Headache & Migraine Treatment
Over half of migraine patients in the United States have never received a correct diagnosis. They cycle through medications that were never matched to their headache type, prescribed by providers who never performed a neurological examination. A headache disorder is a neurological problem. It deserves a neurologist’s evaluation.
Beyond the Prescription Pad
The standard headache visit in American medicine lasts about seven minutes. The patient describes their pain. The provider writes a prescription—a triptan, topiramate, amitriptyline, maybe a beta-blocker—and schedules a follow-up in three months. If the first medication doesn’t work, they try another. If the second doesn’t work, they try a third. The headache diary goes unreviewed. The neurological exam never happens. The cervical spine is never assessed.
This is not a fringe problem. Lipton and colleagues published a population-based study in Neurology in 2007 analyzing over 162,000 respondents and found that only 56% of individuals meeting diagnostic criteria for migraine had ever received a correct diagnosis. Nearly half of all migraineurs in the United States are being treated empirically for a condition nobody has formally identified.
The consequences of misdiagnosis compound over time. A patient with cervicogenic headache treated with triptans will not improve. A patient with medication-overuse headache given more medication will get worse. Bigal and colleagues reported in Headache in 2008 that medication-overuse headache affects one to two percent of the general population—a condition caused entirely by the treatments prescribed to help. The problem is not that good medications don’t exist. The problem is diagnostic. Treatments work when they are matched to the correct headache type. They fail when they are not.
Dodick published a landmark review in the New England Journal of Medicine in 2018 detailing the role of calcitonin gene-related peptide in migraine pathophysiology. The CGRP pathway has transformed our understanding of why migraine happens at the molecular level. But that knowledge only helps if the clinician first determines whether the patient actually has migraine—and which subtype—before reaching for a treatment.
How a Neurologist Evaluates Headache
Headache diagnosis begins with a structured history. Not a checkbox intake form, but a detailed interview: onset pattern, frequency, duration, location, quality, associated symptoms, aggravating and alleviating factors, aura characteristics, sleep patterns, hormonal influences, dietary triggers, medication history including over-the-counter analgesic use, and family history. Headache classification under the International Classification of Headache Disorders requires this level of detail. Without it, the diagnosis is a guess.
The neurological examination adds objective data. Cranial nerve testing evaluates the trigeminal and facial nerve pathways that mediate head and face pain. Fundoscopic examination screens for papilledema. Cervical spine evaluation identifies mechanical contributors—restricted range of motion, upper cervical facet tenderness, and referred pain patterns that distinguish cervicogenic headache from primary migraine. Palpation of the pericranial and cervical musculature identifies myofascial trigger points that may be driving or amplifying the headache pattern.
Neuroimaging is ordered when clinically indicated, not reflexively. MRI with and without contrast is the appropriate study when red flags are present: new-onset headache, change in established pattern, focal neurological findings, positional component, or headache refractory to appropriate treatment. Routine imaging for typical migraine with normal examination adds cost without clinical value.
Laboratory evaluation targets specific contributors. Inflammatory markers, thyroid function, metabolic panels, vitamin D, magnesium, and hormonal profiles can reveal treatable factors that perpetuate headache chronicity. A patient with low magnesium and migraine has a correctable metabolic deficit. A patient with subclinical hypothyroidism and daily headache needs thyroid management, not another preventive medication.
This evaluation takes time. It cannot be completed in a seven-minute visit. That is exactly why most headache patients have never had one.
Our Treatment Approach
Once the headache type is classified and contributing factors are identified, treatment is matched to mechanism. Different headache disorders require fundamentally different interventions. A chronic migraine patient with peripheral sensitization benefits from chemodenervation. A patient with occipital neuralgia needs a nerve block. A patient with cortical hyperexcitability may respond to neuromodulation. These are not interchangeable.
Chou and colleagues published data in Headache in 2019 confirming that chemodenervation reduces headache frequency in chronic migraine through peripheral denervation of trigeminal and cervical afferents. Ambrosini and colleagues demonstrated in Cephalalgia in 2003 that migraine patients show measurable cortical hyperexcitability on transcranial magnetic stimulation testing—evidence that the migraine brain is physiologically different, not just more sensitive.
