Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.

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.

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

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

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

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

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Get Migraine Relief Right up the Coast, Beverly Hills

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

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

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

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"A Novel Surgical Approach to Chronic Temporal Headaches"

My paper, "A Novel Surgical Approach to Chronic Temporal Headaches" has been accepted into for publication in Plastic and Reconstructive Surgery!  This is a huge honor and  will help me reach a large audience to let them know what you already know if you've been following our site - Chronic Temporal Headaches can be relieved with surgery.  If you suffer from migraines or chronic headaches, there is a way to help.

 

Keep an eye on this blog and our Facebook and Twitter pages to read the article in full when it's released.  If you have questions about migraines or nerve surgery, you can read all about them here at peledmigrainesurgery.com or call us to talk about it at 415-751-0583 on San Francisco or 925-933-5700 in Walnut Creek.  You don't have to live with chronic migraines any more.  Don't spend another day in pain.

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The Staged Approach to Migraine Pain Relief

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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.  The first is that in many cases, patients often say that one area usually flares up first and when very severe or unable to be controlled, 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 the 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 such 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.  Secondly, 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, however, in that if the occipital procedure is performed correctly and for the right indications, but yields no result, I would wonder whether or not a temporal/frontal procedure would be indicated since I would be less confident surgical intervention in those areas would be successful if 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 given 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.  Greater degrees of discomfort often lead to increased opioid use which, as many people will agree, 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 patient’s should ask their potential surgeons is how they approach patient and why, especially if their case will involve more than one or two incisions.  I hope that these thoughts are helpful.

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

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Our New Walnut Creek Address

Peled Plastic Surgery has moved our Walnut Creek office!  We are now located at 100 N. Wiget Lane, Suite 160 in Walnut Creek, CA.  The new office will allow us to see patients more efficiently. We are happy to have our new Walnut Creek base of operations up and running, and are looking forward to seeing you there!

 

Call us at 925-933-5700 to make an appointment for plastic surgery, migraine surgery, or any of our other treatments, and visit www.peledplasticsurgery.com to learn more about us!

 

About Dr. Peled

 

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.

In addition to his cosmetic and reconstructive work, Dr. Peled helped to found a peripheral 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.  He continues to volunteer for the American Diabetes Association and has recently traveled to South America to provide reconstructive surgery to underprivileged children. In his spare time, he actively competes in both Half-Ironman and Ironman-distance triathlons.

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If Botox Doesn't Work, What's Next For Chronic Migraines?

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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".

Botox works primarily by relaxing muscles. In some people with chronic headaches, the nerves responsible for the pain that they feel are pinched by spastic muscles in the neck, temple or forehead. Injection of Botox into the muscle fibers around where the nerves are pinched may produce pain relief by relaxing those specific muscle fibers and reducing pressure on the nerve. However, the doses of Botox used and the injection technique are critical to achieving the desired result. Many patients have had Botox administered over numerous injection points (e.g. >30 injections) using relatively low doses at each injection site. Often, many of these injection sites don't correspond to the location of a pinched nerve within the muscle being relaxed by the Botox. While this technique may be successful some of the time, I have found much greater success and more accuracy by targeting points where nerves are known to pass through spastic muscles with slightly higher doses of Botox. By targeting specific areas of muscle known to be potential nerve compression sites, the overall dose of Botox and number of injections can be minimized. This technique not only reduces overall discomfort, but can keep costs to a minimum while still optimizing the potential benefits. Stated another way, the effectiveness of this approach is often much higher because the spastic muscle fibers immediately around a nerve are more relaxed and other muscle areas that don't have a nerve around them are left alone. The take-home message is that Botox must be used with appropriate dosing and appropriate injection techniques in order to achieve the desired result. If these parameters are not in place, a negative result may occur, but may not mean that the Botox was ineffective.

