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Headaches & Migraines

Headaches & Migraines are extremely common and, unfortunately, they can stop you right in your tracks.  An intense headache or migraine can last just a few minutes or for days at a time.  The pain can be so excruciating that it may cause a person to stay in bed or a dark and quiet room, praying that the pain will stop.  Some headaches like cluster headaches will occur like clockwork at certain times of the year with the remainder of the year being relatively normal, while other types like migraines that will come on throughout the year.

Currently, there are over 150 different types of headaches and facial pain – as such, the treatment can be completely different depending on the exact type.  Treatments can range from oxygen therapy or high dose anti-inflammatory medications to injections with botulinum toxin (aka Botox) and nerve blocks within the skull.

Headaches, migraines, and facial pain are collectively considered to be one of the 3 most painful conditions known to man (the other 2 being Complex Regional Pain Syndrome and Pelvic Pain).  The doctors at the Ainsworth Institute are amongst a handful of physicians across the country trained to perform select procedures to treat this type of pain at the source, and in some cases, eliminate it altogether.

Relevant Anatomy

trigeminal nerve, botox for headaches, headache, migraine, cluster headachePain, in general, is transmitted by nerves.  The anatomy of the nerves in the head and face is extremely complex.  The trigeminal nerve and the occipital nerves are the 3 main sensory nerves of the head and face.

Trigeminal Nerve

The trigeminal nerve is the 5th 12 cranial nerves (nerves that come directly from the brain).  The Roman numeral for the number “5” is “V” so you may notice that the letter “V” is used as an abbreviation for the trigeminal nerve in many cases.  The trigeminal nerve is predominantly a sensory nerve and is responsible for the feeling of pain in the face.  It has 3 smaller branches: Anatomy of Trigeminal Nerve

  1. V1 – Ophthalmic
  2. V2 – Maxillary
  3. V3 – Mandibular

The Ganglion (root where the 3 branches come together to enter the brain) can be responsible for perpetuating pain. The whole trigeminal system itself can also be responsible for spreading pain to other nerves.

Occipital Nerves & Great Auricular Nerve

There are 2 sets of occipital nerves, one for the left half of the head and one for the right half.  Each side has 3 branches:

  1. Greater Occipital Nerve
  2. Lesser Occipital Nerve
  3. Third Occipital Nerve
occipital nerve, occipital neuralgia, headachesm mnigraines, botox
* click to enlarge

Each branch covers a different area of the back of the head.  The Occipital Nerve are branches of the cervical spinal cord.

The Greater Auricular Nerve also comes from cervical spinal cord and covers a small area behind the ear on each side of the head.

Ganglia of the Head & Face
headache, migraine, cluster headache, facial pain, atypical facial pain, triptan, topamax, botox
* click to enlarge

A “ganglion” is a small area where the cell bodies of neurons are all grouped together.  These are important for the transmission of pain as they are typically located at a point were several branches of a nerve or different nerves come together and meet before sending a signal onward to the brain.  In the head and face, there are 2 important ganglia (plural for ganglion):

 Sphenopalatine (SPG) Ganglion
 Trigeminal Ganglion (aka Gasserian Ganglion)

The SPG is located in the pterygopalatine fossa and hangs off the V2 branch of the Trigeminal Nerve.  It is part of both the sympathetic and parasympathetic nervous systems.  The Trigeminal Ganglion is located in the foramen ovale at the bottom of the skull and is where the 3 branches come together.

Cervical Spine

headache, migraine, cluster headache, facial pain, atypical facial pain, triptan, topamax, botoxThe cervical spine is the top segment of the spine and contains 7 cervical vertebra and 8 spinal nerves.  The top vertebra of the cervical spine (C1) connects to the bottom of the skull via the Atlanto Occipital Joint (AO).  The 2nd cervical vertebra from the top (C2) is connected to C1 via the Atlantoaxial Joint (AA).  Both the AO and AA can become arthritic like a knee or a hip and when that happens it causes headaches.  The connection between the 2nd and 3rd cervical vertebra is the C2/3 facet – this is also the location of the Third Occipital Nerve.  When this joint becomes painful is causes headaches to form in the back of the head along the distribution of the Third Occipital Nerve.

Headaches stemming from the cervical spine are called “Cervicogenic Headaches.”  These can be very elusive and many headache specialists will not common suspect the neck as a potential cause for someone’s headache.

Learn More About the Sympathetic Nervous System

What is the Trigeminocervical Complex?

