central nervous system thus leading to the perception of and symptoms of a headache. If this mechanism were in fact the culprit, then identifying and correcting the cause of such irritation could produce relief from the headache symptoms. Plastic surgeons have been doing exactly that with a common nerve irritation problem known as carpal tunnel syndrome. In this syndrome, a nerve within the wrist is compressed (i.e. pinched) and surgeons decompress (i.e. un-pinch) it thereby relieving the symptoms of pain with a greater than 90% success rate. 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.

Peled Migraine Surgery of San Francisco has emerged as a leader in the development of peripheral nerve surgery as a migraine relief technique. Ziv M. Peled, MD* is a Board-Certified plastic surgeon trained to perform the full spectrum of aesthetic and reconstructive plastic surgical procedures. He completed his medical school training at the University of Connecticut School of Medicine where he earned honors in multiple surgical disciplines. He subsequently completed four years of rigorous general surgical training at the University of Connecticut during which he also completed an additional two-year, post-doctoral Basic Science Research Fellowship at Stanford University under the tutelage of Dr. Michael T. Longaker, a pioneer in the field of scarless wound healing. During that time, Dr. Peled not only helped establish Dr. Longaker’s laboratory at Stanford, but was also awarded a 5-year NIH grant for his work in keloid biology and scarless wound repair. Ziv then completed a prestigious and highly sought-after plastic surgical residency at Harvard University. While there, he was awarded an “Excellence in Teaching” award from the Harvard medical students. Dr. Peled continued to hone his specialty skills with an additional year of training in peripheral nerve surgery at the Dellon Institute for Peripheral Nerve and Plastic Surgery. He is Board-Certified by the American Board of Plastic Surgery, which means that he graduated from an accredited medical school, completed numerous years of residency training, and successfully passed a series of comprehensive written and oral examinations. The American Board of Plastic Surgery is one of only a select few specialty boards recognized by the American Board of Medical Specialties (ABMS) and is the only ABMS board which certifies candidates in the specialty of plastic surgery of the entire body. Dr. Peled is also a member of the California Society of Plastic Surgeons and the American Society of Peripheral Nerve PN) - the leading society of peripheral nerve surgeons.

In addition to his cosmetic and reconstructive work, Dr. Peled helped to found a perpiheral nerve surgery institute here in San Francisco. In that institute, he served as Director and Chief Plastic & Peripheral Nerve Surgeon. His specific training enables him to perform a unique set of surgical procedures designed specifically to restore sensation and minimize/eliminate pain in patients suffering from migraines as well as neuropathy due to diabetes, chemotherapy and thyroid disorders. He has also treated many patients with various forms of nerve trauma as well as many other types of nerve disorders. Dr. Peled has authored and co-authored over 40 manuscripts and book chapters on all aspects of plastic surgery and has presented his work at numerous national meetings. He has performed several hundred peripheral nerve procedures of various kinds. Ziv is an Active Member of the American Society of Plastic Surgeons and was also recently elected as a member of the American Society for Peripheral Nerve. This honor recognizes and highlights Dr. Peled's breadth of work with peripheral nerve patients suffering from migraines and diabetes as well as his published work on peripheral nerve surgery.

Visit http://peledmigrainesurgery.com today for more information, and to make an appointment to relieve your migraines.

Los Angeles is home to just under 4 million people. Since 18% of women and 6% of men suffer from debilitating migraines, this means that almost 720,000 women and 240,000 men suffer from the headaches. Where can these people turn to for treatment of migraines?

Up the coast in San Francisco, Dr. Ziv Peled specializes in migraine and headache surgery, giving Californians an opportunity for migraine relief. Dr. Peled uses peripheral nerve surgery to relieve the tension around the nerves that are causing the migraines.

Surgical decompression for chronic headaches is performed as an outpatient procedure at an accredited surgery center or in the outpatient department of the California Pacific Medical Center. The procedures can last anywhere from 1 hour to 3 hours depending on the number and locations of the nerves being treated. There are few restrictions following the procedure and discomfort is usually very well tolerated with oral pain medication. 

As an outpatient surgery, you can come to our San Francisco offices or we can perform the surgery at a center near you. You can be back home that night, well on your way to recovery from your migraines. Dr. Peled has performed hundreds of these procedures. Our testimonials page is filled with patients thanking Dr. Peled for changing their lives for the better.

If you are in Los Angeles, Rancho Palos Verdes, Pacific Palisades, Burbank, Alhambra, Carson, Glendale, Hawthorne, Inglewood, Lancaster, Pasadena, Pomona, Santa Clarita, Santa Monica, West Covina, or any of the surrounding areas and are suffering from migraines, we can help.

Call Dr. Peled today at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about how peripheral nerve surgery can help you with your headaches. Headache surgery in Los Angeles can be a phone call away.

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 not only dozens of medications used to treat migraines, but dozens of classes of medications such as triptans, anti-depressants, muscle relaxants, blood pressure medications, narcotics, anesthetics, ergotamines, and so on. Fortunately, a different perspective on chronic headaches has produced remarkable results that have been previously unheard of.

This different school of thought suggests that peripheral nerve irritation (i.e. irritation of nerves outside of the brain and spinal cord such as those within the scalp or forehead) can cause irritation within the central nervous system thus leading to the perception of and symptoms of a headache. If this mechanism were in fact the culprit, then identifying and correcting the cause of such irritation could produce relief from the headache symptoms. Plastic surgeons have been doing exactly that with a common nerve irritation problem known as carpal tunnel syndrome. In this syndrome, a nerve within the wrist is compressed (i.e. pinched) and surgeons decompress (i.e. un-pinch) it thereby relieving the symptoms of pain with a greater than 90% success rate. 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.

