Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.


How Diabetes Affects Peripheral Nerves

How Diabetes Affects Peripheral Nerves

The relationship between diabetes and peripheral nerves is an important one.  As many people already know, diabetes is the leading cause of neuropathy, which in its simplest definition means some pathology of the nerves.  Therefore, diabetes obviously negatively affects nerves, but how? There are a number of ways in which diabetes can affect a peripheral nerve.

In a diabetic, despite the best glucose control there is always more glucose in the bloodstream as compared with a non-diabetic.  This excess glucose is taken up by many cells in the body, among them nerve cells. When inside the nerve cell, the glucose is metabolized into another sugar called sorbitol which then acts as an osmotic load (e.g. as a sponge) , drawing more water into the nerve cell. In effect, because of this excess water in the nerve cells, diabetic nerves are swollen.  When any object swells inside a fixed space which cannot expand, that object is under pressure. This process partly explains why carpal tunnel syndrome is more common in diabetics than in non-diabetics and it stands to reason that the same process would affect the symptoms of another nerve compression problem, ON. Although the correlation between diabetes and ON has never formally been elucidated, several studies have hinted at a causal relationship. Another way in which diabetes can affect peripheral nerves is by causing a low grade inflammation of the blood vessels within the nerves.  With inflammation comes swelling and the process noted above worsens even further.

Two other processes have also been identified, but with very different mechanisms.  Diabetes has been associated with increased molecular cross-linking of certain proteins within the nerve cells walls.  This cross linking effectively makes the nerves “stiffer” than they otherwise would be which causes then to bang around more within their tight spaces and resulting in more micro-trauma.  This process is especially true around joints such as the wrist (carpal tunnel) or at the base of the neck (ON) where all of the structures are moving around, hopefully gliding smoothly past one another. When coupled with an impaired ability to repair themselves secondary to decreased axoplasmic flow, repeated micro-trauma likely results in scar build-up over time thereby decreasing already tight spaces even further. While I’m sure that other processes have also been identified, the bottom line is that diabetes has multiple negative effects on peripheral nerves and is the reason why in a diabetic patient, optimal glucose control is the first line of therapy. Poor glucose control is likely to exacerbate nerve-related symptoms (whether carpal tunnel or ON) for all of the reasons noted above.  Despite tight controls on sugar levels, diabetics still have symptoms and sometimes these even worsen over time. In these cases, I believe that a meticulous search for nerve compression is important because if found, decompression can potentially be very beneficial symptomatically.

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Why Does It Hurt So Much After the Injections?!?

Why Does It Hurt So Much After the Injections

A number of patients have come to the office over the years consistently telling me that they had worse pain AFTER their injections with their other doctor.  This phenomenon seems to occur irrespective of what is being injected, whether 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.

Second, these injections, by design, are performed AROUND (not into) nerves which means that you are injecting several mL of fluid around a nerve.  This fluid causes some irritation of the nerve itself because of the mechanical pressure from the fluid, not so much the make-up of the fluid itself and hence theoretically would be equivalent with Botox, local anesthetics or steroids so long as the same volume was used with each. If a local anesthetic is used, the effects of the anesthetic provide relatively immediate, albeit temporary relief when injected properly. Yet when the effects of the local anesthetic wear off, the nerve irritation from the fluid pressure often remains and can cause worse pain for a few hours or days afterward.  Once again, this situation is usually temporary as the residual fluid is absorbed by the body, although the discomfort can last several days on occasion.

A third reason an injection can cause pain afterwards is some complication from the injection itself.  For example, following any violation of the skin (e.g. surgery, injections, IV placement) an infection can occur.  With infection comes the inflammation noted above often causing localized pain from irritation of the nerve endings in the surrounding skin as well as from irritation of the target nerve. A hematoma (a collection of blood) can result from an injection although it is uncommon.  Blood is a great culture medium and can be a factor in promoting infection (see above) as well as a mechanical force impacting the local tissues (e.g. the target nerve). One potential sign of a hematoma is significant bruising following an injection, especially one involving a small needle and a small injection volume.  Finally, and fortunately very rarely, an intra-neural injection (into the nerve itself) can be the culprit. If a significant volume of anything is injected into the nerve itself, it can disrupt the microscopic blood supply to the nerve and cause permanent damage, which can result in permanent problems. However, since nerves are usually quite small, since the injection needles are small and since the required injection volumes are low, intra-neural injections are about as common as finding a needle in a haystack or a four leaf clover.   The take home message for my patients: knowledge is power. If patients are told what MAY happen following their injection, they are much calmer if and when it does occur and hence better prepared to deal with the situation.

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Migraine Surgery: The Staged Approach

Migraine Surgery The Staged Approach

I was recently asked why some people require more than one operation to obtain optimal relief.  As usual, the answer has many components to it so I will try to delineate some of these issues below.  Let me preface these remarks by stating that what I write below is my opinion only and how I approach patients, but should not be considered dogma.  While a number of colleagues also use this approach, it is not necessarily shared by every peripheral nerve surgeon, some of whom will be more aggressive and some less aggressive.

In situations where there are many nerves that will require surgical intervention to achieve an optimal result, there are number of reasons why I prefer to stage the operations.  First, patients often say that one area usually flares up initially and when very severe or uncontrollable, causes the headache and discomfort to spread to other areas. For example, s/he will state that their neck gets tight, they get occipital headache pain and if medication is unable to help, the headache spreads to the temples and forehead.  In these particular cases, there may be a reasonable assumption that the occipital area is triggering the frontal and temporal headaches.  Therefore, theoretically if the occipital nerves are appropriately addressed, with time and healing, those triggering nerves should calm down such that the frontal and temporal areas are only triggered infrequently and hopefully to a much lesser degree.  In other words, if you can remove the fuse, the dynamite stick will never explode and therefore an operation to address the frontal and temporal nerves may never be required. Even if this patient continues to have some degree of headaches, these headaches may be so infrequent and/or relatively mild that they feel the remaining symptoms are easily manageable and don’t want another operation.  As I’ve said in prior posts, no one should tell you whether or not you should live with whatever pain you have. Doing so is making a value judgment - only the patient can and should make that determination.

