HEADACHES & PERIPHERAL NERVE SURGERY

About Peripheral Nerve Surgery

Dr. Christopher G. Williams has founded the Rocky Mountain Peripheral Nerve Institute at Park Meadows Cosmetic Surgery.  The mission of Rocky Mountain Peripheral Nerve Institute is to improve the quality of life and educate patients with Peripheral Nerve conditions that are amenable to surgery; such as nerve injury, nerve compressions and certain neuropathies.  The Rocky Mountain Peripheral Nerve Institute does not specialize in back pain, back/spine surgery, or surgery of the brain.

Dr. Christopher Williams is specifically trained in Peripheral Nerve Surgery and Plastic and Reconstructive Surgery with an emphasis on the craniofacial area.  Dr. Williams is not a Neurologist, but a Plastic and Reconstructive Surgeon trained at The Johns Hopkins University (ranked by US NEWS AND WORLD REPORT as America’s #1 hospital for over 13 years) with special interest and advanced training in working with peripheral nerves – those outside the spine and skull – (i.e. arms, legs, face, etc.) and certain pain syndromes.  He has received extended fellowship training in Peripheral Nerve Surgery with one of the world’s experts, A. Lee Dellon, M.D., Ph.D. www.dellon.com 

Offering Non-Surgical & Surgical Treatment For Migraine Headaches

• Conservative estimates suggest that there are over 28 million migraine sufferers in the United States.  [Lipton et al. Headache. 2001]
• 1 in 4 households has a migraine sufferer. [Lipton et al. Headache. 2001]
• Those who suffer from migraines outnumber those who suffer from diabetes and asthma combined. [Centers for Disease Control data]
• Up to 12% of the United States population suffers from migraines. [CDC data]
• Migraines are a major source of lost productivity and workdays in the United States.
• There are many medications on the market that are used to treat migraines.
• Many patients do well and are well controlled with lifestyle changes and medicines.
• However, many patients still suffer frequently from debilitating migraines despite medical therapy, even when medical therapy is maximized and patients are followed closely by a headache specialist.
• Up to 5% of 28 million people (1.4 million people) do not respond to any medication for migraines. 
• Until now, there has been little hope for these patients.  However, research over the last 8 years shows exciting and promising long-term elimination of migraines or greater than 50% reduction in migraine frequency and duration with outpatient surgical procedures that treat the nerves in the muscles and skin of the face and neck that may be a source of migraine triggers.
• These procedures have been shown to reduce the long-term cost of migraine treatments, reduce the need for migraine medications, reduce the number of missed workdays, and decrease overall disability for migraine sufferers.

Patients who still suffer from frequent, severe migraine headaches despite maximal medical therapy may be candidates for relatively simple nerve releases in the head and neck (similar to Carpal Tunnel Release for Carpal Tunnel Syndrome that affects the hand).  These procedures have been shown to eliminate migraine headaches in 45 to 50% of patients and can dramatically reduce the frequency and intensity of headaches in approximately 30% of others.  Total response rates range from 80 to 90% in several published surgical studies.  

Patient evaluation begins with evaluating 4 common trigger sites that may be “Peripheral Activation” sites of migraine headaches.  As the migraine headache grows and progresses, it moves deeper into the brain and becomes “Centralized” and harder to treat or abort with medications. Treating the peripheral trigger spots often reduces the number and severity of migraine headaches. 

Utilizing BOTOX® (Botulinum Toxin A) to relax certain muscles in the face will often help migraine headaches (currently an off-label use of BOTOX®, but BOTOX® it is currently being studied for FDA approval for Migraine treatment).  Patients not only get a beneficial cosmetic effect by relieving facial wrinkles, but they get a very effective treatment for migraine headaches that can last 3 to 4 months.  Patients who respond to BOTOX® can either continue with BOTOX® injections every 3 to 4 months or choose an elective, outpatient surgery to release or “decompress” the nerves that are compressed by the muscles in the specific trigger points. 

