Published October 7, 2019 By Adam Lowenstein

Speaker 1: 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, and today we are again, speaking with headache specialist, Neurologist Dr. Hussain Ansari, from University of California San Diego. Again, Dr. Ansari is kind of a world expert on headaches. It’s a real pleasure to be able to speak with him. While I’m one of the few surgeons around the country that specialize in migraine surgery, it’s just a treat to be able to get the perspective of a neurologist, and a headache specialist regarding the procedures that surgeons, such as myself, perform. So thank you for being with us, Dr. Ansari, again.
Dr. Ansari: Thank you very much, Dr. Lowenstein, to inviting me again. And hopefully we can educate your audience regarding the headache, migraine, and the different treatment that we have for you.
Dr. Lowenstein: Today, I think, let’s talk about procedures that we can do headaches, for migraines in particular. I should kick off by, can you tell me what kinds of procedures you recommend for your patients?
Dr. Ansari: Sure. For migraines, the only procedure that the FDA approves is Botox treatment, and that’s for chronic migraine only. And so that is the treatment that we are doing for over ten years now. We briefly talk about that during previous podcasts. That’s relatively easy procedure, although sounds getting 20 or 30 injection in the head is a little unpleasant for the patient, but you would be surprised how much patients like that, and they come and get the procedure because when they get migraines, it’s painful, and that’s definitely help for a migraine.
Dr. Ansari: The injection technique is a little different, I think we talked about that last time. A little different depending on neurologist and non neurologist injections. But no matter what it is, it’s helpful, and it’s the approved treatment for chronic migraines.
Dr. Ansari: The other procedure that is not approved, but all of the neurologist almost, or all of the headache specialists at least, do that procedures, or nerve block. The different nerve block we do for migraine, occipital nerve block is the one that most of the non headache neurologists do. But we do other nerves as well, like the temporal, the zygomaticotemporal, and [inaudible 00:03:08] nerve. These are treatments that give patients short relief, because what we do, we just use the local anesthetic injection to the nerve, and basically numb the nerve, and stop the firing of the nerve, and stop the pain cycle of the migraine.
Dr. Lowenstein: I’m sorry, it’s just, I also have patients who are, on occasion here, and they tell me that they’ve had their neurologist add cortisone, or some kind of steroid, to the injection to help with inflammation. Do you do that as well, or only local?
Dr. Ansari: So first of all, the steroid injection is only for occipital nerve. Of course for other nerves it’s not safe. Plastic surgery, you know, if you get steroid in the supraorbital nerve, for example, that can cause a lot of issue, right? But in the occipital nerve, sometimes adding the steroid might increase the duration of the pain. However, there’s a study done, multiple studies, by neurology team, and it’s shows in the migraine, actually adding the steroid, it does not change anything.
Dr. Ansari: So that’s why the only time that we use that steroid for occipital nerve block, in the patient who had cluster headache, or any kind of, what we call the trigeminal, or [inaudible 00:04:39] cluster, is part of that family of the headache disorder. I personally do not use a steroid, in my migraine, because even I’ve found, that on myself, it really doesn’t matter if you use a steroid or no, the duration does not change.
Dr. Lowenstein: When you’re talking about these different types of injections for migraines, but as we’ve talked about on previous podcasts, there’s lots of different headache diagnoses. Do you differentiate how you treat those with different procedures, and different types of injections?
Dr. Ansari: Absolutely. And in the occipital area, actually, there’s a lot of controversial, or maybe problem with understanding, the different type of the headache that can happen in the occipital area. So the most common pain in the occipital area, which is back of the head, is the migraine. And we call that cervicogenic migraine, there’s a different diagnostic code for that, that’s called cervicogenic migraine.
Dr. Ansari: But we also have the headache which is mimic cervicogenic migraine, and that is cervicogenic headache. That is totally different type of the headache. Although, sometimes it’s very similar to migraine, particularly in term of the location. But it is different kind of headache. In order to diagnosis the cervicogenic headache, the injection needs to be done by pain specialist, or by neurologist who train in the pain, because this is an injection that needs to be done with needle ultrasound, or fluoroscope, and that’s called a facet injection. So if the patient responds to the facet injection, then the diagnosis of cervicogenic headache compares. So that is different kind of headache, and those are the kind of patients who will benefit from other procedures, including RFA procedure.
