Untreated Sleep Apnea is often accompanied with headaches. These headaches occur in about 10 to 30 percent of patients diagnosed with Obstructive Sleep Apnea.
These headaches are usually described as squeezing, pressure-like sensations localized in the bifrontal (forehead) region. They are recurrent, happening at least 15 days per month or more. This headache subtype is not accompanied by typical migraine symptoms. For example, no associated nausea, vomiting, light or noise sensitivity. Typically, these headaches resolve within 30 minutes to an hour after waking up.
Symptoms of Sleep Apnea include excessive daytime sleepiness – snoring, coughing, or gasping during sleep, morning brain fog or nighttime restlessness.
According to ICHD -II diagnostic criteria, sleep apnea must be demonstrated on overnight sleep study and headaches must be resolved within 72 hours with no recurrence after effective treatment of sleep apnea.
A detailed history in addition to a thorough physical examination is needed to diagnose and/or treat these headaches.

To learn more about your migraines, contact The Manhattan Center for Headache & Neurology and speak to one of our caring providers!

By: Jordan Shankle, PA


Dizziness can originate from a problem in the nervous system (the inner ear, vestibulocochlear nerve, the brainstem, or the cerebellum) or from systemic causes. Dizziness can be neurological, but it can also be caused by cardiovascular disease, anemia, endocrine issues (i.e. hypoglycemia or thyroid disease), or medications affecting the nervous system. The practitioner can try to determine from a patient’s description whether the symptom can be categorized as one of the following:
Vertigo, a sensation of room spinning or tilting movement, is generally neurologic in origin
Light-headedness can be more cardiovascular in origin
Imbalance can be a gait disorder, which may be neurologic or orthopedic
Other/nonspecific dizziness can psychogenic

Other aids in diagnosis include a history of timing, triggers, and associated symptoms, and whether the dizziness is acute or chronic, continuous or episodic. Possible diagnosis can include stroke, vestibular neuritis, lesion (tumor, Chiari malformation), Meniere’s disease, vestibular migraine, transient ischemic attack, benign paroxysmal positional vertigo. Please call MCHN to make an appointment for a thorough evaluation with one of our caring providers.

–Alice Wong, NP

Berkowitz A.L.(Ed.), (2017). Clinical Neurology and Neuroanatomy: A Localization-Based Approach. McGraw Hill.


Meditation is a mindfulness practice that has been found to be helpful for many different health conditions in addition to mental health conditions.

But what exactly is it?

It is the practice of training your brain to maintain focus and attention in the present moment. To do this, one sits quietly for a specified period of time with closed eyes, often focusing attention on breath and dismissing any thoughts that arise. The goal is to bring stillness to your mind that may allow you to be more present in the moment when you are not meditating.

One study from 2014 showed that it may actually reduce the number of migraines per month in people who practice. Another study revealed that meditation reduced patients’ perceived pain intensity related to migraine.

To get started, there are many apps available for cellphone which offer guided or non-guided timed meditations. Common apps include Calm and Headspace. When you first start meditating, try it for 10 minutes in the morning. The length of meditation may be increased as you get used to it, but benefit may be found from even short periods of meditation.

Research has found that meditation is also good for other conditions including anxiety, depression, high blood pressure, irritable bowel syndrome, sleep issues, heart disease, cancer, and asthma.

For more information about meditation, speak with your health care provider or your mental health therapist.

By: Brooke Steiger, NP

Migraine Attributed to Epileptic Seizure

Migraine and seizure are common neurologic disorders seen and diagnosed in clinical practice. Occasionally they are accompanied by one another. The term, “migralepsy” refers to a migraine aura preceded by or triggering a seizure – additionally this can be followed by a migraine attack.
More common occurrence is seizure followed by migraine headache.
Clinical trials and studies have shown a higher prevalence of certain types of seizures associated with migraine, for example tonic clonic generalized seizures or occipital lobe seizures.
Furthermore structural lesions may result in seizures with migraine headaches.
A detailed history, physical examination, blood work and neuro imaging is needed to diagnose and treat migraines attributed to Epileptic Seizure

By: Jordan Shankle. PA


Relivion is an external combined occipital and trigeminal neurostimulation device available as a self-administered home treatment for migraine. The mechanism of action for the technology in Relivion is built around proven practices in neuromodulation. Neuromodulation is the alteration of nerve activity (such as pain) through targeted delivery of a stimulus (such as an electrical stimulation) to specific nerves in the body (such as the trigeminal and occipital). Relivion concurrently stimulates the two primary nerve pathways in the brain associated with migraine. The device targets six branches across the across the occipital and trigeminal nerves. A recent study of fifty-five subjects with episodic and chronic migraine were randomly assigned to active or sham (dummy) treatment. Subjects performed a 60-min home treatment within 45 min of migraine onset. Active treatment was significantly more effective than sham stimulation for decreasing pain intensity at 1 hour and 2 hours. Pain-free ratings were also greater for the active treatment arm at 1 hour and 2 hours. Overall headache relief was significantly higher in the active treatment group at 1 hour and 2 hours. Mild, transient side effects reported by a few subjects resolved without treatment. Per this study, the Relivion device provides superior and meaningful relief and freedom from migraine pain compared to sham treatment. The MCHN is pleased to offer this treatment to our patients. Please make an appointment with one of our providers to discuss if this device is appropriate for you.

