How I Avoided Knee Surgery

Parkinson disease was first described by James Parkinson in 1817 Over the years, various medication therapies have been FDA approved for Parkinson disease. In the 1960s, Sinemet (carbidooa-levodopa) was approved. Sinemet was and still is the gold standard therapy for Parkinson disease. While it is the gold standard, it should not be the first drug used to treat Parkinson disease. It should be the third or fourth drug used. Early use of Sinemet can result in unwanted, irreversible side effects.

Dopamine agonist were FDA approved in the 1990s for first line Parkinson disease therapy. These medications mimic the effect of dopamine in the brain of Parkinson disease patients. Dopamine is the brain chemical that is deficient in these patients. Mirapex (pramipexole) and Requip (ropinirole) are two commonly used dopamine agonists in the treatment of Parkinson patients.

The newest dopamine agonist which was FDA approved for Parkinson treatment is Neupro. Neupro is unique in that it is a dopamine agonist patch medication. This transdermal patch system is applied once daily to clean, dry skin. The benefit is that Parkinson patients get a 24 hour continuous medication dosing. Patch application sites need to be rotated daily, to prevent skin irritation. Neupro comes in several dosage strengths. Like other Parkinson medications, the dose needs to be adjusted for ideal patient functioning, with minimal side effects.

Dopamine agonists can have potential side effects. This class of medication can cause symptoms of hallucinations, confusion, lowered blood pressure, drowsiness, sudden sleep attacks – particularly while driving. Other side effects include stomach upset, nausea and compulsive behaviors – including gambling, eating and hypersexuality.

Parkinson disease does not need to be a disabling condition. With careful neurological management and detail to your specific needs, a Parkinson patient can have an excellent, functional quality of life for many years.


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Sarasota Neurology is proud to announce the addition of Nora Davis, ARNP to the practice. In addition to her medical experience of 20 years, she has had extensive training and interest in dermatology to enhance patients’ facial appearance. Nora brings to Sarasota Neurology her expertise in skin health and rejuvenation. Additionally, with her medical experience and interest in neurology, she is seeing neurology patients as well. Dr. Kassicieh has had over 20 years of experience in performing Botox therapy for many different medical conditions. As a bonus, doing Botox for cosmetic purposes came naturally. Since 2009, he has been doing platelet rich plasma therapy (PRP), the first Sarasota platelet rich plasma doctor doing non-surgical neuro-orthopedics. Platelet rich plasma therapy is done in the office, using your body’s own natural ability to heal itself. PRP therapy can also be used for cosmetic purposes in hair growth and natural, non-surgical face lifts.
Nora is a Board Certified, Advanced Registered Nurse Practitioner, who has been practicing medicine for over 25 years, trained in dermatology aesthetic procedures and most recently joined an Osteopathic specialist, Sarasota neurologist Dr. Daniel Kassicieh. She has her Master of Science Degree from the University of South Florida. Nora is a member of the American Academy of Nurse Practitioners, Southern Gulf Coast Nurse Practitioner Council, Board member of the American Cancer Society of Charlotte County and Certified American Heart Association CPR instructor.
Five years ago Nora entered the dermatology field of Medical Aesthetics. In primary care Nora found a passion in dermatology. Beauty in treating and preventing skin conditions such as acne, rosacea, and skin cancer became her main focus. She has had extensive education and training in aesthetics for facial skin care, laser therapy, Botox, Juvederm and other treatments to reduce or eliminate facial wrinkles and other signs of aging. The goal is to avoid She is an educator and clinician with the Obagi® skin care systems. Additionally she does chemical peels, and performs facial injectable procedures. She focuses on tissue regeneration for wrinkles, laxity, brown spots, dryness and dullness. This, combined with platelet rich plasma therapy to replace facial collagen is the ultimate in facial skin care. Nora promotes wellness and beauty for health management in all ages. She is dedicated and committed to providing the best possible care to her patients to feel and look their best. It is all about quality of life – if you look better, younger – you feel better. Call Sarasota Neurology now for your appointment for a new youthful look and start to reverse the effects of aging.


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How I Avoided Knee SurgeryI remember it like it was yesterday. While playing racquetball in December 2011, I felt a sudden click in my right knee. I just knew that I had torn my right knee medial meniscus. The knee MRI  proved it. The pain was excruciating, and it was compounded by the thought that this happened 9 weeks before my annual Rocky Mountain ski trip.

