Doctor Who Treats Migraines: Breaking the Cycle of Pain

Migraine sits at the intersection of neurology, immunology, and pain medicine. That is why the best care rarely comes from a single prescription. When I meet a patient whose life has been trimmed down by pain, the first job is to understand the pattern. Is this a once-a-month migraine that explodes behind one eye and fades by the next morning, or a daily, squeezing headache with light sensitivity that never quite lets go? The answer determines whether you need a neurologist, a pain management physician, or both. It also shapes how aggressive we should be and how many tools we bring to the table.

Migraine is not just a bad headache. It is a brain network disorder with sensory amplification, altered pain processing, and a tendency to flare under certain triggers. Genetics set the stage. Hormones, sleep, stress, neck dysfunction, and medication overuse often push it into a chronic loop. Breaking that loop requires precision, patience, and clear goals.

Who actually treats migraines

Patients often ask whether they should see a primary care clinician, a neurologist, or a pain management specialist. The right answer depends on frequency, severity, and response to first-line care.

A primary care clinician can diagnose and manage many episodic migraines, start acute medications like triptans or gepants, prescribe first-line preventives, and coordinate referrals. Neurologists bring deep expertise in the biology of migraine and comorbid neurologic conditions. A pain management doctor focuses on the sensory and muscular components, interventional options, and complex cases where nerve pathways and neck structures play a role. In practice, the best results happen when these professionals collaborate. A board-certified pain specialist who understands migraine physiology can bridge the gap between neurology and interventional pain medicine, particularly when neck pain, occipital neuralgia, or medication overuse causes the headaches to snowball.

If you are having headaches 15 or more days per month for over three months, with at least eight days carrying migraine features, this counts as chronic migraine. That is when a pain medicine physician or chronic pain specialist adds real value. If you have warning signs like a sudden thunderclap headache, neurologic deficits, seizures, or a dramatic shift in pattern, a neurologist’s evaluation comes first.

What a thorough evaluation looks like

A careful history is more powerful than any scan. I start with a calendar and a clock. How many days per month? How many severe days? How long does a typical attack last untreated, and what helps? What does the pain feel like: throbbing, stabbing, pressure? Where does it start, and does it migrate? Light, sound, smell, or motion sensitivity? Nausea or vomiting? Aura features like zigzag lights, numbness, or speech changes? This detail separates migraine from tension-type headache, sinus pressure, cluster headache, and cervicogenic headache.

I examine the eyes, jaw, neck, and upper back. Trigger points in the trapezius, tight suboccipital muscles, and tender greater occipital nerves often drive or amplify pain. I check for cervical range-of-motion limits, joint line tenderness, and posture. Blood pressure matters, as do neurologic reflexes and sensation. I review sleep, hydration, menstrual pattern, caffeine, alcohol, stress, and daily routines. I ask about over-the-counter pain medications, triptans, and combination products. Medication overuse can quietly turn episodic migraine into an everyday problem. If patients need pain relief more than about 10 days a month with triptans or at least 15 days with NSAIDs or acetaminophen, I start planning an exit ramp.

Imaging is not routine. I reserve MRI for red flags: sudden severe onset, neurologic deficits, new headaches after age 50, cancer history, or infection risk. Most patients do not need scans to get excellent care.

The role of a pain management specialist in migraine care

When headaches grow frequent, refractory, or complicated by neck and shoulder issues, a pain management specialist adds options. The training spans pharmacology, interventional procedures, musculoskeletal medicine, and multidisciplinary coordination. A pain management doctor, whether anesthesiology, neurology, or physiatry trained, looks at pain circuits and peripheral input that keep the brain sensitized. That means attention to occipital neuralgia, temporomandibular joint pressure, cervical facet joint irritation, and myofascial triggers. A pain medicine physician can integrate nerve blocks, targeted injections, and neuromodulation with migraine preventives, behavioral therapy, and physical rehabilitation.

Many patients arrive after trying several pills without durable relief. They may say, “My head is the problem, why are you treating my neck?” Yet for a subset, the neck is the ignition source and the head carries the flame. Addressing the source matters.

Breaking the cycle: acute, preventive, and procedural tools

Most migraine care follows two tracks: acute relief to stop an attack, and preventive therapy to reduce frequency and severity over time. When the pattern is chronic or complicated, interventional steps can interrupt pain circuits and give other treatments room to work.