Peled Migraine Surgery of San Francisco has emerged as a leader in the development of peripheral nerve surgery as a migraine relief technique.  Ziv M. Peled, MD* is a Board-Certified plastic surgeon trained to perform the full spectrum of aesthetic and reconstructive plastic surgical procedures. He completed his medical school training at the University of Connecticut School of Medicine where he earned honors in multiple surgical disciplines. He subsequently completed four years of rigorous general surgical training at the University of Connecticut during which he also completed an additional two-year, post-doctoral Basic Science Research Fellowship at Stanford University under the tutelage of Dr. Michael T. Longaker, a pioneer in the field of scarless wound healing. During that time, Dr. Peled not only helped establish Dr. Longaker’s laboratory at Stanford, but was also awarded a 5-year NIH grant for his work in keloid biology and scarless wound repair. Ziv then completed a prestigious and highly sought-after plastic surgical residency at Harvard University. While there, he was awarded an “Excellence in Teaching” award from the Harvard medical students. Dr. Peled continued to hone his specialty skills with an additional year of training in peripheral nerve surgery at the Dellon Institute for Peripheral Nerve and Plastic Surgery. He is Board-Certified by the American Board of Plastic Surgery, which means that he graduated from an accredited medical school, completed numerous years of residency training, and successfully passed a series of comprehensive written and oral examinations. The American Board of Plastic Surgery is one of only a select few specialty boards recognized by the American Board of Medical Specialties (ABMS) and is the only ABMS board which certifies candidates in the specialty of plastic surgery of the entire body. Dr. Peled is also a member of the California Society of Plastic Surgeons and the American Society of Peripheral Nerve PN) - the leading society of peripheral nerve surgeons.

In addition to his cosmetic and reconstructive work, Dr. Peled helped to found a perpiheral nerve surgery institute here in San Francisco. In that institute, he served as Director and Chief Plastic & Peripheral Nerve Surgeon. His specific training enables him to perform a unique set of surgical procedures designed specifically to restore sensation and minimize/eliminate pain in patients suffering from migraines as well as neuropathy due to diabetes, chemotherapy and thyroid disorders.  He has also treated many patients with various forms of nerve trauma as well as many other types of nerve disorders. Dr. Peled has authored and co-authored over 40 manuscripts and book chapters on all aspects of plastic surgery and has presented his work at numerous national meetings. He has performed several hundred peripheral nerve procedures of various kinds.  Ziv is an Active Member of the American Society of Plastic Surgeons and was also recently elected as a member of the American Society for Peripheral Nerve. This honor recognizes and highlights Dr. Peled's breadth of work with peripheral nerve patients suffering from migraines and diabetes as well as his published work on peripheral nerve surgery.

Visit http://peledmigrainesurgery.com today for more information, and to make an appointment to relieve your migraines.  

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.
Pain by definition is a subjective experience. There is no objective way to measure it such as with a blood test or an MRI. This fact represents one of the biggest challenges in treating people with pain. Moreover, what I've gleaned is that it's not only the actual episodes of pain that often constitute the greatest burden to people. Many times it is the constant lifestyle adjustments and manipulations often required to stave off the onset of pain that are the most difficult for people to manage. Patients often have to avoid social situations they'd like to be in, avoid foods they love to eat, and avoid activities they used to love participating in. To add insult to injury, I've also been informed by patients that their other headache doctors told them that they would terminate them as patients if they undergo surgical decompression.
I find such statements quite sad because they often leave patients very conflicted perhaps due to the fact that this other doctor has provided some measure of relief that they are afraid they will lose if they pursue other options. It also goes against my general opinion of how chronic headache pain (and all chronic pain for that matter) should be managed. I believe that a multi-modality approach that yields the best results. Just like in breast cancer treatment during which a patient often has surgery to remove the cancer with a breast surgeon, chemotherapy/hormone therapy with a medical oncologist and radiation treatment with a radiation oncologist. Only when these physicians work together do patients derive the optimal benefit.
Who then is anyone else to say how much any individual person should suffer? I believe that the role of the physician in these cases should be to establish a diagnosis if possible and formulate a treatment plan to address the pathology in question if possible often in combination with other clinicians. The physician should then educate the patient about his/her diagnosis and the possible treatment options. Patients must then decide for themselves based upon an evaluation of the potential risks and benefits of the proposed treatments which treatment options are best for them. The take home message - don't let anyone else make a value judgment for you. They can't.

I saw an interesting question posted today – something to the effect of, ‘If you have nerve decompression and/or transection, shouldn’t you feel immediate relief?” This question is a very important one, but the answer may not be intuitively obvious. The nervous system is truly complex and often quite difficult even for medical professionals to understand. Therefore, in an effort to explain why it can often take many months before a patient experiences the hoped for improvement, I’ll use an analogy to which many people can hopefully relate.

Most everyone has at some point, had the experience of falling asleep on their arm and waking up with slightly numb fingers. Upon waking, you notice the altered sensation in the fingers, shake them out and within a few seconds, sensation returns to normal. Many people have also had the experience of waking up after having fallen asleep on their arm for a longer time, getting up and realizing that they not only have very numb fingers, but also that they have difficulty moving their elbow, wrist and/or fingers very well. “Oh my gosh, did I just have a stroke?!?”, often comes to mind. In this scenario, you try to shake out the arm as best you can and it often takes a few minutes before things start to move again and sensation returns to the digits. Moreover, once the blood starts flowing again and sensation begins to recover, there is often a period of hypersensitivity before things settle down.

