Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.


Real Patient Stories: Shirley

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What is your name?

 Shirley Jaeger

Where are you from?

 Brisbane, Australia

What was happening in your life before the headaches became chronic?

 I worked as a nurse for many years which eventually caused neck pain. I had a neck operation to alleviate the pain where they replaced the disc between C3/C4 with a metal cage.

How long ago was that?

 The neck operation was here, in Australia, March 2014. The operation left me with chronic pain above my left eye.

Describe a good day with chronic pain.

 5 on a scale of 10, but good days are rare.

Describe a bad day. What does/did the pain feel like?

 10 on a scale of 10, which included bad migraine symptoms.

Where did you experience the pain?

 At the supraorbital notch, near the middle of my left eyebrow, radiating out into most of my head.

What meds were you taking?

 I was unable to take opioid derivatives as I am allergic. I tried six other prescription drugs but they offered no relief and/or made me feel sick. A low dose of Gabapentin I could take, but still got very little relief.

Did you have any success with other pain relief methods besides medication?

 I received 10 Botox injections, on two separate visits, without success. I tried expensive, medical-grade cannabis oil--working up to a high dose--without any effect at all. For 6 months, I wore the Cefaly Tens head electrodes approximately 4 hours per day with no relief. I also tried handheld Tens treatments at the physiotherapists’ office. I then had a temporary, trial electrical nerve stimulator implanted underneath my skin, near my eyebrow, which very slightly reduced my pain, sometimes. During these years, I also had several anaesthetic block injections in the forehead and neck. These assorted treatments were the result of visiting three different, well-established, pain clinics, but in the end, no option provided sufficient pain relief.

How did you hear about Dr Peled?

 In despair, after suffering for 4 years, I joined a local, self-help group on Facebook where I read an article by Dr. Peled.

What inspired you to speak with him?

 I wrote to him, explaining how I had had dozens of types of scans, consultations with several top neurologists and neurosurgeons, and even a gamma-ray operator, without a solution. He then organized a Skype consultation with me.

Tell me about your surgery, including when you had it, what happened.

 My surgery with Dr. Peled was in May of 2018. The operation lasted for a bit over an hour. The pain originated from the supraorbital nerve, which did not have enough blood supply from the artery, due to restricted flow where the artery exits the skull. Dr. Peled corrected the blood flow issue during the operation, thereby rejuvenating the problem nerve.

 Do you remember how you felt in the first few days after surgery?

 I had nausea caused by an allergic reaction to the strong pain relief medication, but otherwise, I felt a lot better.

How are you feeling now?

 My pain is no longer. I still have slight nerve tingles in the area where I had the operation, but feel confident that these will lessen month by month.

How has your life changed as a result of this surgery?

 I am back to doing activities I did not do for over 4 years and now enjoy life again.

What is next for you?

 To go on a holiday with my husband.
What would you say to anyone wondering whether to meet Dr Peled?

 A consultation with Dr. Peled is worth every bit. My many other consultations before meeting Dr. Peled cost me a lot and achieved nothing.

Describe your overall experience with Dr. Peled and his office.

 Very professional and caring.

Do you have any advice for prospective patients who are thinking of coming to the practice?

 Have all your facts ready for discussion and bring any supporting scans, including reports. Ask his team for advice on how best to make your visit a success.

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Anyone that likes to watch professional football on TV has probably read at least one news story about concussions and the subsequent traumatic brain injury that can occur after prolonged and repeated blows to the head and neck. Sadly, this phenomenon is not limited to football and can be seen in any number of sports from volleyball and soccer, to equestrian and car racing. Moreover, the pathology from such injuries is not limited to the brain. It has now been noted in a few papers in the published literature that occipital neuralgia can occur following sports-related injury. The etiology, at least in my mind, is most likely a traction (i.e. stretch) injury to the occipital nerves. What exactly happens as a result of this type of injury remains unclear, but there are several possibilities.

Studies of concussion patients using advanced imaging techniques that are not yet widely available have shown that there can be disruption of the myelin sheath of neurons in the brain. This sheath represents an important component of nerve support and insulation that allows physiologic conduction of nerve impulses. A similar event could happen as a result of trauma to a peripheral nerve and represents one possible cause for neuralgia. Another possibility is post-injury scarring reducing the space through which these nerves have to glide and thereby causing compression. Third, the scarring may be intra-neural (i.e. within the nerve) thus, in effect making the nerve stiffer and unable to glide smoothly with certain movements. These latter two possibilities may help explain why people who develop ON following sports-related concussions often report increasing pain or triggering of their pain with certain movements such as head rotation. Finally, if left untreated, prolonged compression has itself been shown to cause thinning or elimination of the myelin sheath and eventually neuronal cell death.

