Migraine Management
Quarterly physician-led clinical evaluation
Individualized therapeutic recalibration at each encounter
Direct-access physician relationship
Neurological
Medicine
Physician-led diagnosis and management of migraine, headache disorders, and chronic neurologic pain — delivered with clinical precision, academic rigor, and the longitudinal continuity that complex neurological conditions genuinely require.
01
Neurological Evaluation
Comprehensive evaluation of complex neurological presentations — including autoimmune and neuroinflammatory etiologies, refractory symptom constellations, and diagnostic uncertainty cases warranting extended physician oversight.
02
Interventional Neurology
FDA-approved and clinically validated interventional modalities — OnabotulinumtoxinA (Botox), occipital nerve blocks, CGRP pathway therapies, and physician-administered IV infusion support.
03
Migraine & Headache Medicine
Physician-led diagnosis and longitudinal management of chronic migraine, episodic and transformed migraine, trigeminal autonomic cephalalgias, and refractory headache disorders across the full ICHD-3 classification spectrum.
04
Longitudinal Neurological Care
Continuous, physician-directed management for patients with chronic or recurrent neurological conditions — with individualized care architectures that adapt to clinical response, evolving comorbidities, and long-term neurological trajectory.
Who We Treat
Who We Treat
Patients managing chronic or high-frequency episodic migraine with meaningful functional impairment across occupational, domestic, or social domains
Those with treatment-refractory headache disorders who have not achieved adequate clinical response through conventional first- or second-line therapies
Patients presenting with complex or undifferentiated neurological symptoms requiring extended clinical investigation — not a compressed, high-throughput diagnostic encounter
Individuals seeking a fundamentally different care model — one built on physician continuity, clinical depth, and outcomes that the conventional healthcare system is not structured to deliver
Conditions
Conditions We Treat
Condition
Chronic Migraine
15 or more headache days per monthChronic migraine means living with 15 or more headache days per month — at least 8 of which have the quality of a true migraine attack. This is not simply "bad headaches." It is a recognized neurological condition that rewires pain pathways over time. Work, sleep, relationships, and daily life are all affected. Many patients who come to us have tried two, three, or four medications without finding lasting relief. That history doesn't disqualify you — it's exactly why a physician who specializes in this condition matters.
Insurance-accepted for this diagnosis
Condition
Episodic Migraine
Fewer than 15 days/month, but still severely disablingEpisodic migraine typically means fewer than 15 headache days per month — but within those attacks, the experience can be completely disabling: one-sided pain, nausea, and an extreme sensitivity to light and sound that can make any room feel impossible to be in. We also evaluate patients whose migraines are increasing in frequency. Early, precise intervention is one of the most effective ways to prevent episodic migraine from becoming chronic.
Preventive treatment often covered by insurance
Condition
Cluster Headache
Among the most painful conditions in medicineCluster headaches are one of the most severe pain conditions documented in medicine — frequently described by patients who have also experienced childbirth or kidney stones as distinctly worse than either. They strike on one side of the head, usually around or behind the eye, and may occur multiple times a day in cycles lasting weeks or months. They are often accompanied by eye redness, tearing, and nasal symptoms on the same side. We treat this condition with the urgency and precision it demands.
Specialist evaluation is essential for this diagnosis
Condition
Tension-Type Headache
The most common headache type — still worth treating properlyTension-type headaches are the most common headache disorder — a steady, pressing pain that wraps around the head, often described as a tight band or a weight pressing down. While generally less intense than migraine, frequent or chronic tension headaches erode quality of life significantly, especially when they occur alongside or overlap with migraine. We evaluate both patterns together, because they often share root causes and respond to the same treatments.
Often coexists with migraine — combined evaluation recommended
Condition
Neuralgia & Facial Pain
Shooting or burning pain along the nerves of the face or headNeuralgia refers to pain that originates from a specific nerve rather than from muscle tension or vascular changes. In the head and face, this includes trigeminal neuralgia (sharp, electric-shock pain along the face) and occipital neuralgia (shooting pain from the base of the skull up through the scalp). These conditions are frequently misidentified as migraine or sinus headache and undertreated as a result. Precisely placed nerve blocks — a clinical strength of this practice — can provide relief when general pain medications have failed.
Nerve blocks often provide rapid relief in these cases
Condition
Post-Traumatic Headache
Headache that begins after a head injury or concussionPost-traumatic headache develops in the days or weeks following a head injury, concussion, or whiplash — and can persist for months or years when not properly evaluated and treated. It often mimics migraine or tension headache but may also present as an entirely new pattern. Post-traumatic headache is real, neurological in origin, and one of the most undertreated conditions in headache medicine. We provide thorough evaluation and a personalized treatment plan designed around your specific post-injury presentation.
