Headache Surgery Questions

• If you have an unexpected clinical concern, you can call our office at any time, as instructed on the written post-operative instructions received in our office at the time of scheduling surgery: Ms. Melanie Lewis (RN, BSN), Ms. Inga Dixon (Exec. Assist) or Ms. Gwen Gill (Patient Coordinator) at (703) 992-9233 or the on call service at (703) 732-7183.
• The first postoperative office visit is about 8-9 days after surgery for migraine/headache patients who had surgery using upper eyelid incision. All other migraine/headache/neuralgia patients, are seen in the office 3 weeks after the surgery. Please note that after any surgery, you need to call our office to schedule your post-operative office visit.
• Patients who are out of town have similar follow up schedules with their local physician.

This varies with the procedure performed, but overall, patients who had peripheral nerve surgery for migraine or headaches of any kind do not require dressings. Instead, triple antibiotic ointment (usually Bacitracin / Neosporin, unless allergy exists) is applied twice a day for the first three days after surgery. Thereafter, the incision is kept clean and dry.

• Migraine/Headache/Neuralgia patients can shower next day but they must keep their hair dry for the first three days, at which time they can wash their hair and discontinue the application of ointment.
• While sutures are in place, you should not take a bath, go into a jacuzzi, a pool, a lake or an ocean.

Ambulation is permitted right after surgery as tolerated. Patients should refrain from any strenuous activities and exercise for at least 3-4 weeks.

Patients with upper eyelid sutures should have them removed 7-9 days after surgery, while the sutures in the occipital (back) and temporal (side) sites are kept for 3 weeks.

Depending on the surgery, most patients can drive when they are no longer taking narcotic pain medications. Please note that safe driving is your responsibility, so you should ensure that your safety and the safety of others is not compromised.

Depending on your job, most patients take a week off work or school. With more physically demanding jobs or if having more extensive underlying medical conditions, some patients might need 10-14 days or more off from work or school. Each patient is given recommendations based on their individual presentation; type of surgery performed and job requirements, but the actual recovery time may individually vary.

“Migraine, Headache, Neuralgia” link, with its subtitles detail answers to this question. Briefly, following the initial evaluation by your headache specialized provider, migraine/headache/neuralgia work-up, and medical treatment, if no improvement is observed within six months, evaluation with an experienced peripheral nerve surgeon, such as Dr. Ducic, is recommended. To define your eligibility for surgical treatment, you can complete New Patient Questionnaire under Patient Forms and submit it to Dr. Ducic for review.

This varies, depending on both yours and our schedules. In average, it takes about three -four weeks to schedule an appointment with Dr. Ducic. If cancellations occur, earlier openings may be available as well. Once requested, our office will inform you if appointment opening becomes available sooner.

It is patient’s right to choose their doctor. It is also the patient’s responsibility to choose a qualified professional. Understandably, patient will always prefer local treatment instead of travel; surgeons will often advertise themselves offering many different types of surgeries, while the Internet can further add to confusion if misinformation is offered. The end result is that the patient might not get the best doctor for their problem. Often this is not recognized until a treatment failure or complications occur. Thus, patients need to carefully define “The Quality” denominator. So, instead of usual marketing show and tell parameters, patients would benefit by defining important quality and safety variables when choosing a surgeon:

