It’s the time of year for drinking green beer

St. Patty’s Day is officially here

But headaches await, if you read this too late

So look through these hints and face the day with no fear!

Many migraineurs already know that alcohol can trigger a headache.  Migraine sufferers are less likely to drink alcohol, studies have shown.  For some people, wine is the main culprit, but other forms of alcohol can trigger, including beer and liquor.  In fact, some studies suggest that alcohol in these other forms is just as often or more often a trigger. Several studies have looked at various ingredients in wine that may be acting as triggers, including tannins, tyramines, histamines and sulfites, but none of these has consistently panned out.

There are 2 main types of migraine triggered by alcohol, acute migraine occurs within 2-3 hours of drinking alcohol, and a second delayed type, which occurs the next day.  Often referred to as a hangover, the delayed type headache is usually much worse in a migraine sufferer than a non-migraine sufferer.

When people drink alcohol, they may get dehydrated, which can possibly lower the threshold for a headache, and if you drink alcohol and skip dinner or eat unhealthier foods while out at that party, these dietary issues may also be the culprit.  

It is likely that a combination of factors surrounding alcohol intake contribute to headaches.  So, before you partake, read through these tips.

  1. Drink plenty of water in between alcoholic beverages
  2. Limit your drinking to 1 or 2 drinks
  3. Eat with your beverage, something healthy
  4. Avoid sugary, and sugary drinks
  5. Before you go out, have a snack, so you don’t go too long without eating
  6. get a good night’s sleep

You should talk to your doctor about how drinking alcohol might affect you, and your headaches.  Review with your doc what treatments are available to you to remedy this type of headache. If dehydrated and nauseous, sometimes IV treatments can help a lot, too.\

By:  Audrey Halpern, MD, BC in Headache Medicine

What Is Neurostimulation For Migraines?

It may sound counter-intuitive… why would I want to stimulate my nervous system if I am having a migraine or suffer from migraines?  Well, headache specialists are not crazy. Stimulation of the nerve can actually cause the brain to settle down, and remain calm.

The migraine brain is a very sensitive brain, and we look for ways to help the brain to stay calm and be less sensitive.  Neurostimulators may actually “stimulate” the areas of your brain that send the calming messages to the rest of the brain or nerves.

There are many different neurostimulators either on the market or currently being researched.  There are devices to stimulate the supraorbital nerve (sits right at your eyebrow), the occipital nerve (back of the head), the SPG or sphenopalatine ganglion (right behind your nose/cheek), and even the vagus nerve in the neck.

Some of the neurostimulators are just applied to the skin and used to get rid of a headache, and others are surgically implanted devices for more intractable and chronic headache disorders.  These devices can be used alone or in combination with other treatments to relieve headaches of various sorts.

By: Audrey Halpern, MD, BC


What is Emgality?

A new kind of drug

Emgality belongs to a new class of drugs called calcitonin gene-related peptide (CGRP) antagonists. CGRP antagonists were designed specifically to prevent migraines. Emgality is a brand-name prescription medication that’s used to prevent migraines in adults. It comes as a prefilled pen or syringe that you use to give yourself a monthly injection.

Emgality can be used to prevent both chronic and episodic migraines. In clinical studies of people with chronic migraines, 28 percent of people who took Emgality for 3 months cut in half their number of migraine days per month. In clinical studies of people with episodic migraines, about 60 percent of people who took Emgality for 6 months cut in half their number of migraine days per month.

Emgality may be an especially effective option for people who’ve been unable to reduce their number of migraine days enough with other therapies. It may also be a good option for people who can’t take other medications to prevent migraines because of drug interactions or difficult side effects.

Side Effects  The most common side effects of Emgality are injection site reactions. This can include the following effects at the site where you inject the drug






Long-term side effects: Emgality is a recently approved medication in a new class of drugs. As a result, there’s very little long-term research on Emgality’s safety. The longest clinical study of Emgality lasted one year, and people in the study did not report any serious side effects caused by Emgality.

Injection site reaction was the most common side effect reported in the year-long study. Other side effects reported included:

respiratory tract infection

back pain

sore throat

sinus infection

Call The Manhattan Center For Headache & Neurology to find out if you are a candidate for Emgality. Learn about the Emgality copay card!

By: Rajni Bala, NP



GammaCore: Device for Headache Treatment


The vagus nerve stimulation device was first approved by the FDA in April 2017 for the acute treatment of episodic cluster headaches.  January 2018, announcement of the new Migraine treatment marks gammaCore’s first approval for Migraine.

  •         gammaCore® (nVNS) is a non-invasive, hand-held medical device that treats the acute pain of a cluster headache attack or a Migraine attack by stimulating the vagus nerve.
  •         The device is held to the neck and mild electrical currents pass through the skin to stimulate the fibers of the vagus nerve, a large nerve system that connects the gut to the brain . gammaCore passed the test in clinical studies as a new Migraine treatment, showing a significant reduction in acute Migraine or cluster headache pain after use of the device.

·         gammaCore is the third neuromodulation device approved by the FDA for acute Migraine treatment. Cefaly ACUTE was approved for acute use in September 2017.  Meanwhile, eNeura’s TMS unit was approved for acute use in December 2013. While each device operates differently, they all offer patients the option of aborting a migraine attack without drugs, and minimal side effects.

Call The Manhattan Center For Headache & Neurology to find out more about this device! We look forward to seeing you!

By: Rajni Bala, NP

Primary Headache Associated with Sexual Activity

This headache disorder is rare. It is previously known as pre-orgasmic (appears during sex and increases during mounting excitement) or orgasmic headache (sudden explosive headache followed by severe throbbing immediately before at the point of orgasm). It is considered a primary headache because there is no other underlying cause.

