Peled Migraine Surgery Blog

This is really the million dollar question for human kind, but in the case of nerves, I believe we have some ideas. I was recently asked why nerves are buried into muscle and what happens to them once they are in that location.  Conventional wisdom states that by burying a transected nerve end into muscle, a neuroma will not form.  This concept is based in large part on a paper written in 1985 which demonstrated in a non-human primate model that when a nerve is buried into muscle, the structure of the regenerating nerve fibers is different than a severed nerve left in the subcutaneous tissues.  It is thought that this structural difference accounts for the relative paucity of symptoms post-operatively when a nerve is buried into muscle.  However, as noted by some people, muscle burial isn’t always effective.  Why is that?  One possibility, of course is that the original theory is incorrect.  Another is that the buried nerve has come out of the muscle which is why it is important to bury a good length of nerve into the muscle to minimize the chance of this occurrence.  Another is that the amount of muscle covering the nerve is small and there is therefore still pain as a result of cutaneous pressure over the region.

A corollary to these questions is, “Why does it take a long period of time for the buried nerves to stop causing pain?”  The simple answer to this question is that no one really knows however there are several plausible explanations.  Keep in mind that a transected nerve is still attached to the spinal cord and the brain (we don’t rip them out of there) and therefore nerve impulses from the brain through the spinal cord to the nerve end continue to be generated.  One reason that the patient might have discomfort following implantation is that the muscle into which the nerve is buried is still functioning which could irritate the nerve end thus sending messages back to the brain telling the patient that they have nerve irritation and hence pain. The original theory noted above would also presumably postulate that once the buried nerve has had a chance to regenerate in its non-neuromatous manner, the nerve would “calm down” and the pain would eventually decrease significantly or go away altogether, but this process doesn’t happen overnight.  I personally believe that there is another potential explanation which comes from our recent experience with targeted re-innervation patients. 

Re-innervation surgery literally involves rewiring the body’s peripheral nervous system, usually in an extremity, to alleviate the pain often caused by neuromas that form at an amputation stump.  There are other goals of re-innervation, of course, but this goal is a primary focus.  Among the steps performed in such operations is neuroma excision and coaptation (i.e. connection) of a sensory nerve to a motor nerve end within a muscle which is no longer relevant because of the amputation.  An example would be a functional gastrocnemius (calf) muscle in a person who has a below-knee amputation.  The calf muscle can still fire, but its purpose is to plantar flex the foot at the ankle (i.e. “step on the gas”); but the foot no longer exists, thereby making this muscle function irrelevant.  My experience and the limited literature on this topic suggest that when a sensory nerve is connected to a motor nerve heading into a muscle (after removal of the injured portion, i.e. neuroma) the pain relief can be dramatic.  While the muscle may not function as well (it is an irrelevant muscle as noted above), the signals from the sensory nerve attached to the motor nerve don’t match up; however a neuroma doesn’t form because the regenerating sensory nerve fibers have been given something to do, namely hook up with the motor nerve fibers downstream.  Therefore, my feeling is that by burying a nerve end into muscle a neuroma doesn’t form because the nerve ends eventually make connections with motor nerves heading into that muscle.   As above, however, such connections can take time to form which is why the patient may experience discomfort for several weeks-to-months after burial of a sensory nerve into a muscle.

I 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.

The 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. I have attached a link to one of the more interesting ones as part of this post. One of the most surprising comments contained therein 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.  

Dr. Ziv Peled of Peled Migraine Surgery explains how "Text Neck" can develop in people from looking down at their phones all day long.  You can learn how this can be avoided and treated in Dr. Peled's post https://peledmigrainesurgery.com/blog/entry/what-are-some-causes-of-migraine-headaches-and-occipital-neuralgia.html. See how you may be affected or at-risk. Learn more about the modern scourge of "text neck"

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.

The 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. I have attached a link to one of the more interesting ones as part of this post. One of the most surprising comments contained therein 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.  

Dr. Peled invites anyone suffering from Chronic Migraines or Chronic Headaches to visit Peled Migraine Surgery.  Dr. Peled is a specialist in Mograine Surgery, where he can use peripheral nerve surgery to reduce or even eliminate migraines from eligible candidates.  If you suffer from migraines or headaches and traditional cures haven't helped, call Dr. Peled's office as soon as possible to make an appointment.

Dr. Peled explains what the term "Peripheral Nerve Surgery" means, and how it pertains to Migraine Surgery and Headache 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 www.peledmigrainesurgery.com to learn more about this life-changing surgery.  Don't live with migraines if you don't have to.

