The concept of rhinopathic migraine has evolved during the last few years, although its pathophysiology and treatment are still controversial. This prospective study was conducted to assess the efficacy of endoscopic sino-nasal surgery in its treatment. Fifty patients with diagnosed migraine who failed to improve after full neurological work up and treatment underwent complete sino-nasal evaluation. Thirty-five patients met the diagnostic criteria of rhinopathic migraine [chief complaint of migraine, positive response to nasal anesthetic and the absence of significant sino-nasal symptoms]. Endoscopy and sinus computed tomography revealed either anatomic variations [e. g. septal deviation, 71.4% and concha bullosa, 25.7%] and/or mucosal disease [e. g. thickening, 40% and retention cyst, 11.4%] in all 35 patients. Endoscopic surgery, tailored to the pathology of each patient, succeeded in eliminating or significantly reducing migraine attacks in 32 patients [91.5%], while 3 patients [8.5%] failed, to improve [mean follow-up period of 24 months]. We conclude that endoscopic sino-nasal surgery is highly effective in eliminating rhinopathic migraine in carefully selected cases