Brain Fog is a symptom of COVID-19 and migraine? What do COVID-19 ‘long haulers’ and migraineurs have in common?

In the news recently have been a number of articles about the potential long term effects of COVID-19, one of which is ‘brain fog’. This is now a well- recognized potential symptom of coronavirus infection, but what it really is, is unclear. Brain fog is something we have been very familiar with as neurologists, for many years. It is not uncommon in association with migraine, as well as other neurological conditions such as concussion. But what is it?

People with brain fog describe feeling like their brain is “slow”, not performing like usual. Not 100%. Difficulty with concentration, attention and memory are common complaints, but all in all, the feeling tends to be non-specific.

The mechanism of brain fog in migraine is unclear, but may be due to impaired metabolic performance of the brain during an acute migraine, or even between migraines in someone suffering from frequent or prolonged migraine. But..there is clearly inflammation in the brain, blood vessels and meninges associated with migraine. Now with the understanding that COVID-19 causes inflammation in the vessels, scientists have hypothesized that this is potentially leading to brain fog. Could inflammation in the blood vessels, meninges and brain be the common underlying cause of brain fog? More research needs to be done to further characterize brain fog and its causes.

In people with symptoms such as brain fog and a history of migraines, head injuries or COVID-19 infection, workup may need to be done including testing such as MRI of the brain or EEG, monitoring of the symptoms may be important, and treatment may be available for these conditions.

By: Audrey Halpern, MD


Nerivio is a prescription-only device, when applied to the arm, emits mild electrical stimulation to help provide relief from a migraine attack. The device is controlled using a smartphone app, which also collects data on its use since it came to market about 1 year ago.
Recently, the manufacturer Theranica, has released data from the first 6 months of use in the US market. The data showed encouraging results including that 59% of patients (662 of 1123) seen by headache specialists and 74% (23 of 31) of patients seen by other providers reported pain relief at 2 hours for at least half of their treated migraines. Additionally, the data showed complete pain freedom 2 hours after application in at least half of treated migraine attacks in 20% of the patients treated by headache specialists and 36% of the patients treated by non-headache specialists.
These “real-life” results give us more information regarding the effectiveness of this device. It may be a good option for many patients including those already taking other medications and can be used in combination with other abortive medications. However, it is important for the device to be set up and used correctly in order to achieve maximum therapeutic benefit.
If you are interested in trying Nerivio as an acute treatment call The Manhattan Center for Headache & Neurology. We look forward to treating you!

Brooke Steiger, NP


Traumatic brain injury or TBI occurs as a result of direct trauma to the brain or acceleration/ deceleration forces. It is a common and typically benign diagnosis. However, TBI can have serious short and long term effects. The pathophysiology of TBI includes primary and secondary brain injury. The main causes of these injuries are falls, motor vehicle accidents, recreational/occupational accidents, violence, combat injuries or blast explosives. It is frequently used as an analogy to concussion which is a milder subset of head injuries.
TBI encompasses a broad range of pathologic injury to the brain. Within the first thirty minutes of a brain injury leading to TBI multiple things can occur which include a central nervous symptom inflammatory response, brain ischemia, vascular injury or occlusion, cerebral edema, herniation or brain death. These causes can manifest as multiple neurologic symptoms.
Traumatic Brain Injury is classified using the Glasgow Coma scale which is a scoring system to describe a patient’s level of consciousness and help gauge the severity and prognosis of acute brain injury. This universal rating tool classifies TBI as mild, moderate or severe.
Repetitive brain injury can be associated with a constellation of symptoms due to structural and biochemical changes. Post concussion syndrome commonly occurs after mild TBI. This syndrome usually develops within a few days with resolution taking up to weeks to months.
Signs and symptoms include dizziness, amnesia, neuropsychiatric symptoms, and cognitive impairment.
In addition, Post Traumatic Headache occurs in up to 27-78% of patients after mild TBI. According to The International Headache Society ( HIS) criteria, Post Traumatic Headache usually occurs 7 days after the traumatic event. Symptoms and characteristics of this headache may have a similar pattern to non traumatic headache syndromes like Migraine or Tension type Headache.
Other Neurologic disturbances related to TBI include Cranial Nerve Syndrome ie Facial Nerve Palsy, Vestibular Migraine, Trigeminal Neuralgia, Post Traumatic Epilepsy, Chronic Traumatic Encephalopathy, Sleep Wake Disturbances, sustained neck pain and subarachnoid hemorrhage.
Patients with TBI are complex and require a multidisciplinary approach. If you have had a recent head injury or have a history of repetitive head trauma and are experiencing neurological symptoms, The Manhattan Center for Headache and Neurology has competent providers to further evaluate and facilitate acute and extended management.
Jordan Shankle, PA

