Migraine Surgery Explained: A Nerve Decompression Deep Dive with Dr. Adam Lowenstein

00:03 – Announcer: 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.

00:20 – Dr. Adam Lowenstein: Hello and welcome to the Headache 360 Podcast. I’m your host, Dr. Adam Lowenstein, and today we’re going to talk about migraine surgery. That’s what I do as a treatment for migraines and chronic headaches of all types. The way that I want to address this is I’m going to

00:41 – Dr. Adam Lowenstein: provide an excerpt from a podcast that I was on called Beauty and the Surgeon by Dr. Jason Martin. I strongly urge people to listen to his podcast. He has a lot of very interesting people on his show, and he’s a board-certified plastic surgeon and very well respected. I am indebted to him for having me on his podcast.

01:04 – Dr. Adam Lowenstein: But we went into a lot of the details about migraine surgery, nerve decompression surgery, and the types of patients that I help. I think that providing you with that information here will be an excellent introduction into the ways that I can help migraine sufferers.

01:27 – Dr. Adam Lowenstein: So please enjoy the following excerpt from Dr. Martin’s podcast, Beauty and the Surgeon. In this format, he interviews me. I hope you enjoy it, and I hope you find it very informative.

01:44 – Dr. Jason Martin: You made a name for yourself as a very talented surgeon. I came in contact with you through the American Society of Plastic Surgeons. You were on the board, you were head of the Young Plastic Surgeons Organization, which is part of ASPS, and you were part of the mentor board, I think, at one point in terms of implants. A very successful surgeon, primarily cosmetic-surgery oriented, and everything’s going

02:10 – Dr. Jason Martin: well. Then all of a sudden, I’m talking to you on the phone and you start talking about headache surgery. Here’s a person who has it all, inherently, with where they’re located, with the practice and everything, and you’re talking about headache surgery. In some ways I was like, what’s Dr. Lowenstein talking about here? It’s a little bit crazy.

02:31 – Dr. Jason Martin: Yeah, that’s justifiable. But I do think it’s important to note that your interest in headache surgery really goes back to all your experiences throughout training and also your personal experiences. You were microsurgery-trained, a very successful surgeon, very talented, and you saw an opportunity to help people like yourself and also use your surgical talents that you

02:53 – Dr. Jason Martin: inherently have from your training and your private practice.

02:56 – Dr. Adam Lowenstein: I’m not sure this is probably what you’re getting at, but I will say this about what we do. Plastic surgery is a very, very diverse field, and not a lot of people know that, for example, the first transplants were done by plastic surgeons. The pioneering spirit of people in our field is great.

03:18 – Dr. Adam Lowenstein: I’ve had a really great opportunity in my career to reinvent myself several times. I did reconstruction here in Denver for many years, and it was fantastic. Then I thought, okay, what’s the next challenge that we can look at?

03:39 – Dr. Adam Lowenstein: When I left Kaiser, and again, it was a fantastic practice, but I’m an only child, and at the end of the day, after a period of time, I’m kind of better off making my own decisions and being on my own than in a big company, which is

04:01 – Dr. Adam Lowenstein: why I decided to leave Kaiser. I ended up in Santa Barbara, not even knowing where Santa Barbara was or what it was like initially. But I got lucky and ended up there. I got to train there with one of the top aesthetic surgeons. As you know, a lot of fellowships for aesthetic

04:22 – Dr. Adam Lowenstein: surgery are, what, three months to maybe a year. I got to work with this guy for three years all the time and basically did a three-year aesthetic fellowship. Then he retired and I took over his practice. So for the last 10 years I’ve been doing aesthetic surgery. It’s great, I love it, it’s a lot of fun. But I was kind of thinking, okay, what’s the next challenge

04:46 – Dr. Adam Lowenstein: that I can look at? This headache surgery seems to be a great opportunity. It fits with my world because, again, I’ve had these issues. I can identify with patients, and I think a lot of patients really appreciate that because, again, if you haven’t had this, you don’t know what it’s like.

05:08 – Dr. Adam Lowenstein: At the end of the day, I’m just very, very lucky to be doing what I’m getting to do in the field that we’re both in.

05:18 – Dr. Jason Martin: But in this podcast, we don’t believe in luck. You have circumstances, and then you have an innate ability to understand those opportunities and take advantage of them. When I say take advantage, I don’t mean in a way that’s manipulative. I mean that you utilize all your experiences in life. You were fortunately a good surgeon at the right time, you were very well connected and respected, so you came into

05:39 – Dr. Jason Martin: contact with Dr. Guyuron or Dr. Janis or all these people working in this field, and you were able to reach out and implement that in your practice. You should be commended for that. More importantly, we need people like you in our field. We need people to reach out and grab some of these

05:59 – Dr. Jason Martin: novel surgeries and keep expanding, to keep trying to improve the health of people from a plastic-surgery standpoint, but in this case from a functionality standpoint. Quality of life.

06:12 – Dr. Adam Lowenstein: Yeah, I mean, that’s the biggest issue with what we’re doing. It’s a quality-of-life issue.

06:18 – Amy Kilian: I can absolutely see that. I’ve never had a migraine, but I can definitely understand, having spoken to people who have, that it can take a while to be understood. There are so many symptoms that can add to it, and people can get so deep in their treatment or lack of treatment that people stop believing them. They think their symptoms are fake. So going to someone who’s experienced those symptoms and

06:39 – Amy Kilian: knows that they’re not faking it, they’re not making these up.

06:44 – Dr. Jason Martin: At the very least, they can be compassionate and relate.

06:47 – Amy Kilian: They can understand that, yeah, these symptoms are all real. They’re in your head, but they’re not in your head.

06:52 – Dr. Adam Lowenstein: Yeah, I mean, a lot of people get a social stigma about them from having migraines, and a lot of people lose their job because they can’t function at work. Sick days turn into one after another after another, and if you don’t have an understanding boss,

07:13 – Dr. Adam Lowenstein: you can’t do your job. It can ruin people’s lives. I’ve had patients tell me that they were considering assisted suicide. We operate on them and then they’re like, I haven’t felt

07:35 – Dr. Adam Lowenstein: this great in years. You hear that from somebody and it fills you for the rest of your life.

07:41 – Dr. Jason Martin: Exactly. All right, let’s get into it. If people have migraines, what do they usually do first? They go see a neurologist or get referred to a neurologist?

07:51 – Dr. Adam Lowenstein: They usually go to their own doctor, and then their own doctor will often send them to a neurologist. From there, so many different things can happen. You can go to headache specialists, you can go to pain doctors. A lot of my patients are seeing multiple physicians.

08:13 – Dr. Adam Lowenstein: There are so many different ways to try and attack this. One of the things the neurologists get is an MRI of the brain, because at the end of the day you want to make sure there’s nothing else going on. You want to make sure there’s no brain tumor or

08:35 – Dr. Adam Lowenstein: anything like that. Then you get people who are looking so hard for a reason that this is happening, and they get an MRI and their brain looks normal, and they’re crushed. Like, I was hoping there was going to be a tumor there, right?

