At Westchester Medical Center (WMC), the flagship of the Westchester Medical Center Health Network (WMCHealth), clinicians representing a variety of specialties collaborate to pinpoint the causes of, and provide patients lasting relief from, chronic headaches.
Kaveh Alizadeh, MD, MSc, FACS, Co-founder and Program Director of WMC Headache Specialists, Chief of the Division of Plastic and Reconstructive Surgery at WMC, and Associate Professor of Surgery at New York Medical College, performs a neuroplasty procedure on a migraine patient.
This common yet debilitating condition takes many forms, including:
- Cervicogenic headaches, which arise from pinched nerves and other disorders of the cervical spine
- Tension headaches, which occur when head and neck muscles contract
- Chronic cluster headaches, which occur around one eye during painful attacks that may last weeks or months
- Sinus headaches
- Medication-related headaches, which often result from overuse of nonsteroidal anti-inflammatory drugs or other medications
The most common type of chronic headache is migraine, a condition characterized by pounding headaches. What precipitates migraines remains unclear, although overexcited nerve endings may play a role, as may heredity. Possible triggers include certain foods and beverages, stress, lack of sleep, sensory stimuli — such as strong odors and bright lights — compressed nerves, and, for women, hormonal changes related to menstruation, birth control and menopause.
One of the most crippling diseases known to medicine, according to the World Health Organization, migraines can cause a range of symptoms, including pain, fatigue, blurred vision, nausea and vomiting. The headaches can prevent individuals from performing regular activities, such as going to work or school, and can affect relationships.
Approximately 12 percent of Americans have migraines, the National Institute of Neurological Disorders and Stroke notes. The condition is three times more common in women than men, according to the American Migraine Foundation. Migraines are especially burdensome for the 1–3 percent of Americans who have the chronic form of the condition — headaches that occur at least 15 days of the month for three months.
Nitin Sekhri, MD, Co-founder of WMC Headache Specialists, Section Chief of Pain Management at WMC and Assistant Professor of Anesthesiology at New York Medical College, performs a cervical epidural steroid injection on a patient suffering from cervicogenic headaches.
Eliminating Fractured Care
Traditionally, care of chronic migraines and other forms of persistent headache has been varied among clinicians, such as internists and neurologists, who have treated patients in the context of their own specialty. At WMC, however, patients are benefiting from a model of care unique in the region: an interdisciplinary headache center offering surgical solutions. WMC Headache Specialists, which includes four physicians — representing internal medicine, neurology, pain medicine and surgery — opened in October 2016. The physicians’ offices are located at 19 Bradhurst Ave. in Hawthorne.
“All of us had been involved in caring for chronic headache patients for many years in our own practice settings,” says Kaveh Alizadeh, MD, MSc, FACS, Co-founder and Program Director of WMC Headache Specialists, Chief of the Division of Plastic and Reconstructive Surgery at WMC, and Associate Professor of Surgery at New York Medical College. “We wanted to collaborate to offer evidence-based, outcomes-driven management of this complex group of patients in a university setting where all of us are held accountable for improving results.”
Migraines account for the majority of cases at WMC Headache Specialists. Patients proceed along a clinical pathway that begins with an evaluation by an internist, followed by appointments with a neurologist and a pain-management specialist, as necessary, until they gain relief. If symptoms persist, patients are typically eligible for a minimally invasive nerve decompression procedure with Dr. Alizadeh. The team of clinicians gathers monthly for an action-oriented dialogue about patient cases and plan of care.
“Headaches are so common that the typical primary care physician is bound to treat them daily,” Dr. Alizadeh says. “For the most part, they are quite successful at managing these patients with medication. However, if a patient has headaches for longer than one week a month and doesn’t obtain adequate relief from standard drugs, it’s reasonable to refer him or her to an interdisciplinary center such as ours, where alternative treatments are available.”
Which of those treatments patients receive depends on the etiology of their headaches.
“If a patient’s pain is muscular-driven, he or she may benefit from Botox injections by the neurologist,” Dr. Alizadeh says. “Headaches related to a neuropathy or other nerve disorder may require a nerve block or ablation by the pain-management specialist. If the patient has an anatomic point of compression, such as a scar or vessel impinging on a nerve, we can perform a procedure to relieve the pressure on the nerve and, potentially, cure the patient of pain.”
