Headache 360 – The Pressure Within

00:03 — Announcer:

Welcome to the Headache 360 Podcast, a place to listen and learn about the diagnosis and treatment of chronic headache and migraine pain, because information can be the best medicine.

00:20 — Dr. Lowenstein:

Well, this is Dr. Lowenstein, and welcome to the podcast. Today, I thought I would provide a little insight into my new book, which I think everybody should be aware of by now. But if you’re new to the podcast, I wrote a book called Headache Surgery: Understanding a Path Forward.

The purpose of this book is to provide information to patients about what headache surgery is, how it works, and why it works—primarily why it works, because I think that is an area of misunderstanding—but also why you’re not hearing about it from other people and things like that.

01:07 — Dr. Lowenstein:

It covers all of those things. There are a couple of headache surgery books, but they are meant for doctors and focus on how to perform the surgery. This is really the only patient-facing book out there, meaning that it is for patients to understand these things. I hope you all get some good education from it.

I thought I would read Chapter Five.

01:35 — Dr. Lowenstein:

This is called “The Pressure: Understanding Headaches and Nerve Pain.” It provides a little understanding of what causes a lot of headaches.

For some background, this book also incorporates my own personal history, so this chapter includes a little bit about me and my history with headaches. It starts with a quote from Sigmund Freud: “I am once more overcome by the feeling of my head being split apart.”

02:08 — Dr. Lowenstein:

Sigmund Freud experienced chronic migraines throughout his life. His migraines were intense and debilitating, with symptoms of severe pain, nausea, and sensitivity to light.

The chapter goes as follows:

Before I could specialize in pediatric or plastic surgery, I had to establish a foundation in general surgery, a highly competitive field with limited residency spots. Success in this journey required more than academic excellence. It demanded critical thinking.

02:41 — Dr. Lowenstein:

It also demanded the ability to build meaningful patient relationships. The path to securing a top residency position meant proving my capabilities both in the classroom and through real-life decision-making.

During a cardiology rotation, critical thinking was once demonstrated to me through humor. A top-ranked student fell for a cardiologist’s joke about inserting an IV into the optic vein behind the eye—an absurd approach that would never actually be performed.

03:11 — Dr. Lowenstein:

After failing to place an IV in a patient’s arm, she prepared to try this technique, but I intervened in time to prevent a serious mistake. The incident highlighted how essential sound judgment is in medicine, beyond what can be taught in textbooks or classrooms.

Throughout medical school, I dealt with significant headaches at least twice a week but pushed through, driven by my passion for becoming a doctor. I eventually secured a residency in a rigorous five-year general surgery program at Jefferson University in Philadelphia. Those years were marked by relentless stress, intense training, and unyielding pain.

03:51 — Dr. Lowenstein:

Reflecting on that time, I’m amazed I endured it. I often found myself rubbing my neck or temples, seeking a small measure of relief from the severe pain that had become a constant companion.

The next heading is “Why We Rub Our Temples, Foreheads, and Necks: Nerves and Headache Pain.”

Rubbing areas where sensory nerves run is common during headaches because many headaches are linked to irritation of these nerves.

04:21 — Dr. Lowenstein:

Applying pressure can reduce distress signals sent to the brain by temporarily limiting nerve function.

Typical spots people rub, such as the temples, above the eyes, or the back of the neck, align with the locations of peripheral sensory nerves involved in headache pain. These nerves lie close to the skin and aren’t part of the brain or spinal cord, making them accessible for relief through pressure and relatively easy to access during outpatient nerve surgery.

At the front of the head, four key nerves—the supraorbital, supratrochlear, zygomaticotemporal, and auriculotemporal nerves—are commonly associated with headaches. The supraorbital and supratrochlear nerves, branches of the frontal division of the trigeminal nerve, provide sensation to the forehead and front of the scalp.

05:04 — Dr. Lowenstein:

These nerves contribute to headaches, including migraines with pain concentrated in the forehead and behind the eyes.

The trigeminal nerve is a large sensory nerve that emerges from the trigeminal ganglion at the base of the skull and divides into three branches: the frontal, maxillary, and mandibular branches. Each branch further subdivides to serve the upper, middle, and lower face.

Trigeminal neuralgia, which is a painful condition, arises from irritation at the ganglion, while neuralgia of the branches can result in headaches. Compression or irritation of the supraorbital and supratrochlear nerves can occur in various ways.

