Until recently there was little to offer for chronic migraines and other facial pains other than medications in the form of pills and injections. Nearly two-thirds of patients discontinue prescription medications due to inadequate relief and side effects.
But now there are procedures available in a comprehensive treatment plan at The Migraine Treatment Center which can provide temporary or long-term relief from migraines and facial pain in the majority of patients as well as a surgery option for more permanent relief.
1.Botox® injections can temporarily relieve migraines for up to three months in some cases by “freezing” the muscles which encapsulate the nerves causing the pain.
Botox injection sites for migraine treatment.
2. SPHENOBLOCK® is Dr. Hochman’s trademarked treatment, a minimally invasive procedure designed to temporarily block a collection of nerves (the sphenopalatine ganglion – SPG), effectively delivering pain relief. The SPG lies in a bony cavity which is deep in the midface nasal cavity and is related to a variety of facial pain conditions, such as migraines, cluster headaches and atypical facial pain. It provides effective care for a difficult group of patients.
The sphenopalatine ganglion (SPG) block was first described over 100 years ago by Greenfield Sluder as a treatment for a variety of headaches and facial pain syndromes. The block originally used a cocaine solution. In the early 1980s, interest in the procedure returned as headache specialists started to report success treating difficult and refractory headaches. Because the SPG represents a “crossroad” of neurons involved in pain processing, clinicians using SPG blocks have reported its effectiveness in a variety of central pain syndromes, from complex regional pain syndrome to fibromyalgia.
Dr. Hochman administers the SPHENOBLOCK® to:
SPHENOBLOCK® can often give immediate relief to an ongoing pain episode and/or help to give longer term relief by “resetting” this group of nerves (SPG). The relief from the pain is almost immediate and lasts for up to 3 months. It can over time, have a cumulative effect on migraine pain.
Most insurance companies, as well as Medicare, cover the procedure. We will work with you if it is not covered. Please read about our payment options.
If you’re currently taking medicine for migraines or other chronic facial pain, this simple procedure may over time reduce the need for narcotics or other pain medications. It fits into the overall treatment plan with regard to medications, Botox injections, Focused Cold Therapy™, ketamine infusions and surgery for migraines.
3.Ketamine is not a new drug. It has been used for five decades in human and veterinarian medicine. It is typically thought of as an anesthesia medicine, pain medication or even a club drug, but is now generating a lot of interest among pain management specialists as a useful approach to hard-to-treat migraines and chronic pain, which often go hand in hand with depression. In this scenario the dosage is only a fraction of what is used in anesthesia or the street drug.
In addition, ketamine can have a positive effect on depression, which is often seen in chronic pain conditions such as migraines. Ketamine was named by the Cleveland Clinic as one of the Top 10 Medical Innovations in 2017.
Ketamine works fast, blocks pain, opens the lungs, it is easy on the heart, and has anti-inflammatory properties. It may also have anti-cancer properties. Ketamine is being extensively tested for the treatment of depression that does not respond to medications.
The drug is transferred via infusion in small doses over a period of about 45 minutes. Working on a receptor involved in transmitting pain messages in the brain (NMDA receptor), it has been studied in various painful conditions. By blocking the receptor and closing the channel to ion transport, pain signal transmission is interrupted giving central pain centers a chance to “reboot”. One or a series of low dose ketamine infusions can dramatically alter or even eliminate chronic pain. Ketamine infusions have been most often used when other treatment modalities have been less effective.
4.Cranial Nerve Blocks provide relief for migraines, cluster headaches, chronic treatment-resistant headache, pain associated with head injury, or other types of occipital neuralgia, and atypical facial pain. An occipital nerve block may take effect immediately after a procedure, or a few days afterward, and remain effective for a month or more. Cryotherapy blocks (IOVERA) can last longer.
5.The next option is iOVERA®. Dr. Hochman is the first to introduce this Cryotherapy treatment in South Carolina. “The ioverao treatment uses the body’s natural response to cold to immediately reduce pain without leaving anything behind. It precisely targets the source of your pain for immediate and lasting relief without the use of drugs or pharmaceuticals. The ioverao treatment is FDA cleared to block pain. it has been used successfully for years on joint nerve pain. The ioverao treatment works by applying targeted cold to a peripheral nerve which immediately prevents the nerve from sending pain signals.
The ioverao treatment is a new way of using a safe and trusted technology, cryotherapy, that goes back to the 1950s. This technology harnesses the power of cold to safely deliver precise treatments to relieve pain. The ioverao system has revolutionized the delivery of cryotherapy because the Focused Cold Therapy™ delivery device enables doctors to deliver controlled doses of cold temperature to immediately stop pain. The device uses liquid nitrous oxide that is contained within the device, and delivers it at very high speeds down a closed-end needle, where it undergoes a phase change. This process draws in heat energy from the surrounding tissue, creating a precise zone of cold to treat the intended nerve. The gaseous nitrous oxide is expelled out from the device, leaving nothing behind in the body. The effect on the nerve, called Wallerian Degeneration, is temporary and allows the nerve to regenerate.” The pain relief is almost immediate and lasts for approximately 3-4 months.” This is typically longer than Botox or Cranial Nerve Blocks. Visit http://www.iovera.com
iOVERA treatments are typically covered by insurance, depending on the plan.
The more permanent option is surgery. Are you a candidate?