Dr. Lowenstein: I’ve got a technical question for you here. This is what I don’t understand about that. When we do… If you’re doing an occipital block, and you’re doing a block with local, and you’re getting the greater occipital nerve, and that is coming out of the C3, C2, that area, if you block… The facet, doing the facet block more centrally, and I’m afraid I’m going to get a little too technical for a lot of listeners, but if you’re going closer into the spinal cord, for these blocks, aren’t you effectively also blocking what would be blocked if you did the greater occipital nerve?
Dr. Ansari: Yes.
Dr. Lowenstein: So how can you discern-
Dr. Ansari: You do and you do not. Because in the facet, you’re injecting one facet, certain facet. But when you talk about the occipital nerve, there’s a lot of variation. And yes, the main one is C2, C3. But we have other areas of the spinal cord that occipital nerve can originate. Plus, the other thing, which is very important, is the history. So when you see the patient with headache, based on the history, at least 99, 5 person, you can differentiate between cervicogenic headache and cervicogenic migraine, that’s one.
Dr. Ansari: And the second thing, yes, in the patient with cervicogenic migraine, if you do facet block, you might get response, patient might get better, right? That’s your question. But in cervicogenic headache, if you do occipital nerve block, patient should not get better.
Dr. Lowenstein: Okay, so that’s what I’m saying. It seems to me, that if you, by definitely you’re saying a cervicogenic headache requires a facet block for diagnosis, and a successful one. But it seems to me that, by diagnosis, you should also require a unsuccessful occipital nerve block, to isolate the problem being more central.
Dr. Ansari: Yes, exactly. And actually their response with the facet block is part of the diagnostic criteria for cervicogenic headache, based on International Headache Society classification.
Dr. Lowenstein: And so my problem, clinically, when I see patients is, I see people who have these diagnoses, who have not had these, all of these, diagnostic procedures. And so, again, personally it seems to me that it’s important that you really get a diagnosis of somebody who’s very familiar with headaches, because misdiagnosis in my practice seems to be somewhat rampant, unfortunately.
Dr. Ansari: Exactly. And let’s emphasis again, the diagnosis of the headache and migraine, is a clinical diagnosis. Over 95% of the patient, percent of the time, diagnosis between cervicogenic migraine, and cervicogenic headache easily can be done by good history. Those diagnostic block is for less than 5% of the population that symptoms overlap very, very, basically, high, and sometimes clinically you cannot make the diagnosis and you need to diagnose the block.
Dr. Ansari: But again, the history, history, history, is what we make the diagnosis of the headache, and migraine.
Dr. Lowenstein: Okay.
Dr. Ansari: So going back to the occipital area, there’s a third kind of headache in the occipital area, which is called occipital neurologia. You hear this from your patients, I am sure, a lot, all the time. And when we talk about the neurologia, in general. Neurologia has a definition. Neurologia means the sudden, severe pain, which has abrupt onset, and abrupt termination. It’s kind of jabbing, electric shocks. So I usually explain to my patient, I’m sure you’ve hit your funny bone, sometime, somewhere, and you get that sharp pain, that is neurologia.
Dr. Ansari: So when neurologia happens in the occipital area, that’s called occipital neurologia. But in the clinical practice, I see a lot of patients that are referred to me with diagnosis of occipital neurologia, and when you take the history, the patient doesn’t give you any neurology picture of the pain, plus the pain is constant in the occipital area, so that’s not occipital neurologia.
Dr. Lowenstein: And can occipital neurologia lead to chronic pain?
Dr. Ansari: Yes, if you don’t treat occipital neurologia, you still get those jabbing, jolting pains, and in between, you can have the burning sensation, a little dull pain. But again, that’s very easy to diagnosis. The occipital neurologia from cervicogenic migraine, and cervicogenic headache shouldn’t be problem, clinically. Yes, cervicogenic migraine, cervicogenic headache, sometimes difficult, as we discussed, but occipital neurologia, clinically, we should able to, basically, diagnose. And one of the part of diagnostic treatment for occipital neurologia is immediate response to occipital nerve block.
Dr. Lowenstein: Got it. Now, occipital, or cervicogenic migraine will also respond to occipital nerve block, right?
Dr. Ansari: Cervicogenic migraine sometimes responds, yes.
Dr. Lowenstein: Sometimes.