08:56 – Dr. Adam Lowenstein: But that’s normal. Then it’s, how can we attack something that we can’t see? The problem is right here, or it can devolve into a whole, I’m seeing this person for my narcotics, I’m going to see this person to get a nerve stimulator put in.

09:20 – Dr. Adam Lowenstein: That’s one of the things some people do. I’m going to see this other doctor for medication issues. A lot of these things are successful. There’s something called a daith piercing. Do you know what that is?

09:41 – Dr. Adam Lowenstein: A lot of people will get a daith piercing and it helps them with their headache, which is awesome.

09:41 – Amy Kilian: I didn’t know there was a correlation there.

09:41 – Dr. Adam Lowenstein: Yeah. People say to me, should I go get this piercing? Absolutely. Lots of different things work for lots of different people.

09:54 – Amy Kilian: So that’s on the theory of Eastern medicine, that it’s somehow disrupting your qi in that area?

09:59 – Dr. Adam Lowenstein: There haven’t been any studies. There’s a lot of discussion about this, and it doesn’t work for everybody by any means. A lot of people have said, yeah, I tried that, it didn’t work. But it’s not really understood. And that is part of the problem, that migraines are not

10:22 – Dr. Adam Lowenstein: completely understood. It’s interesting that, of all these doctors you would see with a migraine, the plastic surgeon is about the last guy on that list.

10:36 – Dr. Jason Martin: For the patient with a migraine, what percentage do first-line treatments really work for? Like 80% or 70%?

10:44 – Dr. Adam Lowenstein: First-line treatments? I would probably ballpark around 50%. But then there’s a tiered thing of going to one thing, then another thing, then another thing.

10:57 – Dr. Jason Martin: And then you’re literally at the end of the rope.

11:00 – Dr. Adam Lowenstein: Yeah. Look, I love the surgery. It’s awesome, but it’s not for everybody. I haven’t had the surgery because I take Zomig, which is a type of triptan, and I can function on Zomig. Zomig wipes out some people; it makes them so exhausted.

11:20 – Dr. Adam Lowenstein: But you and I have had five days of operating straight without eating or sleeping, and I’m kind of used to that, so that side effect doesn’t bother me. Won’t stop, can’t stop. There you go. But some people can’t take that type of

11:41 – Dr. Adam Lowenstein: side effect, so Zomig doesn’t work for them. But a lot of people can. The point is that if daith piercing, medications, nerve stimulators, if these things work for you, that is awesome. That’s really the thing to do. You only go to surgery if nothing else works. But in those patients where nothing else works, and we can

12:05 – Dr. Adam Lowenstein: do some of our screening tests, which I’m assuming we’ll talk about in a little bit, the efficacy or the ability for this to actually work is extraordinarily high. That’s a great thing.

12:19 – Amy Kilian: Are you seeing an increase in the number of people who are finding out about the surgery and actively seeking you out?

12:25 – Dr. Adam Lowenstein: That is a hard question. Are we seeing an increase? More people know about this today than yesterday, than last week. But today, hardly any people know about this.

12:38 – Dr. Jason Martin: So 15% of all Americans, 35 million people, are migraine sufferers. About 50% of those get help from first-line therapies, the drugs and stuff. Then you do CAM or alternative treatments. There are millions of people out there suffering from migraines who are not totally getting relief or even

13:00 – Dr. Jason Martin: functional improvement with all these therapies. In reality, the surgery has a lot of potential, at least from the data that’s out there.

13:09 – Dr. Adam Lowenstein: Yeah, I mean, the data that’s out there is very favorable. My personal experience is very favorable. But the biggest problem with migraine surgery is people don’t know it exists. We also have a reasonable amount of

13:33 – Dr. Adam Lowenstein: difficulty getting people to refer to us because, as we were talking about earlier, neurologists may feel similarly: the plastic surgeon is about the last person you need when you have a migraine. So for a plastic surgeon to go to a neurologist and say,

13:56 – Dr. Adam Lowenstein: I may be able to help the subset of people who are not getting better with what you’re doing, they’re skeptical. I can understand that. If I was a neurologist and said, look at my plastic surgery research, I have a great way to do a facelift, you should look

14:18 – Dr. Adam Lowenstein: at it, you’d be like, come on. I totally get it, but it’s on us to get people the data to review and actually see the success rates, which are better than 90%. That’s part of what we’re having to

14:40 – Dr. Adam Lowenstein: do right now.

14:40 – Dr. Jason Martin: I mean, the data – I’m sorry, just real quick – goes back 15 years, or more than that, almost 18 years now. It’s robust data. I personally looked at it. I highly advise people who like that kind of stuff to look into it themselves and see that these are real studies with larger numbers and statistical significance, and an efficacy that is formidable. We can go into

15:04 – Dr. Jason Martin: that, what that means, but there is a real improvement.

15:08 – Dr. Adam Lowenstein: Dr. Guyuron in Cleveland is kind of the father of all of this. His first study used sham surgery. I don’t even know how you get that passed through the IRB.

15:29 – Dr. Jason Martin: Because if you’re at the Cleveland Clinic or Mayo Clinic, you can do what you want.

15:32 – Dr. Adam Lowenstein: Maybe. Well, Dr. Guyuron is Dr. Guyuron. He’s a very, very well-respected plastic surgeon in the world. He put people to sleep, made incisions, and in half the people he did the decompression, and in the others he didn’t do any decompression.

15:52 – Dr. Adam Lowenstein: You can see that’s as strong a study as you can possibly do. When you see huge statistical significance that the people who got the surgery largely got better, and the people who got the sham surgery largely didn’t get better, it’s not vague, right?

16:10 – Dr. Jason Martin: What percentages are we talking about here in some of those studies? I know it depends on the site, and we’ll get into it in more detail, but what percentage are we talking about?

16:17 – Dr. Adam Lowenstein: When we talk about improvement, there’s a subset of patients who never get another migraine. That can be variably in the high 30s to low 40%.

16:17 – Dr. Jason Martin: So about a third are cured with surgery?

16:17 – Dr. Adam Lowenstein: Cured – never have another migraine, right.

16:39 – Dr. Adam Lowenstein: And if you look at having a successful procedure as decreasing your migraine symptoms by at least 50%, that means you have less than half the number of headaches you’re used to, and those

17:01 – Dr. Adam Lowenstein: headaches are less than half as severe as they used to be. Some studies show that happening in the high 80% range, some in the low 90% range. In the worst-case scenario, let’s say 80%, but in fact it’s more closely to 90%. We can

17:22 – Dr. Adam Lowenstein: decrease these headaches to be basically normal headaches. Everybody has headaches, right? I have patients who still have headaches, but they’ll email me a happy email: Hey, I had a headache today, I took Tylenol, and it got better.

17:44 – Dr. Adam Lowenstein: That is unheard of to a migraine patient. That’s never happened to these patients before. So even just to celebrate having a normal headache, that’s what these patients are dealing with.

18:02 – Dr. Jason Martin: If you think about it, plastic surgery is criticized a lot for the level of data it has in studies. This is one of the situations where we actually did a pretty good job. I’m saying that from my professional opinion. Other people may differ with me, but that’s what I thought was remarkable when I was researching for this podcast.