Second, let’s assume that a person has the appropriate operation over the occipital nerves and has a successful outcome with respect to their posterior headaches, but the temporal and frontal headaches persist even after several months of recovery.  In those cases, while another operation may be required to address the temporal and frontal nerves, there is now good reason to believe that the second procedure is likely to be successful. The converse is also true - if the occipital procedure is performed correctly and for the right indications, but yields no result, I would question whether or not a temporal/frontal procedure would be indicated.  I would be less confident surgical intervention in those areas would be successful since the same approach was unsuccessful over the occipital area, thereby precluding the potential for complications in areas where surgical intervention may not be successful. Therefore, staging an operation has the potential to give you information about whether or not a second procedure will be helpful.

A third reason for staging these operations relates to the safety of an operation.  While I obviously agree that neuralgia (occipital or trigeminal branch) is a significant medical problem, these operations are elective.  Therefore, the most important thing we can do for the patient is give them a safe operation and try to minimize complications while maximizing the potential for a successful outcome.  From a technical standpoint, the longer a surgical procedure takes, the greater the chance for complications or issues arising from anesthesia. While long operations can certainly be done safely, when it comes to elective surgery, the more efficient a procedure can be the better.  Therefore, if I had a choice between one 8-hour operation or two 4-hour operations, I would choose the latter because there is likely a lower risk for deep vein thrombosis (blood clots in the legs that can embolize), the need for an in-patient stay, post-operative nausea and other anesthesia-related issues.

A fourth reason for staging operations has to do with recovery.  In my opinion (and as many of my patients will attest), one of the hardest parts of the surgical experience is the post-operative recovery which often has many ups and downs apart from the immediate, peri-operative surgical discomfort.  With respect to the latter, if you have incisions on the front, the sides and the back of your head bilaterally, I can only imagine how uncomfortable the whole head must feel and I often wonder how these patients rest at night since sleeping on any portion of the scalp is likely to result in discomfort.  Rest post-operatively is critical and lack thereof is potentially problematic. In addition, as decompressed or transected nerves are manipulated in the operating room, the normal, post-operative inflammation can lead to many nerve-related symptoms which, if they occur all over the scalp as opposed to just posteriorly or over the temples, is likely to be quite uncomfortable.  More discomfort often leads to increased opioid use which can lead to a whole host of other issues such as constipation, cognitive impairment (e.g. sedation), nausea etc.

One last comment: I don’t use any one of these contra-indications in isolation.  They are all considered together as part of the overall clinical impression when I go over a patient’s records, examine him/her and perform whatever diagnostic maneuvers are necessary.  It is for these reasons among many others that I always recommend a consultation with a peripheral nerve surgeon when deciding if surgical intervention (whether decompression/neuroplasty or neurectomy/implantation) is appropriate.  

I also believe that among the many questions patients should ask their potential surgeons is how they will approach the surgery. It is important for patients to understand their surgeons’ plan, particularly if their case will involve more than one or two incisions, and make an informed decision about the path forward.

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In my humble opinion, the possibility that mechanical compression of a peripheral nerve in the head and neck can cause headaches is vastly underestimated.  I realize this is a big statement, but I think it is legitimate. It is primarily for this reason, that the diagnoses of occipital neuralgia and trigeminal branch neuralgia are not made nearly as often as they should. What is particularly fascinating is that many practitioners will use nerve blocks to provide temporary relief from headaches successfully.  

What do those practitioners think is happening when they temporarily and chemically inactivate a peripheral nerve or nerves and the headache improves significantly or goes away, albeit for a short period of time - usually until the numbness wears off?  What exactly does one conclude from this information? In my mind, the most obvious answer is that the nerve(s) that was blocked must be involved in the generation of headache symptoms. So why is this concept so foreign to so many? I believe there are a number of reasons for this phenomenon and I will delineate some of these reasons below.

The first is that the central concept of chronic headaches has been around a long time.  It is generally widely accepted that most chronic headaches (e.g. migraines) are caused by chemical or vascular imbalances in the brain.  And yet, if we understand the chemical imbalances, how come we not only have dozens of drugs to treat ‘migraines’, but numerous classes of drugs.   Pharmacologic treatment of migraines includes the use of anti-depressants, neuroleptics, serotonin-modulating agents, CGRP-modulating agents, opiates, muscle relaxants, anti-seizure medications, anti-hypertension medicines, anti-anxiety drugs and others.  

If there is a clear chemical problem, how come there aren’t one or two classes of drugs that treat that problem effectively? I will say that these medicines work for many, but the problem is so prevalent (more than 36 million people in the US are diagnosed with migraines), that even if they fail for just 20%, that means more than 7 million people continue to suffer.  The point is that the central concept of chronic headaches is deeply ingrained in medical teaching and hard to overcome. Therefore, the notion of peripheral nerve compression causing these problems would be somewhat of a paradigm shift - something that doesn’t occur easily and without some resistance.

A second issue is that this concept is being championed by primarily plastic surgeons.  One of my mentors once told me, “Ziv, don’t go into plastic surgery unless you are willing to spend the rest of your life apologizing for your colleagues.”  While I disagree with this blanket statement, I understood his point - when most people think of plastic surgeons, they think only of cosmetic surgery.

Yet, plastic surgeons reconstruct breasts after mastectomies, repair difficult lacerations, fix cleft lips/palates, provide coverage for difficult wounds following trauma, do face transplants and replant fingers, forearms and whole arms (including nerves) after accidents.  Some of us have made peripheral nerve surgery a focus of our practices and spend time teaching others what we know, publishing our work for others to read and critique and educating patients so that they can be more informed. Yet I suppose if a neurologist came up to me and told me that I was doing my tummy tucks incorrectly and that they had a better way to do it, I might look at them slightly askance at first. Skepticism is always healthy, especially when it comes to surgical intervention,  so it makes sense that practitioners who care about their patients wouldn’t want them to do something they were unsure of.

