PONOS CLINIC · TURIN
Turin Headache Centre
Complex migraine and craniofacial pain
When headache changes, becomes chronic or no longer responds to treatment, the first aim is to reconstruct the clinical picture and understand what has changed.
When to reassess
Worsening headaches do not all follow the same course
A new phase of the condition may reflect increasing frequency, loss of treatment response, pain in new areas or a different headache phenotype.
Frequency increases, pain-free intervals shorten or the headache becomes chronic.
It is necessary to check what has actually been tried, for how long, at what dose and with what benefit.
The neck, occiput, TMJ, face or trigeminal territory may add a separate pain component.
Duration, laterality, frequency or autonomic symptoms may suggest a different diagnosis.
Four clinical pathways
The clinical question comes before the procedure
Has migraine become chronic?
Assessment covers frequency, disability, use of acute medication, factors contributing to chronicity and response to previous preventive treatments.
Is it truly resistant or refractory?
Treatment failure must be reconstructed accurately before a headache is described as refractory.
Has a peripheral component developed?
Cervical structures, occipital nerves, the TMJ or the trigeminal nerve may be involved alongside migraine without automatically being its cause.
Has the type of headache changed?
Strict unilaterality, brief attacks, periodicity or autonomic symptoms require reassessment of the phenotype.
Specialist care pathways
The main areas covered by the Headache Centre
The pages are organised by clinical problem, rather than by technique.
Chronic migraine
When headaches become more frequent and chronicity, disability and associated factors need to be distinguished.
Learn more →Resistant and refractory migraine
When several appropriate preventive treatments have not provided sufficient control or cannot be tolerated.
Learn more →When migraine changes
A change in frequency, pattern or pain location calls for a fresh assessment of the clinical picture.
Learn more →Headache originating in the neck
Neck pain may coexist with headache: diagnosis requires clinical concordance, not imaging alone.
Learn more →Occipital neuralgia (Arnold’s neuralgia)
Occipital pain, allodynia and symptoms along the occipital nerves require focused assessment.
Learn more →TMJ pain and bruxism
Temporomandibular disorders and bruxism may coexist with migraine and alter the pain presentation.
Learn more →Trigeminal and facial pain
Not all facial pain is trigeminal neuralgia: distribution, quality and clinical history guide the diagnosis.
Learn more → · ITASphenopalatine ganglion
The SPG is assessed in selected cases involving a specific trigeminal-autonomic clinical question.
Learn more →First headache consultation
A carefully reconstructed clinical history makes differential diagnosis and care planning more effective.
How to prepare →Diagnostic focus
Trigeminal autonomic cephalalgias (TACs)
When pain is strictly unilateral and cranial autonomic signs occur, attack duration and frequency become central to the differential diagnosis.
The main types
Clinical method
A sequence of clinical decisions, rather than a sequence of procedures
Reconstruct
Changes over time, headache days, associated symptoms, treatments and differences compared with previous years.
Reassess
The diagnosis, treatments actually tried, relevant imaging and possible associated conditions.
Identify
Possible cervical, occipital, temporomandibular, trigeminal or trigeminal-autonomic components.
Measure
Benefit, headache days, medication use and functional recovery during follow-up.
Interventional pain management
When a procedure may be appropriate
There is no single procedure for “migraine”. In selected patients, a peripheral target may be assessed when the clinical history, examination and — where appropriate — a diagnostic test are concordant.
Interventional treatment complements neurological headache care and does not replace preventive medication when indicated.
Examples of selected targets
- upper cervical facet joints in clinically concordant presentations;
- occipital nerves when an occipital neuropathic component is present;
- the auriculotemporal nerve in TMJ pain with a selected neural component;
- trigeminal branches or the sphenopalatine ganglion in appropriate clinical presentations.
First consultation
Coming prepared makes the assessment more useful
Turin Headache Centre
If your headache has changed, treatments are no longer enough or pain has appeared in new areas, the first aim is to reconstruct the clinical picture before choosing treatment.
Contact PONOS Clinic Prepare for your consultation