Surgical Relief for Chronic Migraine

Consultations offered at our three convenient locations in Austin, TX, San Antonio, TX and Westlake Hills, TX

Specialized Nerve Decompression Surgery by Dr. Scott Reis in Austin, TX

If you’ve been living with chronic migraines or unrelenting head and neck pain that hasn’t improved with medication, injections, or other therapies, there is hope. Dr. Scott Reis is one of a select group of plastic surgeons in the United States specializing in occipital nerve decompression surgery: a highly targeted, life-changing procedure for carefully selected patients whose migraines are triggered by nerve compression.

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.

Not all chronic headaches and migraines are the same, however. There are many different types and causes of chronic 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. Patients with especially severe or frequent migraines may not be able to work at all.

Understanding Occipital Nerve Compression/Occipital Neuralgia

The occipital nerves—primarily the greater, lesser, and third occipital nerves—are responsible for sensation in the back of the head and upper neck. When these nerves are compressed or irritated by surrounding muscles, fascia, blood vessels, or scar tissue, it can lead to chronic, debilitating headaches, known as occipital neuralgia, which is often mistaken for migraines.

Common Symptoms of Occipital Nerve Compression:

  • Persistent or stabbing pain in the back of the head or upper neck
  • Headache pain radiating behind the eyes or to the scalp
  • Sensitivity to touch, light, or neck movement
  • Numbness, tingling, or burning along the scalp
  • Pain that worsens with prolonged posture or head movement
  • Often symptoms appear immediately or years later following trauma or injury to the neck, often following a car accident or sports injury

Could Nerve Decompression Surgery Help You?

You may be a candidate if:

  • You’ve had chronic, treatment-resistant headaches for more than 6 months
  • Your migraines start at the base of the skull or neck and radiate forward
  • You’ve had temporary relief from nerve blocks, Botox, or steroid injections
  • Medications, physical therapy, and other interventions have failed

Most of Dr. Reis’s patients are referred by neurologists who have ruled out other causes and confirmed that occipital nerve compression is a likely source of symptoms. These patients often suffer from Unremitting Head and Neck Pain (UHNP), a clinical subset of occipital neuralgia that can mimic traditional migraine.

Diagnostic Process for Nerve Decompression Surgery

One of the key features of the migraines Dr. Reis most frequently treats—of those caused by compression of the occipital nerves—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, the forehead, and the face, and may also be accompanied by nausea and sensitivity to light (photophobia). These occipital neuralgia events often progress and cause secondary facial trigeminal migraine symptoms as well.

Neurologists and specialists like Dr. Reis often face a challenge when diagnosing this specific type of migraine: linking a patient’s near-constant and severe discomfort to anatomic compression of the occipital nerves. This is especially difficult because head and neck pain can stem from a wide range of causes. Several tests 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, such as:

  • 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 pain is eased by the injection of a local anesthetic to temporarily block and numb the occipital nerve, compression of this nerve is likely at least one source of their migraines.
  • BOTOX® Injections: Some patients report a decrease in migraine frequency and intensity when the neurotoxin BOTOX (onabotulinumtoxinA) 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.

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

Migraine surgery is an outpatient procedure performed under general anesthesia at Dr. Reis’ surgery center in Austin, and the procedure typically takes 3-4 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, optimizing long-term results.

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 once the sutures are removed. Dr. Reis also only shaves hair at the incision sites, a technique that most other surgeons do not use since it’s easier to just shave the back of the head.

Once he gains access to the 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 the 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 higher-than-average cure and improvement rate for qualifying patients he has treated.

The benefits of this procedure for suitable candidates are immediate and remarkable. Following occipital nerve decompression surgery, after waking up from anesthesia, most of Dr. Reis’s patients have immediate improvement in or total 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. Some patients can eliminate preventive and abortive migraine medications altogether.

Recovery After Migraine Surgery

Occipital nerve decompression is an outpatient procedure, which means that patients can return home the day of surgery. It is normal for patients to experience numbness and 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. If the numbness and tingling become 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. Patients must attend physical therapy following surgery 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.

Expected Results After Migraine Surgery

In properly selected patients who have been identified and diagnosed by a qualified neurologist specializing in migraine and chronic headache, patients universally experience a significant reduction in headache frequency and intensity, with some achieving complete relief. Results often improve over several months.

Migraine Surgery FAQs

How do I know if my headaches are from occipital nerve compression?

If your headaches start at the base of your skull or upper neck and radiate forward, especially if they improve temporarily with nerve blocks or Botox, occipital nerve compression may be the cause. This pain also commonly involves pain radiating to the face, sides of the head, the forehead, as well as pain behind the eyes. A consultation and diagnostic injections can help confirm this.

Is this the same as migraine surgery?

Occipital nerve decompression is a form of migraine surgery, specifically targeting peripheral nerve trigger compression. While not all migraines are caused by nerve compression, a significant subset of patients with chronic migraine-like symptoms can benefit from this targeted approach.

What kind of anesthesia is used?

The procedure is performed under general anesthesia to ensure your comfort and safety.

How long does the procedure take?

Surgery typically takes between 3 to 4 hours, depending on the number of nerves involved and each patient’s individual and unique anatomy.

Will I have visible 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 incisions and resulting scars are generally hidden within the hairline as they heal

Will I have to shave my head before surgery, or will Dr. Reis do so in the OR? 

In general, no. 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 only shaving small strips of hair at the incision sites is far outweighed by the effort required with shaving the entire back of the head.

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:

– Bleeding
– Pain
– Infection
– Incomplete resolution of migraines and/or occipital neuralgia
– Very rarely, long-lasting or permanent numbness, tingling, or itching of the posterior scalp

What is the success rate?

Studies and clinical experience show that 70–90% of patients experience a significant reduction in headache frequency or intensity. Some patients report complete resolution of their symptoms.

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 to prevent future compression and minimize 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 and necessary medication treatment 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 before 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. If 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.

Does insurance cover the cost of occipital nerve decompression surgery?

Insurers consider this surgery “experimental” or “not medically necessary”. Accordingly, Dr Reis’ practice does not accept insurance coverage or reimbursements for these procedures

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. Relief is possible—and I’m here to help you explore your options with care, experience, and a personalized approach.

To learn more about this procedure and whether you are a candidate, please contact us to schedule a consultation with Dr. Reis and take the first step towards lasting migraine relief.

Patient Testimonials

“I had migraines every day before having a nerve decomposition surgery. I’m 2 months post-surgery and have not had one since. Dr Reis and his office have been wonderful throughout the whole process.”

– Heather M.
“I cannot say enough good things about Dr. Reis and his staff. I am 2 weeks out of surgery for chronic migraines/occipital neuralgia, and I am so happy to say that I have not had one headache since my surgery. Dr. Reis and his staff (specifically Morgan) worked so hard on my behalf to get my procedure covered by insurance. You will be in great hands if you use Dr. Reis!”

– Jessica S.
“I was suffering for almost 20 years with chronic migraine headaches. I tried everything I could: [nerve] injection, Botox, Treximet…I was tired of every treatment because nothing [made] me feel better. Until I [met] Dr. Reis who [gave] me a new life. He did decompress nerve surgery on November 15 of 2021. Since that day, I don’t have [any] more migraine headaches…”

– Olga V.

References

  1. Migraine Research Foundation. What is migraine? 
  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/. 
  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. 
  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/. 
  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/.