Bell’s palsy, also referred to as idiopathic facial nerve palsy or facial nerve palsy of suspected viral etiology, is the most common cause of acute spontaneous peripheral facial paralysis.
Patients with Bell’s palsy typically present with the sudden onset (usually over hours) of unilateral facial paralysis. Common findings include the eyebrow sagging, inability to close the eye, disappearance of the nasolabial fold, and drooping at the affected corner of the mouth, which is drawn to the unaffected side.
Decreased tearing, hyperacusis, and/or loss of taste sensation on the anterior two-thirds of the tongue may help to site the lesion in the fallopian canal, but these findings are of little practical use other than as indicators of severity.
The diagnosis of Bell’s palsy is based upon the following criteria:
1. There is a diffuse facial nerve involvement manifested by paralysis of the facial muscles, with or without loss of taste on the anterior two-thirds of the tongue or altered secretion of the lacrimal and salivary glands.
2. Onset is acute, over a day or two; the course is progressive, reaching maximal clinical weakness/paralysis within three weeks or less from the first day of visible weakness; and recovery or some degree of function is present within six months.
The Manhattan Center for Headache and Neurology has competent providers to further evaluate and facilitate acute and extended management.

Jordan Shankle, PA

Managing Associated Nausea From Migraine

As many as 20% to 50% of migraineurs have associated nausea or vomiting with their migraine episodes. Nausea is often reported as one of the most distressing aspects of having a migraine. There are many ways to help manage your nausea ranging from simple at home techniques, natural supplements, over the counter medications and prescription medications.
The following suggestions are some simple things you can do at home that may make the nausea more manageable. Doing things such as loosening your clothes (especially around your stomach) or taking deep slow breaths may provide some relief. Applying an ice pack to your head or neck, opening a window or stepping outside to get fresh air can help with feeling nauseous. When nauseous it is good to avoid foods with strong tastes and odors. When attempting to eat, start with small amounts of food and make sure the food is bland. Staying hydrated is also important, try small sips of water, tea, ginger ale or clear broth.
Alternative therapies can also be beneficial for migraine symptoms, specifically the associated nausea. Ginger is a great natural option used in the treatment of nausea. Ginger can be consumed in many different forms such as raw slices directly from ginger root, ginger candy, ginger tea, ginger ale. Acupressure is a method of Chinese medicine and another beneficial alternative therapy for migraine associated nausea. Stimulation of acupressure point PC6, which is located on the forearm, can decrease nausea associated with migraines. You can manually massage this area or purchase items such as wristbands that stimulate this area. Additionally, alternative therapies such as aromatherapy can be helpful with nausea. Inhaling concentrated essential oils like lavender or eucalyptus may provide symptom relief.
There are also many over-the-counter therapies that are effective for nausea. Medications commonly used for the treatment of motion sickness, such as Dramamine (dimenhydrinate), Bonine (meclizine), and Benadryl (diphenhydramine) often help with nausea. Over-the-counter treatments typically used for gastrointestinal issues such as Pepto-Bismol (bismuth subsalicylate) may also be helpful but are less effective than treatments for motion sickness.
If you have severe nausea with your migraines, your provider may suggest a prescription anti-nausea medication. Effective options include Zofran (ondansetron) and Reglan (metoclopramide). These medications are available in different formulations that may be more tolerable if nauseous, such as dissolvable pills, suppositories, and injections. Treating the actual migraine may also help with the nausea. Keep in mind that prescriptions medications for your migraine also come in more tolerable formulations. They are often available in inhalable, injectable, suppositories, or dissolving forms which can be more tolerable for you if you are severely nauseated.
– Caroline Pruski, NP


Alcohol is a fairly common reported trigger for migraines. Because each individual is unique it may not cause migraines in some people. Compared to the general public, people with a history of migraines consume less alcohol.

Alcohol has been known to cause headaches within a few hours of ingesting or more delayed, such as the next day “hangover” headache. Known as the delayed alcohol-induced headache, it’s onset usually occurs within 12 -24 hours of alcohol ingestion. The migraine may be provoked by small quantities of alcohol.

Current research supporting the link between alcohol and migraines is weak. However, one study found an increase in the number of migraines in study participants with reported sensitivity to red wine when given red wine versus vodka. Other studies in Italy and France have found that ingestion of white wine is associated with migraines. It is theorized that alcohol sets off a cascade causing dilation of blood vessels or changes in the level of a neurotransmitter called serotonin leading to headache.

It has been theorized that other components of alcohol tyramine, phenylethylamine, histamine, sulfites, flavonoid phenols may be triggers. Specifically, histamine which is present in wine as well as foods such as fish, aged cheese, aged meats such as salami or sausage, and some vegetables. Additionally, histamine release in the body may be triggered by these foods and alcoholic beverages however compounds called sulfites. Another component called sulfites which is found in wine as well as soy sauce, pickles, raisins, and other dried fruit may trigger migraines. A substance called tyramine which is found in aged cheese and most meats and fermented foods has been the most widely studied of the alcohol-related components although results of the studies has shown no correlation. In fact, it has been found that the amount found in food far surpasses the amount found in wine or alcohol.

