As a pain management specialist, I see patients every week who feel like they have tried nearly everything. They come to me after months, or even years, of battling chronic or refractory headaches. Their primary care doctor and neurologist have already walked them through the usual first-line options, yet the pain keeps coming back relentlessly. It steals their focus, disrupts their sleep, and robs them of the simple joys in daily life. These are the cases I love helping the most. Even when standard migraine preventives, calcitonin gene-related peptide (CGRP) therapies, and basic injections have not brought full relief, we still have powerful, targeted tools that can create meaningful and lasting change for many people. I define a refractory headache, whether it involves chronic migraine, occipital neuralgia, or cervicogenic headache, as disabling pain that continues despite adequate trials of multiple appropriate therapies. Patients often describe 15 or more headache days per month, with at least eight of those days severely limiting their function and quality of life. According to the European Headache Federation’s consensus, refractory chronic migraine involves failure of adequate trials of at least three preventive classes without medication overuse. At this stage, my role is to take a fresh, comprehensive look, rule out any overlooked contributing factors, and build a personalized, layered plan. This plan combines advanced interventional procedures and neuromodulation options while supporting the whole person through lifestyle adjustments, physical therapy, and attention to emotional well-being.
Re-evaluating the diagnosis and identifying cervicogenic headache
I always start by sitting down with the patient and listening carefully to their full story. Even if a neurologist has already done a thorough workup, I revisit the key elements of the history and physical examination. Many people I see have an underrecognized cervicogenic component, meaning the headache actually originates from structures in the neck, such as the cervical facet joints, muscles, or upper cervical nerves. Cervicogenic headache is typically one-sided. It often begins in the back of the head or neck and worsens with neck movements, prolonged postures, or pressure on tender spots in the upper cervical region. Patients frequently report accompanying neck stiffness, limited range of motion, or a history of whiplash, trauma, or arthritis. It can closely mimic migraine by including nausea or sensitivity to light and sound, which is exactly why it sometimes gets missed.
Simple bedside assessments, such as the cervical flexion-rotation test, can provide important clues. Studies have shown this test has strong diagnostic accuracy for identifying cervicogenic headache related to C1/C2 dysfunction, with sensitivity and specificity often exceeding 85 to 90 percent in experienced hands. Temporary improvement after a diagnostic occipital or cervical nerve block offers another strong indicator. I also carefully screen again for medication-overuse headache, sleep disturbances, stress, poor posture, or other modifiable factors that may be keeping the cycle going. Once we have a clear picture and address these barriers, we move forward together as a team.
Fine-tuning medications before or alongside procedures
Even in these challenging refractory cases, I review the current medication regimen in detail one more time. If a patient has not completed a full, well-tolerated trial of CGRP monoclonal antibodies or if there is room to optimize acute treatments, we explore those adjustments thoughtfully. I avoid opioids, if possible. Instead, we may use short courses of antiemetics or targeted anti-inflammatory medications. That said, the greatest progress often comes from interventional procedures that help interrupt the persistent pain cycle. Recent American Headache Society guidelines (updated in 2025 for acute migraine treatment in the emergency department) emphasize the value of greater occipital nerve blocks alongside other parenteral options, reinforcing their role even beyond the clinic setting.
Interventional options: nerve blocks and Botox as reliable bridges to relief
Office-based procedures frequently offer rapid, meaningful relief when oral medications alone fall short. Greater occipital nerve blocks, using a local anesthetic often combined with a small dose of steroid, remains one of my most reliable first steps. These can reduce pain within minutes to hours and provide relief that lasts weeks to months, especially when cervicogenic features are prominent. For patients with confirmed chronic migraine who have not yet tried it or who need additional support, I recommend botulinum toxin A (Botox) using the established PREEMPT protocol. This standardized approach came from large phase 3 PREEMPT trials and has been reinforced by real-world evidence. We administer a total of 155 units across 31 fixed sites in seven head and neck muscle groups: corrugator (10 units in two sites), procerus (5 units in one site), frontalis (20 units in four sites), temporalis (40 units in eight sites), occipitalis (30 units in six sites), cervical paraspinals (20 units in four sites), and trapezius (30 units in six sites). Treatments repeat every 12 weeks.
When the patient’s specific pain pattern calls for it, I may use a “follow-the-pain” approach and add up to 40 additional units in eight extra sites, for a total of 195 units. Real-world data from the REPOSE study and similar analyses through 2025 confirm that 156 to 195 units of botulinum toxin A is safe, well-tolerated, and effective, with no new safety signals and meaningful reductions in headache frequency. The strength of this protocol lies in its fixed-site, fixed-dose design, which makes it highly reproducible from one visit to the next. In the original trials and subsequent real-world data, patients typically experience about eight to nine fewer headache days per month. Benefits often build over repeated cycles and can be sustained for years. Many patients referred to me have had partial success with Botox before, so I customize the exact injection sites based on their individual pain map and frequently combine it with nerve blocks for better coverage. Side effects are generally mild, such as temporary neck soreness or eyelid drooping (ptosis), and they usually improve with each subsequent cycle. For cervicogenic headache that does not respond completely, I may incorporate pulsed radiofrequency treatment of the occipital nerves or targeted therapy to the cervical facet joints. These are low-risk, office-based steps that also help confirm the pain-generating structures before moving to more involved options.