The 4 most common trigger points include:

1. The supraorbital and supratrochlear nerve under the corrugator supracilli muscle (above the eyebrows)
2. The zygomaticotemporal nerve within the temporalis muscle (temple area)
3. The greater occipital, lesser occipital, and third occipital nerves within the semispinalis capitis muscle and the trapezius facia (back of neck and posterior scalp)
4. Intranasal pathology in some patients such as septal spurs, enlarged turbinates, and choncha bulosa (inside the nose) 

Research for Perhipheral Nerve Decompression and Correction of Nasal Pathology for migraine sufferers is being pioneered by Plastic Surgeons, Peripheral Nerve Surgeons, and Neurologists at several major universities such as Case Western Reserve University, University of Texas, Southwestern, and Georgetown University.  Credit is given to them for this exciting new work.  There are too many physicians interested in this topic to list; however, Dr. Bahman Guyuron, Jeffrey Jannis, M.D. Ivan Ducic, M.D., Ph.D., David Branch, M.D., Joseph Poggi, M.D., Deborah Reed, M.D., and Jennifer Kriegler, M.D. are to be commended for their pioneering work.   

Dr. Christopher G. Williams at the Rocky Mountain Peripheral Nerve Institute endeavors to work with Neurologists and pain specialists who are interested in migraine headache treatment.  Together they can provide a multi-specialty approach to migraine treatment and other peripheral nerve problems such as diabetic neuropathy, chemotherapy-induced neuropathy, chronic pain and nerve injuries.

• These surgeries have been proven safe, reliable, long lasting, and potentially curative to relive severe debilitating migraine symptoms. 
• Various surgeons have reported good to excellent results in the vast majority of patients since 2000.  (See related articles.)  However, there is still a 10 to 20% non-response rate.  New research continues to improve techniques to reduce that number.
• Many physicians are not yet familiar with these procedures.
• Unlike many medical or surgical procedures, nerve releases for migraine headaches can be incorporated into cosmetic surgery approaches and actually have cosmetically beneficial side effects such as a rejuvenated, relaxed brow (brow lift), or improved nasal form and breathing -- Rhinoplasty/Septoplasty.

If you are a patient who suffers from intractable or severe migraines despite maximal medical therapy and have been diagnosed with migraines by a Neurologist, you may desire to seek consultation with Dr. Williams.  Not everyone is a candidate for surgery or BOTOX®, but Dr. Williams can help you decide your best course of action.

If you have other Peripheral Nerve Disorders such as diabetic neuropathy, chemotherapy-induced neuropathy, lower extremity nerve compressions, foot drop, chronic pain, chronic knee pain (even after total knee replacement), or nerve injuries, you may contact us to see if you would benefit from a consultation.

All Surgery Carries Some Uncertainty & Risk.

Despite proven safety records for these novel outpatient Peripheral Nerve Surgeries for migraine headaches since 2000, all surgeries carry inherent risks.  They are safe and efficacious if performed by an appropriately trained surgeon.  Operative risks include, but are not limited to, excess bleeding, infection, poor skin healing, permanent scars, damage to nerves and blood vessels and numbness.  Smokers are at higher risk for many of these complications.  It is important to stop smoking at least 1 month before surgery.

Additional Surgeries: In many cases your headaches can be treated in 1 surgery.  However, some patients may benefit from a staged approach with 2 shorter surgeries.  Your surgeon will help you decide the best approach for you.  A few patients may need a secondary procedure in the future if migraine symptoms return and are amenable to treatment.  Your surgeon will help decide your best course of action.

Delayed Wound Healing and Dehiscence: In some instances, the incision site takes longer to heal than normal.  Fortunately, this is very rare in the head and neck.  Cigarette smoking, poor nutritional status and a compromised immune system can all cause delayed wound healing or wound separation.

Scars: A surgeon cannot perform peripheral nerve releases with out making incisions.  Any incision will produce a permanent scar.  Fortunately, incisions used for these surgeries are well-accepted cosmetic incisions used for either a Browlifting or Blepharoplasty (Cosmetic Upper Eyelid Surgery).  Any incision in the back of the head/neck is well hidden in the hair. Your surgeon will discuss with you one of several approaches depending on your individual case.  Almost all patients are happy to trade these incisions for a reduction in migraine headaches.