For more information, and to make an appointment with us to discuss Botox or peripheral nerve surgery to alleviate your headaches, contact our San Francisco Office at (415) 751-0583, our Walnut Creek Office at (925) 933-5700, and visit us online at today.http://peledmigrainesurgery.com 

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How long does recovery take following nerve decompression surgery for chronic headaches?

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

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

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

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

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Why Did I Get Occipital Neuralgia?

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

 

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

 

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

 

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

 

For more information, read http://peledmigrainesurgery.com/blog/entry/whiplash-and-occipital-neuralgia-what-s-the-connection-1.html and visit www.peledmigrainesurgery.com for information on how to reduce your migraines and nerve pain.

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Dr. Ziv M Peled Wins Most Outstanding Paper at CSPS

Dr. Ziv M. Peled's paper entitled, "A Novel Surgical Approach to Chronic Temopral Headaches" won the 'Most Outstanding Paper Award' at the 2015 California Society of Plastic Surgeons annual meeting this past weekend in Monterey, CA! The paper was presented by Dr. Peled during the 4-day event that featured the top plastic surgeons in California giving presentations on their areas of expertise. Dr. Peled's paper was chosen from dozens of nominees as the top paper overall.

 

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CSPS Title

 

Ziv Presents

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Can You Get Migraine Relief Outside of San Francisco As Well?

headache - mediumDo you have to live in the San Francisco Bay Area to get relief from your severe, chronic headaches? No, anyone may be able to achieve significant and lasting relief no matter where they call home! We have helped patients from all across the United States, and as far away as India and Brazil. We are excited to help people from all over the globe as peripheral nerve surgery is an area to which I have dedicated a large portion of my practice and is something about which I remain very passionate. We wish to extend an invitation to everyone anywhere to look us up and decide for themselves whether we might be able to help to reduce or eliminate their chronic headaches with peripheral nerve surgery.

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

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

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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.

One obvious conclusion is that there are other trigger points that have yet to be treated surgically and were not detected prior to the operation in question.  In some cases, operating on many trigger points is done in a staged manner on purpose because recovery after release of, for example, 16 different nerve trigger points throughout the head, neck and scalp would be a very prolonged and rather uncomfortable post-operative recovery process.  In other cases, once the primary and most painful trigger were adequately treated, areas that were and remained less severely compressed and therefore less noticeable reared their ugly heads. In these instances the treatment was to work up these additional potential trigger points as I did the primary trigger points and treat them surgically if deemed necessary.

A second possibility also occurred to me quite some time ago as I spoke to patients about how they treated their residual headaches. There are a number of patients who have told me that pre-operatively they would take whatever preventative or abortive medication(s) they were prescribed by their treating physicians and that the medicine would work “approximately 50%” of the time. In other words flip a coin.  Post-operatively, however, when these same patients experienced severe headaches, they found that the same medications almost always worked. I would hear this refrain over and over again and many a patient was puzzled by the change.

If you think about it, however, the answer actually makes perfect sense.  I believe that some patients actually have a combination of mechanical compression over one or more nerves in addition to chemical imbalances within the brain that cause their headaches. Once a surgical procedure has treated the former, the latter is all that remains.  Therefore, when a post-op patient experiences a severe headache that cannot be attributed to a persistently compressed nerve in another area, it could be secondary to a chemical imbalance.  If that is true, then medication will help and explains why medication seems to be more effective after surgery, when needed.  With this combination of treatment modalities, patients tell me on a consistent basis that their chronic headaches have gone from a debilitating to a very manageable problem.

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CHRONIC MIGRAINE RELIEF

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 is permanent.

For more information, please visit www.peledmigrainesurgery.com and call 415-751-0583 to setup an appointment!

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Hey Dr Peled, What Is 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.


