Mostly talking, then an examination. Almost nobody expects that.

BEHIND THE DOOR

A first headache clinic visit is a long history, a count of your headache days and medication days, and a review of what has already been tried. There is also a physical examination that includes the neck and the occipital nerves (the nerves at the back of the head). It ends with a working diagnosis and a plan with an abortive side and a preventive side.

Mostly talking, then an examination, then two counts and a plan with both halves in it. The equipment is not the point. That is the thing that surprises people most.

What happens at the first headache clinic visit?

How does a headache clinic tell migraine, tension-type, cluster and cervicogenic headache apart?

By the pattern in your history and by the examination, because a scan cannot separate them. Migraine comes in attacks of four to 72 hours that throb, get worse with ordinary movement, and bring nausea or a need for the dark. Tension-type is a pressing band on both sides that you can work through.

Cluster headache is one-sided pain around the eye lasting 15 minutes to three hours, with a watering eye or running nostril on the same side, and it makes you pace rather than lie still. Cervicogenic headache starts in the neck, never switches sides, is set off by neck position, and is confirmed with a diagnostic block. Getting this sorting right on day one is what keeps a neck problem from cycling through migraine preventives.

What is the difference between abortive and preventive headache treatment?

An abortive plan is what you do when an attack starts. A preventive plan is what reduces how often attacks start. A great many people arrive with only the first half. They have been given stronger and stronger abortives for years, and nobody ever wrote the second half — which is also the mechanism that produces medication overuse headache.

Prevention is a category, not a drug. It includes oral and injectable medication. It also includes interventional options such as occipital and sphenopalatine blocks where the diagnosis supports them. Which ones apply is a clinical decision made from your history, not a menu. There is no set course of three of anything.

Can sleep and meal timing reduce headaches?

Roughly 40 to 50 percent of the treatment protocol here is behavioral and lifestyle work. It is delivered in-house rather than referred out. That is not a wellness gesture. Sleep timing, meal timing and light exposure each have a measurable effect on attack frequency. That is because they are the inputs a migrainous brain has the most trouble buffering.

Two biological drivers make that concrete. Unstable blood glucose widens the swings the brain must absorb. Chronic metabolic inflammation lowers the threshold at which a swing becomes an attack. The third driver is the one a prescription cannot reach: a work pattern that makes regular sleep and regular meals impossible. The plan has to survive your actual week, so we ask about it.

How we decide on scans and procedures

We order a scan when the history and examination call for one, not to reassure you — that is covered on do I need a scan. Every series of procedures has a stated endpoint. Your medication list is read as clinical history, not as a character assessment. And where the finding belongs to neurology or to an emergency department, you are told that on the day.

Questions about the visit

What do they do at a headache clinic?

Take a long history, examine you including the neck, establish frequency and medication days, review what has failed and why, and write a plan with an abortive and a preventive side. The step list above is the actual order.

How long is the appointment?

The first visit is built around history and examination rather than a procedure, so allow real time for it. Anything interventional is normally a separate, shorter appointment once the diagnosis is settled.

How long the whole workup takes, from the first visit to a treatment answer, is set out in how long a headache workup takes.

Will I get an injection on the first visit?

Usually not, and you should be wary of anywhere that promises one before examining you. Blocks are placed when the diagnosis supports them, which is a decision that comes after the history.

What if I have already been to a headache clinic?

Bring the records. The most useful thing you can supply is what was tried, at what dose and for how long — an incomplete trial of a preventive is very different from a failed one. That difference changes what is worth trying next. What to bring.

How do I prepare for a headache specialist appointment?

Bring a headache diary and the record of what has been tried. The diary gives the two counts: headache days a month and medication days a month. The record should list each treatment, the dose, how long you took it and what it actually did. If you have been to a headache clinic before, bring those records too.

What tests are done at a headache clinic?

The main tests are a long history and a physical examination that includes the neck and the occipital nerves. That is the part most often skipped elsewhere. We will not order a scan to reassure you when the history and examination do not call for one. The equipment is not the point; the history, the two counts and the examination are.

What if my headache needs a neurologist or the emergency room?

You will be told on the day. A first visit ends with a working diagnosis and an explanation of what it is and what it is not. Where a finding belongs to neurology or to an emergency department, we say so at that visit rather than keeping you in a plan that does not fit.

Before a first visit

• What to bring
• How many days did you lose last month?
• Headache specialist or neurologist?
• Do I need a scan?
• When the medication stopped lasting
• Dr. Gurpreet Singh Padda