Acute treatments work best when taken early, at the first sign of pain or aura. Triptans are the classic option, effective for many, though not ideal for those with vascular disease. Gepants, a newer class that blocks the CGRP receptor, offer fewer cardiovascular concerns and minimal medication-overuse risk compared with older options. Ditans can help when triptans are not tolerated, though sedation and driving restrictions apply for several hours after dosing. NSAIDs still have a place if used thoughtfully. Combining an NSAID with a triptan can improve results for some patients. The key is judicious use and protection of the gut, especially in people with reflux or bleeding risk.

Preventive therapy makes the biggest difference in life quality when headaches occur more than once a week, or when a few monthly attacks still cause major disability. Traditional preventives include beta blockers, topiramate, valproate in selected cases, certain antidepressants like amitriptyline or venlafaxine, and calcium channel blockers. These have decades of real-world experience behind them but can bring side effects like fatigue, weight change, tingling, or mood shifts. The CGRP monoclonal antibodies represent a major step forward. Monthly or quarterly dosing reduces migraine days for many patients by 3 to 8 days per month, sometimes more. They work without the sedation and cognitive fog that drive patients away from older preventives. Insurance coverage varies, so I pair medical necessity documentation with a clear headache diary to support approvals.

For chronic migraine, onabotulinumtoxinA injections across scalp, neck, and shoulders can lower monthly headache days by about 7 to 9 after several cycles. Technique matters. I mark and treat the procerus, corrugators, frontalis, temporalis, occipitalis, cervical paraspinals, and trapezius with the standard protocol, then tailor to the patient’s pattern. Some need more coverage posteriorly when occipital tenderness dominates. Others need careful dosing along the forehead to avoid brow heaviness. The first cycle may underwhelm; benefit often builds by the second or third.

Interventional pain procedures can reset hyperactive pain pathways. Greater occipital nerve blocks, performed with a small amount of local anesthetic and sometimes steroid at the https://www.facebook.com/metropaincenters/ base of the skull, often calm an attack within minutes and can provide days to weeks of relief. Repeated blocks can reduce sensitization. Patients with a focal, sharp pain at the back of the head that radiates forward often respond best. Sphenopalatine ganglion blocks, done transnasally, help some with severe autonomic features like tearing and nasal congestion. Trigger point injections in the trapezius, levator scapulae, and suboccipitals break painful muscle loops that feed the migraine network. These procedures do not replace a prevention plan, but they buy time, reduce medication loads, and restore control.

For the rare patient with disabling, refractory headache despite multiple preventives and procedures, peripheral nerve stimulation or occipital nerve stimulation may be considered in specialized centers. This is not a first or second-line option. It demands careful selection, realistic expectations, and the support of a multidisciplinary team.

When the neck fuels the head

Cervicogenic headaches and migraine often mingle. Poor posture, whiplash history, desk strain, and sleep positions can load the upper cervical facets and compress the greater occipital nerve as it pierces tight muscle. The brain, already primed for migraine, reads this barrage as pain and threat. Addressing the neck can lower the temperature of the entire system.

I work closely with physical therapists who understand migraine. This is not about forcing range of motion on day one. We start with gentle isometrics, scapular setting, breath mechanics, and postural alignment that patients can perform every day without triggering flares. Soft tissue work around the suboccipitals and upper traps reduces peripheral input. As tolerance improves, we add controlled mobility and strengthening for the deep neck flexors and mid back stabilizers. If a patient can turn a stiff, achy neck into a quiet, strong, mobile neck, the head often follows.

For patients with focal facet pain that reliably triggers a headache, medial branch blocks can confirm the pain source. Radiofrequency ablation of those medial branches may then provide months of relief. Not every migraine patient needs this. The best candidates have reproducible mechanical neck pain and a clear response to diagnostic blocks.

Controlling triggers without living in a bubble

Triggers are real, yet chasing them can become its own trap. The goal is to soften vulnerability without building a life around avoidance. Poor sleep often tops the list. A regular sleep window, gentle wind-down, and consistent wake time reduce the brain’s susceptibility to pain. Skipping meals, dehydration, and rapid caffeine swings provoke attacks. Regular meals, steady hydration, and predictable, moderate caffeine often help more than an austere diet. Hormonal swings can be powerful. For some, a short-term mini-preventive approach around menses with a triptan or NSAID can blunt the flare. For others, longer-term preventive therapy evens the terrain.

