Headache 360 – The Headache Neurologist on the Cutting Edge

Announcer [00:01]: Welcome to the Headache 360 Podcast, a place to listen and learn about the diagnosis and treatment of chronic headache and migraine pain. Because information can be the best medicine.

Dr. Lowenstein [00:18]: Hello and welcome to our next episode of the Headache 360 Podcast. I’m your host, Dr. Adam Lowenstein, and I have a very special guest today. Excuse me, Dr. Pamela Blake is a renowned neurologist from Texas, and she has done a tremendous amount of work and research and clinical work with both with headache patients as well as discovering new ways to take care of patients and is really very active in the field, and Dr. Blake, I can’t thank you enough for joining me here today.

Dr. Blake [01:05]: Thank you for having me.

Dr. Lowenstein [01:06]: Actually, one thing we haven’t chatted about: you spent a lot of time in Georgetown.

Dr. Blake [01:06]: I did.

Dr. Lowenstein [01:06]: And Baltimore. Where are you originally from?

Dr. Blake [01:16]: I’m originally from Scranton, Pennsylvania.

Dr. Lowenstein [01:18]: That’s right. So I’m going to Georgetown on Saturday. My mother lives on Dent Place. You know where that is?

Dr. Blake [01:25]: Oh, I know very well where that is, yes.

Dr. Lowenstein [01:27]: Oh yeah. I was brought up right outside of DC, and I’m looking forward to some good food. Santa Barbara has great American food and great Mexican food, but I’m going to get some good Chinese and French food and enjoy the multicultural aspects of Georgetown.

Dr. Blake [01:48]: It’s a wonderful place. Oh, it’s great.

Dr. Lowenstein [01:49]: It’s a great spot. And so tell me, how did you end up in Houston?

Dr. Blake [01:55]: I remarried to a petroleum engineer, and this is where they all live. They can’t leave here. So yeah, so my husband is a petroleum engineer, and I had been in Washington for 20 years when we were sort of working out how this would work in terms of where we lived, and I thought I’m ready for — Washington’s a wonderful place, and I thought I’m ready for something a little bit different. And so Texas has been just wonderful, and it’s been wonderful personally for me, and it’s been great professionally also.

Dr. Lowenstein [02:27]: Oh, that’s great. I guess so, yeah, Washington’s sometimes not humid enough, I guess. So, right?

Dr. Blake [02:33]: It’s better for the skin, you know, to be in the humidity.

Dr. Lowenstein [02:36]: Yeah. I actually took my plastic surgery boards in Houston, and we were in suits and it’s very, very high pressure. It’s several days of being grilled and in, you know, questions and answers and stuff. And all you want to do is go outside. And we were at the DoubleTree Hotel, which was coated — you couldn’t see outside because of the condensation. And all you wanted to do is go outside and get some air, but you were going to sweat more if you walked outside than if you were getting grilled. And that’s my memory of it.

Dr. Blake [02:58]: Maybe they do it on purpose that way, so you don’t move on.

Dr. Lowenstein [02:58]: Yeah, they’re grueling a couple of days and anything that they could do to make your life worse, they certainly did. But anyway, so let’s — I really want to touch on this most recent paper that you put out called “Emerging Evidence of Occipital Nerve Compression in Unremitting Head and Neck Pain.” I have even found this paper really, really important in my practice because having a conversation with local neurologists before and after this paper has been a totally different experience.

Dr. Blake [03:44]: Really?

Dr. Lowenstein [03:44]: And I would say that before your paper, the local neurologists really did not want to talk about much in this way. And now they’ve asked me to come give grand rounds to them, and it’s based on the fact that a well-known neurologist yourself is clearly receptive to the concept of nerve compression being a major cause of head and neck pain. And I think that’s kind of what it took to get some of the non-headache neurologists on board for this. So it’s been great. Can we start by talking a little bit about unremitting head and neck pain being a symptom as opposed to a diagnosis? My conversations with many people on this podcast revolve around diagnoses, and I think the problems that people have getting the right diagnosis, and how nerve decompression can help multiple different diagnoses. But can you talk a little bit about your experience with unremitting head and neck pain and kind of where you come from — why you’re honing in on that as opposed to chronic migraine or cervicogenic headache or something like that.

Dr. Blake [05:44]: Sure. Well, first of all, I would like to acknowledge my colleague and co-author on this paper, Rami Burstein, who has been a wonderful colleague and mentor of sorts in this work. And it was by pure serendipity — well, no, I take that back. It wasn’t complete serendipity. I approached Rami at a meeting in 2009 that I attended, that he was speaking at in Boston. It was a meeting about pain. And Rami, from the platform, made the comment that there is something happening in the neck of these patients with chronic headaches. And at that time I had already had some experience, a fair amount of experience, with the nerve decompression surgery, beginning in 2004 at Georgetown when Ivica Ducic, the plastic surgeon I was working with there — who’s published quite a bit in this area as well — approached me one day and said Bahman Guyuron had shown a poster at a plastic surgery meeting about occipital nerve decompression. And at that time I thought, why should that help? Everybody knows — this was my thinking at the time — that pain in the distribution of the upper cervical nerve roots in chronic migraine is due to central sensitization, which is a heightened sensitivity of pain receptors in the nervous system, in the brain, and it happens as a result of chronic headaches, chronic migraines, thinking of migraines as being a primarily brain-mediated process.

