Published June 26, 2019 By Adam Lowenstein

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.

Hey, and welcome again to our podcast. I’m your host, Dr. Adam Lowenstein. And today, we are … Today, you just got me. We are going to do a listener questions session here where I want to talk about a question I got emailed to me at I appreciate that.

And the question goes like this: I have been listening … Starts out with hello, actually. It says, “I have been listening to your podcast and wanted to ask some questions relating to my condition. I’ve been having post-traumatic headaches since a concussion I had five months ago which caused me to take leave of absence from the military and school due to my constant pain. I feel as though I have 24/7 pain, that I haven’t had a day without since the injury.”

“My question is how do post-traumatic headaches differ from other types of headaches? Is the approach to treating them the same, of course, being that all of these persons MRIs and scans are clear. Finally, is the approach to continuous headache the same as, say, someone who has headaches half of the days of the month? Thanks so much for all of your information on the podcast.”

Well, so firstly, thanks for the kind words about the podcast. And I’m really glad that we’re helping. And I’m going to address this in a couple of different ways. Firstly, I want to say that there are whole centers that are dedicated to the treatment of post-traumatic headaches and post-traumatic brain injury. And so here again, every case is individualized. You really need to run things by your doctor.

But I want to give you some perspective from me in the world of nerve decompression and migraine surgery and things that I do. The way I think about post-traumatic headaches are twofold. It’s either something that is intrinsic, which means that it is a primary brain problem. Your brain gets knocked around during head trauma and there’s something going on in your brain that is causing the headaches. I don’t usually see those patients. There’s not that much that I can do about that. I’m not a neurologist, but those are the kinds of patients that see multidisciplinary clinics for post-traumatic brain injury, et cetera.

The second, and in my experience, frequent issue as far as post-traumatic headaches, is that while your head gets knocked around, your head sits on your neck. And your neck, the job of your neck is to stabilize your head. When your head gets knocked around, let’s say from a car accident or from a sports injury, there’s often an issue with your neck trying to stabilize and prevent the injury from happening in the first place. Your neck is trying to stabilize your head during the injury. And subsequent to the injury, a\er the injury, your neck is trying to stabilize your head in an ongoing fashion even though that it might have go]en some degree of injury.

Now, your neck can have lots of different types of injuries. You can have an actual spine problem which happens. You can have an actual spinal cord problem which happens. But for the most part, what I see is there is damage to the muscles and the nerves at the base of the neck and skull. These are called the occipital nerves. It’s in the region of the occipital portion of your head.

If you take your hand, put it behind your head and feel for the spot that sticks out the most, that’s called your occipital protuberance. And right on either side of that is where a lot of muscles engage with your scalp. Those muscles, again, are there to stabilize your head.

When you have … I mean, you can think about playing soccer, and you trip or you fall and you pull a muscle in your leg and it hurts. You can pull muscles just like that all over your body. And when you do, your muscles heal with some degree of scar tissue and some degree of residual tightness. That’s why somebody in the NBA who pulls a muscle, they can be out for a long period of ;me because they are trying to loosen up and heal those muscles.

When you’re doing this in the head and neck though, your head has always got to be stabilized. It can be hard for your muscles to relax and heal, so you can get further micro-injuries, ongoing fatigue, and you can get scar in your neck from both the injury as well as the subsequent attempts at stabilizing your head following the injury.

What happens there? The muscles can be tight around these occipital nerves. Now, these nerves, they come out from the spinal cord, and you can find out a lot more information about all of these on our website. But just from the anatomic standpoint, you have the greater occipital nerve and that’s a sensory nerve that provides sensation to your scalp, to the back of your head and o\en to the top of your head. You’ve got the third occipital nerve which is a smaller nerve that is just below that greater occipital nerve and that innervates. It means it provides sensation to an area like a size of about a silver dollar, kind of right behind your ear.

Then you have the lesser occipital nerve. The lesser occipital nerve actually comes from the side of your head, and that comes out near your sternocleidomastoid muscle. It’s a long word but it’s the muscle that goes from the back of your head over to your collarbone on each side. You can o\en see it when you’re turning your head. And all of those muscles that surround these nerves can squeeze on the nerve. They can cause nerve irritation from scar bands or from tight muscles right around there.

