In this second installment about fears and misconceptions about headache/migraine surgery, I’ll address several other concerns people have raised when considering these procedures. As before, hopefully these discussions are helpful in making a more informed choice about whether such procedures are right for you.

• Misconception 3 – The results of surgery are only temporary and the pain will eventually recur. I often tell patients that it may be scar tissue that is pressing on their nerves or preventing them from gliding back and forth as they move their neck and hence cause pain.  Patients naturally ask why more scar tissue wouldn’t form after their operation.  This question is a good one.  The answer is that scar tissue always forms after any operation, but excessive scar tissue that re-entraps nerves can be mitigated by creating sufficient space around the nerves during the operation and by allowing/instructing the patient to move their neck normally as soon as they wake up.  We know from our work on tendon injuries in the hand that as little as 5 mm of gliding can prevent clinically significant adhesions and the same physiology holds true in other parts of the body and with respect to nerves.  To back this fact, the 5-year results from these operations were actually published back in February 2011.  In this study, 5 years following their operations, 88% of patients were still reporting at least a 50% reduction in frequency, severity and/or duration of their symptoms and 29% were completely migraine-free.  In the medical cancer literature, if you are free of your disease after 5 years, you are typically considered to be in remission.   Similarly, if you are significantly better or migraine-free after 5 years, we consider these essentially permanent results.
• Misconception 4 – My insurance considers these operations experimental which means they are unproven. Sorry, but I get on a bit of a soap box about this one.  In my humble opinion, insurance companies are not the arbiters of what is medically appropriate.  That decision is between the doctor and the patient – period.  Your insurance company doesn’t know you, hasn’t examined you, hasn’t spoken with you about your condition and hasn’t evaluated your records. The American Society of Plastic Surgeons put out a formal position statement regarding headache surgery which clearly states that when more conventional modalities have failed, that these operations are not only reasonable, but should be considered the standard of care.  This 13-page document is exhaustively researched and cites 89, peer-reviewed articles in high-impact factor journals, which speak to the efficacy of this approach to chronic migraines/headaches.  It continues to boggle my mind why insurance companies claim this treatment approach is unproven because it is simply untrue.

https://www.plasticsurgery.org/Documents/Health-Policy/Positions/ASPS-Statement_Migraine-Headache-Surgery.pdf

• Misconception 6 – I had a nerve block with another doctor which was unsuccessful and therefore I am not a candidate for these procedures. Results of the nerve block will vary based upon several parameters: what you inject, how much of it you inject, where and how you inject, and for what reason you are injecting.  I can’t tell you how many patients have told me that they had a nerve block of the greater occipital nerve which was unsuccessful, but when I ask them if the back of their head was numb at all, they reply ‘no’.  If you have no numbness following a nerve block, that means the nerve was not blocked and simply put, you have had no idea whether or not numbing that target nerve would give you a successful result.  Therefore, if nothing else, if the nerve block which was performed initially was unsuccessful, then may be a repeat block performed in a slightly different way with a slightly different technique may be successful.  It is thus important to have these blocks performed sequentially and by a clinician with a reasonable amount of experience with these procedures.

Hope these explanations help to some degree.  In a future blog post, I plan to address still other misconceptions that seem to strike fear in the hearts of those considering an operation for relief of their chronic headache pain.

In Episode 9 of Burning Migraine Questions, Ziv M. Peled, MD talks to Ronny Ead about what has happened since The Doctors was taped a year ago, why they didn't discuss Occipital Neuralgia or Trigeminal Neuralgia on the show and why these mechanically-triggered conditions are so under-diagnosed. They also discuss extra-cranial surgery being designated as the standard of care for head pain, when other treatment modalities have failed. Dr. Peled advocates for medical and paramedical practitioners coming together as a treatment team to address the chronic pain epidemic.

I was proud to appear in today's episode of The Doctors, where I discussed my patient Ronny's surgery and recovery, and how peripheral nerve surgery had helped eliminate his migraines.

With more than 37 million migraine sufferers in the United States, you probably know someone who is suffering from debilitating headaches.  Ronny was one of these 37 million Americans until he came to see me.  He shared his story with The Doctors and let the show into the operating room with us as he had his peripheral nerve surgery to rid him of migraines.

Ronny's migraines had been steadily worsening since 14, and had pain coming from the back of his neck that would spread to the front of the forehead and to his eyes and his temples.  He also suffered from extreme nausea, leaving him unable to get out of bed and having trouble working.

After trying many different meds and therapies, like acupuncture and massage, Ronny also went through changes to how he went about his regular life.  Even stress management and diet changes brought no relief.  After seeing over 15 doctors and dentists, he was at the end of his patience.  Then he came to our office.

The most common misconception about migraines is that an abnormality inside the brain is the cause.  This is not always true.  They can also be caused by nerve compression outside of the brain, where scar tissue, abnormal blood vessels or spastic muscles can impinge on the nerve.  This was what Ronny was dealing with.

I operated on Ronny to release the nerves at the back of his head and get them away from the spastic muscles.  We showed this procedure in the video that was shared with The Doctors as I operated on the nerves in the front of the head and the temples.

We then joined the studio panel for The Doctors, where Ronny shared his story, and that he is nearly 100 percent pain-free after the surgery.  I was asked by Plastic Surgeon Dr. Andrew Orton why Ronny was such a good candidate for this surgery.