Dr. Lowenstein [07:14]: Right.

Dr. Blake [07:15]: And so it didn’t make sense to me why this should work, but I had several patients in my practice who had pain that was clearly in the occipital nerve distribution, meaning in the back of the neck and the back of the head radiating to the temples or the forehead. And everything we were trying for these patients just was not working, nothing was helping. And so it may have been a little bit more out of a sense of desperation combined with a recognition that the surgery is unlikely to cause problems. It’s a fairly superficial procedure, meaning it’s not going into the skull or into the spinal cord, and I thought, well, I don’t think it will hurt, and it may help. And it did help. It helped quite a bit. So much so that by the time I left Washington to come to Houston in 2006, we had already performed surgery on about 200 patients. And so by that time it was a very important part of my practice. So when I went to that meeting in Boston, that pain meeting in 2009, and Rami made that comment, I approached him after the meeting and said, I think that this occipital nerve compression, the pressure on those nerves, has something to do with this neck pain and probably also something to do with their headaches. And so that started our collaboration, and it just so happened in that year, 2009, Rami published his first paper — which I do talk about in this most recent article — and his paper was the first to show connections between the extracranial space and nerve cells that originate intracranially, trigeminal branches that are innervating the meninges, the membrane around the brain, and then exiting through the skull. So this was a very important foundational paper because it demonstrates that the brain alone is not the only potential source of pain and that forces on the outside of the head may be important. And so in our working together over the years and seeing more patients with nerve compression, and in my close collaboration with my plastic surgery colleague Carlton Perry, we’ve learned a lot more about how these patients present, what kinds of treatments they may respond to, and when nerve decompression is the right way to go. It is absolutely correct that there is no one straightforward way that these patients present, and they will overlap with a lot of different ICHD — International Classification of Headache Disorders — diagnoses. The ICHD is a very useful tool. It’s the classification of headaches; it’s in its third edition right now. It’s very valuable in that it gets everyone on the same page, making sure that we are talking, at least with regard to symptoms, about the same type of problem. So a patient in a study in Denmark and a patient in a study in the United States will be similar in terms of what types of head pain they have. But there are two very important things to remember. Number one is that the ICHD is primarily symptom-based. There is very little that speaks to the pathophysiology or the etiology of the pain in these headache disorders. And number two, it’s headache. So other than the diagnosis of cervicogenic headache, which does talk about neck pain, the involvement or the presence of neck pain in somebody with chronic migraine is not mentioned. It’s nowhere to be found. And I think it took me several years to realize that when somebody says I have headache three days a week, but I have a constant daily pain in the upper part of the back of my neck, that’s really important. And that’s a part of their headache problem.

Dr. Lowenstein [11:11]: It seems like — I think a lot of patients, at least in my experience, they’ll talk about their headaches, but they won’t necessarily talk about their neck unless asked about their neck.

Dr. Blake [11:20]: Oh yes.

Dr. Lowenstein [11:21]: So, you know, they just — they’re thinking that’s — and I actually, I’m one of them. I’ve got migraines and I know, I mean, I have occipital compression. And I, throughout my residency, spent every moment that I could pushing my head up against corners of machines and things like that, trying to massage the back of my neck. But if you asked me, I would have said I had a headache. And I think what you’re talking about is not only an issue with diagnosis from the physician’s standpoint, but also a description of the actual pain from a patient standpoint.

Dr. Blake [12:03]: Well, just the last patient I saw today — a patient who is coming in for botulinum toxin injections — at the last visit, we had a long conversation about the fact that, based on our conversation from the visit before, that in addition to her frequent headache, she has a constant pain in the left occipital and suboccipital area. And the muscle tightness in the back of her neck going down along the top of her back and the middle fibers of the trapezius is worse on the left side. And so at that Botox injection 12 weeks ago, when I administered the Botox, I put a higher dose in all of the muscles on the back on the left side, and she found it to be much more effective than the regular PREEMPT protocol. This woman has had this probably going on for years, and until the attention is really focused and directed at it, and people think about it and pay attention to it, they don’t, because it’s just sort of part of the background noise of life. You know, they’ve had it for so long and they just don’t really think about it. But it’s relevant and it’s important, and when somebody is having chronic neck pain, I think that to categorize this person — who may be having headaches only one or two days a week — as an episodic migraine patient would not be correct, because there’s something more going on. It’s not normal to have your neck hurt every day.

