What is a migraine?

Migraines are more than regular headaches, and many migraines differ from one person to another and sometimes even in the same person from episode to episode. A classic migraine is characterized by severe pain, often with throbbing, that is accompanied by other symptoms such as nausea, photophobia, vomiting, dizziness, tinnitus, or sensitivity to sound. Some migraines don’t even involve head pain, but only have other accompanied symptoms. Many migraines have distinct stages, including a prodrum, an aura, a headache, and a postdrome. These stages are not always present and some migraines are not accompanied by one or all of these different stages.

 

What is a migraine prodrum?

A migraine prodrum is the first stage of a classic migraine, which is often followed by a migraine aura and headache. A migraine prodrum often involves irritability, depression, sleepiness, and/or problems concentrating.

 

What is a migraine aura?

A migraine often precedes or accompanies a migraine headache. Migraine auras can include visual disturbances, temporary loss of sight, tingling or numbness in parts of the body, tinnitus, or other symptoms. An aura is not always present in a migraine, and the symptoms of an aura do not always mean that a migraine headache is coming. Migraine patients can experience different symptoms or no symptoms of an aura from one headache to another, and different patients may experience different migraine aura symptoms.

 

What is a migraine postdrome?

During the postdrome of a migraine, patients often feel foggy with an inability to concentrate and may be tired. Migraine patients often refer to a “migraine hangover” with these symptoms and/or accompanying general malaise.

 

What is migraine surgery?

Migraine surgery involves the release, or decompression, of peripheral nerves in the head and neck that are known triggers of migraine pain. Migraine surgery is an outpatient operation that usually takes one to thee hours. Migraine surgery is NOT brain surgery, as the procedures are performed on nerves that lie just below the skin, or in the superficial muscles of the back of the neck. In many migraine patients, it is the irritation of these peripheral nerves that is the cause of chronic migraine or tension headache pain. When Dr. Lowenstein releases these nerves from the compression and irritation of the surrounding tissues, the nerves stop transmitting distressing signals to the brain, and the migraine pain is relieved.

 

What medications are best for migraine?

There are many medications used for migraine headaches. Some migraine patients use over the counter medications such as Tylenol, Advil, or Excedrin. Other medications that are used for other medical problems can be helpful for migraines. Beta blockers that are used for high blood pressure may be prescribed. Antidepressants such as amitriptyline, and anticonvulsants are other medications used for migraines. Narcotics such as oxycodone are dangerous to use for migraine relief. Triptans such as Sumatriptan (Imitrex) or Zolmitriptan are thought to be the most definitive migraine medications, but many patients can’t tolerate the side effects of these migraine medications, such as drowsiness and difficulty concentrating. The newest migraine medications are CGRP inhibitors such as Aimovig, Ajovy, Emgality, and Vyepti are injected medications that work for some patients, though the success rate of these medications are lower than the success of migraine surgery. Patients can report local injection site irritation or intolerance of the side effects of these medications as well. Importantly, most migraine specialists warn against the overuse of migraine medications such as Excedrin, narcotics, and triptans, which can produce medication overuse headaches that can be very difficult to treat.

 

What is medication overuse headache?

Medication overuse headache is often referred to as a rebound headache, and occurs when the temporary relief provided by a migraine medication is followed by a recurrence of the headache pain, requiring more migraine medication. Excedrin Headache is a medication that is often associated with rebound headaches, as are triptan medications when used more than twice each week.

 

Should I use narcotics for migraine relief?

Narcotics are dangerous medications that can cause rebound headaches and addiction. Chronic use of narcotics such as oxycodone “rewires” the pain centers of the brain, often causing pain syndromes that are ongoing, recurrent, and very very difficult to treat. Dr. Lowenstein strongly urges patients to consider migraine surgery before taking any narcotic medications.

 

How do I get rid of a migraine?

The first line of defense for headaches is often Tylenol, though true migraines can often be resistant to these over the counter medications. Patients with migraines should see their primary care doctors, who may prescribe one of several different migraine medication prescriptions. Migraine patients who are resistant to these medications are often referred to a neurologist, and some neurologists have studied migraine disease more extensively than others and may be considered migraine specialists. Migraine surgery is another option for patients with chronic migraine headaches, tension headaches, or other types of problematic headaches. Migraines can be very difficult to treat with medications, though candidates for migraine surgery see an improvement in their pain over 90% of the time.

 

How do I find a migraine doctor?

Migraines can be treated by a variety of doctors, and usually patients first see their primary care doctor for migraine care. When a specialist is required, patients are often referred to see a neurologist. Some neurologists have done further training in migraine and headache and specialize in migraine care. Patients who are looking for a long lasting option that does not involve chronically taking medications seek out the care of a migraine surgeon such as Dr. Lowenstein. Patients may also seek out a migraine surgeon if they are unhappy with the side effects of their medications or have failed other treatments.