The difference in these two scenarios is the degree of pressure and the duration of pressure on the nerves in the upper extremity, obviously worse in the second scenario. Given the overall greater amount of pressure in this second scenario where you’ve probably slept on your arm for a few hours, it takes longer for the nerves to recover. Now take this second scenario and stretch it out much longer. In other words, let’s assume you’ve had pressure on your upper extremity for several years? Would the nerves be expected to recover in a few hours or days following decompression? Given what we know from the above examples, the answer is, ‘Probably not’. Recovery in these cases can take many months. The situation with neurectomy is a little bit different in mechanism, but the same in practicality. When you transect a nerve proximal (i.e. upstream) from an injured segment, you now have a “live” nerve end that you bury within the local muscle. However, doing so is not the same as turning off a fuse to an outlet with a short where the sparks stop immediately. Remember that this nerve is still attached to the spinal cord and therefore the brain, so impulses will still travel back and forth to that “live” end. However, with time, that sensory nerve end will likely make connections with other motor nerves within the muscle and in effect this “fools” that sensory nerve into thinking that it has found its downstream counterpart. You now have a sensory nerve connected to a motor nerve, a situation in which the impulses travel as they normally would, but have no effect on the muscle since the muscle only responds to motor nerve impulses. It would be like me having written this post in Sanskrit (which hopefully nobody reading this post understands). You might recognize it as writing, but it would make no sense and therefore would elicit no reaction. That being said, this process takes time which is the reason that relief following neurectomy with muscle implantation is often not immediate. The take home message is that recovery from any nerve operation is a process, not a moment in time. Hopefully that helps.

I was asked by a member of this forum to comment on the concept of atlantoaxial instability (AAI) and how it might relate to symptoms of ON. This is an interesting question, but one that is important as it has relevance for patients with a number of clinical conditions such as Ehlers-Danlos Syndrome (EDS – which is not known to be associated with AAI) or those with rheumatoid arthritis (RA – which has been associated with AAI). I also promise to try to minimize the alphabet soup of abbreviations in an effort to avoid confusion.

First of all, what is AAI? Briefly, AAI results from osseous or ligamentous pathology between the two cranial-most vertebrae (spinal column bones) – the atlas (i.e. C1) and the axis (i.e. C2). This instability can result in too much or abnormal movement between the bones and soft tissues surrounding these two structures. AAI can happen secondary to a traumatic event, degeneration due to an infectious or inflammatory insult (e.g. rheumatoid arthritis) and/or a congenital abnormality such as Down Syndrome. When there is excessive or unusual movement of the atlas on the axis a number of problems can occur. The vertebrae can impinge directly on the spinal cord thereby resulting in neurologic manifestations. Compression of the nerve roots as they emerge from the spinal column in also a possibility as is neural pathology more peripherally as will be mentioned below. The good news is that AAI is quite uncommon in patients without any pre-disposing factors.

While the most common presenting symptom is non-descript neck discomfort and/or headache, these symptoms are quite non-specific. Appropriate imaging along with neurosurgical evaluation if pathology is discovered in patients, especially those who have predisposing risk factors are therefore warranted. Fortunately, almost all of the patients I see in my practice have already these evaluations and have come up without a diagnosis of AAI and remain unclear as to the cause of their pain. So how does any of this information relate to ON?

Well, as you can imagine, if you have abnormal or excessive motion at the bony level, it may result in undue traction on the overlying soft tissues which can certainly include the peripheral nerves. As I’ve mentioned in a previous blog post about whiplash and occipital neuralgia about two years ago, (http://peledmigrainesurgery.com/blog/entry/whiplash-and-occipital-neuralgia-what-s-the-connection.html) traction on peripheral nerves can lead to microscopic and in some cases macroscopic tears of the nerve itself which, in turn, can result in outright neuroma formation or cause scarring around the nerve. This scarring that can result in mechanical neural compression or limitation of motion and further traction injury. Similarly, in EDS, the same excessive motion can result from overall laxity in ligamentous structures. Please keep in mind that I am not a neurosurgeon or an orthopedic spine surgeon and this blog post should not take the place of a trained neurology, ortho spine or neurosurgical evaluation. That being said, from what little I’ve read and do know, the take home message is that when you have neck pain and/or headaches, it is unlikely to be AAI in most patients. As always, a good work up and exclusion of other causative factors is important, but if despite that, everyone is left scratching their heads, ON may just be the culprit.

The title of this post is really the $60,000 question. I have posted many times in the past about how Occipital Neuralgia can be caused by compression from spastic neck muscles, compression by tight connective tissue (i.e. fascia) and/or compression from surrounding blood vessels. Many of the patients I see have had headaches ever since they can remember. However, there are just as many for whom the headaches began seemingly spontaneously one day. The question for these folks remains: What happened? Why now?

There have been recent articles that hint at possible answers to these questions and they may surprise you. I have attached a link to one of the more interesting ones as part of this post. One of the most surprising comments contained therein was that craning the neck downward only 60º puts as much as 60 pounds of pressure on the cervical spine and neck muscles. With that kind of pressure, you can imagine that nerves (among other structures) would be compressed. So the explanation as to why you might all of a sudden develop ON can almost be summed up in one word - overuse. This explanation is one of the potential causes of carpal tunnel syndrome, the most common compression neuropathy recognized (even by neurologists). Why could that not be the case for ON. Nerves are very susceptible to chronic compression (see post - ‘What Causes Occipital Nerves to Malfunction’) even if intermittent. The occipital nerves take very circuitous routes through all of the nuchal soft tissues. When you add to that fact the constant motion of our necks that require the nerves to glide constantly and then compound those factors with an additional 60 pounds of added pressure, there are many things that may occur to those nerves.