This headache is usually bilateral and often located to occipital areas. Severe headache due to sexual activity can lasts anywhere from 1 minute to 24 hours. Milder headache can last up to 3 days. This headache may have migrainous features and should be differentiated from a migraine triggered by sexual activity. Can occur in anyone who is sexually activity regardless of age. More common among men than women.

People with new onset headache associated with sexual activity or if never evaluated for this headache should consider seeing a doctor to r/o underlying causes. Imaging studies may be ordered to rule out serious conditions such as subarachnoid hemorrhage, arterial dissection and reversible cerebral vasoconstriction syndrome.

Medications are available for headache associated with sexual activity, and should usually be prescribed after all imaging studies are completed.

American Migraine Foundation (2019)

Tanesha Reynolds, DNP, FNP-BC, Certified in Headache Medicine


Cluster Headaches

The term cluster headache comes from the recurrence of headache attacks usually in a series (cluster periods) lasting for weeks or months, separated by remission periods (periods of headache freedom) usually lasting months or years.

Cluster headaches are often said to be the most painful of all headaches. They have been described as “boring,” “bearing,” “burning,” “like a hot poker in the eye,” and as “suicide headaches.” The age of onset of cluster headache is most often between 20 and 40, and they are more common in men than women at a ratio of 3:1.

Cluster headache is a primary headache disorder that consists of severe headaches on one side of the head associated with :

  • red or teary eyes,
  • runny or stuffy nose,
  • flushing or sweating of the face or a sense of restlessness and agitation.

Cluster headache is classified as a trigeminal autonomic cephalalgia or TAC:

Trigeminal refers to cranial nerve 5, which is the nerve that controls sensation of the face. For this reason, the pain associated with cluster headache often localizes to the face particularly around and behind the eye.

Autonomic refers to symptoms like red or teary eye, runny or stuffy nose, sweating or flushing of the face, drooping of the eyelid, or sense of fullness in the ear. In cluster headache, these symptoms occur on the same side as the pain.

Symptoms of Cluster Headache

Cluster headaches are attacks of severe pain lasting 15-180 minutes and occurring from once every other day up to eight times in one day—averaging 2 per day over typically 4-6 weeks then entirely disappearing for 6-12 months.

  • Severe Pain
  • Unilateral (on one side of the head)
  • Orbital (near the orbit, the bone framing the eye), supraorbital (above the orbit), temporal (at the temple) or a combination of those sites and sometimes more towards the back of the head

These attacks also include one or more cranial autonomic symptoms on the same side as the pain (ipsilaterally):

  • Red eye (conjunctival injection)
  • Eyelid swelling (edema)
  • Forehead and facial sweating
  • Tearing (lacrimation)

Abnormal small size of the pupil (miosis)

Nasal congestion

Runny nose (rhinorrhea)

Drooping eyelid (ptosis)


There are no diagnostic tests to confirm cluster headache. Diagnosis is accomplished by reviewing personal and family medical history, considering associated symptoms, and an examination. .

Acute treatment

The most commonly used therapies to shorten or abort a cluster attack are:

  • High-flow 100% oxygen (O2) by mask
  • Sumatriptan nasal spray or in the skin (subcutaneous) injection
  • DHE-45 nasal spray or injection
  • Zolmitriptan nasal spray

Referance: www.americanmigrainefoundation.org

By: Rajni Bala, NP

High Altitude Headache (HAH)

A headache is the most common symptom that one experiences usually over 3000 meters above sea level. Other common complaints are loss of appetite, nausea and sleep disturbances.

A high altitude headache must have at least 2 of the following characteristics:

  1. Pain on both sides of the head
  2. Located to the frontal or frontotemporal area
  3. Dull or pressure-like quality
  4. Mild or moderate intensity
  5. Aggravated by exertion, movement, straining, coughing, or bending

The headache must develop within 24 hours after ascent and resolves within eight hours of descent.


A HAH can be prevented by a slower ascent, usually 300 meters per day, allowing 2 days to become acclimated before engaging in strenuous exercise at high altitudes, avoiding alcohol, and increasing hydration.


Over the counter medications such as paracetamol or ibuprofen have proven to be effective in treating HAH. Triptans are also effective.

Acetazolamide may reduce susceptibility to acute high altitude sickness.

Tanesha Reynolds, DNP, FNP-BC, Certified in Headache Medicine

If you are experiencing a HAH that has not gone away, please schedule an appointment to see one of our providers at MCHN.

Cyclical Vomiting Syndrome (CVS) and Migraine

Cyclical vomiting syndrome is accepted as a migraine syndrome from childhood by the International Headache Society. The criteria for diagnosis according to The Migraine Trust (2019) is:


  • A. At least five attacks overall fulfilling criteria B and C;
  • B. Episodic attacks, stereotypical in the individual patient, of intense nausea and vomiting, lasting one hour to five days;
  • C. Vomiting during attacks occurs at least four times per hour for at least one hour;
  • D. Symptom-free between attacks;
  • E. Not attributed to another disorder.
  • History and physical examination do not show signs of gastrointestinal disease.

Migraine medications can sometimes help stop or even prevent cyclic vomiting episodes. These meds may be recommended for patients with frequent and long lasting symptoms and even patients with family history of migraines. Treatment usually focuses on controlling the signs and symptoms. Prescriptions may include: anti-nausea medications, pain-relieving medications, anti-reflux medications, antidepressants and anti-seizure medications. IV fluids are often necessary to prevent dehydration. Treatment is individualized based on severity, duration or presence of complications.

If you are experiencing CVS with no evidence of gastrointestinal disease, you may be having migraines, which require treatment by a headache specialist. At MCHN, we provide IV hydration and medications to treat CVS.

Tanesha Reynolds, DNP, FNP-BC, Certified in Headache Medicine