Botox Injections
Chronic migraine is a painful neurological condition that results in headaches for 15 days per month over a three-month period and for greater than 4 hours per day. 
Approximately 2-4% of the world population suffers from chronic migraines.
Frequently Asked Questions
What is the purpose of this procedure?
The purpose of this procedure is to manage and help prevent migraine headaches, cervical dystonia, and TMJ or other significant pain secondary to muscle spasm.
How is the procedure performed?
You will be sitting upright and Botox is injected into multiple locations in key areas around the head, neck, and trapezius muscles.
How much time does the procedure take?
Botox injections typically take around 5-10 minutes.
What medicine is injected?
Approximately 5 units of Botox (onabotulinumtoxinA) is injected per injectioin site. A total of 31 injections are performed for migraines with a very fine needle. Most patients describe the injection feels like a small pinprick.
How long will it be before I get relief?
Many patients report gradual relief as early as a few days from getting the injection, however, it may take up to 2-3 weeks to notice optimum relief.
How long does the effect of the injection last?
Once the Botox has successfully blocked the nerve signals, which may take 2 weeks, most patients report up to 3 months or greater of pain relief.
What if the injection doesn’t work?
If there is minimal pain relief from the first injection, do not get discouraged. I may take a second injection before you begin to notice benefit.
What are the risks and side effects?
Like most procedures, they are not risk free and there is always possibility of side effects. Complications of Botox injections are rare. Uncommon reactions can include eyelid drooping, neck pain, muscle weakness and stiffness at the injection site, and headache. (use Tylenol for headache)
Post Procedure Instructions
- Avoid rigorous activity for 24 hours after injections, walking or low impact activity is fine
- Keep your head up and don’t lie flat for 2 to 4 hours, recliner is ok
- Do not rub or massage injection sites for 24 hours. Washing your face or applying makeup is fine
Epidural Steroid Injection
Frequently Asked Questions
What is the purpose?
Theoretically, the steroid reduces the inflammation of the nerve roots as they exit the spine.
How is the procedure performed?
The procedure is performed under fluoroscopic x-ray guidance. The patient is lying on his/her stomach. The skin is cleaned with antiseptic solution. A local anesthetic is used to numb the skin and then the injection is performed.
How long does the procedure take?
The procedure typically takes 5-10 minutes.
What medicine is injected?
A steroid medication is injected, although sometimes, depending on which type of epidural, a local anesthetic is administered along with the steroid.
Will the injection hurt?
The procedure is performed under local anesthetic, which is used to numb the skin and deeper tissues. You may feel a burning sensation that will last only a few seconds from the local anesthetic and some pressure but typically not much pain.
How will I feel after the injection?
You may have a sore back briefly after the injection because of the medication that was injected but then you should feel some relief. Using an ice pack for 20 minutes a few times that day will help with this.
How long does the effect of the injection last?
The steroid starts having an effect in 24 to 48 hours and may last several days to several months. Everyone is different and there is great variability among patients.
How many injections can I have in a year?
The number will depend upon the cause of your pain and whether or not you have other health related issues.
What are the side effects of the injection?
Initial side effect is local soreness from the injection. Ice for 20-minutes throughout the day will help with this. Late side effects are related to the steroid. Elevated blood sugars for 24 to 48 hours, therefore if you are diabetic, increase the amount of blood sugar checks. Also flushing of the face, dizziness, and headaches may occur.
What are the possible complications of the procedure?
The most common complication is dural sac puncture, which could cause headache. The other complications are bleeding and infection, but these are rare. Very uncommon complications include nerve or spinal cord injury.
Who should not have the injection?
If you are taking any drugs that affect blood coagulation (blood thinners such as Plavix, Coumadin, Xarelto, Eliquis, or others) or if you have any active infection, you should not have the procedure without further discussion. Also, please warn us of any allergies, especially to local anesthetics, x-ray dye, seafood, and latex.
iovera° Treatment
iovera° is an innovative cryoanalgesia technology that allows health care providers to block pain for immediate and long-term relief by delivering precise cold therapy to a targeted nerve. It has shown to provide long-lasting pain control for osteoarthritis of the knee, or patients undergoing TKA, helping to reduce opioid consumption without permanent damage to nerve structure.
How does iovera° work?
iovera° is a handheld device that lets your doctor apply just the right amount of extreme cold only to the nerves they want to target—the ones causing you pain. The iovera° treatment is localized, non-surgical, and does not contain medicine or opioids.
What makes iovera° different from other pain treatments?
iovera° is an innovative type of pain-relief treatment known as cryoneurolysis (kri-o-nuh-rol-i-sis), or cold therapy. It uses targeted cold to temporarily stop nerves from sending pain signals to the brain.
How do I know if the iovera° treatment is right for me?
iovera° is an option for people who are experiencing OA pain in the knee. It can also be given before or after knee replacement surgery to make recovery easier and less painful. Ask your doctor about iovera° knee treatment if you have tried other pain treatments for OA, or if you are discussing having knee replacement surgery.
What kind of results can I expect?
Pain relief from the iovera° treatment can be felt immediately after treatment. When the treatment is applied to a specific nerve, it will interrupt that nerve’s ability to send a pain signal, providing an immediate reduction in pain.
Does the iovera° treatment hurt?
The iovera° treatment should not be painful. An injection or topical numbing medication will be used on the treatment area to manage any potential discomfort. Some people describe feeling pressure or tugging during the iovera° treatment. Cold, warm, and tingling sensations are also normal, as is some level of discomfort. Tell your doctor right away if you feel any pain during your treatment. Individual patient results may vary.
