Cervical dystonia, also known as spasmodic torticollis, is the most common isolated focal dystonia seen in clinical practice. It affects the muscles of the neck and shoulders. Cervical dystonia may appear as horizontal turning of the head (torticollis), lateral tilt of the neck (laterocollis), flexion of the head (anterocollis), or extension of the head (retrocollis).
A subset of patients with cervical dystonia have an associated head tremor. In some patients, the head tremor is of relatively large amplitude, jerky, and irregular; other patients have a smaller-amplitude, more regular tremor that resembles essential tremor. A head tremor due to cervical dystonia is usually distinguished from essential tremor by the directional preponderance of the movement imposed by the neck dystonia.
Patients with cervical dystonia may also have an associated hand tremor that does not have dystonic qualities. Although still controversial, it is generally accepted that nondystonic hand tremor in cervical dystonia is a part of the dystonic syndrome, as opposed to reflective of comorbid cervical dystonia and essential tremor.
Isolated dystonia is separated from dystonia attributable to another underlying condition by the absence of additional neurologic abnormalities (with the exception of tremor) and the lack of a possible acquired.
The age and anatomic distribution of dystonia at onset are important clinical clues for diagnosis. Atypical presentations (eg, a child with onset of dystonia in the neck or face, an adult with onset in the leg, or an adult who develops generalized dystonia) are not characteristic of isolated dystonia; they indicate the need to evaluate for another genetic or acquired cause. Generalized dystonia is rare with adult onset. In such cases, an acquired etiology should be sought such as exposure to dopamine receptor antagonists.
Laboratory testing in patients with dystonia is part of the etiologic evaluation for suspected acquired and hereditary dystonias or dystonia with atypical features. The specific workup varies depending on age and associated clinical findings. A workup may also include neuroimaging such brain MRI or CT of head.
Contact The Manhattan Center for Headache and Neurology to evaluate and facilitate acute and extended management. Our exceptional providers are passionate about treating you!

Jordan Shankle, PA


Migraines are a significant burden to those who have them, affecting their mood and motivation. But it goes beyond that. People who suffer from migraines are more likely to have anxiety andB depression and there is even some evidence that it may be more common in people with bipolar disorder.

The science behind this is that serotonin which is implicated in anxiety and depression also believed to activate nerve endings associated with migraine. Additionally, there is a strong hormonal link between migraines, depression, and the female sex hormone estrogen. Some studies show that a decrease in estrogen in the body may lead to migraine.

Several oral medications that are typically prescribed to treat migraines are also effective in treating depression and bipolar disorder.

Additionally, therapeutic counseling may help you manage your migraines. CBT, also known as cognitive behavioral therapy, has been found to help decrease the frequency of migraines and headaches.

For more information about migraines and mental health, speak to your healthcare provider. To book an appointment with our psychiatric NP Roxanne Singer Gheorghiu contact our office.

Brooke Steiger, NP


Migraine is a common neurologic disorder causing head pain. It is often accompanied with nausea, vomiting, visual disturbances and reduce activity/ productivity. Many medications that are used for acute migraine attacks may have side effects, are not tolerated well and cannot be used during pregnancy or in patients with ischemic heart disease. Magnesium deficiency has been proposed to play a role in the pathophysiology of migraine, and treatment of migraine with magnesium has gained considerable interest.
Though magnesium can be used medicinally in a variety of forms, attention has been given to the administration of intravenous (IV) magnesium sulfate as a migraine rescue therapy. Magnesium administration intravenously has better absorption and does not cause diarrhea or abdominal cramping. The typical amount of magnesium sulfate given intravenously is 1 to 2g.
Given its high safety profile, several clinical trials over the past few decades have sought to determine the efficacy of magnesium sulfate in treatment of severe or intractable migraines.
Treatment of migraine is multifactorial. Patients should monitor headache frequency, use trigger identification and implement early treatment strategies to optimize care and minimize symptoms. Acute treatment like IV therapy is available at The Manhattan Center for Headache and Neurology, please contact us for further evaluation and treatment options.

Jordan Shankle, PA


Natural Supplement Profile: Vitamin C

Vitamin C, also known as ascorbic acid, is a water-soluble vitamin that is naturally occurring in foods including fruits and vegetables. It may be found in vegetables such as peppers, cabbage, brussel sprouts, broccoli, potatoes, and spinach and in fruits such as citrus, berries, and tomatoes.

The benefits of vitamin C include enhancing function of your immune system, maintaining eye health, and protecting against cardiovascular disease. It also is important in blood vessel health and the maintenance of collagen and cartilage in your body.

Some people may be more susceptible than others to deficiencies in vitamin C including smokers, people with certain gastrointestinal conditions, or those with a limited diet.

You may have heard about high dose vitamin C recently in the news due to its recent use in treatment of acute severe COVID-19 infections. There are currently clinical trials underway to evaluate its effectiveness against COVID-19.

We are pleased to announce that our office will be offering vitamin C IV infusions by appointment.

If you are interested in this treatment, please schedule an appointment with one of our providers at The Manhattan Center for Headache & Neurology!

By: Brooke Steiger, NP


Cerebellar ataxia is a common neurologic finding. Although cerebellar degeneration may be chronic and slowly progressive, acute cerebellar swelling due to infarction, edema, or hemorrhage can be an emergency. Persons with ataxia may lose muscle control in their arms and legs which can lead to a lack of balance, coordination, and trouble walking. Ataxia may even affect eye movements, and slurring of speech.
The symptom of ataxia can be caused by many things including stroke, Multiple Sclerosis, tumors, alcoholism, nerve damage, metabolic disorders and vitamin deficiencies. In these cases, treating the condition that caused ataxia may improve it.
While the term ataxia usually describes symptoms, it also describes a group of specific degenerative diseases affecting the central nervous system called the hereditary and sporadic ataxias. Hereditary ataxias is a subtype caused by a defect in a gene that a person is born with. Sporadic ataxias is a subtype that usually starts in adulthood and has no known family history.
Ataxia is typically diagnosed by medical history, family history, and complete neurological physical examination. Medical professionals may also include laboratory test, genetic testing or MRI. We advise to always see your healthcare provider for a diagnosis. Call the Manhattan Center for Headache & Neurology and speak to one our caring health care providers for more information!

Jordan Shankle, PA


Migraine Book Review

Migraine has been documented in literature over many years, described in many works including those by Joan Didion and Virginia Woolf.

Author Kathleen J. O’Shea has chronicled migraine in literature in her book So Much More than a Headache: Understanding Migraine through Literature.
In her book, she has gathered excerpts from books, poetry, an original essay, and a short play along with commentary to address the stigma surrounding migraines.

The book is specifically geared towards those who suffer with migraines and their friends and family in order to elucidate the experience of migraines. Additionally, this book may be beneficial to medical students and healthcare providers, particularly those working in the field of headache medicine.

For migraneurs, this work aims to acknowledge their hardships and experiences and the physical and mental consequences of the condition.

The book may be purchased on from Kent State University Press, Amazon, and Barnes and Noble and may be purchased for Kindle device.

Brooke Steiger,NP


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