• Does the surgeon have specialized structured training relevant to peripheral nerve surgery. Note that after completing a 6-year plastic surgery residency, Dr. Ducic obtained an additional year of peripheral nerve surgery fellowship, focusing on nerve problems/surgery only.
• What percentage of surgeon’s annual practice is peripheral nerve surgery, indicating practice focus?  Dr. Ducic’s nerve surgery volume has been high and accounts for about 95% of his practice.
• Does surgeon reports his/her experience in local paid magazines or publishes his/her research in peer-reviewed professional journals; and what is the topic of that research? These important questions define if someone is recognized by his peers as a true contributor to the clinical science and patient’s care. Dr. Ducic publishes his reports in peer-reviewed journals only, with vast majority of his innovative studies focused on peripheral nerve surgery. As recognition for his contributions and dedication to the field, Dr. Ducic was trusted by his peers to be the President of American Society for Peripheral Nerve (2011/2012), the highest national and international organization focusing on peripheral nerve problems. In addition, Dr. Ducic published at least 12 peer-reviewed studies and wrote textbook chapter on Headache/Migraine/Neuralgia topic, further underlying his contributions and expertise in this field and patients care.
• These are only few of the reasons why 1/3 of Dr. Ducic’s practice includes patients who travel abroad to seek treatment with him from different parts of the country, including international patients. You, the patient, have right to choose the best for yourself, so choose wisely.

• Dr. Ducic performed his first headache surgery on February 16, 2005. The first patient was a 34 year-old PhD student, unable to finish her studies due to constant chronic migraine, headache and neuralgias. According to the patient herself, her surgery was a success, as is featured (under “Patient Stories“) in one of the TV interviews. Finally, headache free, she was able to complete her PhD studies, as her Thank You note nicely indicated.
• Since that first surgery, now with over 12-year experience, twelve scientific studies and a book chapter on this very subject, Dr. Ducic performed over 2000 surgeries for patients with chronic headache, migraine or neuralgia, otherwise suffering despite specialized medical care provided. This extensive experience and comprehensive expertise only further reinforces dedication to the care of the patients like you.

This varies from patient to patient and is strictly individualized, based on location, severity, and distribution of symptoms. In addition, location of nerve tenderness and response to nerve blocks or Botox will aid in determining a surgical plan. Nerve blocks can be more practical over Botox, as the same information is obtained but at less cost. The final treatment decisions are made at the time of the office visit, while the operative plan includes the most involved/painful area (occipital vs temporal vs frontal). Once the outcome of the surgery is observed, other anatomical areas are evaluated and treated on individualized bases. As up to ¼ of patients may have referred pain from the most involved area to other parts of the head, Dr. Ducic’s protocol does not routinely include all anatomical areas at once. Certain exceptions may exist due to insurance, health or other individual reasons.

As is discussed in the introduction, under “Home Page/Nerve Section“, my approach to surgical treatment is focused at the cause of the problem rather than chasing symptoms via alternative symptomatic treatments. In addition, patients who had failed treatment with RFA/Nerve Stimulators and decide to have nerve decompression afterwards, their treatment with decompression surgery has been found to be less effective due to intraneural and extraneural changes/scarring following RFA/Nerve Stimulator. Therefore, nerve excision over nerve decompression is likely necessary for these patients. Although there are some appropriate indications for treatment of peripheral nerve problems via these methods, due to aforementioned reasons, I do not use RFA or Nerve Stimulators.

Nerve decompression is always preferred, while nerve excision might be required in special circumstances, including the severity of symptoms, unopposed duration of the condition present, anatomical, previous traumatic and/or defined surgical history in relevant anatomical area. If nerve excision were done, as discussed in other parts of this document, usually transient itching and more permanent numbness would follow in the nerve distribution. Patients with chronic migraine/headaches tolerate numbness well, but the surgeon’s experience and technique applied at the time of nerve excision is very important to minimize continued pain, phantom pain or hypersensitivity, thus potential failure.

Although each individualized outcome may be difficult to predict, a peripheral nerve surgeon needs to be experienced and know what intraoperative protocols to apply in order to prevent painful neuroma or phantom pain from occurring. Still, despite all measures, some patients potentially can experience hypersensitivity or pain in anatomical area of nerve excision, possibly requiring additional treatments until its subsides. As discussed earlier, this is why a patient should be careful when choosing his/her peripheral nerve surgeon. Patients should pay particular attention to a surgeon’s background ensuring he/she has specialized training in peripheral nerve surgery and if peripheral nerve surgery is a priority in the surgeon’s practice. This is unfortunately often overlooked and unrecognized until a failure or complication occur.