The misery did not last long though. I’ve been through this scenario before. I did the exact same thing to my left knee in 2010. (I have the MRI for that one, too!) So, I turned to the revolutionary treatment that got me back up on my feet and on the slopes last time this happened.

If I had gone the surgery route, my trip would have been cancelled, as surgery and rehab can take 3-6 months – with no guarantee of outcome. But I was on the slopes as planned! — Not just any slopes, but the “Expert” slopes! I skied for three gorgeous days in a row without pain or problems! No surgery. No downtime. No rehabilitation. Just a simple injection and then my body did the rest.  I was completely healed, completely pain free by the time I left for my trip. All this only eight weeks after treating my right knee.

Sound too good to be true? Well it’s not…it’s PRP – platelet rich plasma. PRP is the cutting-edge therapy that even professional athletes have turned to when faced with career-limiting injuries.

PRP is short for platelet rich plasma. With PRP, a patient’s own blood is drawn and the platelets are extracted into a small amount of your own blood plasma. Platelets contain numerous beneficial, natural growth factors and chemical messengers that initiate and aid in healing and tissue regeneration. As the PRP is derived from the patient’s own blood, there is no risk for rejection or disease transmission. The PRP is then injected into the injury site. In my case, my knee. It’s that simple. Still not convinced? Let’s compare PRP therapy versus traditional arthroscopic knee surgery, which would be the usual prescribed course of treatment for an MRI proven torn meniscus.

Risks associated with Surgery may include:

  • Possible complications due to anesthesia
  • The surgical procedure itself – with no guarantee of pain relief
  • Increased knee pain during recovery process
  • 3-6 months rehabilitation after surgery
  • 3 hours or more of lost work per week due to therapy plus drive time to appointment
  • Use of narcotics to manage pain
  • Possible risk of addiction to pain killers

Risks associated with PRP:

  • Essentially zero

Pretty startling contrast between the two, don’t you think? Oftentimes, patients may complain PRP is not covered by traditional insurance and therefore too expensive to pay out-of-pocket.  If you look at it a different way: Add up the co-payments associated with both the surgery and 3-6 months of rehabilitative therapy plus the missed time at work, you could have easily covered the cost of PRP therapy. That does not even include the downtime that you will have before and following surgery.

Remember, with PRP therapy there is no recovery time, no anesthesia, no narcotics, no downtime. You have one shot on Friday and are back to work on Monday.

PRP may not be right for every situation, but if you have an injury or condition that you’ve been told requires surgery, it’s definitely worth checking out! This is true not only for knee problems (not limited to a torn meniscus) but also for shoulder pain, rotator cuff injuries, hip pains, ankle injuries and plantar fasciitis (foot pain.) Remember: surgery is irreversible and narcotics are addictive. Surgery never comes with a guarantee and frequently patients have more pain after the surgical procedure. Avoid them if at all possible! For more information on the non-surgical treatment of joint pains and learn more about Sarasota PRP here.

I remember discussing my knee with my physical therapist friend who marveled at my rapid, complete recovery. He looked at me and said, “Why isn’t there a line out your door right now of patients waiting to get PRP instead of surgery?”  I thought to myself, “He’s right. Too many patients are getting knee, shoulder and foot surgery who could do extremely well with PRP therapy.”

Ready to make your appointment today and start living pain free?


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Parkinson’s disease is a complex constellation of symptoms. As reported in the August 30, 2011 issue of Neurology, neurologist care of Parkinson patients greatly improves their quality of life and long term clinical outcome. Parkinson disease affects approximately 1 million Americans. It is only second to Alzheimer’s disease as a common neurodegenerative illness. Early diagnosis, recognition of associated symptoms and comorbidities as well as comprehensive care are necessary if a Parkinson patient’s long term clinical outcomes and quality of life are to be maintained.

Neurology has commonly not been taught in the detail that is necessary in most medical schools. Medical students graduate, generally with a limited understanding of neurological diseases and the treatment required for each. Neurology has a vast scope of illnesses, each requiring intimate knowledge and understanding of the disease process as well as the treatment required to optimize patient well being and life quality. It is beyond the scope of medical school, internship and even family medicine or internal medicine residencies to train the young physician sufficiently in the details of neurological disease.

