Published April 26, 2024 By Adam Lowenstein

The following presentation is by Dr. Adam Lowenstein, MD who is a plastic surgeon Board Certified by the American Board of Plastic Surgery, who specializes in nerve decompression surgery for chronic headaches and migraines.


Hi, it’s Dr. Adam Lowenstein, and it’s been a while since. I feel like a lot of you have seen me. I’m probably a little older looking. It’s a little more gray here, more gray there as well. But I have been getting complaints and I really, I don’t like complaints and I have people complaining that I have not updated the podcast in a long time and I haven’t put many videos on recently. And honestly, all these things are true. And I’m sorry, but just honestly between being busy here at work and having a 9-year-old and a 12-year-old, soccer and volleyball and lacrosse and all kinds of things, I’ve been poor at finding the time to update things. So I am going to try and add some podcast episodes and combine them with videos in the manner that I’m going to make extended videos and shorter podcasts.

So I’m going to talk today about some diagnosis issues and such. And also we’ll put this on our YouTube channel. We’ll add this to our podcast. It may not be the 45 minute or hour long podcast that we’re used to, but one of the big things that I’m hearing about are I’ve got patients who call or email me and say, I’ve got this diagnosis or that diagnosis. Do you treat people with these various diagnoses? And honestly, I understand why these diagnoses exist, and yet they drive me crazy. So what we have to realize is that from a neurologic standpoint, and also unfortunately from an insurance standpoint, there are so many various different types of diagnoses for headaches. And in fact, I downloaded this here, video, people will see it, but podcasts, you’re just going to have to trust me. It’s a description. Let’s see if I can get that in focus, maybe not. But it’s the International Classification of Headache Disorders third edition, and it is 28 pages long. And as you might be able to see, I started to go through all of these diagnoses and I used a highlighter on the diagnoses to say, okay, these are all diagnoses that we can help. And I’m going to get into this in a little bit. Yeah, you see that? And then it got boring. It got kind of crazy. And so I eventually just said, okay, enough, I’m not going to do this anymore. But the point of this is that when people are diagnosing headaches, migraine without aura, migraine with aura, migraine with typical aura, typical aura with headache, migraine with brainstem aura, chronic migraine status, migraine, this probable migraine, probable migraine without or all of these things are different diagnoses, infrequent episodic headaches, frequent episodic, probable cluster headaches, episodic cluster headaches, chronic cluster headaches. So the point is that basically your headache diagnosis is more of a subjective, subjective situation where your provider, neurologist, sometimes primary care doctor, is going to ask you questions about the nature of your headaches, how often they happen, what happens during a headache, what do you get nauseated?

Do you not get nauseated? Is this happening every day? Is it happening three times a week? How long have you had this happening? Et cetera. And so when we look at these diagnoses from a subjective standpoint, it says nothing about what is causing the headache. A different diagnosis such as new, chronic, persistent daily headache is not necessarily a different causality. It’s not from a different process than a chronic problem. That’s not new. It’s just the nature of the headache that creates the diagnosis. This is not all the time. There are headaches that are diagnosed based on brain infarcts or strokes, for example, that actually do correspond to a specific causality. And those particular ones produced by stroke, not things that I can work with, but most of the common headaches, again, migraine tension, headaches, new daily persistent headache status ness.

Let’s just pick trigeminal, a whole bunch of trigeminal headaches, primary exercise headaches, and you’ll have to, excuse me again, I’m taking an opportunity to do this while lots of other stuff is going on in my office. So you may hear people walking by my office at the same time, but if I’m going to put stuff up on my podcasts and my YouTube channels, I need to be opportunistic. And I just have a little bit of time right now. So actually give me one second. I’m going to make this door a little more closed. Anyway, I’m back. So the point of the story is when we’re looking at headaches, rather than look at the diagnosis, what is important in our world of being able to fix these headaches is looking at the cause and the cause of so many of these headaches is actually peripheral neuralgia.

And again, as hopefully a lot of you understand now that you’ve listened and watched and things on our channels, a neuralgia is an irritation of a nerve. And so what we know is that irritation of these peripheral nerves, sensory nerves in the head and neck, can cause various types of headaches. Now, what these 26 pages talk about, not fully but largely is the nature of what happens in the brain after these triggers start to cause pain. And that can be very variable. Just think of, hey, pain is a variable experience. Some people have a high pain tolerance, some people have a low pain tolerance. When some people are in pain, they wince, others scream, others don’t do anything at all. So it’s very similar that in some people when they’re having these triggers, the brain processes them as nausea, photophobia, hemiplegia. In severe cases, sometimes people say, well, my eye twitches, other people say my eye swells.

The brain accepts these signals and then processes, processes them and how these signals are processed, that becomes how the headache is manifested. And how that headache is manifested is how it is diagnosed in many, many cases. So what we do is we look at what is causing the headache. And so for example, if an infarct or a stroke is causing the headache, that is clearly an acute problem and it’s not something that you want to see me for. That’s something that you should be seen by emergency room and neurosurgeons and whatnot for. But chronic headaches, migraines, and these other tension headaches are not always but very often caused from peripheral neuralgia. Okay, so if we were going to look at how to diagnose these headaches, let’s say we were going to reconstruct how to diagnose headaches, the words occipital neuralgia, for example, would become pervasive because occipital neuralgia in actual terms says this is a neuralgia or an irritation of the occipital nerves.