18:24 – Dr. Adam Lowenstein: Yeah, there’s a lot of data. They’re now looking at five- and ten-year data, and it’s all favorable.

18:30 – Dr. Jason Martin: Yeah.

18:31 – Dr. Adam Lowenstein: But I do want to say this one thing. There are people who have the surgery and it doesn’t work. There are non-responders out there.

18:44 – Dr. Jason Martin: And that’s going to happen with any surgery. No surgery has a 100% success rate in most cases. But do you think some of those people have etiologies that really have not been deduced and it’s even more complicated than we think, or is that a technical issue?

19:05 – Dr. Adam Lowenstein: I think there are a lot of different possible reasons. I’ve seen some redo operations of other surgeons who maybe didn’t release the entire nerve adequately. I think some people may have gotten this operation and not necessarily been great candidates.

19:29 – Dr. Adam Lowenstein: I have a particular way that I diagnose whether a patient is a candidate, and for me that’s worked consistently. But there are always going to be mistakes in that diagnostic kind of situation.

19:50 – Dr. Adam Lowenstein: For example, and we can talk about this in a little bit, we do a local block to see whether somebody’s headache gets better, whether or not that nerve is something that we can work with. Certain people could get a nerve block and get better, but it could be serendipitous rather than an actual anatomic issue, and those people then get an

20:14 – Dr. Adam Lowenstein: operation, but this wasn’t the problem in the first place. Just like any surgery, there are going to be lots of different reasons that a small subset of those people are not helped. We are fortunate in the fact that the people who are not helped by this are a very small subset of less than 10%.

20:33 – Dr. Jason Martin: To have a surgery that has about a 90% success rate is pretty darn good. If I was going to implement a different surgery in my practice, I would be okay with a 90% success rate, being open with the patient themselves. All right, so we’re a patient. We have severe headaches,

20:54 – Dr. Jason Martin: we have migraines, we go through all the treatments beforehand, and we get referred to Dr. Lowenstein, who, by the way, is in Southern California. What is the process by which we as the patient get evaluated?

21:11 – Dr. Adam Lowenstein: In an ideal situation, you show up in my office in pain. We’ll talk to you before you come for your visit and say that different people have different triggers. We talked about perfume; a lot of people have red wine, caffeine, chocolate. We say, the night before you come in to see me, have

21:36 – Dr. Adam Lowenstein: chocolate with red wine and a coffee chaser and do everything you can to try to come in with a migraine. Optimally, patients come in in pain. It’s a strange thing to say, but it is what it is. Then we have you fill out, prior to this, a

21:58 – Dr. Adam Lowenstein: very, very detailed history. We want to make sure you actually have migraines, that you’ve seen a neurologist, that you’ve had an MRI, and that we know this is the problem we’re working with. Then I’ll do a physical exam. There are about 14 nerves in the head and

22:18 – Dr. Adam Lowenstein: neck, seven on each side, that we know can trigger these headaches. From the history, I try to find out where a person’s headache is coming from. Is it coming from above the eye and radiating to the back? Is it coming from the back and radiating here, et cetera? We try to figure out where that is from.

22:41 – Dr. Adam Lowenstein: I look for what’s called a Tinel sign. A Tinel sign is where you tap on the nerve and get some reaction, either an increase in pain or tingling. A lot of patients will have sensitivity to tapping or a Tinel sign in various nerves.

23:04 – Dr. Adam Lowenstein: So that’s where the headache seems to be coming from primarily. In my practice, then what I’ll do is use some local anesthetic, lidocaine and Marcaine. Lidocaine has a quick onset and lasts for about an hour. Marcaine has a little bit of a longer onset,

23:25 – Dr. Adam Lowenstein: but lasts for about four hours. I will give you a shot where I know that nerve is.

23:31 – Amy Kilian: Do you use ultrasound guidance, or do you just know where it is?

23:35 – Dr. Adam Lowenstein: I don’t. A lot of people do. Once you’ve operated on the nerve enough times, you kind of know where it is. A lot of the ultrasound is also used, and again, this is a couple layers further than we’re going here, to try and find

23:56 – Dr. Adam Lowenstein: the blood vessels that could be crossing these nerves and causing compression. But basically, I’m going down to where the nerve starts and giving this local anesthetic. Then we turn off the lights in the room, I go back to my office and do some charting, and I come back in

24:16 – Dr. Adam Lowenstein: about five minutes. More often than not, the patient will say, my pain has decreased from, let’s say, an eight to X. If they say, I had an eight five minutes ago and now my pain is gone, then we can be pretty certain that that nerve

24:39 – Dr. Adam Lowenstein: is the problem and most of the problem, if not all of the problem.

24:44 – Dr. Jason Martin: Can I ask you a question? Do you inject only one nerve at a time, or do you inject multiple areas? How do you deduce that out?

25:00 – Dr. Adam Lowenstein: I inject one nerve at a time, and this is what I call targeted injection mapping. The idea is we’re mapping out the problematic nerves. When I have injected that first nerve and I come back, and let’s say they say, I had an eight and now my pain is down to a three, we basically start again.

25:20 – Dr. Adam Lowenstein: Now where is it coming from? It was coming from back here, and we fixed this right behind the head. Now the remaining pain is kind of in my temple or above my eye. So we look for a Tinel sign there. But even if there’s not a Tinel sign, if this is where it’s coming from, then we give another shot there.

25:42 – Dr. Adam Lowenstein: I leave the office, go do some charting, and come back in five minutes. Now what’s your pain? What we’re doing is trying to work down to a pain of zero and, in doing so, mapping out each of the nerves that are problematic in a targeted way. So by the end of the consultation, you may have

26:05 – Dr. Adam Lowenstein: several injections, or you may just have one. But the idea is that we’re moving from severe pain toward, if not to, a pain-free state by blocking these nerves.

26:16 – Dr. Jason Martin: You’re localizing the areas. Also, in some of these studies, like PREEMPT, neurologists do Botox. Some of these studies actually use Botox as the localizing agent. Explain the difference between lidocaine and Botox.

26:33 – Dr. Adam Lowenstein: Lidocaine literally blocks the nerve. It works directly on the nerve to prevent any signals from going through that nerve or back to the brain. Botox, we know, has some effects on the actual nerve itself, but the majority of the effects of Botox are on the muscles surrounding the nerve.

26:54 – Dr. Adam Lowenstein: I guess we should track back and say that what we’re trying to fix is nerve compression. What we’ve found is that compression or chronic irritation of these nerves is what causes or triggers the migraine headache.

27:14 – Dr. Adam Lowenstein: What we’re trying to do at the endpoint is take these compressed, tight areas around these nerves and release them so the nerve can be in a relaxed situation, without these compressions causing chronic irritation and migraines. So by using a nerve blocker like lidocaine or

27:36 – Dr. Adam Lowenstein: Marcaine, we’re actually preventing any signal from that irritation further out from getting back to the brain to cause the pain.

27:47 – Amy Kilian: So even if it’s still compressed by muscles, you’re stopping the symptom.

27:51 – Dr. Adam Lowenstein: The nerve can’t relay those distress signals back to the brain. Botox works by relaxing those muscles that are causing the compression. Ideally, let’s talk about the nerves in the brow. You have the supraorbital and supratrochlear nerves.

