Migraine and other headache conditions are a common cause of pain. Migraine headaches are the leading cause of temporary disability in the work force. Fortunately, there are many medications that can be used to prevent and treat migraines.

The first therapeutic event which needs to happen is the correct diagnosis of migraine to be made. Patients can have multiple headache types. Headaches which are severe enough to limit activity and are associated with light and sound sensitivity with nausea and sometimes vomiting are most likely migraines. Migraines usually have a pulsating, heartbeat type pain – made worse by movement.

A common type of headache which can mimic migraine is occipital neuralgia. Occipital neuralgia starts at the base of the skull. There the occipital nerve exits the spine and runs up the back of the skull to the forehead. This nerve carries pain fibers. If it becomes irritated, due to trauma, “sleeping wrong” or just routine daily activities; occipital neuralgia headache occurs. The pain can be just as severe as a true migraine. The pain can be on one side, both sides or even isolated to the front of the head. Diagnosis of occipital neuralgia is made by gently pushing at the base of the skull, over the occipital nerve. If this reproduces the headache symptoms, the diagnosis of occipital neuralgia is made. The most effective treatment for occipital neuralgia is a simple injection in the upper neck in the region of the occipital nerve.

Botox was approved by the FDA in 2011 for treatment of intractable migraines. Botox migraine treatment is not for everyone. In order to have insurance or Medicare to pay for Botox, certain criteria must be met. These criteria include:

– 15 headache days a month
– Failed various migraine prevention medications
– AEDs
– Antidepressants
– Certain blood pressure medications
– muscle relaxants
– physical therapy
– migraines must be incapacitating causing missed work or school

All of these criteria must be met before insurance will authorize and pay for Botox therapy for migraines. Once approved, Botox for migraine is a simple, in-office procedure. For experienced migraine doctors, giving Botox for migraine takes about 20 minutes. Botox does not work immediately to relieve intractable migraines. Effects can be felt as soon as two weeks but maximum benefit is at 6 weeks after Botox treatment. Duration of pain relief can be from 6-8 weeks. With repeated Botox treatment for migraine headache, there is a cumulative benefit in many patients. The minimum time in between Botox treatments is 90 days.

For optimum migraine control, affected patients should be treated every 3-4 months. This results in the best migraine control. This in combination with oral medication migraine prevention therapy.

In conclusion, Botox is effective treatment for many headache patients with chronic, intractable migraines. Proper diagnosis and treatment must be given. For insurance to pay for Botox for migraine, specific criteria must be met. If you suffer from persistent, frequent headaches, call Sarasota Neurology today for an appointment. Start improving your quality of life today.


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In this episode of the Sarasota Neurology Podcast, Dr. Kassicieh, a recognized expert  in clinical Botox, provides an overview of  current techniques for treating dystonia, muscle spasm (which may be associated with pain), spasticity from stroke or brain injury with Botox.

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Botox was first FDA approved for medical use in 1989. Since then, Botox has found many medical uses to treat clinical conditions that were previously difficult to treat. Conditions such as cervical dystonia, blepharospasm, hemifacial spasm and spasticity such as that seen in cerebral palsy, stroke or spinal cord injuries have all been successfully managed with Botox.

Other similar products such as Dysport and Xeomin all have uses for cervical dystonia. Most recently, Botox was approved for use for treatment of chronic migraine headaches. Listen for more information on the clinical use of Botox and other similar products.

If you would like to learn more about the benefits of Botox, please call (941) 955-5858 or click here to schedule your appointment today. If you’re outside the Sarasota area and unable to travel here, please locate a neurologist in your area.


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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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Migraine headaches are a common medical condition in the United States, affecting approximately 12% of the entire population. It is estimated that there are 35-45 million migraine and headaches sufferers in the U.S.  An unfortunate fact is that only 50% of all headache and migraine patients are medically treated. Individuals with different types of headaches (or migraines) are either undiagnosed or undertreated. In the 21st century, it is not necessary to suffer needlessly from migraine headache – the number one medical cause of temporary, total disability in the United States.