Migraine pathophysiology also involves mitochondrial dysfunction. Reduced mitochondrial oxidative phosphorylation has been documented in migraine patients between attacks, suggesting a persistent metabolic vulnerability that predisposes to cortical spreading depression. NAD+ repletion addresses this deficit at the substrate level.
We combine these interventions based on each patient’s specific headache classification, examination findings, and treatment history. Learn more about our full neurological services on our neurological services page.
Treatments We Use for Headache Disorders
Each treatment targets a specific mechanism involved in headache pathophysiology. The right combination depends on the diagnosis.
Chemodenervation
$175 / session
Targeted injections into specific muscle groups in the head and neck reduce peripheral sensory input to the trigeminal system. FDA-approved for chronic migraine with 15 or more headache days per month. Reduces headache frequency by approximately 50% in responders.
Occipital Nerve Block
$175 / side
Local anesthetic injection at the greater and lesser occipital nerves. Serves both diagnostic and therapeutic roles in occipital neuralgia, cervicogenic headache, and migraine with posterior predominance. Relief can begin within minutes.
Trigger Point Injection
$175 / session
Targeted injection of local anesthetic into myofascial trigger points in the cervical, trapezius, and pericranial musculature. Addresses the myofascial pain component that frequently coexists with and amplifies primary headache disorders.
NAD+ IV Therapy
Nicotinamide adenine dinucleotide supports mitochondrial oxidative phosphorylation, which is impaired in migraine patients even between attacks. IV NAD+ restores the metabolic substrate that energy-depleted neurons require for normal function.
Our Diagnostic-First Approach
Every headache evaluation at The Neurogenesis Project follows a structured protocol designed to classify the disorder before selecting treatment. We do not prescribe empirically.
Structured headache history. We review headache diaries, prior imaging, medication history, and patterns of attack frequency, duration, and associated symptoms. The International Classification of Headache Disorders recognizes over 300 headache subtypes. Accurate classification requires detailed characterization.
Neurological examination. Cranial nerve testing, fundoscopic exam, motor and sensory screening, cerebellar testing, and assessment of cervical spine mechanics. The examination identifies focal findings that may indicate secondary headache and localizes the pain generator in cervicogenic and myofascial presentations.
Neuroimaging when indicated. MRI brain with and without gadolinium, MRA when vascular pathology is suspected, cervical spine imaging when mechanical contribution is identified. We follow evidence-based imaging guidelines and do not order scans that will not change management.
Laboratory evaluation. Inflammatory markers (ESR, CRP), thyroid function, complete metabolic panel, magnesium, vitamin D, and hormonal profiles as indicated. These labs identify correctable metabolic and endocrine contributors that standard headache workups overlook.
Treatment trial protocols. When diagnostic nerve blocks or other interventional procedures serve a dual diagnostic and therapeutic role, we use them systematically. An occipital nerve block that eliminates the headache confirms occipital nerve involvement. A trigger point injection that reduces headache severity identifies a myofascial contributor. These responses guide subsequent treatment decisions.
Related Treatments
Migraine Chemodenervation
Targeted peripheral denervation of trigeminal and cervical afferents for chronic migraine. Reduces headache frequency and the peripheral sensitization that drives attack progression.
Occipital Nerve Block
Diagnostic and therapeutic injection at the greater and lesser occipital nerves. Effective for occipital neuralgia, cervicogenic headache, and migraine with occipital predominance.
Frequently Asked Questions
How is your approach to headache treatment different from what I’ve already tried?+
What types of headaches do you treat?+
Do I need imaging for my headaches?+
What is migraine chemodenervation and how does it work?+
Does insurance cover treatment at your clinic?+
How quickly can I expect results from treatment?+
Your Headache Deserves a Real Diagnosis
If you’ve been cycling through medications without improvement, the problem is probably not the medications. It’s the diagnosis. Dr. Orr and the team at The Neurogenesis Project provide subspecialist headache evaluation and treatment in St. Marys, Georgia.