 

How are migraines treated?

Migraines are most often treated with medication. For patients with problematic migraines who are not interested in taking medications for the long term, or for patients who cannot tolerate migraine medication side effect, migraine surgery provides improvement in over 90% of patients who are candidates for migraine surgery.

 

Am I a good candidate for migraine surgery?

Most migraine and tension headache patients are good candidates for migraine surgery. To asses whether a patient is a good candidate for migraine surgery, a migraine surgeon such as Dr. Lowenstein will perform short term nerve blocks to the nerves suspected in triggering a patient’s pain. These nerve blocks often relieve the pain of a migraine headache for a short time, indicating that the nerve that has been blocked is the cause of the migraine pain, and that addressing this nerve surgically should provide long term migraine relief.

 

What is the recovery for migraine surgery?

Recovery from migraine surgery is variable. Many patients report that their pain is gone immediately following migraine surgery in the recovery room. Other patients can have ongoing intermittent headaches in the weeks following migraine surgery. The surgery itself is performed through relatively small incisions that are well hidden, and so scarring is not usually a significant issue for migraine surgery patients. Postoperative pain from the incision and dissection is usually present for the first few days, but not a significant issue for recovery. Just as migraine pain is perceived differently by different patients, the recovery from migraine surgery can vary from person to person. Most patients are up and around the day following migraine surgery, and back to activities of daily living the following week.

 

How long does migraine surgery take?

Migraine surgery can take between one and three hours, depending on the number of nerves that require attention. Pre-operative nerve blocks by Dr. Lowenstein allow the doctor and patient to understand the location and number of the nerves involved, and so migraine surgery patients are well aware of the expectations for their particular surgery which is tailored to their particular needs.

 

Am I a good candidate for migraine surgery

Dr. Lowenstein will be able to tell if a migraine or tension headache patient is a good candidate for migraine surgery by using nerve blocks pre-operatively. In the pre-operative consultation, Dr. Lowenstein will perform short term nerve blocks based on the individual patient’s complaints to determine the particular peripheral nerves that are causing the migraine pain. The rare patient that does not respond to the nerve blocks that Dr. Lowenstein uses is not felt to be a surgical candidate. Most migraine patients that we see at our Migraine Surgery Specialty Center are good candidates and immediately respond to the nerve blocks Dr. Lowenstein uses to evaluate each patient.

 

What is Botox treatment for migraines?

Botox is an injected drug that paralyzes muscle. In patients that have muscle tightness that is causing irritation of the nerves above the eyes or in the back of the neck, Botox can help relax the tight muscles and decrease the nerve irritation, solving the migraine problem for the 2-3 months that the Botox lasts. Botox does not always work in migraine patients, because it may be the case that blood vessels or fasciae (connective tissue) or bone is what is irritating the nerves causing the migraine. Migraine surgery can correct the problematic nerve irritation in any of these cases, releasing the problematic peripheral nerve from the bone, muscle, blood vessel, or connective tissue that is causing irritation and migraine pain.

 

How do I know if I have a migraine?

Migraines are usually diagnosed by a physician. The classic diagnosis of migraine involves the four stages of migraine: prodrome, aura, headache, and postdrome. Since many migraines do not have all of these stages, an evaluation by a physician can help with diagnosis and can be based on headache severity, headache length, and how often a patient gets their headache.

 

Is migraine surgery brain surgery?

Migraine surgery is NOT brain surgery. Migraine surgery is performed on nerves found just below the skin in the muscles of the head and neck, which are relatively close to the skin itself. Migraine surgery does not involve the brain at all. Migraine surgery prevents headaches from occurring by preventing the distress signals from the peripheral nerves from irritating the brain in the first place.

 

Is migraine surgery done in a hospital?

Migraine surgery can be done in a hospital but is most often performed in an outpatient surgery center. At the Migraine Surgery Specialty Center, Dr. Lowenstein has a specialized operating room and private recovery to provide optimal outpatient care for migraine surgery patients. His team is experienced in migraine surgery to make the operative experience as streamlined and easy as possible for migraine headache patients.

 

Does migraine surgery require an overnight in a hospital?

Migraine surgery does not require an overnight stay in a hospital or facility. Migraine surgery patients are seen the day after surgery and a few days following to answer any questions that might arise. In some cases, a visit a week following surgery may be needed to remove sutures. Dr. Lowenstein continues to follow patient for months after each procedure, either in person at one of his migraine surgery offices in Los Angeles, Santa Barbara, or Denver, or virtually by phone or by video call.

 

What is nerve decompression surgery?