Trigeminal nerve, trigeminal nerve nucleus, headache, migraine, cluster headache, facial pain, atypical facial pain, triptan, topamax, botoxThe cells of the Trigeminocervical Complex (TCC) are are the major conduit for pain signals from the meninges (the outer lining that covers the brain) and cervical structures – all making this an important pathway for headaches, migraines and facial pain.(2)

The nucleus of the trigeminal nerve is the largest of all 12 of the cranial nerves – it extends through the midbrain, pons, medulla and into the high cervical spinal cord.  It is divided into 3 sections:

  1. Mesencephalic Nucleus
  2. Chief Sensory Nucleus
  3. Spinal Trigeminal Nucleus

The Spinal Trigeminal Nucleus is the portion responsible for deep/crude touch, pain, and temperature from the ipsilateral portion of the face.

Trigeminal nerve, trigeminal nerve nucleus, headache, migraine, cluster headache, facial pain, atypical facial pain, triptan, topamax, botoxDue to the complexity and sheer extent of the TCC, the trigeminal nerve plays a part in almost every type of headache or facial pain, not just Trigeminal Neuralgia. 

 Occipital Neuralgia: The TCC allows the trigeminal nerve to directly communicate with the Occipital Nerve making it an accomplice
 Cervicogenic Headaches: The C1, C2 and C3 spinal segments connect to the caudal aspect of the Trigeminocervical Nucleus.
 Cluster Headaches: The Sphenopalatine Ganglion is connected to the V2 branch of the Trigeminal Nerve
 Migraines: inflammation or irritation of the meninges of the brain is communicated via the TCC
 ….and the list goes on and on

What is a Headache?

Face and mouth pain disorders are diagnosed according to the standards published in the International Classification of Headache Disorders (ICHD-2) and are broken into three types (1):

1) Primary Headaches
2) Secondary Headaches
3) Cranial Neuralgias Central and Primary Facial Pain

Primary Headaches

Primary Headaches are split into 3 basic categories: Common, Uncommon and Rare

Tension HeadacheExertion HeadacheIce Pick Headache
Cluster HeadacheHypertension HeadacheSpinal Headache
Migraine HeadacheRebound HeadachedThunderclap Headache
Chronic Daily HeadacheExercise HeadacheParoxysmal Hemicrania
Allergy HeadacheHemicrania Continua
Sinus HeadacheHormone Headache
Post-Traumatic HeadacheNew Daily Persistent Headache
Caffeine HeadacheSerotonin Headache
Rebound Headache

Types of Primary Headaches

Tension Headaches

This is the most common type of headache.  These tend to come and go over time.  There is a lifetime prevalence in the general population ranging from 30%-78%.  There are 2 basic types of Tension Headaches: Episodic and Chronic.  The exact cause is not known however it is believed that Episodic Tension Headaches manifest from peripheral pain mechanisms where as Chronic Tension Headaches are more centrally originating.  Increased pericranial tenderness is the most significant abnormal finding in patients with any type of Tension Headache.  According to the IHS Classification ICHD-3:

Pericranial tenderness is easily detected and recorded by manual palpation. Small rotating movements with the index and middle fingers, and firm pressure (preferably aided by use of a palpometer), provide local tenderness scores of 0-3 for frontal, temporal, masseter, pterygoid, sternocleidomastoid, splenius and trapezius muscles. These can be summed to yield a total tenderness score for each patient. These measures are a useful guide for treatment, and add value and credibility to explanations given to the patient.

Migraine Headaches

Migraine Headaches come in many shapes and forms with a variety of different characteristics:

  • With Aura
  • Without Aura
  • Hemiplegic
  • Status Migrainosus
  • with Vertigo
  • with Torticollus
  • with Vomiting
  • Abdominal
  • Infarction
  • Aura-Triggered Seizure

Migraine Headaches can list as little as 4 hours to as long as 3 days.  Patients tend to describe the pain as throbbing and/or pounding.  There may be what is known as an “aura” associated with the migraine that lets the person know a migraine is on the way and coming soon.  Other specifics include sensitivity to light, sound, touch and smell as well as a feeling of nausea.