Dr. Ansari: Sometimes. So in the patient with migraine, cervicogenic migraine, if you do occipital nerve block, and patient does not respond, you cannot tell this is not cervicogenic migraine, correct? But in occipital neurologia, if you block, and patient does not respond, that’s not occipital neurologia. You already ruled out that diagnosis, because that’s part of the diagnostic criteria.
Dr. Lowenstein: Okay, okay.
Dr. Ansari: So focus is clear. Occipital neurologia, cervicogenic headache, cervicogenic migraine, is very confusing, even for some of my neurologist colleagues, this is a little confusing and not clear.
Dr. Lowenstein: Right. I think that’s part of the problem. You have a patient who has head pain, and they may see several different doctors, who have several different levels of understanding of this, and get several different diagnoses. It can be very frustrating. Trying to work through that, especially when your head hurts. That’s, I think, part of the general problem with the complexity of headaches. And just for our patients, just so you understand, you have your brain, and you have your spinal cord that leads to your brain. And then you have nerve roots that lead to your spinal cord, that lead to your brain. And those nerve roots go out in the area of the facet, so that’s what a facet block is, is blocking the nerve roots. And then you have the nerve trunks, that lead to the nerve roots, that lead to the spinal cord, that lead to the brain. And then you have nerve branches, that lead to the nerve trunks, that lead to the nerve roots, that lead to the spinal cord, that lead to the brain.
Dr. Lowenstein: So what we’re talking about is blocking things, and treating things at different levels, either near the spinal cord, or further out. An occipital nerve block treats, preferably, one of the nerve trunks of the greater occipital nerve. And face block treats the nerve roots, which are closer to the spinal cord.
Dr. Lowenstein: So that’s my little anatomy lesson for today. But it’s a very complex subject, that we’re very fortunate to have people like Dr. Ansari to help elucidate, figure out.
Dr. Lowenstein: So from the perspective of a headache surgeon, Dr. Ansari, what’s your feeling about migraine surgery?
Dr. Ansari: Sure. Before we talk about that, just briefly, since we took out the procedure, I have forgot about another procedure, which is called sphenopalatine ganglion block. That is the procedure, again, the office based procedure. The sphenopalatine ganglion, is the ganglion in the back of the nose area. And we put in a little lidocaine through the nose in that area, sometimes you can block the nerve fibers, basically, that come from ganglion.
Dr. Ansari: Although we call sphenopalatine ganglion, the office based procedure that we do, is not really blocks the ganglion, it blocks the nerve fibers. You have this sphenopalatine ganglion block by fluoroscope, which done by pain specialist, that’s different. In that way, they go directly and inject the sphenopalatine ganglion. But the one that we do in the office, with a certain catheter, where there’s a two company making this catheter, we put small amount of lidocaine, and inject through the nose, and that’s another… Because we have FD approval, it’s worth to mention if your audience at least know about that procedure, that also we do sometimes.
Dr. Lowenstein: Great, yes.
Dr. Ansari: So now, going to the surgical part. That is, of course, a very controversial subject. One thing, at the beginning, we need to talk about, is the origin of the pain in migraine. It is very important to know where the pain in the migraine originates. Because when we talk about neurologists, of course, they call migraine a brain disorder. So this is both right, and not right. Right, but not incomplete. Yes, migraine is a brain disorder, but the question is, if the pain part of the migraine originates from the brain, then goes to the periphery, or originate from the periphery, then goes to the brain, or both. That is the key question that we need to answer.
Dr. Lowenstein: The chicken or the egg.
Dr. Ansari: Yeah, exactly. Which nobody will be able to answer. Exactly, this is chicken or the egg. Nobody is going to answer this because it’s very clear that both, and actually, if you look at a lot of new literature by very giant headache experts, in the article that they published, multiple articles that they published, they are telling, yes, the pain is peripheral. The pain in the migraine is more peripheral. And even, then you, and I’m going to call and talk about which we discussed last time, this anti-seizure medication, those medications does not even pass the blood brain barrier. So that doesn’t even work inside the brain. So how those medications help headaches? Because they work in the peripheral. And that’s why we, or at least I, think the pain part of the migraine has more peripheral physiology, rather than central. But migraine is brain disorder, because migraine not just headache. Your audience can go to other first…
Dr. Lowenstein: Our first discussion topic.
