June is Migraine and headache awareness month

June is National Migraine and Headache awareness month.
Every year during the month of June, the AMF provides a platform for education and patient advocacy.

This year’s theme for the American Migraine Foundation’s Migraine Headache Awareness month is “Advocate for Treatment Access”. This theme centers around barriers to treatments like medications, including step therapy. This is a method used by insurance company health plans to reduce costs by forcing patients to choose a cheaper option before gaining access to a more expensive, newer treatment.

Throughout the entire month, there are days dedicated to different topics regarding migraine awareness and education. There will be opportunities for discussion on social media platforms such as Twitter, Instagram, and Facebook.

There will also be a ‘Migraine the State of the Union’ webinar led by migraine specialist and chair of the Board of Directors of AMF, Dr. Larry Newman.

For more information about Migraine and Headache Awareness visit https://americanmigrainefoundation.org

By: Brooke Steiger, NP


Extensive evidence-based studies and trials have been completed to support the role in botulinum toxin-based medications, helping to alleviate and prevent migraine attacks. Evidence suggests that these medications interfere with the pathway of pain transmission between the central nervous system and the peripheral nervous system.
A migraine attack can be described as a multifactorial neuronal dysfunction which results in releasing substances called neurotransmitters and molecules associated with pain. Botulinum toxin interferes with the transmission of these substances, typically where the nerves and muscles meet. Moreover, injecting Botulinum into the muscles around the face, head and neck, it is taken up by the nerves and interferes with pain-associated neurotransmission.
Xeomin is a type of botulinum toxin type A, similar to Botox. However, it is incobotulinum type A, so it doesn’t have the binding proteins that stabilize the molecule, resulting in potentially fewer side effects.
Xeomin is indicated for chronic pain and spasticity, we often use Xeomin to treat Chronic Migraine as well. Contact The Manhattan Center for Headache and Neurology to learn more about Xeomin!

By: Jordan Shankle, PA


Status Migrainosus is a continuous debilitating migraine attack that lasts 72 hours or longer. It is an episode that is not responsive to your usual abortive medications and can cause loss of sleep and severe dehydration due to nausea and vomiting. Your provider will check for “red flag” symptoms such as vision changes, numbness, weakness, and changes in speech to rule out a more serious condition, such as a stroke. You may then be offered a combination of abortive treatments which can include the following, typically through IV or injections:
Non-steroidal anti-inflammatory drugs
Triptans or dihydroergotamine
IV Fluids
Anti-nausea medications
Nerve block
If you have a migraine episode that persists, please call for an evaluation and abortive treatment at the Manhattan Center for Headache and Neurology.

–Alice Wong, NP


A migraine is associated with many different accompanying symptoms including sensitivity to light and noise and nausea. Another very common symptom is sensitivity to odors, also known as osmophobia. In some cases, odors may even trigger migraine attacks. This may include but is not limited to perfumes, air fresheners, car exhaust, cleaning products, nail polish, and cigarette smoke.

For some people, olfactory hallucinations, or smelling odors that are not present, or part of their migraine pattern. This may include smells of something burning, metallic scent, or even rotten meat.

At times, it may be difficult to avoid these odor related triggers however there are a few things you can do to adapt. Be observant and aware of your environment – if you notice strong scents do what you can to modify the environment such as opening a window or step outside. Also, be aware of your premonitory symptoms such as fatigue, neck pain, dizziness which may signal an impending migraine. By doing so, you can take the steps to avoid strong odors if possible or adjust your environment.

If you would like more information about migraine and osmophobia, speak with your healthcare provider.

By: Brooke Steiger, NP


New daily persistent headache (NDPH) is a type of chronic daily headache that typically does not subside or remit. NPDH can persist for many years and may be refractory to multiple treatment modalities. Triggering factors most identified with NDPH include increased life stressors, suppressed immunity, and/or post-operation.

The International Classification of Headache Disorders, 3rd edition (ICHD-3), published in 2018, describes NDPH as a persistent and continuous headache with a clearly remembered onset. The pain lacks characteristic features and may be migraine-like or tension type–like or have elements of both.

The following are the ICHD-3 diagnostic criteria for NDPH:
●(A) Persistent headache fulfilling criteria B and C
●(B) Distinct and clearly remembered onset, with pain becoming continuous and unremitting within 24 hours
●(C) Present for longer than three months
●(D) Not better accounted for by another ICHD-3 diagnosis

A detailed history in addition to a thorough physical examination is needed to diagnose and/or treat NDPH. Call The Manhattan Center for Headache & Neurology to set up an appointment with one of our caring providers.

