Sarasota Neurology

Occipital neuralgia is a commonly missed headache diagnosis. The symptoms for headaches can be quite different. Occipital neuralgia can mimic migraine headaches but do not respond to standard migraine medications. Occipital neuralgia rarely occurs as a headache syndrome by itself. The majority of patients with occipital neuralgia have one or more other types of headache including: migraines, tension headache, rebound headache and cluster headaches. Occipital neuralgia is frequently misdiagnosed as migraine or cluster headaches. Patients with prominent face pain as part of their occipital neuralgia may be incorrectly diagnosed with tic delaroux (trigeminal neuralgia.)

Occipital neuralgia is caused by an irritation of the occipital nerve as is comes through the muscles in the back of the neck. The occipital nerve is formed from branches of the second and third cervical nerve roots. This nerve passes posteriorly up the back of the head, piercing through the muscles of the upper neck. The occipital nerve then curves over the back of the head to the frontal area, stopping at approximately the hair line. This nerve provides pain and sensory information over the back 2/3 of the head. When the nerve becomes irritated from various causes such as strained or tense neck muscles, whiplash injury, neck arthritis or even just sleeping wrong - getting a kink in your neck.

The headache symptoms of occipital neuralgia include upper neck pain, pain at the base of the skull, which may be on one or both sides, and pain traveling up the back up the head as far forward as the forehead. Some patients experience pain behind the eyes or even facial pain. The pain is commonly made worse by laying on your back. The back of the head or scalp can be sore to touch. The head pain can be anywhere from a nagging aching pain to an excruciating migraine headache type of pain, which can be debilitating. The latter type of occipital neuralgia pain is frequently missed and instead treated as a migraine. Most migraine therapies do not work to relieve occipital neuralgia.

Diagnosis of occipital neuralgia is made by careful neurological examination of the patient. Most individuals have normal exams except for exquisite tenderness at the base of the skull, in the area of the occipital nerve. If pressing on this area reproduces the occipital head pain, the diagnosis is made. Treatments can include the use of anti-inflammatory agents such as aspirin, Tylenol, naproxen (Aleve) or ibuprofen (Advil, Motrin.) Ice to the back of the neck and head can provide temporary relief. One of the most effective therapies, which can be curative for occipital neuralgia, is an occipital nerve block. This is a very safe procedure and consists of injecting a mixture of a local anesthetic with a long acting cortisone. This injection is put in the neck muscles just below the skull base, in the area where the occipital nerve pierces through the muscled. The needle is directed away from the spinal cord and is outside the skull so there is no chance of injury to the spinal cord or brain. The anesthetic works immediately and may cause some temporary scalp numbness. The cortisone is long acting - slow release so that it may take a week to be fully effective. Success rates of up to 80% have been reported. In patients with additional types of headaches, it is not uncommon to add an antidepressant to prevent migraines and other similar headaches. The antidepressants are the mainstay therapy in headache treatment and prevention and have nothing to do with their use for treatment of depression. If you think you have occipital neuralgia or have persistent headaches, particularly ones that are always on one side, you should seek out care from a neurologist who is also a headache specialist.

Carpal tunnel syndrome is the most common “pinched nerve” condition that neurologists see. It is a form of compression neuropathy The typical patient comes in with complaints of hand or arm pain associated with one or more numb fingers. There is usually sparing of the little finger. This painful numbness will frequently wake affected patients from their sleep. They will complain of a swollen feeling in their hand (or both hands) associated with painful numbness affecting all but the little finger.

Carpal tunnel syndrome is caused by compression of the median nerve (the “carpal tunnel nerve”) as it pass under the carpal tunnel ligament. The carpal tunnel is located at the wrist. There is a small band of tissue across this to hold down the median nerve and vein. When the carpal tunnel becomes too narrowed, the median nerve becomes “pinched” and the vein is compressed. This combination of events results in the hand becoming numb and swollen. Carpal tunnel symptoms frequently occur only at night, during sleep. This is because we all have a tendency to sleep with our wrists slightly flexed. This position further narrows the carpal tunnel, causing symptoms. As the carpal tunnel narrows further, with time, patients will develop daytime hand numbness. Holding a newspaper, magazine or steering wheel can bring on symptoms. In more severe cases hand grip weakness can occur. Patients find that they have difficulty removing jar lids or may drop objects. Carpal tunnel syndrome occurs in both hand about 50% of the time.

