Published July 10, 2019 By Adam Lowenstein

Dr. Lowenstein: Hello and welcome to The Headache 360 Podcast. This is your host, Dr. Adam Lowenstein. And as I’m imagining most of you know by now, I’m a migraine surgeon. I do nerve decompression for migraine and chronic headaches. And my goal here is to try and get some information from lots of different people who take care of migraine and chronic headache patients. And today we have a very special guest. Dr. Matt O’Neil is a physical therapist. He’s from Nebraska, and he got his doctorate in physical therapy from Creighton University. And I am really, really pleased to have you on the show, Matt. Thanks for being here. Can you tell us a little bit about yourself?

Dr. O’Neil: Yeah, absolutely. First, thanks just for having me on. It’s awesome to be able to talk with other people and other professionals about what we treat and how we can treat people and make their lives better. So this is an awesome avenue to be able to equip people with the proper information and hopefully with application. So, yeah. Like you said, I’m a physical therapist. I got my doctorate from Creighton University in 2003. And I started practicing right away in Texas. And then nine months later I opened my own practice, Alpha Rehab in Kearney, Nebraska in the middle of nowhere. And the goal of that was really just to focus on can we get specialized care to everyone?

Dr. O’Neil: So you don’t have to go to the big city. You don’t have to … for us, Lincoln or Omaha. You don’t have to go there to get the qualified and specialized care. And that’s really what we set up and what we prided ourselves with. My background as I was a student, I was actually wanting to be at Ranchos Los Amigos in California. And I ended up in this little tiny town of probably 1,000 people in Nebraska. And I met this amazing therapist. Jen Peterson was her name. And she had spent pretty much her entire life devoted to treating headaches. And I begged and begged and went through this process. And she actually started to teach me her headache treatment techniques.

Dr. O’Neil: And then I kind of, like I tend to do, modify them as I go along. And I’ve made them a little bit more efficient, a little faster, and tried to put the onus on the person to be a part of the solution. And so, yeah. So I’ve treated headaches for a good 14, 15 years now. And out of the ones that come to me … And I’m not saying all headaches in general. But the ones that eventually get to me have about 90-95% success rate of eliminating those headaches.

Dr. Lowenstein: Oh, that’s great.

Dr. O’Neil: Yeah.

Dr. Lowenstein: Fantastic. So where do you get your patients from? Are they referred by physicians, or do they just find you? How does that happen?

Dr. O’Neil: The vast majority are referred from a physician. Some of them will find me, but I don’t advertise. I never did advertise for headaches other than listing it on our website. And the reason for that is because I think that if I listed that I can treat headaches, that’s all that I would do all day long. And I like to have diversity in what I do. And so, yeah, I just built relationships with physicians and the clients who I got rid of their headaches for them. And then that word of mouth is something that drove us and my entire career.

Dr. Lowenstein: That’s great. I know I’ve got a lot of patients who have seen physical therapists, and some of them many physical therapists, and it seems like there’s some variation in what different peoples’ approaches are. And certainly the people who get to me are the people who kind of failed everything else and they’re not people who come through you because, especially if you’ve got that kind of success rate, which is great. Can you talk a little bit about your approach and what you do with headache patients?

Dr. O’Neil: Yeah, absolutely. And then at the end one of the things that we can talk about is what therapist not to see. Right?

Dr. Lowenstein: Right.

Dr. O’Neil: Because that’s part of what you and I … You nailed it on the head. When everything else fails, that’s when they ended up at you. And that’s kind of what I saw with mine as well. When everything else failed, and they wasted all this time and money and energy, then they ended up at me. And I don’t want to be people’s last resorts. And I don’t want you to be the last resort. I want the best result possible with people. So, yeah. My approach is really kind of multifaceted. It starts from the moment that they walk in. I begin to start to educate and ask them questions. For me what I’m looking for is I’m looking for what are these people’s triggers. Okay? Because I’m not going to be treating hormonal imbalances. I’m not going to be treating psychosomatic or the things that a counselor or a psychologist is going to need to be able to treat.

Dr. O’Neil: I’m not going to be … Even if they need surgery, I’m not going to be treating those types of things. So the type of patient that comes to me is somebody that’s having, they might be having cluster headaches, migraines, tension headaches, whatever you want to call them. But they’re really when we come down to it, I guess we’ll jump to their symptoms here in a second. But I’m looking for their triggers. So for me-

Dr. Lowenstein: Let me just interrupt you for a second here.

