Headache, Migraine & Facial Pain

The neurosurgeon in Kuala Lumpur who manages headache from first consultation to surgical intervention — when medicine alone is no longer enough.

Oxford DPhil · Consultant Neurosurgeon & Interventional Pain Specialist · Tawakkal Specialist Hospital & Ampang Puteri Specialist Hospital

Why a Neurosurgeon for Headache?

Most patients with chronic headache have already seen a GP. Many have seen a neurologist. They arrive here having been told their scans are normal, their medications have been adjusted multiple times, and that nothing more can be done.

That is the point at which a neurosurgeon’s perspective changes everything.

A neurosurgeon understands the anatomy of headache from the inside — the nerve roots, the vasculature, the posterior fossa, the craniocervical junction. And unlike a neurologist, a neurosurgeon can act on that understanding: with a nerve block, a radiofrequency procedure, a neuromodulation implant, or an operation.

The full clinical spectrum — from a first consultation through to surgical intervention — is available within a single specialist relationship. No sequential referrals. No being passed between specialties. One clinician who holds the whole picture.

The Three Tiers of Care

→ Chronic Migraine treatment guide → Trigeminal Neuralgia guide — MVD surgery & RFA

Tier 1 — Diagnosis & Medical Optimisation

The entry point. Every patient receives a comprehensive headache assessment: full ICHD-3 classification, neurological examination, imaging review, and a clear diagnosis. Most patients have never received one.

Conditions managed at this level include episodic migraine, tension-type headache, medication overuse headache, new daily persistent headache, and vestibular migraine.

A correct diagnosis is not a minor step. It determines everything that follows.

Tier 2 — Interventional

This is where the practice separates from every neurology clinic in Kuala Lumpur.

A neurologist prescribes. A neurosurgeon with interventional pain training does.

Available procedures — performed in clinic, no hospital admission required:

• Greater Occipital Nerve Block — for occipital neuralgia, cervicogenic headache, and refractory migraine
• Sphenopalatine Ganglion Block — for cluster headache and trigeminal autonomic cephalalgias
• OnabotulinumtoxinA (Botox) — PREEMPT Protocol — established preventive treatment for chronic migraine; 31 injections across head and neck musculature every 12 weeks
• Pericranial Trigger Point Injections — for myofascial and tension-type headache
• Cervical Medial Branch Radiofrequency Ablation — for cervicogenic headache and upper cervical facet pain

Tier 3 — Surgical

The ceiling that no neurologist in this conversation can reach.

Surgical options are reserved for patients with clear structural pathology or those in whom all other approaches have failed. These are not last resorts — they are the right treatment for the right patient, offered at the right time.

• Occipital Nerve Stimulation — implanted neuromodulation for refractory chronic migraine and cluster headache
• Microvascular Decompression (MVD) — the definitive surgical treatment for trigeminal neuralgia; addresses the underlying vascular compression rather than damaging the nerve
• Posterior Fossa Decompression — for Chiari malformation with symptomatic headache

When the diagnosis is trigeminal neuralgia with confirmed neurovascular conflict on MRI, MVD offers pain freedom rates above 90% — an outcome no medication can match. Surgery at that point is not aggressive. It is appropriate.

Chronic Headache

What Is Chronic Headache?

A headache disorder is classified as chronic when headaches occur on 15 or more days per month for more than three months. Chronic headache impairs work performance, disrupts relationships, and profoundly affects quality of life.

Chronic Tension-Type Headache (CTTH)

Characterised by a bilateral, pressing or tightening sensation — often described as a “band around the head” — mild to moderate in intensity, not worsening with activity.

• Duration: 30 minutes to several days
• Features: No nausea; photophobia or phonophobia (not both)
• Triggers: Stress, poor posture, disrupted sleep, muscle tension
• Management: Tricyclic antidepressants (amitriptyline), physiotherapy, biofeedback

Medication Overuse Headache (MOH)

One of the most underrecognised causes of chronic daily headache. MOH develops when pain-relieving medications are used too frequently — typically ≥10–15 days per month, depending on the agent. The medication that once provided relief begins to sustain the pain cycle.

