A Headache Center with knowledge INTRODUCTION: Our approach to treatment and management of the migraine headaches with its very rewarding results encouraged me to re-shuffle in the scientific literature. I just went back to study once again the very basic knowledge of the morphology, anatomy, Physiology of the Trigeminal Nerve per se, and Occipital nerve particular. The basic thought was how is that a simple approach brings longer term relief than all other sophisticated treatment approaches? Migraine is an episodic neurovascular disorder characterized by recurrent unilateral headaches accompanied by nausea, vomiting, photophobia, phonophobia, conjunctival injection, and lacrimation. Not to mention loss dysestheia/hypoestesia of the tongue, TMJ pain, and dental pain. Current theories suggest that the initiation of a migraine attack involves a primary event in the central nervous system (CNS), probably involving a combination of genetic changes in ion channels and environmental changes, which renders the individual more sensitive to environmental factors; this may, in turn, result in a wave of cortical spreading when the attack is initiated. (General hypothesis). Other hypothesis suggests genetic etiology of the Migraine Headaches. Genetically, migraine is a complex familial disorder in which the severity and the susceptibility of individuals are most likely governed by several genes that vary between families. (Department of Internal Medicine, Lund University Hospital, S-221 85 Lund, Sweden.) However, most of those suggestions lacks of genetic studies of the hypothesis. The exact pathogenesis of migraine remain unknown and in the begin of 21 st century still remains to be doubtlessly understood. Triggering factors such as bright light, flickering light and certain visual patterns, smells, noises, as well as life style distress can trigger a migraine attack, and visual cortical hyperexcitability has been hypothesized to be responsible for it too. Migraine is a common and potentially serious chronic, disabling disease. The prevalence of migraine in the U.S. adult population is roughly 80% among women and 20% among men. This equates to approximately 30 million American adults who suffer from migraine. Data shows that greater than 75% of patients report one to 14 headaches per month with nearly 14% having five to 14 headaches per month. Over half of these attacks produce severe impairment, forcing the individual to bed rest. Estimates range as high as 112 million bedridden days per year, translating into reduced productivity with the likelihood of missing work, planned events, and interfering with daily activities. The financial burden on patients and businesses is immense; with a cost to employers calculated at $14 billion annually. (Cephalgia) Page 1
For these reasons, it is imperative for primary care health professionals to understand and treat migraine as a potentially burdensome and chronic disease. Yet, ironically, epidemiological studies show that about 50% of patients seeking medical consultation for migraine are not being diagnosed, regardless of the reported impact and severity of the disorder. The pattern of disorder, consequently demonstrates depression, anxiety, generalized phobia, and other nonspecific mood disorder may added to individual s disorder during the period of chronicity of Migraine headaches. Vice versa is not proven to be objective and universal. It remains just on the basis of hypothesis. Dynamic of the Migraine attacks with its broad range of manifestations gave raise to plenty of scientific and nonscientific cause hypothesis, and theories. Most of them need to be scientifically proofed. In order to understand our empiric treatment, and satisfactory long term results I determined to reshuffle the theories/hypothesis, laboratory research results from involved medical investigators in Migraine headaches literature. I made all effort to be objective and critical. Trigeminal nerve (TN), Greater Occipital nerve (GON), and all the peripheral nerves system in all vertebrate species physiologically are under the control of sympathetic and parasympathetic nerve system. The peripheral and central vascular system to higher degree influenced by autonomous nerves. A profound organic understanding of this system would provide closer understanding of the trigeminal neuralgia, and occipital neuralgia. The autonomous nerve system is an independent, self-managed, and self-controlled system serving a complex multifunctional internal system of organs. Its function continues even when the cognitive cerebral centers are out of function. Autonomous nerve system demonstrates dual function of pro and contra functioning system called sympathetic and parasympathetic nervous system. Their activities may affect human and animal emotions and vice versa. The diffuse and broad bands network of sympathetic and parasympathetic nerve fibers therefore, make it impossible for surgeons to have a successful complete sympathectomy, even neurectomy. The painful malfunctions return after a while. Reflecting the complexity of understanding