Third, we who do these operations need to continue to publish our data, educate other medical professionals (as well as the public) and hopefully build bridges between the various specialties so that ultimately patient care is optimized.  While a reasonable number of surgically-treated patients experience elimination of their headaches, many continue to have symptoms albeit significantly reduced in frequency, severity and duration. So we all still need our neurologists, pain managements docs and physical therapists to help manage the remaining issues.  This multimodality approach remains elusive in headache care, but is a dream of mine before I retire. Because peripheral nerve surgery is the newest and smallest voice at this potential table, the things we have to offer are often not acknowledged.

Despite these hurdles, the shift to wider acceptance of this concept is underway. There are board-certified neurologists now writing about “nerve compression headaches”, which are not currently listed in the International Classification of Headache Disorders as a distinct clinical entity to my knowledge. So while the wheels of change slowly turn, patients have to be advocates for themselves. If the pharmacologic agents, injections and conservative modalities are not giving lasting relief, then seeking a qualified surgeon to test for mechanical compression may be the next course of action…...and the solution.

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POST TRAUMATIC HEADACHESJust a few days ago, I read an Instagram post that discussed post-traumatic headaches. There was a description of someone who had suffered a head injury following an assault and suffered a skull fracture that healed without surgery. This person subsequently began to experience headaches that were unremitting. The MRIs of the brain and neck did not identify any pathology and the patient had failed physical therapy and massage treatments. He was diagnosed as having a concussion and treated accordingly, but the headaches persisted.

The remainder of the post went on to detail how, over the ensuing years, he was presumed to have developed ‘migraines’ and tried on various medications, all unsuccessful. There were descriptions of altered brain activity, presumed (but never identified) problems with the blood vessels in the brain and various suspected chemical abnormalities (hence all the drugs). During this entire time, the patient was complaining of consistent pain in a specific area of the head/scalp.

Unfortunately, this story resonated with me because it sounded all too familiar. The remarkable thing for me was that no time during the entire saga did anyone even entertain the possibility that there might be a peripheral nerve in the scalp that had been injured with the fracture and subsequent scarring that occurred. It struck me as odd that if the same thing had happened in the forearm with an ulnar bone fracture and the patient began to experience hand pain in the small finger, the concept of a nerve injury would be at the top of the possible causes. The fact of the matter is that this person might just have an entrapped peripheral nerve in the scalp that is causing the pain.

I wanted to reach into the phone and suggest to this patient that he consider this possibility.  He should have a nerve block and if, successful, perhaps an outpatient procedure might just fix the issue permanently.  This whole scenario also got me thinking about why people don’t consider the peripheral nervous system in these cases. I think there are many explanations for that observation. More about that topic in an upcoming post.

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Is there a Problem If You Can't See It?

Is there a Problem If You Can't See It

As with many things in life, there are positive and a negative ways to perceive anything. Just because the MRI was negative, clearly doesn’t mean that there’s nothing wrong. Let me explain why below. First, however, let’s look on the bright side. You don’t have a brain tumor. You don’t have an aneurysm. It doesn’t appear as if you’ve had a stroke. And you don’t have lesions on your brain that might be suggestive of multiple sclerosis, Alzheimer’s or ALS (Lou Gehrig’s disease)….all good things NOT to have.

So what do you have and if it’s so bad, how come you can’t see it. Well, with standard MRI sequences, nerves are often not visualized as well as other structures such as muscle and bone. However, there are certain modifications which the MRI technician and radiologist can perform (if knowledgeable enough) to highlight nervous tissue. There are a special set of MRI sequences collectively called Magnetic Resonance Neurography (MRN for short) that, when combined can produce high resolution images that preferentially highlight nerves and their pathology. Unfortunately, this type of technology is still relatively new and is certainly not available at every hospital. 

There are a couple of technical considerations when deciding whether or not a suspected nerve can be evaluated with MRN. The first is the strength of the coil (magnet) within the MRI machine. Standard MRI uses a 1.5 Tesla (1.5T) coil to image routine structures. More recently there has been a prevalence of 3T coils and these machines are sometimes considered “high resolution” MRI scanners. The images they produce are more refined and specific. Think of it as the difference between the images from a VHS player versus a DVD player. There is even a well-known, local institution that supposedly has a 7T scanner. The image quality will probably be that of a Blue-Ray player. The second issue at play is the size of the nerves being imaged. The larger the nerve, the easier it is to detect any pathology. MRN has been shown to be quite effective and useful in imaging larger nerve bundles such as nerve roots emerging from the spine, the sciatic nerve in the thigh and even the brachial plexus in the neck and upper arm. It has been less well-studied in more peripheral and hence smaller nerves such as those involved in carpal tunnel syndrome and occipital neuralgia. The third, rate-limiting step in imaging the nerves is interpreting the images - this step requires a good radiologist. The more experienced they are in reading such images, the more likely they are to pick up fine details that may represent true pathology.

So if the MRI is “negative”, it may be because the optimal MRI sequences were not used - perhaps the radiologist thought you were really looking for a brain tumor and simply didn’t see one. Make sure the ordering physician specifies that they think you may have ON and are looking for compression of, for example, the greater occipital nerve. If the MRI is “negative”, it may be because the MRI machine is not capable of producing high resolution images that would highlight small nerves such as the greater occipital or supraorbital. If the MRI is “negative”, it may be because the radiologist interpreting the images is not experienced enough in MRN to pick up subtle differences in the appearance of a compressed, small nerve versus a normal one. Knowledge is power in these cases. One final note: given the novel nature of MRN technology, most insurance companies still consider such tests “experimental”. 

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Is Occipital Neuralgia (ON) Truly Idiopathic or is the Cause More Often Than Not Some Sort of Compression?

Is occipital neuralgia ON truly idiopathic or is the cause more often than not some sort of compression

One of the most common questions that I get from my patients when they come into the office to see if they are a candidate for nerve decompression surgery goes along the lines of, “Gee Doc, I hope you find something! What if you get in there and don’t find anything wrong? What will you do?”