Jin Li, MD, PhD, FAAN, FAANEM, Co-founder of WMC Headache Specialists, Section Chief of Neuromuscular Medicine at WMC and Associate Professor of Neurology at New York Medical College, performs neurological exams on a headache patient.
Searching for Secondary Causes
WMC Headache Specialists patients begin by seeing internist Gary Rogg, MD, FACP, Co-founder of WMC Headache Specialists, attending physician in the WMC Department of Internal Medicine and Associate Professor of Medicine at New York Medical College. In addition to managing headache patients in his private practice, Dr. Rogg spent seven years caring for individuals with acute headaches while leading the emergency department at Montefiore Health System Jack D. Weiler Hospital (Einstein Campus), in the Bronx. Like his colleagues, Dr. Rogg sees great value in interdisciplinary headache care.
“One of the most valuable things a clinician can do is investigate to determine whether a previous diagnosis a patient has been given is accurate,” he says. “Some patients are labeled as having migraines and are prescribed certain medications, but they may not have primary headaches. They may have headaches secondary to another condition. Our model of care at WMC Headache Specialists allows my colleagues and me to consider patients’ headaches from different perspectives.”
During patients’ initial evaluations, Dr. Rogg searches for secondary causes of headaches; hypertension is a common one.
“My emphasis is on obtaining a thorough history of patients’ headaches — when they started, what their triggers are and what therapies patients have tried in the past,” Dr. Rogg says. “I perform a blood workup and look for anything that might cause or exacerbate headaches, such as immunologic, rheumatologic or inflammatory factors, as well as vitamin and mineral deficiencies. If a patient hasn’t had an imaging study recently, such as an MRI of the head, I order one.”
For some patients, such as those with hypertension, curing chronic headaches might take nothing more than a medication to control blood pressure. However, if Dr. Rogg rules out all plausible secondary causes, he refers patients to the next level of care: neurology.
Gary Rogg, MD, FACP, Co-founder of WMC Headache Specialists, attending physician in the WMC Department of Internal Medicine and Associate Professor of Medicine at New York Medical College, examines a migraine patient.
Climbing the Treatment Ladder
Patients whom Dr. Rogg determines to be true migraineurs — those with migraines not caused by a secondary condition — see neurologist Jin Li, MD, PhD, FAAN, FAANEM, Co-founder of WMC Headache Specialists, Section Chief of Neuromuscular Medicine at WMC and Associate Professor of Neurology at New York Medical College. Dr. Li is one of a small number of physicians in the region who are board-certified in headache medicine. Dr. Li begins her interactions with patients by educating them about migraines and behavioral modifications that may reduce their frequency and intensity.
“I use an integrated approach to treat chronic headaches,” Dr. Li says. “The treatment algorithm begins with talking with patients about the importance of getting adequate sleep, exercising regularly, and recognizing and avoiding environmental triggers. Those steps can make a huge difference. Some patients may benefit from vitamin B2, CoQ10 or magnesium supplements as well, and we have many pharmacologic options to prevent headaches, including anti-seizure medications, antidepressants and beta-blockers.”
If patients fail to gain relief from multiple preventive medications, they may be candidates for injections of botulinum toxin — Botox — which can provide relief for up to 90 days. Dr. Li may inject Botox in multiple areas to achieve adequate relief.
For acute pain relief, migraine-specific medications such as triptans, nonsteroidal anti-inflammatory drugs or a combination of the two are very effective.
“Pain leads to more pain,” Dr. Li says. “When a patient has headache pain, it keeps intensifying. If we don’t control headaches from the start, they can last for days. Botox helps by decreasing the intensity of headaches. It works in two ways: by releasing tense muscles and, according to recent evidence, by blocking pain signals from nerves.”
If chronic headaches persist, or if they are nerve-related, patients continue along the clinical pathway to an appointment with pain-management specialist Nitin Sekhri, MD, Co-founder of WMC Headache Specialists, Section Chief of Pain Management at WMC and Assistant Professor of Anesthesiology at New York Medical College.
Members of the WMC Headache Specialists team meet to review patient cases.