and decoding those interconnections of rami Communicantes seems extremely challenging for the Neurophysiology. Both system of sympathetic and parasympathetic nervous system are highly functional independent systems in natural balanced coexistence. There is physiologically a switching system which genetically determines the silencing or desilencing, e.g. Sympathetic nerve innervates dilator pupillary muscle, and parasympathetic nerve innervates the pupillary sphincter muscle. Migraine headaches seems to demonstrate a dysbalance between sympathetic and parasympathetic innervation of the cerebrovascular system rather than central cortical cause. Shortcoming evidence of EEG studies in the event of Trigeminal or Occipital Neuralgia speaks it for itself. It seems to be a chronic periodic vasoconstriction in ganglia and associated peripheral Page 2
nerves, which are predilections to anoxia/hypoxia and consequent acute inflammatory reactions, possible neuritis and perineuritis. DISTRIBUTION OF TRIGEMINAL NERVE BRANCHES IN HEAD AND FACE Our approach to treatment and management of the migraine headaches gave us a curious perspective to shuffle in the recent and past scientific literature. I just went back to study once again the very basic knowledge of the morphology, anatomy, physiology of the Trigeminal nerve, and Occipital nerve per se The basic thought was why is that a simple Page 3
approach brings longer lasting relief than all other sophisticated surgical interventional approaches, and pharmaceutical treatment? THE PAST WAS ALTERABLE. The past never had been altered. SPASM PASSED (George Orwell 1984). Since 2000 I was involved in the search for the role of the nerve growth factor (NGF) in Port Wine Stains, which I believed related to sympathetic nerve supply of the skin capillaries. Rita Levi Montalcini a pioneer scientist gave the basic light into it. Now I am following the same path of curiosity. Migraine starts attacking at any age. Females affected more than males. Migraine is frequent, disabling recurring headaches. Symptoms may vary in intensity, quality and specific nerve branch involved. Migraine pain can be mainly felt in the temples, forehead, behind the eyes, in the face, as well as in the occipital region. In some individuals, complicating Migraine typically associated with hypersensitivity to light, noise, and smells. Visual disturbances such as flashing lights, zigzag s, and blind spots even temporary peripheral visual loss are involved too. Nausea and vomiting are other disabling common symptoms. Some Migraine headaches may be preceded by an aura, a temporary short lasting neurological syndrome that slowly progresses and just resolve just as the pain begins Care that bring salvation, and abundant pain Our treatment plan includes one session treatment with rewarding results. The therapy starts with introductory evaluation of patient s medical records, medications, history and special pain behavior. Patients with classical Trigeminal neuralgia, and Occipital neuralgia then selected after an educational process. All medications taken for migraine discontinued as of the day of treatment agreement. Individual returns to clinic for necessary tests if any required, and she/he returns in pain or at the begin of the pain. They will receive immediately the treatment which may take over one hour. We request to hold medications such as Plavix, Coumadin, aspirin, fish oil, and vitamin E few days prior to treatment. We utilize a mixture of very potent Steroid and Local anesthetics in minimal doses to the branches of the Trigeminal and Occipital nerves. The mixture administered meticulously in minimal portions using thinnest needle. Patient is comfortable in supine and then in prone Page 4
position. No premedication or intravenous access necessitated. No down time, and patient may return to daily activity at the same day. Our Treatment does not require or offers a continuation of standard medications, nor augment any life style and diet modifications or referrals after treatment. There are normally no adverse reactions and complications of administered medications. There may be very rare some minimal bruises by touching some skin veins. Over results reflects 98% successful migraine relief. Our treatment experience started in 2005, based on single facility & single investigator observation. We witnessed the longest lasting Migraine free patient is beginning her 6 th year of life without Migraine headaches after 30 years of suffering and undergoing several treatment modalities. Normally, We do not recommend a standard or alternative medications for continuation of care, nor augment any life style and diet modifications or referrals. In one word, our patients did not express for any need to it. The patient leaves our clinic normally pain free and just returns for follow up visit every quarter for 12 months. Our patients are able to return to work with appreciation of their daily life. However, most of patients report mild non distracting normal tension headaches responding well just to Ibuprofen or Acetaminophen. % Page 5