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Many patients feel that certain foods trigger their migraines. In fact, migraineurs often avoid particular foods or ingredients to avoid headaches.

Common food triggers include alcohol, caffeine and compounds found in foods including nitrates (found in cured meats), histamine (in dried fruits, fermented foods), tyramine (in wine), phenylethylamine (in lentils, beans, nuts).

There is mixed evidence regarding food triggers.

In a 2020 meta analysis in the Journal of Head and Face Pain, forty-three studies looking at dietary migraine triggers were examined, and alcohol and caffeine were found to be most common diet related triggers. However, it was concluded that currently there is poor evidence from studies and more high-quality research is needed. A 2020 study of chocolate as migraine trigger found that although a small number of patients reported chocolate as migraine trigger, but provocative studies could not confirm chocolate as migraine trigger, in fact, eating chocolate may be more associated with food craving or premonitory symptoms.

The best way to determine if food triggers are affecting you is by keeping a headache diary. Because we are all unique, some common food triggers that may affect one person, may not affect another.

To learn more about migraines and food triggers, speak with your healthcare provider.

By: Brooke Steiger, FNP


Warmer weather is on the horizon and with that comes a plethora of spring/summer dietary changes. Intermittent fasting is having a significant moment in the wellness world. Some researchers propose that fasting techniques can help ease the symptoms of various chronic health problems, while simultaneously aiding in weight loss. Who doesn’t want to look fabulous in their new spring/summer attire!
Although several diet strategies exist to help individuals lose weight, one regimen has gained popularity within the past decade. Intermittent Fasting, (IF), is a diet that generally involves alternate day fasting and time restricted feeding.
Significant findings suggest that IF is an effective strategy to help lose weight, however it does come with side effects. Fasting headaches are more common in people who have a prior history of headaches and may resemble their diagnosed headache syndrome. These headaches are more likely to develop as the duration of fasting increases and are less likely secondary to hyperglycemia or duration of sleep.
Fasting headaches are generally frontal, diffuse, and non-pulsatile. Mild to moderate intensity. They generally occur by a fast of greater than 16 hours and resolve within 72 hours after resumption of food.
For patients who are diagnosed with a headache syndrome, we recommend consulting with a licensed Nutritionist and your neurologist prior to trailing this new diet fad.
Cheers to Springing forward!
By: Jordan Shankle, PA

Medication Overuse Headache

Medication Overuse Headache
Medication overuse headache (MOH) is a headache occurring on 15 or more days per month from regular overuse of acute headache medication for more than 3 months. Many acute symptomatic medications used to treat headaches have the potential for causing MOH. Risk is highest with opioids, butalbital-containing combination analgesics, and acetaminophen-aspirin-caffeine combinations. Triptans (sumatriptan, rizatriptan etc.) have moderate risks and some studies indicate NSAIDs (ibuprofen, naproxen, diclofenac, indomethacin etc.) also has high risks.
A history of symptomatic medication use for more than two to three days per week in association with chronic daily headache is suggestive of MOH. Nausea, asthenia, difficulty concentrating, memory problems, and irritability can accompany MOH.
The precise mechanisms that lead to MOH are still uncertain. However, multiple factors seem to play a role, including genetic predisposition, sensitization of pain processing, and biobehavioral factors.
The management of MOH includes patient education, initiation of effective preventive therapy, discontinuation of the overused medication (through tapering down or with assistance of bridge therapy), and follow-up to prevent relapse.
If you are experiencing headaches for 15+ days a month, please make an appointment with a MCHN provider for an evaluation.
–Alice Wong, NP

Insurance Issues: Prior authorizations

Navigating the sea of medical insurance can be challenging for patients at times. Insurance companies create guidelines and policies to keep their costs down which sometimes prevent patients from accessing medications, tests, and procedures ordered by their provider.

One method that is used is called a prior authorization. This means that the doctor’s office has to submit evidence to the insurance company to “prove” that a patient qualifies for a specific drug, test, or procedure. They often require step therapy meaning that the insurance company will require patients to try older medications prior to trying ones that are newer (and more expensive for insurance companies). For example, many insurance companies require that a patient try and “fail” (medication ineffective, side effects, or contraindications) medications from the triptan class before being able to qualify for Nurtec or Ubrelvy.

A “workaround” set up by pharmaceutical companies is something called a Bridge program. This is a partnership between pharmaceutical companies and specific pharmacies to provide a new to market medication to patients in an efficient manner at low or no copay. This allows the patient to receive the medication before the prior authorization process is completed. It also allows time for providers to meet step therapy requirements. For example, our office sends Nurtec to ASPN pharmacy which participates in the Bridge program and will then ship the medication to the patient’s home.

For more information about medical insurance issues call the office to speak with our registered nurse Olivia or ask your healthcare provider.