28:12 – Dr. Adam Lowenstein: This is when people get aesthetic Botox. What we’re doing is putting Botox in what’s called the corrugator muscle, which causes the wrinkles in the glabella, the 11s people get when they’re frowning. These nerves go through that muscle. Botox often will prevent headaches in patients who have

28:36 – Dr. Adam Lowenstein: these muscles causing compression, which is causing the migraines. Some people, instead of doing this with lidocaine, will give Botox and then assess over a period of time. As we know, Botox takes about four or five days to take effect. The issue I’ve found with Botox is because you are

28:58 – Dr. Adam Lowenstein: adding volume to the muscle, which is already compressing the nerve, things can get worse before they get better.

29:06 – Amy Kilian: That’s really interesting, because people sometimes, especially people who haven’t had Botox before, will complain of headaches after their first Botox injection.

29:15 – Dr. Adam Lowenstein: Because that volume you’re putting in there is causing more irritation. That’s tough for the patient because, I came to the surgeon to get better and he made me worse. For the first week, there are a lot of phone calls. But a lot of those patients after that period of time will

29:37 – Dr. Adam Lowenstein: find that their headaches are improved because, as the Botox takes effect, there’s less compression, less irritation, and less of that distress signal going back. However, Botox works on muscle, but it doesn’t work on blood vessels or bones or fascia, which is connective

29:58 – Dr. Adam Lowenstein: tissue. A lot of times there are other non-muscular things causing the compression. So if Botox doesn’t work, it doesn’t necessarily mean the surgery won’t work. But if the lidocaine doesn’t work, that’s a better prognostic indicator in my world.

30:20 – Dr. Adam Lowenstein: I can tell you I’ve seen that only twice. Almost everybody who gets to me is improved by these blocks, which is remarkable. Granted, I’m seeing a very small subset, but if almost everybody I’m seeing is responding to this,

30:41 – Dr. Adam Lowenstein: you’ve got to wonder how many people are out there who are potential responders, right?

30:54 – Dr. Jason Martin: Yeah. You have peripheral nerves, and those nerves get compressed, and that’s what we think is going on. There are certain areas of the head where we see this over and over with migraine sufferers. Most of the time it’s muscle, but it can be other things, like fascia, where the nerves come out of the bone, or the bone itself. Different anatomy can affect that.

31:15 – Dr. Jason Martin: They come in, you use lidocaine to numb the nerve, and if they get resolution of symptoms or improvement, then you have a good idea that something around this nerve is irritating it. If I can go in there and release it and give it some freedom, it won’t be so angry and send painful stimuli back to the brain,

31:35 – Dr. Jason Martin: which then relates to this chronic problem called migraines.

31:42 – Dr. Adam Lowenstein: Exactly.

31:42 – Dr. Jason Martin: I just want to add one thing, and it’s really interesting. Science sometimes comes upon things accidentally. The way this all came about was that in the old days we used to do – and some people still do – endoscopic brow lifts, where you would go in with small holes up in the hair area and take out the muscles between the eyebrows, the corrugator and

32:03 – Dr. Jason Martin: procerus, the ones that cause the 11s. You would actually physically remove them. What they saw in a small subset of those patients who were migraine sufferers was that they didn’t have migraines

32:25 – Dr. Jason Martin: who were migraine sufferers was that they didn’t have migraines in that area anymore. Luckily, we had intelligent physicians and surgeons who said, maybe there’s something around these muscles, or this muscle itself is causing something that leads to these migraine symptoms.

32:26 – Dr. Adam Lowenstein: Yes, I agree that luckily we have intelligent people, but don’t point at me. That was Dr. Guyuron who really noticed that. Then he did a whole bunch of subsequent studies. He and another friend of mine, Jeff Janis, who’s at Ohio State, did all of these anatomic studies

32:48 – Dr. Adam Lowenstein: on cadavers, finding different nerves, testing with Botox and lidocaine, and really figuring out which of these nerves are problematic. We’re still, relatively speaking, in the early stages of this. We may find other nerves down the line that are

33:09 – Dr. Adam Lowenstein: still an issue. But right now, we’re dealing with three nerves in the back of the head, two nerves in the temple area, and two nerves above the eye, and we’re having good success with those.

33:24 – Dr. Jason Martin: Let’s get into that. For those listening, you can also watch it on video. We’re going to describe it as we talk about the different nerves, but there’s also an associated video where you can see Dr. Lowenstein actually pointing. We actually have a head here.

33:43 – Amy Kilian: What is his name? I have to know.

33:44 – Dr. Adam Lowenstein: The patient’s head? You know something, gosh, I feel bad. I haven’t named the head. I think Amy, maybe. No, it’s a male. Or a short-haired female, I don’t know, with dark eyebrows.

34:03 – Amy Kilian: Can I say one thing for the common person out there? Most people listening probably haven’t been in a cadaver lab to understand the beautiful, delicate nature of nerves. When you’re in a cadaver lab doing dissections and you find these nerve bundles, they’re amazingly intricate and so delicate, but at the same time shockingly large in some areas of the body.

34:24 – Amy Kilian: These nerves are big.

34:26 – Dr. Adam Lowenstein: There are a couple of these nerves that are big, and a couple that are wispy small. A lot of the nerves actually branch. Again, who are the non-responders? To get a complete surgical outcome, we’ve got to ideally find each branch and

34:48 – Dr. Adam Lowenstein: decompress each branch, which can be a maze.

34:52 – Amy Kilian: Yeah, because they have these beautiful long tendrils. Nerves are really beautiful.

34:57 – Dr. Jason Martin: All right, let’s imagine we have a patient and all areas are involved. We’re going to have you quickly go through the different trigger or localized areas and give an idea of what that patient would go through on the day of surgery, how many surgeries it would take, and the process of surgery for each location.

35:15 – Dr. Adam Lowenstein: Okay, let’s actually move back. We’re going to call the head Thomas because there is Dr. Muehlberger in Germany and England. He has several centers in Europe and treats a lot of migraine patients, and he was good enough to send me this

35:38 – Dr. Adam Lowenstein: head, this prop. We’ll call it his name. He looks like a Thomas. There you go. There’s some stuff that’s really nicely shown here. There are a couple of nerves that are not shown, but here we can see the greater occipital

36:02 – Dr. Adam Lowenstein: nerve.

36:03 – Dr. Jason Martin: He’s pointing to the back of the head.

36:04 – Dr. Adam Lowenstein: That nerve comes from what’s called C2, which is one of the branches of the spinal cord. It goes through several different muscles, including the trapezius muscles, which, as we know, when we’re stressed, a lot of people hold their stress in their neck and

36:26 – Dr. Adam Lowenstein: shoulders. This nerve can be compressed by the trapezius, as well as what’s called the splenius capitis, which is a deeper muscle and helps with head stability. It can also be compressed by the occipital arteries, which are often up here in the

36:49 – Dr. Adam Lowenstein: higher portion of the back of the head. They can have arteries that cross and cause problems.

36:55 – Dr. Jason Martin: If you feel your neck and go up to where you can start to feel the skull, that’s the area he’s pointing at right now.