Now an irritation of the occipital nerves causes migraines, chronic headaches, tension headaches, status ness, acute persistent daily headache. I can go on and on depending on the timing and the nature of the headache. So are all of those things actually occipital neuralgia? Well, when you talk to your neurologists, occipital neuralgia is characterized by sharp and shooting pains in the back of the head at the occipital nerve. And that we see those patients. We do treat patients with occipital neuralgia in the same way that we treat patients with migraines that come from their occipital region, but they’re different diagnoses. So the confusion that the patient population is having with regard to how to treat various diagnoses of headaches is really frustrating. It’s frustrating to me, and I’m sure it’s super frustrating to patients. And so the questions of do I treat headache x, headache Y or headache Z?

The different diagnoses is not as important as my headaches are coming from a neuralgia of the occipital nerve or the supraorbital nerve or these other nerves that we treat. And again, we treat the occipital nerve, we treat the greater occipital nerve, lesser occipital nerve auricular, temporal nerve zygomatic or temporal nerve supraorbital nerve supra tr nerve, and you add ’em on both sides. So figuring out what the source of the pain is and therefore what the source of the diagnosis is, is the key. And how do we do that? We do that with nerve blocks. Again, if you come in with a severe headache and a diagnosis of migraine or you come in with a severe headache and a diagnosis of tension, headache or cluster headache, and I give you a nerve block in the area that it hurts and that causes the pain to go away, it doesn’t matter what the diagnosis is.

What matters is that it is being caused by an irritation of that nerve and by releasing that irritation of that nerve, your headache is very, very likely to get better again in my hands. But over 90% of the time, your headache’s going to get better. 50% of those people get a hundred percent better. 50% of those people get at least 50% better as in take a Tylenol and go on with your day. So again, I just wanted to have a discussion about clarify the issue of diagnosis and its confusion in an already very confusing aspect of headache care. I mean, I know that so many of you listening out there have seen so many doctors and a lot of had, I’ve had patients that I think I may have talked about this and in other videos I’ve had a single patient with I think four different diagnoses from the same neurologist of four different headache syndromes that she had. At the end of the day, the problem was our occipital nerve and we fixed it and fixed all four headaches or just fix this one patient. But again, I know that it can be so confusing for patients and that’s really frustrating. And I like people to start to think about what is the cause as opposed to what is the diagnosis for these headaches?

And I know a lot of patients are very, they’re obsessed with their diagnosis and this is going to actually make some patients angry to hear, to say, look, we’re migraine patients. We’re not occipital neuralgia patients, or we have occipital neuralgia. Don’t confuse us with migraine patients. I’m sorry to upset those people, but I would argue that you can all be fixed, not all be fixed. That’s misleading. Many of you can be fixed by the same process and therefore getting a workup for a peripheral neuralgia with a nerve block is just a great thing to do. And look, if you get a nerve block and it doesn’t make your pain better, then you’re not one of those people who has a neuralgia as their source, and I wish you the best. It’s not something that we can fix as headache and migraine surgeons, but most of you’re going to find that when you get a nerve block, you pain gets better.

And again, let me just really, let’s just go into that really quickly. Again, there’s several different types of nerve blocks. There’s therapeutic nerve blocks, there’s diagnostic nerve blocks. Either way, when you get a nerve block, often you should have a lidocaine or a local anesthetic that goes in that should alleviate your pain for a short period of time. Lidocaine only lasts for a half hour or 40 minutes. So if you get a nerve block and your scalp goes numb in the area, you get that nerve block, the area that nerve supplies. So supraorbital nerve that should make this whole area go numb, occipital nerve, this whole area should go numb and your pain goes away for a half an hour. That is a positive result from a nerve buck. I’m not trying to make your headache, I shouldn’t say that these nerve blocks are not intended for long-term improvement.

These nerve blocks are just telling us that when the scalp went numb, the pain went away. Now, if you get a steroid nerve block and your steroid is irritating the nerve, as it often does in the short term, you may get a short term of numbness, headache gets better, and then headache comes back as a rager. Well, that’s because as the local anesthetic stops working, then you just have the irritation of the steroid in the actual injection, which is making that nerve very, very irritated causing a headache. It’s even more example and more support that the nerve is the problem. And taking away the irritation with migraine or headache surgery should provide you significant improvement. So again, getting those nerve blocks and finding numbness in the area that those nerves are treating, not treating those nerves are supplying. And in doing so, getting temporary relief, only temporary is what we expect. But temporary relief, that’s a positive diagnostic sign from that nerve block and an indicator that nerve is causing whatever headache diagnosis that you have. So I hope that provides some clarity.

As I said, I’m sorry for my long absence. I’m going to try and find a couple of these ongoing areas of confusion to provide information for the podcast and for some of these extended videos while still being able to be a good dad and get my kids to soccer. Alright, as usual, we’ve got our phone number and our websites and stuff should come up here shortly. But headache and our phone number is (805) 969-9004. And more than happy to have virtual consultations with people if they need some further clarification or you want to get more information on how we fix migraines or headaches. It’s the other thing, we call it migraine surgery. We should call it headache surgery because it could be called, again, tension type headache surgery, or it could be called cluster headache surgery. But if we call it all these different things, it’s even more confusing, I’d say. I hope that helps. Yeah, I hope I didn’t make it worse. Alright, take care. Feel better and please get in touch if we can help you. Bye-Bye.

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