Headache 360 – Procedures for Migraines and Headaches

Announcer [00:03]: Welcome to the Headache 360 Podcast, a place to listen and learn about the diagnosis and treatment of chronic headache and migraine pain.

Dr. Lowenstein [00:21]: Hello, and welcome to the Headache 360 Podcast. I’m your host, Dr. Adam Lowenstein, and today we are again speaking with headache specialist and neurologist Dr. Hossein Ansari from the University of California, San Diego. Dr. Ansari is a world expert on headaches. It’s a real pleasure to speak with him. While I’m one of the few surgeons around the country who specializes in migraine surgery, it’s a treat to get the perspective of a neurologist and headache specialist regarding procedures that surgeons such as myself perform. So thank you for being with us, Dr. Ansari. Thank you again.

Dr. Ansari [01:06]: Thank you very much, Dr. Lowenstein, for inviting me again. And again, hopefully we can educate your audience regarding headaches, migraines, and the different treatments that we have for them.

Dr. Lowenstein [01:20]: Yeah, so today I think let’s talk about procedures we can do for headaches, particularly migraines. To kick off, can you tell me what kinds of procedures you recommend for your patients?

Dr. Ansari [01:37]: Sure. For migraine, the only FDA-approved procedure is Botox treatment, and that’s for chronic migraine only. And so that is the treatment that we have been doing for over 10 years now, and we briefly talked about that during previous podcasts. And that’s a relatively easy procedure. Although getting 20 or 30 injections in the head sounds a little unpleasant, you’ll be surprised how much patients tolerate it because migraine itself is painful, and the treatment definitely helps. And the injection technique is a little different — I think we talked about that last time — a little different between what neurologists and non-neurologists do. But no matter what, it’s helpful, and it’s an FDA-approved treatment for chronic migraine. The other procedure is not approved, but almost all neurologists — or at least all headache specialists — do nerve blocks. We use different nerve blocks for migraine. The occipital nerve block is the one most non-headache neurologists use, but we also block other nerves, such as the auriculotemporal, zygomaticotemporal, and supraorbital and supratrochlear nerves. These treatments give patients short-term relief because we use a local anesthetic injection to numb the nerve, stop its firing, and stop the pain cycle of the migraine.

Dr. Lowenstein [03:30]: I also have patients who occasionally tell me that their neurologist added cortisone or some other steroid to the injection to help with inflammation. Do you do that as well, or do you use only local anesthetic?

Dr. Ansari [03:47]: First of all, steroid injection is only used for the occipital nerve. For other nerves, it’s not safe. As a plastic surgeon, you know that if you give steroid around the supraorbital nerve, for example, that can cause a lot of issues. But with the occipital nerve, sometimes adding steroid might increase the duration of relief. However, multiple neurology studies show that in migraine, adding steroid does not change anything. That’s why the only time we use steroid with an occipital nerve block is in a patient with cluster headache or another trigeminal autonomic cephalalgia, of which cluster headache is part of that family of headache disorders. I personally do not use steroid for migraine because I have found that it really doesn’t matter whether you use a steroid or not; the duration does not change.

Dr. Lowenstein [04:56]: When you’re talking about these different types of injections for migraines, as we’ve discussed on previous podcasts, there are lots of different headache diagnoses. Do you differentiate how you treat those with different procedures and different types of injections?

Dr. Ansari [05:16]: Absolutely. In the occipital area, there is a lot of controversy — or perhaps difficulty — around understanding the different types of headaches that can occur there. The most common pain in the occipital area, which is the back of the head, is migraine. We even call that cervicogenic migraine; there is a diagnostic code for it. But we also have a headache that can mimic cervicogenic migraine, and that’s cervicogenic headache. That is a totally different type of headache, although it can sometimes be very similar to migraine, particularly in terms of location. To diagnose cervicogenic headache, the injection needs to be done by a pain specialist or a neurologist trained in pain management, because this is the type of injection that needs to be done with either ultrasound or fluoroscopy, and it’s called a facet injection. If the patient responds to the facet injection, then the diagnosis of cervicogenic headache is confirmed. That’s a different kind of headache, and those patients can benefit from other procedures, including RFA procedure.