One, they may simply get kinked as they make their way through the neck to the scalp. Not a week goes by when I don’t see a patient in the office who, in describing their headaches contorts their head to recapitulate their symptoms and when they get it just right, it’s like a thunderbolt of pain. Two, even if not kinked, the pressure will compress the vasa nervorum - the microscopic blood vessels within the nerves themselves that supply blood to those nerves. After numerous episodes of compression, especially if for prolonged periods, these blood vessels can clot and the nerves become ischemic (i.e. choked). The neurons that comprise that nerve then die off and try to regenerate causing the hyperesthetic symptoms so typical of ON. Three, even if the nerves recover from each successive insult, the additive microtrauma will likely result in some inflammation and the subsequent formation of scar tissue in the surrounding structures, thus closing off already tight corridors through which these nerves must pass - another compressive force. While no one has demonstrated these possibilities in real time, I see the sequelae of them in the OR weekly.

So what to do we do? Good posture, stretching and avoidance of triggering activities seem to make common sense. In addition, as many of you know and as intimated in the article, steroids seem to be the mainstay of treatment amongst some practitioners, but as also stated, the effects are often not permanent. The reason is obvious - the compressive forces remain, even if inflammation is temporarily suppressed. Therefore, I continue to believe that decompression (or neurectomy & implantation for permanently injured nerves) are reasonable options as they are safe and effective. Moreover, they address the underlying problem, the mechanical compression of these poor nerves caused by our ever more technologically demanding lifestyles. So next time you pick up your smartphone, remember to pick up your head as well.  

Dr. Peled appeared on Tri-County news to discuss migraine surgery and how it can help people with their chronic headaches and migraine pain.

Dr. Peled covers the definition of migraines, signs that you have a migraine, and ways to deal with the pain along with the surgical options. 

Botulinum toxin has been used for quite some time to manage chronic migraines, specifically as a preventative agent. Like any treatment modality, the possibility for variable results exists. Certainly some people have had great results with treatment, but many have not. Very recently people have asked what their results with this treatment modality mean. Unfortunately, the answer is not straightforward for a number of reasons that I will delineate below.   Please keep in mind that these thoughts/opinions are general comments and not meant to be interpreted as specific to any particular patient’s situation. You will have to have a discussion with your treating physician as to how to interpret your specific results.

Botlinum toxin is most commonly used according to what’s known as the PREEMPT protocol. Briefly, this protocol calls for 31 injections for a total of approximately 155 units of botulinum toxin with some modifications allowed at the discretion of the treating physician. The PREEMPT protocol has been discussed in a number of journal articles, including a major article published back in 2010 in the journal Headache. In this study, patients were given either injections of botulinum toxin or placebo (both patients and physicians were blinded as to what was being given) and then followed for a total of 24 weeks. Botlinum toxin was injected at time 0 and again at 12 weeks with the final endpoint metrics assessed at 24 weeks. The authors demonstrate statistically significant differences in migraine and headache frequency (among other metrics) during the treatment period, in those patients receiving botulinum toxin as compared with placebo-treated patients. They conclude that botulinum toxin is a useful treatment modality for prevention of migraine headaches. So why doesn’t everyone use it? In my opinion, I believe there are a couple of very relevant criticisms of this study and the conclusions you can draw from it.

First, while clearly disclosed on the title page, the authors of this study are either employees of, have received research dollars from, or are paid consultants for the company that makes the specific form of botulinum toxin used; certainly a potential a conflict of interest although one that doesn’t necessarily invalidate the data presented. Second, while the data are somewhat obtuse and I am certainly no mathematician, if my calculations are correct (and I have redone them several times just to check) the patients in the Botox arm of the study had about 5 fewer headache days in about 6 months compared with those that were injected with placebo. If I told you as a patient that I would poke you with a needle 62 times over two visits and that if you were lucky and responded, you would have 5 fewer headache days in 6 months, would that be worth it? Perhaps and it’s better than nothing, but this result is hardly the wow factor many clinicians make it out to be. Second, let’s play devil’s advocate and say that a huge number of Botox patients had a complete response and had no headaches for the entire 24 weeks. My question to them would be: ‘Which of the 31 injections you got in each round was responsible for the great results?’ The answer would be impossible to give because botulinum toxin doesn’t work right away (it takes several days to become effective) and you got all 31 injections at the same time. So do you really need 31 injections or just 21, or perhaps just 5? You would have no idea. Third and going along with this line of thinking, if you had a great result with Botox, the presumption would be that you would need to continue with this type of therapy in perpetuity - not such a great proposition if you’ve got 40 years of injections to look forward to. I have also wondered what would happen to the neck muscles if they were constantly relaxed by botulinum toxin. Would they atrophy and weaken over time and if so, how would that affect your posture and your ability to lift your head? I don’t know the answer, but I would not want to find out on myself. The take home message is that you should have an open and honest discussion with your treating clinician about what you/they hope to accomplish with the results of any treatment you select along with the potential risks and benefits. Hope that helps.

For more information on headaches and headache relief, visit www.peledmigrainesurgery.com or call 415-751-0583 to make an appointment.

This post is a rather long one, but an important one nonetheless in my humble opinion. Over the years that I have been performing headache surgery, I have heard from so many patients that they are frustrated with their current treating physicians because their symptoms are not under control to the degree that they would like. Anyone who has been on these forums for a few hours has certainly run into a post or several posts describing a bad patient-physician interaction or a bad patient-health system interaction. To all of those people - I completely empathize and you have every right to feel as you do. Having been a patient on several occasions myself, I know what it’s like to speak with a physician or an insurance adjustor and feel like you are talking to the clouds. It is very frustrating and can often leave you feeling helpless – and I’m a surgeon. As a peripheral nerve surgeon, especially one that operates on people with chronic, intractable headaches, I have often heard criticisms from other practitioners whom I don’t feel even understand what it is that I do. However, in those situations I often find myself trying to put myself into the shoes of the doctor across from me. What I have found is that there is always common ground to be had somewhere and that understanding their perspective can help me find it. In addition, since we are (or should be) on the same side, I have found that viewing things from a team perspective is particularly and practically very helpful.

