Clinical training

You will be an integral part of the headache team with responsibilities for evaluating and treating challenging outpatient cases. During your core headache rotation you will see patients where you direct the diagnostic evaluation (if indicated) and treatment plan. You will see a broad range of headache disorders and conditions including but not limited to migraine, cluster headache and other trigeminal autonomic cephalalgias, cervicogenic headache and occipital neuralgia, spontaneous intracranial hypotension, idiopathic intracranial hypertension, thunderclap headaches, hypnic headache, first bite syndrome, temporomandibular joint disorders, trigeminal neuralgia and other cranial neuralgias, and various secondary headache disorders. During the core schedule you will have time dedicated to gain experience in procedures used to treat craniofacial pain and will have time dedicated for research.

Example Core Headache Rotation Schedule*

	Monday	Tuesday	Wednesday	Thursday	Friday
AM	CSF Clinic	Headache Clinic	Headache Clinic	Headache Clinic	Research or Headache Hospital consults when present
PM	Botox	Nerve Block Clinic	Headache Clinic, CSF Clinic or Botox	Research	Nerve Block Clinic

*Variations will occur depending on the clinical needs of the Headache Division.

Rotation Schedule

In addition to a core headache rotation, you will have 8 weeks of rotation time with some required rotations and some elective rotations.

Rotation	Length
Ultrasound course	Half day required – fundamentals of ultrasound course
Injection workshop	Half day required with additional days available as needed based on needs of fellow.
Pain Medicine	2 weeks required
Pediatric Headache	2 weeks required
Neuro-Ophthalmology	1 week required
Neurosurgery - Neuromodulation and Facial Pain	1 week required
Pain Rehabilitation Center	1 week elective
Dizzy Clinic	1 week elective
Brain Rehabilitation (TBI/Concussion) Clinic	1 week elective
Research	1 week elective

The schedule of clinical activities is designed to ensure that you have experience with different aspects of headache and craniofacial pain care.

Rotation descriptions

Headache Clinic

As a headache fellow, you will see patients in the Headache Clinic, where you will be supervised by one of our headache subspecialist faculty as a part of your core schedule comprising of three to four half days per week. You will see a myriad of patients with a broad array of headache and facial pain disorders coming from both locally and across the world.  As part of each evaluation, you will formulate a diagnostic evaluation as indicated and create a comprehensive care plan. 

Headache Procedural (Nerve Block) Clinic

Two half days per week, you will rotate in the Headache Procedural Clinic and get hands on experience with injections for the treatment of headache and facial pain.  You will learn common landmark guided injections such as greater occipital nerve, lesser occipital nerve, supraorbital nerve, and sphenopalatine ganglion (SPG) blocks.  If you have interest, you can have the opportunity to get hands on training with ultrasound (US) guided injections for headache and facial pain including pterygopalatine fossa (PPF) field blocks, proximal greater occipital nerve blocks at the level of C2, great auricular nerve blocks, auriculotemporal nerve blocks, and masseter trigger point injections.

Headache Botox Clinic

You will regularly rotate (one to two half days per week) in a high-volume Botox clinic where you will perform Botox injections following a chronic migraine (PREEMPT) protocol. Following completion of Headache Fellowship, you will be equipped with the know-how to continue providing Botox injections in a high throughput fashion and be able provide this highly effective treatment to patients you care for that are suffering from chronic migraine.

CSF Dynamics Clinic

As part of your core rotation, you will regularly spend time in the CSF Dynamics Clinic (one to two half days per week) assessing patients whom come from across the country for treatment of spinal CSF leaks or idiopathic intracranial hypertension. For spontaneous intracranial hypotension, you will develop the skillset to systematically assess patients for spinal CSF leaks and provide patients with a broad array of treatment options that goes beyond epidural blood patches. Following completion of headache fellowship you will know when to refer patients with spontaneous intracranial hypotension for epidural blood patch, venous embolization, or surgical repair. You will direct the diagnostic evaluation using the most advanced imaging modalities in the country including photon counting CT myelography and digital subtraction myelograms which have increased the yield of CSF-venous fistula and CSF leak detection in our practice. For idiopathic intracranial hypertension, you will be a part of the multidisciplinary team with neuro-ophthalmology and assess patients for medical (e.g. carbonic anhydrase inhibitors, GLP-1 agonists) management and determine when to refer for interventional treatment.

Research

During your core rotation, you will have time with one to two half days per week dedicated to research where you have the opportunity to develop and execute a project under the direction of faculty mentors focusing on a research question related to migraine, cluster headache, interventions for headache, spontaneous intracranial hypotension, and/or any other headache related topics of your interest. Our faculties have excellent research productivity and are leading the field in multiple areas, including artificial intelligence and machine learning in headache medicine, genetic studies of headache disorders, CSF leak and procedural headache management. We also have a structured, detailed headache database that several residents and fellows have leveraged in the past for research projects. In the past, projects have ranged from retrospective reviews all the way to prospective randomized controlled trials in the most highly motivated of headache fellows. Most fellows prepare a IRB protocol on a headache related topic of interest and complete at least one retrospective review by utilizing data collection from Mayo Data Explorer resulting in at least one publication in a peer reviewed journal. Presentation at national and international headache meetings are highly encouraged, and our fellows have successfully presented their research in the American Headache Society meetings and the American Academy of Neurology meetings. If needed, a headache fellow will have the opportunity to be able to utilize an elective week for research time with a goal of 20 percent research time for the year.

