Published June 10, 2019 By Adam Lowenstein

Introduction: 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: Hello and welcome to the Headache 360 podcast. I am your host Dr. Adam Lowenstein. I am a board certified plastic surgeon and I’m also a peripheral nerve migraine and headache surgeon. I do peripheral nerve decompression outpatient surgery for migraine headaches and chronic headaches, occipital neuralgia and tension headaches and headaches of multiple different diagnoses. My effort here on the Headache 360 podcast is to get perspectives on diagnoses and treatments of severe headaches from multiple specialists that a migraine patient might see before they see me. As a surgeon, I’ve got a very high rate of success in reducing pain, however, what I do is surgery and therefore most patients see many different specialists before they see me.  So, we’re going to be interviewing and having some candid conversations with these other specialists and we hope to provide a lot of education and information for migraine patients as well as their family and friends.   Today I have the honor of interviewing Dr. Andrew Germanovich. Dr. Germanovich is an interventional pain specialist who has a particular interest in headache patients.  He’s originally from Chicago and he did most of his training there but he did his pain medicine fellowship at UCLA and decided to stay out west and he’s currently practicing in Irvine, California.  So welcome Dr. Germanovich.

Dr. Germanovich: Thank you, Dr. Lowenstein. I’d like to have a lively discussion about how we treat patients for migraines and a little bit about myself. I’m a board certified anesthesiologist and a pain specialist, as you have mentioned earlier, however I have a slightly different training background in the sense that I also use manual manipulation in my practice. And so my area of specialty, in addition to standard pain management, which is anesthesiology and medication based, is paying close attention to the relationship between structure and function. And so a lot of people, especially online health professionals in the field, advertise themselves as pain management and those could be chiropractors, those could be physical therapists and when you ask them, “Why do you say you’re pain management?”, they say, “Well, we manage pain with tools other than needles or injections or other therapies.” So, there’s a difference between interventional pain management and other forms of pain management so to speak and typically an interventional pain management physician is someone who has fellowship training in several disciplines, not just one, and typically this kind of training borrows from different disciplines such as neurology, psychiatry, physical medicine rehabilitation, anesthesiology and radiology.

Dr. Germanovich: So, I have to be able to interpret my own images, I have to understand how medications work, I also have to understand the central and peripheral nervous system and musculoskeletal anatomy. However, my particular interest is in etiology of migraines that appear or intensify after traumatic injury, specifically whiplash type or any type of injury. For example, someone falls of the bike and they maybe had one migraine before and now they have several a month and it becomes progressively more debilitating.

Dr. Lowenstein: Are all people in your field primarily starting with anesthesiology or can you become an interventional pain specialist from another route?

Dr. Germanovich: Currently there’s four routes. There used to be five. You could come in into pain management from radiology fellowships, however some of the governing bodies determined that they didn’t have enough training in physical examination in the residency of radiology. So, right now it seems there are four ways. One is anesthesiology, second is physical medicine rehabilitation, third is psychiatry and fourth is neurology, and all of us are trained from a different perspective and my strength as an anesthesiologist is that I understand opioids real well. So, I’m very frugal with the use of these medications because I see first hand how lethal they can be, even when someone’s continually watching them. And also, you know, I’ve done enough trauma and have managed patients undergoing surgery before and after surgery to have a slightly different insight than my non surgical colleagues have. So, I think anesthesiology is a link between surgical and medical management and I kind of see both worlds and I believe I’m more open to treatment, one way or the other, than some other physicians from different camps are because the surgeons, everything’s surgical, to a medical or clinical specialist only everything’s, you know, non interventional.

Dr. Germanovich: So, I keep my eyes out open for all possible treatment options and I always offer them to a patient. I don’t say that, “You have to have this. You have to have that.”, I offer treatment options to patients and ultimately it is their job to decide and my job is to explain each option in as great of a detail as I can and also explain the nature of their illness so they can decide. I believe in a treatment partnership rather than a relationship where I basically hand them down a treatment pathway.

Dr. Lowenstein: Yeah. I think that’s fantastic. One of the things I see, particularly on social media and the things that people will ask me, somebody will see one of their friends who has migraines would say, that uses triptan and it works for them and they immediately want to use that same triptan. The problem that we have with these types of headaches is that there is not one answer for every patient and it’s a very individualized care plan that we have to provide. Even for what I do, you don’t just release all the nerves, you figure out which nerve’s the problem and then you release it. Sounds like in your case as well, you know, figuring out which option is going to be best is much of the issue, but doing it in partnership with the patient is a great way to go about it.

Dr. Germanovich: Absolutely. I agree. In fact, a lot of the patients come in to me very frustrated and I’m not a first or second, even third physician that they saw. They see plenty of physicians before me, but the way I approach their frustration and their complaints is I go by a very methodical process and approach their complaint or their symptom like a complex mathematical problem. Say you have a problem in calculus and when you first look at it it looks terrible, it looks almost like it’s unsolvable, but if you just take your time and you break it down into parts and you determine what type of pain it is that they have, you can break it down into parts and solve it one by one and in the end you can come together and solve even the most complicated pain syndromes. And part of my success as a pain management doctor has been the fact that I listen to people and I don’t necessarily accept their diagnosis given by someone else as dogma or truth. I’m skeptical a little bit of everything I receive and I start over from scratch for myself.

Dr. Germanovich: I try to confirm their diagnosis, number one, and also number two, I always look at options. Even if they’re on a regimen that works, that doesn’t necessarily mean that they don’t suffer from side effects and consequences of these medications. They’re not without harm and they have harm even long term and even after discontinuing these medications. I just recently had a patient who took a statin, a medication to combat high cholesterol level, a year ago and then after a year of stopping the use of this medication developed a horrendous disease called “Rhabdomyolysis” and all his muscles failed and he was bed bound for months.

Dr. Lowenstein: It’s a horrible disease process.

Dr. Germanovich: And so to say that medications are great and if they manage your disease you also have to weigh that, what lifelong effects of those medications will be because you’re not just managing this disease for today and tomorrow, this is life long. This is life long and so when people think about medications, I think about medications, I always ask myself a question, “Can this be reduced? Are there any alternatives to this medication?”, because your liver changes from day to day, it’s not static. It’s a constantly changing organ and with limited capabilities and so I always ask the patient, I ask myself, “Can something else be done?”, and of course my background in anesthesiology, I have to understand how drugs work, otherwise I can not use them and I have to know everything about them. I typically, when I use a drug, I approach that drug as an anesthesiologist. I have to know every single side effect that exists and potential for interaction because the medications I use in my practice are very dangerous. Opioids, for one, kill people. Benzodiazepines or anxiety medications, a whole class of drugs, is very dangerous as well, also kills people in their sleep and so I have to know if there’s drug interactions. And I can tell you that there isn’t a drug that does not have a drug-drug interaction, they all do. So, my treatment approach is comprehensive.