The procedures performed on these peripheral nerves ultimately depend upon the pathology in question. If there is external pressure on the nerves causing irritation, this external pressure is relieved. An example of this type of procedure is that performed during a nerve decompression to treat chronic headaches. If there is a tumor within the nerve, it can often be removed and the nerve preserved or in other cases reconstructed to preserve sensation and function. If a nerve has been cut, it may be able to be repaired surgically.
Plastic surgeons with peripheral nerve experience have been performing peripheral nerve surgery for years to correct a common and well-known malady known as carpal tunnel syndrome, where the surrounding tissue pinches the one of the main nerves at the wrist. These surgeons decompress or un-pinch the nerve by adjusting the tissue surrounding it, leaving the nerve intact. This procedure has a very high success rate. Recent research has demonstrated that just like at the wrist, there are nerves within the head and neck that are compressed and that decompressing them, can produce significant or even complete relief from chronic headaches that can be permanent. The results with these latter procedures have been quite dramatic. In one study out of Georgetown University, data from 190 patients with chronic pain/headaches in the back of the head who underwent surgical decompression were analyzed. One year after surgery, the patients were evaluated and over 80% of patients reported at least 50% pain relief and over 43% of patients experienced complete relief of their headaches! In February 2011, the five-year results of such procedures were published in the medical journal, Plastic and Reconstructive Surgery. This study demonstrated that five years following their headache operation, 88% of patients were still reporting greater than 50% improvement in their headache symptoms and 29% were completely headache-free!
To find out more about these exciting developments, please visit http://peledmigrainesurgery.com or call us at (415)751-0583 to schedule a formal consultation.

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Aneurysmal Superficial Temporal Artery Compressing the Auriculotemporal Nerve

 

A short video showing the Aneurysmal superficial temporal artery compressing the auriculotemporal nerve.  Click on the images below to get an annotated view of what you're looking at.

 

 

Aneurysmal superficial temporal artery compressing the auriculotemporal nerve2Aneurysmal superficial temporal artery compressing the auriculotemporal nerve  1

 

 

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

Botox InjectionI’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.

Second, keep in mind that the 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 mentioned above several times 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 quite 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.

For more information, visit www.peledmigrainesurgery.com and call 415-751-0583 for appointments.

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Whiplash and Occipital neuralgia: what’s the CONNECTION?

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

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

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

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

For more information, visit www.peledmigrainesurgery.com today and call 415-751-0583 for appointments.

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WHAT CAUSES OCCIPITAL NERVES TO MALFUNCTION?

Axon -mediumAs I have posted several times in the past, the occipital nerves can be compressed by a number of different structures such as blood vessels (e.g. the occipital artery), fascia, scar and muscle. But someone recently asked me how these structures can cause pathologic changes in the nerve so I thought I’d put down a few thoughts. First, there are changes that can occur after injury whether surgery or a stretch injury as one would get with “whiplash” (see post: “Whiplash and occipital neuralgia: what’s the connection?”, 01/21/14). Many of the post-surgical changes are detailed in my more recent post, “WHY DO NERVES TAKE SO LONG TO RECOVER?”, 04/29/14) and will not be repeated here. So what happens to a nerve after prolonged compression?

Well, way back in 1995, some of the first peripheral nerve surgeons were able to demonstrate exactly that in a non-human primate model. They induced carpal tunnel syndrome in cynomologous monkeys and then biopsied the nerves at various time points thereafter. They then also looked to see what happens when those same nerves were decompressed. The results are seen in the attached picture. In the upper left “normal”, you see a biopsy of the median nerve in a non-compressed animal. The black rings are the thick myelin sheaths that surround the white spaces which are the nerve fascicles themselves and help the nerves conduct impulses more efficiently. After six months of compression (upper right) you can see that the myelin sheaths are already beginning to thin out and the nerves no longer conduct as quickly. Clinically that may manifest as intermittent numbness and tingling and on EMG you are likely to find prolonged conduction velocity. With prolonged compression (12 months, bottom left) you not only see further thinning of the myelin sheaths, but fewer numbers of nerves (white spaces surrounded by thin black rings). Now you may clinically have constant numbness and the EMG may find decreased amplitude since there are fewer nerve fibers actually conducting impulses. You can imagine what would happen if the nerve were left alone even longer. After decompression (bottom right) you can see that the myelin sheaths never fully return, but the number of axons (nerve fibers) increases as the nerve recovers.