Dr. Ansari: Yeah, exactly. Because migraine is not just headache, and not every headache is a migraine. But when we talk about the migraine, headache part of the migraine most likely originate from the peripheral. And another simple, and clear example, or reason that I’m talking about this, is nerve block, which I do every day in my [inaudible 00:19:19] and most of the headache physician does. So if the pain originates purely from the brain, why even the patient with the migraine, particularly at the beginning of their [inaudible 00:19:30], and we do nerve block, which is purely peripheral procedure, right? It is completely [inaudible 00:19:35]. Even think about this orical, or temporal nerve, which you operate all the time, is superficial, right?
Dr. Lowenstein: Absolutely, right.
Dr. Ansari: So you block that nerve, superficial orical or temporal, and patient pain completely subsides in ten minutes, why?
Dr. Lowenstein: And I’m kind of jumping ahead to some degree, but it’s one of the things that I struggle with is, when people hear about migraine surgery, they think it’s brain surgery, and it’s not. What migraine surgery does is, it operates on peripheral nerves, and it’s outpatient, and it’s just a couple of hours, and it’s not brain surgery. Because what we’re treating is not the central portion of the migraine. We’re treating the beginnings, the triggers that cause the pain, like you said.
Dr. Ansari: Exactly. And sometimes it’s not even a couple of hours for this orical or temporal-
Dr. Lowenstein: Yeah that’s ten minutes.
Dr. Ansari: Actually ten minutes, exactly, it’s literally ten minutes by the time you are finished. So yes, it’s not brain surgery. Basically what a migraine surgeon does, does the block, the nerve permanently. So rather than doing repeated block, I have the patient, I think last time you mentioned, come every two weeks to do the nerve block, for years. So in that patient, rather than patient come every two weeks and put this needle in their head and inject, and numb the nerve, you basically permanently block the nerve. Either with the compression, and in one of the nerve, which is zygomaticotemporal nerve with evulsion of the nerve. So that is very simple concept, and again I really don’t know why some people really struggle or try to question this very, very easy concept.
Dr. Ansari: Even if you look at the old headache, I like the history of the headache and there’s a very, very old physician in Iran, [inaudible 00:21:46] he’s very famous actually, he has a book. And if you look at his book, it’s very interesting, the way that he treats or the headache patient sometime, he put the tight band in the area of the head and tied it exactly in the area that is nerve[inaudible 00:22:04]. If you look at his book, the picture he has in his book, it’s very interesting how he does the same thing that we do now with the nerve block and you do with the compression surgery.
Dr. Lowenstein: Interesting.
Dr. Ansari: So that is nothing, so rather than do chemical nerve block, which we do in office, you’re doing mechanical nerve block, is that right?
Dr. Lowenstein: Well, yes and no. I think that when we are dividing or evulsing the nerve, then we are doing a permanent nerve block. When we’re decompressing the nerve, we are taking away an irritant, right? So the question is, why are you having the head pain? Well you’re having the head pain because the peripheral nerve is sending distress signals to the brain. And so when you do a nerve block, we’re chemically stopping those distress signals. When we cut the nerve, we are mechanically stopping those distress signals. And when we decompress the nerve we are preventing the surrounding structures from putting pressure on the nerve that makes those distress signals. So when we decompress the nerve, the nerve’s still in tact. So ideally you still have feeling in the area of the nerve. And again, all of these nerves are sensory nerves, they’re not motory nerves, so the occipital nerves provide sensation to your scalp. So when you touch the back of your head, your occipital nerve branches are picking up the feelings of you touching the back of your head and sending it to your brain.
Dr. Lowenstein: When we do a nerve block or cut the nerve, then you don’t feel that you’re touching your scalp, because the nerve is not able to send that signal. When we decompress the nerve, the nerve stays in tact, so once the healing is done you still feel in that area, but because there’s nothing pushing on the nerve to cause distress, then the distress signals don’t exist and the pain is not there.
Dr. Ansari: Exactly, that’s why I’m calling is kind of block, right? I mean you basically blocking the nerve from having distress from outside muscle or arteries or vessels.
Dr. Lowenstein: Correct.
Dr. Ansari: Even in one of the nerve, which is auriculotemporal, now you’re cauterizing the artery, you’re not even doing any decompression. All you do is cauterize the artery which that pulsation of the artery in the nerve stops, so basically you are permanently blocking that nerve by pulsation of the arteries.