Dr. Lowenstein [06:43]: I’ve got a technical question for you. This is what I don’t understand. If you’re doing an occipital block with local anesthetic and you’re getting the greater occipital nerve, which is coming out of the C2–C3 area.

Dr. Ansari [07:04]: Sure.

Dr. Lowenstein [07:04]: If you block the facet 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 to the spinal cord for these blocks, aren’t you effectively also blocking what would be blocked if you did the greater occipital nerve? Right. So how can you distinguish that?

Dr. Ansari [07:47]: You do not, because with the facet you’re injecting one specific facet. When we talk about the occipital nerve, there is a lot of variation. Yes, the main roots are C2 and C3, but there are other areas of the spinal cord from which occipital nerves can originate. Plus, the other thing that is very important is the history. So when you see the patient with headache, based on the history, at least 90–95% you can differentiate between cervicogenic headache and cervicogenic migraine. That’s one. And the second thing, yes, in the patient with cervicogenic migraine, if you do facet block, you might get a response. The patient might get better, right? That’s your question.

Dr. Lowenstein [08:35]: Yeah.

Dr. Ansari [08:35]: But in cervicogenic headache, if you do occipital nerve block, the patient should not get better.

Dr. Lowenstein [08:42]: Okay, that’s what I’m saying. If, by definition, cervicogenic headache requires a successful facet block for diagnosis, it seems to me you should also require an unsuccessful occipital nerve block to isolate the problem being more central.

Dr. Ansari [09:07]: Yes, exactly. And actually the response to the facet block is part of the diagnostic criteria for cervicogenic headache based on International Headache Society classification.

Dr. Lowenstein [09:19]: My problem clinically is that I see people with these diagnoses who have not had all of these diagnostic procedures. Again, it seems to me that it’s important to get a diagnosis from somebody who’s very familiar with headaches, because misdiagnosis in my practice seems to be somewhat rampant, unfortunately.

Dr. Ansari [09:52]: Exactly. Let’s emphasize again that headache and migraine diagnoses are clinical diagnoses. More than 95% of the time, the distinction between cervicogenic migraine and cervicogenic headache can be made with a good history. Diagnostic blocks are for the small percentage of patients whose symptoms overlap significantly and for whom the diagnosis cannot be made clinically, so a diagnostic block is needed.

Dr. Lowenstein [10:24]: Okay.

Dr. Ansari [10:24]: But again, history, history, history is how we make the diagnosis of headache and migraine.

Dr. Lowenstein [10:31]: Okay.

Dr. Ansari [10:32]: Going back to the occipital area, there is a third kind of headache called occipital neuralgia. I’m sure you hear this from patients a lot, and we hear it all the time.

Dr. Lowenstein [10:43]: Yeah.

Dr. Ansari [10:44]: When we talk about neuralgia in general, neuralgia has a definition. It means sudden, severe pain with an abrupt onset and abrupt termination — kind of a jabbing, electric-shock pain. I usually explain to my patients, I’m sure you’ve hit your funny bone at some point and felt that shock-like pain. That is neuralgia.

Dr. Lowenstein [11:12]: Yeah.

Dr. Ansari [11:12]: When neuralgia occurs in the occipital area, that’s called occipital neuralgia. In clinical practice, I see many patients referred with that diagnosis, but when you take the history, the patient doesn’t describe neuralgic features. Plus, the pain is constant in the occipital area, so that’s not occipital neuralgia.

Dr. Lowenstein [11:35]: Now, can occipital neuralgia lead to chronic pain?

Dr. Ansari [11:40]: Yes. If you don’t treat occipital neuralgia, you still get those jabbing and jolting pains, and in between you can have a burning sensation or a dull pain. But again, distinguishing occipital neuralgia from cervicogenic migraine and cervicogenic headache should not be difficult clinically. Cervicogenic migraine and cervicogenic headache can sometimes be difficult to distinguish, as we discussed, but occipital neuralgia should generally be diagnosable clinically. One part of the diagnostic criteria for occipital neuralgia is an immediate response to an occipital nerve block.

Dr. Lowenstein [12:01]: Got it. Now, occipital or cervicogenic migraine will also respond to occipital nerve block, correct?