Dr. Peled explains the American Society of Plastic Surgeons' recent position statement on Migraine Surgery and Chronic Headache Surgery.

I was asked by a member of this forum to comment on the concept of atlantoaxial instability (AAI) and how it might relate to symptoms of ON. This is an interesting question, but one that is important as it has relevance for patients with a number of clinical conditions such as Ehlers-Danlos Syndrome (EDS – which is not known to be associated with AAI) or those with rheumatoid arthritis (RA – which has been associated with AAI).  I also promise to try to minimize the alphabet soup of abbreviations in an effort to avoid confusion.

First of all, what is AAI?  Briefly, AAI results from osseous or ligamentous pathology between the two cranial-most vertebrae (spinal column bones) – the atlas (i.e. C1) and the axis (i.e. C2).  This instability can result in too much or abnormal movement between the bones and soft tissues surrounding these two structures.  AAI can happen secondary to a traumatic event, degeneration due to an infectious or inflammatory insult (e.g. rheumatoid arthritis) and/or a congenital abnormality such as Down Syndrome.  When there is excessive or unusual movement of the atlas on the axis a number of problems can occur.  The vertebrae can impinge directly on the spinal cord thereby resulting in neurologic manifestations.  Compression of the nerve roots as they emerge from the spinal column in also a possibility as is neural pathology more peripherally as will be mentioned below.  The good news is that AAI is quite uncommon in patients without any pre-disposing factors. 

While the most common presenting symptom is non-descript neck discomfort and/or headache, these symptoms are quite non-specific.  Appropriate imaging along with neurosurgical evaluation if pathology is discovered in patients, especially those who have predisposing risk factors are therefore warranted.  Fortunately, almost all of the patients I see in my practice have already these evaluations and have come up without a diagnosis of AAI and remain unclear as to the cause of their pain.  So how does any of this information relate to ON?

Well, as you can imagine, if you have abnormal or excessive motion at the bony level, it may result in undue traction on the overlying soft tissues which can certainly include the peripheral nerves.  As I’ve mentioned in a previous blog post about whiplash and occipital neuralgia about two years ago, (http://peledmigrainesurgery.com/blog/entry/whiplash-and-occipital-neuralgia-what-s-the-connection.html) traction on peripheral nerves can lead to microscopic and in some cases macroscopic tears of the nerve itself which, in turn, can result in outright neuroma formation or cause scarring around the nerve.  This scarring that can result in mechanical neural compression or limitation of motion and further traction injury. Similarly, in EDS, the same excessive motion can result from overall laxity in ligamentous structures.  Please keep in mind that I am not a neurosurgeon or an orthopedic spine surgeon and this blog post should not take the place of a trained neurology, ortho spine or neurosurgical evaluation.  That being said, from what little I’ve read and do know, the take home message is that when you have neck pain and/or headaches, it is unlikely to be AAI in most patients. As always, a good work up and exclusion of other causative factors is important, but if despite that, everyone is left scratching their heads, ON may just be the culprit.

The American Society of Plastic Surgeons has released its official position on the utilization of peripheral nerve surgery for the treatment of chronic headaches/migraines.  The world’s largest plastic surgical society has concluded that the “long-term effects of surgical intervention for MH cannot be reasonably attributed to placebo.”  This statement helps formalize a treatment option for migraine sufferers that may not have been available or visible to them in the past and may help start them on a path to significant relief.

“I am so proud of the American Society of Plastic Surgeons for formally supporting the concept of surgical intervention for chronic headaches and migraines, am proud to have been at the forefront of these procedures and to be a part of their ongoing development.” – Ziv M. Peled, MD

Patient Impact

Thousands of patients in the US and around the world have already experienced the benefits of peripheral nerve surgery for their chronic headaches.  This development will hopefully further raise awareness of this treatment modality thereby encouraging many more people, for whom conventional therapy has been unsuccessful to discuss these procedures with their treating physicians. When traditional methods have failed and left patients with debilitating migraines that stretch on for years, peripheral nerve surgery has proven to be effective in reducing or eliminating the symptoms by relieving the pressure on the nerve(s) that causes these terrible headaches. Peripheral nerve surgery has been demonstrated to be effective in more commonly recognized nerve pathologies such as carpal tunnel and tarsal tunnel syndrome, but has also been proven to work on nerves in the head and neck when the nerves have become impinged or crowded by scar tissue (e.g. in whiplash injuries) and surrounding spastic muscle.  By demonstrating their support for surgical intervention, the ASPS is giving patients that may have been hesitant to explore this option another reason to believe in its efficacy. This statement will aid many migraine sufferers as the procedure becomes more mainstream.  Ziv M. Peled, MD has been performing this surgery for many years and has helped hundreds of patients lessen or eliminate their migraines.