Dr. Lowenstein: And that’s for patients who a lot of times have pulsating pain in their temples, but Dr. Ansari’s talking about the auriculotemporal nerve which goes right along the temporal artery right in front of the ear, and is actually just below the skin. And in a lot of people you can just feel your pulse in front of your ear, and you get a nerve that’s right there as well. So that pulsation pushes on the nerve, causes a distress signal to be sent to your brain every time your heart beats, and you get this pulsating pain and that’s really easy to fix.
Dr. Ansari: Yes. Okay. So going back to the surgery, right? Your question is when we do surgery, or..[crosstalk 00:25:38]
Dr. Lowenstein: So who do you recommend surgery for?
Dr. Ansari: Okay. So let’s be very clear. So migraine treatment still is the medical treatment, so that is no question, because the majority of the patient will responds to the medical treatment. First of all, the surgery is kind of prophylactic treatment, again if your audience can go back to our second podcast, we talk about the abortive versus preventive. So if the patient does not need to be in preventive, in that mean patient get one headache per week responds to the Tripton, so he doesn’t need to be on any preventive treatment including surgical intervention.
Dr. Lowenstein: Right.
Dr. Ansari: And so that percentage of the patient that needs to be on preventive but cannot tolerate the preventive or preventive treatment does not respond in them, those are the people that we can consider surgical intervention. When we talk about the consider, that mean, not all of the patient that does not responds with the medical treatment will be surgical candidate. From that patient, also small percentage will be candidate for surgical intervention. So who is that small percentage?
Dr. Ansari: So number one is the diagnosis needs to be clear. Make sure there is no other contributing factor or comorbid factor, playing a role in the patient’s headache and migraine. And the main contributing factor that you as a surgeon, and all of the surgeon colleagues need to be aware of that is medication overuse headache which still biggest problem in the headache medicine. And so this is something that we have to make sure that patient does not have medication over headache before doing any surgical intervention for multiple reason.
Dr. Ansari: Number one, if patient is medication over use headache, very, very unlikely procedure even if done correctly, in the correct nerve, won’t be successful. Because medication overuse headache is the different animal. It’s not simple headache, this is basically type of the headache that affect the brain. Medication overuse headache is the headache that originate from the brain. This is different than migraine which we talk about that, and I think pain of the migraine is peripheral, but the pain in the medication overuse headache is purely central, and you cannot fix the centrally originated pain by interacting in the peripheral level.
Dr. Lowenstein: So can I ask you, if you have a patient with a medication overuse headache, can an occipital nerve block work sometimes?
Dr. Ansari: Sometime it work, but that doesn’t mean anything, because that patient with medication overuse headache probably has underlying migraine or some other headache disorder, right?
Dr. Lowenstein: Mm-hmm (affirmative)-
Dr. Ansari: So you’re treating for a short-term you might treat that underlying headache and patient might get better. Plus, remember every time you do any injection you have a very high rate of [inaudible 00:29:13] response, particularly in the patient or chronic pain.
Dr. Lowenstein: Okay.
Dr. Ansari: So that’s why I always emphasize even two weeks ago during the migraine surgery course, my talk was about the medication overuse headache and importance of that, because that is biggest issue that we have in the headache medicine. Let’s actually ask you maybe if it be interesting for your audience. Also, what do you think the percentage of the medication overuse headache in headache clinics? What percentage of the patient that come to the headache clinic had medication overuse headache?
Dr. Lowenstein: I’m going to say 25%.
Dr. Ansari: Okay, so in the [inaudible 00:29:59] Headache Center, and this is actually published, in the [inaudible 00:30:02] Headache Center, 50-80% of the patient that is seen in the clinic, have medication overuse headache and in my clinic in San Diego, I’m towards 80% [inaudible 00:30:13] sure.
Dr. Lowenstein: Wow. I remember you telling me that in I guess our first podcast, that Excedrin was evil, was not a good thing for headache..
Dr. Ansari: Excedrin and there is of course, opioid and the medication that we hate, called Fioricet.
Dr. Lowenstein: Yep.
Dr. Ansari: And that is the medication that is extremely overused, and that’s a problem. Opioid also even this year 2018, day talk show, opioid prescription increased for headache patient and this is something that Dr. [inaudible 00:30:50] and I, and the American Headache Society [inaudible 00:30:52] a few months ago presented and there is also online webcast that he has, and he talk about that. So that is very unfortunate that we have this issue, and again everybody needs to be careful and your audience, if they are taking opioid for the headache or Fioricet for the headache, or Excedrin for the headache needs to be really careful because the chance that they have medication overuse headache is very high. And when you have medication overuse headache the part of physiology of the headache shift from peripheral to central, and that would be extremely difficult to treat.
