Dangers of Nitric Oxide Toxicity

Nitrous oxide is increasingly being used as a recreational drug. Prolonged use of nitrous oxide can have disabling neurological sequelae due to functional inactivation of vitamin B12.
Patients can present with sensorimotor peripheral neuropathy with demyelinating features with no clinical or imaging evidence of myelopathy, emphasizing that not all patients develop subacute combined degeneration of the spinal cord (the typical presentation of functional vitamin B12 deficiency). Diagnosis is mostly based upon the history of nitrous oxide use. Notable abnormal lab values would be raised levels of homocysteine and/or methylmalonic acid. All patients should be treated with parenteral vitamin B12. Timely diagnosis and treatment is important to prevent long term or permanent disability.

Rosenberg H, Orkin FK, Springstead J. Abuse of nitrous oxide. Anesth Analg. 1979 Mar-Apr;58(2):104-6. PMID: 571232.

By: Andrew Chan, PA


Fertility Treatment and Migraine Frequency

Many women have noticed that their migraines may increase around their menstrual period. This is caused by fluctuation in levels of hormones.

Hormone levels that are stable lead to a reduction of headache frequency and severity. A decrease in estrogren causes migraines in about 60% of women. During fertility treatments, exogenous hormones may be introduced at levels much higher than occur naturally in the body to help create conditions more suitable for pregnancy.

Some studies suggest that, similarly, hormonal shifts caused by fertility treatments may increase headache or migraine frequency.

During the course fertility treatments, the patient may be asked by their specialist to stop migraine medications prior to implantation or after implantation. It is important to discuss your migraine medication regimen with your fertility specialist.

There are medications that may be appropriate during the course of fertility treatments. This should be discussed with your headache specialist prior to starting fertility treatments.

By: Brooke Steiger, NP

Chronic Post Traumatic Headache

Chronic Post Traumatic Headache is any headache that occurs within 7 days of an injury and persists for at least 90 days. Neurological symptoms may include cognitive impairment, irritability and poor concentration. Additionally, patients may report sleep disturbances.

These types of headaches have no typical characteristics and can be diagnosed with or without associated loss of consciousness. Patients may experience post traumatic amnesia for up to 48 hours and extreme fatigue.

Neuroimaging to include brain MRI is often performed to rule out traumatic brain lesions i.e. cerebral hematoma or intracranial hemorrhage. Brain contusions and/or fractures can be seen as well.

The Manhattan Center for Headache and Neurology has exceptional providers to help diagnose and potentially treat chronic post traumatic headache.

By: Jordan Shankle, PA

Triptans for Migraine

Triptans were developed specifically for the acute treatment of migraine. The first clinically available triptan was sumatriptan, which has been marketed since 1991. All of the triptans inhibit the release of vasoactive peptides, promote vasoconstriction, and block pain pathways in the brainstem. Triptans inhibit transmission in the trigeminal nerve, thereby blocking input to neurons; this effect is probably mediated by reducing the levels of calcitonin gene-related peptide (CGRP).  

The available triptans include sumatriptan, zolmitriptan, naratriptan, rizatriptan, almotriptan, eletriptan, and frovatriptan. Sumatriptan can be given as a subcutaneous injection, as a nasal spray, as a nasal powder, or orally. Zolmitriptan is also available for both nasal and oral use. The others are available for oral use only. The choice of a triptan should be individualized; different pharmacologic properties and delivery routes may help guide the choice. Patients who do not respond well to one triptan may respond to another. Sumatriptan offers the most options for routes of drug delivery, with subcutaneous sumatriptan offering the fastest onset of action. Naratriptan and frovatriptan have the slowest onset of action among the triptans and may have the lowest propensity to cause side effects. 

Triptans have proven to be safe and effective for most patients with migraine. As with all medications, there are concerns, risks, and contraindications. The risks and benefits should be discussed with a provider, and patients should be monitored.  

–Alice Wong, NP




Botox is often associated with beauty, but have you ever considered it for migraines? In a study of adults who get chronic migraine headaches, injections of Botox decreased the total number of headache days experienced. In another study, nearly half the participants who had two rounds of Botox injections reported that the number of headache days each month decreased by half. After five rounds of treatment, 70% of the people of the participants experienced a decrease in headache days. Botox is a neurotoxin that blocks the chemicals known as neurotransmitters that send pain signals in the brain. Think of it as a big STOP sign on a road – it stops the signals of pain from getting through to the nerves. Botox treatments are administered every 12 weeks to ensure maximum efficacy. Botox is an excellent tool in fighting migraines

The Neurologist’s Troponin?

What is Neurofilament Light Chain (NfL)? NfL is a biomarker that is found specifically in neurons. In mature myelinated axons, neurofilaments are the single most abundant protein. When there is neuro-axonal injury, NfL is released into the cerebrospinal fluid (CSF), and then into the blood. The concentration in the blood reflects the rate of neurofilament release from neurons. Testing for levels of NfL may provide valuable data in clinical trials for neurological disorders. It has the potential to help guide treatment decisions, used as a screening tool, monitor disease progression, or assess treatment response. NfL is being looked at for multiple neurological conditions, including Alzheimer’s disease, Multiple Sclerosis, Migraine, and Concussion. NfL testing was previously done testing the CSF and could only be found in highly specialized laboratories but is slowly becoming more accessible to your healthcare providers through serum/plasma testing.

