Headache & Migraine Treatment
Headache and migraine treatment at The Neurogenesis Project starts with a neurological diagnosis that most patients have never received — over half of migraine patients in the United States are still undiagnosed. 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.
Available at our St. Marys, Georgia clinic.
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.
What to Expect
Headache history and pattern analysis
Estimated time: 30 minutes
Dr. Orr takes a detailed headache history covering frequency, duration, location, character, triggers, aura symptoms, medication use, and impact on daily function. He classifies your headache type and evaluates for red-flag features that may warrant urgent imaging.
Neurological examination
Estimated time: 20 minutes
A focused exam evaluates cranial nerves, fundoscopic exam to rule out papilledema, cervical spine and shoulder musculature, temporomandibular joint, and trigger points. The exam helps differentiate primary headache disorders from secondary causes.
Diagnostic imaging when indicated
Estimated time: 30 minutes
Brain MRI with or without contrast is ordered when the headache pattern is new, changing, or accompanied by neurological symptoms. MRA may be added to evaluate cerebral vasculature. The imaging rules out structural lesions, vascular malformations, and other secondary causes.
Treatment plan development
Estimated time: 20 minutes
Dr. Orr develops a treatment strategy based on headache type and severity. Options include preventive medications, abortive therapies, nerve blocks, chemodenervation with botulinum toxin for chronic migraine, trigger point injections, and lifestyle modifications targeting known triggers.
Follow-up and treatment adjustment
Estimated time: 15 minutes
Treatment response is monitored through headache diaries and follow-up visits. Dr. Orr adjusts the treatment plan based on frequency reduction, severity changes, and medication use patterns. The goal is measurable reduction in headache burden.
Frequently Asked Questions
How is your approach to headache treatment different from what I’ve already tried?+
Most headache care is trial-and-error with medications. We start by diagnosing exactly what type of headache you have, what is causing it, and what is making it worse — then treat the actual mechanism, not just the pain.
Read the full answer
Most headache care follows a trial-and-error medication model: try a triptan, switch to a preventive, adjust the dose, repeat. That approach skips the most important step. We start with a structured diagnostic evaluation to classify the headache disorder accurately, identify contributing factors like cervicogenic dysfunction or medication overuse, and build a treatment plan that targets the actual mechanism rather than suppressing the symptom. Many patients who come to us have never had their headache formally classified by a neurologist.
What types of headaches do you treat?+
All types — migraine, tension headache, cluster headache, post-concussion headache, medication-overuse headache, and others. Each type has a different cause and needs a different treatment, which is why accurate diagnosis comes first.
Read the full answer
We evaluate and treat the full spectrum of primary and secondary headache disorders: migraine with and without aura, chronic migraine, tension-type headache, cluster headache, cervicogenic headache, post-traumatic headache, medication-overuse headache, and new daily persistent headache. Each of these has a distinct pathophysiology and requires a different treatment strategy. Accurate classification is the first step in every evaluation.
Do I need imaging for my headaches?+
Not always. Imaging is warranted for new headaches after age 50, sudden severe onset, worsening patterns, or headaches accompanied by neurological symptoms. Dr. Orr determines whether imaging is needed based on your specific situation.
Read the full answer
Not every headache patient requires neuroimaging, but the decision depends on the clinical picture. Red flags such as new-onset headache after age 50, sudden thunderclap onset, progressive worsening, focal neurological findings, or headache triggered by exertion or position change warrant imaging. We order MRI when it is clinically indicated and avoid unnecessary scans when the history and examination point clearly to a primary headache disorder.
What is migraine chemodenervation and how does it work?+
Targeted injections into head and neck muscles that help trigger migraines. Clinical trials show it reduces headache days by about 50 percent in chronic migraine patients. Sessions take about 15 minutes, cost $175, and are repeated every 12 weeks.
Read the full answer
Chemodenervation involves targeted injections into specific muscle groups in the head and neck that are implicated in migraine pathophysiology. The treatment reduces peripheral sensory input to the trigeminal system and has been shown in clinical trials to reduce headache days by approximately 50% in chronic migraine patients. Sessions take about 15 minutes and are repeated every 12 weeks. At our clinic, each session is $175.
Does insurance cover treatment at your clinic?+
No. We operate outside insurance networks, but we provide documentation for out-of-network reimbursement. Many procedures are $175 per session — often less than a hospital copay.
Read the full answer
The Neurogenesis Project operates outside of insurance networks. We provide detailed superbills and medical documentation that patients can submit to their carriers for potential out-of-network reimbursement. Many of our procedures, including chemodenervation, nerve blocks, and trigger point injections, are priced at $175 per session, which is often less than the insurance copay at a hospital-based headache center.
How quickly can I expect results from treatment?+
Nerve blocks can provide relief within minutes. Chemodenervation takes two to three weeks to reach full effect. Preventive medications may take longer. We set realistic expectations at your first visit.
Read the full answer
Response timelines depend on the headache type and the treatment selected. Occipital nerve blocks can provide relief within minutes and are also diagnostically valuable. Chemodenervation typically reaches full effect within two to three weeks.We set realistic expectations at the initial consultation and track headache frequency and severity with structured follow-up.
Do you offer CGRP monoclonal antibody injections for migraine prevention?+
Yes. We prescribe the newer CGRP migraine prevention injections — Aimovig, Ajovy, and Emgality. In clinical trials, about half of patients saw their monthly migraine days cut in half or more.
Read the full answer
Yes. We prescribe erenumab (Aimovig), fremanezumab (Ajovy), and galcanezumab (Emgality) for patients with chronic or high-frequency episodic migraine. The CGRP class has demonstrated a 50 percent or greater reduction in monthly migraine days in approximately half of patients in clinical trials. We select the appropriate agent based on insurance coverage, prior treatment history, and individual response.
What non-medication treatments do you offer for migraine?+
Chemodenervation, occipital nerve blocks, trigger point injections, and IV magnesium infusions. For many patients, combining medication with these non-drug approaches works better than either alone.
Read the full answer
Our non-pharmacologic treatments include chemodenervation, occipital nerve blocks, trigger point injections, and IV magnesium infusions. Each has a defined mechanism of action and a published evidence base. For many patients, a combination of targeted preventive medication and non-pharmacologic intervention produces better outcomes than either approach alone.
What should I bring to my first headache appointment?+
A headache diary (or notes on how often headaches occur, how long they last, and what triggers them), your full medication list, a list of past treatments and whether they helped, and any prior brain imaging on disc.
Read the full answer
Bring a headache diary or written estimate of frequency, duration, intensity, and triggers. Bring a complete medication list including over-the-counter medications and supplements, and note which medications you have tried previously and how well they worked. If you have had brain imaging, bring the actual images on disc. Reports from previous neurologists or emergency department visits are helpful. The more information we have, the more efficiently we can focus on what has not yet been evaluated.
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 at our neurology clinic in St. Marys, Georgia, a short drive from Kingsland, Yulee, Fernandina Beach and Brunswick.