Procedures frequently performed Dr. Reis
Nerve Decompression Surgery for Migraine in Houston
Dr. Scott Reis is proud to be one of a small number of specialists in the United States to perform nerve decompression surgery for migraine. If you suffer from severe, chronic migraines caused by compression of the occipital nerves or the facial trigeminal nerve branches that do not respond well to medication, it is possible that you could benefit from this life-changing procedure.
What is Migraine?
Migraine is a highly prevalent neurological disease that impacts up to 1 billion people worldwide. Far from just a headache, migraines are a collection of neurological symptoms that can cause incapacitating pain, visual disturbances, nausea, vomiting, dizziness, tingling, numbness, and extreme sensitivity to light and sound, not to mention significant or even complete disability.
There are many different types and causes of migraine, headaches and migraine-like pain, some of which are much more difficult to diagnose and treat than others. While some patients respond well to prescription medications for migraine, others may not. According to the Migraine Research Foundation, more than 90% of migraine sufferers are unable to perform normal activities or even function well enough to work during a migraine attack. Every year, employers in the United States lose more than 157 work days due to migraine. Patients with especially severe or frequent migraines may not be able to work at all.1
Who is a Candidate for Nerve Decompression Surgery?
Candidates for this type of surgery suffer from migraines triggered by compression of the facial trigeminal nerve branches, or more commonly in Dr Reis’s practice patients suffer from chronic unremitting head and neck pain (UHNP) specifically triggered by compression of the occipital nerves which are located on the back of the head and upper neck. There are three paired occipital nerves on each side of the head and neck: the Greater Occipital, the Lesser Occipital, and the Third Occipital nerves. Clinically, these UHNP symptoms are known as Occipital Neuralgia. These patients represent a small subset of migraine sufferers, and Dr. Reis’ patients are generally referred by a migraine specialist neurologist who has ruled out other potential migraine causes through careful diagnostics. These patients have often experienced years of failure with every medical, injectable and non-surgical treatment for their chronic and debilitating pain.2
Diagnostic Process for Nerve Decompression Surgery
One of the key features of migraines caused by compression of the occipital nerves, the type of migraines Dr. Reis most frequently treats, is unremitting head and neck pain, or UHNP. When these nerves become compressed by the muscles, fascia, connective tissue and vessels of the neck, the result is often constant mild to severe discomfort, pressure, or tightness at the back of the neck. During a migraine, this becomes intense pain that often radiates to the back of the head, the neck, the temples, forehead, and the face and may also be accompanied by nausea and extreme sensitivity to light (photophobia).3 These occipital neuralgia events often progress and cause secondary facial trigeminal migraine symptoms as well.
The struggle for neurologists and specialists such as Dr. Reis when diagnosing this specific type of migraine is linking the patient’s near-constant and severe discomfort to anatomic compression of the occipital nerves, as head and neck pain can be attributed to so many sources. There are a number of tests that may help Dr. Reis and his colleagues eliminate other potential migraine causes and pinpoint occipital nerve compression as the trigger point for a patient’s UHNP:
- Point Tenderness: In most patients, a manual examination of the head and neck reveals point tenderness, or soreness directly over the compressed nerve when it is touched.
- Anesthetic Injections: If a patient’s UHNP is eased by the injection of a local anesthetic to temporarily block and numb the occipital nerve, it is likely that compression of this nerve is at least one source of their migraines.
- BOTOXⓇ Treatment: Some patients report a decrease in migraine frequency and intensity when the neurotoxin BOTOX (onabotulinumtoxin) is injected to paralyze the muscles that can compress and irritate the occipital nerves. This is a good sign that these patients may benefit from surgical decompression of the nerve.
- Steroid Injections: If steroid injections to the occipital nerve result in a reduction of the frequency or intensity of a patient’s migraines, by decreasing overall inflammation, it is likely that compression of this nerve resulting in chronic inflammation is one source of their UHNP.
- Doppler ultrasound: Using sound waves to detect blood flow can also be used to confirm compression sites, since many times the occipital artery and veins encircle the adjacent nerves and cause compression as well.