Dr. Lowenstein: Okay. So let me ask you, how many patients would you say, have you referred for migraine surgery?
Dr. Ansari: So, it’s hard to tell the number, but I can’t tell, maybe 1% of the patient that I see.
Dr. Lowenstein: Okay, 1 %.
Dr. Ansari: So that percentage is that small, because as I mentioned, most of the patient responds to the treatment good. Although, I have to tell that one of the reason that maybe percentage is a little bit smaller, because of the financial problem, because this is not approved by insurance. Insurance doesn’t cover, and not all of the patient have financial, basically ability to go for this procedure. So if financial problem was not there, maybe that percentage can go to 5% also.
Dr. Lowenstein: So potentially 5% of patients would be candidates, but 1% of patients actually go through with it. And you’re preaching to the choir here, that we deal with insurance companies all the time, and it’s unfortunate. Do you think that’s going to change as far as the insurance companies?
Dr. Ansari: I doubt it.
Dr. Lowenstein: Really?
Dr. Ansari: Yes.
Dr. Lowenstein: So is that from, in general, I would say the surgical community is optimistic, so that’s an interesting..
Dr. Ansari: No that’s not going to happen, and the reason of that is more political, so we cannot discuss here out loud, but I will tell you later why this is not going to happen.
Dr. Lowenstein: Okay, all right. So, I guess, do you think, we see referrals from people at your level for surgery, because you’re truly a headache specialist and very familiar with the surgery. Tell me, why do you think, it seems to me that there are many less referrals than there should be from general neurologists, and I can tell you personally, that I’ve talked to neurologists in the past, I’ve even spoken to a couple of headache specialists in the past and told them about what I do, and they’re answer was, well, it doesn’t work. And my response to that is, you know, hey, that’s interesting and can you please get me the studies that you’re siting for the fact that this doesn’t work. And they’ll go, “Well you know, I don’t really have studies, I just know it doesn’t work.” And then I say, “Well if you don’t mind, I have this huge stack of studies that says it does work, if you’d like to review it.”
Dr. Lowenstein: And so I’m not sure if it’s just people are not aware of the surgery, of the success, or if there’s some kind of medical versus surgical bias against people referring for surgery, or I mean, I guess I’m interested in your thoughts about the kind of the thoughts of the medical community in general about this.
Dr. Ansari: Yes, one of the main reason is lack of knowledge about this procedure. So a lot of people doesn’t even know about it at all, neurologists. I mean I talk to different neurologists, they don’t even know that such a thing exist. And then, even when you talk to them or they basically superficially look at that, they think, oh it’s a brain surgery, they don’t even go..
Dr. Lowenstein: Right, right.
Dr. Ansari: It’s not even brain surgery.
Dr. Lowenstein: Yeah.
Dr. Ansari: So that is other thing. And the third thing is, this part of physiology part that we discussed today, peripheral versus central. There’s still, I think a majority of neurologists believe that the migraine is a purely central phenomenon and disease, and they think migraine is purely brain disease. And that’s why they think and they believe that something that’s purely central and from the brain doing any procedure in the peripheral does not work. Although, when I talk to those neurologists, say so why you do nerve block? Do you think you’re injecting inside the brain. And I say, well, no. So there’s no answer obviously, right?
Dr. Lowenstein: So why do you think, what is the thought, I mean I think I understand why Botox works, but when you talk to your neurologists, what do they think that Botox is doing to..
Dr. Ansari: There’s a true theory to the Botox. One is a central theory, and one is peripheral, but what is approved is peripheral, because the way that if FDA approved Botox, say intramuscular injection, so when you inject in the muscle, Botox works in neuromuscular junction. That’s all we know about the Botox. Rest of them is theory. And just shown in animal and mainly in the rat, that might have some central effect. So in the human, it does not show that have any central affect.
Dr. Ansari: Plus, again, it’s approved for intramuscular injection, until another study done and they inject the Botox around the nerve or subcu, which now some of the headache expert believe that and does that. And we talk about the headache expert say, “Oh no, we are not injecting the muscle, we are injecting in the nerve or around the nerve.” But it’s not FDA approved. FDA approved as intramuscular injection and Botox intramuscular works, in no muscular junction which is purely peripheral part of physiology.
