Migraine Headache Surgery: Before and After

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.

00:28 — Dr. Lowenstein:

Search for Migraine Surgery Specialty Center, or you can look at it on our website, headachesurgery.com, under the media tab. [00:39] The video includes intraoperative photography with a little blood. If that is not your thing, please feel free to listen instead. If you would like the visual aspects of this podcast, please check the videos on our website or YouTube. [01:03] Thanks. [01:04] Hey, this is Dr. Lowenstein. If you’re listening by podcast, welcome to the Headache 360 Podcast. If you’re watching by video, I hope you find this informative. We have something really special here. We’re following a patient from the preoperative stage

01:27 — Dr. Lowenstein:

of her surgery. You’re going to see her the morning before surgery and what that whole process is like. Then, during the surgery, you’ll see several issues involving nerve compression in the occipital area. [01:48] You’re going to see several video clips. The video is intended only for people with strong stomachs. Otherwise, I strongly recommend listening on the Headache 360 Podcast. This patient had several problems, [02:15] including blood vessels, fascial impingement of her nerve, and lymph nodes. You’ll see all of this in the video clips. The next day, you’ll see her return and [02:36] describe her experience going into surgery and how she felt the following day. I hope this helps set expectations and provides an understanding of what it’s like to have migraine surgery, headache surgery, or nerve decompression surgery.

Preoperative Consultation and Surgical Planning

02:58 — Dr. Lowenstein:

It is all the same procedure. I hope this is helpful. All right. Hi, this is Dr. Lowenstein. We are here today before surgery, and we’re going to talk about how we got here and what we’re planning. Please say your name and tell us how you got here.

03:24 — Courtney:

I’m Courtney. [03:25] I’ve been dealing with migraines since I was in my early 20s. I’m in my mid-40s now.

03:25 — Dr. Lowenstein:

But you look like you’re in your early 20s.

03:25 — Courtney:

I mean, yes—with all my makeup off, that’s totally different. But I’ve dealt with chronic migraines since my early 20s. [03:45] I’ve tried every type of medication you can think of, including herbal remedies and prescription medications. I’ve seen numerous doctors, but nothing really works at this point. As I’ve gotten older, [04:06] I don’t want to keep taking so many different medications. I’d rather find something that helps at this point in my life. Botox and the other treatments are not things I want to continue indefinitely.

04:18 — Dr. Lowenstein:

And so, how often are you having headaches now?

04:21 — Courtney:

Now I’ve been having them probably daily. Yeah.

04:29 — Dr. Lowenstein:

Daily. And Andreas is your husband?

04:29 — Courtney:

Yeah. [04:33] There was a period when I stopped all migraine medications and used only herbal remedies. I went about four months with only an occasional headache. But once my body adjusted, the migraines returned in full force. [04:55] So that’s actually where Andreas was like, oh, you should meet Dr. Lowenstein. He specializes in migraines. I was like, okay, we’ll see what happens.

05:07 — Dr. Lowenstein:

All right. Can you talk about what happened when you came into the office for your consultation?

05:17 — Courtney:

Correct.

05:18 — Dr. Lowenstein:

Can you just talk a little bit about your experience with the consultation?

05:22 — Courtney:

I essentially came in, and we spoke about the nerve block—how it would work or could work. If it worked, it wasn’t a treatment; it was just to see if surgery was right for me.

05:22 — Dr. Lowenstein:

Diagnostic, not therapeutic.

05:22 — Courtney:

Correct. I think our conversation took longer than the actual nerve block. [05:43] The nerve block took maybe a minute, and then it worked. It was great right away.

05:53 — Dr. Lowenstein:

When you say it worked, what does that mean?

05:55 — Courtney:

I had nothing—no pain at all. It was how I imagine people without headaches normally feel. Once the nerve block wore off, however, I was down for about three days.

06:12 — Dr. Lowenstein:

That can happen, although it is uncommon. The needle and medication can temporarily irritate the nerve. Some patients, however, get prolonged relief; I spoke with someone yesterday who remains headache-free for about three weeks after the same type of block. [06:32] There is a lot of variability. You got the short end of it and had a strong reaction to the irritation from the nerve block. For some people, the block interrupts the pain cycle, allowing the muscles around the nerve to relax. [06:56] That can produce longer-lasting relief. Usually, we expect one to three hours of relief before the headache returns, but sometimes the response is better and sometimes worse. I’m sorry that happened to you.

07:10 — Courtney:

It was pretty bad.

07:12 — Dr. Lowenstein:

It was almost a week, I think.

07:14 — Courtney:

It lasted about a week. The block worked—it was amazing—until it wasn’t.