Breast cancer is sadly a disease that touches too many people throughout the world. Over the past few decades, the medical profession has made incredible strides in fighting this dreaded disease and we now have cancer remission rates that were once thought impossible. One of the biggest factors in helping this development along has been the team approach. In our community, a patient with a new breast cancer diagnosis is immediately given a team of physicians and clinicians to help them navigate the process that is dealing with this pathology. To be sure, there is a “captain of the ship”, usually the breast surgeon or oncoplastic surgeon who is coordinating all of the moving parts, but every member of the team is critical to ensuring success. While the breast surgeon may remove the cancer physically, there is often a plastic surgeon to help reconstruct the resultant defect, a radiation oncologist who will help ensure that any disease that might have spread locally is controlled and a medical oncologist who will determine if the risk of distant disease is high enough to warrant a regimen of chemotherapy or hormonal therapy, There is also often a psychologist and nurse navigator who can help the patient deal emotionally and psychologically with the fear often accompanying a cancer diagnosis. Only when you put all of these components together, do you get the wonderful results that modern medicine has been able to achieve.   If you think about it, the same team principles apply to a football team (American football as well as soccer), a dance troupe or a team of scientists working to find a cure for something. So what the heck does this diatribe have to do with headache surgery?

Well, for years I have been saying to my patients that hopefully someday soon, we will realize that chronic pain should be best treated with a multi-modality approach as with breast cancer. Chronic headaches are a form of chronic pain. There are certainly many patients for whom medical management works very well. Those people do not need any injections or surgical intervention. There are those for whom pharmacologic agents are simply ineffective and in those cases, nerve decompression may be a good option. However, for most, a combination of therapies is necessary to control the underlying symptoms. I have heard from countless patients who tell me that prior to surgery their medication (say Imitrex) was inconsistently helpful. “I could flip a coin” they would tell me, take it early in the middle or late in a headache attack, but they could never figure out why sometimes it was effective and sometimes not. Following surgery, their headache attacks are much less frequent and often much less severe, but what was interesting to me was that they would tell me that when they would get an attack, the Imitrex was almost always effective. “Why is that?” they would ask. Well….it is likely that they have two problems contributing to their headache symptom complex. One is a chemical imbalance that medication would treat, and the other is a mechanical compression of the nerve(s). Pre-operatively, when you had a headache, you reached for what you had which was Imitrex, but if it was the mechanical compression that was irritating the nerve that day, you didn’t get any better. If it was the chemical imbalance aggravating the nerve, you did get better. Post-operatively, the mechanical compression has been relieved so the headache frequency and severity are much less, but there are still headaches. However, now when you take the Imitrex, lo and behold it almost always works, because it is actually treating the underlying chemical imbalance that is causing those residual symptoms. The take home message is that patients still often need to have those pain management physicians and neurologists involved to manage those medicines so that their symptoms remain under optimal control. Those that have seen me know that I often like to communicate with the very same such doctors prior to surgery to ensure we can optimize the post-operative recovery period which certainly can have its share of ups and downs. In the end, we all have to partner in this endeavor together as a team.

I was recently invited to attend a meeting on the use of multimodality therapy to decrease the use of opioids in the US population.  Unless you’ve been away on a remote island for a long time or completely eschew any sort of media including newspapers and TV, you’ve probably heard that we have a problem with opioid use in this country.  I knew the numbers were bad, but frankly I came away from this meeting completely floored. Here are some statistics that should make you pause and take notice:

Pain Physician. 2012; 15(3 suppl):ES9-ES38.

Carroll I, et al, A pilot study of the determinants of longitudinal opioid use after surgery. Anesth Analg. 2102; 115(3): 694-702.  NIH, National Institute on Drug Abuse. Prescription and over-the-counter medications. Drug Facts. Revised Nov 2015. http://www.drugabuse.gov/publications/drugfacts/prescription-over-the-countermedications. Accessed 08/24/16.

Wang M, et al. Predictors of 12-month opioid use after elective cervical spine surgery for degenerative changes [abstract]. Spine. 2103; 13(suppl): S6-S7.

Manchikanti L, et al. Opioid epidemic in the United States. Pain Physician. 2012; 15(3 suppl): ES9-ES38.  Office of National Drug Control Policy. 2013 Drug overdose mortality data announced: prescription opioid deaths level; heroin-related deaths rise[press release]. 01/12/15. http://www.whitehouse.gov/ondcp/news-releases/2013-mortality-data. Accessed 08/24/16.

Busch S, et al. Abuse of prescription medication risks heroin use. Infographic created for: National Institute on Drug Abuse. http://www.drugabuse.gov/related-topics/trends-statistics/infographics/abuse-prescription-pain-medication-risks-heroin-use. Accessed 08/24/16.

Obviously, given the scope of the problem, you might suspect that there is no one or easy answer and you would be correct.  There is plenty of blame to go around on all sides of this major issue, but that also means there may be many avenues from which to address the problem. The people in the conference today are at the forefront of this epidemic and have a number of interesting ideas and strategies as to how to begin to tackle this problem.  Stay tuned….