CTS is diagnosed, most commonly by a neurologist, on the basis of the patient’s symptoms and detailed neurological exam. Electrical diagnostic testing, nerve conduction studies (NCV), are necessary to confirm carpal tunnel syndrome - particularly if surgery is being considered. Many patients can have carpal tunnel symptoms and have normal NCV studies. These patients are not candidates for surgery. The standard of care medical treatment for CTS is wearing a cock-up wrist brace. These braces prevent wrist flexion, thereby reducing the pressure on the median nerve. Frequently patients can “cure” their CTS with wearing a brace. For more severe symptoms with abnormal NCV studies, surgical decompression may be indicated. This is a procedure done under local anesthesia. A small incision is made at the wrist and the carpal ligament is cut. This relieves the pressure on the median nerve. Success rate for this surgery is approximately 90%.

If you feel that you have carpal tunnel syndrome, you should see a neurologist and have diagnostic studies performed. Most patients will do well with conservative, non-surgical treatment. For more detailed information click here.

Recent studies have suggested that qualifying Parkinson patients benefit from earlier treatment with deep brain stimulation, as reported in Clinical Neurology News. The study indicates that younger Parkinson disease patients are more likely to benefit from early brain stimulator treatment. There is information that may suggest that this therapy may have a protective effect in delaying the progression of Parkinson’s disease. Deep brain stimulation (DBS) was FDA approved in 2002 for treatment of Parkinson’s disease. Symptoms that are best controlled include tremor and dyskinesias although brain stimulation can also help reduce freezing and off time. Younger Parkinson patients develop motor complications such as dyskinesias, off time and freezing much earlier than older patients with Parkinson’s disease. As reported by Dr. David Charles, a Vanderbilt University Medical Center Parkinson neurologist, “No therapy…has bee shown to slow the progression of Parkinson’s.” The previous thinking was to wait until a patient had severe motor complications that could not be controlled with medications prior to considering DBS therapy. The new thinking, and research, is exploring benefits of DBS in earlier stages of Parkinson’s disease. In various reported cases, patients not only benefited from better control of their Parkinson motor symptoms but also had improved quality of life. Added advantages is that Parkinson patients treated earlier with DBS used less medications over an 18 month period, as shown in one small study. There are two studies currently looking at the benefits of early DBS therapy in Parkinson patients: EARLYSTIM is a French study and a smaller study at Vanderbilt University are in progress. It should be noted that Parkinson’s disease is a progressive neurodegenerative disorder. Even patients with DBS therapy do have progression of their symptoms. Memory loss can be a part of the Parkinson syndrome and is not helped by DBS therapy. DBS is not a substitute for optimal neurological and medication management of Parkinson symptoms. Dr. Kassicieh, at Sarasota Neurology, provides medical and neurological management for patients with Parkinson’s disease and brain stimulators. For more information click here.

Myasthenia gravis is a rare disorder of muscle weakness, affecting approximately 70,000 individuals in the United States. Many confuse this with multiple sclerosis. Multiple sclerosis is a central nervous system disorder affecting the insulation (myelin) on nerve cells in the brain and spinal cord. In contrast myasthenia gravis is a muscle disease where transmission of electrical impulses to the muscle fail. This results in the muscle not contracting fully, resulting in weakness. This condition can selectively affect the eye muscles, muscles of the head and neck or be generalized affecting all muscle, including the diaphragm. If the diaphragm is involved, patients can have varying degrees of breathing problems, including respiratory failure.

Myasthenia gravis (MG) is the standard model of a neurological autoimmune disorder. It is the the best understood of all autoimmune diseases. In autoimmune diseases, the body’s immune system fails to recognize a particular body system as being part of “itself.” In MG, the immune system does not recognize the transmitter receptors for acetylcholine (the muscle communication transmitter) as being part of the body’s own system. The immune system for antibodies against the receptors and attacks them. With fewer receptors on the muscle membrane, the muscle does not get the full chemical message to contract. This causes affected individuals to have weakness in the muscles affected by MG. These antibodies can be detected by a blood test for acetylcholine receptor antibodies. It is important to note, however, that not all patients with myasthenia will have a positive antibody test, known as a false negative (as high as 25%.) Particularly patients with ocular myasthenia frequently have negative tests. This does not mean that they do not have the condition.