Dr. Ansari [12:31]: Cervicogenic migraine sometimes responds, yes. If a patient with cervicogenic migraine does not respond to an occipital nerve block, you cannot conclude that it isn’t cervicogenic migraine. But with occipital neuralgia, if the block does not work, then that’s not occipital neuralgia. You have ruled out that diagnosis because that’s part of the diagnostic criteria.

Dr. Lowenstein [12:57]: Okay. Okay.

Dr. Ansari [12:59]: This can be confusing: occipital neuralgia, cervicogenic headache, and cervicogenic migraine are not always clearly distinguished, even among some neurologists.

Dr. Lowenstein [13:11]: Right. I think that’s part of the problem — is 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, and it can be very, very frustrating trying to work through that, especially when your head hurts. I think that’s part of the broader problem with the complexity of headaches. Just so patients understand: you have your brain and spinal cord, and then nerve roots that lead to the spinal cord and then to the brain. Those nerve roots exit near the facet joints, so a facet block is targeting the nerve roots. Then you have nerve trunks that lead to the nerve roots, and nerve branches that lead to the nerve trunks. What we’re talking about is treating the system at different levels, either closer to the spinal cord or farther out. An occipital nerve block treats one of the nerve trunks of the greater occipital nerve, while a facet block treats the nerve roots closer to the spinal cord. That’s my little anatomy lesson for today. It’s a very complex subject, and we’re fortunate to have people like Dr. Ansari to help clarify it. From the perspective of a headache surgeon, Dr. Ansari, what’s your feeling about migraine surgery?

Dr. Ansari [15:13]: Sure. Before we talk about that, I forgot one other procedure: the sphenopalatine ganglion block. This is also an office-based procedure. The sphenopalatine ganglion is located toward the back of the nose. By placing a small amount of lidocaine through the nose in that area, we can sometimes block the nerve fibers coming from the ganglion. Although we call it a sphenopalatine ganglion block, the office-based procedure does not truly block the ganglion; it blocks the nerve fibers. There is also a sphenopalatine ganglion block performed with fluoroscopy, which is done by pain specialists. That’s different because they inject the sphenopalatine ganglion directly. The office procedure uses a special catheter. Two companies make these catheters, and we place a small amount of lidocaine through the nose. Because the device has FDA approval, it’s worth mentioning so your audience knows that procedure is also available. Now, going to the surgical part, this is of course a very controversial subject, and one thing we need to discuss at the beginning is the origin of migraine pain. It is very important to know where the pain in migraine originates because neurologists, of course, call migraine a brain disorder. That’s correct, but incomplete. Migraine is a brain disorder, but the question is whether the pain component originates in the brain and then goes to the periphery, originates in the periphery and then goes to the brain, or involves both. That’s the key question. It’s the chicken-or-the-egg question, which nobody can answer completely because it’s very clear that both mechanisms can be involved. If you look at newer literature from major headache experts, multiple articles suggest that the pain component is peripheral, or at least more peripheral. Even the newer monoclonal antibodies we discussed last time — the anti-CGRP medications — do not cross the blood-brain barrier. So how do they help headache? Because they work in the periphery. That’s why I think the pain component of migraine has more peripheral pathophysiology than central pathophysiology. But migraine is a brain disorder because migraine is not just headache. Your audience can go back to our first discussion — we said migraine is not just headache, and not every headache is migraine. But the headache component of migraine most likely originates in the periphery. Another clear example is the nerve block, which I perform every day in my clinic, and most headache physicians do. So if the pain originates purely from the brain, why, when a patient with migraine — particularly at the beginning of an attack — comes in and we do a nerve block, which is a purely peripheral procedure, does it help? It’s completely peripheral. Think about the auriculotemporal nerve, which you operate on all the time. It is a superficial nerve right below the skin, correct?

Dr. Lowenstein [19:42]: Right.

Dr. Ansari [19:43]: So you block that superficial auriculotemporal nerve, and the patient’s pain can completely subside within 10 minutes. Why?

Dr. Lowenstein [19:53]: I’m jumping ahead a little, but one thing I struggle with is that when people hear about migraine surgery, they think it’s brain surgery, and it’s not. Migraine surgery operates on peripheral nerves. It’s outpatient, usually a couple of hours, and it’s not brain surgery because what we’re treating is not the central portion of migraine. We’re treating the beginnings, the triggers that cause the pain, like you said.

