Many people consider a migraine to be a really bad headache. The truth is it is a severe, neurologic condition. However, when perusing the medical literature, it becomes apparent that the term ‘migraine’ in many practical instances, is actually a name that we have given to a constellation of symptoms as opposed to a specific medical issue with a specific, identifiable cause.

If you go to WebMD or the Mayo Clinic or just Google the term “migraines”, what you’ll consistently find is that they are defined as very severe headaches. You’ll also find that they have all sorts of descriptive characteristics. For example, they predominantly affect women between, have a peak incidence between 25 and 55 years of age, and can last anywhere from 4 to 72 hours, etc. Migraines also typically have 4 phases:

  1. Prodrome – the period of time when people start to feel a bit off before their head pain sets in

  2. Aura – a period during which some patients experience symptoms such as flashing lights, unusual smells, light/sound sensitivity, etc.

  3. Headache – the actual experience of head pain; however, there are acephalalgic (i.e. painless) headaches or atypical symptomatic expressions of this stage during which people experience, for example, primarily nausea and dizziness without the head pain

  4. Post-drome – which is akin to a post-seizure state during which the actual head pain has either diminished or gone away, but the patient is left with acute after-effects such as drowsiness, confusion and/or irritability

While we have a broad range of characteristics that describe these headaches, at the end of the day, the question that migraine sufferers most want answered is ‘What causes them?’ In most cases, we don’t really know. This fact is demonstrated by the sheer number of medications and numerous classes of medications that are used to treat migraines. Examples of the latter include anti-seizure medications, pain medications, muscle relaxants, neuroleptics, antidepressants, serotonin-modulating drugs (like all the triptans), the new range of CGRP receptor antagonists and several others. Generally speaking, in life as well as in medicine, when there are multiple different ways of treating a problem, one can rest assured that not one of those methods is clearly the most effective, otherwise everyone would be using it. I say to my patients that the two most important questions for any diagnosis are: one, can you figure out what is causing the problem and two, what can you do about it?

Peripheral nerve surgeons treat chronic headaches differently when compared with the traditional way physicians are taught to think about these problems. We focus on specific peripheral nerve triggers that might be causing your headache. Hence when we use the term occipital (meaning back of the head) neuralgia (meaning nerve pain), the real question is: “Can you figure out which ‘neur’ (i.e. nerve) is causing the ‘algia’ (i.e. pain). That is the crux of the diagnostic work up when a patient comes to see me for this issue. At the end of the evaluation, with the help of a thorough history, physical examination and a set of sequential, peripheral nerve blocks, I will have a much better sense of which nerve or nerves might be involved in your headache symptom complex and whether or not surgical intervention might be of benefit.

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