Often covered by auto or workers' compensation insurance
Our Approach
How We Think About Your Care
01
Adaptive longitudinal management
Migraine rarely follows a linear course. We approach every patient relationship as an evolving clinical partnership — continuously reassessing treatment efficacy and recalibrating based on real-world response data.
02
Dynamic diagnostic refinement
An initial diagnosis represents a working clinical hypothesis, not a fixed conclusion. As objective and subjective data accumulate across visits, we refine our diagnostic formulation and modify treatment strategy accordingly.
03
Outcome-driven protocol calibration
No patient is maintained on a therapeutic regimen that has failed to yield meaningful clinical response. We track quantifiable outcomes at every interval and recalibrate proactively — not reactively.
04
Stratified therapeutic escalation
Escalation decisions are governed by clinical evidence, validated safety profiles, and longitudinal neurological risk calculus — not by patient preference or prevailing therapeutic trend.
Treatments
Interventional Protocols
01
Botox for Chronic Migraine
FDA-approved OnabotulinumtoxinA therapy delivered across the standardized 31-site head and neck injection paradigm at 12-week intervals. Among the most rigorously validated preventive therapies for chronic migraine, with demonstrated efficacy across multiple randomized controlled trials.
02
Occipital Nerve Blocks
Precision anesthetic nerve blocks targeting the greater and lesser occipital nerves — capable of interrupting an acute migraine cycle and providing sustained relief in cervicogenic, occipital, and cervicotrigeminal headache presentations.
03
Trigger Point Injections
Targeted myofascial injection therapy addressing pericranial and cervical trigger zones implicated in headache amplification and chronification — an evidence-supported adjunct to comprehensive migraine management.
04
Neuromodulation Strategies
FDA-cleared, non-pharmacologic neuromodulatory devices for acute and preventive migraine management — offering an evidence-based therapeutic avenue for patients with pharmacological intolerance, contraindication, or inadequate first-line response.
05
Infusion Therapy
Physician-supervised IV infusion therapy encompassing acute migraine rescue agents, magnesium sulfate, NAD+ neurological support, and individualized adjunctive formulations — indicated for refractory, high-frequency, and perioperative migraine presentations.
Ongoing Care
Care Programs
Headache Continuity
High-frequency, close-interval clinical monitoring
Botox every 12 weeks
CGRP pathway agent coordination and optimization
Breakthrough support access
Infusion Therapy
IV migraine rescue therapy
Magnesium + NAD+ support
Physician-supervised
Our Process
What to Expect
01
A complete clinical history, unhurried
Your first visit is designed for depth, not efficiency. We review your complete symptom chronology, therapeutic history, current medications, and the functional burden your condition carries — before forming any clinical impression.
02
A precise, structured diagnosis
Applying ICHD-3 diagnostic criteria, we classify your specific headache phenotype, neurological profile, and clinical burden — establishing a precise diagnostic foundation and a defined therapeutic direction.
03
Customized therapeutic architecture
Your treatment plan is constructed from evidence-validated modalities selected specifically for your diagnosis, clinical history, and therapeutic goals — not a templated pathway, but a clinical design built for your case.
04
Structured longitudinal follow-up
We monitor outcomes at defined intervals, reviewing your clinical response and executing the therapeutic adjustments your case requires. Neurological care, at this level, is a sustained relationship — not a single clinical encounter.
How We Practice
How We Practice
Every therapeutic recommendation is preceded by a thorough, individualized clinical evaluation
Treatment decisions are governed by clinical evidence, validated safety data, and long-term neurological risk calculus — not by patient preference or trend-driven prescribing
We adhere to conservative therapeutic sequencing as a foundational standard, escalating only when objective clinical indicators support doing so
Clinical restraint is part of our care philosophy
Our Goal
What we’re working toward
Most patients arrive after exhausting standard therapeutic options without achieving durable relief. Our clinical objective is specific and measurable: a meaningful, sustained reduction in migraine frequency, functional burden, and neurological suffering — with outcomes that hold over time.
A clinically significant reduction in migraine days per month
Restored occupational and functional capacity across professional, domestic, and social domains
Stable, longitudinally maintained symptom control
An ongoing clinical partnership with a physician of record who maintains comprehensive familiarity with your case
Neurological health that improves — and holds — over time
Continuity of Care
Why patients continue their care here
The same physician at every visit — someone who knows your full history, not just your chart
Appointments designed around complex cases — unhurried, attentive, and genuinely thorough
Treatment refinements made over time, based on how you’re actually responding
A practice small enough to know you, with the clinical depth to make a real difference
Care that continues long after the first improvement — because lasting results take time
Our Team
Our Clinical Team
Our clinicians specialize in migraine medicine and neurological care. Complex conditions deserve unhurried attention — and that is precisely what every patient relationship here is built on.