Dr. O’Neil: Absolutely. Yeah.

Dr. Lowenstein: Because one of the things that is a thing with me are diagnoses. And there are providers who divide these patients up into various diagnoses. And then if you get X diagnosis, then you go to Y provider or Y therapy, and you get Z diagnosis you go to Q. And, yeah, I find that to be more confusing than helpful, because I treat patients across basically almost all of the diagnoses of chronic headache, tension headache, occipital neuralgia, cervicogenic headache. Cervicogenic headache I hear a lot that, “I have cervicogenic headaches, so this will not help me.” And I find that not to be the case. Do you treat your patients with this paradigm that you’re about to explain? Because I interrupted you, and I apologize. Do you treat people differently with different diagnoses, or are you finding that your paradigm is working across different diagnoses?

Dr. O’Neil: I think that we see so much of the cervicalgia, the cervicogenic headaches because of coding. I think that we as medical providers are taught new coding techniques … Or not techniques, but terminology. And in order to get paid we actually adopt those terminologies, when in reality you and I both know that it’d be great to have a lot more freedom in that.

Dr. Lowenstein: That’s a really, really, really good point. And frankly I wasn’t sure if you said coding or codeine. Both of these things are problems. But, yeah. I do think the codification of … And you need that when you’re a diabetic, or you need that in different … What am I trying to say? Pathologies. You do need to have some kind of codification. But in headaches I think a lot of times it makes things worse rather than better. But okay. So let’s go back and pretend like I was not a rude host and tell me more about what you do.

Dr. O’Neil: Yeah. So the triggers. Triggers are really, really important. And so I like to point them out to people and then give them help for that. That’s part of what we’re trying to do here, right, is give them a little bit of meat today that they can go home and chew on. One of the biggest ones that I find with people is weather patterns. They’re like, “Oh, I always get headaches before storms,” or, “I guess this …” Or they’re not even aware of it until I get them to journal their headaches. And what I recommend people to do is to download a weather app that has a barometric pressure change on it so you can actually look at it. So when you get a headache-

Dr. Lowenstein: Sure. That’s interesting.

Dr. O’Neil: Yeah. You open the app and you say, “Okay, this is what” … And you write down what that pressure chain is. And you keep track of that. Because what I found interesting in my own life is that I get headaches or pressure changes. I recognize that on the backend of storms, and my wife recognizes it on the front end of storms. So she knows when one’s coming, and I know when one’s passed.

Dr. Lowenstein: All right. Wow. You guys should work for the weather service.

Dr. O’Neil: Absolutely. But what I tell people is drink lots of water, because the more water you drink, the pressure effects you less. So I always tell people the analogy is that of a water balloon. If you have a little bit of water in there you can squeeze and manipulate and push it around. Well, your brain, your joints, your muscles, everything is surrounded and attached to water. So the less water or more dehydrated you are, the more impact it’s going to have on you. So if you are properly hydrated or even on the high set of hydration, it’s like a really, really full balloon. That pressure’s not going to affect you as much. So that’s number one. Tidbit number one is drink lots of water.

Dr. O’Neil: The next one that I go through is food and alcohol. And food triggers are really interesting. I treated this girl and couple of times. I can get rid of her headaches. And every time she came back she goes, “Yeah, I got another one.” And I’m like, “Gah, what’s going on?” I talked with her, and then it came out. She was [inaudible 00:10:14] 14, so she doesn’t tell me all the information at the time. Her mom was a chocolatier or whatever. She makes chocolate. And every time she’d go home she would try the new chocolate, and then she would have a headache from that. It’s like, “Oh, okay. Well, it sucks to be you, but stop eating chocolate.” And that fixed that. The alcohol thing-

Dr. Lowenstein: If my mother was a chocolatier I’d have a different problem. You wouldn’t be able to fit me through the door.

Dr. O’Neil: We’d be back to the diabetes thing, right?

Dr. Lowenstein: Right. Right. Exactly. Exactly. But all right. Everybody’s got their thing.

Dr. O’Neil: But the alcohol thing was really interesting. I learned something last week. And specifically with regards to wine. People say, “I get headaches from wine.” Number one, stop drinking wine out of a box or out of a bag or out of the backwoods from Nebraska. Right? But if it is out of a bottle, what this guy told me, and this is one of … He actually works with me. Tom Black is his name, and he’s one of the leading experts in the world on wine. And he says take an antihistamine before you have that glass of wine. He said a lot of times it’s almost like allergic reaction to the wine is what it is.