Dr. Lowenstein: Let me just add, the one thing I do want to say when we’re speaking in these podcasts are that you’re going to hear, listeners are going to hear different stories about different things, you know, don’t stop taking your statins because of the story that Dr. Germanovich just told you. That can happen, but that’s an unfortunate but rare situation. And again, we want you to follow your physicians advice, the purpose of what we talk about here is not necessarily to change an individual’s care, it’s just for you to learn about different prospects that you can take to your physician and discuss. So, and I think that listeners will hear, not only over and over again in the next hour or so, but on many of our podcasts about the difficulties with opioids. For me, hearing from my patients when they are weaning and stopping their pain medication, that’s like the best part of my job to get patients off of their pain meds, which as you said are very dangerous.

Dr. Germanovich: Absolutely.

Dr. Lowenstein: Do you always, no go on. I’m sorry.

Dr. Germanovich: Yeah. The point I was trying to make with the statin is not to scare people about statins, but the fact that drugs have side effects and sometimes they’re not apparent when you take them and you can have side effects months, years after you stop them. And so especially with anxiety medications like benzodiazepines, when someone has successfully deescalated a daily dose of Xanax for example, they can have brain zaps months, sometimes even years after discontinuing these drugs, same thing on antidepressants. So, the point was is that one patient may respond to a medication real well and be fine on it with no side effects and other people are not so lucky. And even in anesthesia I just see this vast interpersonal or interindividual variability in their ability to tolerate drugs and side effects. It’s just absolutely fascinating to me how much variability there is between individuals with, number one, a response to treatment and, number two, side effects which they get from these medications. It’s vastly different between individuals.

Dr. Lowenstein: And it changes with time. I mean, there’s so many times you see a waif of a 110 pound person who you can give narcotics to and don’t blink, but then you get this linebacker looking person who’s much more susceptible and the longer you’re on these medications, the less well they work, which require more, which can be more dangerous. So, there’s certainly a lot. That’s a whole big black box that we can get to at some point too. Let me just ask you, you were talking about a lot of patients have seen multiple doctors before you. Do all patients see other doctors before you and get referred to you or do you see patients as their first and primary caregiver for their headaches?

Dr. Germanovich: So, I see both. This patient-doctor interaction and the way patients get access to physicians in 2019 has changed from what it was 15-20 years ago. Patients now feel like they’re more empowered and they behave more like consumers and so when a patient behaves like a consumer they want to find the best possible care and so there’s tools nowadays that they rely on, which is online grades of sorts, like health grades, vitals, Yelp, et cetera. And they now turn to that to make decisions as to what doctor they’re going to see and they’ll also input key words into search engines, such as Google, Yelp, et cetera and they sort of, these engines guide them to which doctors they see. Also, I of course get plenty of referrals from primary care physicians, sometimes neurologists and for the most part surgeons and I don’t take any HMO patients. So, I don’t really rely on the fact of a model practiced by a lot of HMO companies, which is a gatekeeper model, “You have to have this bill, this, before I send you to a specialist.” So, I receive patients who are self referred through family members and through all sorts of media, which patients rely to find me, and that seems to be an evolving field, where patient is more empowered to be a consumer, rather than just being sent from one doctor to another in an endless cycle of frustration.

Dr. Lowenstein: Yeah, wow. Most people who come to see me have been through one, if not 10, different stops along the way and I think that’s appropriate because nerve decompression surgery is not something to take lightly, but it sounds as if the stop at the interventional pain specialist is often where patients can find relief because of the different options that you have. Do you have, for example, to see me first, I always want to see an MRI of the brain because I don’t want to be doing peripheral nerve decompression if somebody actually has a brain tumor or something like that, I want to make sure that I know what their problem is or I should say I want to make sure I know what their problem is not before I do something. Do you have any similar types of first line diagnoses, not diagnoses, but-

Dr. Germanovich: Requirements?

Dr. Lowenstein: … diagnostic requirements before somebody sees you?

Dr. Germanovich: I don’t. I actually prefer to see patients without anything because you can fall into certain types of bias when they come in and it goes right and be misled down a specific treatment pathway. I do order the studies myself and I’m blessed to be in a multi-specialty group that has on-site digital X-rays and an MRI scanner. So, I can order those when I need to, but my first set of tools I rely on heavily is just good old fashioned physical exam. I still use my hands to a great extent and this is an art that’s dying in medical specialties. We all want to see things from the inside out, but I like to see things from the outside in. So, I still perform a classic detailed neurologic exam. I rely on that and then I make a certain medical impression based on physical exam and I order imaging to support what I already suspect or know, not the other way around. I don’t try to find something that I believe exists based on no evidence. I look for evidence based on my interaction with the patient. So, first I get a detailed history, I listen.

Dr. Germanovich: I sit there and listen and let the patient talk for 15-20 minutes and then sometimes I let them talk and continue to examine them, do my own thing, and then I come to a conclusion, you know, “There’s something I see. Tell me more about this. Tell me more about that.”, and then I get a complete picture when I have everything available to me, physical exam findings and imaging findings, I put those together and I usually get a really good idea. Part of what I take pride in is my ability to do standing and postural exams, both for physical exams to establish whether there’s some kind of an anatomic abnormality, such as a short leg syndrome and also to see if there’s these abnormalities under X-ray in their natural state, which is standing and weight bearing. That is particularly important in whiplash type injuries, whether there’s a continued aggravation after this injury, why they do not heal under certain conditions. So, to kind of answer this safely, yes, I rely on imaging, but I also prefer to hear the story first hand. I don’t like, you know, to be misled by a specific diagnosis.

Dr. Germanovich: I always accept patients, what their diagnosis, as well as the treatment history and I tend to almost put that aside and make my own conclusion before I review all of their records because in the end I have a more complete picture. So, in my history, they’ll tell me what they’ve tried and failed. They’ll tell me medications they’ve tried and field, so I have that. But it happens to me all the time where a surgeon will send me a patient and say, “Listen, this is what’s going on.”, and I find something entirely different. So, the reason I find something entirely different is because I don’t take their diagnosis and treat it, like for example, I get a referral for an injection, I try tog et my own impression before I proceed with the treatment.

Dr. Lowenstein: Right. So, tell me, what kind of surgeon refers to you?

Dr. Germanovich: Typically-

Dr. Lowenstein: I would’ve thought that you had gotten more neurology medical type of-

Dr. Germanovich: No. Typically, I have much more referrals from surgeons than I do from primary specialists or medical specialists and it’s because of the type of practice that I’m in. So, the name of my practice is “Restore Orthopedics and Spine”, and as the name implies we see the majority of patients who have musculoskeletal problems. Well, with these problems a lot of these patients that I treat for, chronically degenerative conditions, the spine and joints, they say, “By the way doc, I have these terrible migraines. Do you treat that?”

Dr. Lowenstein: I see, yeah.

