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
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


The trigeminal Nerve, also known as cranial nerve V, is the fifth of 12 cranial nerves. Its primary function is to provide sensory and motor innervation to the face. Pain sensations from the front of the head and face as well as the anterior skull contents, is mostly carried by the trigeminal nerve.
The trigeminal nerve consists of three branches on either side of the face. The different branches are ophthalmic ( V1), maxillary (V2) and mandibular (V3) nerves. Each branch has a different responsibility for sensory innervation at a specific location over the face.
The trigeminal nerve provides both sensory and motor innervation. More specifically the sensory information that includes touch, pain, and temperature. The sensory information is then relayed, through a series of “check points” back to the brain. The motor portion is carried by (V3) and supplies muscles that assist with chewing (masseter, temporalis, etc.)
Disorders of trigeminal nerve include trigeminal neuralgia, post traumatic neuropathy and postherpetic neuralgia.
A detailed history in addition to a thorough physical examination is needed to diagnosis and/or treat disorders of the trigeminal nerve.

By: Jordan Shankle, PA


Magnesium, an essential mineral in the body, is involved in protein synthesis, muscle and nerve function, blood glucose control, and blood pressure regulation. It is required for energy production and is important to nerve impulse conduction, muscle contraction, and normal heart rhythm.
Magnesium deficiency is related to factors that promote headaches, including neurotransmitter release and vasoconstriction. People who experience migraine headaches have lower levels of serum and tissue magnesium than those who do not. There is some evidence that 300 mg magnesium twice a day, either alone or in combination with medication, can prevent migraines. In their guideline update, the American Academy of Neurology and the American Headache Society concluded that magnesium therapy is possibly effective for migraine prevention.
Magnesium is naturally present in many foods, added to other food products, and available as a dietary supplement. Green leafy vegetables, such as spinach, legumes, nuts, seeds, and whole grains, are good sources of magnesium. Approximately 30% to 40% of the dietary magnesium consumed is typically absorbed by the body. Dietary surveys of people in the United States consistently show that many people consume less than recommended amounts of magnesium. Assessing magnesium status is difficult because most magnesium is inside cells or in bone. Less than 1% of total magnesium is in the blood serum.
Absorption of magnesium from different kinds of magnesium supplements varies. Forms of magnesium that dissolve well in liquid are more completely absorbed in the gut than less soluble forms. Small studies have found that magnesium in the aspartate, citrate, lactate, and chloride forms is absorbed more completely and is more bioavailable than magnesium oxide and magnesium sulfate. Forms of magnesium most commonly reported to cause diarrhea include magnesium carbonate, chloride, gluconate, and oxide.
Please discuss whether magnesium supplementation is appropriate for you with one of our providers.
–Alice Wong, NP


Migraine World Summit

The Migraine World Summit is a yearly event meant to inform and educate migraineurs and advocates about all things migraine-related including the latest research and the newest treatments and therapies.

This year the free event March 16- 24 will last 9 days and will be held virtually.

As part of the event, there will be 30 minute interviews with experts from around the world sharing their knowledge about migraine and migraine treatments. Some topics include nutrition for migraine, physical therapy and headache, new treatments for migraines, development of migraine research and treatment resistant chronic migraine.

The event is free and open to the public with registration at

By: Brooke Steiger, NP


The term papilledema most properly describes optic disc edema, or inner eye edema, usually as a result of increased intracranial pressure. This increased pressure is transmitted to the optic nerve sheath and often causes serious consequences.
Common causes of increased intracranial pressure are intracranial mass lesion, cerebral edema (infection or severe TBI), increased cerebrospinal fluid production, and obstructive hydrocephalus.
Symptoms of increased intracranial pressure include headaches, usually positional, worsening with recumbency or in the morning. Associated symptoms can include visual disturbances (worsening eye vacuity, seeing double, loss of peripheral vision) and pulsatile machinery-like sounds in the inner ear.
The causes of papilledema often have serious consequences, therefore urgent brain MRI and lumbar puncture with opening pressure should be completed.
Additionally, serial measurement of visual acuity and fundoscopic exams should be used to assess the course of papilledema and response to treatment.
The Manhattan Center for Headache and Neurology has exceptional providers for further evaluation and potential treatment options.

By: Jordan Shankle, PA