Dr. Lowenstein: Huh. Because I have that problem, so I’ll try that.

Dr. O’Neil: Yeah, yeah. Just an antihistamine before you drink your wine. The next thing that I focus is and that I look at is posture with people. Are they slouching? Do they have a head forward posture? How do they look at their phone? How do they read. What position are they in when they’re sleeping? What position are they in when they’re watching TV, when they’re working? Those things are so important, and we’ll get to that here why they’re important in the skeleton system for my approach in a second. But posture. I always am cuing people to sit up straight. And that’s one of the hardest things that we can do based on our culture with these phones that we have sitting in front of us.

Dr. O’Neil: Next one is sleep patterns. And that is really broad from the standpoint of what position do you sleep in at night. Kids that have headaches, teenagers that have headaches, and young adults that have headaches, a lot of time they have not gotten out of the stomach sleeping mode. And so their neck is losing its mobility as they’re growing, and they’re just cranking the heck out of it. And the upper cervical region is just getting really compressed. So what I do is I recommend everybody to sleep on their side. And then I recommend everybody to use a body pillow. So go to Target or wherever and get a $10 body pillow.

Dr. O’Neil: And that way when you’re sleeping, your arm isn’t twisted around. Your legs aren’t collapsing down. You’re not twisting your spine. And if you are seeking that anterior pressure on your body for stomach sleeping, that’s what they’re doing, they’re seeking that deep pressure. That body pillow will stop you from fully rolling over onto your stomach, but it’ll still give you that pressure. And so that has helped a ton of people with cervical problems, post rehab for shoulder injuries, everything. I’ve used one for 20 plus years, and I sleep like a baby.

Dr. Lowenstein: Everything you’re saying, it actually makes sense. Everything from a anatomic and physiologic … These are little things, but the water balloon. All of this, it’s great. It really makes a lot of sense.

Dr. O’Neil: Awesome. Yeah. I try to give everybody so much practical information that they understand it, and then they will actually go and do it. I always tell people that we have an explosion of information. You want to learn about headaches, google it. You will get so much stinking information out there, and the vast majority of it’s wrong.

Dr. Lowenstein: Some of it’s good. Right. Exactly. Only a little bit of it’s good.

Dr. O’Neil: Yeah.

Dr. Lowenstein: I’ve got a mug that my staff gave me that says, “Don’t confuse your google search with my medical degree.”

Dr. O’Neil: Absolutely. Absolutely.

Dr. Lowenstein: I mean, there is a lot of good information there as well. But for the layperson it’s almost impossible to figure out what’s what, right?

Dr. O’Neil: Yeah. I use that one as well. But then I use another one which is … The fastest way to determine if you’re going to die is to google your symptoms.

Dr. Lowenstein: Right.

Dr. O’Neil: So I got a sore throat. Google it, and you’re going to die. So then for me, sleep patterns as well is timing. So I always tell everybody, “Wake up at the same time every day.” I wake up at 5:30 every day, and I’ve just trained myself to do that. I work out in the mornings, and I get rolling. So it doesn’t matter if I’m on vacation, if I’m out touring, if I’m working. I’m waking up at the same time every day. And then what I do is I have people count backwards by an hour and a half segments, because that’s the typical sleep pattern. And count backwards by an hour and a half segments, and that will tell you when you need to go to sleep. And if you do that, then you will actually be waking up in your most alert state, and you’re never going to interrupt yourself in a deep sleep.

Dr. O’Neil: If any of us that have kids, and you wake them up and they’re just completely out of it, well, it’s because they were in a deep sleep. Now they’re just a bear. That is just not a good thing to do. So even with raising our kids, we have always followed this pattern, and my kids wake up great. I barely ever have to tell them to wake up in the morning because they’re already alert and refreshed at that moment.

Dr. Lowenstein: So at any combination of hour and a half segments previous to when you’re waking up is a good time to go to sleep. That’s what you’re saying.

Dr. O’Neil: Yeah. And so for me it’s seven and a half hours. I’m in bed typically eight hours before I need to wake up, and I’m asleep at 7 and a half hours before I need to wake up.

Dr. Lowenstein: Okay. That’s interesting. Okay.

Dr. O’Neil: So sleep pattern is huge, and I love sleep. It’s my favorite thing in the world. So we just got through triggers. That’s the first thing is really just kind of analyzing these people’s patterns and trying to get to the root cause. And I always make this joke. It’s a really bad Arnold Schwarzenegger impersonation, but it’s not a tumor, right? I try to get through people’s mind when they get to me that, “Listen. I know your head hurts. I know you have pounding. I know you have pain. I know you have all these things. But typically it’s not coming from your head. It’s not a tumor. Your head isn’t going to explode. It’s caused by something else. Let’s find that cause instead of putting bandaids on this thing.”