I have never encountered a patient on the operating table where there hasn’t been some element of nerve compression. Sometimes this is seen in the form of how the occipital nerve interacts with the occipital artery where the latter wraps around the nerve a bit like an anaconda. Sometimes, compression can be caused by a spastic muscle and sometimes, compression can be caused when the connective tissue tunnel through which an occipital nerve passes in the neck to the base of the skull is excessively narrow.

While some element of compression has always been present, there are a couple of caveats to these observations:

  1. We don’t have an empirical method for measuring occipital nerve compression. If a patient suffers from a critical condition like compartment syndrome in the leg, in which when pressure builds up, there are established tools to measure what critical pressure is and when to operate. A similar baseline has yet to be established for nerve compression causing head pain, so there is no defined way to measure the degree or severity of the compression that we see.
  2. Secondly, we also don’t know what degree of compression will cause symptoms of pain. This amount of pressure will likely vary based on a number of parameters such as which nerve is involved.  For example, the greater occipital nerve is a much larger and heartier nerve and therefore is likely to be able to tolerate more pressure before becoming symptomatic as compared with the lesser occipital nerve.  
  3. Lastly, we don’t ever operate on people who don’t have symptoms nor where candidacy for surgery has been not been verified via history, physical examination and nerve blocks. In other words, when you only have symptoms on the right side, I’m not going to dissect and open the left side of the neck just to look so that I have a comparison of what “normal” supposedly looks like.  Doing so exposes those left-sided nerves to potential injury unnecessarily. That being said, there was an important study conducted by Dr. Guyuron several years ago to validate the outcomes of headache surgery. It was what was known as a sham surgical trial, 76 patients knowingly participated with 49 patients undergoing the actual nerve decompression procedure and the remainder undergoing what’s called a sham operation. On the day of the surgery, Dr. Guyuron would open an envelope and it would tell him if the patient was having the real surgery or not. The sham surgeries had to seem like they could be real, so these patients were still induced under anesthesia, were cut open and their nerves exposed, but ultimately left alone for a typical time that the operation would take. The patients who had the actual surgery did statistically better in terms of frequency, severity and duration of their headaches when compared to the sham surgical patients. In addition, while there was some placebo effect, none of the patients who received the sham surgery were headache-free, while a statistically greater percentage in the actual surgical group did report this outcome.

The take home message is this:  There is still much work to be done in order to establish a measurable baseline for nerve compression that leads to head pain.  However, in the meantime we can work with what we know and that is if a patient experiences chronic pain, has exhausted all non-surgical methods of treatment and responds well to nerve blocks, they are reasonably good candidates for nerve decompression surgery.

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What Is a Migraine?

What Is a Migraine

Many people consider a migraine to be a really bad headache. The truth is, it is a severe, neurologic condition. However, when perusing the medical literature, it becomes apparent that the term ‘migraine’ in many practical instances, is actually a name that we have given to a constellation of symptoms as opposed to a specific medical issue with a specific, identifiable cause.

If you go to WebMD or the Mayo Clinic or just Google the term “migraines”, what you’ll consistently find is that they are defined as very severe headaches. You’ll also find that they have all sorts of descriptive characteristics.  For example, they mostly affect women between ages 25 to 55, and can last anywhere from 4 to 72 hours, etc. Migraines typically have 4 phases:

  1. Prodrome - where people start to feel a bit off before their head pain sets in
  2. Aura – a period during which some patients experience symptoms such as flashing lights, unusual smell and sound sensitivity, etc.
  3. Headache - the actual experience of head pain; however, there are acephalalgic (i.e. painless) patients or atypical expressions of this stages where people experience, for example, primarily nausea and dizziness without the head pain
  4. Post-drome - which is akin to a post-seizure state during which the actual head pain has either abated or gone away, but the patient is left with acute after-effects such as drowsiness, confusion and/or irritability

While we have a broad range of characteristics that describe these headaches, at the end of the day, the question that migraine sufferers most want answered is ‘What causes them?’ In most cases, we don’t really know. This fact is demonstrated by the sheer number of medications and numerous classes of medications that are used to treat migraines. Examples of the latter include anti-seizure medications, pain medications, muscle relaxants, neuroleptics, antidepressants, serotonin-modulating drugs (like all the triptans), the new range of CGRP receptor antagonists and several others.  Generally speaking, in life as well as in medicine, when there are multiple different ways of treating a problem, one can rest assured that not one of those methods is supremely effective, otherwise everyone would be using it. I say to my patients that two most important questions for any diagnosis is to figure what is causing that problem and if you can figure that out, what can you do about it.

Peripheral nerve surgeons treat headaches differently when compared with the traditional way physicians are taught to think about these problems. We focus on specific peripheral nerve triggers that might be causing your headache.  Hence when we use the term occipital (meaning back of the head) neuralgia (meaning nerve pain), the real question is: “Can you figure out which ‘neur’ (i.e. nerve) is causing the ‘algia’ (i.e. pain). That is the crux of the diagnostic work up when a patient comes to see me for this issue.  At the end of the evaluation, with the help of a thorough history, physical examination and set of peripheral nerve blocks, I will have a much better sense of which nerve or nerves might be involved in your headache symptom complex and whether or not surgical intervention might be of benefit. 

The take home message is that the term “migraine” is often very non-specific and not often helpful.  While people with headaches caused by pinched nerves in the occipital area technically have “migraines” from a purely definitional standpoint, the more accurate diagnosis is ‘occipital neuralgia’ or even more specifically greater (and/or lesser, third) occipital neuralgia.  The reason the latter diagnosis is more useful is that it points to a specific cause which can be treated.  That is the reason we have these diagnostic terms in the first place.

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Ziv M. Peled M.D. Discusses Migraine Awareness Month

 MHAM D1 video



Ziv M. Peled M.D. discusses what migraines are and how they affect people's health and well-being. To learn more about Migraine Surgery and Migraines, visit today.

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Burning Migraine Questions with Becky Ellefsen May 16 2019



In Episode 10 of Burning Migraine Questions, Ziv M. Peled, MD talks to Becky Ellefsen about her journey from a whiplash injury to chronic head pain to relief.