To me, the ideal candidate:

1. Has been diagnosed with migraines by a board-certified neurologist or headache specialist
2. Has failed conventional therapies including various drugs and injections
3. Has a good physical exam that shows there's a peripheral nerve that is casing the headaches
4. Has responded well to an injection of a numbing agent or a local anesthetic in the office.  For example, the headache goes from 9 to 1 on the pain scale

When the patient has been numbed in the office, I can identify the problem nerves and the patient also gets the chance to "test drive" their results, to see where they would be numb if we did cut those nerves.

While Ronny was afraid of having his nerves cut prior to the surgery, the pain was awful enough that he felt he had no choice but to undergo the procedure.  He does report some numbness behind his ear and in his forehead, but says he hasn't had any really noticeable side effects form the surgery, and in fact, doesn't even think about it any more!

If you're dealing with migraines and want to know if migraine surgery can help you. here's how to find the right surgeon for you:

1. Look for someone with specific training in peripheral nerve surgery during either a residency or fellowship.
2. Use a surgeon who has done nerve surgery not just in the head and neck but all over the body
3. Preferably find a surgeon with specific training in this headache operation 
4. Utilize a surgeon who could provide patient references, ideally from several years out, to show the results are lasting
5. You can use the American Society for Peripheral Nerve to look for members

While Medicare covers migraine surgery, many insurance policies don't because the surgery is new.  Always discuss insurance with your surgeon's office because they will help you understand the costs, what is covered and what is not. 

1. Has been diagnosed with migrianes by a board-certified neurologist or headache specialist
2. Has failed conventional therapies including various drugs and injections
3. Has a good physical exam that shows there's a peripheral nerve that is casing the headaches
4. Has responded well to an injection of a numbing agent or a local anasthetic in the office.  For example, the headache goes from 9 to 1 on the pain scale

When the patient has been numbed in the office, I can identify the problem nerves and the patient also gets the chance to "test drive" their results, to see where they would be numb if we did cut those nerves.

While Ronny was afreaid of having his nerves cut prior to the surgery, the pain was awful enough that he felt he had no choice but to undergo the procedure.  He does report some numbness behind his ear and in his forehead, but says he hasn't had any really noticeable side effects form the surgery, and in fact, doesn't even think about it any more!

If you're dealing with migraines and want to know if migraine surgery can help you. here's how to find the right surgeon for you:

1. Look for someone with specific training in peripheral nerve surgery during either a residency or fellowship.
2. Use a surgeon who has done nerve surgery not just in the head and neck but all over the body
3. Preferably find a surgeon with specific training in this headache operation 
4. Utilize a surgeon who could provide patient references, ideally from several years out, to show the results are lasting
5. You can use the American Society for Peripheral Nerve to look for members

While Medicare covers migraine surgery, many insurance policies don't because the surgery is new.  Always discuss insurance with your surgeon's office because they will help you understand the costs, what is covered and what is not. 

Ziv M. Peled , M.D. Presents Burning Migraine Questions for April 18, 2019. Dr. Peled discussed he following questions:

0:41 Can thyroid surgery cause occipital neuralgia?

1:58 Why are migraines on the left side or the right side, and why not on both sides?

7:35 Is Platelet Rich Plasma (PRP) an option to potentially lessen the pain of occipital neuralgia?

9:18 Following an occipital nerve block, I had a pronounced dent in the back of my head where my neurologist injected (it is tissue thinning, secondary to steroids). Is that a common reaction? Will it resolve with time?

13:42 Are nerve blocks mandatory prior to surgery? How long do they last?

16:50 You talk about removing a piece of muscle in the neck. How is that not going to leave me paralyzed?

21:12 You are a plastic surgeon; why are you operating on the brain and spinal cord for these operations?

23:05 Is the pain in the tongue associate with occipital neuralgia?

23:40 Can these operations be done arthroscopically (or endoscopically)?

For more information visit peledmigrainesurgery.com and be sure to watch Dr. Peled on The Doctors April 25th!

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 www.peledmigrainesurgery.com today or call 415-751-0583 to make an appointment.

Ziv M. Peled M.D. Presents Burning Migraine Questions Episode 7 April 4, 2019

Dr. Peled answered the following questions:

• 0:32 Is Occipital Neuralgia truly idiopathic or is the cause more often than not some sort of compression? Have you ever encountered inflammation of the nerve with no visible cause?
• 6:10 Why do surgeons use different incision techniques for the same procedure? Is one technique better than another?
• 7:34 Do you use botox injections for chronic migraines?
• 12:46 What is your opinion on occipital nerve blocks for neck pain relief and how often should they be done?
• 16:27 Why could you get a rebound headache after an occipital nerve block?
• 23:02 I was told by another provider to never get nerve decompression surgery because the nerves would grow back, regenerate and cause more pain. Can nerves regrow? Can scar tissue prevent subsequent decompression surgery?

What is your name?

Eleanor Thaler.

Where are you from?
I am from Eugene, Oregon, but currently live in Minneapolis, Minnesota.

What was happening in your life before the headaches became chronic?
I started having migraines at age 14. At that time, I was a typical, young student heavily involved in both music and dance. Outside of school, I took lessons in piano and violin as well as ballet and pointe.

How long ago was that?
At first, the migraines occurred every other day, beginning when I was 14, and I would plan my life and schoolwork around this schedule. Throughout high school, my headaches increased in frequency until I was having 5-6 headache days per week. When I started college at age 18, my migraines became constant and more intense. I had two procedures with Dr. Peled--one at age 20 and one at age 21. I am now 22.

Describe a good day with chronic pain.

On a good day, distraction from pain was possible. When I was able to adequately manage my pain with medication, I spent time with friends or studied in the library rather than my dimmed room. If I had enough energy, I could go to the gym or for a short run, although my energy was limited.