Additionally, the byproducts of alcohol fermentation or congeners such as phenols and tannins, which give alcohol and wine unique flavor profile have often been associated with migraine, however, scientific research does not support this. Generally, the darker the alcoholic spirit, the higher the amount of congeners. It is often reported that darker spirits such as whisky trigger migraines more frequently than lighter ones, but the research is limited.

It is likely that the migraine may be caused or triggered by multiple factors. To help manage your alcohol-induced migraines, it may be helpful to keep a headache diary and note specific alcohol consumption including type and quantity of alcohol, foods eaten, and other factors (including increased stress levels and weather).

The best advice regarding alcohol in people with migraines applies to everyone- it is best to drink in moderation.

If you feel you have a drinking problem, call the Substance Abuse and Mental Health Services Administration 24/7 hotline for a free and confidential referral for help at 1-800-662-4357.

By Brooke Steiger, NP


Trigeminal neuralgia(TN) is characterized episodic unilateral (one – sided) shock-like/ stabbing pain abrupt in onset and termination, in the distribution of one or more divisions of the fifth cranial (trigeminal) nerve that typically are triggered by stimuli. . It usually lasts from one to several seconds, but may occur repetitively, anywhere from 0 to more than 50 times a day. A refractory period of several minutes during which a paroxysm cannot be provoked is common.
The trigeminal nerve is the sensory supply to the face and the sensory and motor supply to the muscles of mastication. It has three major divisions. Compression of the trigeminal nerve root is the main mechanism of TN.
Nearly all patients with TN experience triggered. Trigger zones in the distribution of the affected nerve are common and are often located near the midline. Lightly touching these zones often triggers an attack, leading patients to protect these areas. Other triggers of TN paroxysms include chewing, talking, brushing teeth, cold air, smiling, and/or grimacing. Autonomic symptoms, usually mild or moderate, can occur in association with attacks of TN including excessive tearing, conjunctival injection, and nasal drainage.
The course of TN is variable. Episodes may last weeks or months, followed by pain-free intervals of weeks to years, although most remissions last for only a few months.
For more information regarding TN and treatment options please speak with your provider.

By: Jordan Shankle, PA


The use of technological devices is almost unavoidable since they play such a significant role in our everyday lives. People start off their day by checking the weather or their emails on their phones. During the work day people are constantly in front of their computer, now even all in-person meetings are now on zoom due to COVID. Exercise after work can at times include staring at another screen, such as the screen for the peloton bike or a phone screen for certain workout apps. Then back to the phone to order food or look up a recipe for dinner. Finally, the end of the day consists of more screen time by either checking social media or watching a show on television.
Eye strain occurs when your eyes become fatigued after using them intensely for extended periods of time. It takes approximately two hours of staring at a screen for eye strain to set in. Eye strain can be uncomfortable and can lead to symptoms such as blurred vision, burning eyes, itching eyes, light sensitivity, sore and tired eyes. Eye strain can also lead to headaches which can additionally reduce your ability to concentrate. Also, due to our posture while using our technological devices neck, shoulder and upper back pain is common. In addition, excess screen time can negatively affect our sleep and mood.
One study displayed that 64%-90% of computer users reported either eyestrain, dry eye or headaches. According to another study from the Headache Research Foundation in Boston, screen exposure triggered significantly more head pain for people with chronic headache. They concluded that eye strain factors are “far more important than is generally recognized” for people with chronic head pain. Additionally, the American Optometric Association defines Computer Vision Syndrome (CVS) as a group of vision-related issues that come from long-term use of devices. Common symptoms of CVS include eyestrain, blurred vision, neck and shoulder pain and headaches.
Tips for Screen Use:
· Take a break from your devices. For example, follow the 20-20-20 rule developed by The American Optometric Society. During screen time sessions take a break every 20 minutes for 20 seconds to look at an object or person that’s 20 feet away.
· Adjust the lighting in the room to prevent glare. When using screens, darken the room (either by closing the blinds, or dimming the lighting) so your screen has less light to reflect.
· Consider an anti-glare cover.
· Invest in a proper ergonomic workspace.
· Use eye drops such as artificial tears, which can be found over the counter. These can help prevent dry eyes that can lead to eye strain.
· Use lenses that filter out blue light or are designed to help prevent eye strain.
· Trial apps such as “f.lux” that alter the computer screen to mimic the time of day.
· Avoid screen time two hours before bed.
· Print certain things out.
· Invest in a larger screen to help make certain documents easier to read.

By: Caroline Pruski, NP



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