They discuss the challenges faced by sufferers of headaches that don't find relief from medication, how it feels not to be believed by your practitioner, that the prescribed medications are often insufficient and the courage needed to face the fact that you can be fired by your practitioner for pursuing an alternate course of treatment.

Dr. Peled reiterates that "surgery is never the first option" and talks about the importance of patient advocacy for raising awareness of this approach when other treatments have failed.

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In this second installment about fears and misconceptions about headache/migraine surgery, I’ll address several other concerns people have raised when considering these procedures. As before, hopefully these discussions are helpful in making a more informed choice about whether such procedures are right for you.

  • Misconception 3 – The results of surgery are only temporary and the pain will eventually recur. I often tell patients that it may be scar tissue that is pressing on their nerves or preventing them from gliding back and forth as they move their neck and hence cause pain.  Patients naturally ask why more scar tissue wouldn’t form after their operation.  This question is a good one.  The answer is that scar tissue always forms after any operation, but excessive scar tissue that re-entraps nerves can be mitigated by creating sufficient space around the nerves during the operation and by allowing/instructing the patient to move their neck normally as soon as they wake up.  We know from our work on tendon injuries in the hand that as little as 5 mm of gliding can prevent clinically significant adhesions and the same physiology holds true in other parts of the body and with respect to nerves.  To back this fact, the 5-year results from these operations were actually published back in February 2011.  In this study, 5 years following their operations, 88% of patients were still reporting at least a 50% reduction in frequency, severity and/or duration of their symptoms and 29% were completely migraine-free.  In the medical cancer literature, if you are free of your disease after 5 years, you are typically considered to be in remission.   Similarly, if you are significantly better or migraine-free after 5 years, we consider these essentially permanent results.
  • Misconception 4 – My insurance considers these operations experimental which means they are unproven. Sorry, but I get on a bit of a soap box about this one.  In my humble opinion, insurance companies are not the arbiters of what is medically appropriate.  That decision is between the doctor and the patient – period.  Your insurance company doesn’t know you, hasn’t examined you, hasn’t spoken with you about your condition and hasn’t evaluated your records. The American Society of Plastic Surgeons put out a formal position statement regarding headache surgery which clearly states that when more conventional modalities have failed, that these operations are not only reasonable, but should be considered the standard of care.  This 13-page document is exhaustively researched and cites 89, peer-reviewed articles in high-impact factor journals, which speak to the efficacy of this approach to chronic migraines/headaches.  It continues to boggle my mind why insurance companies claim this treatment approach is unproven because it is simply untrue.

  • Misconception 6 – I had a nerve block with another doctor which was unsuccessful and therefore I am not a candidate for these procedures. Results of the nerve block will vary based upon several parameters: what you inject, how much of it you inject, where and how you inject, and for what reason you are injecting.  I can’t tell you how many patients have told me that they had a nerve block of the greater occipital nerve which was unsuccessful, but when I ask them if the back of their head was numb at all, they reply ‘no’.  If you have no numbness following a nerve block, that means the nerve was not blocked and simply put, you have had no idea whether or not numbing that target nerve would give you a successful result.  Therefore, if nothing else, if the nerve block which was performed initially was unsuccessful, then may be a repeat block performed in a slightly different way with a slightly different technique may be successful.  It is thus important to have these blocks performed sequentially and by a clinician with a reasonable amount of experience with these procedures.

Hope these explanations help to some degree.  In a future blog post, I plan to address still other misconceptions that seem to strike fear in the hearts of those considering an operation for relief of their chronic headache pain.

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Ziv M. Peled, M.D. Presents Burning Migraine Questions Episode 9 May 2, 2019





In Episode 9 of Burning Migraine Questions, Ziv M. Peled, MD talks to Ronny Ead about what has happened since The Doctors was taped a year ago, why they didn't discuss Occipital Neuralgia or Trigeminal Neuralgia on the show and why these mechanically-triggered conditions are so under-diagnosed. They also discuss extra-cranial surgery being designated as the standard of care for head pain, when other treatment modalities have failed. Dr. Peled advocates for medical and paramedical practitioners coming together as a treatment team to address the chronic pain epidemic.

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Ziv M. Peled, M.D. on The Doctors!

Ziv M Peled MD on The Doctors

I was proud to appear in today's episode of The Doctors, where I discussed my patient Ronny's surgery and recovery, and how peripheral nerve surgery had helped eliminate his migraines.

With more than 37 million migraine sufferers in the United States, you probably know someone who is suffering from debilitating headaches.  Ronny was one of these 37 million Americans until he came to see me.  He shared his story with The Doctors and let the show into the operating room with us as he had his peripheral nerve surgery to rid him of migraines.

Ronny's migraines had been steadily worsening since 14, and had pain coming from the back of his neck that would spread to the front of the forehead and to his eyes and his temples.  He also suffered from extreme nausea, leaving him unable to get out of bed and having trouble working.

After trying many different meds and therapies, like acupuncture and massage, Ronny also went through changes to how he went about his regular life.  Even stress management and diet changes brought no relief.  After seeing over 15 doctors and dentists, he was at the end of his patience.  Then he came to our office.

The most common misconception about migraines is that an abnormality inside the brain is the cause.  This is not always true.  They can also be caused by nerve compression outside of the brain, where scar tissue, abnormal blood vessels or spastic muscles can impinge on the nerve.  This was what Ronny was dealing with.

I operated on Ronny to release the nerves at the back of his head and get them away from the spastic muscles.  We showed this procedure in the video that was shared with The Doctors as I operated on the nerves in the front of the head and the temples.

We then joined the studio panel for The Doctors, where Ronny shared his story, and that he is nearly 100 percent pain-free after the surgery.  I was asked by Plastic Surgeon Dr. Andrew Orton why Ronny was such a good candidate for this surgery.