07:22 — Dr. Lowenstein:

Got it. Okay. So today, and this was occipital, correct? Some people have surgery in the front; we’re going to operate in the back. And so I’m going to show you what we do as far as the whole pre-op situation. You just got here a little bit ago, right? [07:43] And you have your IV in? Correct. Right? Okay, so you saw Jody, she puts your IV in. Are you nervous?

07:52 — Courtney:

Yeah, of course I’m nervous.

07:54 — Dr. Lowenstein:

Okay. Not good—but that is normal.

07:58 — Courtney:

I remember you saying that I’m allowed to be nervous because you’re not nervous.

08:01 — Dr. Lowenstein:

Right. I’m not nervous; I’m excited because this is one of my favorite procedures. As a patient, you’re supposed to be nervous. When I have surgery, I’m nervous because giving up control is difficult. But generally, you want to make sure your doctor is not nervous. [08:23] All right. Let’s do the next step—the fun part: shaving your head. We’re not shaving your whole head. I’m going to shave a narrow strip so there is no hair in the operative field. Please turn your legs toward your husband. [08:48] You’ve put your hair up, which is great. It is positioned vertically, so we won’t accidentally cut hair from one side. We want it as vertical as possible. [09:08] Let’s take that out. Hold this for me.

09:17 — Courtney:

I’m going to try to lift my arm. Okay. [09:20] Okay.

09:22 — Dr. Lowenstein:

I’m going to have you hold your hair so I can keep it positioned from back to front.

09:31 — Courtney:

I put this in pretty securely, thinking I wouldn’t have to take it out.

09:35 — Dr. Lowenstein:

They’re going to take it out later anyway so they can braid your hair. I want to preserve as much of your hair as possible. We’ve also found something interesting: you have a stork bite. Do you know what that is?

09:51 — Courtney:

Yeah, I do. I think we talked about it last time. You have one as well.

09:55 — Dr. Lowenstein:

Yes, I do. We’ll show everyone afterward. It is a capillary malformation, and many patients have one, including me. This is going to make a terrible sound.

11:16 — Courtney:

The worst part is when I tell you that, in my prior career, I was a cosmetologist. I’ll grade you on this later.

11:25 — Dr. Lowenstein:

All right, fair enough. I don’t usually show patients what I take out, but the viewers may see it. It looks traumatic, but you won’t even be able to tell afterward.

11:39 — Courtney:

My hair is really curly, so I brushed it out. It’s going to look crazy anyway.

11:39 — Dr. Lowenstein:

It looks like my wife’s hair.

11:39 — Courtney:

Yeah, your wife has really curly hair too, so you know what it looks like when it’s brushed out.

11:55 — Dr. Lowenstein:

The strange thing is that my hair used to be almost as long as yours. When I brushed it out, it did the same thing—but that was a long time ago. I’m going to bring this over here. [12:21] This is what the hair looks like after shaving. This strip is the operative area. I’ll make an incision from here to here, entirely within the hairline. [12:41] The skin is red from the razor, but you can see the small spots from the capillary malformation. I’ll show you that as well. [13:05] Back to our very professional videography. I’m going to get a marker. This is your occipital protuberance.

13:27 — Dr. Lowenstein:

You can sit upright. [13:28] Upright is better. Head up—there you go. This is the occipital protuberance in the midline, near the base of your hairline. I’m marking the planned incision and measuring the nerve locations. [14:00] We’re going 3 centimeters down from the occipital protuberance, then 1.5 centimeters to each side. Is that about where the pain is?

14:00 — Courtney:

Yeah, that’s it.

14:22 — Dr. Lowenstein:

And there as well? Right. That is where the nerves are. We’re also going to address the lesser occipital nerves because they may be contributing to pain on the sides. [14:46] Look straight ahead. We measure from the external auditory meatus—the opening of the ear—and go down about 5.5 centimeters. [15:08] Then we measure about 6.3 to 6.5 centimeters across, and do the same on the other side. [15:29] Those marks identify the lesser occipital nerves. We’ll make small incisions that line up very well with their expected locations. Let’s pull the hair up here.

15:43 — Courtney:

Just this little section. I’ll lift it—cosmetology 101. There we go. At least we have a better view.

15:59 — Dr. Lowenstein:

Right there is where the lesser occipital nerve emerges. I’ll mark where I expect the nerve to be and make a small incision. I’ll do the same on the other side. This corresponds to the back of the sternocleidomastoid muscle. [16:22] This muscle runs from behind the ear down to the clavicle, and the nerve emerges from behind it. It is less visible on this side, but the anatomy is the same. [16:43] When we use these measurements, the location consistently falls along the posterior border of the sternocleidomastoid. We’ll make small incisions on both sides, divide those nerves, and bury the ends in muscle. [17:05] Those nerves supply sensation to only a very small area, so you’re unlikely to notice the numbness. When irritated, however, they can cause significant headaches. The central incision will be a little smaller than this marking.

