Chronic Migraine Treatment in Kuala Lumpur

Most headache doctors manage migraines with medications. As a neurosurgeon who has also trained specifically in interventional pain management at the University of Malaya, I approach migraine from both directions — medical and surgical — which means I can offer options most neurologists cannot.

If you have been on preventive medications for years and still suffer frequent attacks, this page is for you.

What Makes a Migraine “Chronic”?

The International Headache Society defines chronic migraine as 15 or more headache days per month for more than 3 months, with at least 8 days meeting full migraine criteria.

Chronic migraine affects approximately 2% of the global population. In Malaysia, it is significantly underdiagnosed and undertreated. Many patients are told to “manage stress” or are given ever-higher doses of triptans, which can paradoxically worsen headache frequency through medication overuse headache (MOH).

Types of Headache I Treat

Chronic Migraine

Episodic migraine that has transformed to ≥15 days/month. Typically throbbing, unilateral, associated with nausea and photophobia. Often triggered by hormonal changes, sleep disruption, weather, or specific foods.

Cluster Headache

The most painful primary headache disorder. Attacks of excruciating, strictly unilateral periorbital pain lasting 15–180 minutes, occurring in clusters (multiple times daily) over weeks to months. Associated with autonomic features — tearing, nasal congestion, ptosis on the affected side. Predominantly affects men.

Occipital Neuralgia

Sharp, shooting pain in the back of the head and neck, following the distribution of the greater or lesser occipital nerves. Often caused by nerve entrapment or irritation. Responds very well to occipital nerve block and, in refractory cases, radiofrequency ablation.

Trigeminal Neuralgia

Severe, electric-shock-like facial pain along the trigeminal nerve distribution. Often triggered by touch, eating, speaking, or cold air. Typically treated with carbamazepine initially; surgical options (MVD, rhizotomy) available for medication-refractory cases.

→ Full Trigeminal Neuralgia guide

Hemiplegic Migraine

Rare migraine variant with transient motor weakness mimicking stroke. Requires careful exclusion of secondary causes. Specialist management essential.

New Daily Persistent Headache (NDPH)

Daily headache from onset, without prior episodic history. A diagnosis of exclusion after imaging excludes structural cause.

My Approach to Migraine Assessment

Every new patient with chronic headache receives:

1. Full headache history — onset, frequency, duration, character, associated features, triggers, previous treatments and responses, medication history.

2. Neurological examination — to identify any focal deficit suggesting secondary (structural) cause.

3. MRI brain — I do not accept a headache as “just migraine” without adequate imaging, especially for new-onset headache, change in headache pattern, or red flags.

4. Headache diary review — minimum 4 weeks of prospective diary data to accurately characterise frequency and identify patterns.

5. Medication overuse assessment — if you’re taking acute headache medication >10 days/month, this may be perpetuating the cycle and must be addressed before preventive treatment can work.

Treatment Ladder

Step 1: Optimise Preventive Medication

Many patients arrive undertreated. First-line preventive agents — topiramate, propranolol, amitriptyline, valproate — are frequently underdosed or abandoned too early. A proper preventive trial requires 3 months at therapeutic dose before judging efficacy.

CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) represent the most significant advance in migraine prevention in decades. Highly effective, well tolerated, monthly or quarterly injection. I prescribe these where appropriate and clinically justified.

Step 2: Interventional Procedures

When medications fail, I offer targeted interventional options — my speciality within the neurosurgical field.

Occipital Nerve Block Injection of local anaesthetic and steroid around the greater and lesser occipital nerves at the base of the skull. Immediate relief of occipital headache; can interrupt the migraine cycle. Useful both diagnostically and therapeutically. Performed in the clinic, no sedation required.

Sphenopalatine Ganglion (SPG) Block Targeted block of the SPG — a key node in the trigeminovascular pathway responsible for migraine and cluster headache. Can be performed via intranasal or transoral approach. Particularly effective for cluster headache.

Radiofrequency Ablation (RFA) of Occipital Nerves Where nerve block provides temporary relief but symptoms recur, RFA delivers controlled thermal energy to disable the nerve’s pain signalling for 6–12 months. Performed under fluoroscopic guidance with local anaesthesia, typically as a day procedure.

Botulinum Toxin Type A (BOTOX) for Chronic Migraine The PREEMPT protocol: 31 injections across the head and neck every 12 weeks. Approved for chronic migraine (≥15 headache days/month). Reduces headache frequency by 50% in approximately 50% of patients. Safe for long-term use.

Step 3: Surgical Intervention

For carefully selected patients with refractory cluster headache or intractable occipital neuralgia, surgical options include:

Occipital Nerve Stimulation (ONS) A spinal cord stimulator electrode placed percutaneously at the level of the greater occipital nerve, providing continuous neuromodulation. Evidence supports its use in refractory chronic migraine and cluster headache.

Microvascular Decompression (MVD) If trigeminal neuralgia is present alongside the headache disorder, MVD — moving or removing a blood vessel compressing the trigeminal nerve at the brainstem — provides long-term relief in >80% of cases.

Red Flags: When Headache Is Not Just Migraine

I cannot overstate this: not every severe headache is migraine. As a neurosurgeon, I am acutely aware of the secondary causes that must not be missed.

Seek urgent evaluation if your headache:

• Came on suddenly and reached maximum intensity within seconds (“thunderclap”)
• Is the “worst headache of your life” — unlike anything before
• Is associated with fever, neck stiffness, and sensitivity to light (meningitis)
• Is associated with new neurological symptoms: weakness, vision loss, speech difficulty
• Worsens progressively over days to weeks
• Occurs in someone with known cancer or immunosuppression
• First presents after age 50

These warrant immediate MRI or CT before any diagnosis of primary headache is made.

Frequently Asked Questions

Q: I’ve tried four preventive medications. Am I running out of options? No. CGRP antibodies, Botox, and interventional procedures — nerve blocks, RFA — are separate treatment categories that work through different mechanisms. Most patients who have failed oral preventives have not yet tried all these options.

Q: Is Botox for migraine covered by insurance in Malaysia? Coverage varies by policy and insurer. I can provide clinical documentation to support your insurance claim. The clinic team can assist with pre-authorisation letters.

Q: How long does radiofrequency ablation last for migraine? Typically 6–18 months. The procedure can be repeated when symptoms return. Over multiple treatment cycles, many patients find the intervals between procedures extend.

Q: Can a neurosurgeon treat migraine, or should I see a neurologist? Neurosurgeons and neurologists both manage headache disorders. My specific advantage is the ability to offer the full range — from prescribing CGRP antibodies to performing nerve blocks, RFA, and surgical neuromodulation — within a single clinical relationship.

Book a Consultation

Bring your headache diary (even rough notes on your phone count), a list of every medication you’ve tried and for how long, and your most recent brain MRI if you have one.

WhatsApp the clinic: +6011 3723 5061 Book online: KPJ Tawakkal Appointment Portal Call the clinic: +603-4026 7777 ext 5099

Educational purposes only. All treatment decisions require direct clinical consultation.