Nerve decompression surgery is the same as migraine surgery. As we have learned that many if not most migraines are caused by compression and irritation of the peripheral nerves in the head and neck, specialized migraine surgeons have developed the means to decompress these nerves found just below the skin and in the muscles of the head and neck to provide migraine relief. Nerve decompression surgery for migraines provides relief from migraine pain and symptoms in over 90% of cases.

 

What is the difference between migraine surgery and brain surgery?

Brain surgery is much more involved than migraine surgery. Brain surgery is done in a hospital and involves accessing the brain through the skull. Because brain surgery in so invasive, there are significant concerns for various risks and different types of side effects. Migraine surgery is done as an outpatient procedure and has very little risks and no side effects. Migraine surgery usually takes one to three hours and patients go home the same day, with the immediate ability to return to their activities of daily living.

 

What are the scars like after migraine surgery?

Migraine surgery is performed through very well hidden incisions that heal with hardly noticeable scars.

 

What is the success rate for migraine surgery?

Migraine surgery is extremely effective in reducing or eliminating pain and symptoms of migraine headaches. Over 90% of patients who have migraine surgery have a significant (at least 50%) improvement in their pain and migraine symptoms. About half of those patients (about 43% of all migraine surgery patients) achieve complete relief from all of their migraine pain and symptoms.

When should I consider migraine surgery?

• Different patients consider migraine surgery at different times and for different reasons. You may want to consider migraine surgery if”
• You have tried many other means of controlling your migraines without success
• You are unhappy with the side effects of the migraine medications that you are taking
• You no longer want to deal with the ongoing expense of migraine medications and visits to your migraine doctors
• You have been unable to find a medication that controls your migraine pain
• You have been prescribed narcotics and do not want to risk narcotic dependency or medication over-use headaches
• Migraine surgery is usually reserved for pattens who have multiple migraines each month and for whom their migraine disease causes significant limitations in their life style.

 

Does migraine surgery need to be repeated?

• Once migraine surgery is successfully performed, the results should be long lasting and there should not be any need to repeat migraine surgery. In the few patients who do not respond to migraine surgery, secondary revision surgery can be performed with different maneuvers to control nerves that are particularly troublesome. This second surgery is required less than 10% of the time.
• In patients that have multiple nerves in multiple areas of the head and neck that are causing their migraine pain, procedures might be required in different areas to provide migraine relief. Needing to repeat migraine surgery on the same set of nerves occurs in less than 10% of patients.

 

Does insurance cover migraine surgery?

Different insurance companies and different insurance plans cover different types of procedures, so it may be necessary for you to contact your insurance carrier to determine the coverage that your plan provides.

 

How can I find migraine relief?

Relief from migraine pain can be very difficult to obtain. First line therapies often involve medications which may be effective, or may not provide relief. Patients with migraine pain should discuss their situation with their doctor, and will sometimes be referred to a headache specialist. Some patients will try chiropractors, physical therapy, acupuncture, or pain doctors to try to help control their migraine pain. For migraine sufferers who no longer wish to take medications or who have not been able to control their migraine pain with chiropractors, physical therapy, acupuncture, or pain doctors, migraine surgery often provides migraine relief, and does so in more than 90% of patients who undergo migraine surgery.

 

Is migraine surgery a cure for migraines?

Migraine surgery provides long lasting relief from migraine symptoms in over 90% of patients who have the surgery. About 43% of patients who have migraine surgery obtain complete relief from their migraine headache and other migraine symptoms.

 

Can migraine surgery help other types of headaches?

Migraine surgery can be effective for many different types of headache pain, including tension headaches, chronic daily headaches, cluster headaches, post-traumatic headaches, and even hemiplegic migraines. Patients with occipital neuralgia are outstanding candidates for migraine surgery, also called nerve decompression surgery.

 

What causes a tension headache?

Tension headaches are characterized by pain in the head and neck often caused by tight muscles. Many people are known to “hold their tension” in the shoulders and neck and the muscles in that area, particularly the trapezius muscle, becomes tense and tight. Because the greater occipital nerve (GON) runs through this muscle, the tightness around the nerve causes the greater occipital nerve to send distress signals to the brain which produces severe headache pain. Patients with tension headaches are so often astonished when Dr. Lowenstein relieves their headache with a simple nerve block to the GON, proving that this nerve is the case of their tension headache pain. A simple outpatient operation called nerve decompression surgery, often referred to as “migraine surgery” can release the GON from the tight and tense muscles, providing long term headache relief.

 

Can migraine surgery help tension headaches?