Cluster Headaches

Cluster Headaches are the most severe of the “Common”-class and are 3-4x more common in males – the may also be genetic (autosomal dominant in 5% of cases).  They fall under a classification known as “Trigeminal Autonomic Cephalalgias,” or TAC’s for short.  The diagnostic criteria for Cluster Headaches according to the IHS Classification ICHD-3 are:

  1. At least five attacks fulfilling criteria 2-5
  2. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-180 minutes (when untreated)[1]
  3. Either or both of the following:
    1. at least one of the following symptoms or signs, ipsilateral to the headache:
      • – conjunctival injection and/or lacrimation
      • – nasal congestion and/or rhinorrhoea
      • – eyelid edema
      • – forehead and facial sweating
      • – miosis and/or ptosis
    1. a sense of restlessness or agitation
  4. Occurring with a frequency between one every other day and 8 per day[1]
  5. Not better accounted for by another ICHD-3 diagnosis.

Patients typically describe intense burning or piercing pain behind or around one eye.  In addition, the eyelid may droop, reddening of the eye, pupil constriction or even tearing.  Cluster Headaches typically last between 15 minutes and 3 hours.  The term “cluster” comes from the fact that the headache episodes tend to occur in clusters or groups within a certain time frame during the year, then stop spontaneously for the rest of the year without any headaches, only to start back up again around the same time the following year.  These headaches can render a patient completely disabled due to the pain.

Common triggers for Cluster Headaches include alcohol, histamine and nitroglycerin.  Acute pain attacks involve activation of the posterior hypothalamic grey matter.

Trigeminal Neuralgia

Trigeminal nerve, trigeminal nerve nucleus, headache, migraine, cluster headache, facial pain, atypical facial pain, triptan, topamax, botoxTrigeminal Neuralgia, also known as Tic Douloureux, is considered by many to be one of THE most painful conditions known to man.  It is typically described as an electric jolt or shooting pain across the face in the distribution of the affected branch of the Trigeminal Nerve.  It most commonly affects women over the age of 50 and is typically due to compression of the Trigeminal Nerve by an adjacent blood vessel.  Of the 3 branches of the Trigeminal Nerve, it most commonly affects V3, followed by V2, V1, and V2/3, respectively.

It affects roughly 1 in 15,000 to 20,000 people in the general population.  It is often misdiagnosed people who have severe, one-sided facial pain.  It is almost always unilateral, although it can affect both sides of the face in rare instances.  There are typically no triggers and can occur out of nowhere.  The nickname “Tic Douloureux” comes from the tendency for patients to have an uncontrollable muscle twitch or Tic that occurs whenever patients feel the pain.  The pain may be so intense that people are unable to brush their teeth, shave or generally take care of themselves such that their general hygiene suffers.

How is Trigeminal Neuralgia Diagnosed?

Trigeminal Neuralgia Atypical Facial Pain New York New York City Facial Pain Treatment Trigeminal Neuralgia Treatment NYC Facial Pain New YorkTrigeminal Neuralgia is typically described as:

 Sharp, stabbing or shooting
 Electric shock-like sensations
 Burning, area of face on fire
 Sudden and unbearable “exploding” pain

The diagnostic criteria for Trigeminal Neuralgia according to the IHS Classification ICHD-3 are:

  1. Recurrent paroxysms of unilateral facial pain fulfilling criteria for 13.1.1 Trigeminal neuralgia
  2. Demonstration on MRI or during surgery of neurovascular compression (not simply contact), with morphological changes[1] in the trigeminal nerve root.

What Causes Trigeminal Neuralgia?

True “Trigeminal Neuralgia” is caused by compression from a nearby blood vessel.  There are variants of Trigeminal Neuralgia that may be caused by a variety of other pathologies:

 Result of aging
 Aneurysm (rare)
 Arteriovenous malformation
 Surgical injury
 Facial injury/trauma
 Multiple Sclerosis
 Postherpetic neuralgia (shingles)

Learn More About Trigeminal Neuralgia

Occipital Neuralgia

Occipital Neuralgia is a unilateral or bilateral pain in the back of the head in the distribution of the Greater, Lesser and/or Third Occipital Nerves.  It is described as a sudden stabbing or shooting pain that is usually associated with tenderness over the affected nerve(s) and sometimes accompanied by a decreased sensation in the affected area.

The diagnostic criteria for Occipital Neuralgia according to the IHS Classification ICHD-3 are:

  1. Unilateral or bilateral pain in the distribution(s) of the greater, lesser and/or third occipital nerves and fulfilling criteria 2-5
  2. Pain has at least two of the following three characteristics:
    • recurring in paroxysmal attacks lasting from a few seconds to minutes
    • severe in intensity
    • shooting, stabbing or sharp in quality
  3. Pain is associated with both of the following:
    • dysaesthesia and/or allodynia apparent during innocuous stimulation of the scalp and/or hair
    • either or both of the following:
      • a) tenderness over the affected nerve branches
      • b) trigger points at the emergence of the greater occipital nerve or in the distribution of C2
  4. Pain is eased temporarily by local anaesthetic block of the affected nerve(s)
  5. Not better accounted for by another ICHD-3 diagnosis.