What we see is that the greater and third occipital nerve which come up through muscles called the splenius capitis and the trapezius, those muscles can squeeze on the nerve in several different layers. The sternocleidomastoid and the deeper muscles for the lesser occipital nerve can also be irritating. What I see is patients come in, and sometimes they don’t even remember that they have a post- traumatic issue. We could be discussing their head pain and when their headache started. And in fact, they’ll say, “Oh, you know what? I just remembered I was in a car accident about three months before this pain started.” That is technically the results of the trauma being a post-traumatic issue.

And so after the trauma, you’ve got disk compression and that causes what’s called a neuralgia, which is an irritation of the nerve.The point of those kinds of injuries are to either loosen up that muscle, and that can be done with physical therapy. It can be done with Botox sometimes. That can be done sometimes with massage, but sometimes, these things just don’t work and when the more conventional treatments like those don’t work, then you end up in an office like mine, and we go down and surgically make some room and release the muscles around those nerves and allow those nerves to relax.

Now, sometimes you also can get actual damage to the nerves. You can get what’s called the traction injury where the nerve itself is inflamed just from the trauma. And again, through releasing these nerves and giving them some … Not really room to breathe because it’s surrounded by muscle but just room to relax. It increases blood flow to the nerves and allows the nerves to heal. And the lack of compression reduces the neuralgia or the irritation of the nerve.

Then these nerves which usually … Well, usually in normal people, not like you or me, these nerves are just providing sensation to the areas of your scalp. In not normal people, in people like myself who have occipital neuralgia which is a technical way of saying irritation of the occipital nerves, our nerves are sending these distress signals to the brain and that is coming from this irritation of the nerves. It’s coming from the peripheral nerve going to the brain and that’s what’s triggering the headache.

What we’re trying to do is prevent that trigger from happening. We’re trying to prevent those distress signals from being sent from these nerves to the brain to start the whole onslaught of migraine, and headache, and all of the symptoms that surround the condition.

To find out whether what we do is an appropriate approach for your pain, it involves a whole workup. It involves doing some nerve blocks, and again, you can find all of this kind of information. I’m not going to go into all of that right now. You can find all that information on our website, But suffice it to say, it’s pre]y straightforward whether or not to figure out whether or not a post-traumatic headache patient can benefit from the surgery. Surgery takes about three hours. It’s done in an outpatient setting.

We have about a 90 … Well, a little over 90% success rate with nerve decompression. And again, just because you have something like this going on in your neck, it does not preclude which means it does not mean that something else is not also going on with the primary brain issue that’s causing pain. So it’s really important to have a proper workup when you have post-traumatic headaches and post-traumatic brain issues.

I hope that is a helpful response to that question. Just in the second part of the question, what’s the approach to treating constant pain versus episodic pain? And in my practice, there’s no difference. I see a lot of patients who have pain 24/7 and have had pain for 15 years before we operate on them. And then I have other patients who just have 10, 15 migraines a month and that’s what we would call episodic pain. The approach is the same. The workup is the same. Once we identify the nerves involved, the surgical release is the same and the results are the same.

That’s what I got. We are going to hope to have an expert in traumatic brain injury on the podcast in the coming months. At that point, we’ll be able to talk about all different kinds of both primary brain injury as well as injury of the peripheral nerves that cause headache. And again, I hope we’ve been helpful. Thanks very much for listening.

Hey, everybody. This is Dr. Lowenstein once again. And I have two last things to ask you. Firstly, the thing that you can do for fellow headache sufferers is to please remember to subscribe and to rate our podcast. The more ratings and subscriptions that we get, the more visibility that we get and the more listeners will be available to find us, the more help and information we can provide with a 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 that you hear on the internet to broaden your knowledge. But consult with your physician before acting on any information that you hear on podcast or YouTube or anywhere on the internet.

I, as a physician, don’t necessarily endorse the opinions or practices of my guests, and if you have particular questions that you would like to consult with me directly about, please call our Headache Surgery Venter. Our number is 805-969-9004, or email us at And my staff will set up a consultation to discuss your specific case. Thanks, and best wishes from all of us here at Podcast 360.

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