Dr. Lowenstein [13:28]: Right. That’s a very good point. And we — Houston is fortunate to have you, but you have people in Chicago and North Dakota and whatnot who don’t have access to even any neurologist, but certainly headache specialists, and I see a lot of — I don’t want to say misdiagnoses, but questionable histories, and these people are categorized potentially in a manner that won’t allow them to progress to the next level of help, if that makes sense.

Dr. Blake [14:13]: Well, it does, but a person may meet the International Classification, the ICHD diagnostic criteria for chronic migraine, and that’s fine. But I’m not satisfied with that — to say to somebody, well, you have chronic migraine, and so we will treat you with medications and we will simply continue to use medications for an indefinite period of time. And that’s why I find it more interesting and sort of intellectually satisfying to try to say, well, what’s causing this? It’s not normal to have — especially if the pain is unilateral and they have allodynia, tenderness on the back of the head, and that muscle is tight — and for instance, a history of, this is another historic fact I talked about with a patient not too long ago: every time I’m in a certain class and I have to turn my head to the side to look at the instructor in the front of the class, I get a headache.

Dr. Lowenstein [15:14]: Yeah.

Dr. Blake [15:14]: No, that’s not supposed to happen, right? So there’s something — maybe, but when the headache is on one side of the head and starts in the back of your neck and comes up the back of your head, that’s probably not just the professor. Although I do find that aspect fascinating as well — what role might stress or emotional factors play in this as well, knowing that they do have an influence on inflammatory processes. So I think it’s just really interesting to be able to get into the weeds of what exactly is causing this pain and what we can do to isolate that and then fix it. I mean, that’s what we would do anywhere else in the body, right? We think that the head has some sort of mystical thing about it that, oh, if it’s a headache, it’s sort of something not to be fully understood. If you go to a doctor because you’re having pain in your knee, you’re not going to want to walk away with a chronic knee pain diagnosis. You’re going to want imaging studies and some way to diagnose exactly what’s wrong with your knee and let’s fix it. It’s a mechanical structural problem. And so I think it’s helpful to kind of think about headaches and neck pain that way as well, although imaging right now is not able to tell us too much.

Dr. Lowenstein [16:25]: So let me ask you a little bit about that. So do you get imaging on patients preoperatively?

Dr. Blake [16:37]: No. Not as a matter of routine.

Dr. Lowenstein [16:39]: Not as a matter of routine. Because one of the things that I’ve always done is I always make sure that somebody’s gotten some kind of intracranial imaging to make sure that there’s nothing else going on. But you don’t find that to be critical.

Dr. Blake [16:57]: No, I don’t. The American Academy of Neurology guideline — well, this guideline is specifically for migraines — is that if there is nothing worrisome in the history that would indicate some type of intracranial structural or other process going on, and if the neurological examination is normal — and that’s a careful neurological examination, which I do with every new patient, which includes a careful fundoscopic examination, looking at the optic discs, looking for spontaneous venous pulsations, and then a full neurological examination — if that’s all negative, and if the history is straightforward for occipital nerve compression, I really would not. Now I don’t think there’s any role for imaging. Certain situations may be a little bit different — if somebody was just treated for cancer, for instance, or if somebody has terrible cervical spine disease, from other — then they’ve had multiple cervical spine surgeries, something for that, yes, of course, in that situation we’d want to get some imaging, but that’s not the typical patient. The typical patient is in pretty good health and does not have too much else going on medically to drive the need for imaging.

Dr. Lowenstein [18:09]: The other thing that I’m trying to remember where I heard this, but it might have been watching your Facebook Live with Dr. Peled, who’s a good friend and an awesome surgeon as well. But I think at some point I heard you say that you don’t use nerve blocks as diagnostic criteria either. Is that accurate?

Dr. Blake [18:38]: That is accurate. I don’t think they are necessary to make the diagnosis of nerve compression. Sometimes they’re very helpful, which is great — it can provide a therapeutic benefit for the patient. Sometimes if the history is not completely clear, they may be helpful diagnostically. But I do not require that somebody has had occipital nerve blocks or occipital trigger point injections — which is what I prefer to call them — with steroid, and had a positive response, in order to feel confident that the patient has occipital nerve compression. And one of the main reasons for that is that they just don’t work with everybody. For instance, today I saw a patient who, gosh, I’ve probably followed for a few years now, and I missed the diagnosis because I was focused on other aspects of her history that got our attention. But as we spoke about it over the last few visits, it’s become very clear — and I should say there are other factors sort of cognitively going on that played a role in that, and that’s not uncommon, by the way. So getting the history correct is really, really important, and it does not always happen at the first visit. But her pain is occipital and suboccipital and it radiates to the front, and she’s got a lot of occipital allodynia, and so I did a steroid, an occipital steroid injection, two weeks ago, and it provoked a lot of pain.

Dr. Lowenstein [20:06]: Yep, makes it worse, right?

Dr. Blake [20:06]: Right, it makes it worse. And so to me, a provoked headache is sort of diagnostic.

Dr. Lowenstein [20:06]: Sure, sure.