The “gold-standard” for diagnosing Occipital Neuralgia is an Occipital Nerve Block and/or C2/3 Facet Block.

What Are "Cervicogenic" Headaches?

headache, migraine, cluster headache, facial pain, atypical facial pain, triptan, topamax, botoxSome headaches are not actually caused by pain in the head at all – Cervicogenic Headaches are caused by issues stemming from the neck ((i.e. nerves and/or joints in the cervical spine).  Cervicogenic Headaches can be either unilateral or bilateral with patients typically describing the pain as a constant throbbing and aching with the feeling of a stiff neck.  It is commonly caused by whiplash injuries from car accidents.  The culprits for Cervicogenic Headaches are the Atlanto Occipital (AO), joint, Atlantoaxial (AA) joint or C1/2 facet, or the C2/3 facet (which has the Third Occipital Nerve right near by).

This is typically diagnosed with nerve blocks performed under Fluoroscopic guidance.

Burning Mouth Syndrome

As the name suggests, Burning Mouth Syndrome is a type of headache that causes the sensation of burning in one’s mouth.  The criteria for Burning Mouth Syndrome is the feeling of burning for more than 2 hours/day over more than 3 months, without clinically evident causative lesions. The pain is typically on both sides and most common felt at the tip of the tongue. There are 2 types of Burning Mouth Syndrome: Locally Caused versus Caused by Systemic Disorder

  • Local Disorder: Candidiasis, Lichen Planus, Hyposalivation
  • Systemic disorder: Medication Induced, Anemia, Deficiencies of Vitamin B12 or Folic acid, Sjögren’s syndrome, Diabetes

The diagnostic criteria for Burning Mouth Syndrome according to the IHS Classification ICHD-3 are:

  1. Oral pain[1] fulfilling criteria 2 and 3
  2. Recurring daily for >2 hours/day for >3 months
  3. Pain has both of the following characteristics:
    • burning quality[2]
    • felt superficially in the oral mucosa
  4. Oral mucosa is of normal appearance and clinical examination including sensory testing is normal
  5. Not better accounted for by another ICHD-3 diagnosis
Types of Rare & Atypical Headaches

Paroxysmal Hemicrania

Paroxysmal Hemicrania resembles Cluster Headaches except that they are more common in females (rather than males) and can happen several times a day.  Much like Cluster Headaches, the eye on the affected side may appear red and watery.  In stark contrast to Migraines, Paroxysmal Hemicrania will typically only last a few minutes at a time and then resolve spontaneously.  The diagnostic criteria for Paroxysmal Hemicrania according to the IHS Classification ICHD-3 are:

  1. At least 20 attacks fulfilling criteria 2-6
  2. Severe unilateral orbital, supraorbital and/or temporal pain lasting 2-30 minutes
  3. Either or both of the following:
    1. at least one of the following symptoms or signs, ipsilateral to the headache:
      • – conjunctival injection and/or lacrimation
      • – nasal congestion and/or rhinorrhoea
      • – eyelid oedema
      • – forehead and facial sweating
      • – miosis and/or ptosis
    2. a sense of restlessness or agitation
  4. Occurring with a frequency of >5 per day[1]
  5. Prevented absolutely by therapeutic doses of indomethacin[1]
  6. Not better accounted for by another ICHD-3 diagnosis.

The most common triggers for Paroxysmal Hemicrania are stress, relaxation after stress, exercise or alcohol.

Serotonin (Antidepressant) Headaches

Headaches are a common side effect in patients who take medications that elevate levels of serotonin like Tricyclic Antidepressants (TCA’s), Selective Serotonin Re-uptake Inhibitors (SSRI’s), Selective Norepinephrine Re-Uptake Inhibitors (SNRI’s) and Tramadol.  When one takes a medication such as these, they will experience temporary increases in their levels of serotonin.  Over the course of the day, their levels will decrease to return to normal, causing a headache to occur.  Patients will typically experience these in the morning and are common located in the forehead.  The most common description is a slight burning or the sensation of warmth or heat.  The headache will quickly subside once an additional dose of the medication is taken.