Dr. Ansari [20:25]: Exactly. And sometimes it’s not even a couple of hours. For the auriculotemporal nerve, it’s actually 10 minutes — literally 10 minutes from start to finish. So yes, this is not brain surgery. Basically, what a migraine surgeon does is permanently address the nerve. Rather than doing repeated nerve blocks — for example, I have a patient who has come every two weeks for years — you can address the nerve surgically. Instead of the patient returning every two weeks to have a needle placed and the nerve numbed, you can permanently address the nerve, either with decompression or, for a nerve such as the zygomaticotemporal nerve, with avulsion. It’s a very simple concept, and I don’t understand why some people struggle with it so much. Even if you look at older headache literature, there is a famous physician from Iran, Avicenna. In his book, it’s very interesting to see how he treated headache patients. Sometimes he puts a tight band around the area of the head and ties it exactly over the painful nerve area. If you look at his book, the picture is very interesting because he is doing something similar to what we now do with a nerve block and what you do with decompression surgery.

Dr. Lowenstein [22:16]: Interesting.

Dr. Ansari [22:17]: So rather than doing a chemical nerve block, which we do in the office, you’re doing a mechanical nerve block. Is that right?

Dr. Lowenstein [22:27]: Well, yes and no. When we divide or avulse a nerve, then we are creating a permanent nerve block. When we decompress a nerve, we’re taking away an irritant. The question is: why are you having head pain? You’re having 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 in a way that creates those distress signals. When we decompress the nerve, the nerve stays intact. Ideally, you still have sensation in that area. And again, these are sensory nerves, not motor nerves, so the occipital nerves provide sensation to the scalp. When you touch the back of your head, branches of the occipital nerve pick up that sensation and send it to your brain. When we block or cut the nerve, 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 intact. Once healing is complete, you still have sensation in that area, but because nothing is pushing on the nerve and causing distress, those distress signals disappear and the pain is not there.

Dr. Ansari [24:19]: Exactly. That’s why I’m calling it a kind of block. You’re protecting the nerve from distress caused by surrounding muscle, arteries, or vessels. With the auriculotemporal nerve, for example, you’re cauterizing the artery rather than decompressing the nerve. The goal is to stop the artery’s pulsation against the nerve. In that sense, you’re permanently removing the pulsatile irritation of the nerve.

Dr. Lowenstein [24:53]: That’s often relevant for patients with pulsating pain in their temples. Dr. Ansari is talking about the auriculotemporal nerve, which runs next to the temporal artery in front of the ear and lies just beneath the skin. In many people, you can feel the pulse in front of the ear, and the nerve is right there as well. And 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 [25:29]: Yes. Going back to surgery, your question is: who do you recommend surgery for? Let’s be very clear. Medical treatment remains the primary treatment for migraine because the majority of patients will respond to medical treatment. Surgery is a type of preventive or prophylactic treatment. As we discussed in our second podcast, there is a difference between abortive and preventive treatment. If a patient does not need preventive treatment — for example, they get one headache per week that responds to a triptan — then they don’t need to be on any preventive treatment, including surgical intervention.

Dr. Lowenstein [26:21]: Right.

Dr. Ansari [26:22]: The patients we consider for surgery are those who need preventive treatment but cannot tolerate it or do not respond to it. Even among those patients, not everyone is a surgical candidate. Only a small percentage will be candidates for surgical intervention. So who is in that small percentage? First, the diagnosis needs to be clear. Make sure there is no other contributing or comorbid factor playing a role in the patient’s headache and migraine. One major contributing factor that surgeons need to be aware of is medication-overuse headache, which is still one of the biggest problems in headache medicine. We need to make sure the patient does not have medication-overuse headache before any surgical intervention, for several reasons. Number one, if the patient has medication-overuse headache, a procedure is very unlikely to be successful even if it is performed correctly on the correct nerve. Medication-overuse headache is different; it is not a simple headache. It affects the brain. Medication-overuse headache is a centrally mediated headache. This is different from migraine, where I think much of the pain component is peripheral. You cannot fix centrally originated pain by intervening in the peripheral level.