Thebault, Simon, Ronald A. Booth, and Mark S. Freedman. “Blood neurofilament light chain: the neurologist’s troponin?.” Biomedicines 8.11 (2020): 523.

Yuan, A.; Rao, M.V.; Veeranna; Nixon, R.A. Neurofilaments and neurofilament proteins in health and disease. Cold Spring Harb. Perspect. Biol. 2017, 9, a018309.

By: Andrew Chan, PA

Language and Motor Aura

Approximately 23% of people with migraine experience one or more focal neurological symptoms in the second phase referred to as Aura or Migraine with Aura. Typical Auras include acute and transient visual disturbances. However, aura can be presented in multiple ways. Two less common auras associated with migraine are Language and Motor Auras.

Language Aura is characterized by transient speech difficulties. Examples are slurred speech, difficulty word finding or dysphasia / paraphrastic errors.

Another type of aura is motor which is often considered the rarest type. Patients with motor aura can experience difficulty walking, falls and or muscle weakness. These symptoms emulate stroke like symptoms – therefore it is imperative to get a proper evaluation.

Neuro imaging is needed to rule out underlying structural abnormalities. In addition, blood work and other neurologic testing may be ordered such as EEGs or Trans Doppler ultrasounds.

The Manhattan Center for Headache and Neurology has exceptional providers to help diagnose and potentially treat your migraines and aura.

By: Jordan Shankle, PA


Zavzpret (zavegepent) is a new medication for acute migraine. It is in the medication class of CGRP receptor antagonists.

Zavzpret is administered via a spray nozzle with plunger that does not require priming, for quicker administration. To administer, you spray one spray in one nostril and then discard the empty unit. One spray may be used in a 24 hour period.

In the clinical trials, some subjects had relief in 15 minutes and return to normal functioning in 30 minutes.

Zavzpret may be especially appropriate for migraineurs suffering from nausea and vomiting as accompanying symptoms.

Schedule an appointment at The Manhattan Center for Headache & Neurology to speak with one of our skillful providers for more information.

By: Brooke Steiger, FNP


The prevalence of migraine among women is highest during reproductive years. Expert consensus suggests that devices are relatively safe for use in pregnancy, thus neuromodulation devices are prescribed during pregnancy by headache specialists in clinical practice; however, there are no treatments specifically approved nor investigated for the treatment of migraine in pregnant women, creating a great unmet need.
The remote electrical neuromodulation (REN) device (Nerivio®) is a drug-free, non-invasive, wearable, battery-operated stimulation device, wirelessly controlled by a smartphone application, worn on the upper arm for 45-min treatments. It is Food and Drug Administration–cleared for the acute and/or preventive treatment of migraine with or without aura for episodic and chronic migraine patients aged 12 years and older. While REN is not contraindicated in pregnancy, a precaution mentions that it had not been tested during pregnancy.
A new study, with our own Dr. Audrey Halpern as a coauthor, was recently published in the Headache journal: Safety of remote electrical neuromodulation (REN) for acute migraine treatment in pregnant women: a retrospective controlled survey-study.
The controlled study consisted of a retrospective survey of women with migraine between 18 – 45 years of age who were pregnant during the study period. Participants in the REN (Nerivio) group (59 women) used Nerivio for at least 3 treatments during the study pregnancy period,
While participants in the control group (81 women) treated with various standard care treatments during pregnancy, except for Nerivio.
The study found no statistically significant differences in the following outcomes between pregnant women who used the REN device during pregnancy to treat their migraine, compared to those who did not use the device during this period: gestational age at delivery, baby’s birth weight, miscarriage rate, stillbirth rate, preterm birth rate, birth defects rate, baby meeting developmental milestones 3 months after birth, and rate of emergency room or urgent care visits
Results indicated that the REN device is a safe treatment of migraine during pregnancy, not increasing the risk for adverse pregnancy outcomes, and therefore offering a much-needed non-pharmacological alternative for women with migraine during pregnancy.

A link to this study can be found here: https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.14586

By:Alice Wong, NP


Migraines can be severe and debilitating, but there has been an influx of new migraine treatments in the last several years. Preventing migraine is one such goal of treatment, and Vyetpi is one such treatment that became FDA approved in 2020 for the prophylaxis of migraine.
Vyepti is unique in that it is the only approved preventative for migraine given through IV. It is administered once every 3 months. It is known as a CGRP receptor blocker – calcitonin gene-related peptide. CGRP plays a role in migraine, and Vyepti works to bind to and block CGRP receptor activation.
Vyepti is a good option for migraine sufferers who prefer not to take a daily oral preventative. It must be administered by a medical professional, meaning patients need to come in once every 3 months for an infusion. Infusion time is about 30 minutes, and patients are good to go back to school or work after.Schedule an appointment at The Manhattan Center for Headache & Neurology if you think Vyepti might be a good choice for managing your migraines.


Sana Marzouq, DNP