Describe a bad day. What does/did the pain feel like.

During college, my pain was constant. Pain was always there, waiting for me, when I woke up in the morning, and it would increase steadily throughout the day. It felt like a stake had been driven through my right eye and was being continuously hammered into my skull. I would take naps for 2-4 hours daily, as focusing during morning classes while struggling against mounting pain was utterly exhausting. As the day wore on, I would become dizzy and nauseous as the pain worsened, and eventually, my hands would start to shake, making it difficult to write or study. More than once, I had to wear sunglasses to my afternoon classes to tolerate even the dim fluorescent lights in my lecture halls. After school, I would drag myself home and collapse in my darkened room, and I counted the hours until I could sleep again.

A social life was not an option. It became too painful to watch friends become disappointed and frustrated with me when I was no longer able to attend social outings; most of my friends fell away over time. Focusing my attention on school, in an attempt to distract myself from pain, was what made it possible to endure the suffering. I dreaded the time that I had to spend awake each day. At my lowest point, I only kept myself going for the sake of my parents.

Where did you experience the pain?

My pain was located just above my right eye with occasional radiation to my right temple.

What meds were you taking?

I had run the gamut of available medication, both prophylactic and abortive, for migraine pain. For prophylactic management, I had tried topiramate, lamotrigine, gabapentin, propranolol, indomethacin, nortriptyline, amitriptyline, Fioricet, duloxetine, riboflavin, and magnesium. For acute management, I had tried Toradol injections, sumatriptan, naratriptan, eletriptan (my personal favorite), rizatriptan, and zolmitriptan. I had prescriptions for two triptans at a time and would cut tablets in half to ration them throughout the month. I knew I was giving myself rebound headaches by taking medication too frequently, but I didn’t know what else to do

Did you have any success with other pain relief methods besides medication?

I tried trigger point injections and Botox injections. My first round of Botox gave me significant relief, but I did not get any relief from the second round. Trigger point injections only helped for a few days at a time. I also tried massage therapy, physical therapy, acupuncture, meditation, and dietary changes without much relief.

How did you hear about Dr Peled?

After six years of worsening pain, I often felt forgotten by my providers after the first few treatment attempts were unsuccessful. I got the sense that my providers did not understand just how much my pain had taken from me. I began to feel invisible. Desperate for relief, I began conducting my own research into treatment options and clinical trials. I found Dr. Peled’s work through a database of clinical trials. I followed the study for a year and a half before I reached out directly to his practice.

What inspired you to speak with him?

After being told several times by other providers that I was out of options, I decided it was time to take the initiative and reach out to Dr. Peled’s office myself. I had followed the clinical trial for over a year and a half, and I knew it was time to trust the research that I had done and be my own advocate.

Tell me about your surgery, including when you had it, what happened.

I have had two procedures with Dr. Peled. My first procedure was in May of 2016. I arrived on a Friday and had diagnostic nerve blocks that significantly reduced my pain. Surgery took place the following Monday. At that time, branches of my right auriculotemporal, zygomaticotemporal, supraorbital, and supratrochlear nerves were cut and embedded into the surrounding muscle. In addition, my right supraorbital notch was widened to relieve the compressive pressure on my supraorbital nerve from a nearby blood vessel. I saw Dr. Peled two days post-op for a follow-up appointment and flew home to Oregon later that day. He continued to check in periodically throughout the year by phone.

About one year after my first surgery, my pain returned. I again tried conservative pain management without significant relief. I reached out to Dr. Peled’s office again and scheduled a second trip to see him. This second procedure was in January of 2018. I again arrived on a Friday for diagnostic nerve blocks. During my second surgery, Dr. Peled found that a separate branch of my right supraorbital nerve was embedded/encased in my frontal bone. He chiselled off small slivers of my frontal bone to free the compressed supraorbital nerve and then used fat from my eyelid to pad the nerve and protect it from further damage. By doing so, he was able to salvage the nerve. I flew home following my post-op appointment two days after surgery. In January of 2019, I had my final follow-up call with Dr. Peled one year after the second surgery.

Do you remember how you felt in the first few days after surgery?

I woke up from my first surgery without pain. I did not need any post-operative pain medication,  and was working full-time one week after surgery.

My second procedure was more extensive, and thus recovery was a little slower. Still, I only required pain medication for two days following surgery. I had intermittent swelling in the right supraorbital region (which was expected) over the first several months, but this decreased in both frequency and severity over time.

How are you feeling now?

Since my recovery, I have had the privilege of watching my limitations fall away. I now live a life without pain, and only get occasional tensions headaches (once or twice per month) that respond to Excedrin. Prior to surgery, my headaches could not be managed by OTC medication.

How has your life changed as a result of this surgery?
I am able to work a full-time job with a variable schedule, including overnights, without pain. I can drive places without being afraid that I will be in too much pain to get home. I don’t need to nap during the day, and I don’t need to make sure I have triptans in my pocket every time I leave the house. Most importantly, I can be more present in my life and engage fully in the things that interest me. I certainly live more courageously now that pain is no longer a looming presence in my life. I am able to have closer relationships with my friends and family now that I have the bandwidth to do so. For a long time, pain was in the driver’s seat of my life, but now I am in control and get to choose how to use my time and energy each day. After eight years of merely surviving, now I am able to really live.

What is next for you?
After a relatively non-linear path through school due to pain, I am so excited to be starting medical school in the fall. My journey through pain (and the opportunity to help other patients feel supported during their own journeys through illness) was largely what drew me to a career in medicine. The relief I have gotten from my surgery is what made the pursuit of this dream possible.