Overall, along with the patient’s history, presenting symptoms and detailed description of their pain, response to one or more of these diagnostic and therapeutic tests indicates a high likelihood that they will benefit from surgical decompression and release of one or more involved nerves.
The Migraine Surgery Procedure
Occipital nerve decompression surgery is an outpatient procedure performed under general anesthesia at Dr. Reis’ surgery center in Houston, and the procedure typically takes 4-5 hours. Dr. Reis also injects EXPAREL, a 3 day long-lasting non-opioid pain medication, plus a months-long steroid anti-inflammatory to ease postoperative pain and minimize postoperative inflammation and resulting scar tissue formation.
Using meticulously designed cosmetic surgery access techniques, Dr. Reis makes a vertical incision at the base of the posterior skull down to the bottom of the hairline and/or paired incisions located behind the ears, keeping all incisions within the hairline, so they are completely hidden one the sutures are removed. Dr. Reis also does not routinely shave hair at the incision sites to avoid visible shaved patches that can take months to years to regrow, a technique that almost all other surgeons do not use since it’s easier to just shave the back of the head.
Once he gains access to the occipital nerves, Dr. Reis carefully frees the nerves from the fascia, muscle, blood vessels, and connective tissues that are compressing them and repositions the nerves adjacently to avoid formation of aggressive scar tissue and potential recurrent compression during the healing phase. Additionally, to prevent compression from recurring, Dr. Reis strategically pads the nerve with a fat flap and also injects long-acting steroids into and around the nerves to serve as an anti-inflammatory and minimize dense scar tissue formation that can lead to recurrent compression. The incision is closed with small buried absorbable sutures, and the patient is gently awakened from anesthesia in a recovery area.
Nerve Decompression Migraine Surgery Results
Occipital nerve decompression surgery is a delicate operation. Thanks to Dr. Reis’ meticulous attention to detail and advanced microsurgical skill, he has demonstrated a near complete cure rate for all qualifying patients he has treated.
The benefits of this procedure for suitable candidates are immediate and absolutely remarkable. Following occipital nerve decompression surgery, after waking up from anesthesia most of Dr. Reis’s patients have immediate resolution of the occipital neuralgia pain which is long-lasting and usually permanent. Although not Dr Reis’s experience in practice, patients can sometimes experience persistent but minimal symptoms like before surgery or have other migraine sites appear at different locations not surgically released. However, the patients are universally able to take dramatically less preventative or abortive migraine medications at much smaller doses, while also showing a significant long-term improvement in their pain intensity, frequency and duration.
Recovery After Migraine Surgery
Occipital nerve decompression is an outpatient procedure, which means that patients are able to return home the day of surgery. It is normal for patients to experience numbness or mild soreness following the procedure, but this is reduced in severity thanks to Dr. Reis’ injection of EXPAREL during the procedure which miraculously numbs the operative areas for a full 3 days. Patients are also sent home with a prescription for pain medication to enhance their comfort. Most patients require no more than an over-the-counter pain medication within a week of the procedure. Tingling, numbness, and changes to sensation are completely normal, and although not painful cause an odd sensation that patients all notice but are infrequently bothered by. As nerves heal, repair and regenerate very slowly compared to all other superficial tissues, these sensations may be present for up to 6-12 months. In the event that the numbness and tingling becomes uncomfortable, there are additional oral non-opioid medications available to treat these symptoms if indicated.
Following nerve decompression surgery, most patients feel comfortable returning to work and other daily activities within 1-2 weeks. Dr. Reis recommends that patients refrain from exercise or strenuous activity for 4-6 weeks while they heal.
Dr. Reis will monitor patients’ progress after performing nerve decompression surgery, and patients’ postoperative physical therapy rehabilitation is typically directed by their neurologist. It is important that patients attend physical therapy following surgery in order to maintain flexibility and range of motion, and to minimize the formation of scar tissue. Many patients also find massage and even acupuncture to be beneficial during their recovery period.
Migraine Surgery FAQs
Will I have scars after my migraine surgery?
Dr. Reis makes incisions for occipital nerve decompression above the hairline at the back of the head and behind the ears within the hair bearing part of the scalp, so all incisions and resulting scars are hidden within the hair.
Will I have to shave my head before surgery or will Dr. Reis do so in the OR?