–Alice Wong, NP

Daniel O, Tepper SJ, Deutsch L, Sharon R. External Concurrent Occipital and Trigeminal Neurostimulation Relieves Migraine Headache: A Prospective, Randomized, Double-Blind, Sham-Controlled Trial. Pain Ther. 2022 Sep;11(3):907-922. doi: 10.1007/s40122-022-00394-w. Epub 2022 Jun 4. PMID: 35661128; PMCID: PMC9314547.

Post Concussion Syndrome

Post concussion syndrome is a series of symptoms that may persist for a period of time, usually weeks or months, after a mild traumatic brain injury or other head trauma.

Symptoms include headaches, difficulty concentrating, dizziness, anxiety, fatigue, difficulty sleeping, brain fog, memory issue, difficulty with word-finding, and sensitivity to light. These symptoms may be exacerbated by certain triggers including alcohol, computer use, or strenuous exercise.

Treatments include supportive therapies and lifestyle modifications including cognitive rest and break from strenuous activities. In some cases, medication may be used including medication to treat migraine. Studies have shown that a type of talk therapy called cognitive behavior therapy may help with recovery.

If you feel you may be suffering from post-concussion syndrome, speak to your healthcare provider.

By: Brooke Steiger, NP

Intracranial Hypotension

Intracranial hypotension occurs when imbalance in the production, absorption, or flow of cerebrospinal fluid (CSF) leads to low intracranial pressure and sagging of the brain within the skull. This may cause traction on connected nerves – leading to postural headaches. Intracranial hypotension most commonly occurs from a persistent CSF leak after lumbar puncture but may also be spontaneous. Typically, headaches are described as throbbing or dull pain – which may be generalized or focal. Pain may intensify upon standing or sitting upright and relieved with recumbency. Associated signs and symptoms may include:

Nausea and/or vomiting
Neck pain or stiffness
Changes in hearing
Visual changes (blurred vision, seeing double)

A detailed history, a physical examination, blood work and possibly neuro imaging is needed to diagnose and/or treat intracranial hypotensive headaches.

By: Jordan Shankle, PA


In 1980, C. Miller Fisher described late-life migraine accompaniments as transient neurological episodes in individuals over 40 years old. This disorder is not rare in clinical practice and can occur without headache. Visual symptoms are the most common presentation, followed respectively by sensory, speech, and motor symptoms. In the study group of 120, the patients were categorized as follows: Visual, 25; visual and paresthesias, 18; visual and speech disturbance, 7; visual, and brain stem symptoms, 14; visual, paresthesias, and speech disturbance, 7; visual, paresthesias, speech disturbance and paresis, 25; recurrence of old stroke deficit, 9; miscellaneous, 8. Headache occurred in only 50% of cases. 

Transient neurological disturbances in migraine can mimic other serious conditions such as ischemic attacks and can be easily misdiagnosed. Appropriate investigations are essential to exclude secondary causes. 

–Alice Wong, NP

Summer is here and it’s a hot one!

Dehydration Headaches

With hot temperatures come increased sweating which may lead to dehydration. One of the first signs of dehydration is often a headache. These headaches are considered secondary headaches but may trigger migraines.

Symptoms of dehydration headaches include mild tension over entire head but also may occur only in specific areas. It may have a pulsating quality and may be worsened with physical activity, bending over, or changing positions. Other accompanying symptoms may include confusion, dizziness, fatigue, muscle cramping, dry mouth, extreme thirst, darkly colored urine. There may also be loss of skin elasticity and low blood pressure or increased heart rate. In more severe cases there may be loss of consciousness.

There is risk for dehydration with vomiting, diarrhea, sweating, fever, and excessive urination.

Treatments include increasing fluid intake and replacing lost electrolytes. Dehydration may require more aggressive therapy such as IV rehydration. For severe symptoms seek immediate medical care as complications may lead to serious risks to health.

For more information speak with your healthcare provider.

By: Brooke Steiger, NP

Treatment of Headache in Special Populations

Headaches and Migraine is common among females in their childbearing years. For patients with headache, the fetal safety of maternal headache treatment is necessary and extremely important. Each provider treating a patient during pregnancy or while lactating should be familiar with ICDH-II to avoid health complications to the fetus and or mother.
In pregnancy all medications should be utilized minimally if possible. Vomiting and dehydration may be injurious. Non Pharmacological measures are the treatments of choice.
Evidence has shown that anywhere between 50 – 80% of women who have migraines without aura and or menstrual associated migraine will have significant reduction in headache attacks by the end of the first trimester.
With any worsening of headache pattern the clinician should always consider the possibility of secondary headache. Acute therapy in pregnancy includes Acetaminophen (Tylenol ), suppository may be preferable than oral route. Additionally, anti-emetics such as metoclopramide, prochlorperazine and promethazine may be useful.
During acute severe attacks, IV infusion with magnesium and or occipital nerve blocks with 1% lidocaine can be reasonable. Furthermore, selective triptans ie (sumatriptan) has no increased occurrence of birth defects and can help abort headache pain.
When necessary, several medications are category C: propranolol, amitriptyline, topiramate.
The Manhattan Center for Headache and Neurology has exceptional providers to treat you. Contact the center for further evaluation and potential treatment options.

By: Jordan Shankle, PA