05:46 — Dr. Lowenstein:

These nerves pass through a notch or tunnel in the upper orbital bone, which is at the top of the eye socket, and at the orbital rim, which you can feel with your fingers between your eye and eyebrow.

At the orbital rim, tight connective tissue or narrow bone structures may compress the nerves. Each nerve is accompanied by an artery and vein, which can push against the nerve and cause irritation.

I should note here that there are diagrams and pictures in the book, but it is hard to read a diagram or picture aloud. Anyway, I’ll go on.

06:23 — Dr. Lowenstein:

Another spot where these nerves can become compressed and irritated is the band of muscle that lies above the orbital rim, behind the eyebrow. These nerves travel through this muscle on their way to providing sensation to the forehead.

This muscle is called the corrugator muscle and is responsible for frown lines on the forehead. It is targeted by Botox in cosmetic procedures when patients are seeking to prevent the “elevens,” which are the wrinkles that form in the center of the forehead when these muscles contract.

“Botox and Migraines: How Muscle Relaxation Eases Nerve Compression.”

07:02 — Dr. Lowenstein:

Botox is a paralytic, meaning the muscles where it is injected tend to relax and stop contracting. By paralyzing the corrugator muscle, the patient is unable to create the frown lines associated with the contraction of this muscle.

Some patients are treated with Botox for their headaches, and with an understanding of anatomy, we can see how this works. In some patients, the corrugator muscle compresses the supraorbital and/or supratrochlear nerves as they pass through the muscle. This compression irritates the nerves.

07:33 — Dr. Lowenstein:

By applying Botox to the corrugator muscle in these patients, the muscle is made to relax and the compression no longer occurs. Without compression, the nerves do not transmit distress signals to the brain, and the cascade of events associated with migraine pain does not happen. The migraine is relieved.

As we said, irritation of these nerves is known as supraorbital neuralgia, supratrochlear neuralgia, and sometimes supraorbital syndrome. This irritation is associated with many different headache diagnoses.

08:04 — Dr. Lowenstein:

Again, we know this because many patients with pain from migraines, new daily persistent headaches, cluster headaches, and other diagnoses whose headache pain is in the front respond to nerve blocks of the supraorbital and supratrochlear nerves.

Botox often helps these people, but in cases where the compression is due to fascia, bone, or blood vessels rather than muscle, Botox will not have any effect. In these patients, the muscle is not the culprit compressing the nerve.

Regardless of what structure is causing nerve irritation, a nerve block shuts down the nerve, providing numbness in the forehead and often complete relief from the headache pain. If this happens, the patient is a good candidate for headache surgery, even if Botox has not been effective.

08:51 — Dr. Lowenstein:

The zygomaticotemporal nerve and the auriculotemporal nerve in the temporal region can also contribute to headache pain, though they provide feeling to only small areas of the scalp.

It can be hard to localize the small area of numbness that a nerve block creates here, but significant relief from headache pain can occur when these nerves are blocked in corresponding patients. These nerves can be irritated by muscle compression, accompanying blood vessels, or muscles.

When you are rubbing your temples, it may be because these nerves are getting your attention.

We’ve already discussed the anatomy of the greater occipital nerve in previous chapters. It originates in the nerve roots of the upper spinal cord and travels through significant amounts of muscle—the semispinalis and trapezius—before ascending to the scalp to provide sensation to the skin at the back of the head.

09:41 — Dr. Lowenstein:

This nerve has many areas where compression commonly causes irritation.

“How Muscle Tension and Scar Tissue Cause Headache Pain.”

Tight muscles are often the culprit in occipital nerve irritation, as we have seen in tension-type headaches or other headache diagnoses associated with stress.

Bands of scar tissue or fascia can also be present and compress the greater occipital nerve within or around the muscles through which the nerve travels. This is particularly common in patients with previous injuries, such as whiplash.

10:13 — Dr. Lowenstein:

These muscles fight to stabilize the head during a whiplash injury, and small tears in the muscles at the time of the injury can heal as scar tissue, creating nerve compression and irritation.

“Blood Vessel Compression: The Pounding Headache.”

As the greater occipital nerve emerges from the muscle, the occipital artery crosses the nerve toward the base of the skull. This artery can lie on top of the nerve or even split around the nerve, creating a lasso of artery around the greater occipital nerve.