By: Brooke Steiger, NP


High Altitude Headache commonly occurs when climbing altitudes greater than 2,5000 meters.
In general this headache type tends to affect females more than males. Additionally younger people are more susceptible, possibly due to lack of brain atrophy,
Typical semiology described as dull/achy – pressure like sensations, localized in bifrontal or frontotemporal location. Usually, mild – moderate in severity. Occasionally associated with dizziness – but not frequently.
Onset usually occurs within 24hrs of ascent and resolved within 8 hours of descent. They can be aggravated by movement, exertion, straining, bending, or coughing.
Typically responsive to NSAIDs or Tylenol.
These headaches appear to be independent of individual headache history – although patients who suffer from primary headache disorders like migraine may experience more severe attacks.

By: Jordan Shankle, PA


Stress Management and Migraine prevention

For many individuals, stress can be a significant trigger for a migraine attack.
Unfortunately, stress can also prolong migraines as well.

The mechanism behind this involves certain hormones that are released during stress which cause the blood vessels in the brain to constrict and dilate.

Stress can be managed in a variety of ways. Therapeutic counseling by a certified counselor is an evidence-based method of addressing stress. Cognitive behavioral therapy is a method used to help change unhealthy thought patterns and learn better ways of coping.

Mindfulness is a practice of being aware of thoughts and feelings.

Another technique is relaxation practices which may include visualization, progressive muscle relaxation, and deep breathing to help diffuse stress in the body.

Exercise is another means of releasing stress in the body that is good for mental and physical health. This may include more vigorous exercise like HIIT (high intensity interval training) and light exercise like walking.

For more information about stress management, consult with our Psychiatric Nurse Practitioner Roxanne Singer-Gheorgiu.

By Brooke Seoger, NP

Tarsal Tunnel Syndrome

Nerve roots emerge from the spinal column from the second lumbar vertebrae to the fourth sacral vertebrae — passing through the neural foramina and joining to form the complex known as lumbosacral plexus.

The largest nerve that emerges from the lumbar plexus is the femoral nerve, which descends and divides into smaller branches.
Tarsal tunnel syndrome refers to tibial nerve compression in the region of the ankles as it passes under the transverse tarsal ligament. Often compared to carpal tunnel syndrome in the wrist.

The most common cause of TTS ( Tarsal Tunnel Syndrome) is fracture of dislocation involving the bones of the ankle joint. Other etiologies include rheumatoid arthritis, infectious disorders or idiopathic inflammatory responses ie diabetic neuropathy.
Patients with tarsal tunnel syndrome may experience pain in soles of feet and toes, which radiates to the heel area. This pain is often described as achy, burning sensations. Accompanied by numbness and tingling sensations. The pain is often worse at night or after prolonged standing.

The Manhattan Center for Headache and Neurology has exceptional providers to help diagnose and potentially treat this syndrome.

By: Jordan Shankle, PA


Hypnic headaches are a rare headache-type that occur at night, during sleep. They are recurrent, causing the individual to awaken from sleep, and typically last from 15 minutes to 4 hours per episode.

These headaches are more common in older people with about 90% occurring for the first time after the age of 50.

The causes of hypnic headaches are not fully understood but theories include dysregulation of melatonin and issues with a structure within the brain called the hypothalamus.

Other symptoms that may accompany the headaches include runny nose, drooping of the eyelids, and tearing of eyes.

If you think you might have hypnic headaches, talk to your Health care provider about treatment options.

By: Brooke Steiger, NP


The calcitonin gene-related peptide (CGRP) is an amino acid neurotransmitter released by trigeminal ganglia nerves and is a potent vasodilator of cerebral vessels. CGRP plays a role in pain transmission from intracranial vessels to the central nervous system and affects vasodilation and neurogenic inflammation. Studies establish that CGRP release is part of the mechanism of migraine headaches. The FDA approved the monoclonal antibody CGRP antagonists erenumab, fremanezumab, and galcanezumab in 2018, eptinezumab in 2020, and rimegepant and atogepant in 2021 for migraine prevention. The FDA approved ubrogepant in 2019 and rimegepant in 2020 for treatment of acute migraine in adults. Please make an appointment with a MCHN provider to discuss whether these effective CGRP migraine preventative and abortive medications are appropriate for your pain.  

–Alice Wong, NP 



Low pressure headaches typically result from leakage of cerebrospinal fluid – often from the thoracic spine or lower cervical spine and is commonly attributed to minor trauma. Headaches tend to be positional, on both sides of the head and predominantly in the occipital region.

Associated symptoms included dizziness, visual disturbances and sometimes changes in hearing. Visual symptoms have been attributed to traction of the optic nerve which is in the back of a person’s head. The great majority of patients improve spontaneously, although it can take up to months.
Diagnosis of these types of headaches can be made with evidence of low csf pressure seen on brain MRIs. Additionally, evidence of fluid leakage can be seen on other diagnostic testing ie ( CT myelography).

Proposed treatment options include rest, analgesics, caffeine, steroids, and hydration. In severe cases epidural saline infusions and/or a blood patch can be done.

By: Jordan Shankle, PA