Dr. Blake [20:06]: But sometimes it doesn’t have to be a benefit, and sometimes they just don’t really have much of a change of anything.

Dr. Lowenstein [20:28]: Well, let me ask you this, and you may or may not know this — again, you work with Dr. Perry, who’s a great migraine surgeon down in Texas, and maybe I should be asking him — but I kind of delineate between therapeutic and diagnostic blocks. So I fully agree that you don’t necessarily need to have a steroid type of block to respond, but we do just lidocaine diagnostic blocks prior to surgery. Does Dr. Perry do that before operating either? Or when you’re talking about nerve blocks, or as you say, trigger point injections, are you exclusively talking about the ones that neurologists will often do using steroids?

Dr. Blake [21:22]: That’s correct. Yes. No, I don’t think he does any blocks like that around the time of surgery. And also let me just add that, as you know, there’s a lot of variability with the anatomy, and I don’t know how we could be sure that you’re actually getting all of the branches of the nerves.

Dr. Lowenstein [21:41]: Well, the way I do it is I inject somebody with lidocaine and I wait to make sure that they’ve got — they’re numb in the distribution of the nerve. And it is actually very, very rare, but on occasion I will inject somebody and they will get numb but say that their pain is unchanged. And that person I tend not to operate on. Most people — 90% of people — I inject and they sit there and their pain goes away and they will start crying and say, this is fantastic, this is wonderful. And that then tells me — and I can also say this is what it’s going to feel like after surgery, because when we operate, oftentimes the nerve shuts down for a couple of days before it comes back — but I know then that the pain is definitely mediated by those nerves.

Dr. Blake [22:41]: Now I use that approach, I should say, certainly in people with trigeminal branch compression and when there’s facial pain, and we’re looking for that. I do find nerve blocks in the trigeminal branches to be very helpful. How much lidocaine or Marcaine are you injecting to get complete anesthesia?

Dr. Lowenstein [23:04]: I use about two and a half to three cc’s of half percent. And I will say that most of these patients who come to me honestly have had nerve blocks that have been unsuccessful. But as you say, when it comes to the anatomy, number one, it’s variable. And number two, I would say that you are different because I’m sure that you’ve been involved in these surgeries, but I think when you frequently look at the nerves like I do, you kind of know generally how deep to go and where you’re going to find them. If I do an injection and I don’t get numbness, I do another injection. Sometimes it will take two injections for me to get the numbness I’m looking for. But once I get the numbness, that should, at least logically to me, mediate the pain because I’m shutting down the nerve — that’s the problem. And I also do find that some people have a residual soreness, kind of like if you have a migraine and you successfully take a triptan. A lot of people have what I kind of allude to like a sore muscle — and again, because I have migraines, this happens to me. So some people still will have that kind of generalized soreness as a headache, but the edge is significantly improved from those injections.

Dr. Blake [24:36]: Yes. Well, I think that is an interesting approach, and I think the main reason why I don’t do it is I just don’t know if I find it necessary to do that. I think it really depends on the way that the patient is presenting and what their history is like. What about if the patient’s pain is more in the temples or the forehead?

Dr. Lowenstein [25:02]: So when a patient comes in to see me, I ask them about their pain — where does it start, where does it radiate to, etc. — and I will block the supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, lesser, greater — and the greater and the third get blocked together. I kind of call it nerve mapping. And so that’s how I map out which nerves are the problem. And I usually start posteriorly because, as you talk about a lot, many times the anterior symptoms are a result of the inflammation of the occipital nerves. But a lot of times we see bony entrapment of the supraorbital nerves when it goes through a tight foramen. This is all technical stuff, and if you’re listening and don’t understand this, please refer back to either my website, or I’m sure Dr. Perry has an excellent website about the anatomy of these nerves. But that’s how I use the injections to map out which nerves are the problem, and I keep going until the patient is either pain-free or says, look, I’ve got like a pain of one or two after coming in with a pain of nine. And that’s how I can say, well, we’ve got some issues on the supraorbital, or we can do something just under local at the auriculotemporal nerve, and trace it out that way.

Dr. Blake [26:37]: So have you found that if you inject solely in the occipital area, if the patient’s pain is predominantly frontal, that their frontal pain will diminish when you inject the occipital nerves?

Dr. Lowenstein [26:52]: Often but not always. So there are times that I will inject the occipital, it will get numb, and the patient will still say, I have pain behind my eyes. And then I will do an injection of the supraorbital, supratrochlear — we call it supraorbital syndrome — and their pain will go away. And then I will tell them, look, it seems like the majority of your problem is from, usually, the back, but sometimes it is the front. Sometimes I’ll inject the back and the pain doesn’t get any better, and then I inject the front and the pain does get better. And when I’ve operated on those patients — I had one patient where the foramen was a centimeter and a half long, and I had to unroof the entirety of that canal there in order to free up that nerve. So I do think that a lot of times the frontal pain is mediated by the occipitals, but I think that sometimes that supraorbital syndrome, where you’ve got compression of the anterior nerves, plays a big role.