What would you say to anyone wondering whether to meet Dr Peled?

I hardly have words to describe how grateful I am for having met and been treated by Dr. Peled. He is truly at the top of his field. There is no better time than now to take control of your story and reach out for help – there are so many wonderful things to be a part of in the world when your experience isn’t overrun by pain! My experience with Dr. Peled gave me my life back, and I will forever be grateful for him and his incredible team for taking such good and thorough care of me.

Describe your overall experience with Dr. Peled and his office.

Dr. Peled was the first provider to validate my experience and make me feel seen.  Not only did he listen, but I felt that he truly heard my story and my experience. I felt 100% supported by him every step of the way, even when I required a second procedure a full year after my first, and this meant more to me than I can express. Dr. Peled never gave up on me nor hope for improvement in my pain, and I am so incredibly lucky to have been under his care.

As a young student traveling to the practice from far away, I was nervous leading up to my initial consultation, but Cary-Anne set me at ease and answered all of my questions. She made me feel so comfortable and welcome when I arrived for my appointment, and I am very grateful for her support along the way.

Do you have any advice for prospective patients who are thinking of coming to the practice?

Now is the time to make a change and take your life back – go ahead and call!

Ziv M. Peled, MD answers your Burning Migraine Questions! In Episode 6:

0:32 Does the lesser occipital nerve innervate areas typically innervated by the auricular temporal nerve or does it innervate further up the head?
2:55 How does a patient know whether they are a candidate for a second nerve decompression operation if the first one failed or only produced partial success?
7:35 Can occipital neuralgia cause symptoms or pains in other parts of the body?
9:40 A patient fell down steps and hit the lower part of her head and lower back, and has been in horrible pain ever since. She has symptoms including dysesthesia, or altered sensation: her hair hurts and she hates having people touch it. What is going on?
14:30 Is burning the nerve (radiofrequency ablation) suggested?
20:15 I have a lot of nausea associated with my migraines. Will surgical intervention relieve that?
22:50 If one doesn't respond to nerve blocks, are you not a candidate for nerve decompression surgery?
25:55 If you have a nerve stimulator implanted in the cervical area and is wasn't successful, does that preclude you from having surgery?
27:50 A lot of surgeons have any number of different incisions to access nerves. Which one is better?

To learn more about migraine surgery, visit https://peledmigrainesurgery.com today!

Ziv M. Peled, MD answers your Burning Migraine Questions! In Episode 5:
0:34 Is Occipital Neuralgia considered a headache, a migraine or something else?
6:15 What is a neuroleptic?
6:32 Several years after my surgery, I still have a hyper-sensitive or numb area after nerve decompression (surgery). What does that mean?
10:30 Botox didn't work for my headaches; it actually made my headaches and neuralgia ten times worse. Why does it work for most people but it didn't work for me?
16:00 How do hormones affect migraines?
20:15 What are the different types of nerve blocks used to treat Occipital Neuralgia?

One of the more interesting questions that has come up recently is whether or not a person is safe for surgical intervention if they have other medical conditions.  This query is very important and was addressed in part on a recent episode of Burning Migraine Questions on FB Live, but I’d like to go into more detail here.

The first item that needs to be in place is an accurate diagnosis and cogent surgical plan.  After all, if a person is having the wrong operation, or it is performed inadequately or both, the outcomes will be suboptimal.  The best way to address this issue is to see a headache/migraine surgeon who not only understands the pathology for your particular case and has experience in treating it, but also has specific training in doing so and who understands you and your particular challenges. All of these points have been discussed in greater detail in a previous blog post (How To Choose A Headache Surgeon), but the latter item is the focus of this particular entry.

Since every patient is unique, each will have a specific nerve or nerves that will need to be addressed. Further, each patient will have different medical problems that have nothing to do with their nerve issues.  While no operation (or medication for that matter) is without potential risk, the most important thing a surgeon can do is give the patient as safe a procedure as possible. In some patients, especially those above a certain age and/or those with pre-existing medical issues, a thorough medical workup by the patient’s primary care provider is important in achieving that goal.

For example, one patient may have an aneurysm in a large vessel.  This patient clearly needs to see a vascular surgeon before undergoing headache surgery. While headache surgery is significant, an aneurysm may be life-threatening and should be addressed first.  If cleared and the patient is deemed a candidate for surgery, then they can reasonably proceed.

Alternatively, if a patient presenting for headache surgery is on blood thinners because they have an abnormal heart rhythm, that person must be cleared by their cardiologist before entertaining surgical intervention. The cardiologist and headache surgeon must confer on how to manage that patient’s anti-coagulation around the time of the planned procedure.

Finally, one of the more common issues is how to manage pain medication.  Many patients presenting for headache surgery are on a lot of pain medications because of the severity of their symptoms and the inevitable question arises, “Who will manage those medications before and after the operation?” Do you add another medication to deal with the acute on chronic pain following an operation in a chronic pain patient or do you double the current dose of medication? There is no one right way to handle this issue, but again, a thorough discussion needs to take place between the patient, the headache surgeon and the person prescribing those medicines.  

One of the key aspects of a headache surgeon’s role is to understand you, not as a disease or a medical challenge, but as a person with a medical problem.  We can only do that in partnership with your existing medical team.

San Francisco Magazine has named their Top Doctors for 2019 and included Ziv M. Peled, MD among their number.  Dr. Peled was chosen from hundreds of physicians in the area, and was one of only 22 plastic surgeons named to the list.  You can read the entire list in San Francisco Magazine.  