Hospital Headache Consults

You will have the opportunity for up to one half day per week to see patients admitted to the Saint Marys Campus of Mayo Clinic Hospital who are presenting with secondary headaches related to cerebrovascular disease. One of our supervising headache consultants with dual fellowship training in cerebrovascular disease and headache who rotates on the inpatient cerebrovascular and stroke service will identify interesting cases on service for you to see as time permits on your schedule. This is an educational opportunity for you to gain exposure to acute inpatient headache with expectations to only see patients during a standard work week (e.g. no weekends) and this experience is not intended to fulfill service requirements for patient care. Secondary headache disorders that present with headache that are commonly admitted to the inpatient hospital service include Reversible Cerebral Vasoconstriction Syndrome (RCVS), Posterior Reversible Encephalopathy Syndrome (PRES), aneurysmal subarachnoid hemorrhage, and cervical arterial dissections. The goal is to see one interesting case a month admitted with secondary headaches related to cerebrovascular disease. The intent of this educational opportunity is to develop a better understanding of the clinical-radiographic features and approach to acute management of headache in uncommon secondary headaches associated with cerebrovascular disease.

Ultrasound Course

Trainees will have the opportunity to attend a half day course that will provide education on the fundamentals of ultrasound.

Injection Workshop

At the beginning of the headache fellowship, you will meet with the headache fellowship director and participate in a injection workshop where you will review the basics of drawing up injectates, decision making for choice of injectate, and review techniques for common landmark guided injections in the treatment of headache. You will review the principles of ultrasound guided injections and techniques for common ultrasound guided injections utilized in treatment of headache.  You will receive hands on training in ultrasound guided injections with practice models.  As the year progresses, you will have the opportunity to have refresher ultrasound practice sessions with the headache fellowship director as needed and as directed by your interest. 

Pain Medicine

While on your pain medicine rotation, you will see patients with one of our consulting staff who has dual fellowship training in headache and pain medicine. You will participate in the clinical evaluation and decision making for interventions in treatment of intractable headache and facial pain. During the rotation you will have further opportunity to perform landmark based injections for headache. You will observe flouroscopically guided injections for the treatment of headache and facial pain which may include sphenopalatine ganglion blocks, trigeminal gasserian ganglion blocks, C1-2 joint injections, C2-3/C3-4 facet joint injections, cervical medial branch blocks/ablations, and C2 selective nerve root blocks/ablations. You will have the opportunity to observe neuromodulation cases in the OR, which may include trials/implants for occipital nerve stimulation, supraorbital nerve stimulation, and high cervical spinal cord stimulation.

Pediatric Headache

Trainees will gain experience managing pediatric headache and will rotate with our pediatric neurologist who is fellowship trained in headache.

Neuro-Ophthalmology

During your rotation in neuro-ophthalmology, you will master the skills of the fundoscopic exam and see patients referred for neuro-ophthalmologic evaluation which includes a high volume practice of patients with suspected idiopathic intracranial hypertension.

Neurosurgery – Neuromodulation and Facial Pain

You will rotate with our neurosurgeon who specializes in neuromodulation and the treatment of facial pain. Trainees will learn about the clinical features and patient factors that are incorporated into the decision making process for patient selection in neurosurgical interventions to treat facial pain. As part of the rotation, you will observe neurosurgical interventions used for treatment of craniofacial pain.

Pain Rehabilitation Center

Trainees learn to identify patients who may benefit from a behavioral rehabilitation approach to chronic pain. They are also exposed to various psychometric testing procedures, rehabilitative approaches to therapy, and gain experience in identifying and treating patients with substance abuse and dependence issues. Trainees work under the supervision of the medical director of the Pain Rehabilitation Center during this rotation.

Dizzy Clinic

Dizziness is a common symptom that occurs with or as a part of migraine.  You have the option to rotate in the Dizzy Clinic which specializes in the diagnosis and treatment of persistent perceptual postural dizziness (3PD). This is a common, but underrecognized comorbidity with migraine and this rotation would aid in your ability to differentiate between 3PD and vestibular migraine.

Brain Rehabilation (TBI/Concussion) Clinic

Headache is a core feature to the presentation of post-concussive syndrome and you will have the opportunity to rotate in the Brain Rehabilitation Clinic.  During a rotation in the Brain Rehabilitation Clinic you would participate in the evaluation of patients with traumatic brain injury and learn about management of their non-headache symptoms.

Didactic training 

Clinical conferences, seminars, small discussion groups, journal clubs, and one-on-one instruction are all an integral part of Headache Fellowship.

You will participate in clinical case conferences or research at the following:

• Monday noon Neurology Grand Rounds
• Friday noon Neurology Subspecialty Conference
• Other departmental or interdepartmental conferences as needs and opportunities arise

Research training 

Your research opportunities at Mayo Clinic are outstanding. Our group is leading the headache research advances in the field in multiple areas including artificial intelligence and machine learning in headache, CSF leak and randomized controlled studies on headache therapeutics. We have extensive resources, including comprehensive Electronic Health Records databases, and very supportive faculty to mentor you on research projects.  The hands-on clinical experiences in this fellowship, combined with our highly trained laboratory and statistical support teams, create an environment well-suited to scientific investigation.

At least 20 percent of the Headache Fellowship will be designated to research, grant writing, manuscript preparation and presentations for national and international meetings.

Your participation in any research project will depend upon your professional interests and capabilities. Attendance at a national or international neuroscience meeting will be available for original presentations.

Evaluation

To ensure that you acquire adequate knowledge and develop your technical skills, your performance will be monitored carefully during the course of your fellowship. You will be evaluated formally by the program director.