The second case is that of a 35-year-old male with a diagnosis of chronic paroxysmal hemicrania based on ICHD3 classification. The patient had a 15-month history of very intense 10-15 min of pain, 5-7 times a day, on his left periorbital and temporal regions associated with ipsilateral conjunctival injection and lacrimation with rhinorrhea. Systemic and neurologic examinations, brain and orbital MRIs, and a paranasal CT scan were all normal. He had a great response to 225 mg of indomethacin per day. The patient reported side effects of indomethacin, including dizziness and heartburn, and therefore we had to stop it. Serial nerve block of the left supraorbital, supratrochlear, and zygomaticotemporal branches of the trigeminal nerve, which all were tender in the exam, was successful in controlling his pain. A combination of lidocaine HCL 2% and bupivacaine Hcl 0.5%, 1:1 ratio used was for nerve block. However, due to the fact that it wore off, we had to repeat the nerve block every 3-4 weeks. The transient effect of the nerve blocks forced him to ask for possible permanent therapies. Gabapentin, melatonin, topiramate, and valproic acid were also tried but did not help. He volunteered for the nerve decompression procedure. The left supraorbital and supratrochlear nerves were decompressed using the same technique previously discussed in the first case above. The zygomaticotemporal branch of the trigeminal nerve was avulsed endoscopically using the same technique as well. After a few days of post-operative pain and congestion at the procedure site, he experienced at least 90% improvement in the frequency of his paroxysmal headaches. We followed up with him over time, and at present, 2 years after the surgery, he is pleased with the nerve decompression surgery treatment as he currently has only occasional mild tolerable pain without the need for any analgesic use. He is also on no preventive medication.