Dr. O’Neil: So then that brings us into the next approach which is then your symptoms. Again, this is just me talking to people. And I just say, “Describe to me your symptoms.” And typically they’re going to go to one side of their head or the other, and they’re going to … If they’re chronic here, over a long period of time they’re going to kind of follow that rams horn pattern where they’re going to start in the back of their neck where it connects to the head, and it’s going to kind of wrap up over towards the eye. That’s the typical pattern that I see.

Dr. Lowenstein: Classic what I see, too.

Dr. O’Neil: Absolutely. If they have pain in the right forehead, yes, it can be … That’s where your symptoms come from. But typically it corresponds with the direct location in the cervical spine right there at the base of the skull there. So that’s where I’m like, “All right, if that’s where you’re pointing on your head, I know that’s where I need to go on the neck.” And so it’s really interesting how the symptoms up front in your face and your head correspond with your neck. I think it’s very, very important. And the reason that-

Dr. Lowenstein: Did you see that globally? Because the way I treat a little differently, because you’ve got … And I think you may start getting into some anatomy in a little bit. But you’ve got your occipital nerve, and you’ve got your supraorbital and supratrochlear nerves. And I find sometimes … not sometimes. I mean, I find oftentimes that patients have these neuralgias of both sides.

Dr. O’Neil: Yes.

Dr. Lowenstein: So are you fundamentally treating forehead pain always in the back and doing it successfully? Because that’s really interesting to me.

Dr. O’Neil: Yes and no, right? So what you touched on, I was going to touch on here in a second with the supraorbital stuff. No, absolutely. There’s eye strain. There’s muscular tension that may be occurring chronically. They’re squinting too much throughout the day, and therefore that’s where their pain is coming from. It’s because they’re causing chronic inflammation in front of their eyes. So what you had mentioned is that there could be multiple neuralgias that are occurring, multiple causes for those things. So it might be occipital, but it might be also supraorbital. And that is, absolutely that is the case, because if people don’t have the right prescription or if they are using their bifocal, and their computer is actually down too far or up too high or whatever, and they’re doing these weird positions with their neck during the day, then, yeah, it’s going to be an eye strain thing.

Dr. O’Neil: In which case that supraorbital nerve is going to be inflamed and irritated, and so we need to treat that as well. But when I’ve eliminated those causes, right. When I’ve eliminated eye strain, when I’ve eliminated those other things, then typically, yes. Any pain that’s up front or throughout the course of that’s ram’s horn can be pulled back to that cervical spine. And so for me, the way that I view headaches is, and this is going to be a very simplistic way of looking at it.

Dr. Lowenstein: You can’t wrap all of your experience and doctorate into like a few sentences?

Dr. O’Neil: No.

Dr. Lowenstein: That’s shocking to me.

Dr. O’Neil: No. Absolutely not. And people won’t understand what I’m saying anyways. And I don’t know if I’d understand what I was saying.

Dr. Lowenstein: Right, yeah. No, this is difficult from a different perspective than ours, but yes.

Dr. O’Neil: Absolutely. So what I explain to people is, again, I’m not speaking about every headache globally. We’re speaking about kind of what comes to me. But what I explain to people is in your upper three levels of your vertebras or your upper neck. Three, four, five keeps you alive. Right? We learned that in school. You break your neck above that level, your diaphragm shuts off, you are in trouble. And so the body has these amazing, basically, pressure sensors in those upper cervical spine so that it can indicate instantaneously to your brain and to your body that you have pressure there. And I think it’s a protection mechanism to not break your neck.

Dr. O’Neil: And so what happens is because people’s function or their postures or whatever, if you think about listening to this podcast right now, everybody that’s listening to this, just slouch forward and let your head come forward. And you think about your neck. I’m doing it right now as well.

Dr. Lowenstein: I’m trying to.

Dr. O’Neil: It’s compressing your upper cervical spine. Well, the vast majority of people sit like this all the time.

Dr. Lowenstein: Right. Right.