Dr. Germanovich: And so I end up treating these terrible migraines and I learn from patients more than anybody else and, in particular, six years ago I had this patient who was an engineer and he had tinnitus with his migraine. And to me that was unusual and this individual who was incredibly smart, a brilliant man, would just not give up on the fact that a lot of specialists dismissed him. He was dismissed by EMTs, he was dismissed by neurologists, he was dismissed by spine surgeons and saying something, you know, “There’s no relationship between your tinnitus and your neck injury.” And he was really surprised by the fact that I listened and at that visit I told him, “Listen, I don’t have all the answer to your condition, but I will not rest until I find out.”, and so that day I went and got an orofacial pain text and I read that in a day and a half and I came back with some options and answers actually that he was looking for for a very long time and in the end, it took some time, but in the end we were able to cure him of his tinnitus and that was a journey.

Dr. Germanovich: That was a journey that involved medications, injections, burning of nerves in the neck, it involved placement of peripheral nerve stimulation leads, which had complications and eventually led to surgery, which was fusion of a segment, a C2-C3 segment that was compressing a nerve and causing his tinnitus and that finally cured him, but it was a journey. It was a journey that, number one, nobody believed in that being a cause and left this patient very frustrated, but it took somebody who first and foremost listened. And my belief is if all we do is listen to patients we’ll learn a great deal from them because, to me, that was a great learning experience and it was this patient that made me learn a lot about migraines and tinnitus. I’ve been fascinated with this subject matter ever since and we continue to learn as physicians to say that we are experts in our field is a fallacy because medicine continues to evolve and change. We’ll always have to stay on top of our game and we always have to continue to read. It doesn’t stop at residency, it doesn’t stop at fellowship, it doesn’t stop after our oral exam or our written examination to get board certification, it continues and so my learning is I’m going and I will enjoy it.

Dr. Lowenstein: Well, there’s so many directions I could go with that because I actually have occipital neuralgia myself and I have tinnitus, but we’ll skip over me and move on to, let me just ask you, so you talked a little bit about nerve blocks, you talked a little bit about nerve stimulators and I got to tell you in particular one of the things I run into a lot is frustration with all of the different doctors that patients see and I agree that just sitting and listening to patients you can learn so very much and basically listening to patients leads you in the direction of the best route of care, which I think is, as you said, a law of start. But I see a lot of people who have confusion over the C2-C3 nerve blocks or stenosis and all those diagnoses, versus the peripheral nerves that come out from there, which are what I deal with. Can you talk a little bit about how you differentiate that diagnosis between I’d say occipital neuralgia, where you have an impingement of the nerves more peripherally versus a stenosis or a process down deeper that requires either a C2 nerve block or, in a worst case scenario, orthopedic surgery?

Dr. Germanovich: So, as I mentioned earlier, I see all sorts of patients and they come from different backgrounds as far as presenting a pain diagnosis, which is pain in the base of the neck and then pain at the back of the head and then migraines associated with it, which increase in intensity and frequency as the time goes on. So, one of the patients that I typically get is one that has degenerative spine disease, which afflicts us as we age and low back pain right now is the number one pain diagnosis, headache is the number two pain diagnosis and now an evolving diagnosis because of smartphones and technology, like computers, that makes us look down all the time or forward with poor posture associated with it, creates a lot of degenerative neck disease. And so what I see a lot with degenerative neck disease is that you have vertical shrinkage of intervertebral discs, which are filled with inflammatory molecules, and so as these disks degenerate they leech out these inflammatory molecules, one of which is CGRP, which stands for Calcitonin Gene-Related Peptide, and these molecules leak into circulation and they cause real pain syndromes, one of which is migraine.

Dr. Germanovich: In fact, there’s at least several drugs that are new generation made of mouse antibodies that have been humanizes, meaning with every generation they’ve been created to behave more like a human antibody. They attack this molecule, CGRP, and they decrease incidence of migraines and I have some experience with these medications because I have administered them to my patients in my practice and lo and behold, their migraine frequency drops from 20 a month down to four or six. And so there’s a mechanism in place that one part of the body degenerates creates an inflammatory molecule and this inflammatory molecule creates mischief someplace else, which is inside the head. So, from a degenerative perspective I see that people who are migraineurs, or people who typically get migraines, and they have one or two say a month, or one or two a year, as time goes on have increased incidence of these migraines because of degeneration of structures at the base of their skull and in the neck. Second type of patient I get is a post-surgical patient. We all sorts of degenerative disease people have fusions of the neck, both from the front and from the back. As you know, blood is very inflammatory as it leaves the blood vessels and it can, on occasion, create scar tissue. Some people scar differently than others. Some people have very little scar tissue. Some create a lot.

Dr. Germanovich: So, it’s not scar tissue that you see on the surface of the skin that looks like a hideous-looking scar. It’s internal scarring and it, basically, looks like molten lead enveloping entire structures where an individual bled and then white blood cells cleaned the area up and deposited extensive collagen and scar tissue in the area. That can cause all sorts of entrapment neuropathy. Where nerves typically are not elastic structures. We only have one elastic nerve within our body and that is sciatic nerve. The rest of them do not stretch. They glide in tissue planes. So, if they are trapped, for example, when you move your head to the right, to the left, they are microscopically injured and they release inflammatory molecules and that can lead to headaches and all sorts of peripheral entrapment-type pain syndromes. I deal a lot with entrapment neuropathy in my practice because I get a lot of postsurgical patients, both from spine. I also get referrals from abdominal surgeons for entrapment neuropathies in the abdomen. So, these are real syndromes.

Dr. Germanovich: These are syndromes where the nerves themselves create pain. It’s not the tissue injury that sensitizes nerve endings, which we call nociceptive pain. It’s neuropathic pain where nerve itself is causing pain due to entrapment, due to direct nerve injury, or for another reason. Of course, I’ve also treated multiple patients with traumatic injury such as whiplash. What I see with these patients, following them over time, is they continue to deteriorate long after the initial insult. So, initially they’ll come in, their neck is stiff. They have pain, they have body aches, muscle aches, and they have an enormous amount of muscle pain. But that goes away. Over time, however, I begin to notice when I get MRI two years from date of injury, five years from the date of injury, is they begin to deteriorate rapidly and their discs degenerate much more rapidly than in a person of similar age that did not have this kind of violent injury.

Dr. Germanovich: Several things happen. Number one, they have tears of capsules that wrap the small joints of the neck. We call those facet joint capsules. What happens is you start to get arthritic or nociceptive-type inflammatory pain in these capsules. That pain is communicated to the central nervous system and the central nervous system gets sensitized because of this constant input of information which is a pain signal. So, when the central neurons gets sensitized then all of the central neurons get sensitized, particularly the brain and the brainstem.