Appointments Available

Peled Plastic Surgery takes appointments at our San Francisco and Walnut Creek offices and sees patients from across the globe.  Schedule an appointment or Skype session by contacting us at www.peledmigrainesurgery.com or calling 415-751-0583.

Over 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.

Several people have recently commented on the publicity surrounding the new class of drug being touted as a “breakthrough” treatment for migraines.  This drug known now as erenumab, is what’s called a CGRP (calcitonin gene-related peptide) receptor inhibitor and works by blocking the effects of CGRP which is thought to play a role in migraines.  Let me first say, that anyone who has read my blog posts over the past few years knows that I am a firm believer in the multidisciplinary approach to chronic headaches and chronic pain in general.  Therefore, I applaud the hard work and resource commitment that has gone into the development of this drug class.  Any advance is good for our patients and ultimately, like in breast cancer, I believe that if we put several of these treatment modalities (i.e. medication, surgery, injections, PT) together in precise ways for each individual patient, we will we see a monumental improvement in headache care.  All this being said, I think some clarity into what the actually data show with regard to erenumab is warranted so people are properly informed.

There are several trials of erenumab that have been completed and several ongoing so the data presented here are not the only numbers available, but rather what I consider to be a reasonable sample of what is available and what is likely to be seen in the next few months.  As of this post, erenumab is not even FDA approved and is therefore not commercially available although approval is expected as early as this later this month.  Furthermore, we don’t know for which indications erenumab will be approved and therefore for what conditions doctors will be “allowed” to prescribe it.  This point is important because many of the studies published focus on ‘episodic migraines’ which are defined as fewer than 15 headache days/month with or without aura.  Already, there is a difference in the uses for this medication and headache surgery as the majority of patients I see have many more headache days per month, in fact many have pain 24/7.  Secondly, the numbers must be explained with respect to the results.  What I mean by this statement is that as physicians and patients, we must distinguish between statistical significance and clinical significance. Allow me to elaborate. 

In one of the pivotal publications on this topic in the New England Journal of Medicine in late 2017, erenumab was noted to “significantly reduce migraine frequency, the effects of migraines on daily activities, and the use of acute migraine-specific medication over a period of six months”.  Sounds awesome, right?  But a look at the actual data tell a slightly less impressive story.  The average number of headache days per month in both the placebo and experimental (i.e. erenumab) groups was 8.  The patients who are candidates for headache surgery often have many more headache days per month and hence can be considered much more debilitated on that parameter alone. Moreover, the average days of use per month of acute-migraine-specific medication in these patients was 3.  In other words, these patients were only using abortive medications 3 days per month on average, so aging, the group of patients in this study weren’t as sick as those I often see in my office. The trial lasted six months with monthly injections of the drug and these same parameters were evaluated over the last three months of the trial. At the highest dose of erenumab (presumably the one with the most efficacy), over the last three months of the trial, the patients receiving the active drug had about 4 fewer headache days/month – almost a 50% reduction in frequency.  Sounds good so far.  But in the same trial, patients who were given the placebo had 2 fewer headache days per month. Let me say that again, if you were given the drug at the highest dose possible in this trial, you would have two fewer headache days/month than if you received saline injections.  Furthermore, only 50% of the patients at the highest dose, got this type of result!  Now if you have 8 headache days a month, maybe 4 fewer headache days/month is great, but what if you have 28 headache days a month – perhaps not as dramatic? If you suffer from 28 headache days/month and if I as your doctor told you that you needed monthly injections for the rest of your life, at an estimated cost of $10,000/year and that if you were lucky you would have 4 fewer headache days/month would that be worth it?  The data show statistically significant improvements in those receiving the drug versus placebo, this statement is true, but clinically – meaning to the patient sitting in front of you in the office – are these actual numbers compelling enough? Would the same percentage improvement (50%) hold true for patients with chronic migraines, meaning those who have more than 15 headache days/month?  We don’t know.  Perhaps in those patients, the drug would be completely ineffective or more effective.  However, based upon these initial studies, I would wager that the FDA will approve erenumab only for episodic migraines, so if you have over 15 headache days/month, you won’t even be eligible to get this drug. While these indications may change over time, there is no telling how long that timeline will be. 