Dr. O’Neil: Especially the people with headaches. They sit with that for work. They drive that way, whatever. They’re on their phones. Whatever they’re doing, they’re doing it like that. And so chronically we get this compression that is occurring in that upper cervical spine. When that occurs, then it stimulates your trigeminal nerve. Your trigeminal nerve is a very special thing from a PT standpoint because it does three amazing things with regards to headaches. It increases the tension in your jaw, it increases your pain sensitivity, and it increases your blood flow on each side of your face. So when people are getting those ram horns on one side of the face or the other, from my experience typically it’s a trigeminal nerve is being flared up somewhere along the lines, and therefore that’s where our symptoms are coming from. And so if I can-

Dr. Lowenstein: And just for everybody, the trigeminal nerve is the nerve that provides sensation to your face. So in my practice it’s something that I treat and that’s part of the supraorbital, supratrochlear nerve system. But there’s the purpose of this nerve and there’s dedicated ganglia which is a control center for this nerve. But the purpose of this nerve is a sensation nerve to your face and head. So anyway, please go on.

Dr. O’Neil: Yeah, absolutely. If that’s the case, then I’m approaching this from two different ways from this symptom. If they say, “Oh, I got so much tension, pain, and I got pounding.” Then I’m like, “Ah, sweet. Now I even know even further what’s going on. And I can narrow it down.” So I know that typically I can get rid of the symptoms that are occurring in the head, but I also have to get rid of the tension and the compression and the irritation of that nerve back on the neck as well. So then we jump into actually my hands-on people, which is muscular standpoint. So what I’m looking at is the upper traps, those big beefy neck muscles at the top of your shoulder that attach into your neck.

Dr. O’Neil: Every time somebody raises their shoulders up, because of how those muscles are positioned, it pulls down on the neck. Every time you drop your head forward to look at your phone you have to hang on those muscles. And when you fatigue muscles out like that with prolonged positioning, they only have two options. They can tear, or they can tighten. Well, outside of a car accident you’re not going to tear those muscles. So what do they do? They just slowly tighten up on you like an anaconda squeezing its victim. And when that happens day after day after day after day after day, that’s when you start getting chronic inflammation, and you start getting all these things, and those muscles respond faster and faster to tighten faster and faster.

Dr. O’Neil: So what do I do? I use a technique called strain counter-strain. And I know that’s a … If you google it, that’s actually … You’ll probably find a little bit of information on it. But it’s basically can we shut the brain and the body off long enough for the brain to kind of resets and not anticipate pain. Okay? So somebody could actually potentially do this on themselves. This is actually a very simple technique that I don’t think you need to have a medical degree to do. And so but the easiest way, and let’s just say that you actually have a spouse that cares about you. And my mantra in life is happy wife, happy life. So if my wife has a headaches or something’s going on, I need to help her with that, right?

Dr. O’Neil: Or my kids. My daughter got bucked off a horse about a month ago out on the ranch, and she was having some neck pain. So over the phone I walked her grandmother through how to do this technique. And it’s real simple. Whoever’s having pain, they lay down on the bed. And you kind of look at that muscle that’s on the top of the shoulder there, the big upper track muscle. And you’re not squeezing it. You’re just kind of touching it to say, “Yeah, is that kind of sore or stiff or tight right in there?” And they’re like, “Yeah, it’s really tight.” So, okay. And then you grab a hold of that person’s arm on the same side at the elbow, and you raise their arm up to where kind of … I tell people it’s the whoa is me pose.

Dr. O’Neil: Your hand or your forearm’s kind of across your forehead. It’s like, “Oh, whoa is me. Oh, how sad is my pain.” And you hold that for about 30 to 60 seconds. You can’t do it on yourself because you have to use your muscles. So what you’re trying to do is you’re trying to keep that person relaxed, and you hold it for about 30 to 60 seconds, and then you put the arm back down. And when you do that, then you just kind of wiggle that muscle again, it literally melts like butter within 30 to 60 seconds. And so you can get rid of a lot of muscle pain simply by shutting it off. And the analogy for that is when you have a computer, especially something that’s not a Mac, because I use Macs, of course. But something-

Dr. Lowenstein: You too?

Dr. O’Neil: Yeah. But it’s not working right. And so you can smash it with a hammer and get frustrated or you can just shut it off. You wait ’til the crinkling noise gets out, at least that’s what we used to do when we had the towers, right? The crinkling noise goes away and turn it back on and magically it works again. Well, I can’t explain how that actually happens. But your brain’s the same way. Most people are in this nasty cycle of pain and tension. So at some point maybe they had some pain in their neck. And the muscle goes, “Oh, we need to protect you,” so it tightens up. Or fatigue-related it tightens up, causes pain. Well, then your brain goes, “Oh, well. We have pain. We better tighten up because something’s wrong.” And then it’s tight, which causes pain which then, right, and we’re in this nasty cycle.