Breaking the cycle requires:

1. Supervised withdrawal of the overused medication
2. Prophylactic therapy to prevent recurrence
3. Patient education on appropriate medication limits

Almost any headache medication can cause MOH if overused: paracetamol, NSAIDs, triptans, codeine-containing preparations, and combination analgesics.

New Daily Persistent Headache (NDPH)

A form of chronic headache that begins suddenly — often on a precise, memorable day — and becomes continuous from onset. Difficult to treat; investigation is warranted to exclude secondary causes.

Secondary Causes of Chronic Headache

Not all chronic headache is primary. A thorough evaluation is essential to exclude:

• Idiopathic intracranial hypertension (IIH) — raised CSF pressure without a structural lesion; associated with visual symptoms and papilloedema
• CSF leak — low-pressure headache characterised by positional worsening (worse upright, better lying flat)
• Venous sinus thrombosis — progressive headache with possible neurological signs
• Skull base lesions and meningiomas — slow-growing tumours may present purely as headache for months
• Chiari malformation — occipital headaches worsened by Valsalva manoeuvres
• Cervicogenic headache — headache originating from the cervical spine, often unilateral, exacerbated by neck movement

Migraine

The Neurobiology of Migraine

Migraine is a complex neurological disorder involving cortical spreading depression, trigeminovascular activation, and altered pain processing. It affects approximately 12–15% of the population globally and ranks among the leading causes of years lived with disability in working-age adults.

Classification

Migraine Without Aura (Common Migraine) Unilateral, pulsating headache of moderate to severe intensity. Worsened by routine activity. Associated with nausea, photophobia, and phonophobia. Duration: 4–72 hours untreated.

Migraine With Aura (Classic Migraine) Approximately one-third of sufferers experience aura — focal neurological symptoms preceding or accompanying headache:

Chronic Migraine When migraine headaches occur on ≥15 days per month (with ≥8 days fulfilling migraine criteria). The most disabling end of the migraine spectrum.

Vestibular Migraine Migraine associated with vestibular symptoms — vertigo, dizziness, imbalance — rather than or in addition to headache. Accounts for a significant proportion of recurrent vertigo in adults.

The Four Phases of Migraine

1. Prodrome (hours to days before): Yawning, food cravings, mood changes, neck stiffness, cognitive fog
2. Aura (if present, 5–60 minutes): Focal neurological symptoms
3. Headache phase (4–72 hours): Unilateral, pulsating pain with sensory sensitivities
4. Postdrome (24–48 hours after): Cognitive slowness, fatigue, head tenderness

Migraine Triggers

• Hormonal fluctuations — perimenstrual oestrogen withdrawal
• Sleep disruption — both insufficient and excessive sleep
• Dietary factors — alcohol, caffeine fluctuation, prolonged fasting
• Sensory stimuli — bright lights, strong odours, loud sounds
• Weather changes — barometric pressure changes
• Psychological stress — particularly the post-stress let-down

Acute Treatment

Preventive Treatment

OnabotulinumtoxinA (Botox) — PREEMPT Protocol: 31 injections across head and neck musculature every 12 weeks. An established preventive treatment for chronic migraine, delivered in clinic.

Trigeminal Neuralgia

What Is Trigeminal Neuralgia?

Trigeminal neuralgia is widely regarded as one of the most painful conditions known to medicine. Sudden, severe, electric shock-like facial pain in the distribution of one or more branches of the trigeminal nerve (5th cranial nerve).

The pain is typically:

• Unilateral — one side of the face
• Brief — a fraction of a second to 2 minutes per episode
• Excruciating — often described as the worst pain imaginable
• Triggered by minimal stimuli: talking, eating, brushing teeth, a light touch, a cold breeze

Trigeminal Nerve Divisions

Classification

Classical TN: Caused by vascular compression of the trigeminal nerve root at its entry zone into the brainstem — typically by the superior cerebellar artery. Confirmed on high-resolution MRI with FIESTA/CISS sequences.