17:27 — Dr. Lowenstein:

The greater occipital nerves are located here and here. I’ll dissect down to find each nerve, then release it along its course, as I’ve demonstrated in other videos. [17:54] I’m reinforcing the markings because we’ll clean your head and neck before surgery, and I don’t want them to wash away. You can turn back around. What other questions do you have?

18:16 — Courtney:

I don’t think I have any right now.

18:19 — Dr. Lowenstein:

Okay. Andreas, any questions?

18:19 — Andreas:

How long is the surgery?

18:19 — Dr. Lowenstein:

The surgery will take about 2.5 to 3 hours. After you go to sleep, we have to position you. Positioning takes about 45 minutes because we’re going to place you face down. [18:40] We’ll carefully pad your face so the breathing tube is not under tension and so no sensitive areas are under excess pressure. [19:02] We’ll make sure you’re positioned safely so you don’t develop pressure sores or related problems. The positioning process takes about 45 minutes.

19:10 — Andreas:

Okay.

19:11 — Dr. Lowenstein:

After surgery, you will have been face down on a foam support with an opening for the breathing tube. Because you’ll be in that position for a couple of hours, your face and lips may look swollen when you wake up. [19:34] You may look like you just had your lips done. [19:35] The swelling will go away over the rest of the day. For better or worse, you’ll briefly see what an overdone cosmetic result looks like—but you’ll look normal once the swelling resolves. [19:56] Sometimes I want to take a picture and say, “See—don’t do this,” but we won’t take those pictures.

20:05 — Courtney:

Good, let’s not do it.

20:06 — Dr. Lowenstein:

If there’s an opportunity during the case, I’ll take photographs. I would love to record the entire procedure, but the nerves lie in a small tunnel extending into the scalp, which makes video difficult. [20:26] Even still photography is challenging because a focus difference of only a few millimeters changes the depth of field. We’ll do our best and add narration explaining what we saw. [20:49] I’m not going to record Courtney immediately after surgery because she’ll still be recovering from anesthesia. We may take video tomorrow morning so she can describe how she feels and what the experience was like. [21:11] We’ll see you again next week and the week after. We’ll close the central incision with staples because they evert the tissue and allow hair to grow through the incision more effectively.

21:32 — Dr. Lowenstein:

Sutures are another option, but because they pass in and out along the sides of the incision, they may constrict some hair follicles. Their advantage is that they dissolve and do not need to be removed. [21:54] The disadvantage is that sutures may leave a wider area without hair growth. Because you’re local, I’ll see you in about two weeks to remove the staples. It may look a little Frankenstein-like until then, but your hair will cover it. We’ll take it from there.

Intraoperative Findings

22:15 — Dr. Lowenstein:

All right. After discussing the difficulty of filming the procedure, we decided to try using an iPhone in the operating room, and it worked very well. [22:26] So here you go with a bunch of video and discussion of Courtney’’s operation. [22:33] Shelly is preparing Courtney’s head. We’re cleaning everything thoroughly with Betadine to create a sterile operative field. [22:53] We make the incision and dissect toward the lateral aspect of the neck, where we’ll enter the muscle layers to locate the nerve.

23:14 — Dr. Lowenstein:

We’ve opened the muscle and underlying fascia. The nerve runs from the lower right toward the upper left—from the central neck toward the lateral scalp, where it provides sensation. It appears flat, with limited visible vasculature, suggesting compression. [23:36] The surrounding structures are compressing the nerve. [23:38] When we first found the nerve, it was splayed and severely compressed. It already looks rounder after release. Here, an artery is wrapping around the nerve and compressing it, so we’re going to move it away. [24:02] The nerve is now decompressed through the stabilizing muscles of the neck. This branch is the third occipital nerve, which we’ll bury in muscle. This larger structure is the greater occipital nerve.

24:23 — Dr. Lowenstein:

As we follow it upward, you can see several branches that have been freed into the soft subcutaneous tissue beneath the skin. [24:47] The crossing blood vessels have been cauterized and removed, along with compressing muscle bands. The nerve was previously splayed and compressed; now small blood vessels are visible within it, which is a healthy appearance. [25:07] We’ve completed the decompression on this side and will move to the other side. [25:16] We’re now on the left side, where Courtney has more headache pain. After opening the fascia, we can see the nerve. There is a small blood vessel beside it that we’ll address after fully exposing the nerve and checking for fascial bands.