Dr. Blake [28:02]: Yes. Yeah, that’s interesting. And just to be clear, I don’t think a positive response to the two injections is required to make the diagnosis, but there are certainly times in which it’s very helpful — in a patient for whom the history is just not clear or there are other factors going on, it can be helpful. And I would also like to say at this point that I think it’s important to realize that in many patients, having nerve compression is a part of their headache problem. It may not be the entirety of the headache problem, and there may be what I think of as a more traditionally centrally driven headache process, like quote migraine, end quote, going on. And if there are stress or emotional symptoms that may be contributing, that’s important as well. And so I think it’s important to make clear to listeners, and to other doctors too particularly, that sometimes when a patient goes for surgery, I’ll tell the patient I think this will help 40 to 50 percent of your head pain, but I don’t expect you to be headache-free after this. There are other things that we need to do as well. Now, in this article I talk about a spectrum of headache pathophysiology, where at one end of the spectrum is purely peripheral pain, and at the other end is purely central pain. So the purely peripheral pain might look like a person who has pain only on the back of the head — it may be, for instance, even just unilateral, and it’s constantly tender and it hurts, and they can’t put the back of their head against the sofa or something like that, and they have no frontal pain, no nausea, no sensitivity to lights and sounds, etc. That’s a purely peripheral patient. And if they’re very tender on the nerve, that’s pretty straightforward. And then at the other end, the central end, is, for instance, the patient who has migraine with aura twice a year — somebody who has a very typical visual aura and then may have some sensory changes and some language changes, and they’re having cortical events going on causing their pain that occurs, which is frontal — that certainly is a patient for whom nobody would think about doing anything other than a triptan twice a year.

Dr. Lowenstein [30:18]: Right. Yeah.

Dr. Blake [30:18]: Most patients, of course, are not at those extremes. Most patients are somewhere in between the two ends of the spectrum. And depending on where the person is on the spectrum, I think that will indicate, or suggest and drive, how much better they’re going to get after taking the pressure off of the nerves.

Dr. Lowenstein [30:51]: And I gotta tell you, I could not agree with you more. On your paper, I have a couple of areas with stars right next to it, and I’ve got two stars next to that concept — the whole concept of a spectrum. I don’t say I fight for it, but it seems to me that, as you’ve alluded to with the knee issue and whatnot, there’s a spectrum; there’s such complexity of different factors, including emotional stress, those things that you alluded to earlier, that I think the word “spectrum” is just a fantastic descriptor of how to describe these pain syndromes that can have multiple modalities and multiple causes. And I never tell patients that I’m going to 100% fix their headaches. When we do that, which happens a good deal of the time, it’s fantastic and a bonus. But I’m always shooting for, well, we’re going to reduce your pain and hopefully make your other medications more effective, make them needed less often, and maybe hopefully get you even off the stronger medications so you can take an Advil for your headache, just like everybody else. But different people respond in different manners. And I’m very conservative, which is actually one of the other questions I have for you — the role of surgery in the chronicity of patient care. So I have classically thought of this as a last resort, and it just — getting people to understand that this is not brain surgery, it is a peripheral nerve surgery. There’s not a whole lot of downside except for the post-operative discomfort that you can have while you’re healing. But I have classically thought of this as a last resort. So, if medications don’t work or if you can’t tolerate medications, then go to surgery. It sounds to me, in listening to some of your discussions, that you don’t feel that way and that surgery should be considered earlier on in the care paradigm.

Dr. Blake [33:34]: That’s right. I don’t think it should be something of last resort, because if somebody has a history that’s very straightforward — and we know from the data that’s been out there, if somebody has been on, for instance, four preventive medications, they’ve been on topiramate and amitriptyline and propranolol — what’s the likelihood that they’re going to respond to zonisamide? It’s not very high. Now, with the new medications, the CGRP agents — that’s a completely different class that does work outside the brain, by the way. We don’t know yet exactly where the CGRP agents work, and for all we know, they could be working on some of these patients, and I think they do. But other than that, I don’t think it’s necessary to subject a patient to trying treatment after treatment after treatment, for a few reasons. Number one is, in my experience, in patients with nerve compression, the other treatments just don’t work very well. Botox will work, I think, for a fair amount of people — about half of people, which is very good. In my experience, CGRP agents may be a little less effective than that, but some people definitely do well, so that’s fine — we can certainly use those kinds of treatments. But some people will say, you know, I don’t want to keep getting injections forever, I’d rather just make this problem go away. And when I did my fellowship, the person who trained me used to say there’s two kinds of people — there’s Lady Macbeths and there are Hamlets. And depending on what kind of person you are — if you’re a Lady Macbeth, although that doesn’t sound very nice — I’ve had patients come in who have never been on anything for their headaches. They’ve just sort of dealt with them for five years and it’s getting worse, and now they’re starting to miss work. And if they’ve been reading a lot and they recognize that this is what they have, and they come to me, and I’ll go through the history and the physical, and then I’ll start talking with them about what’s going on, and we review the anatomy and then we start talking about all the treatment options with preventive medicines and Botox injections and steroid injections, and sometimes, if it’s a Lady Macbeth, the patient will just kind of look at me and say, why should we do all that? Just fix it. And I usually — sometimes I just say, yeah, let’s fix it. Sometimes I’ll feel kind of a little bit of an ingrained obligation to say, well, let’s at least try some.