Dr. Lowenstein: It’s a circular thing, right.

Dr. O’Neil: So if we can get rid of one or both of those, and you do that long enough, the brain goes, “Oh, we don’t have any muscle tension. Huh. And it doesn’t hurt anymore. Oh, I guess there’s nothing wrong. I’ll just relax now.” And it relaxes out, and it happens very, very rapidly.

Dr. Lowenstein: So you’re resetting that circular pain cycle.

Dr. O’Neil: Absolutely. Yep. Which then brings us back into that habit of function. If we do that, but we don’t change somebody’s function, their posture, how they’re sitting at work, how they drive, the exercises that they do for strengthening their back, if we don’t change those things, then all we’re doing is wasting their time and their money and making them dependent upon our treatment technique. So it all pulls into itself. You have to focus on what we do as humans as well as how to get rid of the symptoms. And so that’s what I do with the muscles. I do that throughout the neck. Then skeletal with those facets, and the facets are just basically where your spine sits on itself.

Dr. O’Neil: That’s the easiest way of looking at that. The interesting part, though, is that right by those facets, right by those building blocks of the spine. That’s where those nerves come out of your neck, for your muscular nerves, your sensory nerves, that’s where it all comes out. So if you get a little bit of irritation because you’re kind of grinding those joints, your posture is not very good, and you’re kind of grinding on that, that’s going to create inflammation in a very small area. Well, that inflammation then can inflame that nerve root, which causes muscle tension, and we’re back into that pattern again.

Dr. O’Neil: So those facets, number one, I focus on posture. Big time, really getting people to sit up straight, to stand up straight. We’re not in the military. You don’t have to be all hardcore about that, but you do have to be aware. I was out with a band, because as a part of my job of what I do is I tour around the world with rock bands. As I was out with one band, and I improved this band member’s height by two inches while I was out on tour with them.

Dr. Lowenstein: Wow.

Dr. O’Neil: And you think about the tension that was released from his spine. That was great. The problem was, then he didn’t have the stability to maintain that good posture position. So then we had to balance that with the proper exercises on his back in order to not have him fall back into that posture pattern. Yeah, so the skeletal thing is, I don’t do manipulations like a chiropractor might do a manipulation. That is not my bag, and that is definitely not my training. And unless you got a really, really good chiropractor, I wouldn’t be having anybody touch my neck in that manner.

Dr. Lowenstein: Yeah, that always-

Dr. O’Neil: It’s scary.

Dr. Lowenstein: … it makes me very, very nervous. In my general surgery training I was at a spine center, and I had unfortunately … There’s a lot of great chiropractors out there, so this is not a global thing, but I have actually seen paralysis from bad manipulation from chiropractors, and it always makes me very nervous to see somebody’s neck manipulated. And, again, sometimes it’s fantastic, and you do it by somebody who’s got really good training, and it works very well in the right hands. But in the wrong hands it can be an issue.

Dr. O’Neil: Yeah. Absolutely. And we have PTs out there, “Oh, I went to a weekend course on manipulation I can do it.”

Dr. Lowenstein: Oh my goodness.

Dr. O’Neil: I’m like uh-uh, uh-uh. That’s not how we roll, man.

Dr. Lowenstein: It’s like a weekend course in surgery. That is not something you ever want to hear.

Dr. O’Neil: Absolutely.

Dr. Lowenstein: Okay. So, yeah.

Dr. O’Neil: And that falls in line with my approach with treatment. I have a PT buddy. He’s out on the East Coast. And the East Coast, if you’re up in the Boston, DC, New York area, it seems like PT … When you go to a physical therapist, you want to feel pain. And if you feel pain then you know they did something. So they’re using Graston. They’re using all these other techniques which are causing pain. And I’m sitting there going, “Man, you’re insane, because that’s part of our loop.” Our loop is if you cause pain, then that’s going to cause more symptoms. Same thing with the manipulation.

Dr. Lowenstein: You just start the cycle.

Dr. O’Neil: Exactly. If I manipulate your upper cervical spine and I compress that joint, your brain, which is already triggered to it, is going to freak out, and it’s going to say, “There’s something wrong,” and it’s going to create tension. I try to follow this pattern of, “Hey, let’s get rid of your pain. Let’s reduce your stress. Let’s reduce the inflammation. Let’s get rid of these things,” then we can actually keep them gone. That’s that nerve compression and the occipital compression, that type of thing. So all my approaches are elimination of pain and elimination of symptoms as we go through the eval.