Is there concern for Serotonin Syndrome when taking Triptans and SSRIs/SNRIs?

Serotonin is a chemical your body produces that is involved in many biological functions. Serotonin helps regulate your attention, behavior, body temperature, digestive system, blood flow, breathing and much more. Excessive accumulation of serotonin in your body can lead to serotonin syndrome. The most common symptoms of serotonin syndrome include skin flushing, diarrhea, rapid heart rate, elevated blood pressure, confusion and headache. Certain medications increase serotonin levels but serotonin syndrome usually occurs when there are multiple medications on board and when the individual is more susceptible to this reaction.
There are medications used to treat depression and migraine that modify serotonin levels. Migraine medications that effect serotonin are known as “triptans”. Medications for depression that modify serotonin include selective serotonin reuptake inhibitors (SSRIs) and selective serotonin/norepinephrine reuptake inhibitors (SNRIs). People who have migraines and depression may be prescribed both a triptan (for acute migraine treatment) and a SSRI or SNRI (for chronic treatment of depression).
The simultaneous administration of two drugs that promote serotonin’s activity theoretically could cause “serotonin syndrome.” Due to this potential risk, the federal FDA issued a warning to be wary of the co-administration of a triptan and an SSRI or SNRI. However, this warning was based almost entirely upon a theoretical concern and not upon scientifically derived clinical evidence. Clinically significant serotonin syndrome from simultaneous use of these medications appears to be extremely rare. Additionally ,the benefit of adequate treatment for both migraine and depression appears to far outweigh the exceedingly low risk of dangerous “serotonin overload”. Nonetheless, make sure your health care provider is aware of all the medications you are taking.
– Caroline Pruski, NP

Interview with Dr. Audrey Halpern on

Dr. Audrey Halpern was interviewed in-depth by Maya De La Rosa-Cohen on on the topics of finding the right treatments for her patients and battling the gender inequality in neurology. One of Dr. Halpern’s quotes in particular that we’d like to share here is this: “The human body is a changing landscape that continuously feeds into the headache condition. To be an effective headache medicine specialist, I have to be flexible and attentive.” Click here or on the picture below to read the full interview.

Dr. Audrey Halpern interview on Medium


The Cefaly device provides a non-pharmacologic approach to preventing migraines or treating acute migraine attacks.

It is an electrode attached to a strap applied across the forehead. You can apply it during a migraine attack in which case you would leave it on for 1 hour. As a preventative treatment, it may be applied every day, usually in the evening, for 20 minutes.

The device works by stimulating the trigeminal nerve, which is linked to migraine attacks, to either decrease the frequency and severity of migraines or stop the attack.

This device is a great option for patients who prefer to avoid treatment with medication or are taking many medications for other conditions, however, the device is not covered by insurance. Many patients opt to purchase the device using their Health Savings Account.

For more information about the Cefaly, speak with your healthcare provider.