The list was compiled by Castle Connoly Medical Ltd, which is a health care research and information company that asks licensed MDs and DOs, hospital execs, and county medical societies to nominate their own. Doctors cannot nominate themselves, and cannot pay to be ion this list.

Castle Connoly’s research professionals screen each doctor that is nominated for educational and professional experience, and checks for personal identifiers like a top medical degree, what hospitals the doctor is affiliated with, faculty appointments, experience, and board certifications, along with malpractice suits and disciplinary action. With 930-plus nominees over eight Bay Area counties—Ala­meda, Contra Costa, Marin, Napa, San Francisco, San Mateo, Santa Clara and Sonoma—they shortened their list of top docs to 616 names.

The list of Plastic Surgeons is below and we're proud to be included among these fine surgeons on this list. We want to thank San Francisco Magazine and Castle Connoly for this honor, and we can't wait to be back on this list next year!

Ziv M. Peled, MD answered your Burning Migraine Questions on Facebook Live on February 7th at https://www.facebook.com/pg/MigraineSurgery.
If you couldn't be there live, send your questions to us at https://peledmigrainesurgery.com/burning-migraine-questions and we will try to answer your question during the next stream.

To find your answers in the video, here are the times to fast forward to for each Burning Migraine Question of the video:

1:09 Is it possible to have nerve decompression surgery on all of the areas at the same time?
6:10 Can Occipital Neuralgia develop as a result of a B12 deficiency?
8:35 When my ON flares very badly, it feels like my right ear is hot and someone is stabbing a knife in it. Could the auricular nerve be affected as well as the lesser occipital nerve?
11:24 Could nerve decompression surgery be successful for someone with Ehlers-Danlos syndrome, and who isn't responding to nerve blocks?
13:42 What qualifies and disqualifies a patient as a candidate for nerve decompression surgery?
14:29 What defines a "successful" nerve decompression surgery result?
17:07 Why is it that when you have a barometric pressure change or a cold that symptoms flare up?

Ziv M. Peled, MD answers your Burning Migraine Questions on Facebook Live! Join us on February 7th at 2:00pm PST (or February 8th at 9:00am AEDT if you're in Australia!) at https://www.facebook.com/pg/MigraineSurgery.
You can ask us questions during the Facebook Live chat or, if you can't be there live, send your questions to us at https://peledmigrainesurgery.com/burning-migraine-questions and we will try to answer your question during the stream.
We're looking forward to seeing you there!

Ziv M. Peled, MD answered your Burning Migraine Questions on Facebook Live on January 24th at 2:45pm PST (or January 25th at 9:45am AEDT if you're in Australia!) at https://www.facebook.com/pg/MigraineSurgery.
If you couldn't be there live, send your questions to us at https://peledmigrainesurgery.com/burning-migraine-questions and we will try to answer your question during the next stream.

Come join Dr. Peled on Facebook Live!

Ziv M. Peled, MD answers your Burning Migraine Questions on Facebook Live! Join us on January 24th at 2:45pm PST (or January 25th at 9:45am AEDT if you're in Australia!) at https://www.facebook.com/pg/MigraineSurgery.
You can ask us questions during the Facebook Live chat or, if you can't be there live, send your questions to us at https://peledmigrainesurgery.com/burning-migraine-questions and we will try to answer your question during the stream.

We're looking forward to seeing you there!

If you missed our January 11th Facebook Live, you can watch it here to learn more about Migraine Surgery.

We had a very successful “soft opening” to our Facebook Live series of events, which we hope to be able to do with some frequency in the future.  After we went ‘off the air’, many people contacted us who didn't get a chance to ask their questions live.  I have decided to address a few of these over the next few weeks.  

One of the more interesting questions that I would like to address now is: Have you cut the nerves and attached them to another rather than bury them? What was the outcome?

What I tell my patients pre-operatively is that I will often make a ‘game time’ decision as to whether or not any particular nerve I am operating on can be saved or if it needs to be transected.  That is because one can never predict what one will find once the nerve has been exposed - if it is too badly damaged, a decompression alone will not suffice.  As I have mentioned in a previous blog post (Lions & Tigers & Neuromas…Oh my! – Nov 21, 2017), there are several possible options if a neuroma forms following a nerve transection and the same principles apply to a nerve that has just been cut on purpose:

1.  The cut nerve end can simply be freshened and implanted into the local muscle.  
2.  The transected nerve end can be connected to a long, cadaveric nerve graft (i.e. an allograft).  In this case, the surgeon would be utilizing the principle of distance in that it is unlikely the cut nerve would actually grow all the way through the entire graft and hence the end of the allograft would be passive and unlikely to cause pain.
3.  The nerve can be “re-innervated” via a procedure where the nerve is repaired end-to-side or end-to-end to another sensory (or perhaps even motor) nerve. This ‘re-innervation’ procedure is often used to help amputees power the newer myoelectric/bionic prosthetics that appear on the news from time to time and can also be used during migraine surgery.  

It is almost always possible to find another nerve (let’s call it the recipient nerve), adjacent to the nerve that has been cut (let’s call that one the donor nerve), to attach the cut nerve to.  However, any time one operates on any nerve, there is always a possibility that the nerve being manipulated may be injured.  Therefore, the surgeon must recognize the possible negative outcomes if the recipient nerve becomes damaged.  After all, the recipient nerve, is presumably a normal nerve with no pathology relevant to the condition being treated. 