Calming the Nerves
Dr. Sekhri, who is board-certified in both anesthesiology and pain medicine, estimates a quarter of the patients he sees are true migraineurs, and three-quarters have headaches from other causes, such as cervicogenic headaches related to pinched nerves or herniated discs in the cervical spine. For such patients, a cervical joint block in the nerves in the neck or ablation to cauterize the nerves can provide significant relief, he says.
“In some cases, the greater occipital nerve is entrapped at several locations in the cervical spine,” Dr. Sekhri says. “Performing blocks with a numbing agent can be both diagnostic and therapeutic, as patients may experience months to years of relief simply by breaking the pain cycle. Other patients may benefit from a sphenopalatine ganglion block, which they can perform at home by administering a local anesthetic through the nose.”
Another therapy in Dr. Sekhri’s armamentarium is peripheral nerve stimulation. During this treatment, electrodes deliver a mild current to the occipital nerves and replace pain with a tingling sensation. The patient regulates the current using an external stimulator. If the treatment is successful after a five-day trial, Dr. Sekhri implants a permanent, pacemaker-like stimulator.
By partnering with Dr. Alizadeh to examine nerves in the scalp using ultrasound imaging, Dr. Sekhri can help determine patients’ candidacy for a nerve decompression procedure.
“We can administer a temporary block to the nerves that are thought to be triggers for migraines when compressed,” Dr. Sekhri says. “Sometimes, we can see muscles trapping a nerve or a vascular malformation looping around the nerve, similar to neuralgia. A temporary block — or several blocks if necessary — can give us an idea if a particular nerve is, in fact, the pain generator.”
“In seeking relief from headaches, many patients become dependent on medications, including opioids. One measure of success for our team is getting patients off of such agents.”
— Kaveh Alizadeh, MD, MSc, FACS, Co-founder and Program Director of WMC Headache Specialists, Chief of the Division of Plastic and Reconstructive Surgery at WMC, and Associate Professor of Surgery at New York Medical College
For some patients, the best hope for pain relief is nerve decompression, a surgery that can be life-changing. Dr. Alizadeh knows this better than most. Since he began performing nerve decompressions seven years ago, he has helped relieve the burden of chronic headaches for hundreds of patients.
“Nerves can be blocked along their pathway by a muscle, vessel, tendon or bone,” Dr. Alizadeh says. “My job is to relieve physical compression points, which occur in four major areas: the back of the neck, the forehead, the temples and the nose. If we can find a trigger in one of those areas that’s driving the pain cascade, we know with a high level of confidence that surgical decompression can potentially relieve and cure the pain.”
Compression points may develop as a result of injury, such as whiplash that occurs during a vehicular accident, according to Dr. Alizadeh.
“In a whiplash scenario in which bleeding occurs in the neck, a scar may eventually form around the nerve that provides sensation from the back of the neck to the back of the scalp,” he says. “When a patient puts his head in a certain position, pain from the compressed nerve starts in the back of the neck and spreads upward. Leaning over while working at a computer may prompt pain by causing the muscle around the nerve to spasm and trigger the nerve.”
Nerve decompression surgery differs from patient to patient, depending, among other factors, on the area of compression and the nature of the nerve entrapment. In many cases, Dr. Alizadeh resects a portion of muscle to relieve the pressure on a nerve. All procedures are minimally invasive.
“If the nerve above the eye is entrapped, for example, I make the same incision I would make for an eyelid lift, which is less than 2 centimeters long, to gain access to and relieve the nerve,” Dr. Alizadeh says. “Patients experience relatively quick rehabilitation — most return to normal activities within a week. Some individuals experience numbness of the scalp lasting a few months.”
Patients may return home the same day or spend the night in the hospital, depending on the complexity of the procedure and, as necessary, their need for monitoring as they taper off pain medication.
Focused on Growth
As WMC Headache Specialists begins to serve more and more patients, Dr. Alizadeh sees its success as just the beginning. His goal is to make WMC Headache Specialists the premier interdisciplinary headache center in the New York metropolitan area and one of the major destinations in the United States.
“Eventually, we’d like to accumulate data and report on what works with each particular set of patients, based on our experience,” Dr. Alizadeh says. “We want to continue building a community of like-minded physicians who are interested in caring for, and potentially curing, patients with chronic headaches. I invite physicians to join us by sharing information and referring patients so we can help solve these complex conditions.”
For more information about WMC Headache Specialists, visit westchestermedicalcenter.com/wmcheadachespecialists.