In general, no. Although it’s more challenging and takes a little more time and skill to perform the nerve decompressions without shaving large areas around the incisions or even the whole back of the head and neck, Dr. Reis is a meticulous perfectionist and a skilled cosmetic surgeon who strongly believes that the benefit of using completely hidden incisions and not shaving hair is far outweighed versus the extra time and effort required. Occasionally, Dr. Reis will shave a thin strip of hair directly where the incision will be placed.
What risks and complications are associated with nerve decompression surgery for migraine?
Any surgical procedure carries some risk, though occipital nerve decompression is widely considered to be a safe procedure. Risks and complications, though rare, may include:
- Incomplete resolution of migraines and/or occipital neuralgia
- Long-lasting or permanent numbness, tingling, itching of the posterior scalp
Will my migraines ever come back?
Dr. Reis carefully pads the newly-decompressed occipital nerves during surgery and also injects steroids into and around the nerves in order to prevent future compression and the formation of scar tissue that may induce future migraines. Additionally, Dr. Reis works closely with the referring neurologist who coordinates post-operative physical therapy to further minimize the chance of recurrence. Because of these steps, it is unlikely in Dr. Reis’s experience that patients will encounter future compression of the treated nerves.
It is possible, however, for patients to experience “unmasking” or the appearance of secondary migraine trigger sites that weren’t present or at least not evident prior to surgery. This is because these secondary migraine sites are much less intense than the primary migraine sites treated and may not have been previously prioritized by the brain’s processing and sensory signals. In the event that secondary trigger sites do appear after surgery, these are often successfully treated with additional surgical release if nerve compression is determined to be the cause.
Will my insurance cover the cost of occipital nerve decompression surgery?
While many medical insurance plans do cover the cost of nerve decompression surgery for migraine and occipital neuralgia, this is not the case for all of Dr. Reis’ patients. Unfortunately, many private insurers consider this surgery “experimental” or “not medically necessary”, despite the fact that these surgeries have an over 15 year track record of success with many thousands of patients benefiting as well as hundreds of peer-reviews publications supporting the contrary. To ensure that you have access to a potentially life-changing treatment in the event of lacking coverage or being denied coverage of the procedure by your insurer, we can help you explore a range of flexible and affordable payment and financing options.
Contact Dr. Scott Reis
If you suffer from migraine headaches that have not responded well to medication and your neurologist believes that your headaches are triggered by occipital nerve compression, you may benefit from surgical migraine treatment. To learn more about this procedure and whether you are a candidate, please contact us to schedule a consultation with Dr. Reis.
1 Migraine Research Foundation. What is migraine? Available: https://migraineresearchfoundation.org/about-migraine/what-is-migraine/migraine-disease-and-its-impact/. Accessed January 20, 2021.
2 Bink T, Duraku LS, Ter Louw RP, Zuidam JM, Mathijssen IMJ, Driessen C. The Cutting Edge of Headache Surgery: A Systematic Review on the Value of Extracranial Surgery in the Treatment of Chronic Headache. Plast Reconstr Surg. 2019 Dec;144(6):1431-1448. Available: https://pubmed.ncbi.nlm.nih.gov/31764666/. Accessed January 20, 2021.
3 Blake, P., Burstein, R. Emerging evidence of occipital nerve compression in unremitting head and neck pain. J Headache Pain 20, 76 (2019). Available: https://doi.org/10.1186/s10194-019-1023-y. Accessed January 20, 2021.
4 Guyuron B, Nahabet E, Khansa I, Reed D, Janis JE. The Current Means for Detection of Migraine Headache Trigger Sites. Plast Reconstr Surg. 2015 Oct;136(4):860-867. Available: https://pubmed.ncbi.nlm.nih.gov/26397259/. Accessed January 20, 2021.
5 Hatef DA, Gutowski KA, Culbertson GR, Zielinski M, Manahan MA. A Comprehensive Review of Surgical Treatment of Migraine Surgery Safety and Efficacy. Plast Reconstr Surg. 2020 Aug;146(2):187e-195e. Available: https://pubmed.ncbi.nlm.nih.gov/32740592/. Accessed January 20, 2021.