While your medical provider had most likely done all medically was possible, if your chronic headache/migraine/neuralgia is continuing to negatively affect your life, one should not be restricted to seek for additional help, just because some think nothing else might be done. Surgery certainly should not be the first line of the treatment, but based on criteria discussed in several sections under “Migraine/Headache Patients”, and summarized in “Migraine Headache / Neuralgia Lecture“, once your medical provider did initial workup and provided appropriate medical treatment, those patients continuing to experience pain/headaches, consideration for the evaluation for surgical intervention is appropriate next step. Again, unlike pain management interventional options (RFA, Nerve Stimulators) surgical intervention is focused on addressing potential cause of the problem, and thus having highest theoretical chance to help eliminate patient symptoms/probelms.

As medical headache provider is an important part of the treating team, if patient does not have one, upon contacting Dr. Ducic’s office, we will assist you to be evaluated with one of our neurologists and/or anesthesia pain specialists.

• After surgery, we use a generous amount of a long-lasting local anesthetic that temporarily puts the nerves in the surgical area to sleep and thereby prevents severe post-operative pain. This medicine usually lasts between 12-36 hours following surgery, during which time it is normal for you to feel completely numb.
• Once the numbing medicine wears off, patients can have variable sensations that are influenced by post-surgical pain and swelling as well as decompression and surgical manipulation of the nerves. It is common for patients to experience some degree of nerve ‘tingling’ and/or mixed numbness for several weeks after successful decompression surgery, even when the nerves are not cut. Most patients find gentle scalp rubbing/massage (as if one were applying shampoo), practiced few times a day, useful in diminishing these temporary sensations.
• If nerves were intentionally cut as part of your surgery, then numbness will have more permanent nature, as was discussed with you prior to surgery.

Although a number of variables may affect the healing timeframe, incisional healing usually takes about 2-3 weeks, while the functional outcome of and the response to surgery may take anywhere from 2-3 weeks to 3-4 months after surgery.

Standard anesthesia complications are possible with any surgery; therefore, proper pre-operative preparation is important, and is a standard in our office, according to pre-operative anesthesia guidelines. Some of the complications some patients reported included skin infection (requiring additional antibiotics), wound dehiscence (requiring local wound care), scalp hypersensitivity/itching (requiring potential additional intervention), temporary hair thinning (awaiting regrowth cycle), expanded pain, hearing hypersensitivity. As these nerves are sensory, no arms/face paralysis should be encountered. In addition these surgeries do not involve patients spine or brain. Dr. Ducic’s records on over 2000 headache-related surgeries this far indicated no intraoperative mortalities, no nerve paralysis, and no injury to other adjacent structures, all indicating surgeon’s expertise and focus on patient’s safety.

Most migraine/headache/neuralgia patients will start seeing positive results of surgery within the first three weeks after surgery (range 3 weeks – 3 months), if not immediately after surgery. If surgery was done on one anatomical area only, then headache/migraines/pain can still be present due to other anatomical areas that were not addressed with the initial surgery, potentially requiring additional interventions. Some patients, despite proper medical care and surgery, can continue to have migraines/headaches/pain, even report to progressively feel worse. Although anatomically and physiologically it may be hard to explain reasons, certain individual underlying psychological variables, past/present exposure to stress or various abuses may contribute. In addition, the duration and severity of chronic pain that persisted before current nerve surgery can certainly leave negative psychological effect on some patients, contributing to continued or progressive pain, even after nerve excisions was done. This is why it is not possible to predict how each individual will respond to any nerve surgery, and thus not possible to guarantee the outcome, as every patient is informed prior to scheduling surgery. These patients then require evaluation with other specialists to help understand why they deviated from our expected post-operative course. Luckily this does not happen often, so most patients have great relief with nerve surgery.