Dr. Lowenstein: All right. Okay. Yeah. It’s very interesting to me, because frankly we approach things differently to the same issue. And I think that to the people who you see and the people who you’re having success with have reversible issues for all of these things. I treat the occipital nerves that are going through the trapezius muscles. And the people who come to me have either chronic tightness and scarring that just does not get relief, or they have non-muscular problems. So if you have the occipital artery that’s crossing your occipital nerve, then that’s causing inflammation and really nothing besides release of and division of that artery is going to prevent that compression in my experience.

Dr. Lowenstein: And similarly, when you’re talking about supraorbital, supratrochlear nerves and even the zygomatic, atemporal, auriculotemporal nerves, the people that I’m … I operate on a young man … I don’t know even know what day it is anymore. The day before yesterday. Those nerves go through a bony tunnel in some people. And his tunnel was really long and really tight, and I had to resect the bone around that nerve, and he had chronic 24-7 headaches before that. And you take that bone away, and it releases the nerve. But those are not reversible problems. You can’t get to the bone … You can’t release the bone through manipulation and these releasing things.

Dr. Lowenstein: So many people, though, have these muscular issues that are reversible in the right hands with the right treatment. And I think that it’s really interesting to me how different people have different approaches. And at the end of the day, kind of what you said before and it’s not a tumor, it’s not a tumor in your brain. A lot of these headaches are being … They may be centrally mediated, meaning that you feel it centrally in your brain, and there are processes going on in your brain that cause the pain to get worse. But the triggers, the things that are starting these headaches are actually so often in your head and neck outside of your brain and accessible. So I think what you’re doing and what I’m doing is trying to treat the cause. Stopping these mediators in the brain that then bring on the nausea and all of these horrific secondary problems.

Dr. O’Neil: Yeah, absolutely. Yeah, yeah. I can’t agree more. There’s things … I had a gentleman who had headaches every day for 20 years, and this was when I was a student, and I treated him two times, and I got rid of his headaches both times. The second time he sat up on the table and his headache’s gone. He’s feeling great. He leans over to tie his shoes, and he’s kind of got a little belly on him, and he sucks in his breath. He goes … and leans forward, sits back up, let’s out his breath, goes, “Ep, I got a headache.” And I’m like, “Oh, well, because you just shot pressure into your head. You just did a Valsalva maneuver, and you just changed your blood pressure. Ah. Put your foot up on a stook when you tie your shoe or lose your belly, which will take a lot longer.” As soon as he did that, all of his headaches went away after 20 years that’s all it was with a little thing.

Dr. Lowenstein: Interesting. Yeah, yeah, yeah. It’s just behavioral.

Dr. O’Neil: It’s just behavioral. And so that’s I think the thing that sets you and I apart is we are actually looking for the cause, not a bandaid.

Dr. Lowenstein: Right. Yes, exactly.

Dr. O’Neil: Because we want to actually have success. We actually care about the people that come through to us. And we haven’t resigned to the concept that … And this is my bone to pick with PT, but come in, they’re like, “Oh, you got headaches. Yeah, it’ll be three times a week for four weeks.” Well, typically my first visit is I just do a screen on people. Yeah, it’s a 45-minute screen. It’s basically my eval. But I’m going to tell them that day what I can do for their headaches, how long it’s going to take, or if I can’t do anything for them. I’ve had that as well.

Dr. Lowenstein: Right. Yeah.

Dr. O’Neil: I had a kid come in, and he was diabetic. And when we went through the whole thing, he had zero symptoms, nothing that I was going to change. And I was just like, You know what, after talking with you it’s your diabetic medication. You need to talk to your doctor and you actually need to take your meds. You actually need to manage your health better so that you’re not having these blood sugar spikes and drops.

Dr. Lowenstein: Right. Sure. That makes sense.

Dr. O’Neil: And he didn’t want to hear that. The mom didn’t want to hear that, but I’m not here to make people happy. I’m here to tell them the truth. And so for me it’s I go through a number of rules. The first one is like you and I said, find the cause, not putting a bandaid on things. Number two is eliminate the symptoms. Can we in any sort of conservative manner get rid of symptoms before they have to get to the surgical route? Number three is change our habits and our postures. Number four is really important for me, though. It’s empowering the patient. When you have headache pain, you can’t get any closer to your thought process. I mean, in your head. It’s debilitating.

