Migraine Surgery Planning
The first step towards surgery is the use of Targeted Injection Mapping to identify the nerves that are causing the patient’s headache pain. Through precise nerve blocks, Dr. Lowenstein can localize which nerves are the cause of the headache pain and provide a plan for a more permanent treatment going forward.
Once the irritated nerves that contribute to your headache are identified, surgical decompression can be planned and performed. Dr. Lowenstein performs all of his headache operations in his AAAA certified surgery center adjacent to his headache center, staffed with specialists hand-picked by Dr. Lowenstein for their clinical abilities. Your surgical day begins in a comfortable private room at our migraine headache center where you will see our nursing staff, our anesthesia provider, and of course Dr. Lowenstein who will review your migraine headache surgery and put some markings on the areas to be addressed.
Depending on the nerves involved, headache surgery may be performed in the supine position (laying on your back) or in the prone position (laying on your stomach). Special padding is utilized to ensure patient comfort and safety, uniquely combined for each individual’s head and body type and size.
Migraine Surgery Overview
Dr. Lowenstein includes this information and descriptions about migraine surgery for those patients interested in the details of the headache surgery procedure. Some patients who get “queasy” may choose to skip this portion of our website.
All migraine surgery is performed while you are asleep under general anesthesia. After being brought to our state of the art operating room for your headache surgery, you will be gently put to sleep by our outstanding anesthesia staff. Once you are positioned on the operating room table in the safest and most appropriate fashion, the area to be addressed is cleaned and draped in a meticulous manner. The addition of local anesthesia ensures that postoperative comfort is maximized, and additionally helps with the control of any minimal bleeding near the skin surface. While bleeding is tolerated by most types of surgeons, even 2 drops of blood are significant to a migraine surgeon, and meticulous hemostasis (control of even minimal bleeding) is paramount to Dr. Lowenstein.
For headache surgery, special instruments are required and used. Microsurgical instruments, the same as those used for our microscopic repair of small vessels and structures during reconstructive surgery, are used to isolate the nerve complexes and free the nerves from surrounding tissue. Nerves can be compressed by fascia (connective tissue), muscle, bone, or blood vessels. These constricting tissues need to be released in order that the nerve in question lies comfortably in a manner that is not constricting or susceptible to irritation.
A special nerve stimulator is used to discern the difference between sensory nerves that provide feeling to the skin (the headache trigger nerves) and the motor nerves that signal muscles to move. In the performance of migraine surgery, Dr. Lowenstein uses meticulous techniques to avoid important motor nerves. In over 15 years of experience, Dr. Lowenstein has never damaged any of these important motor nerve structures.
How Dr. Lowenstein Targets Problematic Nerves
The problematic nerves that are targeted in your migraine headache surgery can be addressed in one of a few ways. Nerves can be released or disrupted, depending on their position and function.
Some nerves, such as the supratrochlear, supraorbital, and greater occipital nerves provide sensation to the front and back of the forehead and scalp, respectively. These nerves are common causes of migraine headaches and frequently targeted in migraine headache surgery. These nerves are evaluated throughout their course, and any constricting tissues are addressed. Small bony entrapments may be released by removing small amounts of bone. Crossing blood vessels are relatively small yet can provide nerve irritation, and these blood vessels are addressed with specialized cauterizing forceps in order to release the nerve. Bands of connecting tissue that can compress the nerve are released with either micro scissors or cautery. In areas of muscle tension, problematic muscle fibers may be released to allow the nerve to lie in a relaxed and non-constricting fashion. The amount of muscle addressed in these instances is quite small in relation to the size of the whole muscle, but because the nerves can be constricted by even a small amount of muscle, these maneuvers can be very critical.
Other nerves, such as the zygomaticotemporal and auriculotemporal nerves provide sensation to small regions of the skin, These nerves may be released or divided in migraine headache surgery. If these nerves are divided, it is almost impossible for a patient to tell that they are gone. This is because of the biology of neuroplasticity.
Neuroplasticity refers to the ability of the brain or peripheral nerves to take over for nerves that have been damaged. This actually pertains to even the larger supratrochlear, supraorbital, and greater occipital nerves listed above. In the very rare case that these nerves are so distressed that they need to be divided, other nerves will often take over for their function and sensation to the affected region of the skin returns with time, due to neuroplasticity.
When a nerve is divided into migraine headache surgery, it is important that it is done so in a very particular way. Nerves that are simply cut can form inflammatory regions called neuromas that can be abnormal and painful. It is important that when performing migraine headache surgery that the disrupted end of the nerve is buried in an adjacent muscle. This maneuver prevents neuroma formation and prevents further inflammation and irritation of the nerve end.
Post Migraine Surgery
Following appropriate treatment of the nerves that Dr. Lowenstein has targeted in your migraine headache surgery, the wounds are again examined for any bleeding which is stopped if necessary. The wound is then washed out and closed with sutures that may or may not need to be removed the following week, depending on the region of the head and neck that has been operated on. If your migraine surgery has been performed in the prone position, you will be returned to your back and awakened from general anesthesia. Our recovery room at our migraine headache center is a private, comfortable room in which you can wake up gently without bright lights or loud noises, with personalized nursing to aid in the initial stages of your recovery.