So what does this have to do with ON? The answer is that it really doesn’t matter what’s compressing the nerves (muscles, discs, fascia, blood vessels) the long-term effects are the same as those noted above. Has this been proven directly for the greater occipital nerve, for example, - no, but there is no reason to suspect that the sequelae of compression of peripheral nerves in the head/neck would be different than those at the wrist. Therefore it stands to reason that if there is mechanical compression on a nerve, all the medicine in the world won’t relieve that pressure - it has to be removed. If that is done within a timely fashion, the nerve could recover, if not, it won’t. How much pressure is too much and how much time is too much? Those are questions we don’t have answers to and I’m not sure we will any time soon. However, for most people suffering from the often debilitating pain of ON, it cannot be soon enough.

For more information, please visit www.peledmigrainesurgery.com today, and call 415-751-0583 for appointments.

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HOW MANY HEADACHES IS TOO MANY?

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

Pain by definition is a subjective experience. There is no objective way to measure it such as with a blood test or an MRI. This fact represents one of the biggest challenges in treating people with pain. Moreover, what I’ve gleaned is that it’s not only the actual episodes of pain that often constitute the greatest burden to people. Many times it is the constant lifestyle adjustments and manipulations often required to stave off the onset of pain that are the most difficult for people to manage. Patients often have to avoid social situations they’d like to be in, avoid foods they love to eat, and avoid activities they used to love participating in. To add insult to injury, I’ve also been informed by patients that their other “headache doctors” told them that they would terminate them as patients if they undergo surgical decompression.

I find such statements quite sad because they often leave patients very conflicted perhaps due to the fact that this other doctor has provided some measure of relief that they are afraid they will lose if they pursue other options. It also goes against my general opinion of how chronic headache pain (and all chronic pain for that matter) should be managed. I believe that a multi-modality approach that yields the best results. Just like in breast cancer treatment during which a patient often has surgery to remove the cancer with a breast surgeon, chemotherapy/hormone therapy with a medical oncologist and radiation treatment with a radiation oncologist. Only when these physicians work together do patients derive the optimal benefit.

Who then is anyone else to say how much any individual person should suffer? I believe that the role of the physician in these cases should be to establish a diagnosis if possible and formulate a treatment plan to address the pathology in question if possible often in combination with other clinicians. The physician should then educate the patient about his/her diagnosis and the possible treatment options. Patients must then decide for themselves based upon an evaluation of the potential risks and benefits of the proposed treatments which treatment options are best for them. The take home message - don’t let anyone else make a value judgment for you. They can’t.

To learn more about migraine treatments and peripheral nerve surgery, call 415-751-0583 and visit www.peledmigrainesurgery.com to set up an appointment!

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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?

headache, migraine surgeryThis 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.

In reality however, this approach has a number of significant drawbacks. First, if the RFA probe tip is not placed in the exact correct position, the nerve is not completely destroyed. As a peripheral nerve surgeon who routinely uses high powered loupe magnification and operative microscopes in the operating room to find, decompress and/or repair nerves I can emphatically state that nerves are often small and very difficult to find, even when looking at them directly with magnification. Moreover, they are often encased in scar tissue which is tough and can be difficult to penetrate with a scalpel or scissors, much less a tiny probe. Thus if the RFA probe tip doesn’t target the nerve just right to completely destroy it, it creates a thermal zone of injury around the nerve. Sometimes this “stuns” the nerve (i.e. neurapraxia) and there is temporary relief (a few days, weeks or months) until the nerve recovers at which point the pain can return. Other times the thermal zone of injury is far enough away from the nerve that the nerve itself is not affected. In this case, not only can the original pain remain unchanged, but other structures around the nerve can be damaged secondary to formation of scar tissue thus leading to more pain. In addition, one of the maneuvers required when intentionally cutting a nerve is to bury the proximal nerve end into muscle because doing so can significantly reduce the chances of a painful neuroma forming. A neuroma is a regenerating nerve that can cause significant pain. Think of a downed power line in the middle of the street writhing like a snake with high voltage sparks coming out of it. Hence, even if the RFA probe successfully ablates a nerve, but does so in an area where the remaining viable nerve is not surrounded by muscle, a painful neuroma can form leading to more pain.