Diagnosis of myasthenia is based on a careful medical history and detailed neurological exam. All patients with MG have some degree of visual symptoms including double vision or eyelid drooping. The presence of variable eyelid drooping, particularly if it shifts from side to side, is virtually diagnostic of myasthenia gravis. Confirmatory tests can include EMG testing and a chemical test known as the Tensilon test. Tensilon (edrophonium) is a chemical that temporarily blocks the enzyme that stops the action of acetylcholine. This has the effect of making the acetylcholine receptors that are “on” stay on longer, thereby combating weakness. Patient’s with suspected myasthenia can be given Tensilon. This short acting drug will temporarily reverse the weakness that myasthenic patients have. Other lab work should be performed to exclude other muscle diseases, thyroid problems or other metabolic problems that could cause muscle weakness.

Once the diagnosis is made, patients can be treated with Mestinon ( pyridostigmine.) Mestinon is a long acting version of Tensilon and works by inhibiting cholinesterase, the chemical that breaks down acetylcholine. If we did not have this enzyme, we could not relax our muscles. When acetylcholine is removed from the muscle receptor the muscle no longer contracts. Mestinon works well for symptomatic relief of the muscle weakness and associated symptoms of MG. Other symptoms associated with weakness can include chewing and swallowing difficulties, weakness of breathing with shortness of breath and generalized weakness. Double vision and drooping eyelids, conditions made worse by being in bright sun light, are frequent complaints.

For patients that have persistent symptoms, despite Mestinon therapy, clinicians will frequently employ the use of immunosuppressant therapy that will dampen the response of the immune system. This has the effect of limiting the destruction of the acetylcholine receptors on the muscle membrane surface. The most commonly used drug for this is Prednisone, a steroid drug, frequently used to treat autoimmune disorders. Although Prednisone works very well, it has its downside. Prednisone side effects can include weight gain, elevated blood sugar, cataracts, accelerated osteoporosis and other serious medical problems. Other immunosuppressants have been used with success. These include Imuran (azathioprine), cyclosporine, Cytoxan (cyclophosphamide) and CellCept (mycophenolate.) While being helpful in treating MG, these powerful immunosuppresants have their own lists of potential side effects. The purpose of immunosuppressant therapy is to cause myasthenia to go into remission. This is not always successful.

For patient’s with a severe worsening of their myasthenia symptoms, hospitalization may be necessary. Higher dosage, intravenous steroids can be given in combination with a blood filtering technique, known as plasmaphersis. The latter is used to filter out the acetylcholine receptor antibodies. A surgical technique, thymectomy, can be used to remove the thymus gland in the chest. This gland is responsible for making the cells that make the acetylcholine receptor antibodies.

Myasthenia gravis is a serious neurological condition and autoimmune disease characterized by muscle weakness that can affect vision, swallowing, breathing and general activities. Serious complications, including respiratory failure, can develop for untreated patients. Affected individuals should seek out care from a board certified neurologist, preferably one specializing in movement disorders or neuromuscular disease.

Fibromyalgia is a chronic muscle pain disorder that has no underlying identifiable cause. Sufferers have muscle pain, multiple areas of tenderness and fatigue. It is a poorly understood disorder, with many physicians not even acknowledging that it is a real illness. There is , however ample evidence that fibromyalgia is a real condition as it has been estimated that as many as 6 million Americans suffer from this affliction annually. Patients typically see several physicians and become frustrated when all their testing comes back normal. Other accompanying symptoms may include poor sleep hygiene, headache, mental clouding (fibromyalgia fog) and depression. Although this conditions rarely clears, suffers can be treated successfully with a combination of medications and regular exercise.

The FDA has recently approved Lyrica as the first drug specifically for fibromyalgia treatment. Lyrica (pregabalin) was originally approved for treatment of seizures and painful diabetic neuropathy. Based on two large, double-blind studies with 1,800 patients enrolled, the FDA approved labeling for Lyrica to be used in the non-narcotic control of fibromyalgia pain. The exact mechanism by which Lyrica controls the pain of fibromyalgia is not well understood. I have used this drug extensively in my practice to help individuals with fibromyalgia, who have failed other therapies. With FDA approval, more insurance companies will be compelled to cover this otherwise costly medication.