25:41 — Dr. Lowenstein:

We’ll look for any bands that flatten or cross the nerve. [25:52] Here is the nerve with several bands of tissue crossing it. The adjacent blood vessel has been divided but still needs to be dissected away. This area contains several potential headache triggers. [26:12] I’ll carefully get underneath these bands and release them. [26:43] These are compressive fibers. We’ll release them here as well and control the blood vessel with cautery.

27:13 — Dr. Lowenstein:

The blood vessel and crossing bands are now gone. There is still compression higher up, but the nerve already looks rounder, fuller, and healthier. We’ll continue dissecting the small branches and release the nerve further. [27:35] The nerve is now decompressed and continues into the subcutaneous tissue of the scalp. This large lymph node is pressing directly on the nerve. [27:56] We’ll remove the lymph node. We have found blood vessels, fascial bands, and now a lymph node compressing the nerve—several clear reasons for headache pain. [28:17] Courtney’s left side was the larger problem. In addition to the blood vessel, fascial bands, and lymph node, there is another large blood vessel here.

28:40 — Dr. Lowenstein:

This vessel wraps around and actually passes through the nerve, with some nerve branches above it and others below it. We need to control the vessel because each heartbeat causes it to press against the nerve. [29:01] That is another significant source of irritation. Here, the vessel tracks alongside the nerve all the way toward its upper branches. [29:22] We are in the fatty tissue just beneath the scalp. Several nerve branches have been dissected free, including the main trunk that continues high into the scalp. [29:43] A large artery traveled with the nerve, so I had to dissect deeply to control it. The darkened tissue is from cauterizing a nest of blood vessels away from the nerve.

30:04 — Dr. Lowenstein:

The nerve is now free. It remains slightly entrapped lower down, so we’ll continue the decompression toward the neck, creating a clear channel through the muscle. [30:29] The nerve is decompressed from the neck all the way into the scalp. Charlie, come over and look—my scissors are just beneath the skin, confirming a complete release.

Postoperative Follow-Up

30:52 — Dr. Lowenstein:

We have achieved a good release through the scalp. Now we’re with Courtney on the morning after surgery, at about nine o’clock. How are you doing?

31:05 — Courtney:

Good.

31:06 — Dr. Lowenstein:

Good? Is this the best morning of your life? Would you like to feel like this every morning? How was your night?

31:13 — Courtney:

It was okay. It wasn’t too bad. I don’t think it was that bad of a night.

31:16 — Dr. Lowenstein:

You woke up once or twice, maybe.

31:16 — Courtney:

I think I woke up more than that. [31:22] Pain-wise, it’s mainly surgical soreness. I don’t have a migraine.

31:29 — Dr. Lowenstein:

Okay.

31:30 — Courtney:

I’ve taken only three or four pain pills in total.

31:39 — Dr. Lowenstein:

Okay.

31:40 — Courtney:

That is the total since I left here.

31:40 — Dr. Lowenstein:

Okay. And you’re taking Norco? [31:49] Right. I want you to stop the Norco as soon as you comfortably can. Narcotics can cause constipation, grogginess, and other problems. [32:10] The sooner you can transition off them, the better. You may take Tylenol, but do not take it too close to Norco, Percocet, or similar medications because they already contain acetaminophen. Too much acetaminophen can cause severe liver damage. [32:33] Space the narcotic and Tylenol doses by at least four hours. You may need the narcotic tonight and possibly tomorrow, but I’d like you to begin tapering tomorrow and, ideally, use Tylenol alone by the end of the weekend.

32:58 — Dr. Lowenstein:

By the end of the weekend.

32:59 — Courtney:

Sure.

32:59 — Dr. Lowenstein:

Okay. You have compression stockings on. I want them down over your toes and kept on through the weekend. You can take them off on Sunday.

33:10 — Courtney:

Down over my toes like they are right now.

33:12 — Dr. Lowenstein:

Are they?

33:13 — Courtney:

Yeah.

33:14 — Dr. Lowenstein:

Yes—just like that. Some people pull the stockings higher, which can cause toe swelling. You want compression from the toes upward. To reduce the risk of blood clots, stay mobile but avoid exertion. [33:37] No unpacking boxes. Hi, Shelly—come say hello. [33:44] This is Shelly, one of our nurses. [33:47] No exertion, and avoid close contact with pets. Andreas is excluded from that rule. Everything looks good, and we’ll turn you around in a moment.

34:09 — Dr. Lowenstein:

You may shower and wash your hair, but be very gentle around the incisions.