Brooke Steiger, NP


There are many migraine triggers including stress, lack of sleep and certain foods. The relationship between certain triggers and migraine isn’t clear-cut, and no single factor can be directly tied to your attacks. However, There is data that displays migraine may be triggered by certain foods and data where migraine sufferers believe that particular foods trigger their migraines. Below are some of the more common food triggers for migraines.

Excessive Coffee – Excessive caffeine consumption can trigger migraines and cutting back on things such as coffee can help reduce your migraine frequency. The best is to limit yourself to less than two cups per day.
Red Wine – Red wine contains a high amount of the chemical called histamine which is a common migraine trigger.
Aged Cheeses – Cheese contains a high amount of the chemical tyramine which is a common migraine trigger.
Chocolate – One study found that chocolate compared to placebo trigger a migraine in 42% of its subjects.
Artificial Sweeteners – Research suggest that artificial sweeteners such as aspartame commonly found in Diet Coke and other calorie-free drinks may increase the risk of migraine headaches.
Yeast – Food containing yeast such as sourdough bread, donuts, cakes, and breads. Many yeast products contain the ingredient tyramine, which is a common migraine trigger.
MSG or Monosodium Glutamate – MSG is a flavor enhancer used in a variety of processed foods. Many migraine sufferers say MSG is a trigger for them.
Processed and Cured meats – Nitrates are found in many processed and cured meats such as bacon, sausage, ham, and deli meats. Nitrates are known migraine trigger. 
Nuts and Certain Seeds – Peanuts, and many other nuts and seeds contain tyramine, which again is a migraine trigger.

To identify these triggers consider tracking your migraines along with a food diary and seeing if there is any consistency between the two. Also consider an elimination diet or doing certain food allergy testing.

Caroline Pruski, NP


A common bothersome neurological symptom is dizziness and vertigo. A person may experience a sensation of spinning that may be associated with nausea.

When dizziness occurs before, after, or during a migraine, a person may be diagnosed with vestibular migraine.

Accompanying symptoms may include sensitivity to light and noise.
Triggers for vestibular migraines may be similar to migraine triggers and may include stress, lack of exercise, bright lights, and loud noises.

There are other disorders that are more common in people with vestibular migraines including motion sickness and anxiety. DIzziness and vertigo may also be the result of other underlying disorders so diagnostic testing including bloodwork and VNG may be indicated.

If you feel you are suffering from vestibular migraines, call The Manhattan Center for Headache and Neurology and speak with one of our caring healthcare providers.

Brooke Steiger NP


People have been using art to recreate their headache and migraine symptoms. Headache and migraine symptoms can be debilitating, thus inspiring very powerful and beautiful art pieces. A campaign called “Frames of Mind” was a collaboration between Allergan and the American Migraine Foundation. The campaign was created to help bring awareness to the debilitating effects of headaches and migraines. A part of this campaign was selecting and displaying some of these migraine inspired pieces of art. Take a look at some of the pieces selected.

Caroline Pruski, NP


Cluster headaches are a form of headache that presents as stabbing pain around one eye or temple peaking within a few minutes of onset, typically lasting bout 15 minutes, often occurring the same time each day. These headaches, which are severe, and often referred to as “suicide headaches” and are short in duration, often occurring up to 8 times a day. Accompanying symptoms often include tearing, redness, swelling, or drooping of the eyelid on the affected side, or runny nose on the affected side.

They are associated with changes in the seasons, often around when you re-set your clock for daylight savings time. Experts believe that the disruption in sleep cycles due to changes in amount of sunlight from the longer or shorter days that lead to attacks. For this reason, patients may have cycles of headaches in Spring or Fall. Cluster headaches may also be mistaken for allergy-related symptoms due this timing.

Treatment for cluster headaches may involve a combination of pharmacological therapy and lifestyle changes. In particular, sticking to a strict sleep-wake schedule and avoiding alcohol may help prevent headaches or decrease severity of attacks.

If you think you are suffering from cluster headaches, call The Manhattan Center for Headache & Neurology to speak to one of our caring providers