Eagle Syndrome

Trigeminal nerve, trigeminal nerve nucleus, headache, migraine, cluster headache, facial pain, atypical facial pain, triptan, topamax, botox, Eagle SyndromeAlso known as “Stylohyoid Syndrome,” Eagle Syndrome is a rare condition caused by an abnormally long Styloid Process – a needle like bony structure located in the bottom-rear portion on side of the skull.  Pain from Eagle Syndrome is described as a sudden, sharp nerve-like pain in the jaw bone and joint, back of the throat, and base of the tongue. The pain is typically triggered by swallowing, moving the jaw, or turning the neck.

The styloid process is an important area in the head:

  • Medially: The Internal Jugular Vein, Internal Carotid Artery, and Glossopharyngeal Nerve (CN IX), Vagus Nerve (CN X), and Accessory Nerve (CN XI) are all located medial to the Styloid Process
  • Lateral: The Occipital Artery and Hypoglossal Nerve (CN XII) are both located lateral to the Styloid Process

Eagle Syndrome is typically diagnosed with an X-ray to see if the Styloid Process is elongated.

The diagnostic criteria for Eagle Syndrome according to the IHS Classification ICHD-3 are:

  1. Any head, neck, pharyngeal and/or facial pain fulfilling criterion 3[1]
  2. Radiological evidence of calcified or elongated stylohyoid ligament
  3. Evidence of causation demonstrated by at least two of the following:
    1. pain is provoked or exacerbated by digital palpation of the stylohyoid ligament
    2. pain is provoked or exacerbated by head turning
    3. pain is significantly improved by injection of local anaesthetic agent into the stylohyoid ligament, or by styloidectomy
    4. pain is ipsilateral to the inflamed stylohyoid ligament
  4. Not better accounted for by another ICHD-3 diagnosis

Glossopharyngeal Neuralgia

The Glossopharyngeal Nerve (CN IX) is the 9th of the 12 cranial nerve of the brain.  CN IX has sensory, motor, and parasympathetic functions; it originates from the medulla oblongata and terminates in the pharynx.  CN IX is primarily responsible for swallowing and the gag reflex, as well as sensation in the back of the throat.  Glossopharyngeal Neuralgia causes extreme pain in the back of the throat, tongue or ear in the distributions of the glossopharyngeal, auricular and pharyngeal branches of the vagus nerve.  The pain is typically described as sudden (paroxysmal) electrical shock sensation, relatively short lasting (between 30 seconds and 2 minutes long), precipitated by swallowing, coughing, talking or yawning.  The pain may radiate to the ear, nose, chin or even the shoulder.  Due to the pain being causes by swallowing, many sufferers become afraid to even eat causing them to lose weight.

In rare cases, attacks of pain are associated with vagal symptoms such as cough, hoarseness, syncope and/or bradycardia.

The diagnostic criteria for Glossopharyngeal Neuralgia according to the IHS Classification ICHD-3 are:

  1. Recurring paroxysmal attacks of unilateral pain in the distribution of the glossopharyngeal nerve[1] and fulfilling criterion 2
  2. Pain has all of the following characteristics:
    1. lasting from a few seconds to 2 minutes
    2. severe intensity
    3. electric shock-like, shooting, stabbing or sharp in quality
    4. precipitated by swallowing, coughing, talking or yawning
  3. Not better accounted for by another ICHD-3 diagnosis

Nervus Intermedius Neuralgia

This is an extremely rare and elusive type of headache.  It presents as pain in the auditory canal much like an ear ache or infection.  The pain will come on suddenly and feel like a momentary each ache but then pass on its own.  It is typically caused by a vascular compression of the Nervus Intermedius – a branch from the Facial Nerve (CN VII) which provides sensation to the lateral surface of the tympanic membrane, external acoustic meatus, and concha.

What are my Treatment Options?

Your pain management doctor must first understand the history and quality of your headaches and migraines. He/she will ask you about the intensity, duration, and your need for medication. They should also want to know how much the pain has interfered with your lifestyle, and if you can remember events that may have triggered or aggravated the pain in the past.
Treatment for Facial Pain & HeadachesThe doctor will then need to ascertain your complete medical history and conduct a comprehensive physical examination. Further examinations can include evaluations of the trigeminal and facial nerves, as well as the upper cervical nerves, evaluation of muscle function of in the face and neck, examination of the temporomadibular joint, and examination of your mouth. If needed, CT scan, MRI or blood tests may be required.

Conservative Treatment Measures

IV Infusion Therapy An increasingly popular procedure for treating a variety of pain syndromes, as well as depression and anxiety. Patients are hooked up to an IV and special medications are administered intravenously. The infusions can take as little as 30 minutes to complete and is typically covered by insurance.

