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Peripheral nerve blocks have been used for the acute and preventative treatment of a variety of headache disorders for decades. These procedures provide prompt pain relief for many patients that lasts beyond the duration of the anesthesia, from several weeks or even months, possibly due an effect on central pain modulation. Greater occipital nerve blocks for migraine and cluster headaches reduce headache days and give high levels of patient-reported efficacy. Lesser occipital nerve blocks as first-line treatments in trigeminal autonomic cephalalgias may avoid the need for corticosteroids or indomethacin. Patients with headache who have reproducible pain with palpitation over the pericranial nerve area in the scalp are also likely to respond to nerve blocks. Pregnant women with headaches can often be managed throughout pregnancy and the postpartum period with anaesthetic nerve blocks, reducing the need for medications. The nerve blocks we perform at The Manhattan Center include greater occipital, lesser occipital, supratrochlear, and supraorbital injections with anaesthesia. Please call to set up a consultation to discuss if PNBs are a suitable option for your treatment.
–Alice Wong, NP


Over the past few years there have been very exciting developments in the areas of treatment for migraine.

Last week the first oral gepant for the prevention of migraine, atogepant (brand name Qulipta), was approved by the FDA. It was approved for preventative use in episodic migraine. A gepant is a medication that blocks the protein called CGRP from its receptor in the body. CGRP is a compound present in the bloodstream during a migraine attack. By blocking its receptor, the gepant prevents the cascade of events that cause the symptoms related to migraine.

The medication is approved to be taken daily and comes in several different doses.

Clinical trials, side effects were mild and included nausea, constipation, and fatigue or somnolence.

For more information about this medication and to find out if it was right for you speak with your healthcare provider.

By: Brooke Steiger, NP


New daily persistent headache is a common type of daily continuous headache, representing >10% of patients seen in outpatient facilities. Clinically, it is a disorder with an onset that is unexpected. The pain is usually continuous, unremitting from onset or within a matter of days. Patients tend to have no prior history of headaches. These headaches may or may not have migrainous or autonomic features; and tend not to respond well to conventional migraine abortive therapies such as triptans or standard prophylactic medications. It is crucial that secondary causes of new onset daily headaches be ruled out. If you have experienced similar symptoms, please contact The Manhattan Center for Headache and Neurology for further evaluation and treatment options.


Trigger points are areas in a muscle that are very irritable and may produce not only pain in the affected muscle (head, neck, and/or shoulders), but in distant areas, called referred pain. Trigger points may develop because of trauma, injury, inflammation, or other factors. Trigger points can be present in patients with migraine, tension-type, post-traumatic, and other headache disorders.
A trigger point injection is a procedure where a medication, usually a local anesthetic, is injected into the painful muscle to provide relief in the affected muscle and the area of referred pain. In this office procedure, our providers insert a small needle into the patient’s specific areas of pain (trigger points). The injections usually contain only local anesthetics, but occasionally may contain a steroid medication. We can sometimes perform trigger point injections along with peripheral nerve blocks in the same treatment session.
Immediately after the injections, you may feel that your pain has lessened significantly. Most patients need several treatments to completely abort an exacerbation, while others may have only temporary relief of chronic pain. Prolonged positive results are more likely if combined with other treatments, such as medications and/or physical therapy. Consult with one of our providers at the Manhattan Center for Headache and Neurology to see whether this treatment is an appropriate addition to your pain regimen.
–Alice Wong, NP

The Basics of Trigger Point Injections for Headache and Migraine


Since the start of the pandemic, more people have been working from home and spending more time on the computer. In many cases this includes meetings that are conducted virtually and platforms such as Zoom or Outlook Teams.

For patients who suffer from migraines and headaches, this has been a particularly difficult time as many find that their headaches are triggered by “screentime” or extended computer use

For healthier “screentime” utilize the following tips:

-Practice good screen ergonomics. It is important to keep your monitor at eye-level, adjust the brightness of the screen, and make sure you are sitting 2 feet away from the screen.

-Think 20-20-20. Every 20 minutes make a habit of taking your eyes off the screen and focusing on an item 20 feet away for 20 seconds. This will help to prevent fatigue.

-Invest in a blue-blocking or anti-glare screen cover

-Take breaks. It is important to get up from your desk or workstation and move around every so often.

-Stick to a routine. It is important to continue healthy habits including healthy diet, exercise, and keeping hydrated. Try to avoid skipping meals and keep a water bottle on your desk.

If you still find you are having increased numbers of migraines or headaches speak with a healthcare provider for more treatment options.

By: Brooke Steiger, NP


Trudhesa (formally, INP 104) was first approved for acute treatment of migraine on September 2, 2021. Trudhesa uses nasal delivery of DHE (Dihydroergotamine mesylate), 0.725mg per spray. Dihydroergotamine mesylate is a well-established migraine treatment with more than 70 years of therapeutic use. Trudhesa, is advanced because it bypasses the gastrointestinal absorption to provides a quicker delivery of DHE into the bloodstream through vascular -rich upper nasal space. Trudhesa is not indicated for the preventive treatment of migraine or for the management of hemiplegic or basilar migraine. This approval provides another abortive option for a patient to add to their migraine toolbox. Please call The Manhattan Center for Headache & Neurology to speak with one of our caring providers about questions regarding this new advancement in acute migraine treatment!