And these are some of the best data.  Another trial completed and published in early 2018 (ARISE) used the lower dose of erenumab (70 mg monthly) and showed that only 40% of patients achieved the 50% reduction in headache days/month yet in the placebo group, 30% had the same reduction – only a 10% difference.  In addition, the actual numbers showed that these results translated to one fewer headache day/month compared with a placebo! In the more recently reported LIBERTY trial, which included patients with a more debilitating migraine burden, only 30% of patients receiving erenumab had the 50% reduction in monthly headache days which translated to 1.6 fewer headache days/month compared with placebo. Hardly the breakthrough that some in the press would have you believe. The results with headache surgery in patients who seem to suffer many more monthly headaches demonstrate that 88% of patients experience at least a 50% reduction in frequency, severity or duration of symptoms.

There are other unknowns as well.  For example, patients in the New England Journal study were only followed for six months (in the ARISE and LIBERTY trials for only 3 months). What happens afterward? Does the drug continue to be effective, does it become more effective or does it lose its efficacy with time like so many migraine drugs before it? There are 5-year follow-up data for headache surgery that demonstrate continued good results even that far out from an operation.  I have seen this in quite a few patients whom I’m lucky enough to be in touch with that far out.  Most are too busy getting on with their lives. What about side effects?  So far, I believe there is data on erenumab one year out which shows no significant adverse effects. That’s wonderful, but CGRP acts on the vascular system so there are concerns about the long-term risks of stroke and heart attack.  What if you have hypertension, can you use this drug safely?  What if you are a woman of child-bearing age (the major demographic in those suffering from migraines) – can you get pregnant while being on a drug that affects the vascular system and hence possibly the placenta? This question is valid since you will presumably have to take this drug forever.  In the ARISE trial, women of child-bearing age were only included if they were using contraceptives and hence presumably couldn’t get pregnant.

I certainly don’t mean to be a glass is half-empty type of guy as many of you know I am not.  I think this class of drug has a lot of potential and should certainly be studied further.  Maybe with time, we’ll see better results with higher doses or in patients more precisely selected.  Maybe we’ll see this drug used in combination with patients who also have surgery and see more amazing results than in patients having only one or the other.  Time will tell, but I post this so that people who are anxiously awaiting these developments are realistic about what they can practically offer.  Hopefully, that helps.

Seattle is home to just under 1 million people.  Since 18% of women and 6% of men suffer from debilitating migraines, this means that almost 180,000 women and 60,000 men suffer from the headaches.  Where can these people turn to for treatment of migraines?  Seattle Migraine and Headache Surgery is available for you.

Up the coast in San Francisco, Dr. Ziv Peled specializes in migraine and headache surgery, giving Californians an opportunity for migraine relief.  Dr. Peled uses peripheral nerve surgery to relieve the tension around the nerves that are causing the migraines.

Surgical decompression 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. There are few restrictions following the procedure and discomfort is usually very well tolerated with oral pain medication. 

As an outpatient surgery, you can come to our San Francisco offices or we can perform the surgery at a center near you.  You can be back home that night, well on your way to recovery from your migraines.  Dr. Peled has performed hundreds of these procedures.  Our testimonials page is filled with patients thanking Dr. Peled for changing their lives for the better.

If you are in Seattle or any of the surrounding areas and are suffering from migraines, we can help.

Call Dr. Peled today at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about how peripheral nerve surgery can help you with your headaches.  Headache surgery in Los Angeles can be a phone call away.

I was really humbled to see and speak with several of my former and current patients just the other day.  During these discussions, one cannot help but be impressed with the sheer strength of the human spirit and the grit and determination with which these people continue to fight their pain and search for answers.  The journey to relief is more like a marathon than a sprint for sure, but even the longest roads begin with the smallest steps and these courageous people have taken big steps forward. Just as amazing are the spontaneous friendships that I have seen form along the way and the support that each of these incredible people provide to one another.  It continually reminds me that connection is an essential part of the human condition and of the role that hope plays in recovery. I am proud to have been a small part of these experiences. These pictures say a million words (mic drop)…….

Questions and comments continue to be raised both in my office as well as online about the difference between neurectomy/implantation (transection of the nerve and implanting it in the local muscle) and decompression. Along with these questions come many misconceptions about the advantages and disadvantages to each approach. This post hopes to address some of those issues.