In patients where this artery is compressing the nerve, we often find symptoms of a pounding headache.

10:48 — Dr. Lowenstein:

In these patients, each heartbeat provides a pressure wave that causes a momentary expansion of the artery, pushing directly down on the nerve.

This situation can also occur when an artery compresses the supraorbital, supratrochlear, or temporal nerves. Pounding pain in the forehead, behind the eyes, or in the temple is often explained by this phenomenon.

“The Hidden Triggers of Head Pain in the Back of the Head.”

Another culprit that sometimes compresses the greater occipital nerve is a lymph node.

11:22 — Dr. Lowenstein:

Lymph nodes are tiny glands throughout the body that are home to important immune cells. With inflammation or infection, these lymph nodes can enlarge. When inflamed nodes are found at the back of the neck or the base of the scalp, they can push on a nearby nerve.

Patients with a history of illness, either acute or chronic, can have long-term enlargement of these lymph nodes, creating chronic headache conditions.

The smaller occipital nerves can also be culprits. Other nerves that innervate the back of the neck and scalp include the lesser occipital nerve and the third occipital nerve.

11:55 — Dr. Lowenstein:

Similar to other nerves, pain occurs when they are compressed, often by muscle tightness or scar tissue.

The third occipital nerve provides sensation to the small area at the center of the back of the head. This nerve arises from the upper spinal cord, just below the greater occipital nerve, and travels through often-tight muscles where compression can cause central posterior head pain.

The lesser occipital nerve runs along the side of the neck after it emerges from behind the sternocleidomastoid muscle. This muscle connects the mastoid process—the hard bone found behind the ear at the base of the skull—to the collarbone. It can be seen when turning your head as a long, thin muscle band in the neck.

12:40 — Dr. Lowenstein:

The lesser occipital nerve travels up with this muscle to the mastoid area to provide sensation there. It can be compressed by tight tissue near the mastoid process or by the muscle itself.

This nerve is a particular problem of mine, and I’m often rubbing the side of my neck below the back of my ear to try to relieve pain there.

“A Word About Rhinogenic Headaches.”

Rhinogenic headaches are related to other types of nerve compression syndromes. Nerves in the lining of the nose, when compressed, can cause headaches much like those discussed above.

13:14 — Dr. Lowenstein:

Particularly with a severely deviated nasal septum, when one part of the nasal lining is pushed against another part of the nose, the compression can cause localized neuralgia that can lead to headaches.

Rhinogenic headaches are usually felt in the sinus area, though they can radiate elsewhere in the head. Patients with these types of headaches should consult with a plastic surgeon or an ear, nose, and throat specialist who performs rhinoplasty and corrective surgery on the nasal structure. This can release the pressure in these areas.

Irritation of any of the nerves discussed above causes corresponding distress signals to be transmitted to the brain. Depending on how the brain processes signals from the supraorbital, supratrochlear, greater occipital, or other nerves—

14:00 — Dr. Lowenstein:

These chemical cascades are interpreted as headaches, nausea, dizziness, paralysis, and other symptoms that can be associated with various headache syndromes.

It is the way that each person’s brain interprets these distress signals that creates the specific symptoms each patient experiences.

As a headache surgeon, my goal is to address these nerves and eliminate the triggers of these headaches, preventing the symptoms before they even start.

That was Chapter Five, and I hope you found it helpful. The book is meant to educate people and patients about why their pain is happening and, just as importantly, how we can fix it.

14:45 — Dr. Lowenstein:

Again, it is called Headache Surgery: Understanding a Path Forward. I hope that was helpful.

Please send any feedback, and please like and subscribe, as usual. We’re here to continue helping people understand where their pain is coming from and how they can actually find some relief if they’re at the end of their rope.

15:16 — Dr. Lowenstein:

Again, it’s Dr. Lowenstein. Thanks very much for listening.

The more subscriptions we get, the more visibility we’ll receive, 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.

15:47 — Dr. Lowenstein:

The purpose of this podcast is not to give medical advice. Please use the information you hear here on this podcast and elsewhere on the internet to broaden your knowledge, but consult with your physician before acting on any information you hear on podcasts, see on YouTube, or read anywhere 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 would 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. My staff will set up a consultation, and we can discuss your specific case over the phone or in person.

Our website is also filled with information, and that is headachesurgery.com.

Thanks, and best wishes from all of us here at the Headache 360 Podcast.