Founder & Lead Physician
Dr. Ryan Monti
MD · Board-Certified in Internal Medicine
Dr. Monti founded Monti Institute on a conviction born from clinical practice: that chronic migraine and complex neurological disorders require more than a compressed appointment and a formulaic prescription. A board-certified physician in Internal Medicine focusing on migraine medicine and medical aesthetics, he has built a practice that delivers the clinical depth, continuity, and individualized rigor this patient population deserves and rarely receives.
Migraine Medicine
Headache Disorders
Assoc. Prof. MCG
Physician Associate
Sean Kump, PA-C
PA-C · Physician Associate
Sean Kump is a physician associate with concentrated expertise in migraine therapeutics, interventional headache medicine, and complex neurological case management. Known for clinical precision and exceptional attentiveness, he functions as an indispensable clinical partner to Dr. Monti — extending the same standard of unhurried, physician-grade care across every patient relationship.
Headache & Migraine
Neuro-Diagnostic Imaging
Advanced Practice Provider
Zack Ballingham, FNP-BC
FNP-BC · Advanced Practice Provider
Zack Ballingham is a board-certified Family Nurse Practitioner with over 15 years of experience in acute care and hospital medicine. A native Nevadan and graduate of the University of Nevada, Reno, he brings deep expertise in the management of complex medical conditions, inpatient clinical decision-making, and multidisciplinary care coordination. His approach is grounded in evidence-based practice, compassionate service, and an unwavering commitment to patient-centered outcomes.
Headache & Migraine
Neuro-Diagnostic Imaging
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Advanced Practice Provider
Morgan Melton, CPNP-PC
MSN, APRN, CPNP-PC
Morgan Melton is a board-certified nurse practitioner with specialized expertise in neurological wellness and integrative care. Her practice centers on the intersection of neurology and whole-patient health — delivering attentive, evidence-informed care with a long-term orientation that complements the physician-led model of the Institute.
Nurse Practitioner
Integrative Wellness
Pediatric Primary Care
Director of Operations
Megan Phares
Director of Operations
Megan Phares manages the clinical operations at Monti Institute, overseeing specialized workflows and ensuring an unhurried, pristine patient experience across all advanced therapeutics.
Clinical Operations
Practice Management
Neurological Medicine · Clinical Detail
Interventional &
Program I
Program II
Program III
Interventional &
Therapeutic Protocols
Full clinical detail for all neurological interventions offered at the Institute. Treatment selection is determined by diagnostic evaluation, not patient preference.
Protocols
Interventional Protocols
01
FDA-Approved Prevention
Botox for Chronic Migraine
OnabotulinumtoxinA, 31-site protocol, chronic migraine indication (15+ headache days/month)
155–195 units head/neck distribution
12-week cycle
Response assessed after 2 cycles
Chronic migraine candidates only
02
Interventional Block
Occipital Nerve Blocks
Local anesthetic ± steroid per indication
Greater/lesser occipital nerves
Migraine rescue + neuralgia
Repeat as clinically indicated
03
Myofascial
Trigger Point Injections
Suboccipital, trapezius, temporalis, SCM
3–6 sites/session
Adjunct to broader migraine care
04
Neuromodulation
Device-Based Therapy
Non-pharmacologic approaches for refractory migraine
External trigeminal stimulation
TENS-based adjunct therapy
Remote neuromodulation
05
IV Infusion Therapy
Infusion Protocols
Magnesium, NAD+, DHE, ketorolac-based protocols
Physician-supervised
Individualized composition
Acute + preventive support
06
CGRP Therapies
CGRP Antagonist Therapy
Erenumab, Fremanezumab, Galcanezumab
Monthly or quarterly dosing
3-month response evaluation
Episodic + chronic migraine
Structured Pathways
Care Programs
Migraine Management Program
Quarterly evaluation
Direct physician access
Chronic Headache Continuity Program
Botox q12 weeks
CGRP coordination
Neurological Infusion Program
IV therapy per indication
Quarterly review
Insurance & Access
Aetna
Blue Cross Blue Shield
Cigna
UnitedHealthcare
Medicare
Coverage varies by plan and service.
Clinical Glossary
Precision medicine requires precise language. The following definitions are provided to support informed, substantive conversations between patient and physician — not to replace one.
Aesthetic Anatomy
SMAS Integrity
The Superficial Musculoaponeurotic System (SMAS) is the fibromuscular layer that connects the facial muscles to the overlying dermis, functioning as the structural scaffold of the mid- and lower face. SMAS integrity refers to the tensile strength, cohesion, and vertical positioning of this anatomical layer.