37:01 – Amy Kilian: Like where your spine kind of meets up with your head. It makes sense why motion would be such a trigger for people, because some of those muscles you mentioned are really key in keeping our head stable, like keeping our horizon where it is.

37:12 – Dr. Adam Lowenstein: Interestingly, a lot of patients who have this problem, when we’re dealing with these nerves, we call it occipital neuralgia. Neuralgia is inflammation of the nerve; occipital refers to the occipital area or occipital nerves. A lot of these patients have had either a recent or distant history of whiplash because what’s happened is you get a

37:36 – Dr. Adam Lowenstein: whiplash injury and then scarring down of the muscles that were torn during the whiplash injury, and all of that causes tightness around these nerves. A lot of patients I’ll talk to who are considering the surgery, I’ll ask, did you ever have a car accident?

37:58 – Dr. Adam Lowenstein: They’ll say, I forgot about this, but back in so-and-so I did get into a car accident. When did your headache start? About that time, right? It’s interesting to see that a lot of these can be post-traumatic issues.

38:19 – Dr. Adam Lowenstein: But back to these nerves. There’s also a third occipital nerve. There are three occipital nerves, and the third occipital nerve is in the same general area, just a little further down on the neck. It innervates a much smaller area, but can also be a trigger.

38:41 – Dr. Jason Martin: So we see a third nerve. Are they branches, or just three different distinct nerves?

38:45 – Dr. Adam Lowenstein: They’re three distinct nerves, all in the occipital region, and therefore occipital nerves. The lesser occipital nerve actually is not shown here, but it’s down in the lower lateral neck, comes out around what’s called the sternocleidomastoid muscle, which is another neck stabilizer and helps with turning of the neck.

39:07 – Dr. Adam Lowenstein: For me, that’s one of my triggers. When I have a really significant headache, I’m just rubbing right on the side of my neck. Before I knew what I was doing, I was trying to massage those areas to relax the

39:27 – Dr. Adam Lowenstein: muscles. Then when I progressed through plastic surgery and learned about this, it all made sense. In order to get to these nerves, the way I do this is a vertical incision that’s largely here in the hairline.

39:47 – Dr. Jason Martin: Right, so it’s in the midline. A vertical incision. Now do you have to shave the hair?

39:52 – Dr. Adam Lowenstein: Yes. We do. In women, and a lot of patients are women because more women suffer from migraines than men, we can shave the head in a manner that, if you have long hair, you’d never know the difference unless you actually lift up your hair. Some patients go with it and show up to my office with a partially shaved head and a totally new hairstyle.

40:16 – Dr. Adam Lowenstein: But yes, we do have to shave around the incision. Then I go down through the fascia in the midline, down to the muscle layers, and dissect to one side or the other, without going too deep.

40:39 – Dr. Adam Lowenstein: We find the nerve, and then trace the nerve from its deepest point to its most superficial point in what we call the subcutaneous tissue, or the fatty area just below the skin. These are all sensory nerves. At the end of their course, they provide feeling or sensation to parts of the scalp.

41:01 – Dr. Adam Lowenstein: They’re going up into the fat below the skin, and there’s no compression there. So we trace it to get up to that point. Back here, I’m going through the trapezius and the splenius capitis, taking out little pieces of muscle and also making a trough for the nerve to lie in.

41:22 – Dr. Adam Lowenstein: For the nerve to lie in, excuse me. I do that for the greater occipital and for the lesser occipital. Then before we close, we take a flap, a little piece of fat just below the skin, and put it along the nerve to prevent further scar tissue or compression from

41:44 – Dr. Adam Lowenstein: happening. So we pad the nerve with a piece of fat.

41:46 – Amy Kilian: A little phospholipid cushion.

41:47 – Dr. Adam Lowenstein: There you go. For the lesser occipital nerve, I usually make a smaller separate incision down the back of the neck toward the side. That incision is usually an inch, maybe, and we go down to

42:09 – Dr. Adam Lowenstein: the muscle layer. We can find that nerve relatively easily. If it’s easily decompressed, then we’ll decompress it. But for the smaller nerves, including the third occipital, the lesser occipital, and the ones in the temple, these nerves really innervate very small areas. Sometimes if the nerve looks really bad, we’ll just cut the

42:32 – Dr. Adam Lowenstein: nerve and bury it in an adjacent muscle to prevent what’s called a neuroma, or an abnormal growth of the nerve, which can also be painful. Patients won’t really recognize a deficit of feeling from those small nerves.

42:54 – Dr. Adam Lowenstein: The greater occipital nerve can be cut if it’s severely diseased. If it’s a secondary operation where we’ve done a release and it has not been successful, but the patient is still showing us that this is still the problem, then we’ll sometimes go and cut that nerve.

43:15 – Dr. Adam Lowenstein: But that can cause numbness and tingling in a larger aspect of the scalp, and that can be unpleasant.

43:23 – Amy Kilian: Yeah, people find a numb scalp disconcerting.

43:25 – Dr. Adam Lowenstein: Right. But given that versus the severity of their migraines, a lot of patients say, that’s fine, cut the nerve. But if we don’t have to cut that nerve, we try not to. Then we close things up. We use buried sutures, so there are no sutures to come out. Some people use a drain.

43:46 – Dr. Adam Lowenstein: I don’t use a drain. After surgery, you can be sore because we’re cutting muscles. It’s still surgery. But patients can tell the difference between postoperative soreness and migraines. They’re two totally different things.

44:08 – Dr. Adam Lowenstein: Patients will have soreness for a couple of days, sometimes a couple of weeks. Sometimes they’ll have good and bad days of actual migraines afterwards. Again, the nerve has been manipulated during the surgery and is kind of angry.

44:24 – Dr. Jason Martin: And you have postoperative swelling, too.

44:26 – Dr. Adam Lowenstein: Exactly. Some patients will have worse days, better days, and over time, over the next few months, equilibrate to a situation that in more cases than not is favorable to what they had before surgery.

44:41 – Dr. Jason Martin: So in the occipital area, you make a small vertical incision in the midline. That’s in the hair-bearing area, so once that heals you’re not going to see that. You have small incisions on the back of the neck, a little bit to the side if necessary.

44:55 – Dr. Adam Lowenstein: With short hair, you could see them, but they tend to heal very well. They go away.

45:00 – Dr. Jason Martin: How long does that specific procedure take, just for the back of the head?

45:00 – Dr. Adam Lowenstein: It takes about two to three hours if you’re going to do both sides.

45:23 – Dr. Jason Martin: For that surgery, you’ll be laying face down, which we call a prone position. It’s under general anesthesia, which means there’s a tube to help support your breathing, and it would be done in a surgery setting like a surgery center or hospital. There are other areas, too. Let’s talk about those. Poor Thomas, you just took his eye

45:43 – Dr. Jason Martin: off. If people can see this, he just took his eye off. He’s now looking at the left eye, the bones around the eye, and the temporal areas. If you go from your eye to the outside where your sideburn is, that’s kind of the temporal area.

45:49 – Dr. Adam Lowenstein: Right. The nerves above the orbit, or above the eye, the supraorbital and supratrochlear nerves, go through either holes or notches in the bone in the superior orbit, or the eye socket. A lot of times there’s compression there.