Dr. Lowenstein [36:13]: I never want to be that knife-happy surgeon, like, oh, he just wants to cut you up. I’m not that guy, but I want to help everybody. So I’ve got patients who call me and they’ve never seen anybody, and they say, I’ve had a headache for three years, I want you to look at it. And I’m asking you this because I may change the way I do business — I don’t even see those people. I always tell them that they should go see a neurologist, talk to their primary care doctor, go see a neurologist. I’m not the first person for you to see with a headache. And I guess most people get to Dr. Perry through you or with you. But if somebody were to call me and say, I’ve got head and neck pain, and give me a classic pattern, and has not seen anybody else, I wonder — should I have that patient come in, give them my diagnostic blocks, and if they respond to the blocks, go ahead and operate on them, or should I make them go through the usual hoops of nortriptyline, beta blocker, triptan, all that kind of stuff?

Dr. Blake [37:36]: And it’s complicated also by the fact that, of course, there are certain treatment decisions that we don’t really have control over. So the treatment that I like the most, if we’re using something that’s not surgery, is Botox injections. Botox definitely helps these patients, and of course it’s very well tolerated, and the muscle relaxant effect is very, very helpful. The problem is, before somebody can take Botox, they have to try at least two different preventive medications. And so that means putting somebody on an anti-convulsant and an antidepressant, and those medications of course can have side effects and cognitive effects and things like that. And so you kind of go through these steps of, well, let’s first try this. Okay, come back in a month or two, okay, that’s not working, now let’s try this. And it really depends on how bad the headaches are for the patient. If somebody is having bad headaches and triptans work — by the way, for these headaches, with that frontal radiation, triptans definitely work, and I think that’s a really important factor. But if somebody is using 14 triptan doses a month and is missing work and there’s all kinds of problems, then I will say this is not the right way to go.

Dr. Lowenstein [38:58]: I think that to me is an intolerance of the medication, or it’s not going to work. And I think triptans make people tired, and there’s also side effects that some people don’t like. And I actually also find that Botox works a lot of the time, but I’ve had very successful surgeries on patients that Botox did not work on.

Dr. Blake [39:20]: That’s absolutely correct. I would say Botox works about 50% of the time. And I haven’t looked at that scientifically yet in my own practice — that’s one of the things I’m going to be doing going forward. But it definitely works for some people and it definitely does not work for other people. And then for some people it helps partially, and then they have surgery and you may remove a lot of non-contractile tissue, a lot of connective tissue or inflammatory tissue.

Dr. Lowenstein [39:51]: If the occipital vessels are crossing the nerve, no amount of Botox is going to help.

Dr. Blake [39:54]: Right, Botox is not going to help that, but you get the pressure off of the nerves, and then sometimes if they still have some residual headaches, then you can go back. And I’ve had patients go back and do Botox, and I’ve had patients who did not respond well to Botox prior to surgery, who then after surgery, if there are still headaches, do great with Botox. So it’s sort of a mix of things, and again, you have to think about where somebody is on the spectrum and all these different other aspects for treatment. But it really is so much dependent on the patient and what kinds of symptoms a person’s having at the time of presentation and how bad the overall process is. I mean, the patient I mentioned earlier, the one I saw today who had pain on the left side — this was sort of a recent recognition that she developed — she still has pain most days, but if I’m recalling correctly, it’s very mild, it’s about a two out of ten, and her disability score, the MIDAS score, is very low, and she’s very happy with Botox. So great, we’ll keep doing Botox and see. Now, I have had patients for whom we’ve done Botox and the efficacy eventually subsides.

Dr. Lowenstein [41:05]: Wears off, right.

Dr. Blake [41:06]: And that may be underlying nerve compression that is getting worse as time is going by.

Dr. Lowenstein [41:11]: So if Botox — well, we see that as plastic surgeons, we see that just even in cosmetic applications, sometimes Botox will just stop working because the body develops antibodies, or there’s a couple of different pathways that we think that has to do with. But I think, yeah, that again to me would be an ineffectual medication, right? I mean, that would be a reason to have it done. I would love to operate on more people, I just — I’m conservative by nature and I always think, well, you should probably jump through the hoops, but at the end of the day, it is a lot of jumping through hoops, and I think we can help a lot of people with nerve decompression.

