Much can be learned from treating over 15,000 headache hospitalized patients over the course of 30 years. By the very need to be admitted, these individuals are complicated, both physiologically and often psychologically. Founded in 1978, the Michigan Head Pain and Neurological Institute and its hospital unit developed a set of criteria for admission and a growing staff of professionals to serve this complex population of patients. Experience has taught us many lessons; several are considered in this review. Among the important topics discussed are: admission criteria to the hospital unit; treatment protocols and other hospital-based strategies; integration of behavioral therapy and therapists into the treatment system; diagnostic testing of patients with intractable headache; identifying the “problem patient” and “medication misuse” early in the course of therapy; approaching the headache patient with cluster B personality disorder; and the use of interventional and anesthesiological treatment for intractable headache. Outcome data and a review of recent publications are presented.