If the recipient nerve is a purely sensory nerve and is injured inadvertently, then possible negative outcomes from damage to that nerve include decreased sensation, complete numbness, or chronic pain in a new location.  If the recipient nerve is a purely motor nerve and is injured inadvertently, then the patient may experience weakness or even complete paralysis of the muscle which that nerve supplies. 

Many of the recipient nerves in the neck region are motor nerves. If, for example, the greater occipital nerve is too damaged and must be cut, one can find a local motor nerve to which to attach it, but if that motor nerve is injured and stops working then the patient might experience neck weakness and may be unable to fully extend their neck. Therefore, in my humble opinion, if the surgeon is planning on manipulating those motor nerves, it should only be because there is no other option available to prevent a neuroma.  

Since the other options noted above are readily available and often successful, I have never personally had to attach a cut occipital nerve to a recipient motor or sensory nerve.  There are also no data on success rates with such re-innervation procedures for the treatment of chronic headaches.  The take home message is as always - please have a frank discussion with your surgeon about what s/he is planning on doing if a nerve is too badly damaged and decompression may not be successful. 

The following images were from a surgery performed this Monday.  The first image details the Accessory Supraorbital Nerve seen laterally completely surrounded by bone at the Orbital Rim instead of coming out through a notch like its medial counter-part. The second image is the after image showing that now both nerves are released and ensconced in soft fat at the Orbital Rim with no residual compressive structures.  

What is your name?

 Shirley Jaeger

Where are you from?

 Brisbane, Australia

What was happening in your life before the headaches became chronic?

 I worked as a nurse for many years which eventually caused neck pain. I had a neck operation to alleviate the pain where they replaced the disc between C3/C4 with a metal cage.

How long ago was that?

 The neck operation was here, in Australia, March 2014. The operation left me with chronic pain above my left eye.

Describe a good day with chronic pain.

 5 on a scale of 10, but good days are rare.

Describe a bad day. What does/did the pain feel like?

 10 on a scale of 10, which included bad migraine symptoms.

Where did you experience the pain?

 At the supraorbital notch, near the middle of my left eyebrow, radiating out into most of my head.

What meds were you taking?

 I was unable to take opioid derivatives as I am allergic. I tried six other prescription drugs but they offered no relief and/or made me feel sick. A low dose of Gabapentin I could take, but still got very little relief.

Did you have any success with other pain relief methods besides medication?

 I received 10 Botox injections, on two separate visits, without success. I tried expensive, medical-grade cannabis oil--working up to a high dose--without any effect at all. For 6 months, I wore the Cefaly Tens head electrodes approximately 4 hours per day with no relief. I also tried handheld Tens treatments at the physiotherapists’ office. I then had a temporary, trial electrical nerve stimulator implanted underneath my skin, near my eyebrow, which very slightly reduced my pain, sometimes. During these years, I also had several anaesthetic block injections in the forehead and neck. These assorted treatments were the result of visiting three different, well-established, pain clinics, but in the end, no option provided sufficient pain relief.

How did you hear about Dr Peled?

 In despair, after suffering for 4 years, I joined a local, self-help group on Facebook where I read an article by Dr. Peled.

What inspired you to speak with him?

 I wrote to him, explaining how I had had dozens of types of scans, consultations with several top neurologists and neurosurgeons, and even a gamma-ray operator, without a solution. He then organized a Skype consultation with me.

Tell me about your surgery, including when you had it, what happened.

 My surgery with Dr. Peled was in May of 2018. The operation lasted for a bit over an hour. The pain originated from the supraorbital nerve, which did not have enough blood supply from the artery, due to restricted flow where the artery exits the skull. Dr. Peled corrected the blood flow issue during the operation, thereby rejuvenating the problem nerve.

 Do you remember how you felt in the first few days after surgery?

 I had nausea caused by an allergic reaction to the strong pain relief medication, but otherwise, I felt a lot better.

How are you feeling now?

 My pain is no longer. I still have slight nerve tingles in the area where I had the operation, but feel confident that these will lessen month by month.

How has your life changed as a result of this surgery?

 I am back to doing activities I did not do for over 4 years and now enjoy life again.

What is next for you?

 To go on a holiday with my husband.
What would you say to anyone wondering whether to meet Dr Peled?

 A consultation with Dr. Peled is worth every bit. My many other consultations before meeting Dr. Peled cost me a lot and achieved nothing.

Describe your overall experience with Dr. Peled and his office.

 Very professional and caring.

Do you have any advice for prospective patients who are thinking of coming to the practice?

 Have all your facts ready for discussion and bring any supporting scans, including reports. Ask his team for advice on how best to make your visit a success.

What is your name?
Natasha Turner.

Where are you from?
I am Welsh but I have lived in Brisbane, Queensland, Australia since 2001.

What was happening in your life before the headaches became chronic?
I managed an optometry store where I had worked for 4 years. In my spare time, I was an amateur actress, which also involved singing and dancing. I painted and strolled in the nearby forests and bayside, enjoying the almost constant sunshine and warmth here. I was a member of various social groups, and enjoyed catching up with friends over a cup of tea and bite to eat near our local, Pennisula beaches.

How long ago was that?
My headaches started to become really bad 7 years ago. In 2015, I went part-time after my surgeries, but even a 15 hour week was still too much to bear. I stopped working in 2017, when I couldn’t even manage a 4-hour shift.

Describe a good day with chronic pain.
On a good day, I would manage a conversation with a friend face to face for 60 minutes maximum. I may even manage a little early morning or late afternoon walk by the local canal.