46:12 – Dr. Adam Lowenstein: We’ll actually unroof what’s called a foramen, or the hole that the nerve goes through. If it’s a notch, which is also common, a lot of times there’s fascia or connective tissue forming a bridge over the notch, and we’ll release that. Here we’re looking at the

46:33 – Dr. Adam Lowenstein: corrugator muscle, and we’ll trace the nerves and all of their branches through the muscle to try and release these areas as well. A lot of times there are blood vessels associated with these bundles. We’ll ligate, disrupt, or cut those

46:55 – Dr. Adam Lowenstein: blood vessels so they’re not a problem. Again, we’re tracing the nerve from the deeper portion through all of these areas of potential compression out toward the subcutaneous tissue.

47:07 – Amy Kilian: And you’re coming at that superiorly?

47:09 – Dr. Adam Lowenstein: No. There are two ways to do this. There’s the endoscopic way, which is the way Dr. Guyuron originally described it, and then there’s what’s called the transpalpebral, or upper-eyelid, approach.

47:22 – Dr. Jason Martin: Just real quick, it’s the same incision or scar you would have if you went in and did your eyelids for cosmetic reasons. It’s in the crease of the upper eyelid.

47:31 – Dr. Adam Lowenstein: Some patients will say, okay, well let’s get my eyelids done, too. Let’s get my migraines and my upper eyelids taken care of. It’s an aesthetic scar. You’re going to end up with basically a very fine white line in the upper lid,

47:51 – Dr. Adam Lowenstein: in the fold of the lid, where people just don’t see things. That’s a very well-tolerated incision. Then lateral to your eye, you have crow’s feet.

48:03 – Dr. Jason Martin: Right, which means to the outside of your eye. Everybody knows the crow’s feet.

48:07 – Dr. Adam Lowenstein: Here you can see the zygomaticotemporal nerve. If you feel the bone on the side of your eye and then push toward your ear, you’ll see there’s a little divot, a little depression there.

48:27 – Dr. Adam Lowenstein: That’s where the zygomaticotemporal nerve is.

48:30 – Dr. Jason Martin: Right. If you’ve seen the classic thing when people have headaches, they’re kind of rubbing their temples. They’re literally rubbing right where their nerves are.

48:36 – Dr. Adam Lowenstein: They’re trying to release that, and they don’t even know they’re doing it. We can use this upper-lid incision and have it go into the crow’s feet to access that nerve.

48:50 – Amy Kilian: Cat-eye eyeliner.

48:51 – Dr. Adam Lowenstein: There you go.

48:52 – Amy Kilian: Stretch that out.

48:53 – Dr. Jason Martin: Right. We already use that incision from a cosmetic standpoint, so it’s well known to heal well and not be a problem.

48:59 – Dr. Adam Lowenstein: I use the same incision when I’m doing mid-face lifts. When I learned how to do all of this surgery, I thought, oh yeah, I know that nerve. It’s right next to the sentinel vein. I’ve been looking at this nerve for years,

49:22 – Dr. Adam Lowenstein: but now we’re doing a similar operation for a different reason. That nerve will either be decompressed through the temporal muscles, or sometimes that nerve will just get cut.

49:31 – Dr. Jason Martin: Because the distribution for sensation for the zygomaticotemporal nerve is small, you can cut that. Whereas the supratrochlear or supraorbital nerves in the eyebrow area, we don’t usually cut those.

49:48 – Dr. Adam Lowenstein: We try not to cut those. Whenever we do a brow lift or talk about doing these kinds of things, one of the risks we discuss with patients is that you might have that nerve cut. Fortunately, knock on wood, that’s never happened to me. But one of the risk factors is that you would

50:08 – Dr. Adam Lowenstein: have a numb forehead. We certainly want to avoid that. When we’re identifying the nerves and actually tracing them out through the muscles, the only real way they get cut is if we’re doing it intentionally, because we’re going in to look at the nerves.

50:24 – Dr. Jason Martin: Part of this is a little funny because in plastic surgery we spend so much time not cutting nerves. We’re trying to avoid them. That’s the main complication with most cosmetic procedures if you actually cut the nerve.

50:36 – Dr. Adam Lowenstein: But we also spend a lot of time avoiding the area of the nerve. Here, we’re actually looking at the nerve. When you’re looking at the nerve, it’s hard to cut it unless you’re trying.

50:51 – Dr. Jason Martin: One question, just real quick. Dr. Guyuron, in one of his discussions on his technique, talks about taking the fat from the inside portion of the upper eyelid and putting it, like you did in the neck, around the supratrochlear and supraorbital nerves in the eyebrow area.

51:09 – Dr. Adam Lowenstein: And I do that. We take some fat from the medial compartment and use it as a little flap there, again to provide a little pillow for the nerve.

51:21 – Dr. Jason Martin: There’s a common theme here. We’re going in and releasing the compressing areas around these nerves, and then wrapping those nerves in soft tissue or fat, which creates a buffer so when it starts to heal and scar down, you don’t have that scar effect around

51:43 – Dr. Jason Martin: the nerve compressing it down and running into the same effect. Remember, Dr. Lowenstein talked about whiplash. That’s from scar tissue going down and compressing that nerve. The same thing can happen after surgery. Using fat or fat grafting is really common in plastic surgery in terms of softening areas and decreasing tension on things. Fat has a positive component and also stem cells,

52:07 – Dr. Jason Martin: supposedly. The jury’s still out on that. Okay, so you’ve done around the eye, zygomaticotemporal, which is the temporal area going near your sideburn.

52:16 – Dr. Adam Lowenstein: Then there’s the auriculotemporal nerve, which is just in front of the ear, and there’s a blood vessel that is often the culprit there. That’s where sometimes we’ll use ultrasound to find the area where those things cross. We can trace out the blood vessel and at the same time look for a Tinel sign. Where we see the Tinel sign at the blood vessel, that’s

52:38 – Dr. Adam Lowenstein: where oftentimes that nerve is getting compressed. That nerve is the easiest to get to. We can make a little incision, usually within the hairline, and dissect right down. There it is. We ligate the blood vessel and release the nerve in that area, or in a worst-case scenario, cut it because it’s really just

53:00 – Dr. Adam Lowenstein: innervating a relatively small area. That’s a very common area, again, between the temporal headaches you were discussing and people massaging those areas. That’s probably the easiest approach to get to that

53:22 – Dr. Adam Lowenstein: particular nerve.

53:24 – Dr. Jason Martin: Is there any other area on the front of the face that you would address? We’ve talked about three areas so far: the base of the skull in the back, right where your neck meets your skull; above the eyebrow or in the eyebrow area, the upper eyelid; and the temporal area where your sideburns are. Is there any other area?

53:44 – Dr. Adam Lowenstein: Then there’s the nose. A lot of people will have variable nerve compression in the nose from turbinates, which are part of the outcroppings that humidify air.

53:59 – Dr. Jason Martin: They humidify the air that goes through your nose. We’ve talked about that on a rhinoplasty podcast, so you should definitely check that out, Beauty and the Surgeon.