To me, the ideal candidate:

  1. Has been diagnosed with migraines by a board-certified neurologist or headache specialist
  2. Has failed conventional therapies including various drugs and injections
  3. Has a good physical exam that shows there's a peripheral nerve that is casing the headaches
  4. Has responded well to an injection of a numbing agent or a local anesthetic in the office.  For example, the headache goes from 9 to 1 on the pain scale

When the patient has been numbed in the office, I can identify the problem nerves and the patient also gets the chance to "test drive" their results, to see where they would be numb if we did cut those nerves.

While Ronny was afraid of having his nerves cut prior to the surgery, the pain was awful enough that he felt he had no choice but to undergo the procedure.  He does report some numbness behind his ear and in his forehead, but says he hasn't had any really noticeable side effects form the surgery, and in fact, doesn't even think about it any more!

If you're dealing with migraines and want to know if migraine surgery can help you. here's how to find the right surgeon for you:

  1. Look for someone with specific training in peripheral nerve surgery during either a residency or fellowship.
  2. Use a surgeon who has done nerve surgery not just in the head and neck but all over the body
  3. Preferably find a surgeon with specific training in this headache operation 
  4. Utilize a surgeon who could provide patient references, ideally from several years out, to show the results are lasting
  5. You can use the American Society for Peripheral Nerve to look for members

While Medicare covers migraine surgery, many insurance policies don't because the surgery is new.  Always discuss insurance with your surgeon's office because they will help you understand the costs, what is covered and what is not. 

We then joined the studio panel for The Doctors, where Ronny shared his story, and that he is nearly 100 percent pain-free after the surgery.  I was asked by Plastic Surgeon Dr. Andrew Orton why Ronny was such a good candidate for this surgery.
To me, the ideal candidate:
  1. Has been diagnosed with migrianes by a board-certified neurologist or headache specialist
  2. Has failed conventional therapies including various drugs and injections
  3. Has a good physical exam that shows there's a peripheral nerve that is casing the headaches
  4. Has responded well to an injection of a numbing agent or a local anasthetic in the office.  For example, the headache goes from 9 to 1 on the pain scale

When the patient has been numbed in the office, I can identify the problem nerves and the patient also gets the chance to "test drive" their results, to see where they would be numb if we did cut those nerves.

While Ronny was afreaid of having his nerves cut prior to the surgery, the pain was awful enough that he felt he had no choice but to undergo the procedure.  He does report some numbness behind his ear and in his forehead, but says he hasn't had any really noticeable side effects form the surgery, and in fact, doesn't even think about it any more!

If you're dealing with migraines and want to know if migraine surgery can help you. here's how to find the right surgeon for you:

  1. Look for someone with specific training in peripheral nerve surgery during either a residency or fellowship.
  2. Use a surgeon who has done nerve surgery not just in the head and neck but all over the body
  3. Preferably find a surgeon with specific training in this headache operation 
  4. Utilize a surgeon who could provide patient references, ideally from several years out, to show the results are lasting
  5. You can use the American Society for Peripheral Nerve to look for members

While Medicare covers migraine surgery, many insurance policies don't because the surgery is new.  Always discuss insurance with your surgeon's office because they will help you understand the costs, what is covered and what is not. 

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Ziv M. Peled M.D. Presents Burning Migraine Questions Episode 8 April 18, 2019

Dr. Ziv Peled Presents No Date

Ziv M. Peled , M.D. Presents Burning Migraine Questions for April 18, 2019. Dr. Peled discussed he following questions:

0:41 Can thyroid surgery cause occipital neuralgia?

1:58 Why are migraines on the left side or the right side, and why not on both sides?

7:35 Is Platelet Rich Plasma (PRP) an option to potentially lessen the pain of occipital neuralgia?

9:18 Following an occipital nerve block, I had a pronounced dent in the back of my head where my neurologist injected (it is tissue thinning, secondary to steroids). Is that a common reaction? Will it resolve with time?

13:42 Are nerve blocks mandatory prior to surgery? How long do they last?

16:50 You talk about removing a piece of muscle in the neck. How is that not going to leave me paralyzed?

21:12 You are a plastic surgeon; why are you operating on the brain and spinal cord for these operations?

23:05 Is the pain in the tongue associate with occipital neuralgia?

23:40 Can these operations be done arthroscopically (or endoscopically)?

For more information visit and be sure to watch Dr. Peled on The Doctors April 25th!

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Fears and Misconceptions About Headache/Migraine Surgery - Part 1

Fears and Misconceptions About HeadacheMigraine Surgery Part 1

Many patients have told me about their fear and anxiety regarding an upcoming surgical procedure.  Having undergone several operations as a patient myself, I can empathize with these emotions and often tell patients that it is completely normal to feel this way before going “under the knife”.  I also try to re-assure them and their loved ones that they will be taken care of as best as possible before, during and after their procedure.  However, it struck me that there are often many misconceptions about headache/migraine surgery that heighten this anxiety so I though I would address them in a few blog posts.  It would be impossible to discuss every possible misconception I’ve heard, but hopefully some of these explanations will help.

