Peled Migraine Surgery Blog

Information and knowledge about migraine relief surgery.



What to look for when choosing a headache surgeon


  1. One of the first things to assess is whether your surgeon has significant and specific training in peripheral nerve surgery. Since the operations for chronic headaches/neuralgia potentially involve many nerves within the peripheral nervous system, the person performing such operations should have had focused training on the workup, evaluation and management of patients with any number of peripheral nerve problems (chronic headaches included). Because peripheral nerve surgery is performed on all parts of the body (e.g. arms, legs, trunk and head), your surgeon should ideally have experience and training with many of these types of nerve procedures because they provide the procedural foundation now employed in the operations designed for chronic headaches. A sample question that a patient might ask is what percentage of the surgeon’s practice is focused on peripheral nerve surgery.
  2. Another important thing to ask your surgeon is how many of these procedures they have performed. In addition to the specific number of cases s/he has performed, the surgeon should also have experience with the wide breadth of peripheral nerves that are known to be potential causes of chronic, severe headaches. These include nerves within the forehead, temple and occipital regions.
  1. Is your surgeon and member of the American Society for Peripheral Nerve (ASPN)? This society is the leading academic society for peripheral nerve surgeons. It’s mission is to stimulate and encourage study and research in the field of neural regeneration, to provide a forum for the presentation of the latest research and relevant clinical information and to serve as a unifying authority on all areas of neural regeneration and restorative neuroscience. In order to become a member there are a number of qualifications that a surgeon must meet. For example, a candidate has to be nominated by two of their peripheral nerve surgical peers and have published at least one scholarly, peer-reviewed paper on some aspect of peripheral nerve surgery. Looking for ASPN membership can serve as an objective vetting factor in deciding between several surgeons.  It also demonstrates a true commitment to the study of peripheral nerve problems and a genuine interest in advancing the field.
  1. Your surgeon should also be able to provide you with references for the type of procedure(s) he or she is recommending. Not only does this give you the chance to speak with someone who has gone through what you will likely experience, it demonstrates that the surgeon has actually performed the procedure at least once before.
  1. Finally, you should choose a surgeon with whom you have the best rapport. This is the hardest concept to describe or discern.  While there are still so few of us who perform these operations with regularity, realize that there still may be several qualified surgeons technically capable of performing the right operation for the correct indications.  However, just like every patient is different, so too is every surgeon.  Is their office staff professional and pleasant?  Does the doctor answer your questions in a manner that you can understand and make you feel at ease that they understand your particular situation?  Do they spend time actually listening to you and your symptoms?  Are they realistic in setting your expectations for what will happen before, during and after your procedure?  These factors can make the difference between simply a good outcome and a good outcome with a good experience along the way.
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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”. 

To learn more about Migraines and Post Traumatic Headaches, visit today.

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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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What is Peripheral Nerve Surgery For Migraines?

2018 06 15 1602

Dr. Peled explains what the term "Peripheral Nerve Surgery" means, and how it pertains to Migraine Surgery and Headache Surgery. 

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Determining Candidates For Migraine Surgery

Dr. Peled discusses the steps that Peled Plastic Surgery follows to determine if a patient is a candidate for headache surgery or migraine surgery.  The video above will help you determine if you may be a candidate, and then you can follow up with a call to Peled Migraine Surgery at 415-751-0583 or by visiting to learn more about this life-changing surgery.  Don't live with migraines if you don't have to.

2018 06 15 1602

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A Different Way to Think About Chronic Headaches

A Different Way to Think About Chronic Headaches

Chronic headaches represent an enormous medical problem both worldwide and in the US.  Migraines alone represent the most common primary headache disorder for which people seek treatment. It is estimated that over 36 million people suffer from migraines in America1, representing about 11.5% of the population or more than one in 10 people. Chronic migraines are thought to affect 2% of the population or over 7 million people in the US2.  If you factor in both direct and indirect (e.g. days of bedrest) costs to the healthcare system, you are looking at between $10-$30 billion dollars in annual expenditure3,4.  Moreover and specific to migraines, it has been shown that the health-related quality of life of people suffering from this type of debilitating headache approximates that of patients suffering from congestive heart failure, high blood pressure or diabetes5.  Interestingly migraines are primarily defined and diagnoses made by their clinical characteristics.  In other words, headache patients are usually diagnosed as suffering from migraines if they have recurrent attacks, a pro-drome (e.g. warning signal), an aura, a headache and a post-drome (e.g. after effects).  While many patients can relate to these symptoms, not every patient is the same. Specifically, while other types of headaches have slightly different characteristics, there are similarities in symptoms with migraines and sometimes, patients can have symptoms characteristic of more than one type of headache.  In those cases, how should we diagnose the patient? 

In my view, a different way to think about headaches and perhaps to classify them is by what the underlying etiology (i.e. cause) is thought to be.  I am a firm believer in doing the most conservative thing possible that would give you the best result and along those lines, an evaluation by a neurologist and/or headache specialist with a careful work up is a critical first step.  Appropriate imaging (e.g. MRI of the brain, cervical spine, etc.) as necessary and trials of medications are often the first lines of evaluation and treatment, usually with non-operative interventions as adjunctive measures.  Examples of such adjunctive modalities are physical therapy, therapeutic massage, acupuncture, biofeedback, etc.  However, as we note above, there are so many people that suffer from debilitating, chronic headaches that even if only 10% of people fail such measures (the number is likely much higher), then we have millions of people who continue to suffer greatly.  In these instances, we often have to “think outside the box”.  There continues to be a growing body of literature which suggests that some people suffer headaches as a result of peripheral nerve compression in the head and neck region and who find relief from nerve decompression or even neurectomy (i.e. transection of the nerve) with muscle implantation. 

Given that many people who fail traditional treatment as outlined above have been given the diagnosis of migraines (or migraine variants), perhaps it is our diagnoses that are incorrect.  Many of those same people are successfully treated with surgical decompression. Perhaps, many people who have been diagnosed with “migraines” actually have neuralgia.  This word comes from a combination of neur - meaning nerve and algia - meaning pain and hence the word itself literally means nerve pain.  The question is which nerve is causing the pain and what can you do about it?  Fortunately, there are good answers to these questions, but the diagnosis of neuralgia must be on the radar screen of the evaluating physician.  Hence, if traditional modalities have been unsuccessful or only partially successful, don’t lose hope!

  1. Lipton, R. B., Bigal, M. E., Diamond, M., et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007;68:343-349.
  2. Schwedt TJ, Chromic Migraine. BMJ 2014; 348: 1416-1427.
  3. Goldberg, L. D. The cost of migraine and its treatment. The American Journal of Managed Care 2005;11:S62-67.
  4. Hu, X. H., Markson, L. E., Lipton, R. B., Stewart, W. F., Berger, M. L. Burden of migraine in the United States: disability and economic costs. Archives of Internal Medicine 1999;159:813-818.
  5. Turner-Bowker, D. M., Bayliss, M. S., Ware, J. E., Jr., Kosinski, M. Usefulness of the SF-8 Health Survey for comparing the impact of migraine and other conditions. Quality of Life Research : An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation 2003;12:1003-1012.
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Recent Comments
Dear Kathy, I don't do pulsed RFA so I don't have a specific comment on how it works, but my understanding is the same as yours i... Read More
Thursday, 12 April 2018 10:26
I do think that, in general, many conservative modalities, so long as they don't injure the nerves further with too aggressive an ... Read More
Friday, 13 April 2018 10:39


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