Why Was I a Candidate for Migraine Surgery?

What criteria did I meet before being approved for migraine surgery?

What is migraine surgery?

I had migraine surgery on December 2, 2017 with Dr. Ziv Peled.

Migraine surgery is a procedure performed by roughly 250 plastic surgeons worldwide.

This treatment involves identifying peripheral nerves in the neck, temples and eye brows that may be contributing to headache symptoms, and performing either a neuroplasty or neurectomy on the targeted nerves.

Neuroplasty involves freeing the nerve from surrounding tissue that is compressing and inflaming it.

Neurectomy involves severing the nerve upstream of its first compressed location and implanting the remaining live nerve end deeply into muscle.

Whether it involves neuroplasty, neurectomy or a combination of both (as was the case for me), migraine surgery addresses the damaged nerves that are causing migraines.

So what red flags indicated to the doctor that my headaches were caused by peripheral nerve damage in my neck, eyes and temples rather than a chemical imbalance in the brain?

1) The Location of My Pain

I discovered migraine surgery accidentally during an unrelated appointment with Dr. Nicole Phillips at Mass General Hospital in September 2017. She had studied my case prior to the visit and was aware of my chronic migraines.

Her first question was, "where are your headaches located?"

I took my right index finger and placed it directly on the quarter-sized spot on the back of my neck slightly beneath the base of my skull where most of my headaches began and were centered.

"Right here," I said. "They start right here, and then spread to my temples and eyes. And massaging this spot brings the most relief."

She liked my answer.

"Have you heard of migraine surgery?" she responded. And the rest is history.

Below are two photos that identify my primary headache "spot." I took the photos during a severe migraine episode on June 2, 2017, several months before I had migraine surgery.

This spot is in the heart of the compression area of both the right greater and lesser occipital nerves, which are primary migraine culprits.

During surgery, Dr. Peled found severe compression and damage in my left and right greater, lesser and third occipital nerves.

 
 
 

I marked the "spot" with a black X on this pre-screening form that the migraine surgeon had me fill out before agreeing to see me.

 

2) History of Injury and Abuse to the Area of My Pain

As part of migraine surgery screening, I was asked if I had any history of injury to the back of my neck, where most of my pain was located.

I did.

In 2011, playing on the beach, I hurled a football 30 yards without warming up. While throwing it I immediately felt a painful zing in the area of the "spot."

The pain intensified over the next couple of hours, and by midnight the pain and headache were so extreme that I went to the emergency room.

They tested me for meningitis. Two weeks later a neurologist diagnosed me with a strained muscle in my neck.

For four weeks after the incident I was bed-ridden with migraines. I almost missed the fall semester of my senior year in college as a result. 

Dr. Peled also thought that it was relevant that I spent 16 months between 2013-2016 living at a Buddhist monastery, meditating 4-8 hours per day.

I showed him my seated meditation posture, and he agreed that this strained posture may have caused compression and inflammation to my neck over the course of hundreds of hours.

It is worth noting that during this 3 year period of intensive sitting meditation my migraines became significantly worse.

3) Other Treatments Failed

Surgery is a last resort, and any migraine surgeon will want to see a history of attempting more conventional treatments such as medication, diet and lifestyle change, physical therapy, stress reduction, acupuncture, TMD treatment, massage therapy, mineral and herbal remedies, etc.

Peripheral nerve damage is beyond the reach of these treatments, and so the fact that I had little success with them made it more likely that nerve damage might be causing my pain.

Triptans, though, have always been fairly effective at relieving my headaches.

But wouldn't this suggest that the headaches were caused by a chemical imbalance? Maybe not.

Dr. Peled explained to me why triptans may provide relief for peripheral nerve-based headaches.

Triptans are vasoconstrictors (they reduce blood flow and make blood vessels smaller). By constricting blood vessels, triptans may relieve compression on nerves that are compressed directly by blood vessels (as is sometimes the case), or by muscle, scar and other tissue that presses on the nerves when neighboring blood vessels become enlarged.

4) Nerve Blocks Eliminated Migraine Pain

The last and most important part of migraine surgery pre-screening is the nerve block test.

This diagnostic procedure provides migraine surgeons with a smoking gun, indicating to them with near certainty whether or not migraine surgery will provide headache relief.

Basically you have to show up to the surgeon's office with a severe headache. Then the surgeon injects suspected nerves one by one with a local anesthetic similar to dentists' novocaine.

The novocaine takes a nerve offline completely, preventing it from emitting pain signals. So, if the doctor injects a nerve with novocaine and the headache pain goes away, that means that your headache was coming from that nerve.

It's very straightforward.

If you are working with a local migraine surgeon, normally you can call the doctor's office on a day that you are having a bad headache, and he will squeeze you into his schedule that day to perform the test. 

In my case, I scheduled my nerve block diagnostic with Dr. Peled a month in advance because I was traveling from Massachusetts to San Francisco to see him. So I actually had to induce a headache.

After putting myself through the wringer the day before, I woke up the day of the nerve block test with a 10/10 headache on my right side and extreme nausea. This was one of the worst migraines of my whole life.

First, Dr. Peled injected the area of my right greater occipital nerve. Within 5 minutes, that area of my scalp went numb and the headache was reduced to a 7/10.

Next, he injected my right lesser occipital nerve. Numbness ensued, and my headache reduced to a 5/10. Next, he injected my right third occipital nerve, bring the headache to a 4/10.

But I was still having pain in my right eye and temple. Just to be certain that this headache was entirely the result of peripheral nerve inflammation, Dr. Peled proceeded to perform two nerve blocks in my right temple.

Within five minutes, the headache went down to a 3/10. Lastly, using one needle, he injected my right eyebrow in three spots. Immediately I felt the relief flushing in. Within a few minutes, all headache pain and nausea was completely gone. 0/10 had been achieved.

My headaches really were caused by peripheral nerves in my neck, temples and eyebrows.

Dr. Peled scheduled me for bilateral migraine surgery on my greater, lesser and third occipital nerves.

During surgery he found such severe damage to these nerves that he paused the procedure to photograph it, something he does only in exceptional cases.

Since surgery, all headache symptoms in my neck (where Dr. Peled operated) have been eliminated.

I still have mild and infrequent headache symptoms in my eyes and temples, and may have a follow up operation on these areas later this spring to achieve 100% migraine relief once and for all.