Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

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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Migraine Solutions Discussed in USA Today

Dr. Ziv Peled, Peripheral Nerve and Plastic Surgeon, was recently asked to sit down and answer some questions about migraines and migraine relief.  Here is a transcript of the interview.

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Dr. Peled Named To Young Plastic Surgeons Steering Committee

Dr. Peled Named To Young Plastic Surgeons Steering Committee

Another exciting honor for Dr. Ziv Peled!

Dr. Ziv Peled was recently asked to serve on the Young Plastic Surgeons (YPS) Steering Committee of the American Society of Plastic Surgeons (ASPS). This Committee is comprised of several up and coming thought leaders in the field of Plastic Surgery and is in charge bringing information on the ASPS/PSF (Plastic Surgery Foundation) to residents and young plastic surgeons and to encourage their professional development through membership in the ASPS. Members also act as liaisons between plastic surgeons in the early stages of their careers and established ASPS Member Surgeons.
The YPS Steering Committee works proactively to convey information about ASPS/PSEF to residents and young plastic surgeons and encourage their professional development through membership in ASPS. Participation on this subcommittee is an opportunity for young members to become actively involved in the Society and Educational Foundation; the committee also promotes a YPS auditor program that invites young plastic surgeons to audit committees of interest.
The YPS Steering Committee also develops the programming for the Annual Meeting's Residents Day and provides input to the Practice Management Education Committee on programming for the annual Senior Residents Conference. In addition, the committee has responsibility for the Breakfast of Champions event and the Fresh Faces panel presentation during the annual meeting.

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The Road To Recovery From Migraine Pain

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.

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But the Botox Didn't Work On My Migraines! What Now?

But the Botox Didn't Work On My Migraines!  What Now?

One of the questions that I‘m frequently asked during consultations with patients regarding their chronic headaches is, "If I’ve had Botox injections done with other doctors in the past and they have failed, does this mean that Botox injections done with you would not work either?" This is an excellent question and the simple answer is, “No".

One of the questions that I‘m frequently asked during consultations with patients regarding their chronic headaches is, "If I’ve had Botox injections with other doctors in the past and they have failed, does this mean that Botox injections done with Dr. Peled would not work either?" This is an excellent question and the simple answer is, “No".

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How Can You Define Peripheral Nerve Surgery?

How does peripheral nerve surgery help my life, and what can it mean for my migraines?

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.

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How Can Peripheral Nerve Surgery Help My Migraines?

What do migraine headaches and peripheral nerve surgery have to do with each other?

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Ask me, ask me, ask me!

A recently published study in Health Affairs demonstrated that many patients still have significant reservations about asking their doctors questions regarding their health care.

A recently published study in Health Affairs demonstrated that many patients still have significant reservations about asking their doctors questions regarding their health care (). Many of the patients in the study stated that they feared upsetting their physicians and were scared that doing so would negatively impact their care. Moreover, many patients also apparently felt as though their physicians did not listen to or respect what they had to say. These findings are especially poignant in light of the fact that many of the patients surveyed in his study had a very high education level and an annual income greater than or equal to $100,000 per year.

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