  • Misconception 1 - These operations are like brain or spinal surgery. This is a common misconception because we are operating on nerves in the head and neck region.  However, there are numerous nerves in those areas of the body that are not within the skull or spinal column.  Because these nerves are located outside of the central nervous system (i.e. the brain and spinal cord) they fall under the field of peripheral nerve surgery, much like carpal tunnel release.  In fact, most patients have had numerous imaging studies of their brain and spinal cord which have revealed nothing in those areas that their initial treating physicians think would account for their symptoms.  And much like carpal tunnel syndrome, many of these nerves can be compressed at certain anatomic points which fortunately, can be released during a set of outpatient surgical procedures that are safe and very effective.
  • Misconception 2 – Cutting a piece of muscle in my face or neck will leave me paralyzed. I have heard this misconception many times and it is simply untrue.   The amount of muscle we remove when we perform a decompression of say the greater occipital nerve is about the size of a thumbnail in a muscle almost as big as the bicep.  Therefore, it is akin to performing a muscle biopsy, a commonly performed operation.  If you think about it, the target nerves in a headache operation are quite small (which is why they are often unable to be imaged well even with MRI) and therefore the space we need to make for them doesn’t have to be enormous.  I have yet to have a patient return to the office with any decreased muscle function.  While complications such as paralysis can occur with any operation on a nerve, proper technique and a thorough knowledge of anatomy makes this possibility quite rare. It is therefore important, for this and many other reasons, to seek out an experienced peripheral nerve surgeon for your headache/migraine operation (see blog post on “How To Choose A Headache Surgeon”)
  • Misconception 3 – Cutting any nerve will always lead to more pain. If I only had a dollar for every time I’ve heard this sentence.  It is often something that patients will hear from their non-surgical physicians and is simply untrue.  In fact, one of the most common surgical procedures performed is cutting of a nerve between the toes for a condition known as “Morton’s Neuroma”.  If this misconception were true, these operations would no longer exist.  It is also a commonly accepted peripheral nerve surgical dictum, that a neuroma must be removed and the nerve either reconstructed or the nerve end buried in the local muscle.  With these maneuvers, a painful neuroma is very unlikely to form.  While there is always the risk of increased pain when operating on any sensory nerve (even the one in carpal tunnel releases), with proper technique and a thorough knowledge of anatomy the likelihood of this issue is very low.

Hope these explanations help to some degree.  In a future blog post, I plan to address other misconceptions that seem to strike fear in the hearts of those considering an operation for relief of their chronic headache pain.  To learn more about Migraine Surgery, visit today or call 415-751-0583 to make an appointment.

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Ziv M. Peled M.D. Presents Burning Migraine Questions Episode 7 April 4, 2019


Dr. Ziv Peled Presents No Date

Ziv M. Peled M.D. Presents Burning Migraine Questions Episode 7 April 4, 2019

Dr. Peled answered the following questions:

  • 0:32 Is Occipital Neuralgia truly idiopathic or is the cause more often than not some sort of compression? Have you ever encountered inflammation of the nerve with no visible cause?
  • 6:10 Why do surgeons use different incision techniques for the same procedure? Is one technique better than another?
  • 7:34 Do you use botox injections for chronic migraines?
  • 12:46 What is your opinion on occipital nerve blocks for neck pain relief and how often should they be done?
  • 16:27 Why could you get a rebound headache after an occipital nerve block?
  • 23:02 I was told by another provider to never get nerve decompression surgery because the nerves would grow back, regenerate and cause more pain. Can nerves regrow? Can scar tissue prevent subsequent decompression surgery?
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Real Patient Stories: Eleanor

RPS Eleanor 2

What is your name?

Eleanor Thaler.

Where are you from?
I am from Eugene, Oregon, but currently live in Minneapolis, Minnesota.

What was happening in your life before the headaches became chronic?
I started having migraines at age 14. At that time, I was a typical, young student heavily involved in both music and dance. Outside of school, I took lessons in piano and violin as well as ballet and pointe.

How long ago was that?
At first, the migraines occurred every other day, beginning when I was 14, and I would plan my life and schoolwork around this schedule. Throughout high school, my headaches increased in frequency until I was having 5-6 headache days per week. When I started college at age 18, my migraines became constant and more intense. I had two procedures with Dr. Peled--one at age 20 and one at age 21. I am now 22.

Describe a good day with chronic pain.

On a good day, distraction from pain was possible. When I was able to adequately manage my pain with medication, I spent time with friends or studied in the library rather than my dimmed room. If I had enough energy, I could go to the gym or for a short run, although my energy was limited.

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

During college, my pain was constant. Pain was always there, waiting for me, when I woke up in the morning, and it would increase steadily throughout the day. It felt like a stake had been driven through my right eye and was being continuously hammered into my skull. I would take naps for 2-4 hours daily, as focusing during morning classes while struggling against mounting pain was utterly exhausting. As the day wore on, I would become dizzy and nauseous as the pain worsened, and eventually, my hands would start to shake, making it difficult to write or study. More than once, I had to wear sunglasses to my afternoon classes to tolerate even the dim fluorescent lights in my lecture halls. After school, I would drag myself home and collapse in my darkened room, and I counted the hours until I could sleep again.

A social life was not an option. It became too painful to watch friends become disappointed and frustrated with me when I was no longer able to attend social outings; most of my friends fell away over time. Focusing my attention on school, in an attempt to distract myself from pain, was what made it possible to endure the suffering. I dreaded the time that I had to spend awake each day. At my lowest point, I only kept myself going for the sake of my parents.

ET Before painWhere did you experience the pain?

My pain was located just above my right eye with occasional radiation to my right temple.

What meds were you taking?

I had run the gamut of available medication, both prophylactic and abortive, for migraine pain. For prophylactic management, I had tried topiramate, lamotrigine, gabapentin, propranolol, indomethacin, nortriptyline, amitriptyline, Fioricet, duloxetine, riboflavin, and magnesium. For acute management, I had tried Toradol injections, sumatriptan, naratriptan, eletriptan (my personal favorite), rizatriptan, and zolmitriptan. I had prescriptions for two triptans at a time and would cut tablets in half to ration them throughout the month. I knew I was giving myself rebound headaches by taking medication too frequently, but I didn’t know what else to do

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

I tried trigger point injections and Botox injections. My first round of Botox gave me significant relief, but I did not get any relief from the second round. Trigger point injections only helped for a few days at a time. I also tried massage therapy, physical therapy, acupuncture, meditation, and dietary changes without much relief.

How did you hear about Dr Peled?

After six years of worsening pain, I often felt forgotten by my providers after the first few treatment attempts were unsuccessful. I got the sense that my providers did not understand just how much my pain had taken from me. I began to feel invisible. Desperate for relief, I began conducting my own research into treatment options and clinical trials. I found Dr. Peled’s work through a database of clinical trials. I followed the study for a year and a half before I reached out directly to his practice.

What inspired you to speak with him?

After being told several times by other providers that I was out of options, I decided it was time to take the initiative and reach out to Dr. Peled’s office myself. I had followed the clinical trial for over a year and a half, and I knew it was time to trust the research that I had done and be my own advocate.

