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.

https://www.vyepti.com/

Sana Marzouq, DNP

Sensory Aura is a common subtype of aura associated with Migraines. Typically, it follows a visual aura within minutes, but not always. This particular aura can be described as tingling sensations in upper or lower extremities and or abnormal sensations on the face.

If the tingling migrates from one limb to another or from different sides of the face, numbness is left in its wake that may last up to 1 – 2 hours. Tingling sensations can occur inside the mouth and affect taste buds on your tongue.

Like most Auras this type develops gradually over no more than 5 minutes. Treatment with a specific migraine abortive, at the earliest onset, is essential to preventing the symptoms from progressing into a severe migraine attack.

By: Jordan Shankle, PA

For many people who suffer from migraines, during a migraine episode, a rescue treatment is taken and the migraine resolves. Unfortunately, in some cases when a migraine does not resolve it may last for a number of days. A migraine lasting for 72 hours or longer is known as status migrainosus.

In many cases, several rescue medications are tried, yet the headache persists. At this point, some choose to go to the hospital for treatment and assessment.

Status migrainosus may be treated in a variety of ways including with novel rescue medications, multi-day courses of certain prescription medications suited to treating status, nerve blocks, or intravenous infusions.

In some cases, depending on the individual’s medical history and symptoms, a headache lasting this long could be concerning and require further assessment.

If you believe you have suffered from status migrainosus schedule an appointment with our caring providers at The Manhattan Center for Headache & Neurology

By; Brooke Steiger, NP

Previously known as Basilar-type migraine, Migraine with brainstem aura (MBA) presents with characteristic symptoms such as vertigo, dysarthria, tinnitus, diplopia, bilateral visual symptoms, or bilateral paresthesias. This is an uncommon subtype of migraine with aura. It is believed that the neuronal dysfunction of the brain stem can lead to subsequent stimulation of the trigeminal nerve triggering neurogenic inflammation and pain. A notable difference between MBA and migraine with typical aura is the symptoms involving the brainstem or the bilateral occipital hemispheres, whereas typical migraine with aura is mainly restricted to a unilateral hemisphere. Neuroimaging is suggested for all patients with first-ever MBA symptoms to exclude alternative etiologies. Triptans and Ergotamine derivatives are generally felt to be contraindicated in MBA because of the potential for cerebral vasoconstriction, but this is based on outdated vascular theory of migraine and should be reconsidered. Further discussion with your neurologist is needed to determine the appropriate treatment for your MBA.

Yamani N, Chalmer MA, Olesen J. Migraine with brainstem aura: defining the core syndrome. Brain. 2019 Dec 1;142(12):3868-3875. doi: 10.1093/brain/awz338. PMID: 31789370.

By: Andrew Chan, PA

Vestibular migraine is a term used to describe episodic vertigo or other vestibular symptoms attributed to migraine.
Vestibular migraine is characterized by recurrent episodes of vertigo. Most episodes last minutes to hours and may be spontaneous or triggered by visual or motion stimuli (eg, fluorescent lights, watching trains, busy patterns, crowds). Vertigo can be internal (a false sensation of self-motion) or external (a false sensation that the visual surround is spinning or flowing). Other commonly described vestibular symptoms include unsteadiness, visually induced vertigo, head motion intolerance, and nonvertiginous “dizzy” symptoms such as lightheadedness. Migrainous headaches are associated with most episodes of vestibular migraine. However, vertigo may occur without headache.
The typical frequency of attacks varies from daily to one or two each month. However, episodes may occur several times each day or on a near constant basis.
Vestibular migraine episodes are often spontaneous. However, they may also be triggered by environmental stimuli. These triggers include:
•Sleep deprivation
•Stress
•Certain foods
•Visual stimuli (eg, fluorescent lights, moving trains, crowds, busy visual patterns)
•Change of head position
The differential diagnosis of vestibular migraine includes disorders that produce episodic vertigo. These most often include Meniere disease, other migraine variants, benign paroxysmal positional vertigo (BPPV), and TIAs. Neuroimaging can be ordered to rule out transient ischemic attack (TIA) or stroke. Please call MCHN for an evaluation.

By: Alice Wong, NP

Nausea is a common complaint in people who suffer from migraine. Nausea is part of the diagnostic criteria for migraine, and various studies have found the prevalence of nausea to be anywhere from 65-90% of migraine patients. Many of these patients will have vomiting as a result.
The good news is there are very effective methods of treating nausea and prevent it from turning to vomiting. Zofran is an antiemetic medication that is often prescribed for nausea. One formulation of Zofran is as a dissolvable tablet, making it easy to take and it can start to work in the first 30 minutes. Talk to your provider if you are interested in this medication.
Nausea can also be managed non-pharmacologically. Ginger is one such method that can be effective in treating nausea. It is available in many different forms – with tea being a popular and easy to find option.

Sana Marzouq, DNP

Lete, I., & Allué, J. (2016). The Effectiveness of Ginger in the Prevention of Nausea and Vomiting during Pregnancy and Chemotherapy. Integrative medicine insights, 11, 11–17. https://doi.org/10.4137/IMI.S36273
Min, Y. W., Lee, J. H., Min, B. H., Lee, J. H., Kim, J. J., Chung, C. S., & Rhee, P. L. (2013). Clinical Predictors for Migraine in Patients Presenting With Nausea and/or Vomiting. Journal of neurogastroenterology and motility, 19(4), 516–520. https://doi.org/10.5056/jnm.2013.19.4.516

Photophobia is a common symptom associated with Migraine. More than 80% of migraine attacks are associated with and exacerbated by light sensitivity. Research by Harvard researcher Dr. Rami Burstein on the neurobiology of photophobia led to the discovery of pain modulating effects of green light. Of all light to which migraine sufferers are exposed, green light at 525 nanometer wavelength worsens migraine significantly less than all other colors of light. Green light can actually reduce pain by about 20%.

The connection between photophobia and migraine is because the same thalamic trigeminovascular neurons that relay nociceptive pain signals from the dura to the cortex during migraine are the same bundle of neurons that transmits information about light from the eye to the brain.

This discovery will hopefully lead to an effective non pharmacological option to help decrease the disability associated with migraines. Current limitations are the high cost of light bulbs that emit this specific narrow band of green light wavelength. Dr. Burstein is working on developing an affordable light bulb as well as sunglasses that block out all light except for the narrow band of pure green light.

Burstein R, Noseda R, Fulton AB. Neurobiology of Photophobia. J Neuroophthalmol. 2019 Mar;39(1):94-102. doi: 10.1097/WNO.0000000000000766. PMID: 30762717; PMCID: PMC6383812.

Martin LF, Patwardhan AM, Jain SV, Salloum MM, Freeman J, Khanna R, Gannala P, Goel V, Jones-MacFarland FN, Killgore WD, Porreca F, Ibrahim MM. Evaluation of green light exposure on headache frequency and quality of life in migraine patients: A preliminary one-way cross-over clinical trial. Cephalalgia. 2021 Feb;41(2):135-147. doi: 10.1177/0333102420956711. Epub 2020 Sep 9. PMID: 32903062; PMCID: PMC8034831.

By: Andrew Chan, PA