YES! Migraine surgery is also called nerve decompression surgery. In the case of tension headaches, this outpatient surgery releases the greater occipital nerve from the tight and tense muscles that are causing it to be irritated. In patients that have tension headaches, it is that muscle tightness in the neck and shoulders that causes irritation of the greater occipital nerve running through the muscle. The greater occipital nerve sends distress signals to the brain when it is compressed and irritated, and this causes tension headache pain. Migraine surgery decompresses the nerve from the surrounding tense muscles, preventing the nerve from sending distress signals to the brain so the tension headaches do not occur in the first place.

 

What is the difference between tension headaches and stress headaches?

Tension headaches are often referred to as stress headaches. Patients who experience these headaches often hold their stress in the neck and shoulder area causing irritation to the greater occipital nerve that then sends distress signals to the brain causing headache pain. Both tension headaches and stress headaches are virtually the same thing, and both of these headaches can be treated successfully by migraine surgery, achieving headache relief every 90% of the time.

 

Who is a candidate for migraine surgery?

Candidates for migraine surgery are headache patients who find that their headache pain and other migraine symptom cause significant difficulty in their ability to enjoy everyday life and perform normal tasks. In order to show that a patient is likely to respond well to migraine surgery, Dr. Lowenstein performs diagnostic nerve blocks to the nerves that are suspected to be causing the migraine symptoms. These nerves are found in superficial locations in the front and back of the head and neck, and nerve blocks to these nerves usually provides immediate, though temporary relief of headache and neck pain as well as other migraine symptoms. When these nerves are blocked, they can no longer conduct distress signals to the brain causing migraine headache pain. Headache pain relief from these nerve blocks indicates that the nerves are being irritated by the surrounding tissue, either muscle, connective tissue, blood vessels, or bone. Migraine surgery is an outpatient procedure that releases the nerves from the compression and irritation of the surrounding tissue, preventing the nerves from needing to send distress signals to the brain, and thus the migraine symptoms and headaches do not happen. When patients respond to the diagnostic nerve blocks that Dr. Lowenstein performs during a consultation, we can be assured that the patient is likely a great candidate for migraine surgery and the 90% success rate that migraine surgery patients experience.

 

What is in a nerve block?

A nerve block is the injection of medication to the area of the nerve that prevents the nerve from sending signals to the brain. In the case of sensory or “feeling” nerves that cause headaches, nerve blocks prevent the conduction of distress signals from these nerves to the brain, which prevents the headache that these nerves can cause. A nerve block to a sensory nerve should cause numbness in the area that the particular nerve innervates. For example, a successful nerve block to the occipital nerves should cause the back of the head on one side to be numb. “Diagnostic” nerve blocks like those performed by Dr. Lowenstein use lidocaine to temporarily shut the nerve down. Sometimes neurologists will add steroid to their “therapeutic” nerve blocks to try to provide longer term relief. The steroid is meant to decrease inflammation in the region of the nerve, thus preventing the nerve from sending distress signals to the brain which cause the migraine headache. Migraine surgery does a similar thing in a more permanent manner, by physically decompressing the nerve from the surrounding tissue. When the nerve is separated from the inflammation of the surrounding tissue, steroid injections nor other interventions are usually no longer required.

 

When are nerve blocks used for migraines?

Nerve blocks used for migraines as either diagnostic or therapeutic. Diagnostic nerve blocks used by Dr. Lowenstein during a consultation shut down the nerve for a short time, and provide immediate and short term relief to headache pain. These blocks only last an hour or so but are used to indicate that more long lasting nerve decompression from migraine surgery has a 90% chance of providing relief from headache pain and migraine symptoms. Therapeutic nerve blocks are usually performed by neurologists and pain doctors and usually include steroid to try to decrease the inflammation of the tissue around the nerve that is causing it to be irritated. Therapeutic nerve blocks usually last one to three months and then need to be repeated. The advantage of migraine surgery is that it can provide long lasting relief by decompressing the nerve from the inflamed tissue on a more permanent basis so other interventions are no longer needed.

 

What kind of doctor treats migraine headaches?

Migraine headaches are treated by primary care doctors, neurologists, anesthesiologists, pain specialists, and migraine surgeons.

 

What is the difference between a migraine and a headache?

Headache is one very significant aspect of a migraine. Migraines often have other associated symptoms such as nausea, photophobia, sound sensitivity, and tiredness.

 

What is the difference between migraines and chronic migraines?

Chronic migraines are migraines that occur often and over long periods of time. Chronic migraine sufferers often seek many different types of modalities to find relief from their headache pain and migraine symptoms, as they are often debilitated from the long standing effects of their migraine disease. Chronic migraine patients often feel as though they have tried everything before finding migraine surgery as an option. Most of Dr. Lowenstein’s migraine surgery patients have lost hope that they can be helped, and are shocked at the change in their lives following their successful migraine relief following the outpatient migraine surgery procedure.

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