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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 chemicals (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 multiple classes of medications such as triptans, anti-depressants, muscle relaxants, blood pressure medications, narcotics, neuroleptics, ergotamines, and so on. Fortunately, a different perspective on such debilitating, chronic headaches has produced remarkable results with respect to headache relief.


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/compression problem known as carpal tunnel syndromefor decades. 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. 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 can be permanent.



During your consultation with Dr. Peled, he will take a thorough history including all of your past medical problems, but focusing specifically on your headache symptoms. We will discuss all of the prior treatments which you have tried in the past and go over any old imaging studies. Dr. Peled will then perform a comprehensive physical examination to elucidate if there are any physical findings that suggest that a pinched nerve in the head or neck could be causing your headache. Further imaging studies (i.e. MRIs or CT scans) may be required and if so, they will be ordered accordingly. A series of in-office injections with local anesthetics will then be performed sequentially to determine which nerve or nerves may be involved in your particular case. Depending on the results with these various steps, a decision will be made as to whether your headaches could be caused by a pinched nerve and hence your suitability for surgical intervention.




Nerve blocks are very powerful tools in helping determine whether or not a particular person is a good surgical candidate. Nerve blocks are simply injections of local anesthetic which will last typically between 4-8 hours.  Every once in a while, these blocks will last a shorter period of time (e.g. 2 hours) and occasionally they will last much longer (e.g. a day or more). As you might glean from this description, these blocks are diagnostic modalities, not treatment modalities. In other words, they will ultimately not fix your problem, but will help determine which nerve or nerves may be causing your problem. It is important to remember that nerve blocks must be done sequentially so that the treating physician may determine the possible involvement and approximate degree of relief you are likely to obtain if you ultimately operate on the nerve just blocked.  Stated differently, if you come to the office with 9/10 severity pain and you block 3 nerves with one injection and your pain goes to 0/10, even though that is a nice degree of relief you have no idea which nerve that was just blocked was responsible for that result because you blocked all of them at once. Therefore, these blocks have to be done with relatively small amounts of local anesthetic and in such a way so as to minimize the chance of blocking more than 1 nerve at one time. In this way, the operative surgeon may determine which nerves need to be addressed during an operation and will also give the patient a sense of the degree of relief possible, on a permanent basis and ideally without the associated numbness since many nerves are not transected (i.e. cut), but rather decompressed and subsequently allowed to recover thus preserving sensation.

In years past, although it might seem a bit odd, Botox was useful in the work-up to determine whether surgery would be be successful. Many of the nerves which can cause headaches can be compressed by muscles. Since Botox works by relaxing muscles, it may produce results similar to what may be experienced with surgery. As with nerve blocks, these injections must be performed in a very specific way, by someone with a thorough understanding of the anatomy which is being addressed. As a plastic and peripheral nerve surgeon, Dr. Peled had injected Botox hundreds of times for cosmetic as well as diagnostic reasons. The primary advantage of Botox over nerve blocks is that if you obtain relief, it may last a few weeks or even months. However, use of Botox in such situations also has many disadvantages which now are felt to outweiigh any possible advantages. Specifically, Botox can typically take several days to become effective thus requiring multiple office visits in order to identify each nerve involved.  Furthermore, it has now been well established that there are multiple, non-muscular compression points of numerous nerves in the head//neck region that are thought to cause chronic headaches. If these non-muscular compression points are involved in your particular case, then Botox may not be effective, but that doesn't mean that surgical intervention will not be effective (e.g. a false negative result). For these reasons and others (which Dr. Peled can discuss with you during your consultation), Botox is infrequently used as a diagnostic tool these days.




Surgical intervention (whether decompression or neruectomy/muscle implantation) for chronic headaches is performed as an outpatient procedure at an accredited surgery center or in the outpatient department of the California Pacific Medical Center. The procedures can last anywhere from 1 hour to 3 hours depending on the number and locations of the nerves being treated and what actually needs to be done with each individual nerve.  This plan will be thoroughly discussed with you prior to your operation. There are relatively few restrictions following the procedure and discomfort is usually very well tolerated with oral pain medication. The specific post-surgical instructions vary from case to case depending on the number of nerves treated and the manner in which they are treated (e.g. decompression vs. neurectomy).  These instructions will also be thoroughly discussed with you prior to your scheduled operation. The final results with surgical intervention (and this is true of many nerve operations) may not be known for up to one year post-operatively. For more specific information, please contact us for a formal consultation.






The results with these types of procedures have been quite dramatic. In one study out of Georgetown University, data from 190 patients with pain/headaches in the back of the head who underwent surgical decompression were analyzed. Over 80% of patients experienced at least 50% pain relief and over 43% of patients experienced complete relief of their headaches one year post-procedure! In February 2011, the five-year results of such procedures were published in the medical journal, Plastic and Reconstructive Surgery. These results demonstrated that five years following their operation, 88% of patients still reported greater than 50% improvement in their headache symptoms and 29% were completely headache-free! Dr. Peled himself has also published articles that further delineate the compression topography of several nerves treated during headache surgery and even described a novel surgical approach to a commonly treated nerve.

To find out more about these exciting developments, please call us to schedule a formal consultation.






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