Medical MarijuanaCannabis has many medical qualities, one being its ability to act as a pain reliever. The evidence on medical marijuana for pain is very limited right now, even more so for headaches and migraines, however many patients have reported substantial improvements in the frequency of their headaches as well as a decrease in intensity with this treatment.

Botox Injections – Everyone has heard of Botox for wrinkles, but what you may not know is it is extremely effective for treating headaches and certain types of migraines. Botulinum Toxin (Botox) is injected into the muscles of the scalp to paralyze them thus releasing excess tension on the skull. When using it for headaches – it’s covered by insurance, even Medicare!

Interventional Pain Management Treatments

Sphenopalatine Ganglion BlockThe sphenopalatine ganglion is a small organ no bigger than a piece of corn that is buried inside the skull. Amongst other things, it is responsible to conveying pain from the face into the brain. By applying a small amount of local anesthetic onto it, one can effectively stop pain signals from reaching the brain. If the block is successful, you doctor may recommend RFA to provide long lasting pain relief. This procedure is quite effective for a variety of types of facial pain – meaning even if the exact diagnosis is unknown or just unclear, it can still work!

Occipital Nerve Block – The occipital nerve runs along the back of the skull is responsible for a particular type of facial pain called – Occipital Neuralgia. Using fluoroscopic guidance, your doctor will injected a small amount of a local anesthetic called Bupivacaine. This will prevent the occipital nerve from transmitting pain signals. RFA can also be applied to the occipital nerve to provide longer lasting pain relief.

Gasserian Ganglion Block The gasserian ganglion (better known as the trigeminal ganglion) is the meeting point for the 3 branches of the trigeminal nerve (the 5th Cranial Nerve). This ganglion has been implicated in a variety of facial pain syndromes as well as the dreaded Trigeminal Neuralgia. Using X-ray imaging, local anesthetic is injected onto the ganglion, blocking it from sending pain signals to the brain. In cases where the relief is only temporary, RFA may be the next step.

Stellate Ganglion BlockThe stellate ganglion is an important part of the sympathetic nervous system and is well-known for its role in transmitting pain. A small amount of a special long-acting local anesthetic called Bupivacaine is injected near the ganglion using Ultrasound-Guidance to stop the pain signals from reaching the brain.

Neurolysis & AblationIn cases where an injection provides only temporary relief, neurolysis or neuroablation can be utilized to increase the duration. There are several different methods that can be used:

  • Radiofrequency Ablation (RFA)Radio waves are applied to a nerve or plexus, preventing the transmission of pain.
  • Cryoablation Similar to RFA, however cold temperatures are applied to the area instead of radio waves.
  • Chemodenervation The premise is the same as cryoablation and RFA in that the goal is to prevent a nerve or plexus from transmitting pain; rather than applying mechanical stress to the nerve through radiowaves or cold temperatures, small amounts of either alcohol or phenol are injected to block the nerve’s ability to transmit a signal.

Spinal Cord Stimulation (SCS) This is a commonly performed procedure for a variety of pain syndromes. SCS utilizes technology similar to that of cardiac pacemakers whereby small electrodes are placed into the epidural space near the spinal cord. These electrodes will produce a small electrical current over the spinal cord that interfere with pain signals. In the case of facial pain, the leads are placed in the neck which stimulate nerves from the back of the head as well as the face.

Peripheral Nerve Stimulation – The premise is similar to SCS but rather the leads are placed under the skin in the area of the pain. The leads are extremely thin and are totally unnoticeable. Those suffering with pain in the back of the head (i.e. occipital neuralgia) would have 2 thin leads inserted under the scalp. Those with severe pain in the forehead or behind the eyes, the leads would be placed under the skin in the exact region of the pain from behind the hairline making it completely scarless.

The Ainsworth Institute is Here to Help

The doctors at the Ainsworth Institute of Pain Management specialize in managing and treating Headaches & Migraines. Dramatic improvements in pain and quality of life are a single phone call away. Schedule an appointment today with one of our board certified pain management experts to discuss what options for treatment may best suit your needs.


[1] Headache Classification Subcommittee of the International Headache Society. The international Classification of Headache Disorders: 2nd edition. Cephalalgia 2004;24:9-160.

[2] Bartsch T, Goadsby P. The trigeminocervical complex and migraine: Current concepts and synthesis. Current Pain and Headache Reports 2003;7:371–6.