Remarkably, there are over five million Americans living with the sequelae of concussions. Even more frightening is that post-traumatic headache has been estimated to occur in almost 90% of such patients and is one of the more long-lasting symptoms, causing significant disability. Certainly, conservative measures are the first line of treatment and include modalities such as pharmacologic agents, massage, and physiotherapy. However, as with migraines, these modalities are not always successful. Happily, surgical decompression has also been shown to be effective in such patients with positive results reported in up to 88% of those treated. In addition, I personally believe that if occipital nerve compression is suspected, the sooner it is addressed, the quicker nerve function will be restored and the greater the ultimate degree of recovery will be since the amount of neuronal cell death can be limited. This latter postulate has not yet been studied, but certainly makes sense given what we know about chronic compression of peripheral nerves in the upper extremities. Therefore, anyone with such symptoms should look into the possibility of occipital nerve injury and have a frank discussion with their treating clinician regarding a timeline within which to evaluate the current treatment plan and what to do if there are no results within a certain period of time. Always trying to leave on a positive note, the take home message is that there may be a lifeline if chronic post-concussive headaches appear to be refractory to more conventional methods.

For more information on how nerve surgery can help with chronic migraines or the aftermath of concussions, visit or call 415-751-0583 to schedule a consultation with Dr. Peled.

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Chronic Pain and Dementia

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There is a lot of discussion, both in the media and in the medical literature, of the direct medical costs of chronic headaches which is a prototypical form of chronic pain. However, one thing that often gets overlooked is the indirect costs of these conditions. By indirect costs I mean, for example, lost productivity/income from work absences secondary to pain and/or increased costs for care of children and significant others secondary to an inability to perform these tasks oneself. Moreover, and perhaps most significantly, there are the psychological, emotional and physiologic tolls that chronic pain such as chronic headaches/migraines take on patients. In a fascinating study back in 2003, Susan Turner-Bowker surveyed over 7500 people with various health conditions and specifically analyzed a metric known as the health-related quality of life (HRQOL). What she discovered was that migraineurs’ HRQOL was similar to those patients suffering from congestive heart failure, hypertension and diabetes – all devastating illnesses. These results highlight the fact that chronic pain such as chronic headaches/migraines have significant negative impacts on functional health and well-being.

Unfortunately, the data correlating chronic pain with negative physiologic effects continues to mount. Just this week, a study in JAMA Internal Medicine looked at a cohort of over 10,000 elderly patients and followed them for a period of over 12 years. Remarkably, the people in this study who said that they were persistently troubled by moderate or severe pain demonstrated a nearly 10% faster decline in memory function over the subsequent 10 years. In addition, the statistical analysis implied that these same people would have a 16% higher relative risk of inability to manage other medications and an almost 12% higher relative risk of inability to manage their financial situation independently. It was therefore concluded that persistent pain was associated with accelerated memory decline and an increased probability of dementia. These numbers are significant because it has been estimated that as many as 1 in 3 elderly people experience chronic pain. The results seen with this current study are likely multifactorial, but may include the use of medication for pain, whether opioids or even NSAIDs (e.g. ibuprofen, Aleve) both of which have been shown in other studies to be associated with dementia risk. Alternatively, it has been suggested that the cognitive dysfunction associated with chronic pain may be secondary to diminished ability to focus on other functions as a result of the need to manage the discomfort, an effect that has been particularly noticeable on short-term memory. Another possible explanation may be that the stress associated with chronic pain may lead to cognitive decline via cortisol-based mechanisms.

While this particular study focused on elderly patients, it is reasonable to wonder whether or not the same mechanisms leading to cognitive decline suggested in this study also have effects on younger patients. I wonder, for example, if chronic pain beginning that begins at an earlier age leads to an earlier onset of cognitive dysfunction such as dementia. In either case, there is clearly a need to do more for patients than we are currently doing. Perhaps using conventional therapies as well as “thinking outside the box” at other possible causes for pain (e.g. peripheral nerve pathology) will allow us to manage these illnesses more effectively with less of a pharmacopeia. The ray hope from studies such as this one comes in the possibility that there is so much potential for benefit in overall health as well as quality of life even with small improvements in our understanding of these conditions.

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How Peripheral Nerve Surgery Can Help Your California Headaches

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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 today for more information, and to make an appointment to relieve your migraines.

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