What to Try When Nothing’s Working

  • Dawn A. Marcus
  • Duren Michael Ready


When migraines fail to respond to the usual therapies, we can believe that we are either cursed or that we have missed something. Only one of these thoughts allows us to move forward. When we believe that we have missed something, we go back to the beginning. We repeat a history and physical looking for missed clues. We consider intervention previously tried and those untried. We adopt new approaches and mindsets that allow patients to become comfortable with being uncomfortable. When people say that they have done everything, it should be pointed out that it is unlikely that they have “done everything” because they have not found out what the next thing to do is. There are multiple interventions that have demonstrated benefit in refractory cases, and if these interventions fail to improve the condition, then it is always appropriate to adopt new perceptions and behaviors regarding pain. It is always too early to quit.


Perpetuating factors Precipitating factors Modifiable risk factors Migraine progression Medication overuse Stratified care Polypharmacy Pharmacological treatment Nonpharmacological treatment Herbal therapies Occipital nerve decompression Cytochrome P4 50 testing IgG/IgE testing Wearable technologies Migraine comorbidities Anxiety Self-calming skills Fight or flight response Progressive muscle relaxation Relaxation response Visualization Thermal biofeedback Mindfulness meditation Guided imagery Yoga Distraction Ignition failure Reframing Spirit animal Stress response Behavioral sleep Hypothalamic dysregulation Sleep efficiency Stimulus control Sleep hygiene Sleep restriction Autogenic training Adult abuse Trauma Dietary therapies Migraine diet IgG elimination diet Omega-3 fatty acids Oxidative stress Local anesthetic Occipital nerve block Sphenopalatine ganglion block Pericranial bupivacaine injections Onabotulinumtoxin A Collaborative care model SWOT Commitment Adherence Catastrophizing MOAI Serotonin syndrome Hypertensive crisis Tyramine diet Ketamine Stimulants Steroids Pain perception Pain management techniques Central sensitization Neuroplastic changes Sensory discriminative Affective motivational Descending inhibition Long-term potentiation Long-term depression Descending inhibition Tonically active neuron Peripheral stimulation Limitedly augmented pain Cognitive reprogramming Cognitive therapy Benefit finding Resilience Gratitude Affective balance Negative affect Positive affect EMDR Coping skills 

Supplementary material

Video 11.1

Occipital nerve block (MP4 20313 kb)

Video 11.2

Sphenopalatine ganglion block (MP4 300435 kb)


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Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  • Dawn A. Marcus
    • 1
  • Duren Michael Ready
    • 2
  1. 1.University of PittsburghPittsburghUSA
  2. 2.Fellow American Headache SocietyTempleUSA

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