Across the United States, 15-20% of all visits to a primary care doctor’s office (family physician or internal medicine) involve a neurological complaint. While simple problems such as back or neck pain can easily be treated, more complicated illnesses such as Parkinson’s disease, migraine headaches, seizures and multiple sclerosis should be managed by a neurologist – particularly a sub-specialist neurologist in the disease process needing treatment. Surveys in the United States, Europe and Asia show that both medical students and general physicians do not feel as comfortable in managing neurological problems as they do other common medical problems.  The article in Neurology clearly shows that Parkinson patients, managed by a neurologist, have overall better outcomes than those managed by family physicians.

Parkinson patients managed by  a neurologist have  an earlier diagnosis. This leads to starting treatment earlier. With early intervention, patient functioning can be maintained and optimized. This allows for the patient and their families to enjoy more quality time together with an increased ability to engage in social activities and travel. The study reported in Neurology, looked at over 138,000 Parkinson patents. The finding of this study showed that about 20% of patents with Parkinson’s disease never see a neurologist. These patients had a higher rate of falling, hip fractures, nursing home admission and death at an earlier age.

Parkinson patents cared for by a neurologist, by contrast, significantly had fewer hip fractures. Hip fractures are a major cause of disability and death in the elderly. Inherent to Parkinson patients is gait instability and a tendency for stumbles and falls. Falling prevention is a main goal in all elderly patients, but particularly those with Parkinson’s disease. Unfortunately, many who suffer a hip fracture may become wheelchair confined, even with successful hip fracture repair.  One third of all patients who suffer a hip fracture will die within a year of their fracture! The annual cost of managing a patient with a hip fracture is $20,000 per person – not including medical costs. With detailed care of all of a Parkinson patients symptoms, a neurologist can better prevent these patients from falling and suffering fractures.

The second finding of this study was that Parkinson patients getting state-of-the-art care by a neurologist had a lower probability of being admitted to a nursing home. While most Parkinson patients do not need nursing home care, those with more advanced disease, Parkinson related dementia or complications such as hip fractures frequently need skilled nursing facility placement. Parkinson’s disease is complex condition. Not only are the motor symptoms a major problem, but so are the cognitive and psychological problems that go along with this disease. Depression and anxiety occur in over fifty percent of Parkinson patients. Early recognition and treatment  is critical for improved patent and caregiver quality of life. Dementia is also a common problem. It can start as mild memory loss but will progress. Neurologists are sensitive to these problems and there are medications as well as dietary supplements that help to improve these problems.

The final finding of the Neurology study was that there was a statistically significant increase in the six year survival of patients with Parkinson’s disease managed by a neurologist. There are multiple reasons why this may be the case, including earlier use of the many types of medications used in Parkinson management, treatment of coexisting psychiatric problems and addressing the multitude of other medical problems that are frequently associated with Parkinson’s disease.

The conclusion for Parkinson patients and their family or caregivers is to get that patient into see a neurologist, particularly a neurologist who specializes in movement disorders. Patients want more control over their life, improved quality of life and the ability to remain functional as long as possible. This is true for the Parkinson patient as well. Take control of your life, contact Sarasota Neurology for consultation and management of your Parkinson’s disease. It will most likely be the best thing you could do for yourself – for the rest of your life.


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Lower back pain is a common complaint seen by almost every primary care doctor in the United States. So common in fact that 80% of the population will experience at least one episode of significant low back pain in their life. Many will experience recurrent episodes of lower back pains. Of those patients, one third will have some degree of leg pain in one or both legs. Back pain and most cases of associated leg pain do not originate from lumbar (lower back) spinal disc problems. There are many pain fiber bearing structures in the lower back including muscle, tendons, ligaments, vertebral joints and bone itself. The good news is that over 97% of all low back pain problems can be treated without surgery. Low back surgery is the most commonly overly performed surgical procedure in the United States and all too frequently the results are poor and even worse, makes the patient’s condition (back pain) more severe.