I spent most of my time in shady, quiet places, mainly my home and the local library. I wore earplugs all the time. I couldn't wear sunglasses, spectacles, a hat, sleep on my back, nor use digital screens. I was exhausted and medicated all the time, so socializing was draining and focus was impossible. 

Describe a bad day. What does/did the pain feel like.

The pain is like a red-hot iron being held against the right-hand side of my face; it burns into my head, radiating across the right-hand side of my face. My skin feels hot to the touch, and my ear swells. Even the wind blowing against my skin hurts.

After a night of being woken every few hours by the pain, or if I had turned onto the back of my head at all, my only option would be to reach for my anti-epileptic drugs and muscle relaxants. I would angle the blinds in my house nearly closed to minimize glare and keep the doors and windows shut to minimize noise. I moved very gently and slowly due to pain and being medicated. The pain medications make me thirsty so I would drink a lot. I could only answer mobile phone text messages, not phone calls, due to focus issues. 

In the mornings, I read a lot and sometimes find a shady spot to sit in my garden. When the pain is peaking, I meditate and practice mindfulness. Though I barely move, the pain increases as the day goes on. When I can’t read anymore, I listen to audio books and meditation tapes. At 5 pm, I have another dose of anti-epileptic medication. This blurs my vision due to the side effects, so reading is difficult. After dinner, I watch a DVD with the color and contrast turned down. At 7 pm, I take my anti-depressant medication. It is a relief to knock myself out with drugs, as I can no longer function with the level of pain by evening.

I battle suicidal thoughts frequently. I dread the day when I wake. I long for an escape. Every month I get worse. My life gets smaller. I have lost so much. I exist in my room.

Where did you experience the pain?

Lower right side at the back of my skull, arching behind my right ear, over my right ear, inside my right eye socket, and down the right-hand side of my face.

What meds were you taking?

Lyrica 150mg 3 times a day

Endep 75mg at night

Baclofen 20-30mg, when needed

If worse, a 5% lignocaine topical skin patch all day and night

Did you have any success with other pain relief methods besides medication?

No. I tried Botox, nerve block and facet joint injections. I had prolotherapy, physiotherapy, acupuncture, bowen therapy, and reiki. I tried the Cefaly tens machine and low-level laser therapy. I went to two chronic pain clinics. I saw a total of 54 therapists. In December 2017, I even had 85% of my breasts removed in an attempt to reduce a pain trigger, all to no avail.

How did you hear about Dr. Peled?

I am a member of 6 Occipital Neuralgia Facebook support forums, in order to share information, learn all I can about my pain and talk to others who understand. Dr. Peled is frequently mentioned on these forums. His articles are posted along with many patient success stories.

What inspired you to speak with him?

A fellow sufferer had actually spoken with him about my case and urged me to consider surgery with Dr. Peled. I had not entertained this thought prior because:

1. I was petrified of having another failed surgery that could leave me with the same or worse pain.
2. I was worried about how I could afford such a trip and also knew that I would have to travel alone, due to finances.
3. The last time I had been to America I had suffered many panic attacks. This was prior to getting sick, and I could not imagine how I would manage the pain and anxiety on my own.

Tell me about your surgery, including when you had it, what happened.

In May 2015, I had my GON and LON excised and in July 2015, I had my Greater Auricular nerves excised. Both these surgeries took place in Brisbane, Australia and did not result in any numbness or significant pain relief.

My occipital neuralgia pain increased and by 2017, I  had developed Trigeminal and Supraorbital neuralgia. The pain increased continually.

On October 24, 2018, I arrived in San Francisco. The next day, I met Dr. Peled and he performed diagnostic nerve blocks. I had received blocks 4 times in Australia with no success. Dr. Peled was able to reduce my pain from 9/10 to 1/10 within 30 minutes! I spent the weekend staying with a very kind prior patient of Dr. Peled, who lives a 4-hour drive from San Francisco.

On October 29, Dr. Peled successfully excised my GON, LON, and third occipital nerves. He also removed a neuroma. I spent the night in the Surgery Clinic as my host lived too far away. I was given Norco throughout the night when needed, which was twice only. The following morning, my host and another fellow sufferer shared the drive to take me back to my host’s residence.

On October 31, I returned to Dr. Peled for a pre-flight clearance check-up and he gave me more nerve blocks to boost my in-flight pain relief. My occipital area was numb, the surgical pain manageable. I was definitely better than pre-op!

At all times, I was treated with kindness, which eased my anxiety. I knew that I was receiving expert care.

Do you remember how you felt in the first few days after surgery?

Despite the jet lag, I felt quite energized. I was not battling 24-hour searing pain! My friends and my partner remarked that my face looked younger. I moved less stiffly. The incisions were sore, but nothing compared to the pain I had suffered pre-op. My neck muscles were quite tight but I couldn’t believe that I had no pain at the back of my head. I did have tenderness behind my right ear, and at times, trigeminal twinges, which I had expected. I was able to stop the surgical pain medication within a week post-op.

How are you feeling now?

It has only been a couple of weeks, but I feel different - physically and mentally. I still have no occipital pain. I have trigeminal and supraorbital twinges on some days. I have a very tender spot in my right shoulder. All of this I expected. It is very early on in my recovery, and my nerves are settling, with occasional referred pain. I massage my shoulder and my head twice daily.

Mentally, I am letting go of my identity as a person who suffered pain that stole and crushed her soul. I still have anxiety about various activities, as they caused me pain for so long, but I am breaking through this habituated behaviour. I am remaining cautious while I evaluate the extent of the pain relief. I am scared to get too excited after having my hopes being dashed so many times. I truly believe that my pain relief will remain as this recovery is so different from the post-op periods of the previous two surgeries.