To decompress a nerve means simply to remove some form of external compression that is putting excess pressure on the structure. As has been mentioned previously, compression can be a result of scar tissue, tight muscles, abnormal blood vessel anatomy, connective tissue, etc. Decompression also means that the nerve is left intact and that hopefully, once the effects of the operation (e.g. swelling) and the effects of the compression wear off, the nerve will function well again. There are advantages to decompression. The most obvious advantage is that the nerve is preserved so hopefully sensation to that area will also be preserved. Secondly, since the nerve is not cut, the chances of a post-operative neuroma are theoretically low. There also disadvantages to this approach. First, the surgeon and/or patient make a judgement call that the nerve will recover if simply decompressed, but this doesn’t always occur. I believe that this is the primary reason some people who have decompression ultimately require neurectomy and implantation Second, just because the chances of a neuroma are low it doesn’t mean that they are zero - you can still get a neuroma-in-continuity, especially if there is a lot of manipulation required to adequately decompress a nerve. Third, if the compression has been severe and long-standing, the nerve may take many months to fully recover. Fourth, if recovery does occur, there is no guarantee that sensation to the relevant area will be “normal”. It may always feel a little bit off.

The biggest misconception with a neurectomy is that it is like pulling the plug out of a wall outlet. However, the injured nerve is not ripped out of the spinal cord. A better analogy is that the injured portion of the nerve is identified and the area just upstream where the nerve appears healthier is where the nerve is transected. This maneuver is just like cutting the central portion of a power cord to a lamp where the wires have frayed. The downstream part of the nerve (e.g. that which goes to the skin) is now irrelevant just like the part of the cord that is still attached to the lamp. There is no longer any electricity going though that part so the bulb will not turn on. However, that upstream cut end is still a live wire as it is still connected to the wall outlet and therefore must be capped. In the human being the same goal is achieved by implanting the upstream (proximal) nerve end (which is still getting nerve impulses from the spinal cord) into the local muscle. There are advantages and disadvantages to this approach. One advantage is that you may see immediate improvement in symptoms although not always. Sometimes, people continue to experience pain in that nerve even though when they touch their skin they are numb. This situation exists because the nerve that used to go to that area of skin is getting impulses from the spinal cord and brain albeit ending within the muscle and so your brain thinks that part of the skin hurts even though when you touch it is numb. Eventually in most cases, the nerve end in the muscle calms down and the pain improves. Another potential advantage is less dissection because the downstream area of the nerve doesn’t need to be dissected once transected as it is now irrelevant. There are potential disadvantages as well such as persistent nerve pain if the implanted nerve doesn’t calm down, a neuroma if the nerve comes out of the muscle and the obvious numbness in that nerve distribution. Another misconception is that neurectomy is a guaranteed, home-run result which is not true for those reasons mentioned above. There are clearly other nuances that exist which is why discussing these issues with your peripheral nerve surgeon is so important. Just as each patient is unique, each person will have different tolerances for different post-operative outcomes so a good discussion is useful both for the patient and the surgeon.

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 can be permanent.

Peled Migraine Surgery of San Francisco has emerged as a leader in the development of peripheral nerve surgery as a migraine relief technique. 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 and the American Society of Peripheral Nerve PN) - the leading society of peripheral nerve surgeons.

In addition to his cosmetic and reconstructive work, Dr. Peled helped to found a perpiheral 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.

Visit http://peledmigrainesurgery.com today for more information, and to make an appointment to relieve your migraines.

San Diego is home to nearly 1.5 million people.  Since 18% of women and 6% of men suffer from debilitating migraines, this means that almost 270,000 women and 90,000 men suffer from the headaches.  Where can these people turn to for treatment of migraines?

Up the coast in San Francisco, Dr. Ziv Peled specializes in migraine and headache surgery, giving Californians an opportunity for migraine relief.  Dr. Peled uses peripheral nerve surgery to relieve the tension around the nerves that are causing the migraines.

Surgical decompression 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. There are few restrictions following the procedure and discomfort is usually very well tolerated with oral pain medication. 

As an outpatient surgery, you can come to our San Francisco offices or we can perform the surgery at a center near you.  You can be back home that night, well on your way to recovery from your migraines.  Dr. Peled has performed hundreds of these procedures.  Our testimonials page is filled with patients thanking Dr. Peled for changing their lives for the better.

If you are in San Diego, Balboa Park, Hillcrest, North Park, City Heights, College Area, Mission Valley, Marine Corps Air Station Miramar, or any of the surrounding areas and are suffering from migraines, we can help.

Call Dr. Peled today at 415-751-0583 and visit www.peledmigrainesurgery.com to learn more about how peripheral nerve surgery can help you with your headaches.  Headache surgery in Los Angeles can be a phone call away.