An interesting thought occurred to me the other day as I was finishing up a particular headache surgical procedure.   Something that has come up over the years is that patients tell me that their headaches are worse when they are sick with the cold, flu or some other such issue. I have been pondering why this symptom change might be taking place for a long time. As with many of my blog posts, there are several possible causes for this phenomenon in my opinion and so I have decided to delineate these possibilities below.

One reason is that people who are sick are often more stressed either because of or as a cause of their illness. It is considered reasonable that stress, of whatever type, can weaken the immune system and thus mitigate the body’s ability to fight various pathogens. These pathogens can cause all manner of irritation and inflammation in various tissues such as muscles hence the muscle discomfort with the flu, for example. If one type of tissue is irritated, the surrounding tissues might suffer the same fate. In addition, when we are stressed, our blood pressure often rises. Since many of the nerves which we address during our operations are compressed by surrounding blood vessels, it follows that when these vessels beat harder (i.e. during a period of relative hypertension) the nerves which are already irritated may become even more so. But another, third thing happens during an infectious scenario, one to which most people can also relate. Have you ever felt your neck when you feel you have a sore throat or the sniffles? If so, you have probably noticed that the lymph nodes in the area are swollen and often tender. That is because these lymph nodes are the factories for pathogen-fighting cells and they ramp up production (hence swell) when you are sick. As I was dissecting this person’s greater occipital and lesser occipital nerves, I noticed several enlarged lymph nodes located within the already crowded spaces through which these nerves passed. Bear in mind that we don’t operate on people who are sick so these nodes were particularly enlarged given that fact alone. The nodes were further compressing these poor nerves which were already pressured by the surrounding blood vessels and scarred connective tissue. I could only imagine what occurs to these nerves if that person were to contract the flu. Those nodes would surely swell, sometimes quite dramatically and place even further pressure in the area causing even further pain. With pain comes higher blood pressure, hence more compression and so begins the upward spiral. One recurring question from patients is, “What is compressing my nerves?” The answer used to be possibly spastic muscle, tight/scarred connective tissue, enlarged or aberrant blood vessels. It now also includes abnormally large and/or poorly localized lymph nodes. Happily these nodes can be removed carefully and selectively to further relieve pressure during a decompression procedure and many of the patients in whom this lymph node removal was necessary have gone on to do quite well. Finally, none of the nodes which I have biopsied to date have revealed any evidence for malignancy or other pathology, further happily capping a saga that has resulted in many positive outcomes.

So if you suffer from headaches, please visit us at www.peledmigrainesurgery.com or call us at 415-751-0583 and 925-933-5700 to setup an appointment to find out if we can reduce or eliminate your migraines. We look forward to hearing from you!

Surgery for chronic headaches in California is here.  People often call me from cities outside of San Francisco wondering if we can help them.  Happily, many times if they need it, I can help them, no matter where they come from! We have seen patients from all across the United States, and as far away as Brazil, New Zealand and Finland. Since chronic headaches occur in every part of the world, we are excited to help people in even further-flung areas and want to extend an invitation to everyone in California and abroad that we may be able to help reduce or eliminate their “migraines”with peripheral nerve surgery.

I have successfully performed many of these operations using my knowledge and experience in peripheral nerve surgery to ease the pain caused by compressed, irritated or injured nerves in the head that can lead to the excruciating “migraines” that people have been forced to live with for many years. My practice has developed a system to help with travel and lodging  and to ensure that each patient has as seamless an experience as possible.  We have also developed protocols utilizing Skype to confer with patients to discuss the potential for these often life-changing procedures. 

I also firmly believe that care doesn’t end with the surgical procedure. Of course, we do everything we can to ensure that the operation itself is successful, but continue a dialogue with patients often lasting many months following their procedures. While we ourselves cannot be everywhere, the ability to speak with and interact with your surgeon is important to deal with any issues that might arise during the post-operative and recovery phases. While these times can be challenging, our practice has refined the process to ask the right questions and determine if any further action is needed.  With Peled Plastic surgery, you won't be left on your own after your operation.

So if you suffer from chronic headaches or “migraines”, please visit us at www.peledmigrainesurgery.com or call us at 415-751-0583 and 925-933-5700 to set up an appointment to find out if we can reduce or eliminate your symptoms. We look forward to hearing from you!

Los Angeles is home to just under 4 million people. Since 18% of women and 6% of men suffer from debilitating migraines, this means that almost 720,000 women and 240,000 men suffer from the headaches. Where can these people turn to for treatment of migraines?

Up the coast in San Francisco, Dr. Ziv Peled specializes in migraine and headache surgery, giving Californians an opportunity for migraine relief. Dr. Peled uses peripheral nerve surgery to relieve the tension around the nerves that are causing the migraines.

Surgical decompression for chronic headaches is performed as an outpatient procedure at an accredited surgery center or in the outpatient department of the California Pacific Medical Center. The procedures can last anywhere from 1 hour to 3 hours depending on the number and locations of the nerves being treated. There are few restrictions following the procedure and discomfort is usually very well tolerated with oral pain medication. 

As an outpatient surgery, you can come to our San Francisco offices or we can perform the surgery at a center near you. You can be back home that night, well on your way to recovery from your migraines. Dr. Peled has performed hundreds of these procedures. Our testimonials page is filled with patients thanking Dr. Peled for changing their lives for the better.

If you are in Los Angeles, Rancho Palos Verdes, Pacific Palisades, Burbank, Alhambra, Carson, Glendale, Hawthorne, Inglewood, Lancaster, Pasadena, Pomona, Santa Clarita, Santa Monica, West Covina, or any of the surrounding areas and are suffering from migraines, we can help.

Call Dr. Peled today at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about how peripheral nerve surgery can help you with your headaches. Headache surgery in Los Angeles can be a phone call away.