Dr. Lowenstein [28:39]: Can I ask: if you have a patient with medication-overuse headache, can an occipital nerve block sometimes work?

Dr. Ansari [28:50]: Sometimes it works, but that doesn’t necessarily tell you much because the patient with medication-overuse headache probably has an underlying migraine or another headache disorder. In the short term, you may be treating that underlying headache. Also remember that every injection can have a significant placebo response, particularly in a patient with chronic pain.

Dr. Lowenstein [29:16]: Okay.

Dr. Ansari [29:17]: That’s why I emphasize this so much. Even two weeks ago, during a migraine surgery course, my talk was about medication-overuse headache and its importance because it is one of the biggest issues in headache medicine. Let me ask you something that may be interesting for your audience: what percentage of patients who come to a headache clinic do you think have medication-overuse headache?

Dr. Lowenstein [29:54]: I’m going to say 25%.

Dr. Ansari [29:58]: In a tertiary headache center — and this has been published — 50% to 80% of patients seen in the clinic have medication-overuse headache. In my clinic in San Diego, I’m toward the 80% end, for sure.

Dr. Lowenstein [30:14]: Wow. I remember you telling me in our first podcast that Excedrin was basically evil for headaches.

Dr. Ansari [30:21]: Excedrin is not a good choice for frequent headache use. There are also opioids and the medication we especially dislike, Fioricet.

Dr. Lowenstein [30:31]: Yeah.

Dr. Ansari [30:31]: Fioricet is extremely overused, and that’s a problem. Opioids are also a problem. Even in 2018, data showed increased opioid prescribing for headache patients. This was discussed at the American Headache Society meeting in Philadelphia, and there is also an online webcast about it. It’s very unfortunate that we have this issue. Everyone needs to be careful. If your audience is taking opioids, Fioricet, or Excedrin for headache, they need to be very careful because the chance of medication-overuse headache is high. When medication-overuse headache develops, the pathophysiology shifts from peripheral to central, and it becomes extremely difficult to treat.

Dr. Lowenstein [31:33]: Okay. So let me ask you: about how many patients would you say you have referred for migraine surgery?

Dr. Ansari [31:47]: It’s hard to give an exact number, but maybe around one percent of the patients I see. The percentage is that small because most patients respond pretty well to treatment. One reason the percentage may be a little smaller is the financial issue, because insurance does not generally cover this procedure. Not all patients have the financial ability to undergo it. If that barrier were not there, maybe the percentage could go to around five percent or so.

Dr. Lowenstein [32:34]: So potentially five percent of patients might be candidates, but about one percent actually go through with it. You’re preaching to the choir here — 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 [32:57]: I doubt it. I doubt it.

Dr. Lowenstein [32:59]: Really?

Dr. Ansari [33:00]: Yes.

Dr. Lowenstein [33:01]: In general, I’d say the surgical community is optimistic.

Dr. Ansari [33:09]: No, I don’t think it’s going to happen, and the reason is more political. We can’t really discuss that here, but I’ll tell you later why I don’t think it will happen.

Dr. Lowenstein [33:22]: Okay. We do see referrals from people at your level because you’re truly a headache specialist and very familiar with the surgery. Why do you think there are fewer referrals than there should be from general neurologists? I’ve talked to neurologists and even a couple of headache specialists in the past and told them about what I do. Their answer was, ‘Well, it doesn’t work.’ My response is, ‘That’s interesting. Can you show me the studies you’re citing that say it doesn’t work?’ And they’ll say, ‘I don’t really have studies; I just know it doesn’t work.’ Then I say, ‘If you don’t mind, I have a large stack of studies showing that it does work, if you’d like to review them.’ So I’m not sure whether people simply aren’t aware of the surgery and its success, or whether there is some kind of medical-versus-surgical bias against referring for surgery. I’m interested in your thoughts about the medical community in general.

Dr. Ansari [35:10]: One of the main reasons is lack of knowledge about the procedure. A lot of neurologists simply don’t know that it exists. I talk to different neurologists, and some have never heard of it. Even when they hear about it or look at it superficially, they may think it’s brain surgery. It’s not brain surgery. The third issue is the pathophysiology we discussed today: peripheral versus central. I think a majority of neurologists still believe migraine is a purely central phenomenon — a brain disease — and therefore believe that a peripheral procedure should not work. But when I ask those neurologists, ‘Then why do you perform nerve blocks? Do you think you’re injecting inside the brain?’ there really isn’t an answer.

