This post is a rather long one, but an important one nonetheless in my humble opinion. Over the years that I have been performing headache surgery, I have heard from so many patients that they are frustrated with their current treating physicians because their symptoms are not under control to the degree that they would like. Anyone who has been on these forums for a few hours has certainly run into a post or several posts describing a bad patient-physician interaction or a bad patient-health system interaction. To all of those people - I completely empathize and you have every right to feel as you do. Having been a patient on several occasions myself, I know what it’s like to speak with a physician or an insurance adjustor and feel like you are talking to the clouds. It is very frustrating and can often leave you feeling helpless – and I’m a surgeon. As a peripheral nerve surgeon, especially one that operates on people with chronic, intractable headaches, I have often heard criticisms from other practitioners whom I don’t feel even understand what it is that I do. However, in those situations I often find myself trying to put myself into the shoes of the doctor across from me. What I have found is that there is always common ground to be had somewhere and that understanding their perspective can help me find it. In addition, since we are (or should be) on the same side, I have found that viewing things from a team perspective is particularly and practically very helpful.
Breast cancer is sadly a disease that touches too many people throughout the world. Over the past few decades, the medical profession has made incredible strides in fighting this dreaded disease and we now have cancer remission rates that were once thought impossible. One of the biggest factors in helping this development along has been the team approach. In our community, a patient with a new breast cancer diagnosis is immediately given a team of physicians and clinicians to help them navigate the process that is dealing with this pathology. To be sure, there is a “captain of the ship”, usually the breast surgeon or oncoplastic surgeon who is coordinating all of the moving parts, but every member of the team is critical to ensuring success. While the breast surgeon may remove the cancer physically, there is often a plastic surgeon to help reconstruct the resultant defect, a radiation oncologist who will help ensure that any disease that might have spread locally is controlled and a medical oncologist who will determine if the risk of distant disease is high enough to warrant a regimen of chemotherapy or hormonal therapy, There is also often a psychologist and nurse navigator who can help the patient deal emotionally and psychologically with the fear often accompanying a cancer diagnosis. Only when you put all of these components together, do you get the wonderful results that modern medicine has been able to achieve. If you think about it, the same team principles apply to a football team (American football as well as soccer), a dance troupe or a team of scientists working to find a cure for something. So what the heck does this diatribe have to do with headache surgery?
Well, for years I have been saying to my patients that hopefully someday soon, we will realize that chronic pain should be best treated with a multi-modality approach as with breast cancer. Chronic headaches are a form of chronic pain. There are certainly many patients for whom medical management works very well. Those people do not need any injections or surgical intervention. There are those for whom pharmacologic agents are simply ineffective and in those cases, nerve decompression may be a good option. However, for most, a combination of therapies is necessary to control the underlying symptoms. I have heard from countless patients who tell me that prior to surgery their medication (say Imitrex) was inconsistently helpful. “I could flip a coin” they would tell me, take it early in the middle or late in a headache attack, but they could never figure out why sometimes it was effective and sometimes not. Following surgery, their headache attacks are much less frequent and often much less severe, but what was interesting to me was that they would tell me that when they would get an attack, the Imitrex was almost always effective. “Why is that?” they would ask. Well….it is likely that they have two problems contributing to their headache symptom complex. One is a chemical imbalance that medication would treat, and the other is a mechanical compression of the nerve(s). Pre-operatively, when you had a headache, you reached for what you had which was Imitrex, but if it was the mechanical compression that was irritating the nerve that day, you didn’t get any better. If it was the chemical imbalance aggravating the nerve, you did get better. Post-operatively, the mechanical compression has been relieved so the headache frequency and severity are much less, but there are still headaches. However, now when you take the Imitrex, lo and behold it almost always works, because it is actually treating the underlying chemical imbalance that is causing those residual symptoms. The take home message is that patients still often need to have those pain management physicians and neurologists involved to manage those medicines so that their symptoms remain under optimal control. Those that have seen me know that I often like to communicate with the very same such doctors prior to surgery to ensure we can optimize the post-operative recovery period which certainly can have its share of ups and downs. In the end, we all have to partner in this endeavor together as a team.