Dr. Germanovich: There was an individual I met some time ago who was a dentist from Cedars Sinai and, unfortunately, he has passed since I talked to him last. He was a dentist and a scientist. He described an interesting phenomenon where trauma, or a persistent pain signal, from C4 nerve root, C3 nerve root into the brainstem, specifically a relay station which has a name. It’s called subnucleus caudalis. The name is complicated but all that simply means is it’s a small relay station that sits in the brainstem and it’s in a close anatomic proximity to another relay station which controls the cranial nerve number 5 that provides sensation to the face, which is mandible, maxilla, and everything above the eye. It also provides sensation to the dura and dural sinuses, which are structures that wrap the brain.

Dr. Germanovich: So, the brain itself, the cortex, does not have any sensory fibers but the structures that surround it do, including the blood vessels inside the brain. These structures have nerves around them that resemble a fishnet stocking on a leg, and these nerves control the diameter of these vessels. They control their function. They control flow through them, and all of that can go haywire if there’s a problem with communication, or the communication gets an inappropriate signal, which is the case with cervicogenic headaches.

Dr. Germanovich: Some people will dismiss these theories and these diagnosis claiming that migraine is strictly a disorder of the cortex where a small seizure-like focus of irritation spreads through cortical spreading depression, and then everything that happens in the neck is a result of this seizure-like activity in the brain cortex and not the other way around. Well, I could accept this as the dogma or the truth, or I could challenge that notion and say that, “Well, okay, but why if I block the occipital nerve during an active migraine I can stop the migraine?” If this is a primary disorder of a cortex why doesn’t the migraine proceed?

Dr. Germanovich: I’ve also ablated or destroyed with electrical current small nerve fibers that communicate pain from arthritic joint in the neck to the central nervous system, and I have been able to decrease incidence of migraines from 20 a month down to one. So, we would like to think that we understand the genesis of migraines but the reality is we really don’t. We have an idea that some patients get migraines because of genetics but really what triggers them? There are many different sources. Peripheral entrapment of occipital nerves can be the cause. It could be entrapment of the occipital nerves by whatever reason. It could be compression by vessels. It could be entrapment of scar tissue. It could be-

Dr. Lowenstein: You and I have talked about this before. We come from the same ilk as far as seeing these entrapments of … I see them not only in the neck but also above the eye and the temple region. Going through this with patients is … Certainly educating them about this is a lot of what I do and sounds like what you do, as well. There is vasculature, fascia, sometimes in the front of the head there is bone that entraps nerve. Really, anything that tightens around a nerve can irritate the nerve. I couldn’t agree more with what you’re saying as far as the etiologies of these headaches are … I don’t think they have been well understood. A lot of the stuff that we hear is based on thoughts of the vasculature and intracranial, in the skull blood vessels dilating causing pain. I think you and I share the opinion that a lot of these processes, while they may be very valid, are often triggered by peripheral nerve irritation.

Dr. Germanovich: Absolutely, and there is multiple etiologies or pathways which lead to onset of a migraine. For example, we know that estrogen or hormones cause migraines, and women who menstruate will report that there’s two camps, that right before the onset of menstruation they’ll receive this terrible migraine. It’s like clockwork that they get these migraines. Also, at the same time there is a camp of women that has onset of these migraines at a first day of menstruation. So, estrogen does play an effect, and these women have been treated with oral contraceptives to some extent with great success.

Dr. Germanovich: There’s many, many tools available. To say that there’s only one way to treat a migraine which is with medication or with something else is misleading. I think a migraine warrants, or deserves, a comprehensive approach. They’ll be a population of patients that will respond to drug A. They’ll be a population of patients that will respond to injection B. But they’ll be a population of patients that will fail A, B, C, D. You can go down the whole alphabet. They’ll fail everything. Nothing can be more frustrating than have a patient that you really like, that you have a long relationship with sitting and crying in your office that her life is falling apart because she cannot work. She is absolutely incapacitated, and to see this kind of distress and not being able to help that person is very frustrating. At the same time it is very motivating for me as a physician to look for answers, to not be hard-headed about treatment approaches, to continue to look for other options, to always be open to other treatment alternatives.

Dr. Lowenstein: Yeah. On the other side of that I’m going to bet that you’re going to agree that the most satisfying part of my practice are the tears after you’ve fixed somebody, because they have been dealing so long with these problems. I operated on somebody last week and her mother was here and just sobbing that her daughter’s pain was finally gone after her surgery. This woman, not the mother, the patient is 40 years old. She has been dealing with this for 30 years. It is such a challenging thing. I think a lot of the patients who get to you and I as their last line, who’ve been bounced around so much, have just been dealing with so many dead ends for so long. You’re absolutely right, taking the time to figure out what is going to work for a particular individual is so important. Can I ask you, do you do neurostimulators for headaches?

Dr. Germanovich: I have done them in the past and the challenges I’ve run into are the following. Number one is is there is a very high rate of complications, and that complication is typically lead migration, because you can’t fix those leads very effectively to tissues so you basically leave them floating. So, they sort of do their own thing. A head is not like your torso. You move your neck all the time. You move it in every possible direction, and when you’re driving you move it in every possible direction because your eyes take you there. So, these leads kind of poke and prod through the skin and sometimes they can even break the skin and come out. My frustration has been with stimulation is that, because of the population of patients that I service, which is postsurgical typically, I rarely get a referral for a migraine patient who has never had any type of surgery, strictly for the implantation of a peripheral nerve stimulator. In my view that would be great, but I’m not so lucky. There are other physicians that have that-

Dr. Lowenstein: I’m sorry to interrupt you but I just want to understand this. So, you’re saying that patients have had what kind of surgery before you?

Dr. Germanovich: Typically some sort of neck surgery.

Dr. Lowenstein: Like a neck fusion or something like that?

Dr. Germanovich: Yes, and that causes an explosion in their incidence and number of migraines.

Dr. Lowenstein: Right, okay.

Dr. Germanovich: And the frustration I have is that I try to put a peripheral neurostimulator in them but they have scarring, extensive scarring, under the skin, under the muscle, so the scar tissue … One interesting thing about the scar tissue is that it does not conduct electrical current well. Part of the reason why people do so poorly after heart attacks is that the muscle, which normally conducts electrical current, turns into scar, and so they have these dysrhythmias. They have Afib. They have ventricular conduction abnormalities. Those are for heart patients. Well, the same thing happens in patients who have any type of scarring in the periphery by the nerves and you try to stimulate them, is that the nerve doesn’t get the stimulation but everything around it does, the muscle does. What I’ve noticed in the past is that I’ll implant these leads, crank up the amplitude and they will have grabbing of the occipital muscles. The trapezius will fire up. They have all sorts of jerky motions of their head. Whereas the stimulation where I needed it most, which would be over the occipital nerve, would be felt the least. The side effects would outweigh the benefits of the nerve stimulation. In the population of patients that I service this was not a great option.

Dr. Lowenstein: I’ve seen some external neurostimulators and kind of gadgets that people try. Is there any talk on those?