Asymmetry: Every person has some inherent natural facial asymmetry.  One eyebrow is usually higher than the other.  Your surgeon will attempt to correct any natural differences.  However, in any type of surgery, there can be slight differences in healing that are impossible to predict.  A few patients may have their eyebrow position unchanged or asymmetric after healing. 

Sensation: By definition, your surgeon will be operating near and around sensory and motor nerves in the face, head, and neck, just like he would do during cosmetic surgery. Many patients experience reduced forehead and scalp sensation (numbness) because the nerves to the skin can be stretched, temporarily damaged, or cut during surgery. These changes are usually temporary, but can be permanent.  The vast majority of patients will have no long-term noticeable change in their sensation.  A small percentage can experience an itching feeling ranging from slight to intense.  Other patients have described a tingling sensation.

Pain: If you experience severe pain not relieved by pain medicine notify your surgeon immediately. Some discomfort is expected after surgery and you will receive a prescription for pain medication.  You can continue your usual migraine medication post-operatively.  The goal is to wean the patient from medications as the headache intensity is reduced.  Patients who have developed a dependency to narcotics should be prepared to enter a detoxification program after surgery.  Prolonged or intense pain can be due to scarring around a nerve and fortunately is very rare.

Infection: Infections can develop after any surgery.  In the head and neck region this is very rare, but can occur several days to several weeks after the procedure. If an infection does not respond to antibiotic pills, a patient may need intravenous antibiotics in the hospital.  Fortunately, hospitalization is extremely uncommon.

Hematoma and Seroma: A hematoma is a collection of blood under the skin, and a seroma is a collection of the watery portion of the blood under the skin. Hematomas or seromas typically develop within the first few days after surgery. The body can reabsorb small hematomas or seromas. Larger ones require the placement of a drain for proper healing.

Preparing For Your Migraine Surgery

The surgeons at the Rocky Mountain Peripheral Nerve Institute at Park Meadows have 2 licensed and accredited fully staffed state-of-the-art operating rooms affiliated with Park Meadows Outpatient Surgery.  You will be required to have a full preoperative evaluation and work-up prior to any surgery.  A separate preoperative physical will have to be performed prior to any planned surgery to verify your overall health and suitability. You will also get a set of pre-operative instructions describing how you should prepare for surgery.  Certain medications and nutritional supplements can thin the blood and need to be stopped 2 weeks prior to surgery.

After Your Migraine Surgery

You will be given a comprehensive set of post-operative instructions prior to your surgery. Several of the operations are similar to or use the same incisions as cosmetic procedures like Endoscopic Browlifting or Upper Eyelid Surgery (Blepharoplasty).  Recovery is very similar.  If you need a brow approach or surgery on a nerve in the back of the scalp, you will have a small drain for 1 or 2 days.

If you have drains, you and your family will be instructed on how to care for them. Most patients are able to return to work 10 to 14 days after surgery if they do not have a very active job that requires heavy physical lifting or activity. 

Often headaches will go away immediately.  Other patients experience the sensation that they are going to have a migraine, but the migraine never develops.  Still others will have a gradual decrease in headache frequency or severity over time.  10 to 20% of patients will not respond completely or at all from surgery. 

Patients can experience random or shooting discomfort or pain after surgery.  This is normal and typically improves within several months. Some patients will notice changes in their scalp and forehead sensation after surgery.  These sensations tend to even out over time, but in a few cases can be permanent.

Preparing For Surgery

At least 1 month before surgery
Stop smoking at least 1 month prior to your procedure. Smoking reduces circulation to the skin, impedes healing, and can lead to major postoperative complications.

2 weeks prior to surgery
Stop all medications that can thin the blood 2 weeks prior to surgery. These include drugs such as Aspirin, Coumadin, Lovenox, Ibuprofen, Vitamin E, and multiple herbal preparations. These medications may cause bleeding during and after surgery.

Report any sign of a cold or infection that appear the week prior to your surgery. You may need to postpone your procedure to avoid unnecessary complications. Make sure you fill all of your prescriptions provided to you by our doctors prior to your surgery day; this will make the transition from the surgery center to your home as smooth as possible.