Dr. Lowenstein: So, and just to again, from my perspective what you have is, Botox prevents the muscles from contracting around the nerves, which prevents the distress signals from going through the nerve to the brain causing the pain. So for me, if you have success with Botox, than it’s quite likely that you’re going to have success with surgery, because what I’m doing is mechanically preventing the muscles from irritating the nerves, as opposed to the Botox which chemically prevents the muscles from squeezing on the nerves.
Dr. Ansari: Yes, exactly. You’re doing basically the same thing that the Botox does but as a permanent, rather than do every three months. And in fact, in the initial study that Dr. [inaudible 00:38:52] did, he selected the patient based on the response to the Botox. Although, that’s not the case now, we know we use, what we call the consolation of the symptom to select the patient for surgery, not the Botox. But the original study that he did, he used the Botox for patient selection. And even now, we know the patient responds to the Botox has better chance to respond to surgery, because what you exactly do in the surgery is like what exactly Botox does chemically.
Dr. Lowenstein: Except that my argument for some of that is, I have colleagues that still use Botox as a screening technique and you have to respond to Botox before they’ll operate. And my issue with that is, particularly in the front when you have the supraorbitale and supratrochlear nerves that are causing headaches that are happening in the front, and you can put Botox there and prevent the muscles from squeezing on those nerves. But if it’s the bone that’s squeezing on those nerves or blood vessels and similarly in the occipital area you have the occipital artery, which is very often the problem crossing the occipital nerve, the Botox is not necessarily going to affect non-muscle things like fascia, bone, or blood vessels. And so even if you don’t respond to Botox, I don’t think that means that you’re not a surgical candidate. I’ve had great success in patients who’ve not responded to Botox, but have had great success with decompression surgery.
Dr. Ansari: Absolutely, that’s why there’s no more, we are doing the Botox screening.
Dr. Lowenstein: Yeah.
Dr. Ansari: So if patient had response to Botox, I say good, but does not have a response to Botox that doesn’t mean that they won’t response with the surgery.
Dr. Lowenstein: Yeah, that’s important.
Dr. Ansari: And beside the point that you mentioned about the vessel, bone, there is even muscle, the contractions on muscle pressure on the nerve, might not respond to the Botox. And the simple example that I going to give to you in the patient who had cervicogenic migraine, the one that in the back of the head. So the way that preempt trial or FDA approved Botox treatment for the migraine approved, they use 0.5 inch needle in the area, all of the area.
Dr. Lowenstein: Yeah.
Dr. Ansari: So as a surgeon, you know if you use 0.5 inch needle in the occipital area, which we need to target semispinalis capitis muscle, correct?
Dr. Lowenstein: Right, much deeper.
Dr. Ansari: In what percentage of the time, would 0.5 inch needle you can target that muscle. I’m asking you as a surgeon.
Dr. Lowenstein: Yeah, only very, very thin likely women, who very, very few. That muscle is quite deep, and you’re going to, you know when I do a nerve block, I use an inch and a half needle, and so I hadn’t realized that the needle was only a half an inch needle.
Dr. Ansari: Yes, actually published a study a few years ago, in the [inaudible 00:42:26] you can see and we actually looked at the BMI and we showed that the CT scan, you know with the half inch needle the chance that you reach that muscle, it’s almost zero. That basically, that patient had occipital basically headache, migraine from the compression of the occipital nerve by semispinalis capitis, right?
Dr. Lowenstein: Yep.
Dr. Ansari: And that patient getting Botox by preempt trial, is not going to respond. So that mean that doesn’t respond to surgery? Absolutely not, that case is perfect case for surgery because compression point in the semispinalis capitis, as you know is one of the biggest trigger for the migraine. So that patient greatly responds. That’s why the Botox selection it’s out now, and we don’t use that, we use the [inaudible 00:43:15] of the symptom, which is the best way to select the patient for surgery.
Dr. Lowenstein: I go through a lot of education about kind of diagnostic versus therapeutic nerve blocks. But everybody that I operate on, I actually like to do the nerve blocks myself, and prove that we can, with a little bit of Lidocaine, I can improve the pain. And that’s my screening for knowing that I can make the patient better with surgery, but that’s a little different than therapeutic nerve blocks that headache specialists or other neurologists might do on a chronic basis of just keep on trying to break the pain cycle and treat things in that manner.