Dr. Germanovich: There’s newer neurostimulators that do not require implant of the pulse generator, which is a small battery-like device, the battery behind a pacemaker so to speak. There’s a company called Stimwave, and they have these small little leads that can be implanted, and they have a little antenna on the lead that can be stimulated right through the skin with an external device that is a wearable device that could be worn in a pocket, someone nearby. This is relatively new technology. We’ll see how that evolves in the future. I mean technology keeps changing, getting better. There’s always continual improvements. I’m always excited about new technology. I’m also willing to try it as it comes along, for the appropriate patient.

Dr. Germanovich: But, there’s always some kind of complications everything you try that’s implantable. One of these complications is is that every time you put a foreign body into a patient it elicits and inflammatory response. So, the inflammatory response is typically your body recognizing this as foreign. It doesn’t know whether it’s an infection or some kind of invading organism, so it builds a wall around it. This wall is typically made of scar tissue. So, any type of implant leads to more scarring, and typically the reason these leads fail long term is that if you pull the lead out, or if you dissect it out, you will notice that this whole lead, in it’s entire circumference and it’s entire length, is covered in dense, dense scar tissue of variable thickness. That is a body’s way of isolating what it thinks is an invading organism from harming the body. It’s just what our bodies do.

Dr. Germanovich: So, I do like implantable devices but they have their limitation, and you will find that often in significant number of patients over time these therapies fail, and it’s frustrating because you give them this hope that it will cure their condition, or manage their condition, and it does for a time it does, and it’s very frustrating when the therapy slowly fails over time. Very frustrating.

Dr. Lowenstein: I hear of people with broken leads. That’s the key words that I hear a lot. “I had a stimulator and it worked for a while but then the leads broke,” which may just be lay terminology for migration, or scar tissue, or a great many things.

Dr. Germanovich: They do, in fact, break because these leads typically have eight small wires in them that are of some metal. If you have experience of playing around with wires as a kid you know you can break any wire if you bend it enough times. So, they do break, in fact, because one lead which is made of silicone with platinum or cadmium contact points has a metal wire on the inside of that silicone that goes to that platinum contact point to make it work. So, if you bend it enough times it will break. So, if it’s in a location like I said behind the ear, or in a neck and people toss and turn all night long in their sleep, yeah you will break those leads over time.

Dr. Lowenstein: Got it. So, let’s go back to something you were talking about before which is your nerve blocks. When you do nerve blocks what do you use? I spend a lot of time discussing with patients in my practice the difference between diagnostic nerve blocks, which is what I do just to prove that somebody has a neuralgia that we can fix versus a therapeutic nerve block, which is something that’s usually done more in the realm of your kind of practice. My impression is that steroids can be involved or different medications as opposed to just a simple short-term anesthetic that I do for my diagnostic nerve blocks.

Dr. Germanovich: Right. So, when people talk about nerve blocks in my practice there’s two types. There’s a peripheral nerves, and it could be any peripheral nerves. It could be big nerves like sciatic. it could be small nerves like occipital nerve. They can be sensory nerve fibers that act as a communication wire between one structure like the joint of the neck, or low back, and a central nervous system.

Dr. Germanovich: So, when people talk about nerve blocks in my practice eight times out of ten what they mean is I am blocking either a medial branch nerve that communicates pain from an arthritic joint of the spine to the peripheral nerve root that goes in a neck or low back. Or, they talk about an epidural as a nerve block done via transforaminal approach or through a small window on a side of the spine rather than a classic approach that people get when they’re pregnant and they deliver babies. So, a nerve block is many things, and it’s very misleading. They say, “Well, why can’t you just block my nerve?” Nerve block that I do for nerve pain in a leg caused by a herniated disc in a neck or back is an epidural and then it’s therapeutic. The purpose of that is to decrease the inflammation of the nerve which has increased in it’s diameter due to compression by the disc, by a piece of bone, or by inflammatory molecules living inside the disc. So, that is therapeutic when I place steroid on top of that nerve to decrease its diameter due to inflammation, and then to decrease it’s sensitivity, and the symptoms of tingling or abnormal nerve sensation typically goes away along with pain or very different other noxious stimuli. That’s a therapeutic nerve block.

Dr. Germanovich: I also do plenty of diagnostic blocks and, as I mentioned earlier, one diagnostic block that I do is to determine whether a particular therapy can be effective, such as radiofrequency ablation. So, before I kill a sensory nerve that transmits information from an arthritic joint I want to be able to prove that that’s feasible, because you don’t want to destroy something before you prove it that it, in fact, can be done without any harm to a patient. So, those are purely diagnostic blocks. I’ve also done diagnostic blocks like for occipital neuralgia to see if I can do different treatments for that, and the different treatments I’ve done for that would be pulsed radiofrequency, which is nondestructive, nonthermal to decrease the sensitivity of the nerve. But, I had to find out whether the nerve in question was either transmitting or generating particular pain, and what you often have …

Dr. Germanovich: Nerve pain is very, very complex and nerves are not just little wires that bring information from point A to point B. They themselves are capable of generating pain, and they hold grudges so to speak. If you inflame a nerve it will stay inflamed for a very long time and sometimes just with a therapeutic injection, if you can just give the nerve a little reprieve by blocking it for at least a few hours, you will find out that overall pain will decrease. That has to do with something called central sensitization. A concept that I like to use to explain it to patients is the following.

Dr. Germanovich: Imagine that the tip of your finger was caught behind the hinge in a door when somebody closed it and you injured the tip of your finger and you created tissue damage, so that the tip of your finger hurts because you’ve actually damaged it. Well, you will wake up the next morning, you will find out that your whole index finger will be flaming red and you’ll ask yourself a question, “How come if I just pinch the tip of the finger, how come my whole finger is involved?” You will learn that this was a protective reflex that actually happened inside your spinal cord. This can happen not just overnight, it can happen in a few minutes. So, this phenomenon, which is well described, and it’s called wind up, wind up phenomenon, is a protective reflex to protect, basically, a whole extremity against any more insult. That happens in a lot of pain syndromes where a peripheral noxious stimulus, or a peripheral site of injury or pain, will move in centrally after constant input of pain and will centralize. That becomes a very difficult problem, very difficult problem to treat even with medications. Before you get to that point, or even after that point, you can do miracles if you can even temporarily shut down nerve transmission so this central process of wind up can at least come down a little bit and not torment the patient as much.

Dr. Lowenstein: So how often when you do that type of kind of temporizing, calming down of the process in the hopes that it abates, how often does that work?

Dr. Germanovich: It’s hard to say. You know, I do a lot of diagnostic injections with the intent of destroying the nerve eventually. Sometimes what I find is I will do a diagnostic injection with just local anesthetic without any steroid in it, and a patient will report weeks, if not months, of pain relief. I’m just puzzled by it and I’ll say, “That was not my intent, but if it helped you great.”

Dr. Lowenstein: Yeah, whatever works, right?