In the vast majority of patients, a careful history and detailed physical exam is the basis for developing a comprehensive, conservative treatment plan. Most patients show significant back muscle spasm with tenderness. Some will have exquisite tenderness in the sacroiliac joint where the tail bone meets the hip bone – a condition known as sacroiliitis. Piriformis Syndrome can cause low back pain and leg pain, but there is no spine involvement in this condition. The patient’s neurological exam is usually normal – it is uncommon to find clinical evidence of lumbar spinal nerve root compression (“pinched nerve”). In any clinical setting however, non-surgical treatment is indicated. Even in individuals who have evidence of a disc herniated, on exam, need conservative therapy – physical therapy, massage and anti-inflammatory medication. The natural history of disc herniation is to heal without the need for surgery or other invasive procedures such as epidural spine injections. A specifically designed course of hands on physical therapy combined with neuromuscular therapy in combination with self administered back stretching exercises will result in favorable outcomes the majority of the time While not clinically needed, many patients undergo CT or MRI scanning to look for the cause of their low back pain. This is where the road splits on the proper decision to use appropriate conservative therapy or improper decision to go to with an invasive route such as spinal injections or worse, surgery. Studies have shown that epidural steroid injections are no better than placebo. Other studies have shown that the outcome of back pain patients treated surgically is no better than those treated with best medical therapy. Narcotics should be avoided as they are habit-forming and do nothing to clear up the pain.

For patients that do get MRI studies, it is not uncommon to find spine MRI abnormalities. The important fact is that these abnormal MRI findings do not necessarily explain the pain that that individual is experiencing. To account for an individual’s back pain or sciatica (leg pain), the MRI findings must correlate exactly with the patient’s symptoms and neurological exam to have clinical significance. MRI studies of normal individuals without back pain or sciatica have been done. The results have shown that approximately 55% had bulging discs at one or more levels, 28% had disc herniation on the MRI scans. More than 70% of the MRI scans showed abnormalities and yet the patients had no symptoms! These MRI scans were done on patients who never had any back or leg pain – 70% of the MRIs were “abnormal.” The conclusion that just because the MRI scan shows “something”, does not mean that the findings are the cause of any given patient’s back or leg pain.

With conservative treatment and patient cooperation to do the back exercises, most patients have significant relief with clearing of their pain within 4-6 weeks. It is then important that patients continue to do their back exercises on a regular basis, as part of their daily exercise routine. Physical body reconditioning and core strengthening will also help a great deal. Back surgery (or neck surgery) can almost always be avoided. If you have back or neck pain that is troubling you, contact Dr. Kassicieh now for treatment.


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What do you think of when you think of neck or back massage therapy? Most people think of the type of massage you would receive if you went to the spa for the day.  That type of massage therapy is known as a Swedish Massage. Swedish Massage is only one of over 40 types of massage that a person can receive. When you say you went to see your doctor today, what do you think of?  If I went to see my family doctor, my image would be different than if I said I went to see my Cardiovascular surgeon.  They are both doctors, but the exams and procedures that they perform are vastly different.

The field of massage is similar in its sub-specialization within the scope of massage therapy. Swedish Massage is great for relaxation and stress reduction, but if your back just went into spasm and is  locked up, you would be much better served going to a Massage Therapist that specializes in Rehabilitation and back pain relief.   Neuromuscular Therapy, Myofascial Release, Positional Release and Muscle Energy are just a few of the specialized massage techniques that were developed to treat muscle pain and skeletal dysfunction.  These techniques are focused on looking at the role of the soft tissues in causing pain. Soft tissues include muscle, tendon, ligament and fascia. Fascia is the covering over muscles and internal organs that provide stability and strength. Neuromuscular therapy treats fascia and muscle pain. Myofascial Release treats connective tissue disorders, particularly tight fascia which is a painful syndrome that frequently accompanies muscle pain and spasm. Positional Release treats muscle spasms, muscle energy treats joint restrictions.

These techniques are taught to Massage Therapists as advanced, highly specialized postgraduate courses. Just as a doctor can practice medicine after four years in medical school, he/she must first participate in a postgraduate internship and residency program to specialize in his/her specific field of medicine.  A Massage Therapist who is treating patient for acute and chronic muscle and joint pain should have more than just basic, Swedish Massage training. What patient’s want most is pain relief.

