Headache is a symptom. Migraine is a complex neurological condition.

I am a headache and facial pain specialist. That is the entirety of my practice.

Whatever is producing a headache has no interest in the boundaries we draw between specialties.

The cause may be pressure in the spinal fluid, too much of it or too little. It may be blood that cannot drain the way it should. A vessel wall. A hormone that falls on a schedule. A jaw, a sinus, a night of broken sleep, a joint that has been loose since childhood and finally let something go.

A field that lives at an intersection cannot recruit from one road. Fellowship training in headache medicine is open to physicians from neurology, internal medicine, pediatrics, and primary care, because headache does not present to a neurologist first. A headache that feels like sinus goes to an ENT. One behind the eye goes to an ophthalmologist. Most of them go to a primary care physician, who has to sort out which is which.

I came to it from primary care, and I have never stopped using that training. Migraine does not arrive alone. It arrives with blood pressure, mood, sleep, weight, hormones, and a medication list someone has to reconcile, and every preventive I might reach for collides with one of them. The drug that finally quiets the headaches can raise the blood pressure, flatten the mood, add weight, or fail quietly against something the patient has been taking for years. Choosing well means treating the whole person, and I was taught to do that before I was taught headache.

It changed how I think about the time between visits, too. Most of what decides whether a plan works happens at home, on days I am not there, in the moment a patient decides whether this one counts and whether to treat it yet. Years of continuity care taught me to ask about that hour. Plans fail there more often than they fail because the prescription was wrong.

After serving as chief resident, I completed fellowship training in headache and facial pain medicine under Dr. Stewart Tepper at Dartmouth-Hitchcock. I later joined the faculty at Yale School of Medicine, where I co-directed the Headache and Facial Pain Fellowship and led headache medicine at the Stamford and Greenwich sites. Since then my practice has been limited to headache and facial pain: migraine, cluster headache, trigeminal neuralgia, occipital neuralgia, post-traumatic headache, and the conditions that get mistaken for all of them. I also help train the specialists coming up behind me.

Having seen several clinicians already is not a failure of prior care. It is usually the reason a subspecialty evaluation is warranted. My job is to add that layer of depth and to work alongside the physicians you have been seeing, not around them.

The physician who owns the headache rarely owns the cause.