Secondary TN: Caused by an identifiable structural lesion — MS, skull base tumour, vascular malformation, post-herpetic neuralgia.

Idiopathic TN: No vascular compression or structural lesion identified. Diagnosis of exclusion.

Medical Management

Carbamazepine is first-line, with an initial response rate of 70–80%.

Carbamazepine loses efficacy in many patients over time. When medication fails, surgical treatment is not a last resort — it is the appropriate next step.

Surgical Treatment

Microvascular Decompression (MVD)

MVD is the definitive surgical treatment for classical TN. It is the only procedure that addresses the underlying cause — vascular compression — rather than damaging the nerve.

A small craniotomy is made behind the ear. Under the operating microscope, the offending blood vessel is identified, carefully mobilised away from the trigeminal nerve root, and a small Teflon implant is placed to prevent re-contact.

Outcomes:

• Immediate pain relief: >90% of patients
• Long-term pain freedom at 5 years: 70–80%
• Preservation of facial sensation

MVD is recommended for younger patients, those with typical TN features, and when imaging confirms neurovascular conflict. For classical TN with MRI confirmation, it is the treatment of choice.

Stereotactic Radiosurgery (Gamma Knife / CyberKnife)

Non-invasive; focused radiation delivered to the trigeminal nerve root. Effect is gradual over 1–3 months. Pain relief in 70–85% initially; facial numbness in 30–50%. Best suited for elderly patients or those not fit for open surgery.

Percutaneous Ablative Procedures

Performed through a needle inserted through the cheek under X-ray guidance:

• Balloon microcompression — useful for V1 involvement and elderly patients
• Glycerol rhizolysis — selective damage to pain fibres
• Radiofrequency thermocoagulation — controlled heat lesion; allows intraoperative titration

Higher recurrence rate than MVD; shorter hospital stay; can be repeated.

Occipital Neuralgia & Other Facial Pain Syndromes

Occipital Neuralgia

Sharp, shooting pain in the distribution of the greater or lesser occipital nerves — from the base of the skull to the scalp and behind the eye. Distinguished from migraine by localised nerve tenderness and response to occipital nerve block.

Treatment: nerve block, physiotherapy, radiofrequency ablation, or occipital nerve stimulation for refractory cases.

Cluster Headache

Strictly unilateral, severe periorbital pain with ipsilateral autonomic features: lacrimation, rhinorrhoea, ptosis, miosis, conjunctival injection, eyelid oedema. Frequently misdiagnosed as sinusitis or dental pain. Responds to high-flow oxygen, subcutaneous sumatriptan, and verapamil for prevention.

Hemicrania Continua

Continuous, strictly unilateral headache with superimposed exacerbations and autonomic features. Defined by its absolute and complete response to indomethacin — both diagnostic and therapeutic.

SUNHA / SUNA / SUNCT

Extremely brief (seconds), very frequent attacks of severe unilateral headache with cranial autonomic features. Often resistant to treatment; lamotrigine and gabapentin may help.

Red Flag Headache Symptoms

The following features require urgent neurological evaluation to exclude a serious secondary cause:

If you experience a sudden, severe headache of instantaneous onset, treat it as a medical emergency. Go directly to the emergency department.

When to See a Specialist

Seek specialist evaluation if:

• Headaches occur more than 4 days per month or are severely disabling
• Headache character, frequency, or severity has changed
• Over-the-counter medications no longer provide adequate relief
• You are taking pain medications more than 10 days per month
• You experience facial pain, numbness, or electric-shock sensations
• Associated neurological symptoms are present (vision changes, weakness, numbness)
• Headaches significantly interfere with work, study, or daily life
• Previous specialist treatment has been insufficient or exhausted

Next Steps

If you are living with chronic headache, migraine, or facial pain that is not adequately controlled, specialist evaluation may offer answers and options that have not yet been explored.

A thorough clinical assessment, review of your history and imaging, and a clear management plan — tailored to your specific condition.

Discipline · Simplicity · Elegance

Precision care for headache and facial pain disorders — from first consultation to surgical intervention.