Exercise is tricky when every run ends with a pounding head. I favor a slow, steady build, starting with low-impact options and shorter sessions. The aim is to stabilize the nervous system, not chase fitness records. Heat and cold become tools rather than fixes. Some patients swear by a cold pack at the occiput in the first minutes of an attack. Others relax tight shoulders with a warm shower before bed. None of this replaces medication or procedures, but each piece supports the system.

Stress modulation matters, though the word stress often makes patients feel blamed. The migraine brain is sensitive to change. Acute stress, then the letdown afterward, can both provoke pain. Short, daily practices such as breath training, brief mindfulness, or biofeedback can reduce the amplitude of response. I ask patients to think in minutes, not hours. Five to ten minutes most days is more sustainable than marathon sessions that fade by week two.

Medication overuse and the hidden accelerant

A common pattern plays out like this: attacks increase, so the patient leans on over-the-counter pills or triptans more days each week. Relief becomes inconsistent, the baseline dull ache builds, and attacks arrive easier. This is medication-overuse headache, a physiologic state where the brain’s pain processing adjusts to frequent analgesics and sets a higher daily pain tone. It does not mean the patient did something wrong. It means the system adapted.

The fix is disciplined and uncomfortable for a brief period. We plan a taper schedule, add a preventive or optimize the current one, and use nonoverusing acute options judiciously. Nerve blocks during the taper help many patients cross the bridge without losing function. Most notice a shift within two to six weeks. Once the baseline quiets, acute medicines tend to work better again, even at lower total use.

When comorbidities complicate the picture

Migraine seldom travels alone. Anxiety, depression, sleep apnea, irritable bowel syndrome, fibromyalgia, and temporomandibular disorders often coexist. A pain management specialist and a neurologist can coordinate with mental health clinicians, sleep medicine, dentistry, and physical therapy to get all cylinders firing in the same direction. If sleep apnea goes untreated, nocturnal desaturations and sleep fragmentation keep the brain on alert. If jaw clenching strains the temples every night, forehead injections alone will disappoint. If mood symptoms sit unaddressed, pain amplifies the distress, and distress amplifies pain in a tight loop. Targeted treatment, not a generic “reduce stress” directive, is what changes outcomes.

Case snapshots from practice

A 34-year-old teacher with near-daily headaches arrived exhausted. She used an over-the-counter combination analgesic most days and a triptan on top twice a week. Her neck was tender along the greater occipital nerves. We mapped her week, set a taper plan for the overused medications, started a CGRP antibody as preventive therapy, and scheduled a series of bilateral greater occipital nerve blocks and trapezius trigger point injections. She began neck-focused physical therapy two weeks later. By week six, her headache days fell from 25 to 12. By month three, she had eight headache days, two severe. We left the door open for onabotulinumtoxinA if needed, but she did not require it.

A 47-year-old accountant with chronic migraine and clear menstrual flares did well on onabotulinumtoxinA but still lost three days every cycle. We added a targeted mini-preventive: a gepant taken daily for five days starting two days before menses. That change cut her severe days in half and preserved her routine.

A 59-year-old patient with neck osteoarthritis and headaches triggered by head rotation improved after two positive medial branch blocks followed by radiofrequency ablation at C2 to C3 medial branches. He continued simple mobility exercises and remained on a low-dose preventive. His average headache days dropped from 20 to 7 per month.

Coordinating care across specialties

Migraines improve faster when your team speaks the same language. A pain management provider should share notes with your primary care clinician and neurologist. The shared goals are clear: fewer headache days, lower severity, better function, and fewer rescue medications. If a plan does not budge the numbers after a fair trial, change it. Stick with measurable targets, like a 50 percent reduction in monthly migraine days or the ability to work through a week without a rescue. I ask patients to bring a concise headache log. Dates, severity, medication taken, and probable triggers tell the story far better than memory.

Insurance hurdles can slow access to modern options. Prior authorizations often require documentation of failed or intolerant trials of older preventives. A careful record shortens that process. A pain relief physician or neurologist experienced with these pathways can navigate the steps and appeal when appropriate.

When you should seek urgent care

While most migraines are benign, certain features warrant immediate evaluation: a sudden, worst-ever headache that peaks in seconds, a new neurologic deficit such as weakness, drooping face, persistent double vision, confusion, a seizure, a new headache after a significant head injury, or a new pattern in patients with cancer, clotting disorders, or pregnancy. Pain doctors and neurologists alike take these red flags seriously. Better to check once too often than to miss a dangerous mimic.