Dr. Blake [42:06]: So I do sometimes see patients who have nerve compression and it’s just not that problematic, you know — maybe you would include yourself among this group — it’s sort of mild symptoms, and as long as it’s not getting progressively worse, I think it’s fine to just kind of follow it. And learning to avoid the maneuvers that are provocative, such as extended neck flexion, or lifting heavy things, or doing any kind of physical activity that puts the neck in such a way that it triggers the pain to worsen. People can be followed — they don’t always need to have surgery.

Dr. Lowenstein [42:48]: Well, this brings up for me — I had this for five years solid during my residency. And honestly, this was again — I was a general surgery resident and you couldn’t show any weakness, and I didn’t really even know much about migraines at the time. So I’ve lived with much worse than I currently have, but that was probably largely because of the stressful situation I was in. And so you’ve got a classic aspect of tension headaches, which, again, like for myself, I see myself falling into so many different diagnoses — you know, my backyard is torn up right now with landscapers, and I had a tension headache yesterday because they hit the main and pulled all the electricity out of the house. But that’s a whole different story. But that gives me the same symptoms — it causes compression and gives me the headache, and then I take a triptan and my headaches get better. And that’s why people ask me why I haven’t had surgery. Well, I can take a whiff of Zomig inhaler and I’m fine in 10 minutes, and I’m used to being tired from my residency again. So I can deal with the side effects and it’s not that big a deal to me. But I think a lot of people, some people don’t respond to the triptans or whatnot, but a lot of people have tension headaches. And I mean, do all of those people who hold their tension in their trapezius and neck — are all of those headaches occipital compression headaches?

Dr. Blake [44:38]: That’s such an interesting question. I don’t know. The anatomic studies have shown that a lot of people have entrapment of the occipital nerves in the muscles of the back of the neck and in the fascial attachments. I think like forty, fifty, sixty percent of cadavers that were studied anatomically — I think Jeff Janis did some of this work, and Bahman Guyuron — they found that a very high percentage have entrapment. And so if there’s a lot of tension and engagement and contraction of the trapezius muscles in those individuals, might that from time to time cause some pain without it becoming a chronic problem? I don’t see why not.

Dr. Lowenstein [45:26]: Yeah, I mean anatomically it makes sense, but it’s hard to give a blanket statement that if you have tension headaches they can be fixed with surgery. But it’s tempting to say that because anatomically that does make sense.

Dr. Blake [45:43]: I think it’s possible. And of course somebody with tension headaches, by the ICHD criteria, they are milder headaches. And so often those people may not be coming to see the doctor, or they may not feel that something like surgery or even medications is warranted for their headaches or necessary. I think once that frontal radiation starts and it begins to look more migraine-like, with photophobia and phonophobia, sensitivity to lights and sounds, that’s when it sort of turns into chronic migraine. But I just want to say, I mean, one of the things that’s very interesting talking with people with this condition is that when you can get the history over the span of 10 or 15 years of what their headaches have been like, it’s very illustrative of a gradually progressive process. People will often say, my headaches when I was 15 years old, they just happened once a month and it wasn’t really a problem, and I would lay down and sometimes maybe have some vomiting and it would get better and go away. And then when I was in college, they started becoming more frequent, and then my first job in my late 20s, they were up to once or twice a week, and then in my 30s, two and three times a week, and then eventually they just became this constant daily pain. And in headache medicine, of course, we would probably refer to that as the quote “transformation of episodic migraine into chronic migraine,” which I talk about in this paper. Maybe that whole process has been one of progressively worsening inflammation and further compression on the nerve from the inflammatory tissue. And at some point it looked like tension headaches, but then it gradually evolved into more of a migraine-type headache.

Dr. Lowenstein [47:36]: I have not heard that quote-unquote “tension headaches” were mild. There’s — I see a lot of patients with a diagnosis of tension headaches and it’s ruining their lives. So maybe by the headache diagnoses, that’s not the right diagnosis for them or whatnot. But I think you’d hear from a lot of people who have tension headache diagnoses that it’s not a mild problem.

Dr. Blake [48:09]: What I’m referring to is that in the ICHD criteria, the pain is usually mild to moderate and it does not interfere with function. So if somebody’s having severe headaches that are interfering with function, they’re probably not going to meet those criteria. And again, this is where you get kind of caught up in the ICHD criteria, and sometimes it’s really problematic because it sort of puts blinders on, I think, on you, and you just can’t kind of think beyond that. You sort of say, well, this can’t be tension headache — it’s kind of frustrating.

Dr. Lowenstein [48:43]: But I wonder if they’re ever going to make a paradigm shift of these diagnoses from all of these different, you know, new chronic daily headache and whatnot, to this is an intracranial headache, this is an extracranial headache, this is an occipital headache, this is a supraorbital syndrome headache. If we could — and I’m not even sure that’s possible — but it would be helpful from my standpoint to have an anatomically based headache descriptor as opposed to a symptom-based one, because symptoms overlap.