Other medications have been used to help patients with fibromyalgia. Medications in the tricyclic antidepressant family such as amitriptyline, nortriptyline and trazodone have been used with varying degrees of success. Some anti-inflammatory medication may be helpful as well. In combination with medications, it is important for patients with fibromyalgia to get some type of regular exercise that involves muscle resistance. The combination of medications and exercise provide the best hope for controlling the symptoms of fibromyalgia as there is no definitive cure. Mayo Clinic published an excellent summary of fibromyalgia. If you feel that you have this condition, find a neurologist or rheumatologist in your area that has knowledge in treating this condition.

Shingles is a condition characterized by a painful, blistering skin rash. This rash can affect any part of the body. The medical name for shingles is Herpes Zoster. It is the caused by the same virus that causes chicken pox. People who have had chicken pox are potentially at risk for developing shingles later in their life. Patients who have never had chicken pox can get this from individuals who have an active attack of shingles, as the rash is contagious. Shingles can appear anywhere on the body but tend to follow the distribution of the nerves, as this is where the virus lives. Although severe in any part of the body, facial involvement around the eye presents an even greater problem. If shingles involves the upper face, the eye can be affected, potentially leading to eye complications including infection and corneal ulceration. The treatment of an acute attack of shingles involves giving a patient one of the specific antiviral agents such as Zovirax (acyclovir), Famvir (famcilovir) or Valtrex (valacyclovir) along with Prednisone to shorten the duration of the attack and to lessen potential for development of postherpetic neuralgia. Postherpetic neuralgia develops in about 20% of patients who have had shingles. Shingles is much more common in individuals over the age of 50. Approximately 1 million people in the United States get shingles every year.

The FDA has recently approved a shingles vaccine, Zostavax, to aid in the prevention of this condition. This is an injectable medication that requires only one treatment. The Center for Disease Control has recommended that all eligible patients over the age of 60 be immunized. The requirements for receiving the vaccine are as follows: you are in good health and must not have any condition that would lower your immune system function. Conditions that lower your immune system include diabetes, cancer, chemotherapy or steroid therapy, active tuberculosis, excessive alcohol consumption or acute illnesses such as pneumonia. The best available treatment to prevent shingles is this vaccine.

Postherpetic neuralgia (PHN) is an extremely painful condition that follows after having an attack of shingles. Although the rash and blisters clear, affected patients are left with a searing, burning painful sensation on the skin, in the area of the rash. This is a form of peripheral neuropathy. Their skin can be so sensitive that even clothing or bed sheets brushing up against the skin can trigger severe pain. Unfortunately, narcotic pain killers do not help in reducing this pain. Alternate treatment with nonnarcotic medications is necessary. Commonly used medications for treatment of PHN include the anticonvulsants such as Tegretol, Lyrica, Neurontin, Trileptal and Topamax. Other agents that are helpful are the tricyclic compounds such as amitriptyline, imipramine and nortryptiline. A novel approach to treatment involves using Lidoderm patches. These are lidocaine embedded patches that control the pain without having to take an oral medication. These can be used in combination with oral medications to better control the pain of PHN. Most patients will have clearing of their PHN within 1-6 months. Rarely it can persist for a longer period of time. For patients who have received the shingles vaccine, who subsequently develop shingles, the incidence of developing PHN is significantly reduced and the severity of the symptoms are generally less. Please contact Sarasota Neurology for more information.

“Doctor, my feet burning and are numb.” That is a frequent complaint that I here from my patients. Peripheral neuropathy, a nerve condition, commonly starts in the toes or the feet. Affected individuals may feel this as a numbness, tingling, raw or burning sensation. These symptoms very slowly progress over many years. The most common type of neuropathy affects the nerves that supply sensation in the feet. As the condition worsens and spreads up the legs, it can start to affect the fingers and hands as well. Patients who present with these symptoms all need to be screened for diabetes and vitamin B12 deficiency. Other common causes for sensory neuropathy can include chronic, daily alcohol consumption, kidney failure and chemotherapy. For many patients that have sensory neuropathy, a cause is never found. There are two types of sensory neuropathy: painless and painful. While there is no cure for sensory neuropathy, it is rarely disabling. For patients with painless neuropathy, no treatment is necessary other than treatment of any condition that may be causing the symptoms (diabetes, stop alcohol, etc.) For patients with painful neuropathy, many nonnarcotic treatments are available.