By: Jordan Shankle, PA


Nonsteroidal antiinflammatory drugs, also called “NSAIDs,” are medicines that relieve pain and reduce inflammation. More than 20 different nonsteroidal antiinflammatory drugs (NSAIDs) are available commercially. You can buy many NSAIDs without a prescription, including aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve). The choice of NSAID depends upon different factors and individual patients differ in their response to different NSAIDs. Diclofenac can be useful for joint pain and indomethacin is prescribed for certain types of headaches. Meloxicam has slow onset but longer effect and a more appropriate choice in some situations. IV ketorolac (Toradol) is usually a part of the abortive “migraine cocktail” we administer.

NSAIDs can help people who have conditions that cause ongoing pain, but NSAIDs can cause problems of their own, such as ulcers and bleeding. It is important to take the lowest dose you need for the shortest time, and discuss frequent use of NSAIDS with your medical provider. NSAIDs are avoided or used with caution, in older adults and patients (regardless of age) with existing or increased risk for cardiovascular, GI, or kidney disease.

–Alice Wong, NP


Fear of Migraine as Migraine Trigger

For some individuals the fear of migraine may be a significant trigger for having a migraine episode. This is referred to as cephalalgiaphobia.

The body and mind’s response to the anticipation of migraine may actually contribute to the migraine itself. In some cases, this fear may prompt migraineurs to start using medications in absence of migraine. This may actually contribute to rebound headaches, increasing the frequency of the individual’s headache attacks.

Studies have found that this most commonly affects individuals with moderate to high frequency of attacks.

There are treatments including a form of psychotherapy called cognitive behavioral therapy to address this issue.

If you feel you are suffering from cephalalgiaphobia speak with your medical provider.

By: Brooke Steiger, NP

Third Cranial Nerve Palsy

Third Cranial Nerve Palsy is described as dysfunction of the third cranial nerve (oculomotor nerve). The diagnosis and management of third nerve palsy varies according to the age of the patient, characteristics of the third nerve palsy, and the presence of associated signs and symptoms.
Third Nerve palsy may present as “seeing double: or droopy eyelid. Occasionally an enlarged pupil may be seen. This disorder may or may not be associated with pain, usually sudden and severe.
Third nerve palsy requires a specific workup including a detailed physical examination, blood work, and neuroimaging.
Speak with one of our exceptional providers at The Manhattan Center for Headache and Neurology.
By: Jordan Shankle, PA

Migraines WITHOUT Headaches?

A recent New York Times article by Dr. Lisa Sanders is about a 51-year-old man who suffers from strange episodes of utter exhaustion for over 20 years. He would suddenly feel exhausted and weak–he couldn’t walk, stand, or even sit, and would have to lie in a dark room for hours. The next morning, he would be fine. Over the years, the infrequent episodes became monthly, then weekly, and then sometimes a couple of times a week. Over the years, he saw many doctors and had many tests but was unable to get a diagnosis to explain his exhaustion and weakness. He saw a neurologist who ruled out migraines because the exhaustion did not come with headaches. He saw a psychiatrist to rule out depression. Finally, a random comment from a colleague about migraines lead to pursuing this possibility further, but with a headache specialist. The man did have a history of migraines but had not had a migraine headache in years. Experts are aware that migraine disorder can present itself in different ways. Headaches can be preceded by or come with symptoms such as mood changes, food cravings, light or sound sensitivity, fatigue, weakness, visual changes, nausea, vomiting, dizziness, numbness or tingling, or even ringing in the ears or difficulty speaking. Yet it is possible for migraines to change over time so that migraine symptoms occur without headaches. The man was put on a migraine medication and the episodes were aborted. You can read the full article at https://www.nytimes.com/2022/03/31/magazine/acephalgic-migraine-diagnosis.html
If you have neurological symptoms, you can come to the Manhattan Center for Headache and Neurology and be evaluated by our expert providers. Take care and be well.

–Alice Wong, NP

Migraine Postdrome (AKA Migraine “hangover”)

Migraine Postdrome (AKA Migraine “hangover”)

The typical stages of a migraine include a prodrome, aura, migraine, and postdrome. A migraine postdrome is the last stage of a migraine where the individual experiences symptoms that are similar to a hangover from drinking alcohol.

To date, this is one of the least studied aspects of migraine. In a 2016 study, it was found that the severity of a migraine episode did not correlate with the length of the postdrome phase.

Symptoms that may be experienced during this time include digestive issues, mood changes, sore or achy muscles, fatigue, neck pain or stiffness, mild headache, changes in appetite, and difficulty concentrating, and thirstiness. The symptoms may last from hours to days, but many individuals’ postdrome resolve within 24 hours.

Although there is no standard recommended treatment for this phase of migraine it is advisable to maintain a healthy lifestyle during this phase including getting plenty of rest, eating healthy foods, and doing gentle exercise including walking as tolerated.

One important aspect of being aware of the program phase is tracking. Your provider may ask you to track your headache days. These associated days should be included in your headache diary. This helps your provider assess the “burden of migraine” so they can better understand how to treat your migraines.

For more information on migraine prodrome talk to your provider.

By: Brooke Steiger, NP