The Doctors TV Video on Migraine Surgery
6.Patients who have not responded to standard medical, pharmacological therapy or lifestyle modifications may consider surgical treatment of migraine pain. The surgical procedures by Dr. Hochman will eliminate or significantly reduce migraine headaches by removing triggering sites, such as small muscles pinching cranial nerves or deviated septum causing inflammation of the sinuses. Migraines are triggered by various causes, and at most times the main source of pain cannot be easily diagnosed. Due to the redundant symptoms and overlapping ailments displayed by people suffering from chronic migraines, you must be seen or have been seen within the last 5 years by a neurologist, and have a diagnosis of migraine disease or neuralgia to be evaluated. Depending on the character and location of the disease, in addition to physical and x-ray or CT scan findings, we will determine which of the four currently known trigger sites will be evaluated. It is important to note that some patients suffer from migraines from one, two or more zones. Three of these sites—brow, temple, and the back of the neck—can be evaluated with injections of Botox. The fourth site is the nasal passage, and can be tested with nasal sprays, in addition to physical and x-ray findings. Arrangements can be made for undiagnosed or more atypical headache patients to first be seen by a neurologist with whom Dr. Hochman has worked closely. Generally speaking, if migraine headaches are relieved with Botox, that patient will likely benefit from surgery. However, if Botox does not relieve the migraines, the patient could still be a good candidate for the surgery. While Botox is best known as a cosmetic therapy for smoothing wrinkles, it was approved in October 2010 for patients with chronic migraines.
Dr. Hochman, as a facial plastic surgeon, is experienced in treating patients with Botox, thus he has greater expertise when it comes to treating patients with symptoms similar to yours. He has performed numerous highly successful migraine surgeries, bringing greatly needed relief to his patients. The initial visit is an evaluation for testing candidacy. After Dr. Hochman confirms the location and determines your eligibility for successful surgery, he will determine the type of operation to perform.
It is important to note that doctors do not always recommend surgery for migraines, unless the condition no longer responds to treatment and other anti-migraine therapies.
A 5-year study published in January’s issue of Plastic and Reconstructive Surgery has shown that surgery to treat migraines is effective in nearly 90 percent of patients. In about 30% of patients, all migraine symptoms were “completely eliminated” while in a remaining 59%, migraines were significantly reduced.
The study followed patients for several years after surgery to monitor results. In patients who reported significant decrease, the average patient went from having 11 migraines per month to just four. Additionally, symptoms were reported as lasting 34 hours before the migraine surgery, and just 8 hours afterwards.
For the 33% of migraine patients who do not currently respond to non-surgical migraine treatments, this type of surgery can be the only path to relief. 80% of patients, regardless of severity of their migraines, respond to the surgical approaches with significant reduction in the severity and frequency of the attacks.
(Plastic and Reconstructive Surgery is the official publication of the American Society for Plastic Surgeons.)
Frontal Zone surgery can be done through small incisions behind the hairline with all the work done through a telescope, combined with a cosmetic brow lift at a reduced cost if desired by the patient. In other patients it is done through upper eyelid incisions as in a cosmetic eyelid lift, creating a two-fold benefit: you will feel better and look younger!
Most patients notice some numbness in the forehead after surgery, this usually resolves within several weeks to few months.
If most of your headaches start in the temple area, and the side of the head, they are more related to stress and are common in people who tend to grind their teeth. A small nerve can be commonly pinched by the Temporalis muscle. Since this nerve is very small and provides sensation to a very small area, cutting of this nerve is performed without any noticeable numbness.
If most of your headaches start in the back of the head and upper neck, here the greater occipital nerve is pinched by a muscle and by the greater occipital artery and vein. Surgery involves releasing the nerve from the compressing structures including the muscle and vessels. The surgery is done through an incision within the hairline just below the bump on the the skull which you can feel in the midline. Dr. Hochman is one of the few doctors in the country to perform surgery to the area with the patient in a sitting position which is far safer than turning a patient under general anesthesia. This is just one more reason to choose Dr. Hochman for migraine surgery.
These headaches are usually located behind the eyes and around the nose. Often these are weather dependent and get worse when the nose is congested. They are caused by the triggering of nerves in the lining of the nose. As this lining swells in some people (which is the “stuffiness” you feel during a migraine attack),the septum and turbinates touch each other. At these contact points the nerves send impulses back to the brain and contribute to the cascade of events. The purpose of the surgery is to eliminate these contact points.Unlike in the other zones, Botox cannot be used to identify this as a trigger point. Therefore, in patients without an obvious deviated nasal septum, and in those not responding to Botox, nasal spray, an x-ray or CT scan might be ordered.
Surgery is performed as an out-patient procedure under sedation or general anesthesia with the supervision of a board certified anesthesiologist. Affected nerves are decompressed and cushioned with a fat graft.The procedure is day surgery and patients can go home or back to their hotel following the procedure. Patients are out of work for one to two weeks, typically. Exercise and lifting (more than the equivalent of a gallon of milk) is prohibited for these two weeks. Headaches are common during this time, which can be managed with appropriate pain medications. All scars are small and hidden in a crease or within the hair. Nasal airway incisions are inside the nose. Improvements usually begin two to four weeks post-surgery.
We would like you to keep a daily log of the frequency and intensity of your headaches in the diaries listed below which you will bring to your follow-up appointment. You should also continue all of your usual daily medicines until your follow-up appointment.
“Your Migraines At A Glance”- a monthly management diary
“Know Your Migraine” – your detailed migraine diary
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