Dr. Lowenstein [36:29]: What do they think Botox is doing? I think I understand why Botox works, but when you talk to a neurologist, what do they think it is doing?

Dr. Ansari [36:42]: There are two theories for Botox. One is central and one is peripheral, but what is approved is peripheral because the FDA-approved use is intramuscular injection. When you inject into the muscle, Botox works at the neuromuscular junction. That’s all we know for sure about Botox. The rest is theory, mostly shown in animal studies, particularly rats, suggesting there may be some central effect. In humans, we have not demonstrated a central effect. Plus, the approved use is intramuscular injection until another study shows otherwise. Some headache experts inject Botox around nerves or subcutaneously, but that is not the FDA-approved method. The FDA-approved method is intramuscular injection, and Botox in the muscle works at the neuromuscular junction, which is a purely peripheral mechanism.

Dr. Lowenstein [37:55]: From my perspective, Botox prevents muscles from contracting around the nerves, which reduces the distress signals traveling through the nerve to the brain and causing pain. So if you have success with Botox, it’s quite likely you’ll have success with surgery, because I’m mechanically preventing the muscles from irritating the nerves, whereas Botox chemically prevents the muscles from squeezing on the nerves.

Dr. Ansari [38:37]: Yes, exactly. You’re basically doing the same thing Botox does, but more permanently rather than every three months. In the initial study by Dr. Guyuron, he selected patients based on their response to Botox. Although we no longer use Botox alone as the screening test, we now use the constellation of symptoms to select patients for surgery. The original study used Botox for patient selection. Even now, patients who respond to Botox may have a better chance of responding to surgery because the surgery addresses the same general mechanism more permanently.

Dr. Lowenstein [39:24]: My argument is that some colleagues still use Botox as a screening technique and require a response before they operate. My issue with that is that, particularly in the front, when you have the supraorbital 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 had great success with decompression surgery.

Dr. Ansari [40:42]: Absolutely. That’s why we no longer require Botox response as the screening criterion.

Dr. Lowenstein [40:48]: Yeah.

Dr. Ansari [40:48]: If a patient responds to Botox, that’s helpful information. But if they do not respond to Botox, that does not mean they won’t respond to surgery.

Dr. Lowenstein [40:56]: Yeah, and that’s it.

Dr. Ansari [40:57]: Besides the points you mentioned about blood vessels and bone, even muscle-related compression may not respond to Botox. A simple example is a patient with cervicogenic migraine from the back of the head. Under the PREEMPT protocol for migraine, the standard needle is 0.5 inches. In the occipital area, if we need to target the semispinalis capitis muscle —

Dr. Ansari [41:44]: — muscle, correct?

Dr. Lowenstein [41:45]: Right. Yeah.

Dr. Ansari [41:46]: What percentage of the time can a 0.5-inch needle actually reach that muscle? I’m asking you as a surgeon.

Dr. Lowenstein [41:54]: Only in very thin patients, and even then not very often. That muscle is quite deep. When I do a nerve block, I use an inch-and-a-half needle. I actually hadn’t realized that the standard needle was only half an inch.

Dr. Ansari [42:21]: We published a study on this a few years ago. We looked at BMI and CT scans and showed that with a half-inch needle, the chance of reaching that muscle is almost zero. So if a patient has occipital migraine pain from compression of the occipital nerve by semispinalis capitis, right?

Dr. Lowenstein [42:46]: Yeah, yeah.

Dr. Ansari [42:47]: If that patient receives Botox using the standard PREEMPT technique, they may not respond. Does that mean they won’t respond to surgery? Absolutely not. That can be an excellent surgical case because compression at the semispinalis capitis is a major migraine trigger point.

Dr. Lowenstein [43:06]: Right.

Dr. Ansari [43:06]: That patient may respond very well to surgery. That’s why Botox response is no longer used by itself to select patients; we use the constellation of symptoms.