1 week prior to surgery
Do not eat or drink anything after midnight before your surgery. This includes water, ice, or hard candy. The only exception is that you may take your blood pressure or heart medication with a sip of water the morning of surgery.

The day before surgery
Plan to wear comfortable loose fitting clothes to the procedure.
Do not wear jewelry or bring valuables with you on the day of surgery.
You must arrange to have a responsible adult drive you home after your procedure.

When you arrive, you will be escorted to a preoperative evaluation area where you will be asked to change into a gown and will be given foot covers. Your surgeon and the anesthesiologist will meet with you before you enter the operating room suite. During this time, the surgical consent form will be reviewed with you in detail and special markings may be made on your skin at the surgical site. You will have the opportunity to ask any last minute questions.

Once in the operating room, you will be transferred to our padded operating room table. A nurse will start an intravenous drip in your arm and connect you to monitoring devices. The anesthesiologist will give you medication through your intravenous drip to make you feel drowsy.

When your surgery is completed and your dressings are in place, you will be moved to the recovery room. During this period a recovery room nurse will assure your comfort and continue to monitor you closely.

Your stay in the recovery room will last approximately I to 1 1/2 hours. Most patients are fully awake within 30 to 60 minutes after their surgery, but they may not remember much about their time in the recovery room due to some of the anesthesia medication. Once you are ready for discharge, a postoperative appointment will be scheduled and your discharge instructions will be reviewed.

You must have a responsible adult drive you home from the surgery center. This individual should have your prescription filled at the hospital pharmacy prior to taking you home. A responsible adult must stay with you the first night after your surgery because you have been sedated.

Post-operative Instructions

Diet: Start with clear liquids and toast or crackers. If those are well tolerated, progress to a regular diet.

Driving: No driving for 48 hours after your procedure or while taking pain medicine.

Activity: You may walk and climb stairs immediately after surgery. After 2 weeks you may resume light activity such as brisk walking. During the first 4 weeks do not lift anything heavier than a gallon of milk. After 6 weeks you may resume more strenuous aerobic work and lifting activities as tolerated.

Work: Depending on your career and your rate of healing you should be able to return to work within 2 weeks of surgery. Your surgeon will be able to give you a better estimate depending on your physical and professional profile.

Wound Care: Keep your dressings clean, dry, and intact for the first 48 hours.  After that, your dressings may be removed.  If you go home with a drain, empty and record its daily output. Keep a sterile dry dressing over the site where the drain enters the body. Change this dressing daily. Once the drain is removed, you need to keep a dressing over the drain site for 1 to 2 days or until the drain site heals over.

Swelling: Moderate swelling and bruising should be expected during the first 2 to 3 weeks after surgery. Mild swelling will continue for 2 to 3 months.

Bathing: If you do not have a drain you may shower 48 hours after you remove your dressing. If you go home with a drain, you may shower once it is removed. Your surgeon will typically remove your drain 1 to 2 days after surgery. When you do shower do not direct the water spray over your incision site. Do not submerge the incision in a bath or swimming pool for 4 to 6 weeks.

Medications: Ask your surgeon when you should resume your blood thinning medications. All other prescription medications may be resumed immediately as usual while you are taking pain medicine, you are encouraged to follow a high fiber diet or take a stool softener such as Colace (available over the counter), as pain medications tend to cause constipation. Take the full course of antibiotics given by your surgeon, to help prevent infection.

Smoking and Alcohol: Do not smoke for the first month after surgery as it impedes wound healing and can lead to serious wound complications. Alcohol consumption is dangerous while taking pain medicine as it has a tendency to worsen bleeding.

Post-operative Appointment: Your surgeon wi1l schedule follow-up visits at appropriate intervals. Please keep all these appointments so that your progress may be followed closely.

Special Considerations: Call your surgeon immediately if you experience any of the following: excessive pain, bleeding, redness at the incision site, or fever over 101° F.

You will need to continue seeing your medical headache specialist after surgery.  You may need to be weaned off certain medications over time.  If you have been on large doses of narcotics for a long time, you will need to arrange at treatment plan to wean you from these medications.