Peled Migraine Surgery Blog

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.

I recently had the pleasure of taking care of a nice, young woman who came to see me from a far away country. She had been suffering from occipital neuralgia for many years and no one in her area was able to manage her pain.  Of course, she had been tried on numerous medications, and even nerve stimulators, all without success. She had even undergone two operations to try and manage her pain, but without any relief.  One operation even targeted a nerve with no known compression points. This woman came to see me in obvious distress stating that the prior nerve blocks she had received were unsuccessful and that they didn’t even result in any numbness following the injections.  That means the target nerves were missed.  Somehow, despite these results (or lack thereof) a decision was made to operate and yet despite an operative report, it was unclear exactly what was done.  Moreover, the incisions used were in such a location that made it difficult to believe that the surgeon had addressed the nerves in question. She had successful nerve blocks with me (numbness and all) and we ultimately decided to operate on her.

In the operating room, I made my usual incisions and found a huge neuroma of the greater occipital nerve.  The nerve itself had been severed but left in the subcutaneous tissue where it caused a lot of residual pain. People often ask me what exactly a neuroma is.  Basically, from a medical perspective, a neuroma consists of regenerating nerve fibers and scar tissue.  Nerves will always try to regenerate when they are injured and when they grow back in the subcutaneous tissue, they usually cause significant pain and hypersensitivity.  This patient had to wear a lidocaine patch because her skin hurt so much.  There are many unfortunate components to this story, most notably the fact that a person had to suffer for so long with such severe pain and also that it was unclear whether or not the nerve ever had to be severed in the first place.  But just as sad is the fact that had the nerve been buried in the muscle in the first place, her problems might have been resolved many years earlier.  During her operation, we cut the greater occipital nerve where it was healthy and buried that healthy end in the muscle where it would eventually become quiescent. We also operated on two other nerves that were also injured. 

As of this writing, the patient is about 2 weeks post-op and doing very well. The pain she had prior to her operation is now completely gone and she is enjoying the numbness without having to wear any patches or taking much in the way of pain medicine.  Time will tell if her pain relief is permanent, but there is a very high likelihood she will now be a different person.  I tell this story because it illustrates several important points.  One, the surgeon should know what to do with a nerve if it is severed so ask your potential surgeon what s/he is planning before your operation.  Two, the surgeon should understand what a neuroma presents like in the office and should perform blocks to determine whether this is the case. If so, then the nerve needs to be re-explored and the neuroma dealt with so ask your surgeon what they would do if a neuroma occurs.  It happens to even the best surgeons.  Third, always look for solutions and never give up hope. It comes even despite tremendous hardship but is all the more worth it if it requires effort.

We reached out to our patient and she responded with this:  

I am doing really well. Used 10mg oxy for 2-3 days, then 5 mg 2 days, then nothing. Surgical pain mainly gone. More a tight feeling. End of LON incision is raised,sore, not infected though. I had trigeminal and supraorbital neuralgia pain yesterday and the day before. Gone today. The area behind the top of my ear is tender to touch. I am doing gentle neck and shoulder stretches and using a fine hairbrush on my crown. Today I dropped from 450mg a day to 375mg. No difference noticed. Hoorah

I know that there are more changes ahead, and that they may not all be positive. Just observing now, but so far very happy. I can even sleep lying flat on the back of my head, first time in 5 years, makes me cry

I cannot express the magnitude of my appreciation  adequately in words. Thank you is not enough

Oh, and I forgot (how?) to mention...NO OCCIPITAL PAIN!!!! Amazing

An interesting thought occurred to me the other day as I was finishing up a particular headache surgical procedure.   Something that has come up over the years is that patients tell me that their headaches are worse when they are sick with the cold, flu or some other such issue.  I have been pondering why this symptom change might be taking place for a long time.  As with many of my blog posts, there are several possible causes for this phenomenon in my opinion and so I have decided to delineate these possibilities below.

One reason is that people who are sick are often more stressed either because of or as a cause of their illness.  It is considered reasonable that stress, of whatever type, can weaken the immune system and thus mitigate the body’s ability to fight various pathogens.  These pathogens can cause all manner of irritation and inflammation in various tissues such as muscles hence the muscle discomfort with the flu, for example.  If one type of tissue is irritated, the surrounding tissues might suffer the same fate. In addition, when we are stressed, our blood pressure often rises.  Since many of the nerves which we address during our operations are compressed by surrounding blood vessels, it follows that when these vessels beat harder (i.e. during a period of relative hypertension) the nerves which are already irritated may become even more so.  But another, third thing happens during an infectious scenario, one to which most people can also relate.  Have you ever felt your neck when you feel you have a sore throat or the sniffles? If so, you have probably noticed that the lymph nodes in the area are swollen and often tender.  That is because these lymph nodes are the factories for pathogen-fighting cells and they ramp up production (hence swell) when you are sick.  As I was dissecting this person’s greater occipital and lesser occipital nerves, I noticed several enlarged lymph nodes located within the already crowded spaces through which these nerves passed.  Bear in mind that we don’t operate on people who are sick so these nodes were particularly enlarged given that fact alone.  The nodes were further compressing these poor nerves which were already pressured by the surrounding blood vessels and scarred connective tissue.  I could only imagine what occurs to these nerves if that person were to contract the flu.  Those nodes would surely swell, sometimes quite dramatically and place even further pressure in the area causing even further pain.  With pain comes higher blood pressure, hence more compression and so begins the upward spiral.  One recurring question from patients is, “What is compressing my nerves?” The answer used to be possibly spastic muscle, tight/scarred connective tissue, enlarged or aberrant blood vessels.  It now also includes abnormally large and/or poorly localized lymph nodes.  Happily these nodes can be removed carefully and selectively to further relieve pressure during a decompression procedure and many of the patients in whom this lymph node removal was necessary have gone on to do quite well.  Finally, none of the nodes which I have biopsied to date have revealed any evidence for malignancy or other pathology, further happily capping a saga that has resulted in many positive outcomes.

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. 

With the recent concussion settlement between the NFL and their players, and Major League Baseball establishing a new 7-day concussion DL for their players, the effects of concussive impact on athletes is in the news more than ever before.  The science is being studied at higher levels and with more money behind it than ever before.  One thing that is not mentioned in all of this is the care afterwards of athletes who are living the rest of their lives with migraines and nerve pain that in some cases can be reduced or eliminated with peripheral nerve surgery.

The Occipital Nerve is the nerve that causes migraines when it is impinged.  This can come from a variety of sources, including sports.  Athletes in collision sports, or action sports, can suffer whiplash or worse, which can often cause migraines.

These injuries compound over the course of an athlete’s career.  They are not generally treated mid-season, and this can lead to a cascade effect where the injury escalates during the year or career.  When athletes begin to learn to live with pain or treat it with medication the condition can worsen and cause more pain as they age.  Traditional cures such as medication and massage can alleviate the problem, but do not strike at the heart of the problem.  They merely push it off for a while.

Surgical Decompression has been shown to reduce migraines in 88% of cases.  This an extremely effective solution for migraine pain relief.  All athletes, current and former, that suffer from debilitating headaches or migraines should consult their physician for the way forward if traditional cures prove ineffective.

I have performed hundreds of Occipital Nerve surgeries on satisfied patients.  If nothing else has helped, peripheral nerve surgery may be the answer for you.

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"