34:13 — Courtney:

I can actually wash my hair.

34:14 — Dr. Lowenstein:

You can wash your hair and let clean water run over the incisions, but do not submerge them in standing water. No pools, hot tubs, or diving. [34:36] Running water is fine. I’m glad you don’t have headache pain—that is excellent. We haven’t reviewed the surgical findings with you yet, although viewers may already have seen some of them in the video. [34:58] I’ll show you the footage privately in a moment. Your right nerve was flattened and compressed, and we corrected that. The left side, however, had nearly every type of compression we encounter. [35:18] The left nerve was compressed by fascia, an adjacent blood vessel along the lower portion, and deeper tissue as it traveled upward. A lymph node was also pressing on it.

35:40 — Dr. Lowenstein:

Then we found one of the largest arteries I’ve seen piercing through the nerve, wrapping around it, and traveling upward with it. You had the full trifecta of problems. It was a complex case, but it was gratifying to identify and correct each issue. [36:03] I’m very optimistic about your outcome.

36:06 — Courtney:

That is where my migraines were too—mostly on my left side.

36:10 — Dr. Lowenstein:

That makes sense. We expect some numbness because the nerves were manipulated during surgery. From this point, recovery is highly variable. [36:33] The surgical pain should improve over the next several days to a week. The migraine pain may remain absent, return mildly, or flare temporarily. You may have good days and bad days over the next six months. [36:59] You may also experience shooting sensations, called paresthesias, as the nerves recover. These can begin next week, several months later, or not happen at all. Nerve recovery varies greatly. [37:19] Anyone who claims to know exactly what will happen at this stage is not being realistic.

37:21 — Courtney:

Okay.

37:22 — Dr. Lowenstein:

What we do know is that you have a better than 90% chance of being significantly improved compared with before surgery. I’m optimistic that you’ll do very well. If headaches return during recovery, it is not a reason to panic; some fluctuation is expected. [37:43] Prepare for good days and bad days over the next three to six months, occasionally longer. If recovery is easier than expected, that is excellent. [38:04] Do you have any questions?

38:04 — Courtney:

No, not really.

38:04 — Dr. Lowenstein:

Start with Tylenol as soon as you can handle it.

38:14 — Courtney:

Yeah, absolutely.

38:15 — Dr. Lowenstein:

I’ll show everyone what the incisions look like. These small incisions are for the lesser occipital nerves. The central incision is stapled, so it looks somewhat Frankenstein-like right now. [38:39] The skin edges are raised and everted, which supports better hair growth through the scar. Although it looks rough now, it should heal into a better scar. We’ll remove the staples in 10 to 14 days. [39:02] Under the small pieces of tape are incisions closed with absorbable sutures. The tape will fall off on its own over the next week or two, and the incisions will heal without special care. [39:24] I’ll put this here. I went home last night and organized the video clips in iMovie. I’ll get the footage and review it with you.

39:45 — Courtney:

Okay, sounds good.

39:45 — Dr. Lowenstein:

All right. Thank you very much for helping me with all of this and helping people understand what is going on. Thanks again to Courtney for allowing us to learn from her experience. I want to clarify that we expect a variable recovery experience

Closing Remarks and Medical Disclaimer

40:06 — Dr. Lowenstein:

Recovery can vary over three to six months. Some patients have no headaches during that time; others have intermittent headaches. By the end of recovery, we expect significant improvement or complete headache relief. [40:26] The recovery period is the variable part. The long-term result is less variable: more than 90% of patients experience significant improvement, and roughly half of those become completely headache-free. [40:44] Again, thank you to Courtney. If you have questions or would like to discuss your case, please call us. [40:53] Our center’s phone number is (805) 969-9004. My staff will be happy to arrange a consultation so we can talk further.

41:04 — Dr. Lowenstein:

Thanks again for listening, and thanks again to Courtney. Take care. I have two final requests: first, please subscribe to and rate our podcast. More ratings and subscriptions improve our visibility, allowing more headache sufferers to find this information. [41:26] Second, please remember that headache treatment is highly individualized. This podcast is not intended to provide medical advice. Use the information here and elsewhere online to broaden your knowledge, but consult your physician before acting on anything you hear or read. [41:46] As a physician, I do not necessarily endorse the opinions or practices of every guest. If you have specific questions and would like to consult with me directly, please call our Headache Surgery Center at (805) 969-9004. [42:09] You may also email info@headachesurgery.com. My staff can arrange a consultation to discuss your case by phone or in person. More information is available at headachesurgery.com. Thanks, and best wishes from all of us at the Headache 360 Podcast.