Lyrica is a new antiseizure medication that was approved by the FDA for treatment of painful diabetic neuropathy. Many neurologist also use this drug for treatment of other painful neuropathies with great success. Many of the neuropathy treatment drugs are in the anticonvulsant (antiseizure) medication group. These include Neurontin (gabapentin), Tegretol (carbamazepine) and Trileptal. Some clinicians have had success with Topamax for certain neuropathic pain syndromes. If a patient has difficulty tolerating one drug or a particular drug is not working, then they can be switched to one of these other agents. The other class of commonly used medications used to treat symptoms of painful neuropathy are the tricyclic antidepressants. These agents have a mechanism that blocks pain impulses at very low doses. Since many patients are bothered more by their pain at night, these agents have the added benefit of assisting in going to sleep. They are inexpensive and not habit forming. It needs to be noted that although these medications are labeled “antidepressants” their use to treat pain and headache conditions has nothing to do with treatment of depression. Most patients that are on tricyclic antidepressants are not depressed.

A newer, novel approach to treatment of painful neuropathy is to use a patch called Lidoderm. This is a patch with a special form of Novocaine embedded in it. Patients can put the patches over the area of pain, frequently with good relief. One patch is good for about 24 hours. There is no additional numbing sensation from the patch itself. It is important that patients with neuropathy understands that there is no treatment that will give the the sensation back but only to control the pain or discomfort associated with the neuropathy. Lidoderm has FDA approval for treatment of postherpetic neuralgia, a very painful condition seen after an attack of shingles.

Combinations of various modalities of neuropathy treatment are frequently used to provide patients with an improved quality of life. There are other less commonly used drugs and treatments that sometimes help patients function better. It is important to note that narcotic pain medications are not mentioned here as this class of drugs is notoriously ineffective in treating nerve pain. Additionally, they are habit forming, addictive and tend to lose their effect after a while, requiring even higher dosages which lead further to addiction. In summary, if you or someone you know has painful neuropathy, get them in to see a neurologist that has training in treating this condition.

Trigeminal neuralgia (also known as tic delaroux) is a disorder characterized by a severe, electrical shooting pain in the face. The trigger area on the face is typical around the nose or upper lip. Affected individuals experience a brief but intense electrical or burning pain on the affected side of their face. Trigeminal neuralgia typical affects only one side of the face. The cause of this disorder is unknown in most cases and it is not hereditary. On rare instances, there can blood vessels pushing up against the nerve. Patients with trigeminal neuralgia find that air blowing across their face, brushing their teeth, chewing, washing their face, putting on make up or drinking hot/cold beverage will trigger severe pain attacks. At times, talking can even trigger pain episodes. They can have trouble sleeping at night if they lay on the affected side. Although the majority of individuals with this condition are over the age of 50, it can begin at younger ages. Patients may have daily face pain attacks for weeks to months and then the condition will suddenly go into remission for a period of time. This remission period may last weeks to months but then reoccurs as severe as ever. Other less fortunate individuals have the pain continually.

Fortunately good non-narcotic medical treatment exists to control pain. The main medication used is an antiseizure medication called carbamazepine (Tegretol.) This medication is considered by many to be the drug of choice for treatment of this condition. Tegretol frequently provides excellent, prompt relief and control of facial pain. For patients who cannot tolerate Tegretol, or for those who do not respond, there are severe other antiseizure medications that can be helpful. These include Trileptal, Topamax, Lamictal, Neurontin and Lyrica. Another medication, which is not in the antiseizure class, is amitriptyline. It is important to note that narcotic pain killers do not work well for trigeminal neuralgia and should be avoided.

For patients with intractable trigeminal neuralgia that does not respond to the typically used medications, surgery may be an option for treatment. There are severe surgical procedures that can be effective. Radiofrequency rhizotomy is a commonly performed procedure that provides good pain relief for many patients. It is not an invasive procedure which increases the safety. Glycerol (alcohol) rhizotomy is a similar procedure that can be tried. Gamma knife surgery procedure is a noninvasive treatment using focused radio waves to ablate the nerves responsible for pain. These are the more common surgical procedures used to treat trigeminal neuralgia but should be reserved only for those patients who have not responded to several different medication trials.

For diagnosis, it is necessary to see a neurologist familiar with this condition. Patients all too frequently go to a dentist, thinking they have some type of dental problem. I have seen patients who have had multiple teeth taken out as well as root canals and yet their pain persists. This is because trigeminal neuralgia is not a dental problem. Do not suffer unnecessarily, get into to see a physician who can help.