Building a sustainable plan you can live with

Cancer pain, sciatica, joint pain, and neuropathy teach pain specialists a core truth about chronic pain: the plan must fit your life. Migraine is no different. A doctor for chronic pain can help set expectations that balance ambition with realism. We may aim for 50 to 70 percent fewer headache days within three to six months, then focus on resilience and early rescue. A chronic pain physician watches for the small wins that grow into stable change: fewer emergency visits, a steady morning routine, the return of exercise, or the ability to plan a weekend without fear.

There is a temptation to stack treatments in the hope that more is better. Sometimes that helps. Often it increases noise. I prefer a stepwise approach. Start a targeted preventive, give it a fair window, add interventional support when indicated, refine sleep and activity, and pare back acute medication use. If headaches remain stubborn, consider onabotulinumtoxinA or add a second preventive from a different class. If neck or nerve drivers persist, address them specifically. If mood or sleep disrupts recovery, bring those clinicians into the circle.

Practical self-checks between visits

Use these quick checks to keep the plan on track.

How many days this month did I have a headache, and how many were clearly migraine? On how many days did I use acute medication, and which ones? What changed in my sleep, caffeine, meals, or routine over the last two weeks? Did I complete my physical therapy exercises at least four days a week? What single adjustment could I try over the next two weeks to reduce vulnerability?

Five questions, two minutes, meaningful trend lines. Bring these notes to your next appointment with your pain treatment specialist or neurologist. They guide smarter adjustments and faster progress.

Choosing the right clinician for your needs

Look for a board-certified pain doctor or neurologist with meaningful experience in migraine. Ask how often they use nerve blocks, onabotulinumtoxinA, or CGRP therapies. If neck pain or shoulder pain features in your attacks, a pain management clinician comfortable with interventional options may be the best first stop. If you have complex neurologic symptoms or diagnostic uncertainty, start with a neurologist and loop in a pain care physician as needed. The job titles vary: pain management MD, pain medicine physician, interventional pain specialist, or chronic pain doctor. What matters is expertise, accessibility, and a plan tailored to your pattern.

A good doctor will ask about your life, not just your pain. They will explain the reasoning behind each step and avoid reflexively escalating rescue medications. They will track disability and function, not just scores on a scale. They will know when to refer for behavioral therapy, sleep evaluation, or dental assessment for jaw issues. They will return your calls when things wobble. That combination drives outcomes more than any single drug.

The long view

Migraine changes over time. Teenagers with monthly attacks become adults with rare flares or, sometimes, daily pain. Hormones settle, then shift again. Work evolves. Stressors change shape. A doctor specializing in pain management sees these arcs in back pain, sciatica, neuropathy, and cancer pain, and applies the same principle to migraines: keep updating the plan. Record the wins and the stubborn spots, track medications that still earn their keep, retire those that do not, and keep an eye on quality of life, not just headache counts.

I remember a patient who reached a plateau after a year of steady improvement. We had cut headache days from 22 to 9, but he felt stuck. Rather than add another drug, we revisited the pattern. His attacks clustered after long days at the computer. He had reverted to a sharp forward head posture and had dropped his home exercises. We reengaged physical therapy with a tiny, daily regimen he could sustain, added two standing breaks a day, and scheduled a short series of occipital blocks during a difficult quarter-end period. Three months later, he was at 5 headache days per month, and his confidence had returned.

That is the arc to aim for. Not perfect. Better, then stable, then resilient. A pain management expert can help you build that arc, step by step, without guesswork or gimmicks.

A final note on hope and patience

Migraine rewards persistence. If you have tried two or three medications and felt no change, it is easy to assume nothing will help. The reality is more encouraging. Combining the right preventive with a smart acute strategy, addressing neck or nerve pain drivers, and using interventional tools at the right moments can shift even entrenched patterns. The skills of a specialist in pain management dovetail with neurology to push the odds in your favor.

You do not need to accept a life organized around the next attack. Find a doctor for pain management who listens, a neurologist who collaborates, and a plan you can follow on your worst day, not just your best. Keep a simple log. Be open to adjustments. And expect progress measured in fewer lost days, steadier routines, and a brain that flares less often and recovers faster.

If you are reading this between throbs, take one clear next step: schedule an appointment with a pain therapy doctor or neurologist who treats migraines regularly. Bring a two-week headache diary, your current medications, and a short list of priorities. That is how the cycle begins to break.

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Pub: 01 Oct 2025 04:13 UTC

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