Dr. Germanovich: Whatever works. But, majority of the time if there’s a generator of pain, such as an arthritic joint that constantly feeds a pain signal caused by inflammatory molecules coming from this inflamed, arthritic joint then when the nerve wakes up from blockade it will continue to transmit that useless pain information. So, my intent is to confirm a diagnosis, essentially, with a nerve block. It’s basically a diagnostic tool that I use. Every now and then I’ll add a little steroid to it to help the patient on a longer term. Of course, there are complicated pain syndromes where I hope to block the nerve with everything I’ve got just to decrease the transmission of a pain signal through their complex pain syndromes that don’t respond to nerve blockade for long-term pain relief. More often than not they don’t, but sometimes they do. The reason my specialty is called Pain Management is that I try to manage pain as best I can. It’s rare that I cure disease. Because of our degenerative nature as human beings we break down as we age.

Dr. Lowenstein: But, you also … Well, you and I have recently shared a patient, a young man. When you start to see these issues in young people that should be developing rather than breaking down over time can be a very difficult thing. We’re hoping that we-

Dr. Germanovich: Very rewarding if you’re able to help them and get them back to normal life.

Dr. Lowenstein:Let me ask you about this RFA. When you say you ablate the nerves is that what you’re using?

Dr. Germanovich: That stands for radiofrequency ablation. Essentially what that is there’s a machine that takes electrical current with standard frequency of electrical oscillation that comes from the electrical outlet and it multiples it up to a million Hertz. What happens is that this current comes out through a needle that is specialized, so the needle is insulated for the most part like a wire is so it doesn’t allow flow of current through other areas other than the tip. So, the tip has a hot, or active tip, and it’s typically between 5-10 mm in length and a diameter that ranges between 18 gauge to 20 gauge. There’s other sizes. But what it does is at the tip the current encounters very high resistance, which is surrounding tissue structures.

Dr. Germanovich: So, a grounding pad … It’s not really grounding pad but it’s a dispersal pad, similar to the one used for Bovie for cauterization, is placed on the patient’s greatest circuit. So, this very high resistance that’s encountered at the tip of the needle creates a lesion, so a destructive lesion. Basically it cooks everything in a predictable diameter and size based on many studies done on these machines prior to their approval to be used on humans. So, I’ve actually played around myself on pieces of chicken breast to see how these lesions are created and how much time it takes to create a certain lesion size. So, I rely on x-ray technology, or technology similar to x-rays called fluoroscopy, to guide my needle tip to a known anatomic location on the surface of a bone, where I presume that the nerve lives. I don’t actually see these nerves because they’re too small. They’re the size of an eyelash or an eyebrow. They’re way too small to see even with ultrasound but based on anatomy, I create a lesion size that I anticipate is large enough to kill that nerve where it is. That would be for a small medial branch nerve that is transmitting information of pain from a joint in a low back or neck and causes chronic low back or neck pain. I’ve always done that. I’ve also done that for knee pain, chronic knee pain, where a nerve called genicular nerve who’s only job description is to bring sensation of pain from the structures of the inner knee to the rest or peripheral nerve system and so the genicular nerve can be blocked initially, to prove that the fact that the pain can be turned off, not just once, but twice. And if I hadn’t convinced that after blocking this nerve twice, I can then go in there and burn it after anesthetizing with a local anesthetic, the nerve dies and stays dead, but unfortunately a lot of the sensory nerves do tend to recover. They grow back. And the pain returns, but it’s a time that patients can enjoy without persistent pain that is just tormenting them day in and day out, such as chronic knee pain or spinal back pain.

Dr. Lowenstein: And you use that for occipital neuralgia?

Dr. Germanovich: Not for occipital. The reason I haven’t done thermal ablation for occipital neuralgia is because it creates permanent numbness in the scalp. I have on occasion, under certain conditions, have ablated a third occipital nerve, which is part of the occipital nerve, right at the spine, but I have had a discussion with a patient, say, look, there’s a chance that you might have a permanent numbness in back of the skull. There’s also a chance you can develop a condition, which is worse than what you already have, it’s called anesthesia dolorosa. Anesthesia dolorosa stems from incomplete nerve destruction so you go after a nerve and you try to kill it but you only kill the few fibers within the nerve and the remaining fibers have re-wired and create a condition that’s worse than what you had to begin with, which is numbness, and at the same time severe pain. And it’s almost like a phantom pain, yet you have numbness in the area that you’ve attempted to permanently disable. And anesthesia dolorosa is a difficult difficult condition to manage or treat and unfortunately, I’ve run into that more than once. And so I try not to destroy peripheral nerves that are combined nerves that are both sensory and motor if I can. And I only go after small sensory fibers.

Dr. Germanovich: I have not recently destroyed any occipital nerves. So what I try to do is I try to do pulse rate and frequency which is not thermal. It’s not a thermal ablation, so I don’t change their anatomy and their 3D structure, I change their sensitivity and make them less sensitive and less likely to fire after I’ve done that to them.

Dr. Lowenstein: So when I see patients who say that they have failed RFA, these patients say that they’ve had RFA of their occipital nerve and their pain has returned, and those patients are often good candidates for me for nerve decompression surgery. That’s because of the regenerative power of the peripheral nerve?

Dr. Germanovich: Yes.

Dr. Lowenstein: So, that’s a separate issue from this pulsed, the type of pulsed radio frequency that you’re using to desensitize things, as opposed to actually ablate.

Dr. Germanovich: Yes.

Dr. Lowenstein: Got it. Okay. So, we’re coming up, we’ll we’ve come up past an hour, you got a couple more minutes for a couple more questions? Or?

Dr. Germanovich: I absolutely do.

Dr. Lowenstein: Do you want to talk about Botox?

Dr. Germanovich: Sure. So I use Botox in my practice quite a bit. I actually use it on myself because I get migraines and I use 25 units just for the frontalis muscle and maybe, well 25 total, I use about 15 units for the frontalis muscle and a corrugator in the front and I find a couple of strands in a temporalis muscle that I tend to develop trigger points, and my suspicion is that I possibly grind my teeth at night and I get these very infrequent migraines that make me very miserable and if I use just a little bit of Botox, I can typically prevent them entirely, so if I use it on myself, I do believe in their utility on my patients. It helps me, it helps them. However, I use different tools, and I’ve noticed that Botox for some patients, over time becomes a nuisance because it’s a condition that is going to be life long. And they require this four times a year, and it comes with a cost. So Botox is not an inexpensive drug, it’s five to six hundred dollars per vial and it doesn’t come in small little vials, it comes as 100 units for the most part. There’s other manufacturers that makes smaller vials, but you typically end up paying for the whole thing even if you don’t use all of it.

Dr. Germanovich: And so, it’s 500 times four times a year, plus the cost of the injection, and you have to be at the doctor’s office all the time, and so some patients will opt out for the nerve ablation in the upper occipital region to see if that is more effective long term. In some patients it is, and some patients it doesn’t, and I use a combination. I’ll do the ablation of the upper neck, I’ll continue to use the Botox if they still have pain, and some patients are afraid of ablation, they say “I don’t want anything destroyed in my neck” and will only opt out for Botox. And it does work. And again, there’s also new medication out there I mentioned earlier that’s an antibody that’s injected right into the muscle and it mops up all the inflammatory molecules. And so I use everything I’ve got. I never say only use this or only use this therapy, you always use a combination of techniques for optimal results.

