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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