As the SMAS loses integrity with age — through a process of fibrous thinning, gravitational descent, and ligamentous attenuation — the overlying soft tissue structures migrate inferiorly, producing jowl formation, nasolabial deepening, and effacement of the mandibular border. SMAS integrity is assessed as part of every comprehensive facial evaluation at this practice.
Clinical Relevance at Monti Institute
Assessment of SMAS integrity informs whether volumetric
correction alone will produce a stable result, or whether
the underlying structural descent requires biostimulatory
agents or device-based support to address the foundational
layer of facial laxity.
Facial Osteology & Aging
Bony Resorption
Bony resorption refers to the progressive reduction in craniofacial skeletal volume that occurs throughout adult life. The facial skeleton is not a static structure — the maxilla, zygoma, mandible, and orbital rims undergo measurable volumetric loss beginning in the third decade and accelerating after menopause in women.
The clinical consequence is a reduction in the osseous foundation upon which soft tissue structures rest. As the skeletal scaffold recedes, overlying skin and fat compartments lose their anatomical support, producing the characteristic signs of facial aging that are not attributable to soft tissue changes alone. Correcting soft tissue without accounting for underlying bony resorption produces results that are volumetrically incongruent with the patient’s skeletal architecture.
Clinical Relevance at Monti Institute
Identification of bony resorption patterns — particularly at
the infraorbital rim, malar eminence, and pyriform aperture —
directly informs filler placement depth, product selection, and
the long-term sequencing of any injectable treatment plan.
Migraine Neuroscience
CGRP Pathway
Calcitonin Gene-Related Peptide (CGRP) is a neuropeptide released from trigeminal nerve terminals that plays a central role in migraine pathophysiology. During a migraine attack, CGRP is released in elevated concentrations from both peripheral trigeminal afferents and central neurons, producing vasodilation, neurogenic inflammation, and the sensitization of pain pathways that characterize the full migraine episode.
The CGRP pathway has become one of the most significant pharmacological targets in modern migraine medicine. CGRP receptor antagonists (gepants) block the peptide’s action at the receptor level; anti-CGRP monoclonal antibodies target the peptide or its receptor directly, providing monthly or quarterly preventive coverage with a mechanism of action specific to migraine biology.
Clinical Relevance at Monti Institute
CGRP pathway agents are a core component of the interventional
toolkit for eligible migraine patients at this practice. Candidate
selection, dosing intervals, and combination with Botox or
infusion protocols are determined through individualized clinical
evaluation — not a standard formulary approach.
Regenerative Aesthetics
Regenerative Biostimulation
Regenerative biostimulation refers to a class of aesthetic interventions that do not simply add volume or block neuromuscular activity, but instead activate the body’s intrinsic cellular mechanisms of collagen synthesis, dermal matrix renewal, and structural tissue regeneration. The result is improvement in skin quality, firmness, and structural integrity that develops progressively over months rather than immediately.
Primary biostimulatory agents include Poly-L-lactic acid (PLLA, marketed as Sculptra), calcium hydroxylapatite (CaHA, marketed as Radiesse), and polynucleotide complexes. Each activates fibroblast activity through distinct mechanisms, producing neocollagenesis — the synthesis of new collagen within the treated dermis and subdermis — rather than mechanical displacement of existing tissue structures.
Clinical Relevance at Monti Institute
Biostimulatory agents are staged within a 12-month horizon plan
and evaluated at defined intervals. Because results develop over
time, patient selection for these agents requires a commitment to
longitudinal follow-up and an understanding that the full outcome
is not visible at the time of treatment.
Clinical Standards
Documented Clinical Indication
A documented clinical indication is a formally recorded, evidence-based rationale that justifies a specific medical or aesthetic intervention for a specific patient at a specific point in their clinical course. At Monti Institute, no procedure — neurological or aesthetic — is performed without one.
In neurological practice, a documented clinical indication for Botox for chronic migraine, for example, requires a confirmed diagnosis of chronic migraine (≥15 headache days per month, ≥8 of which meet migraine criteria), documented inadequacy of prior preventive treatments, and physician-recorded clinical reasoning supporting this intervention for this patient.
In aesthetic practice, it means that the choice of treatment, product, volume, and injection site is recorded in the clinical record with a specific anatomical rationale — not simply selected from a standard menu. This standard distinguishes physician-led aesthetic care from high-volume aesthetic practice.
Clinical Relevance at Monti Institute
This standard is not a compliance formality — it is the
mechanism through which clinical accountability is maintained over
time. A documented indication creates a record against which future
outcomes can be evaluated, and a rationale that can be revisited,
revised, or defended as the patient’s case evolves.