In summary, specialized massage therapy for medical conditions, requires advanced training on the part of the massage therapist. Many hours of postgraduate massage therapy education and training is necessary for successful outcomes in the treatment of patients suffering from pain in the neck, back, head or extremities. For more information visit Soar Point Massage or contact Jack Ryan, LMT a 941–993-3339 for an appointment.


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Do you have knee pain? Tear a knee meniscus, sprain a ligament or have symptomatic knee arthritis or bursitis? Knee injuries, cartilage tears or tendon sprains are common causes of knee pain. Many patients can get relief with rest, wearing a knee brace and taking an aspirin, ibuprofen or other pain relieving agent. Sometimes a cortisone injection will relieve the knee pain without further treatment. When knee pain persists, patients seek out orthopedic surgical opinions. All too often, patients are told that surgery is their only option. Unfortunately surgery does not always work and patients are left with persistent knee pain. They then resort to narcotic pain killers to relieve pain.

Platelet rich plasma therapy has been FDA approved for medical use for over 20 years. Platelet rich plasma is derived from your own blood, eliminating risk of disease transmission. Two ounces of blood is drawn and the natural healing component of the blood is concentrated by 500%. This is the platelet rich plasma, (PRP). PRP is the concentrated healing component of blood. This can be injected directly into the knee joint (a relatively painless procedure.) Platelet rich plasma will heal damaged knee tissue naturally, using the body’s own healing mechanism to repair the damaged meniscus, ligament or tendon. In patients whom suffer from bone-on-bone arthritis as a cause of their knee pain, platelet rich plasma can stimulate the natural regrowth of cartilage, which relieves the pain. PRP can also help patients who have had arthroscopic surgeries who still have knee pain. Avoid surgery, stay off narcotics.

Using PRP has many advantages: 1) it is an outpatient procedure with no recovery time, 2) it requires no general anesthesia, 3) there is no rehabilitation required, 4) healing occurs by a completely natural process, 5) complications are almost unheard of and 6) cost is much less than surgery. If you have knee pain or other joint pain, you should look into getting platelet rich plasma therapy a proven, non-surgical treatment for joint pain. For more information go to our Sarasota PRP for knee pain page or call Dr. Kassicieh at 941-955-5858 for an appointment.


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Huntington’s disease is a neurodegenerative disease that is a genetic, progressive neurological disorder that slowly takes away a persons ability to walk, talk, and reason. It is characterized by the initial subtle symptoms of change in personality and motor skills ability. As the condition progresses, patients develop involuntary movements known as chorea (hence Huntington’s Chorea.)  The word chorea comes from the Greek word choreia, which means “to dance”, which describes the uncoordinated, jerky body movements associated with the condition. Other motor symptoms eventually appear and may include difficulty speaking, walking or writing.  It was reported in detail in 1872 by the American physician, George Huntington (1850-1916).

Symptoms of Huntington’s disease usually appear between the ages of  35-44 years old. Affected individuals can show a general lack of coordination and an unsteady gait.  Other symptoms include  depression, mood swings, forgetfulness, clumsiness, and involuntary twitching. As the disease progresses, concentration and short-term memory decrease and involuntary movements of the head, trunk and limbs increase. Huntington’s dementia eventually occurs. Patients will have memory loss associated with difficulty in abstract thinking, planning and avoiding inappropriate behavior.

In 1993, scientists discovered the gene that causes Huntington’s disease. HD is a genetic mutation stemming from the formation a chain of abnormal DNA sequences. There are four building blocks of DNA. Repeating DNA chains of cytosine-adenine-guanine (CAG) code for the protein glutamine, an amino acid. As a result, these long glutamine chain proteins clump together and are toxic to brain cells (neurons.) The more CAG repeat sequences there are, the more severe the symptoms of HD.  Scientists have also discovered the more severely the gene is mutated, the earlier the onset of the disease.

There is no known cure for Huntington’s disease at this time .  There are, however, treatments which can be employed to reduce the severity of some symptoms.  Tetrabenazine was developed specifically to reduce the severity of chorea in HD. Other drugs that help to reduce chorea include Haldol, Risperdal and other neuroleptic medications. Valium like drugs known as benzodiazepines may also be helpful. Rigidity can be treated with antiparkinsonian drugs, and myoclonic hyperkinesia can be treated with valproic acid. Depression is common in HD and can be managed with medications in the serotonin reuptake inhibitor family, such as Prozac or citolopram.