You will be discharged from the hospital with a prescription for pain medication and the office may refill it one more time. If you continue to need more pain medications, it is recommended that you follow-up with your neurologist, pain management specialist or primary care physician who will monitor how much medication you require. As we explain to every patient, Dr. Ducic is not a medical pain specialist and prescribes no medications for purposes of medical management of chronic pain or migraine headaches, as those should be managed by appropriate specialists. In order to minimize pain medication side effects, and prevent long term narcotic use issues, Dr. Ducic strongly encourages patients to have only one medical provider prescribing and monitoring what and how much pain medications are given to you.

For our patients that live out of state we recommend you have the sutures and incision looked at by a local physician, as previously discussed. If there are any questions or concerns you can call our nurse Melanie Lewis, RN, BSN at (703) 992-9233. Dr. Ducic would like for you to call the office or send an email at 3 weeks and at 3 months to give us an update on your outcome from surgery.

Yes, for patients who have the supraorbital and supratrochlear nerves decompressed for migraines/headaches you may experience swelling that will last for a couple of days to a week. If your swelling appears severe with excess pain, feel free to call us so we can arrange a time for you to be examined.

Arnold-Chiari malformation is not directly treated with peripheral nerve surgery as it has different pathogenesis. Once its treatment is optimized by appropriate neurology and neurosurgery specialists, those patients who continue having a neuralgia or chronic migraine/headaches should undergo the same evaluation as other migraine/headache/neuralgia patients. If nerve tenderness and positive, although temporary effect of appropriately given diagnostic nerve blocks is present, evaluation by Dr. Ducic for potential peripheral nerve surgery is indicated.

Yes, in fact Dr. Ducic recently had published in journal Headache, the first ever study defining indications and treatment course for patients who develop occipital neuralgia/chronic migraine/headache following acoustic neuroma surgery. This is also discussed under Post-Craniotomy Headache and Pain section.

Most of headache surgeries Dr. Ducic performed were covered by insurance, as we have obtained pre-certification for surgery on behalf of you. Our office will still pursue every appropriate avenue to have your surgery approved, as your condition is not a cosmetic problem, rather is socially, personally and professionally debilitating. It is rather unfortunate and scientifically unacceptable that some insurance plans deny surgery considering it experimental and investigational. Evidence based scientific data available for over a decade now, point to benefits of surgical treatment for properly selected patients whom available medical treatment did not help. Considering that nearly ten percent of US population suffers from migraines or headaches, it is clear that medical treatment has significant limitations, with patient’s condition too often persisting despite the best medical care provided. Thus, insurance carriers and all others should start realizing that surgical treatment is focused on the cause of malfunctioning peripheral nerve, and might be the only hope for those who continue to suffer despite medical care. Once our office obtains pre-certificatin and pre-determination from your insurance carrier, we will set up your surgery date, at what point, if out of town you can start planning your travel. Potential insurance problems can occur for those plans that do not require pre-certificatin and pre-determination, as will be discussed with you by our executive administrative assistant. In such cases we will provide you diagnosis and procedure codes, so you can also check with your insurance carrier for coverage.

Considering aforementioned, some patients may be denied, primarily as their respective insurance companies consider surgery experimental. If that scenario would be faced, self-pay avenue is the only remaining path, in which case we will do our best to assist you. In such cases, considering that hospital fees might be much higher, Dr. Ducic would perform your surgery at a new certified surgery center, and thus help you to significantly offset the facility/surgery cost.

The best way is to first review all relevant information under “Headaches, Migraines & Neuralgias” link, also offered under “Nerve Surgery Subsections“. This will best help you learn about the condition you have and how your situation relates. The next step is to access the New Patient Review of the Records Questionnaire under “Patient Forms“. Once completed, you can email it to Dr. Ducic for review, so he can define your eligibility for surgery. Once accessed, please follow instructions outlined on the first page of the form. As 1/3 of Dr. Ducic’s patients come from different parts of the country, they find this way of communication very effective, as it saves them valuable time and money for initial evaluation.