Now, no procedure is foolproof and peripheral nerve surgery for headaches requires general anesthesia and all the risks that the former and latter entail. But, performed in an accredited institution by a properly trained surgeon, the rates of complications are very low and the complications that do occur are relatively minor. I also believe that the best way to determine whether a nerve is salvageable and can be decompressed or is too injured and must be either excised and buried or reconstructed is to look at it directly in the operating room. So what to do if you’ve had RFA and still have pain? See a peripheral nerve surgeon for a formal evaluation to determine whether surgery is possible and if so, have a frank discussion of the operative plan beforehand. After all, even if the nerve is found to be severely damaged in the operating room, there are still options which can lead to significant pain relief.

For more information, please call 415-751-0583 to setup an appointment and visit www.peledmigrainesurgery.com today to learn more about peripheral nerve surgery.

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Migraine Relief May Be Closer Than You Think

The nerves causing your headaches are typically located in one of four different locations within the head and neck region. The first site is between the eyebrows, also known as the glabella. The nerves that can become compressed in this area are known as the supraorbital and supratrochlear nerves. These nerves can become pinched by the muscles within this region that cause the frown lines with which many of us are familiar. The next site is the temple region and the nerves which can be compressed in this area are called the zygomaticotemporal nerves and auriculotemporal nerves. These nerves can become compressed by one of the muscles used for chewing (the temporalis muscle) or by an artery which can wrap itself around one of these two nerves or its branches. The third area that can be a trigger zone for chronic headaches is the back of the head and the nerves in this area which can be the cause of trouble are known as the greater, lesser and third (or least) occipital nerves. These nerves can be compressed (i.e. pinched) by the strong neck muscles which can be in spasm, by the sinew that surrounds them or by other small blood vessels which can wrap themselves around these nerves as well. Finally, nerves within the inner lining of the nose can also become irritated and result in chronic headaches such as migraines.

Once the nerve or nerves causing the problem have been correctly identified, an outpatient surgical procedure can be performed to remove the mechanical compression causing the nerve irritation. This procedure is performed by making an incision through the skin, identifying the offending nerves, safely protecting them and removing any of the mechanically compressive tissues. In some situations, if the nerves are too damaged, they are actually removed, but only in areas where very little loss of sensation would occur. In many of these cases, patients often never know that a nerve has actually been excised.

A recent study from Georgetown University followed 190 patients who had migraines secondary to occipital neuralgia (i.e. peripheral nerve compression) and who underwent surgical decompression. At an average follow-up of one year, 80.5% of patients experienced 50% or greater pain relief and over 40% of the patients experienced complete relief of their headaches (Ducic, et al, Plastic and Reconstructive Surgery, May, 2009, 1453-1461). In addition, another study published just last year demonstrated that at 5 years post-surgery, these benefits persist with continued reductions in headache severity, frequency, and/or duration (Guyuron, et al, Plastic and Reconstructive Surgery, February, 2011, 603-608). Dr. Peled’s results are comparable to these results and as you can see by going to the ‘Testimonials’ page, many of his patients are now headache-free. It is estimated that migraines afflict over 35 million people in the United States alone. The annual cost to the healthcare system in terms of ER visits, medications, injections and lost productivity is estimated to be in the range of $15 billion per annum. Fortunately, the surgical treatment noted above has shown extremely promising results.

To learn more about migraine relief surgery, visit www.peledmigrainesurgery.com today and call 415-751-0583 to set up an appointment to see Dr. Ziv Peled.

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