Dr. Blake [49:23]: Absolutely. And I would definitely love to see something like that happen — a classification system that is based more on pathophysiology, as opposed to symptoms, because there is so much overlap, and it just feels like something is missing, describing simply the symptoms of the pain and the frequency, etc., without attributing the cause of it. And we don’t do this anywhere else in the body. Cardiologists don’t have a complex classification of chest pain.

Dr. Lowenstein [50:05]: Yeah.

Dr. Blake [50:06]: They go right to the arteries — where is this problem coming from and what can I do to fix it? So I would love to see headache medicine become a little bit more like that. Headaches are one of the leading causes of disability globally, and I think it would be helpful to introduce more pathophysiology-based work in terms of understanding the causes of headaches and also treatment.

Dr. Lowenstein [50:33]: Well, I agree with you fully, and I really thank you for all of your work in promoting and kind of getting everybody to head in that direction. I can’t tell you how jealous I am of Dr. Perry. And I’ve had conversations with Dr. Peled as well where he tells me he says, I wish Pamela Blake had a twin sister. I wish there were three of you. So thank you, thank you so much for all that you do and for taking the time to talk. I really enjoy talking to you and I would love to do this more, as this is something I think we could both talk about for days.

Dr. Blake [51:22]: Well, thank you. And I do hope that as more of this literature is published, I think you’ll find that more of the headache medicine community becomes more aware of this option for treatment and starts to gain more of an understanding of how these patients present and what to do for them, because it’s so rewarding to be able to help people that I can’t see why people wouldn’t want to be involved in that.

Dr. Lowenstein [51:48]: Yeah, it’s how I like to feel too. But there — it’s a very — it’s almost as complex as headaches when you get into the politics of all of that. But yeah, I often say it’s the most gratifying part of my practice, my migraine practice. And you’re really changing lives, and I think it’s a great thing, and I again really appreciate your contribution.

Dr. Blake [52:09]: Well thank you, and I’m so glad you have this podcast. It’s a wonderful way to reach out to people and hopefully help some people learn things that can help themselves, or help other people that they know who are suffering. So thank you very much for having me.

Dr. Lowenstein [52:30]: My pleasure. And just, I guess you and Dr. Perry — your website is chronicdailyheadache.com?

Dr. Blake [52:39]: Is that — yes, well, our new practice here in Houston is the Headache Center of River Oaks, and this is a brand new practice that we just formed not even two months ago, and we’re still in the growing phase right now, and so our website is pretty fundamental right now with just some contact information, but there is contact information there, and it has been really nice working together with him. I think it’s helpful for our patients who are coming in, and certainly for the patients who do go through the surgery process and postoperative physical therapy, and we will be bringing in next year a psychologist who will be doing the very important work of screening for emotional factors that may contribute to pain, and then therapeutic treatments, like cognitive behavioral therapy or supportive psychotherapy for people who need that as an important part of their headache care.

Dr. Lowenstein [53:29]: And I’m trying to do the same thing here in Santa Barbara, and that team approach that, from a plastic surgery standpoint, we learned when we take care of cleft lip and palate patients, it really seems so appropriate for the headache world. And I commend you guys for getting it done. Unfortunately, or fortunately for you guys, but unfortunately for the rest of us, you’re kind of the keystone to that kind of paradigm, and finding forward-thinking neurologists to work in that kind of forum has proven difficult. So if you do walk into a cloning machine, or you hear of somebody who’s interested, I’m working behind the scenes toward bringing somebody like that to Santa Barbara, but I’m certainly happy to hear of some new prospects if anybody wants to try and do those kinds of things, as is Dr. Peled in San Francisco — I think we’ve talked about that a lot as well. So kudos to all of you, and thanks for that contact information. I encourage patients to read and research into everything that Dr. Blake does because it’s really, really helpful. So thanks again for your time.

Dr. Blake [54:58]: All right, thank you very much.

Dr. Lowenstein [55:00]: Hey everybody, this is Dr. Lowenstein once again, and I have two last things to ask of you. Firstly, the thing you can do for fellow headache sufferers is to please remember to subscribe and rate our podcast. The more ratings and subscriptions that we get, the more visibility that we’ll get, and the more listeners will be able to find us, and the more help and information we’ll be able to provide the huge population of people who suffer from headache pain. Secondly, please remember that the treatment of headaches of all types is very individualized. The purpose of this podcast is not to give medical advice, so please use the information here on this podcast and elsewhere that you hear on the internet to broaden your knowledge, but consult with your physician before acting on any information that you hear on podcasts or see on YouTube or read anywhere on the internet. I, as a physician, don’t necessarily endorse the opinions or practices of my guests, and if you have particular questions that you’d like to consult with me directly about, please call our Headache Surgery Center. Our phone number is 805-969-9004, or you can email us at info@headachesurgery.com, and my staff will set up a consultation and we can discuss your specific case over the phone or in person. Our website is filled with information as well, and that is headachesurgery.com. Thanks and best wishes from all of us here at the Headache 360 Podcast.