54:07 – Dr. Adam Lowenstein: There you go. Sometimes there’s septal deviation, which is the central portion of your nose. You can get compression there. That’s the other approach we use to disrupt those areas of compression.

54:28 – Dr. Adam Lowenstein: You’ll either do a septoplasty, where you’re decompressing and straightening the septum, or a turbinectomy, where you actually take out the turbinate. But to be honest with you, what I usually do for those patients is send them to an ENT surgeon.

54:48 – Amy Kilian: I was just going to ask if you work in conjunction with ENT surgery.

54:48 – Dr. Adam Lowenstein: I’ve done those surgeries and I do those surgeries, but these are not aesthetic things. These are functional things. A lot of times we’ll incorporate people who work in the nose and do a lot of nose surgery.

55:10 – Dr. Adam Lowenstein: They work in the nose and do a lot of nose surgery.

55:12 – Dr. Jason Martin: Yeah, we’ve talked about it before. Their primary job is nasal airways and sinuses, so it makes sense that you would send it to them, especially for someone who needs a functional improvement. It has nothing to do with aesthetics. So there are four different areas. When you’re talking about these areas in the face, you do that with the patient lying on

55:33 – Dr. Jason Martin: their back, which we call supine. Again, it’s general anesthesia. Is that correct?

55:35 – Dr. Adam Lowenstein: Unless we’re just doing a small cutdown on the auriculotemporal nerve, but yes, it’s general anesthesia.

55:41 – Amy Kilian: And no twitching allowed during this kind of surgery. You want somebody out.

55:46 – Dr. Jason Martin: All right. So depending on the area, how much improvement can people get?

55:52 – Dr. Adam Lowenstein: We often see no more headaches. You can get the entire spectrum, obviously, but I’ve seen a lot of success in all of these areas. Patients come off narcotics, which right now is a touchstone in this country with the opioid

56:16 – Dr. Adam Lowenstein: issues. This is a little off topic, but a lot of these patients are doing ER visits because their head is exploding, and they end up in the emergency room. The doctors won’t give them narcotics because they think they’re narcotic-seeking.

56:36 – Dr. Adam Lowenstein: They think they’re pain-seeking.

56:41 – Dr. Jason Martin: Exactly, because there is no laboratory study or scan. An MRI won’t show it. You have to trust the patient’s history.

56:50 – Dr. Adam Lowenstein: Yeah. I’ve had patients who are on fentanyl patches, which is a very, very strong opiate, and subsequently wean themselves off narcotics. I try to get them almost immediately back with their pain doctor because if you take yourself off narcotics too quickly, that can be a problem.

57:12 – Dr. Adam Lowenstein: But the patients are so eager to actually be rid of these things that they start to do it themselves. We’ve had great success decreasing medication, getting people back to work, getting people back with their families.

57:28 – Dr. Jason Martin: One of the things I meant by that question is, is there more success in certain areas and less in others?

57:36 – Amy Kilian: Or what percentage of each type of surgery are you doing? Does one seem to be predominant?

57:41 – Dr. Jason Martin: That’s another question I had, too.

57:43 – Dr. Adam Lowenstein: Classically, this started out in the front. It was the supraorbital and supratrochlear nerves, the stuff near the eyebrow. I know a lot of people who say, whatever nerves you’re doing, also go do the supraorbital and supratrochlear nerves in the

58:07 – Dr. Adam Lowenstein: eyebrow because many patients have that problem as well. In my practice, we see a little bit more occipital neuralgia because I think that’s kind of an emerging region. Of all these areas, it was the last kind to be discovered.

58:30 – Dr. Adam Lowenstein: Now that we’re seeing success with that, there are a lot of patients who have these problems back here. But honestly, I think the questions you’re asking are very regional and surgeon-specific. I think Dr. Guyuron does probably more brow surgery because

58:54 – Dr. Adam Lowenstein: that was the original thing and he fostered a very large practice doing that in the beginning. Whereas others of us are finding that a lot of patients have posterior neck issues, and that’s an expanding and growing area.

59:15 – Dr. Adam Lowenstein: As far as the efficacy, I can tell you my experience is equivalent in all different areas. We can look at different people’s experience, but some people are going to have more experience in one part of the face than others.

59:38 – Dr. Adam Lowenstein: We’re doing surgery in all of these areas and having good success.

59:43 – Dr. Jason Martin: I think it’s important to note that if you have multiple trigger areas and they’re on the back of the head and the front, it’s going to be two different surgeries in most cases.

59:53 – Dr. Adam Lowenstein: Some people will do both the front and the back, some people will do the front then the back. In my practice, it depends on what the patient wants and what their

01:00:13 – Dr. Adam Lowenstein: particular circumstances are. There are some issues with operating on the back of the head and then turning the patient and putting pressure right on the back of the head while you’re doing the front of the head, and vice versa. But as far as getting everything done at once, it’s also a very attractive thing for people. It depends on the patient.

01:00:36 – Amy Kilian: Is any of this covered by insurance?

01:00:39 – Dr. Adam Lowenstein: Unfortunately, that’s a very loaded question. Insurance, in my experience, will sometimes pay for some of it, rarely pay for all of it, and often pay for none of it. That’s a very, very difficult

01:01:03 – Dr. Adam Lowenstein: thing for all of us. For me, I know what this is like. I want to operate on everybody, but at the same time I want to keep my doors open. We certainly do everything we can to help people with financing or whatever we can.

01:01:25 – Dr. Adam Lowenstein: But in the current insurance milieu in this country, they want to pay for less rather than more. If you’re looking at an appendectomy versus this, there’s a much longer period of time that people have been doing appendectomies than this.

01:01:48 – Dr. Adam Lowenstein: The insurance companies will often say, well, this is an experimental surgery. You read the data; it’s not experimental. There’s a lot of good data there. But getting the word out to the public is one issue. Getting the insurance companies educated is a whole other issue as far as

01:02:14 – Dr. Adam Lowenstein: having them learn about what the surgery is, how effective it can be, and that frankly we’re improving costs afterward because you’re getting people who are going to the ER weekly, having pain doctors, neurologists, MRIs, and after

01:02:37 – Dr. Adam Lowenstein: surgery, that’s all going away. But that’s a separate fight. Right now we’re all just working toward public knowledge that there can be help out there for a lot of people who are kind of hopeless. There are things that can be done.

01:02:58 – Dr. Adam Lowenstein: Once we tackle that, then tackling the insurance issues comes next.

01:03:05 – Dr. Jason Martin: It starts with the public these days. Insurance companies do offer a great service, but they’re also proprietary and for-shareholder entities. That’s the way it goes. You have to get the word out; people have to be informed. We talked about the whole basis of this podcast being education and empowerment. Getting someone like you on and then discussing what Dr.

01:03:27 – Dr. Jason Martin: Guyuron has developed, and Dr. Janis, is what it’s all about: getting the word out for people who are struggling and severely debilitated. Then to add on top of that, you suffer from the same thing. It’s pretty gripping in terms of the story and the fact that you’ve done all this research and now you’re

01:03:47 – Dr. Jason Martin: actually doing the surgery. That’s the last thing I think we need to bring up. Can you, without violating HIPAA, give us a story of someone who came to you, the backstory, and how it transformed their life?