We are asked quite a bit whether we will see patients from Los Angeles for migraine surgery, or if we’ll see out-of-town patients as well. Of course we do!  Anyone may be able to achieve significant and lasting relief no matter where they call home! We have helped patients from all across the United States, and as far away as India and Brazil. We are excited to help people from all over the globe as peripheral nerve surgery is an area to which I have dedicated a large portion of my practice and is something about which I remain very passionate. We wish to extend an invitation to everyone anywhere to look us up and decide for themselves whether we might be able to help to reduce or eliminate their chronic headaches with peripheral nerve surgery.

I have performed hundreds of decompression procedures on nerves for chronic headaches with high success rates. Many of these people had been living with their headaches for decades and had resigned themselves to a life of chronic pain despite medication. Happily, we proved that was not the case. Furthermore, because we see so many foreign and out of town patients, we have developed a system to help make your overall experience as seamless as possible. We can assist with travel planning, lodging, transportation to and from the operating room and even post-operative nursing care if required. In addition, Dr. Peled is available for initial record review and evaluations via Skype or Google+ to help determine if a trip from home is a worthwhile endeavor. Finally, because post-operative follow-up is an extremely important part of the surgical experience and critical to achieving optimal outcomes, we use these same modalities to keep tabs on our patients after they have gone home and remain available to discuss issues with your local treating physicians if needed. This important time can be hard for patients as well as doctors that can't see their patients directly, but our practice has refined this process to ask the right questions and determine if any further action is needed.

So if you suffer from chronic headaches, please visit us at www.peledmigrainesurgery.com or call us at 415-751-0583 or 925-933-5700 to find out if we can reduce or eliminate your migraines. We look forward to hearing from you!

Dr. Ziv M. Peled, M.D. was recently a lecturer, injector and surgical trainer at the largest plastic surgery meeting in the world. Plastic Surgery The Meeting 2016, held in Los Angeles, CA in September and sponsored by the American Society of Plastic Surgeons, is the premier meeting for plastic surgeons globally. Dr. Peled gave four talks in two sessions over two days on subjects ranging from occipital nerve surgery to coding for headache surgery. The talks were well received and are likely to be repeated in future meetings and to include an expanded curriculum on additional aspects of this exciting treatment option for chronic headaches refractory to conventional therapy.

For more information on how headache surgery can help reduce your "migraine" symptoms, visit www.peledmigrainesurgery.com or call 415-751-0583 to schedule an appointment with Dr. Peled.

What exactly is meant by the term, ‘peripheral nerve surgery’? Peripheral nerve surgery specifically refers to operations performed on nerves within the peripheral nervous system, in other words those nerves located outside of the brain and spinal cord (aka the central nervous system). It also helps to think of these nerves as being located in the periphery of the body such as the arms and legs although it also includes nerves located in trunk and scalp/face regions. Pathology causing problems within the peripheral nervous system can take many forms. There can be pressure on a nerve as it passes through its normal route from the brain and spinal cord to its final location, for example at the toes or back of the scalp. There may be pressure on a nerve from a tumor within the nerve itself or from a tumor external to the nerve. A nerve may have been cut from a prior accident or prior surgical procedure. There can also be injuries to nerves that have been excessively stretched such as may occur following a whiplash-type of injury.

The procedures performed on these peripheral nerves ultimately depend upon the pathology in question. If there is external pressure on the nerves causing irritation, this external pressure is relieved. An example of this type of procedure is that performed during a nerve decompression to treat chronic headaches. If there is a tumor within the nerve, it can often be removed and the nerve preserved or in other cases reconstructed to preserve sensation and function.   If a nerve has been cut, it may be able to be repaired surgically.

Plastic surgeons with peripheral nerve experience have been performing peripheral nerve surgery for years to correct a common and well-known malady known as carpal tunnel syndrome, where the surrounding tissue pinches the one of the main nerves at the wrist. These surgeons decompress or un-pinch the nerve by adjusting the tissue surrounding it, leaving the nerve intact. This procedure has a very high success rate. 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 from chronic headaches that can be permanent. The results with these latter procedures have been quite dramatic. In one study out of Georgetown University, data from 190 patients with chronic pain/headaches in the back of the head who underwent surgical decompression were analyzed. One year after surgery, the patients were evaluated and over 80% of patients reported at least 50% pain relief and over 43% of patients experienced complete relief of their headaches! In February 2011, the five-year results of such procedures were published in the medical journal, Plastic and Reconstructive Surgery. This study demonstrated that five years following their headache operation, 88% of patients were still reporting greater than 50% improvement in their headache symptoms and 29% were completely headache-free!

To find out more about these exciting developments, please visit http://peledmigrainesurgery.com or call us at (415)751-0583 to schedule a formal consultation.

How long does recovery take following nerve decompression surgery for chronic headaches? The answer to that question can be quite variable and depends on a number of parameters, but a few general principles apply.

How long does recovery take following nerve decompression surgery for chronic headaches? The answer to that question can be quite variable and depends on a number of parameters, but a few general principles apply. First and foremost, each patient is different in terms of their tolerance for discomfort. What may be a 9 out of 10 pain to one person may only be a 5 out of 10 pain to another person. Secondly, the number/distribution of the nerves which are decompressed is also unique to each individual. Obviously, if someone has 8 nerves decompressed in one procedure they are likely to have more discomfort than someone who only had one nerve decompressed. Finally, surgical technique and appropriate post-operative care are also important in achieving optimal results with minimal discomfort and downtime.

