Episodic and chronic migraine
The single most consequential question in migraine care is whether you are episodic (fewer than 15 headache days per month) or chronic (15 or more, with at least 8 meeting full migraine criteria). The treatment ladders are different, the preventive evidence base is different, and the insurance coverage criteria are different. Many patients sit just on either side of the line and slide between categories — often without anyone formally tracking it. We start every program with a structured headache calendar so we know which patient we are actually treating, and we re-stage at every visit.
Vestibular migraine
Vestibular migraine is one of the most common causes of recurrent vertigo in adults and one of the most under-diagnosed. Many patients spend years cycling through ENT, cardiology, and neurology workups before someone connects episodic vertigo, motion sensitivity, and a personal or family history of migraine. The treatment principles overlap with classic migraine — preventive medication, trigger work, vestibular rehab — but the acute toolkit is narrower and the response timelines are different. We treat vestibular migraine with the same neurologists who treat the rest of our migraine population, in coordination with vestibular PT when indicated.
Menstrual and hormonal migraine
Menstrual migraine — attacks tightly clustered around the perimenstrual window — affects a large share of women with migraine and often responds poorly to the same preventive that works the rest of the month. Targeted strategies include scheduled mini-prevention with long-acting triptans or NSAIDs across the perimenstrual window, hormonal stabilization in coordination with gynecology, and CGRP antagonists timed to the cycle. Perimenopause adds a layer: migraine frequency commonly worsens for several years before stabilizing post-menopause, and managing that transition deliberately can change the trajectory.
Medication overuse headache
Medication overuse headache is a paradox at the heart of migraine care: the acute medications that abort individual attacks can, when used too frequently, perpetuate the underlying headache disorder. The thresholds are well-established (roughly 10 days per month for triptans, opioids, ergots, or combination analgesics; 15 for simple analgesics). Recognizing and treating MOH is one of the most clinically rewarding things we do — many patients see their baseline headache pattern improve dramatically once the overused medication is withdrawn and a proper preventive is in place. The first two weeks of withdrawal are the hard part, and we plan for them deliberately with bridge therapies and structured check-ins.
Cluster headache
Cluster headache is a distinct trigeminal autonomic cephalalgia with a different clinical profile, treatment toolkit, and natural history than migraine. Attacks are short (15–180 minutes), severe, strictly unilateral, and accompanied by autonomic features (tearing, conjunctival injection, ptosis, rhinorrhea). Effective acute therapy is high-flow oxygen and subcutaneous sumatriptan; preventive options include verapamil at neurology-specific dosing, galcanezumab, and short corticosteroid bridges during a cluster period. We treat cluster headache with the same neurologist team and coordinate oxygen prescriptions through your local DME provider.
Refractory migraine after multiple preventive failures
A meaningful share of patients reach us after trying — and not tolerating or not responding to — three, four, or more preventive medications. Modern headache neurology has a structured way to think about this: confirming the diagnosis is correct (vestibular migraine, NDPH, and chronic tension-type can masquerade as refractory migraine), identifying any unaddressed contributors (sleep apnea, MOH, hormonal drivers, untreated mood symptoms), and then sequencing the newer mechanism classes (CGRP monoclonal antibodies, atogepant, Botox for chronic migraine) thoughtfully rather than adding them on top of a regimen that is already failing.