01:04:00 – Dr. Adam Lowenstein: As a resource rather than a plug, we’ve got some video testimonials on our website, headachesurgery.com. The other thing I want to get in before the end here is that there’s a growing number of people interested in this, but there are a very

01:04:23 – Dr. Adam Lowenstein: select number of us who are really proficient, running with this, and trying to make it a big part of our practice. That’s also an issue. There’s Dr. Peled, who was very instrumental in teaching me

01:04:43 – Dr. Adam Lowenstein: things, Dr. Afifi at my alma mater in Wisconsin, and some people on the East Coast. Dr. Ducic does a lot of this. We hear a lot about these patients on Facebook and try to get them in with those of us who are really

01:05:08 – Dr. Adam Lowenstein: interested. Obviously, Dr. Janis and Dr. Guyuron are also awesome, but a lot of states don’t have anybody, which is one of the reasons I’m interested in doing some of this in Colorado, because there’s nobody else at the moment doing the surgery.

01:05:30 – Dr. Adam Lowenstein: So we’re trying to bring the service to as many people as possible. I can tell you that with my practice in California, I had a gentleman from Kansas who actually flew out for surgery. Relatively recently, we’ve had some tragedy in Santa Barbara, and his surgery was scheduled during this horrific

01:05:51 – Dr. Adam Lowenstein: fire that we just had. He had to go home because I had to cancel the surgery; my office was in an evacuation zone. I’m a very conservative guy, and it was likely not going to be an issue, but I didn’t want to be halfway through the

01:06:12 – Dr. Adam Lowenstein: surgery and have the police knocking at the door saying, you’re not going to be able to do it. So we canceled the surgery. He went home, came back after the fires and the subsequent floods that we’ve unfortunately had, and I did his surgery. He stayed in Santa Barbara for two weeks, which is not

01:06:33 – Dr. Adam Lowenstein: necessary, but he wanted to do that.

01:06:36 – Amy Kilian: He’s from Kansas, let’s be real. It might have been necessary for him.

01:06:39 – Dr. Adam Lowenstein: I saw him just before he left. This was a very specific gentleman. He actually has a known brain tumor, a small one that he’s had for years, and he had gamma knife or radiation treatment. That’s a 33-treatment course, and on his 30th treatment

01:07:05 – Dr. Adam Lowenstein: he began having severe headaches. This gentleman is financially successful, with a loving family who I’ve met. He’s got everything you would want, except a really, really bad pain issue. We operated on him, and again, in the face of this

01:07:28 – Dr. Adam Lowenstein: radiation scarring, I told him I’m not sure this is going to work. He was at the end of his rope; he had tried everything. I said, I’m willing to try this, but you have to understand that it might not work. Before he left, he told me that he had been

01:07:50 – Dr. Adam Lowenstein: planning on making appointments in Washington State where you can have assisted suicide because his pain was that bad. He told me he hadn’t felt this good in years, and on his way back to Kansas, he decided he was going to stop in Telluride and go fly fishing.

01:08:12 – Dr. Adam Lowenstein: It is winter right now. You’re going to Telluride fly fishing in the winter; you’re tolerating some baseline pain right there in your legs. This guy felt so good that this was what he was planning and looking forward to

01:08:35 – Dr. Adam Lowenstein: doing. That was just an amazing story. I feel really thankful that I get to change people’s lives in that kind of fashion. Story after story: I used to not go to my daughter’s softball games, and now I travel all over the

01:08:57 – Dr. Adam Lowenstein: country with her. Single parents – you’ve got to imagine what it’s like to be a parent of a small child and trying to lock yourself in a room, quiet and dark, just because you don’t know what else to do. You still have a child who’s got to be attended to and

01:09:18 – Dr. Adam Lowenstein: fostered and all of that kind of stuff. Just getting patients out, interacting with their family and friends again, is fantastic.

01:09:28 – Dr. Jason Martin: I’m completely envious of the fact that you get to help people that much.

01:09:31 – Amy Kilian: But I think that’s so important, though, that people actually know this exists. That’s so key.

01:09:37 – Dr. Jason Martin: Yeah, in a small way this podcast and the associated video are going to be helpful. But I think starting the discussion with people at their wits’ end is important. They may not be a candidate. That’s the most important thing Dr. Lowenstein said: he’s a board-certified plastic surgeon and very ethical. You need to go to people who know what they’re doing,

01:09:58 – Dr. Jason Martin: people who specialize in this surgery. As long as you go to someone who’s knowledgeable, ethical, and board-certified, you should seek out information and advice. Make sure you’ve had your full neurology workup, you’ve been treated, and go see if you might be a candidate for one of these procedures.

01:10:15 – Amy Kilian: Absolutely.

01:10:16 – Dr. Jason Martin: The downside is not massive. There are scars and some things like that, maybe some numbness in areas, but the upside could be completely transformative.

01:10:26 – Amy Kilian: Getting your life back.

01:10:27 – Dr. Jason Martin: And you could be fly fishing in Telluride. There’s nothing prettier than Telluride, by the way, winter or summer.

01:10:34 – Amy Kilian: That’s true. It’s gorgeous any time of year.

01:10:36 – Dr. Jason Martin: All right, let’s go through your Instagram handle real quick.

01:10:42 – Amy Kilian: How can patients find you?

01:10:43 – Dr. Adam Lowenstein: Headachesurgery.com is our website, and frankly my whole thing on that website is education. I can’t say this for sure, but I think it’s the most comprehensive headache-surgery website out there. I’m not a social media maven, but let’s see, I

01:11:06 – Dr. Adam Lowenstein: think I’m @migrainesurgeon on Instagram.

01:11:09 – Amy Kilian: I was kind of testing you because you didn’t know.

01:11:15 – Dr. Jason Martin: I think it’s under Migraine Surgeon. And then you also have a YouTube channel, too. I think it’s also Migraine Surgeon.

01:11:22 – Amy Kilian: All your social-media links are on your website.

01:11:22 – Dr. Adam Lowenstein: Exactly. That’s the best way to do it.

01:11:28 – Dr. Jason Martin: And then for us, our social-media link is @jasonmartinmd. If you have an interest in plastic surgery, please visit ours – or actually just visit Dr. Lowenstein’s in terms of the cosmetic stuff. If you liked this podcast, please rate it or rank it.

01:11:43 – Amy Kilian: And review us, too.

01:11:44 – Dr. Jason Martin: And review us, and also share it with friends, especially on a topic like this where people may not know. If you know someone who’s suffering from migraines, share this podcast. Let them listen to Dr. Lowenstein, a true expert in this surgery.

01:11:59 – Dr. Adam Lowenstein: 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 we get, the more visibility 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 to the huge population of people who suffer

01:12:20 – Dr. Adam Lowenstein: 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 you hear on podcasts, see on YouTube, or read anywhere

01:12:41 – Dr. Adam Lowenstein: on the internet. I, as a physician, don’t necessarily endorse the opinions or practices of my guests. 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

01:13:02 – Dr. Adam Lowenstein: us at info@headachesurgery.com and my staff will set up a consultation. 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.