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

I have had two procedures with Dr. Peled. My first procedure was in May of 2016. I arrived on a Friday and had diagnostic nerve blocks that significantly reduced my pain. Surgery took place the following Monday. At that time, branches of my right auriculotemporal, zygomaticotemporal, supraorbital, and supratrochlear nerves were cut and embedded into the surrounding muscle. In addition, my right supraorbital notch was widened to relieve the compressive pressure on my supraorbital nerve from a nearby blood vessel. I saw Dr. Peled two days post-op for a follow-up appointment and flew home to Oregon later that day. He continued to check in periodically throughout the year by phone.

About one year after my first surgery, my pain returned. I again tried conservative pain management without significant relief. I reached out to Dr. Peled’s office again and scheduled a second trip to see him. This second procedure was in January of 2018. I again arrived on a Friday for diagnostic nerve blocks. During my second surgery, Dr. Peled found that a separate branch of my right supraorbital nerve was embedded/encased in my frontal bone. He chiselled off small slivers of my frontal bone to free the compressed supraorbital nerve and then used fat from my eyelid to pad the nerve and protect it from further damage. By doing so, he was able to salvage the nerve. I flew home following my post-op appointment two days after surgery. In January of 2019, I had my final follow-up call with Dr. Peled one year after the second surgery.

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

I woke up from my first surgery without pain. I did not need any post-operative pain medication,  and was working full-time one week after surgery.

My second procedure was more extensive, and thus recovery was a little slower. Still, I only required pain medication for two days following surgery. I had intermittent swelling in the right supraorbital region (which was expected) over the first several months, but this decreased in both frequency and severity over time.

ET After outside on the beachHow are you feeling now?

Since my recovery, I have had the privilege of watching my limitations fall away. I now live a life without pain, and only get occasional tensions headaches (once or twice per month) that respond to Excedrin. Prior to surgery, my headaches could not be managed by OTC medication.

How has your life changed as a result of this surgery?
I am able to work a full-time job with a variable schedule, including overnights, without pain. I can drive places without being afraid that I will be in too much pain to get home. I don’t need to nap during the day, and I don’t need to make sure I have triptans in my pocket every time I leave the house. Most importantly, I can be more present in my life and engage fully in the things that interest me. I certainly live more courageously now that pain is no longer a looming presence in my life. I am able to have closer relationships with my friends and family now that I have the bandwidth to do so. For a long time, pain was in the driver’s seat of my life, but now I am in control and get to choose how to use my time and energy each day. After eight years of merely surviving, now I am able to really live.

What is next for you?
After a relatively non-linear path through school due to pain, I am so excited to be starting medical school in the fall. My journey through pain (and the opportunity to help other patients feel supported during their own journeys through illness) was largely what drew me to a career in medicine. The relief I have gotten from my surgery is what made the pursuit of this dream possible.

What would you say to anyone wondering whether to meet Dr Peled?

I hardly have words to describe how grateful I am for having met and been treated by Dr. Peled. He is truly at the top of his field. There is no better time than now to take control of your story and reach out for help – there are so many wonderful things to be a part of in the world when your experience isn’t overrun by pain! My experience with Dr. Peled gave me my life back, and I will forever be grateful for him and his incredible team for taking such good and thorough care of me.

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

Dr. Peled was the first provider to validate my experience and make me feel seen.  Not only did he listen, but I felt that he truly heard my story and my experience. I felt 100% supported by him every step of the way, even when I required a second procedure a full year after my first, and this meant more to me than I can express. Dr. Peled never gave up on me nor hope for improvement in my pain, and I am so incredibly lucky to have been under his care.

As a young student traveling to the practice from far away, I was nervous leading up to my initial consultation, but Cary-Anne set me at ease and answered all of my questions. She made me feel so comfortable and welcome when I arrived for my appointment, and I am very grateful for her support along the way.

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

Now is the time to make a change and take your life back – go ahead and call!

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Ziv M. Peled, M.D. Answered Your Burning Migraine Questions Episode 6 March 21, 2019

Ziv M. Peled M.D. Presents Landscape


Ziv M. Peled, MD answers your Burning Migraine Questions! In Episode 6:

0:32 Does the lesser occipital nerve innervate areas typically innervated by the auricular temporal nerve or does it innervate further up the head?
2:55 How does a patient know whether they are a candidate for a second nerve decompression operation if the first one failed or only produced partial success?
7:35 Can occipital neuralgia cause symptoms or pains in other parts of the body?
9:40 A patient fell down steps and hit the lower part of her head and lower back, and has been in horrible pain ever since. She has symptoms including dysesthesia, or altered sensation: her hair hurts and she hates having people touch it. What is going on?
14:30 Is burning the nerve (radiofrequency ablation) suggested?
20:15 I have a lot of nausea associated with my migraines. Will surgical intervention relieve that?
22:50 If one doesn't respond to nerve blocks, are you not a candidate for nerve decompression surgery?
25:55 If you have a nerve stimulator implanted in the cervical area and is wasn't successful, does that preclude you from having surgery?
27:50 A lot of surgeons have any number of different incisions to access nerves. Which one is better?

To learn more about migraine surgery, visit today!

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Ziv M. Peled, M.D. Answered Your Burning Migraine Questions Episode 5 March 7, 2019


Ziv M. Peled, MD answers your Burning Migraine Questions! In Episode 5:
0:34 Is Occipital Neuralgia considered a headache, a migraine or something else?
6:15 What is a neuroleptic?
6:32 Several years after my surgery, I still have a hyper-sensitive or numb area after nerve decompression (surgery). What does that mean?
10:30 Botox didn't work for my headaches; it actually made my headaches and neuralgia ten times worse. Why does it work for most people but it didn't work for me?
16:00 How do hormones affect migraines?
20:15 What are the different types of nerve blocks used to treat Occipital Neuralgia?

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The Long & Winding Road

One of the most common refrains I hear from patients is that they are flummoxed by the lack of understanding from their neurologists or neurosurgeons

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