Dr. Lowenstein [43:21]: I spend a lot of time educating patients about diagnostic versus therapeutic nerve blocks. Before I operate, I like to perform the diagnostic nerve blocks myself and show that a small amount of lidocaine can improve the pain. That’s my screening tool for knowing that I can make the patient better with surgery. That’s different from therapeutic nerve blocks that a headache specialist or neurologist may perform chronically to try to break the pain cycle. So let me ask one last question. You’re pessimistic about insurance accepting this. Are you equally pessimistic about the general neurology and medical community becoming more accepting of it?

Dr. Ansari [44:29]: Yes, I think so. It’s unfortunate, but I think that will be very difficult, again mainly for political reasons that we can’t really discuss here.

Dr. Lowenstein [44:29]: So you think it’s also going to be difficult to get the medical community to accept surgery?

Dr. Ansari [44:50]: Yes. That’s why the best approach is to educate patients so they know this procedure is an option for a small percentage of people, and then have them see the right surgeon and the right headache specialist who can screen them and make sure they are candidates. I think the approach you’re taking — educating patients — is the best way. They need to know there is an option, but also that it is not for everybody. They need to see a headache expert who is at least open to this procedure or at least agrees that it may be helpful, and then go from there. Unfortunately, not many headache experts or neurologists agree with this yet. But I have seen the success, and I can tell you that some of my happiest patients are the ones who have had migraine surgery. Every year I receive New Year’s or Christmas cards from some of those patients thanking me years later. I don’t usually get cards from patients I treat with medicine, even when they improve. So that’s my answer.

Dr. Lowenstein [46:23]: As I’ve said before, it’s the most gratifying part of my practice. Just yesterday, a patient I operated on — who had migraine with dizziness and imbalance and used to need a walker — sent me an update. When I first saw her, she had to hold onto the wall to come in. She sent me a video from her son’s school. They had an obstacle course, and she ran through the tire drill and completed the whole course. She sent it with a thank-you message, and it’s just the best. It’s a wonderful feeling. Dr. Ansari, thank you very much. I also want to mention that in the episode immediately before this one, I posted an interview where I was on somebody else’s podcast discussing the details of migraine surgery and nerve decompression surgery. If you’re interested in the surgical perspective — how it’s done and what to expect — then please listen to the previous podcast. Dr. Ansari, this is our third podcast together, and I have to tell you they are among the most educational episodes we’ve done. I really appreciate your interest and your help educating the public, and everything you do. Thank you very, very much.

Dr. Ansari [48:13]: Thank you very much for having me again, and have a great day.

Dr. Lowenstein [48:13]: All right. Thanks, and hopefully we’ll all talk again soon about yet another interesting topic related to migraine.

Dr. Ansari [48:13]: Yes. I think the next topic that we need to focus on will be the idea of sinus headache. That’s something I see a lot of misunderstanding about in the general population and even among physicians, so we can certainly talk about that. It would definitely be interesting because that’s also related to surgery; one of the trigger points is in the nose in migraine, as you know.

Dr. Lowenstein [48:35]: That’s great. We can certainly talk about that. All right, we’ll put that on the schedule.

Dr. Ansari [48:56]: Great. Thanks very much.

Dr. Lowenstein [48:56]: Thank you. Hey everybody, this is Dr. Lowenstein once again, and I have two last things to ask of you. First, the thing you can do for fellow headache sufferers is to please remember to subscribe to and rate our podcast. The more ratings and subscriptions we get, the more visibility we’ll get, and the more listeners will be able to find us, and the more help and information we’ll be able to provide to the huge population of people who suffer from headache pain. Secondly, please remember that the treatment of headaches of all types is very individualized. The purpose of this podcast is not to give medical advice, so please use the information here on this podcast and elsewhere on the internet to broaden your knowledge, but consult with your physician before acting on any information that you hear on podcasts, see on YouTube, or read anywhere on the internet. I, as a physician, don’t necessarily endorse the opinions or practices of my guests. If you have particular questions that you’d like to consult with me directly about, please call our Headache Surgery Center. Our phone number is 805-969-9004, or you can email us at info@headachesurgery.com, and my staff will set up a consultation, and we can discuss your specific case over the phone or in person. Our website is filled with information as well, and that is headachesurgery.com. Thanks, and best wishes from all of us here at the Headache 360 Podcast.