Huntington’s Disease profoundly affects not only the patient, but the entire family — physically, emotionally, socially and economically.  Since there is no known cure and the prognosis is poor, a plan of action should be developed jointly with a qualified neurologist who specializes in movement disorders so that the patient’s quality of life can be maintained as long as possible. Your neurologist can also help you locate and connect to some of the many support groups, organizations, and resources available to help with both the patient and the family and caregiver(s).

Innovative research is underway and aims to find better treatment options and ultimately hope and a cure for this debilitating condition.  If you suspect that you or someone you love may be suffering from Huntington’s Chorea, contact Sarasota Neurology for an appointment.


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Patients are being treated currently at Sarasota Neurology with PRP (platelet rich plasma) for a wide variety of joint pain and other pain issues. Among the more common uses for PRP are knee pain, shoulder pain and other painful conditions such as plantar fasciitis, tennis elbow, some types of low back pain. PRP can also be used in patients that have residual joint pain from having had orthopedic arthroscopic knee or shoulder surgery.

PRP works to heal painful joints by using the patients’ own natural biological healing mechanism. The injured or damaged tissue in the joints, ligament and tendons or muscle send out chemical signals that there is injury or incomplete healing. PRP has receptors on the active platelets that seek out these damaged tissues. The PRP graft then biologically and molecularly attach to the damage tissue and trigger the natural healing process of making new collagen. This process takes six weeks to have a full effect although actual healing can continue for up to three months.

PRP may be used in some patients as an alternative to having surgery on their knees, rotator cuffs or in cases of plantar fasciitis (foot pain). Beginning in early 2011, Sarasota Neurology will be offering a new and innovative uses for PRP. This highly effective treatment is ideal for patients who would prefer to avoid the cost, pain and time involved in having surgery for the same problem. Check back with us in February to get more details of this exciting treatment with PRP in Sarasota.


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In October 2010, the FDA gave approval to use Botox for the preventative treatment of chronic migraine headaches. Allergen, the manufacturer of Botox, has long sought approval of Botox for migraine treatment. After conducting numerous nationwide clinical studies using Botox for headache, the most recent study, PREEMPT, showed that patients suffering from chronic migraines who were treated with Botox for preventative therapy, had significantly fewer headaches days a month than those that did not get Botox.

Chronic migraine, as defined by having more than 15 headache days a month, is one of the most disabling conditions a person can suffer from. A severe migraine can be more disabling than blindness, rheumatoid arthritis or even chest pain (angina). It is estimated that there are 3.2 millions Americans who suffer from chronic migraine. This condition affects quite commonly working aged individuals. Seventy-five percent of affected migraine sufferers are female. Migraine and headaches are a complex medical disorder which can be affected by stress, poor sleep and dietary habits. These individuals tend to overuse over-the-counter medications resulting in rebound headaches. Preventative therapy and not constantly taking abortive medication is the correct approach to managing most headache and migraine disorders. The objective is to prevent the headaches from occurring in the first place. With optimized treatment, it is usually possible to get most patients down to a manageable number of headaches per month – in our clinic four headache days or less. Only then would abortive medications be used. Narcotic medications of any kind should almost never be used for the treatment and management of migraines or headaches.

Botox is not the answer to everyone’s headache and migraine problem. This is only one of the many treatment options that headache specialists have to manage chronic migraine and other headache disorders. Careful patient selection and meticulous Botox administration are necessary to have improved outcomes in headache reduction. Not all individuals will respond to Botox, just as any other preventative medication. Botox should not be considered the first or even second line treatment for patients suffering from chronic migraine. It should be reserved for those that meet the criteria for chronic migraine and have adequate trials of most other preventative medications. Botox administration also requires a patient to receive the drug administered via a number of injections in the scalp and upper neck regions. The smallest needles are used to minimize any discomfort. If successful, a patient who responds to Botox may get as much as two to three months of relief. Getting perceived relief for only 2-3 weeks is not considered a successful response to Botox.

If you think that you suffer from chronic migraine headaches, you should call us today for a complete evaluation and then have a treatment plan designed to address your specific type of headaches.


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