Occipital Nerve Blocks
Occipital nerve blocks are performed to treat migraines, cluster headaches, spondylosis of the cervical facet joints, and occipital neuralgia. It involves injecting an anesthetic around the greater and lesser occipital nerves. A recent study found that 64 percent of patients had their headache lessen in five minutes after the injection. 
Frequently Asked Questions
What is the purpose of this procedure?
The purpose of this procedure is to help in the management of headaches.
Where is the occipital nerve located?
The occipital nerve is located in the back of the head, just about the neck and between the first and second vertebrae.
How is the procedure performed?
Either sitting or lying flat on his/her stomach, whichever is more comfortable, a mixture of local anesthetic and steroid is injected into the area with a fine needle.
How much time does the procedure take?
The occipital nerve block takes about five minutes.
What medicine is injected?
A mixture of local anesthetic and steroid.
How long will it be before I get relief?
Depending on the amount of swelling in the nerve, some patients report feeling relief within a matter of minutes. Other patients may not feel relief for a couple of days.
How long does the effect of the injection last?
The effect of the medication can last a few weeks to a few months.
What if the injection doesn’t work?
If the patient doesn’t feel relief from the first occipital nerve injection within the first couple of weeks, then a second block may be necessary. If the results of both injections lack relief, further examination will be performed.
What are the risks and side effects?
Like most procedures, they are not risk free and there is always a possibility of side effects. The most common side effect is pain, swelling, and irritation at the injection site. Bleeding, infection, allergic reaction, light-headedness may also occur.
Who should not have this injection?
Patients who are allergic to local anesthetic and/or steroids, have active infections, or poorly controlled diabetes will need further discussions.
Medial Branch Blocks (MBB)
Medial branch nerves are very small verve branches that carry the pain message from the facet joints and the muscles around the joints. If the nerves are blocked or numbed, they will not be able to transfer the pain sensation from the joints to the brain. 
Frequently Asked Questions
Where are the facet joints?
The facet joints are small joints in the back of the spine that form connections between each vertrebra. Each vertebra has a surface on four facet joints, two on the upper or superior surface and two on the lower or inferior surface of the vertebra. The facet joins limit how far you can twist or bend your back and neck.
What is the purpose?
This is a diagnostic procedure. This is injection is done to confirm the diagnosis of facet joint disease and to find out if the facet joints are contributing to your pain.
How is the injection performed?
The patient lies on his/her stomach. The skin of the back is cleaned with antiseptic solution and is injected with local anesthetic, after which the nerve block is performed under X-ray guidance.
How much time does the procedure take?
The procedure usually takes 5 to 10 minutes.
What medicine is injection?
A local anesthetic such as Lidocaine is injected.
Will the injection hurt?
The procedure is performed under local anesthetic, which is used to numb the skin and deeper tissues. You may feel a burning sensation that will last only a few seconds from the local anesthetic and some pressure but typically not much pain.
How will I feel after the injection?
You may have a sore back briefly after the injection because of the medication that was injected but then you should feel some relief. Using an ice pack for 20 minutes a few times that day will help with this.
How long does the effect of the injection last?
If the facet joints are the source of the pain, you should benefit from the injection relatively quickly. Because this is a diagnostic injection, it is not intended to last, however it may last several hours to several days. Every patient is different.
What is the next step after having good relief?
If you benefit from the procedure, the next step would be consideration of radiofrequency ablation of the medial branch nerves. Typically, two diagnostic tests are required before moving on to the radiofrequency.
What are the side effects of the injection?
Serious side effects and complications are uncommon. The most common problem after the injection is having pain in the area of injection for a few days. The other compilations are injection bleeding, and nerve injury.
Who should not have the injection?
If you are taking antibiotics or if you have any active infection, especially in the area being worked on, you should not have the procedure without further discussion. Also, please warn us of any allergies, especially to local anesthetics, x-ray dye, seafood, and latex.
Radio-Frequency Ablation (RFA)
Radio-Frequency ablation is a procedure using a specialized machine that generates radio-frequency current. A special needle is places next to the nerve that carries pain from spinal facet joints to the spinal cord. The radio-frequency current is passed through the needle. The current generates heat or other physical forces that interrupts transmission of the pain. These nerves recover function slowly over time.
Frequently Asked Questions
How is the procedure performed?
The procedure is performed under x-ray guidance with the patient lying on his/her stomach. The skin is anesthetized and the needles are placed under x-ray guidance.
How long does the effect last?
The effect of the procedure is expected to last anywhere from 3 months to 12 months. Again, everyone is different and there is great variability among patients.
Can RFA treatment be repeated?
This depends on how long it takes for the nerve function to return. In general, because of risks of repeated x-ray exposure, we do not recommend more than twice per year, or once every 6 months.
What are the complications of RFA?
Many patients report soreness; often a sunburn feeling to the area treated that can last 1-3 weeks. Ice for 20-minute periods throughout the day can help. Rare complications include infection, bleeding, and nerve damage.
Who can have this procedure?
Prior to initial radio-frequency, you should have at least two successful diagnostic nerve blocks performed (see medial branch block handout).
Who should not have this procedure?
If you are taking antibiotics or if you have any active infection, especially in the area being worked on, you should not have the procedure without further discussion. Also, please warn us of any allergies, especially to local anesthetics, x-ray dye, seafood, and latex.