Generally speaking, most patients have mild-to-moderate discomfort following surgery. Pain medication and anti-nausea medication are prescribed to help patients manage these symptoms in the first few days-weeks following their procedure. The comment I hear most often from patients describing the first few weeks following their operation is that the chronic headache-type pain that they’ve always had is now gone, but that they now have discomfort at the site of the operation, which is expected. After a few weeks, this incisional discomfort diminishes and patients really start to feel great. I just saw a patient today who was 3 weeks post-decompression of both greater occipital nerves and the left lesser occipital nerve. She used to have severe headaches often lasting hours and even several days at a time and which would come on every other or every day. Over the intervening 3 weeks, she only reported 3 minor headaches which lasted a few minutes. Her surgical pain had diminished to a point where she had not required any narcotic medication after the 5 day following her procedure. Now that her incisional discomfort was at a minimum, she stated that she felt like a new person. The only restriction following her operation was avoiding strenuous exercise for 3-4 weeks. After that, her activity level can gradually be increased to its baseline level over a period of another 2-3 weeks. Patients may eat and drink whatever they like immediately following surgery and can shower in 48 hours. This type of response is fairly typical among my patient population. There are almost never any sutures to remove as they are all dissolvable. After a few weeks, a new you!

To find out more about peripheral nerve surgery and how it may help your migraines, please visit http://peledmigrainesurgery.comor call us at (415)751-0583 to schedule a formal consultation.

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.

Diagnostic criteria for CH have been established by the Cervicogenic Headache International Study Group (CHISG) and by the International Headache Society (IHS). The former’s criteria require signs or symptoms brought on by awkward head movements or positioning or by pressure over the occipital nuchal structures and possibly confirmed by anesthetic blockade. The IHS criteria mandate that the pain be referred from an identifiable and plausible source in the head/neck (as demonstrated on imaging such as MRI) or by successful blockade of a nerve or cervical structure. Moreover, the pain must resolve within 90 days of successful treatment of the underlying problem. However, the IHS criteria do not define when, where, and how much pain is caused by CH (i.e. the clinical features).

In contrast, most neurologists would define ON in a very specific way. The classic description is that of paroxysmal pain in the distribution of the occipital nerves, sometimes, but not always accompanied by changes in skin sensation in the back of the scalp. The symptoms of ON are also thought to have a character of burning or hypersensitivity that may be constant on top of the intermittent shooting pains described above. These symptoms should be temporarily relieved by occipital nerve blocks.

So what to do with all of this information? Unfortunately, I find these definitions and descriptions minimally helpful since many of the symptoms of ON and other headache disorders for that matter can overlap with those of CH. For example, many of my patients with ON who have been successfully treated with decompression had exacerbation of their pain with awkward head positions and motions because these positions further compressed and irritated the occipital nerves. There are many patients who have unilateral ON. Therefore is ON a subset of CH? From my reading of the literature, most neurologists would seem to disagree, but I am uncertain as to why. Is CH a distinct clinical disorder? As stated above, there is disagreement as to whether it is versus just a descriptor of where the pain is coming from.

All of which brings me to the take home message. When it comes to any disorder, but especially chronic headaches, the only relevant questions in my humble opinion are: 1) can you figure out what’s causing it and 2) if you can, can you do anything about it? You can call the headache whatever you like - migraines without aura, CH, George - the names are irrelevant. With that in mind, I believe that the literature has shown that accurate diagnosis of ON with nerve blocks or Botox is a good predictor of a good result with surgical decompression. Moreover, surgical decompression has been shown to be very effective and have a very low complication rate with good long term results.

I was recently asked an interesting question: “If you have bad posture and have a decompression procedure, won’t the results eventually diminish as the bad posture would re-injure the nerves?” There was actually a recent, non-scientific article in a different publication (http://gizmodo.com/my-smartphone-gave-me-a-painful-neurological-condition-1711422212) which suggested that posture secondary to cell phone use was a factor in the development of ON in some people.  As you might suspect, I don’t know of anyone who would argue with the concept that good posture is important for any number of reasons.  However, can it cause ON to recur after an adequate decompression procedure?  Not likely.

As the article above suggests, even a little flexion or extension in the neck can lead to significant increases in pressure on the nuchal structures.  The reason is that many of these structures, such as the nerves, pass through very small spaces on their way to the scalp.  When those spaces which are tight to begin with are narrowed even just a little bit, the increase in pressure on the nerve can be dramatic.  However, it is not the bending or as to the point here, the bad posture that causes the neuralgia, it is the tight space becoming tighter.  When these narrow spaces are opened up, the reverse is also true - the pressure on the nerves can dramatically decrease.  The two pictures of the greater occipital nerve below illustrate the concept (warning- not for the easily grossed out).

                           BEFORE                                                                     AFTER

In the picture on the left, you can see the greater occipital nerve (long arrow) bulging out of the semispinalis muscle (short arrow) - a well-described compression point for this nerve. After removal of a small amount of said muscle (the upper and lower edges of which are denoted by the limbs of the “V”) you can see the GON more clearly.  What is also dramatic is that the nerve appears much smaller even though the picture on the right is at slightly higher magnification.  This all happens within a few minutes in the OR.  Anyone who has ever tied a rubber band tightly around the base of their finger for a minute and had a nice purple digit knows exactly what happens when the rubber band is released. The key here is balance.  As a surgeon I want to make enough space so that the nerve can now move freely with almost any position or posture, but not so much space that I remove too much muscle and cause some imbalance or weakness.  Moreover, when patients move their heads post-operatively, which I insist my patients do gently right away, the gliding prevents significant scar formation and re-narrowing of these spaces. Hence, if done correctly, persistent poor posture following decompression should not cause the ON to return. Hope that helps.

For more information, or to make an appointment, call Peled Migraine Surgery at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about migraine relief through surgery.