Dr. Lowenstein: So let me ask you one less question here. Do you think, you’re pessimistic about insurance accepting this. Are you as pessimistic at the general neurology and medical community becoming more accepting of it?
Dr. Ansari: Yes, I think. And is unfortunate, but I think that could be very difficult. And again mainly for political reasons that you cannot talk here.
Dr. Lowenstein: So you think that’s it’s also going to be difficult to get the medical community to accept surgery?
Dr. Ansari: Yes. That’s why the best way to just educate the patient, and so the patient at least know this procedure is an option in the small percentage of the patients. And so then they see the right surgeon, and the right headache specialist that can screen and make sure that the patient is candidate and go from there.
Dr. Ansari: I think they way that you’re doing, I think the best way, because you’re educating the patient. They need to know there is option, and also they need to know that this option is not for every body. And also, they need to know that they need to see the headache expert who at least open to this procedure or at least agree that might be helpful and then go from there. Unfortunately, not much of the headache expert of my colleague agree to this. But again I see the success and I can tell you for sure my happiest patient are the patient that had migraine surgery. Every year I get the New Year’s card from some of my patient from Ohio, and they send me New Year’s card and Christmas card and they thanks me after years and years. But I never get any thank you card or card from the patient that I treat with medicine, although they got better.
Dr. Lowenstein: Well as I’ve said before, I mean it’s the most gratifying part of my practice. Even yesterday, I had a patient I operated on that had migraine, and she had the whole spectrum, including dizziness and imbalance and she used to use a walker. And when I first saw her, she would hold on to the wall to come in. She sent me yesterday, a picture, a video from her school, from her son’s school, they had a whole obstacle course here and she did the whole tire thing like you do when you’re practicing for football. You know you go one foot into one tire, and running through this whole thing. And then the whole obstacle course, and you know a thank you with it, and it’s just the best. It’s really..
Dr. Ansari: A good feeling, huh?
Dr. Lowenstein: Really, really wonderful. Well doctor, I’m sorry again, thank you very, very much. I do want to say that our last episode, prior to this of this podcast, I posted an interview where I was on somebody else’s podcast that goes into the details of migraine surgery, and nerve decompression surgery, so if you’re kind of interested in hearing..
Dr. Ansari: Sure.
Dr. Lowenstein: The surgical perspective and how it’s done, and what kinds of things to expect, than please listen to the previous podcast. But doctor, I’m sorry, this is our third podcast together, and I have to tell you that they’re the most educational and I really, really appreciate your interest and your help in educating the public and everything you do. So thank you very, very much.
Dr. Ansari: Thank you very much for having me again, and have a great day.
Dr. Lowenstein: All right. Thanks and hopefully we’ll talk again soon about yet another interesting topic related to migraines.
Dr. Ansari: Yes, I mean I think the next topic that we need to focus, would be the idea of the sinus headache. So that is something that I see a lot of misunderstanding in general population and even the physician, so we can certainly talk about that. And that would be interesting because that’s also related to the surgery. One of the trigger point is nose and the migraine as you know.
Dr. Lowenstein: Right. Well that’s great.
Dr. Ansari: So we certainly can talk about that.
Dr. Lowenstein: All right, we’ll put that on the schedule. Great, thanks very much.
Dr. Ansari: Sure. Thank you. Mm-hmm (affirmative)-
Dr. 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 suffers is to please remember to subscribe and rate our podcast. The more ratings and subscriptions that we get, the more visibility that we’ll get, and the more listeners will be able to find us, the more help and information will be able to provide the huge population of people that suffer from headache pain.
Dr. Lowenstein: 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 in this podcast and elsewhere that you hear on the internet to broaden your knowledge, but consult with your physician before acting on any information that you hear on podcasts or see on YouTube, or read anywhere on the internet.
Dr. Lowenstein: I as a physician, don’t necessarily endorse the opinions or practices of my guests, and if you have particular questions that you’d like to consult with me directly about, please call our headache surgery center. Our phone number is 805-969-9004. Or you can email us at and my staff will set up a consultation and we can discuss your specific case over the phone or in person. Our website is filled with information as well, and that is
Dr. Lowenstein: Thanks and best wishes from all of us here at the Headache 360 podcast.

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