Dr. Lowenstein: And when you’re doing your Botox though, you’re doing what I call target Botox as opposed to the other thing that we call kind of the ring of thorns. The FDA cleared [crosstalk 01:05:27]

Dr. Germanovich: No I don’t follow these guidelines. I think they’re overboard. I’ve noticed, especially on myself, I’ve noticed if you just deal with the frontalis for the most part, or corrugator muscles and the temporals, you don’t need the many units of Botox for one. Number two, if you disable a lot of the posterior muscles, like trapezius and occipitalis, in a patient who we’ll say is an office worker, and these muscles now don’t support your posture, your posture drops, becomes even worse, and the muscle strands scar because your body will build up scar tissue in order to support the tension that you place on these muscles. I think that’s actually kind of counter productive.

Dr. Lowenstein: Have you ever had that done to yourself?

Dr. Germanovich: Oh yeah. I hate the feeling.

Dr. Lowenstein: Botox in your neck?

Dr. Germanovich: Yes. I hate the feeling. I hate the feeling.

Dr. Lowenstein: I had that as well and the funny, when I offer it to patients I tell them that my biggest problem was eating soup because you can’t put your neck forward to meet the spoon because of the weakness that you can get. And again, you and I were talking a little earlier, you’ve got, your children are a little older than mine, although I’m a little older than you, so I lose on both counts there but being on the ground, playing with your kids, and lifting your head up after those injections. That was very challenging, but I’ve gotta say I didn’t have headaches after I did it but I only did it once.

Dr. Germanovich: Yeah.

Dr. Lowenstein: And again, you know for me, I use Zomig Nasal Spray and that works for me. Because people ask me all the time if I have occipital neuralgia why I don’t have surgery and my response is if you have something that’s less invasive, that works, then that’s great. And for me, I can take a whiff of Zomig and that makes some people super super tired, for you and I who’ve done our medical training and have done 115 hour weeks, and spent days on end in the ER dealing with traumas and things like that, I deal with, tiredness I don’t even feel. But for what I do, when patients complain that they’ve tried Zomig and it makes them exhausted, well then that’s an intolerance that makes you move to the next line of therapy.

Dr. Lowenstein: So, it’s kind of like a ladder of therapy it seems a lot of times.

Dr. Germanovich: Absolutely and you know I in particular have an interesting etiology for migraines, we talked about etiologies earlier, is that my migraines come when there’s a fluctuation between ambient barometric pressure. So I am a walking barometer. I know that there’ll be a change in pressure because I start to get a prodrome and then I’ll get a migraine. And so I only do Botox in the spring. And then the rest of the year I don’t have any headaches.

Dr. Lowenstein: Yeah. That’s interesting. So, again, you can cut me off when and if you need to leave but I want to talk, I’m going to lead into this, one of the ways that I get migraines is I have an occasional recurring dream where I haven’t read a book for my English class in college, and I’ve got an exam on it, and I am trying to … I don’t know where the exam is and I don’t know where the book is, and I’m super tense and I wake up in the morning basically with a very tense neck, and that’s been squeezing on my occipital nerves for the period of time. And so it flares my occipital neuralgia. And this is my lead in towards diagnoses. So some people would call what I have tension headaches, other people would call it occipital neuralgia, and I think personally, it’s quite sad that a lot of people don’t even know the diagnosis of occipital neuralgia. But you must see patients with both with various diagnoses but also making potentially different diagnoses yourself, but between migraines, status migrainous, tension headaches, chronic daily headaches. There’s so many different diagnoses and I’m interested in your perspective about what you think these conditions share versus what they don’t.

Dr. Lowenstein: We’ve talked with patients about the classic diagnosis of migraine involving a prodrome and the four stages, etcetera. But I’m kind of curious as to what your thoughts are as far as both the vulnerability and the commonality between these diagnoses.

Dr. Germanovich: So, when it comes to diagnosis of migraine, I go by the book, by whatever international headache society establishes the criteria to be. And I don’t agree with a diagnosis of migraine because the patient tells me they have a migraine, I still go through the migraine screening questionnaire. And there’s this five, four, three, two one rule is you have to had five of these attacks before. You have to have at least four hours that they last, it can’t be an hour, it can’t be half an hour. They can last from four hours up to three days in duration. It usually starts off at one side. It can involve both sides of the head, but it has to start off on one side. It feels like pulsating. And it’s severe. It’s incapacitating. And typically it’s associated with nausea, so intense unilateral pain and nausea, for the most part will establish a diagnosis of a migraine if it lasts four hours or more, and it’s repetitive, it happened more than once in a person’s life. And then if it happens on a more frequent basis that, and then of course, there’s other criteria where people have sensitivity to light, they have sensitivity to sounds and I for one, have had an aura, which makes the diagnosis of migraine fall into the category of a classic migraine.

Dr. Germanovich: So there’s classic migraine, which is with aura. And then migraine without aura. Aura is a funky feeling, sensation. In my case, it was a scintillating scotomata, which is a description of an event that happens in the eye and if you can imagine you’re wearing glasses, and somebody took some bacitracin or neosporin cream and just kind of smeared in the center of the left eye, and you just can’t see past it very clearly and it’s just kind of smeared, and this smear just kind of vibrates a little bit.

Dr. Germanovich: The first time I had it, I sort of freaked out a little bit. I didn’t know what was going on so I got some saline and started washing my eye out, was something wrong with my cornea? And then having treated migraine in the past, something actually clicked and my brain said, hey, maybe this is an aura, and in fact, migraine came shortly after, so I actually calmed down that nothing was wrong with my eye.

Dr. Germanovich: But to establish a diagnosis, I followed the migraine criteria and I also see quite a bit of tension headaches as well, and so I will palpate again. I take pride in the fact that I like to touch my patients, I run my fingers up and down the neck. Sometimes I’ll even place them in a face up position on an exam table and I’ll be sitting behind them by their head, I’ll put my hands under their neck and I’ll feel for every single joint. And I’ll feel for T1, thoracic vertebrae one, to C7, C6, all the way, one by one, one by one, I’ll go all the way up to the base of the skull, and I’ll put my fingers into the suboccipital area where there’s a lot of tension typically. And then I’ll also have them turn over and tap along the nerve in a distribution of greater or lesser occipital nerves and, I’ll ask them, what is it that you feel? They say, well, your tapping. But if they’re shrieking and I ask them what did you feel? They say, well I felt this electrical sensation every time you tap me over there, well that’s classic neuralgia.

Dr. Lowenstein: Like shooting pains.