Advanced neuromodulation: a transformative option for the most persistent cases
When nerve blocks and Botox provide only partial or temporary relief, neuromodulation stands out as one of the most promising areas in my practice. These approaches work particularly well for patients whose pain has a prominent occipital or cervicogenic element that has resisted other treatments. Peripheral nerve stimulation (PNS) is often my initial choice. We place thin, flexible leads near the occipital nerves using imaging guidance for a temporary trial. The patient goes home with a compact external stimulator that delivers gentle electrical pulses to interrupt pain signals without causing tissue damage. A 2025 multicenter study found strong outcomes: Approximately 90 percent of patients with refractory cervicogenic headache or occipital neuralgia achieved their primary goals, and 85 percent reported at least a 50 percent reduction in pain intensity and interference. Many maintained these improvements even three months after lead removal. I appreciate how minimally invasive percutaneous PNS is, how quickly we can evaluate its effectiveness, and how well it supports patients who want to reduce reliance on daily medications.
If the temporary trial succeeds, we can proceed to a permanent occipital nerve stimulation (ONS) system. Longer-term data from refractory cases show sustained reductions in headache days and medication use for a substantial proportion of patients. For individuals with broader cervical involvement, high-frequency spinal cord stimulation at the upper cervical level offers another valuable option, especially when neck pain and headache are closely linked. Emerging 2026 data on long-term ONS outcomes continue to support its role in refractory craniofacial pain. I also discuss noninvasive neuromodulation devices as helpful adjuncts for some patients. Yet for truly refractory situations, the implanted or percutaneous methods usually deliver the most consistent and durable results. These therapies are adjustable during office visits, reversible if needed, and allow people to stay active without the cognitive side effects or sedation often tied to heavier medications. Throughout every stage, I prioritize shared decision-making. We talk openly about realistic expectations, potential side effects (such as lead migration or infection, which modern systems manage effectively), and how neuromodulation fits alongside physical therapy, sleep optimization, stress reduction, and other holistic supports.
Putting it all together for enduring relief
Refractory headache care is never one size fits all. After primary care and neurology teams have exhausted first- and second-line options, the pain management specialist steps in to reframe the issue, uncover any cervicogenic contributors, and strategically layer interventional and neuromodulation therapies at the right moments. I have witnessed countless patients who once felt hopeless regain their ability to work, enjoy family moments, and return to the activities that bring meaning to their lives. A 2024 review on resistant and refractory migraine highlights the complex pathophysiology and the need for individualized, multimodal management, which is exactly the approach we use. For fellow clinicians: When a patient’s headaches remain unrelenting, consider an early referral to a pain management colleague. New doors may open that you had not yet explored. For patients reading this: You do not have to accept constant head pain as your inevitable reality. Even after multiple treatments have fallen short, effective pathways still exist and continue to evolve.
Kayvan Haddadan is a physiatrist and pain management physician, and president and medical director of Advanced Pain Diagnostic & Solutions, a multidisciplinary pain management practice in California that he founded in 2012. A physician and surgeon licensed by the Medical Board of California, he is double board-certified in pain medicine and physical medicine and rehabilitation. He is also certified in controlled substance registration through the DEA and serves as a qualified medical examiner through California’s Department of Industrial Relations Division of Workers’ Compensation.
Dr. Haddadan earned his Bachelor of Science degree from the College of Alborz in Tehran, Iran, and his medical degree from Shahid Beheshti University of Medical Sciences. He later received his Educational Commission for Foreign Medical Graduates certification in Philadelphia, completed an internship in medical surgery at Loyola University Medical Center’s Stritch School of Medicine in Illinois, and finished his residency in physical medicine and rehabilitation at the same institution. He completed his fellowship in pain medicine at California Pacific Medical Center’s Pacific Pain Treatment Center and also trained in medical acupuncture for physicians at the University of California, Los Angeles David Geffen School of Medicine.
Dr. Haddadan has contributed to 29 research publications across multiple specialties, including pain management, cardiology, pulmonology, endocrinology, gastroenterology, and infectious disease. His work has examined topics such as hyperlipidemia in high cardiovascular risk patients, hyperuricemia and gout management, type 2 diabetes and hypertension, chronic obstructive pulmonary disease and asthma therapies, influenza treatment, irritable bowel syndrome, and opioid related complications in chronic pain care. His research has also included clinical outcome studies in spinal cord stimulation and award-winning presentations on neuropathic pain management and neuromuscular disorders.
