Peled Migraine Surgery Blog

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A Different Way to Think About Chronic Headaches

A Different Way to Think About Chronic Headaches

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

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

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

  1. Lipton, R. B., Bigal, M. E., Diamond, M., et al. Migraine prevalence, disease burden, and the need for preventive therapy. Neurology 2007;68:343-349.
  2. Schwedt TJ, Chromic Migraine. BMJ 2014; 348: 1416-1427.
  3. Goldberg, L. D. The cost of migraine and its treatment. The American Journal of Managed Care 2005;11:S62-67.
  4. Hu, X. H., Markson, L. E., Lipton, R. B., Stewart, W. F., Berger, M. L. Burden of migraine in the United States: disability and economic costs. Archives of Internal Medicine 1999;159:813-818.
  5. Turner-Bowker, D. M., Bayliss, M. S., Ware, J. E., Jr., Kosinski, M. Usefulness of the SF-8 Health Survey for comparing the impact of migraine and other conditions. Quality of Life Research : An International Journal of Quality of Life Aspects of Treatment, Care and Rehabilitation 2003;12:1003-1012.
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Comments

Guest - Kathy on Monday, 09 April 2018 13:37

As always, it is such a pleasure to read your posts. I always learn something new and the more I learn the more I realize there is so much more to learn. I only wish I had seen this post in the years when everyone told me I had migraines until I finally got the correct diagnosis of ON. I think it happens often because there are so few doctors who understand it, it is just not that common, so they rarely see it, so everyone just assumes migraine. I did not know that neuralgia literally means nerve pain in Latin! Its nice to hear from someone who really understands our suffering, so few people do. Do you have any thoughts to share about pulsed RFA as an adjunctive treatment modality to add to our try/fail list that we all go through before considering surgery? I know the results have been mixed based on journal article review findings, and the relief is temporary and it does not offer complete relief, but I have been told that it is "guaranteed" to not damage the nerve or cause neuritis because the level of heat that is used is lower than that of regular RFA. Do you agree with that? I also wanted to mention that I recently discovered some rescue medicatons for migraine pain like Relpax and other medications that are prescribed for the pain like the antidepressant Amitriptilyne are "ototoxic" so I was wondering if that is the cause of tinnitus that approx. 30% of ON sufferers experience, or is it directly related to the nerve damage itself (or possibly both)? Thanks so much Dr. Peled!

As always, it is such a pleasure to read your posts. I always learn something new and the more I learn the more I realize there is so much more to learn. I only wish I had seen this post in the years when everyone told me I had migraines until I finally got the correct diagnosis of ON. I think it happens often because there are so few doctors who understand it, it is just not that common, so they rarely see it, so everyone just assumes migraine. I did not know that neuralgia literally means nerve pain in Latin! Its nice to hear from someone who really understands our suffering, so few people do. Do you have any thoughts to share about pulsed RFA as an adjunctive treatment modality to add to our try/fail list that we all go through before considering surgery? I know the results have been mixed based on journal article review findings, and the relief is temporary and it does not offer complete relief, but I have been told that it is "guaranteed" to not damage the nerve or cause neuritis because the level of heat that is used is lower than that of regular RFA. Do you agree with that? I also wanted to mention that I recently discovered some rescue medicatons for migraine pain like Relpax and other medications that are prescribed for the pain like the antidepressant Amitriptilyne are "ototoxic" so I was wondering if that is the cause of tinnitus that approx. 30% of ON sufferers experience, or is it directly related to the nerve damage itself (or possibly both)? Thanks so much Dr. Peled!
Ziv on Thursday, 12 April 2018 10:26

Dear Kathy,

I don't do pulsed RFA so I don't have a specific comment on how it works, but my understanding is the same as yours in that it is a lower energy way of trying to manage nerve pain, but therefore also requires many sessions and like any modality, can also be ineffective. As for ototoxicity, so many meds have that as a possible side effect, for example the various "floxins" like Cipro. So I would read about them carefully and discuss the side effects or their possibilities with you prescribing doctor. This comment also highlights that fact that medications themselves are often seen as a 'conservative' treatment option, but like any modality, they can have severe side effects as well. Hope that helps.

Dr. Peled

Dear Kathy, I don't do pulsed RFA so I don't have a specific comment on how it works, but my understanding is the same as yours in that it is a lower energy way of trying to manage nerve pain, but therefore also requires many sessions and like any modality, can also be ineffective. As for ototoxicity, so many meds have that as a possible side effect, for example the various "floxins" like Cipro. So I would read about them carefully and discuss the side effects or their possibilities with you prescribing doctor. This comment also highlights that fact that medications themselves are often seen as a 'conservative' treatment option, but like any modality, they can have severe side effects as well. Hope that helps. Dr. Peled
Guest - Pauline Avery on Friday, 13 April 2018 10:23

Do you think massage has any place in therpy for ON problems.

Do you think massage has any place in therpy for ON problems.
Ziv on Friday, 13 April 2018 10:39

I do think that, in general, many conservative modalities, so long as they don't injure the nerves further with too aggressive an approach can be helpful.

I do think that, in general, many conservative modalities, so long as they don't injure the nerves further with too aggressive an approach can be helpful.
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