How has your life changed as a result of this surgery?
I can wear sunglasses and a hat. I can turn my head to the right. I can go out in the sunshine without pain. I slept on my back for the first time in 5 years! I am not exhausted all the time. I can catch up with friends for a couple of hours in a café because the noise is no longer an issue and I’m able to focus. My depression has reduced significantly (which I’ve had since I was a child, not caused solely by chronic pain).

I have the option of activities in the day. I went for a walk by the beach without an umbrella, in the early afternoon! I recently finished a presentation for a support group that I co-facilitate and I have started another counseling course. I have resumed gallery and museum visits. I am living!

What is next for you?
Eventually, I want to get back to singing, acting, and dancing. I love being on stage! I continued to go to shows whilst sick, with earplugs and medications. I cried through the performance because I wanted to be where the performers were. I hope to resume weekly acting classes and regular performances.

Due to the number of years I have been in pain, I have few friends. I would like to join social groups to expand my circle.

I would like to return to forest rambling, going on day trips, attending cultural festivals, and painting. I would like to explore more of Queensland with my partner.

I would love for my partner to be able to cradle my head, to touch my hair, to kiss me without being so gentle that it feels like a whisper.

By the end of 2019, I hope to set up my own counseling practice. I am about to qualify as a counselor and will specialize in: chronic pain, mental health, LGBTIQA+, abuse and addiction, grief and loss. Until then, I will continue to add to my qualifications, set up local chronic pain face-to-face support groups, and offer Skype counseling sessions. I have already started a local LGBTIQA+ peer support group.

What would you say to anyone wondering whether to meet Dr. Peled?

I wish I had paid the money, got over my anxiety and had my operation with Dr. Peled in 2015. I would have saved over $20,000 in Australian medical expenses, I would still be employed, and I wouldn’t have had to battle suicidal urges for 3 years.

Dr. Peled is the only person I was willing to let open my head up after the first two failed surgeries in Australia. In my opinion, he is the world expert in this field. Why wouldn’t you want him to take care of you?

Describe your overall experience with Dr. Peled and his office.

Dr. Peled’s team is very accomplished with assisting overseas patients and with personalized communication frequently made via Skype.

Dr. Peled has the best bedside manner of any specialist I have ever met, and I have met a lot! He is a kind man. Dr. Peled and his team assisted me patiently with the many travel dramas that occurred.

The surgery center staff knew that I had traveled alone, and also showed me a lot of warmth.

Do you have any advice for prospective patients who are thinking of coming to the practice?

Make the call, change your life, do it now.

Someone recently asked this question on one of the forums and I thought it was a very good question the answers for which may not be immediately clear.  First of all, I think it is important to define exactly what is meant by ‘neuralgia’.  The prefix ‘neur’ simply refers to a nerve and the term ‘algia’ means pain.  Therefore, simply put, neuralgia means pain cause by a nerve or nerves.  The question always becomes which ‘neur’’ is causing the ‘algia’ and if you can answer that question, can you then do something about it?

Occipital neuralgia (ON) is a neurological condition in which the occipital nerves are irritated or compressed (i.e. pinched) and hence cause pain.  The typical symptoms are episodic (i.e. paroxysmal) bouts of “lightning-like” pain in the back of the head although as many of you know and as I have blogged about many times, the symptoms can vary widely.  Because each person is unique, they will each experience pain differently.  Similarly, trigeminal neuralgia (TN) is a neurological condition in which the main trigeminal nerve trunk is compressed.  Not surprisingly, the classic symptoms are episodic bouts of “lightning-like” pain in the face which are the areas innervated by the various branches of the trigeminal nerve. These sets of nerves are not physically connected so why is it that ON often co-exists with TN?  The answer lies in the anatomy. I will have a picture of a peripheral nerve included in this post to help illustrate the points I make below.

Many people don’t realize that the upper-most, neural elements in the neck (e.g. the occipital nerves) have a common connection zone in the medulla which is a part of the brain stem, with the cell bodies forming the trigeminal nerve before continuing into the upper cervical spinal cord.  This zone is known as the cervico-trigeminal complex and can potentially explain why discomfort from lesser occipital neuralgia may sometimes also be referred to the trigeminal nerve territories anteriorly. Referring to the image of a neuron (i.e. nerve cell) below, you can see that when the long part (axon) of the nerve is injured (e.g. in a whiplash accident), the whole nerve becomes inflamed including the cell body.  This injury is depicted in #1 in the attached image. When the cell body of a cervical nerve (e.g. one that begets the greater occipital nerve) is chronically inflamed, the adjacent cell bodies (e.g. those of a trigeminal nerve branch – for example, the supraorbital nerve) also become inflamed. This injury is depicted in #2 & #3 in the attached image.  Then the axons of those latter nerves cause pain in their respective nerve distributions (e.g. in the forehead in the case of the supraorbital nerve). This injury is depicted in #4 in the attached image. In this way, an injury to the GON can ultimately result in forehead discomfort. To use an analogy close to home here in California, think of it as a forest fire that has burned too long and the embers from one part of the forest jump the clearing to the adjacent wooded area and cause a fire there. 

Hopefully, it now becomes clear why ON and TN often co-exist.  It is usually the case that one begets the other and I have seen countless patients in my office whose pain started in the neck area and eventually spread elsewhere.  Fortunately, the process can also reverse itself.  I hope everyone finds relief this holiday season.  Happy Thanksgiving.