Dr. O’Neil: And so what happens is these people over time, they lose hope that anything can actually help them. And so the effectiveness of my treatment actually goes down. So I ask them when they walk in, I ask them, I said, “All right, when you’re done today, yeah, you’re at an 8 out of 10, I’m sorry about that. Not lack of empathy here, but what number do you want to be at when you leave?” And it’s amazing how many people, probably 50% don’t tell me zero. If I come in, and I’m like, “What number do you want to leave at today?” I’m going to be like, “Zero.”

Dr. Lowenstein: Yeah. You’re like, “I want to be pain free.”

Dr. O’Neil: Pain free.

Dr. Lowenstein: Yeah. That’s my goal.

Dr. O’Neil: But they’ve given up … That’s my goal. But they’ve given up so much hope of that. They’re like, “Well, man, if I could just be at a four today I would be happy. That would make my day.” And typically they hit the number that they pick, which is really, really interesting. Whether they pick a four or they pick a zero, they almost always hit that. But I give them the stretches. I give them exercises. I give them the ability to take control of their symptoms the second that they leave that office. Then when they come back a couple of days later I ask them, “All right, your headache is going to come back. Trust me. It’s okay. It’s going to come back, but I want you to pay attention when, why, how. I want you to tell me every detail about that, because that’s going to feed me more information to better treat you.

Dr. O’Neil: And so I really want to empower people and empower the patient. And then we just adjust. They come back and they tell me that information, and we adjust what we’re doing, and we modify … “Okay, well, it is eye strain. All right? Let’s focus on the eyes a little bit more.” And that’s a really simple thing to get rid of as well.

Dr. Lowenstein: That’s great. I really like how you … Individualization of care I think is really important and kind of lost in a lot of today’s paradigms. I really appreciate … I mean, your input, I think is extraordinary valuable, and I really … I couldn’t agree with the stuff that you’re saying anymore. It’s great. We’re kind of approaching our general length of attention for people. Let me just quickly ask you, can you tell me a little bit about you’ve got a new project. And just share what that’s about with the public?

Dr. O’Neil: Yeah. So I started a company last year called Zivel, Z-I-V-E-L, and you can check it out at And we are a recovering performance suite. For a better term that people understand it’s a spa. So we’re a recovering performance spa. And what I’ve found is that people typically, like that lack of hope thing or whatever, they got symptoms all the time, they got stress all the time. And I’ve always looked through my career for what is something that I could do to eliminate that stress, the pain, the whatever, for long enough? And if we can do that, then people will typically have a little bit more hope. They’ll have a little bit more empowerment to actually start eating better, to sleeping better, to performing better in their day, to be better people just in life.

Dr. O’Neil: And so I’ve always looked for those things and at Zivel what we’ve figured out if we found kind of a combination of modalities that we utilize for that. And so it’s outside of the healthcare realm. We’re really focusing on the health side of things and can we affect people’s behaviors and the outcomes before they have to come to you or me as a healthcare provider. And so that’s really what we’re doing, to allow people to recover faster from their performances and doing 5K marathons, rock stars, that type of thing. So, yeah. Check it out at And we can talk about those modalities on another podcast.

Dr. Lowenstein: Yeah. I would really have you back. I know that your experience and expertise in flotation and, is it sensory deprivation … is that the right way to say it?

Dr. O’Neil: Yeah.

Dr. Lowenstein: Not that everybody needs to know this, but we’re doing this kind of first thing in the morning on one of our clinical days. I’m seeing a patient in about an hour who has done sensory deprivation as a successful part of their headache treatment. So I’d like to talk to you about that some time in the future. That would be great. But definitely check out Zivel. And Matt, thank you so, so much. I really appreciate your taking the time to help us inform people. I hope that everybody gets the chance to see somebody that treats people and cares about people like you do.

Dr. O’Neil: Thank you.

Dr. Lowenstein: And I try to do as well. Again, thank you very much.

Dr. O’Neil: My pleasure.

Dr. Lowenstein: And hopefully we’ll talk again soon.

Dr. O’Neil: Yep. Thanks, Adam.

Dr. Lowenstein: All right. You bet. 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 that’ll be able to find us, the more help and information we can 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 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 YouTube or 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 would consult with me directly about, please call our headache surgery center. Our number is 805-969-9004, or email us at, and my staff will set up a consultation and discuss your specific case. Thanks and best wishes from all of us here at Podcast 360.

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