Cognitive behavior therapy, or CBT, is a form of therapeutic counseling used to reframe situations and, in turn, help change patterns in thought and behavior.

It is used for a variety of conditions and issues including anxiety disorders, depression, eating disorder, substance use disorders, and relationship problems. Specific CBT strategies have even been found to be helpful in chronic headache and migraine.

It has been demonstrated in studies to be as effective or more effective than other forms of psychological therapy or psychiatric medications. The focus of the sessions is on what is currently going on in the person’s life and making plans or strategies for more desirable outcomes. Additionally, coping mechanisms and problem-solving skills are usually a focus of the therapy.

If you feel this therapy may be helpful for you, make an appointment for an evaluation with our new psychiatric NP Roxanne Singer Gheorghiu to discuss.

By: Brooke Steiger, FNP


A visual hallucination is a perception of an external visual stimulus where none exists. Furthermore, a visual illusion is a distortion or modification of real external visual stimuli Examples of visual illusions include distortions of sizes, shape, and color. Visual hallucinations and illusions are clinically distinct phenomena, but have overlapping etiologies.
Simple hallucinations are also referred to as “elementary” or “non-formed.” They do not include complex imagery. Examples include lights, colors, lines, shapes, or geometric designs.
Migrainous visual hallucinations are usually simple and typically linear or geometric (ex, zig-zag lines) in appearance. The classic visual aura is the fortification spectra, which is considered pathognomonic for migraine. A scintillating scotoma is another common migraine aura; this is an area of decreased vision that is outlined by a hallucination with geometric design. Patients also describe seeing spots, dots, or shooting stars. Migraine auras tend to be black and white or monochromatic, and are more geometric and linear in shape compared with epileptic visual hallucinations, which are more often colorful and circular or spherical in appearance
Common associated symptoms include headache and other features of migraine nausea, vomiting, photophobia, and phonophobia
Migraine visual aura may occur independently of headache (sometimes called migraine equivalent or acephalgic migraine) and may be confused with ischemia.
Visual hallucinations are a clinical manifestation of neuroophthalmologic dysfunction resulting from a wide variety of underlying etiologies. They can be very disconcerting to some patients, regardless of their insight, and can significantly decrease quality of life.
Jordan Shankle, PA

Sleep Disturbances

In these troubling times, many people are having difficulty sleeping at night. Sometimes, due to passing worries, some people experience difficulty sleeping. This type of sleep disturbance is temporary, lasting a few days to weeks. If you are having difficulty falling asleep or staying asleep for more than a few weeks you may suffer from a more concerning sleep issue.

Symptoms that may indicate an underlying condition include waking up gasping for breath, being observed appearing to choke in your sleep, snoring, and waking up with headaches.

Luckily, with new technology, you may be evaluated in the comfort of your own bed with a device which monitors and records your heart rate and breathing for one night. The streamlined device includes a strap around your chest and a device that attaches to your finger. The recording is then sent to a physician sleep specialist to interpret the results. If any abnormalities are found, recommendations or referrals will be made to help you correct or improve your sleep.

For more information regarding sleep irregularities and testing, talk to your provider.

By: Brooke Steiger, FNP


A headache diary is one of the most important tools that will help you and your provider obtain a better understanding of your headaches and identify the best treatment for you. It can be difficult to remember certain details of your headaches and the treatments you are trialing, thus having a diary is the one of the best ways to recall this information.
Your headache diary should include certain information such as the frequency, duration, severity and characteristics of the headache. There are many different types of headaches varying from cluster headache to migraine, documenting these aspects of your headache can help your provider identify the type of headache you are experiencing. Also, depending on the person and the type of headache, certain associated headache symptoms can be very debilitating. Identifying some of your most bothersome associated symptoms can result in additional specific treatments, such as anti-nausea medication for nausea associated with migraine. A headache diary should also include the different treatments you have been trialing, your response and any side effects. Keep in mind some medications may be more effective than others and keeping a diary is a great way to assess this and recall this information.
A headache diary can also be used to help identify your headache triggers. For example, headaches can be triggered by things such as weather changes, stress, hormones and dietary changes. May people have triggers that are unique to them, knowing what exacerbates your headaches can improve treatment and allow treatment to be individualized.
One of the most important reasons to track migraines is to assess their frequency. Someone who experiences migraines might downplay how often they occur without realizing it, which is why a written record is critical. The frequency of your headaches can drastically affect your treatment plan. More than eight headaches a month usually calls for a preventive medication.
There are many different methods of tracking your headaches. Many people use apps such as Migraine Buddy, iHeadache, and Migraine Diary. You can also use excel or a written calendar. Finding the most convenient and helpful method for you will help you be diligent with tracking your headaches.
– Caroline Pruski, NP


Allodynia is defined as the experience of ordinarily non painful stimuli as painful. It is a common symptom associated with Migraine; However, most patients are unsure of how to describe or even explain this specific symptom. Patients with allodynia often report increased skin sensitivity during hot showers and experience pain to very light touch for example placing their head on a pillow, brushing their hair, wearing earrings or even wearing certain hairstyles.
Allodynia occurs in up to two-thirds of people diagnosed with Migraines. The prevalence of cutaneous ( skin) allodynia is approximately 65%, although some estimate it to be even higher. It is more common in Migraineurs who experience frequent headache days per month (>15) and can be associated with increase morbidity.
This symptom usually occurs one to two hours prior to a migraine attack and can be a predictor of headache severity and progression. Individuals who are diagnosed with episodic migraine and experience allodynia commonly transition to chronic migraine patients.
Allodynia is a part of Migraine attacks and can be improved or even prevented. It is imperative to understand this symptom and speak with your healthcare provider about early intervention which include pharmacologic and non-pharmacologic therapies. Patients should monitor headache frequency, use trigger identification and implement early treatment strategies to optimize care and minimize symptoms. If you or anyone you know have experience similar symptoms, please contact The Manhattan Center for Headache and Neurology for further evaluation and treatment options.

By: Jordan Shankle, PA

The Difference Between Headache and Migraine

Over 37 million people in the United States suffer from migraines, but fewer than 5%  of those affected have been accurately diagnosed and received appropriate care. Before you assume your pain is just a headache, learn the differences between headache and migraine. Knowing the differences between the two diagnoses is the first step towards receiving appropriate treatment for greater relief.
A tension type headache typically feels like a steady ache or discomfort in the head. The pain may be distracting, but not debilitating like most migraines. The pain from tension headaches tends to spread across both sides of the head. Migraine headache is usually described as a severe, debilitating, throbbing pain. The pain is usually unilateral or one sided. In addition to the pain you may have associated symptoms such as light-headedness, dizziness, nausea, vomiting, sensitivity to light and sensitivity to sound.
Migraine is a complex neurological phenomenon. Migraine tends to occurs in four different phases, though not everyone experiences every phase. The phases include: prodrome phase, aura phase, headache phase and postdrome phase. Prodrome phase, sometimes called the pre-headache phase, features painless symptoms that occur hours or days before the migraine arrives. These include mood swings, food cravings and stiffness of the neck. During the aura phase, sensory disturbances can occur before or during a migraine. Auras can affect a person’s vision, touch or speech, though not everyone who suffers from migraines experiences auras. Examples of auras include blurred visions, blind spots that expand over time, numbness in the arm, and slurred or jumbled speech. In the headache phase the pain usually hits, and it may range from mild to debilitating. Physical activity and exposure to light, sound and smells may worsen the pain. The postdrome phase or the final phase is when the pain has subsided. People may feel exhausted, confused or generally unwell during this phase.

By: Caroline Pruski, NP


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