Dr. Germanovich: Shooting pains, or tingling, or parasthesia, any abnormal sensation when you tap the nerve with a fingertip. And it’s not always the same. There’s no clear cut diagnostic tool that says this is clearly neuralgia, versus this is just tension, but that’s why we have a diagnostic tool in place, like an occipital nerve block. So I’ll block the occipital nerve that says you know what, this was magical. Whatever you did was magical. And the occipital nerve block is different from trigger point injections to the trapezius muscle. So trapezius muscle will over time, from constant stretch from poor posturing will develop trigger points. And trigger points generate pain in areas different than the trigger point itself, so if you wanted to squeeze someone right at the base of the trapezius, they’ll report pain in the temple. That’s not lesser occipital nerve producing that. That’s a trigger point cause you to defer pain elsewhere. So you have to be able to distinguish between those two. So if you inject a trigger point in the trapezius, the pain syndrome in the temple will go away because of the nature of the trigger point.

Dr. Germanovich: So there’s tension headache is different from neuralgia, is that it is primary inflammation of the muscle, muscle fibers, muscle strands, and there’s these little sensors in the tendons called golgi tendon organs that help in generation of these triggers and they are mixed structures. They’re like a sensing structure that also has a nerve attached to it. And if you numb them, then a lot of the symptoms go away.

Dr. Germanovich: So there’s tricks and ways of differentiating the two, whether it’s clearly a neuralgia, or it’s a tension type of phenomenon or a trigger point. And so again, it goes back to the physical exams to be able to examining them, check the range of motion, and so where you’ll notice a lot of times is with poor posturing, people have significant tension, not just in the trapezius, but all the para-spinal muscles in the neck, they all tense up, so they have reduced range of motion as a result of that. They have very stiff necks, and if you ask them to turn their chin to the right, to the left, to look up, to look down, they have a very limited range of motion because of all the stiffness. So it truly is tension like headaches, and then they have referred pain in the forehead, temples, et cetera which is with occipital neuralgia it’s very predictable, you tap them and it’s just electrical shocks everywhere and they hate the sensation.

Dr. Lowenstein: Do you find that you have more success with one type of diagnosis than another?

Dr. Germanovich: As far as treatment, so, number one, with tension headaches it’s basically modification of whatever’s offending your muscles. So I tell a typical office worker, you have to take two or three breaks a day. You have to lay down face up, bring your chin up, unload your trapezius muscle and basically take the tension away. When you come home, if you feel the tension building up, lie down on the floor, take a small dose of a muscle relaxant and some clinicians totally hate muscle relaxants. I use them all the time, and people are happy with them, versus a neuralgia, muscle relaxants will not help and so you have to treat that differently with a member stabilizer like a Gabapentin or a Lyrica or a nerve block if you will, or a patch sometimes. A topical Lidocaine patch at the base of the neck will penetrate deep enough to get the nerve and sometimes help with that.

Dr. Lowenstein: So, in my practice, I have seen patients who literally, I’ve seen a single patient who had four different diagnoses, of different headaches. And actually from the same neurologist. And at the end of the day you released your nerve and she’s better. The frustration I have is what seems to be some degree of ambiguity with these diagnoses because I agree with some of what you were talking about but I’ve seen patients with these, that would be called trigger points, in the trapezius region, and it’s in fact the muscle is squeezing on the occipital nerve and their complaint is that they have pain that starts behind their neck and shoots over their temple and into the front and comes out to their eye. That’s a very common thing that the pain starts in the back and comes out at their eye or at their eyebrow or at their forehead, and things like that. And we release the occipital nerve, and it fixes the pain in the front as well.

Dr. Lowenstein: So, that again is a referred pain syndrome similar to what you were talking about, but it seems to me that that inflammation can be caused by primary factors or tightening of the trapezius muscle or an aberrant occipital artery that is crossing the nerve. Lots of different etiologies to this single commonality that we can fix.

Dr. Germanovich: Yes. I agree. You know the anatomy better than I do in the suboccipital area, but there is a small window or opening at the tendon of the trapezius muscle as it goes in the nuchal line and where it serves as a window for the occipital artery and nerve to go through.

Dr. Lowenstein: The trapezium tunnel.

Dr. Germanovich: Yes. And if one looks down persistently like an office worker does, or someone who works at a desk all day, I can see how that compresses both, and will cause a neuralgia, just from the pressure. But sometimes you have people who do manual labor, or physical labor and have trapezius overuse syndromes and they’ll be laying face up and you’ll find a trigger on their trapezius and you’ll squeeze that with your fingers, you can feel the trigger, you can feel a small little ball on the trapezius muscle, and I’m talking lower down, not in a suboccipital area, way down in the trapezius, close to their shoulder blade, and you’ll squeeze that and send a sensation shooting all the way down to their forehead.

Dr. Germanovich: And so I think the medicine behind that is complex. I’m well aware of the cervical trigeminal complex where information from the upper cervical vertebrae produces sensation in a forehead in a distribution of the fifth cranial nerve, or trigeminal nerve through communication of brain stem. So a lot of these structures talk to each other. Nothing works in isolation. And if you have one area that’s constantly aggravated, and you turn that off, you can turn off a lot more than just one aggravating area. You can turn off everything else that’s seemingly anatomically unrelated where in fact it is, through the brainstem.

Dr. Lowenstein: Yeah. Well I’d say the listeners are hearing one commonality through all of this, which is the complexity and tremendously interesting thing that the nervous system and brain are, and it is a complex situation that really does require, as you say, listening to the patients and kind of letting the patients experience and finding out what works and what doesn’t in order to kind of steer their therapy in a manner that’s individualized towards just them.

Dr. Lowenstein: I can’t tell you how much I appreciate you spending time doing this with me today Dr. Germanovich.

Dr. Germanovich: Oh thank you.

Dr. Lowenstein: Can I just say that again Dr. Germanovich is at Restore Orthopedics and you can find out more about his practice at He’s in Irvine and I’m going to bet that there’s going to be a bunch of questions that come out of listeners here, and I would ask people to continue to submit their questions to our email at And I would maybe hope to coax you into doing a follow up at some point so we can maybe field some of the questions that we hear. I think that your perspective is incredibly informative and I really appreciate your being involved here.

Dr. Germanovich: Thank you very much. Thank you for the opportunity to learn from you as well. I’m always looking toward more suggestions, more ways of treating complex syndromes and disease states. This is eye opening and before I met you, I didn’t know these things could be done. It’s so refreshing to hear that people offer different tools in hopeless cases, and I have plenty of hopeless cases in my practice, and it’s very very frustrating to look at a patient who suffers so immensely and being unable to help. And so I’m a proponent of partnering with other physicians and collaborating on difficult to treat disease states and/or problems.

Dr. Lowenstein: I’m of course always open to trying to help your patients and I really hope we get the opportunity to continue to work together, both clinically and to help educate patients in matters like this. So thanks very much and we’ll look forward to our next podcast and we’ll keep our listeners posted. So thank you all for listening.

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