Jordan Shankle, PA

Vitamins and Supplements
Deficiencies in vital nutrients from unhealthy diets; excessive alcohol, caffeine, or sugar intake; poor absorption; stress; or long-term intake of certain medications can contribute to headaches and other neurological conditions. Vitamins and mineral supplements that can help relieve migraines include the following:
–Magnesium: This mineral is essential to many cell and bodily functions from immunity and nerves, to bone and muscles. It prevents production of inflammatory chemicals and acts as a natural anticonvulsant and tranquilizer. Only 1% of the body’s magnesium is found in the serum, so testing for magnesium deficiency is not straightforward. It is common to be deficient in magnesium (up to half of migraine sufferers are deficient) and supplementation can be effective in the prevention of migraines. Whole grains, dark leafy vegetables, avocados, and legumes or supplementation of 400mg to 800mg daily of magnesium is recommended, but some people do not absorb magnesium well through diet or get diarrhea from taking oral pills. The Manhattan Center offers IV magnesium to relieve acute migraine attacks and for supplementation. Some people need a few infusions to achieve normal magnesium levels while a few may need monthly infusions.
–CoQ10: This nutrient is necessary for production of energy and is a common deficiency in migraine sufferers. It is an antioxidant that stimulates the immune system and protects the nerves. The body makes less CoQ10 as it ages and excess exercise can also affect levels negatively. Recommended dosage is 100mg a day.
–Vitamins B12: This vitamin plays a role in formation of red blood cells, production of neurotransmitters and energy, and lowers homocysteine levels. Symptoms of B12 deficiency include depression, dizziness, confusion, fatigue, irritability, and memory loss. Recommended
dosage is 400 to 1,000 mg daily, taken twice a day as part of a B-complex supplement. If you have a mutation of the gene MTHFR, it is necessary to take a methylated form of B12, methylcobalamin.
–Vitamin D: Deficiency in this vitamin is associated with a wide variety of diseases and conditions. While the normal range of vitamin D is from 30 to 100mg ng/ml, we recommend levels at least in the middle of this range. Take in the form of vitamin D3 with high-quality fats such as olive oil, flax seeds, or avocado for better absorption. Existing levels will direct the dose of supplementation necessary to achieve optimal levels a

Headaches During Pregnancy

For patients with a history of migraine, pregnancy can actually bring relief after the first trimester. Many women during their second and third trimesters notice a decrease in frequency of headaches if not complete resolution.

Those who continue to get headaches there are few treatments that are safe during pregnancy. Rescue treatments may include acetaminophen, SPG blocks with lidocaine, metoclopramide, and magnesium IV infusions. Most preventative medications for headache are contraindicated with pregnancy.

It is very important to speak with your doctor if you get headaches during pregnancy, especially in the 2nd and 3rd trimester, as they may be a sign of other medical issues including elevated blood pressure that may lead to preeclampsia.

Non-pharmacological treatments for headaches may include meditation, yoga, acupuncture, myofascial release massage, and use of essential oils. With clearance from your OB/GYN you may be able to use neuromodulation devices such as the Nerivio.

In general, it is very important to consult your OB/GYN and your headache specialist prior to taking any medication or treatments including over-the-counter medications during pregnancy. Also, when planning on conception it is important to speak with your provider well in advance of trying to get pregnant. You will need instructions on how to safely discontinue your preventative medication prior to attempting to conceive, in some cases up to 6 months prior.

For more information regarding headaches and pregnancy, call The Manhattan Center for Headache & Neurology and speak with one of our caring providers!

By: Brooke Steiger, NP

Reversible Cerebral Vasoconstriction Syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) represents a medical condition in which reversible multifocal narrowing of the cerebral arteries occur and manifest in intense “thunderclap” headache; oftentimes associated with neurological deficits.
RCVS is usually abrupt in nature, causing very intense, sometimes excruciating pain, which peak within seconds. Unlike Subarachnoid hemorrhage, headaches associated with reversible cerebral vasoconstriction tend to reoccur over a span of days to weeks. Provoking factors include orgasm, physical exertion and acute stressful or emotional events. Valsalva maneuvers such as straining, coughing and sneezing may also trigger these types of headaches.
In addition, some patients may experience focal neurological deficits to include unilateral muscle weakness, tremor, ataxia and aphasia. Visual disturbances ( blurred vision, seeing double) may also be associated with RCVS.
All patients who present with one or more thunderclap headaches must be evaluated and treated as a medically emergency, beginning with an evaluation for potentially serious secondary causes.

By: Jordan Shankle, PA


Tom Zeller Jr., a former reporter, recently wrote an opinion piece for The New York Times. *
A headache sufferer himself, he describes his bouts of intense pain, and the clinical and cultural ignorance that persists around primary headaches. While Mr. Zeller is grateful for the recent advances in treatment with CGRP inhibitors, he discusses how funding for research into headache disorders remain incommensurate with their enormous social costs, and how far too few young doctors enter in this specialty.

“In a world troubled by all manner of disease and unrest, it can seem absurd to complain about headaches. But this, too, is what makes the path of a chronic headache sufferer . . . a uniquely lonely one. The pain won’t kill us, sure, but we can receive prolonged physical beatings, without explanation, at any moment . . . Ask any people who suffer from migraines or similar headaches about the months spent being dismissed or misdiagnosed by unenlightened doctors . . . They are in your family. Or you work with them. No, they won’t die. But they are very often experiencing inscrutable, exhausting bouts of pain — or living in fear that it’s just around the corner, again.”

At The Manhattan Center for Headache and Neurology, we understand. Come in for a consultation. We can help.

–Alice Wong, NP