A new migraine medication has been approved by the FDA for use in treatment of acute migraine attacks. This new medication is called Sumavel DosePro.  Sumavel is an injectable form of the well known migraine medication: sumatriptan. Sumatriptan was first released in United States in 1992 as Imitrex injectable and subsequently the tablet form. Imitrex injectable system uses a small needle to administer the medication, sumatriptan. While this was one of the most effective treatments for acute migraine attacks, it did involve a minor needle stick. For patients who did not tolerate the thought of a needle stick, even this excellent therapy was not an option for them. Sumavel overcomes this problem by the use of a unique, needle-free injector system. Sumavel uses pressurized air to administer the medication. This is demonstrated in this video.

Sumavel comes in a self-contained injector kit. There is no need for alcohol swabs or drawing up sumatriptan into a syringe. With Sumavel a migraine patient, experiencing an acute migraine attack, needs only to snap of the safety cap, flip the small injector lever and press the injector firmly against the skin on the lower, outer abdomen or thigh. Pressurized nitrogen (a neutral gas) causes the sumatriptan change into an aerosol form and this is literally pushed through the skin into the subcutaneous tissue. This delivers a full dose of sumatriptan (6 mg) into the patient. Therapeutic effect and migraine relief can occur in as few as ten minutes. When the injector releases the pressurized air, you will hear and feel a pop noise.  There is a slight stinging sensation when the medication is pushed across the skin, but there is no needle involved. The used injector can then be disposed of in any trash receptacle. As there is no needle, special disposal is not necessary. Most insurances cover this new, novel migraine therapy.

Migraine headaches remain a major health problem in the United States. Migraines are a leading cause of missed school and work. For migraine sufferers who have too many headache attacks, this can lead to the risk of losing their job. This is unnecessary as many excellent and effective migraine control therapies are available. If you suffer from migraines, cluster headaches or any type of headache, do yourself a favor – call Sarasota Neurology for an appointment. As a migraine specialist, Dr. Kassicieh can help to improve your quality of life, control your migraines and give you your life back.


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The FDA has approved two additional medications specifically for the treatment of fibromyalgia symptoms. The first drug to ever be approved for fibromyalgia treatment was Lyrica. Lyrica was developed as an anti-seizure medication and has FDA approval for this and treatment of painful diabetic neuropathy. Since its initial release, the FDA approved its use for symptomatic treatment of fibromyalgia.

Cymbalta was the second drug to be FDA approved for the treatment of fibromyalgia. This has been a tremendous addition to treatment of this disabling condition. The most recent medication approved for FM treatment is Savella. Prior to the FDA approval of these three medications, there were no proven effective treatments for fibromyalgia. What is fibromyalgia?

Fibromyalgia (FM) is a syndrome of diffuse muscle pains, fatigue, subjective weakness and multiple points of tenderness in spinal muscles (neck pain, back pain) as well as extremities. Other symptoms can be seen with FM. Mental clouding known as fibromyalgia fog is seen in some patients. These patients have a poorly understood clouding of their ability to think clearly. They are able to function but just feel slower in their ability to think and some have memory difficulties as well. It should be made clear that these patients do not have dementia. Fatigue is quite prominent and patients do not seem to be able to be able to get enough rest or restorative sleep. Sleep hygiene is frequently disturbed. Affected individuals have difficulty falling asleep or staying asleep, primarily due to their pain. There is a higher incidence of restless legs syndrome and sleep apnea in FM patients. Other common neurological conditions seen include headache, which is often a mixed headache disorder. Patients complain of a dull low grade daily headache combined with intermittent migraine-type headaches. Due to the chronic refractory nature of their pain and associated symptoms, there is a high incidence of depression in FM patients. It is absolutely necessary to recognize this depression and treat it aggressively to improve the quality of life for FM patients.

The precise cause of FM is not clearly understood. Frequently there is a history of preceding physical trauma. This can be seen after motor vehicle accidents with significant physical trauma or after other physically traumatic events. Some patients may develop FM after particularly severe infections or prolonged acute illnesses. There is a genetic component to FM as it tends to run in families. Put another way, if you have a first degree relative who suffers from FM, you have a higher chance of developing this condition than the general population. There is a clear female predominance of this condition. The exact mechanism of the muscle pain is also not well understood. Extensive study of the muscles has failed to reveal any muscle abnormality. EMG studies in affected patients are normal. More recent theories include the concept of central sensitization. In central sensitization, the FM patient’s brain has a different perception of pain signals. These patients seem to have marked hypersensitivity to lower degrees of pain impulses. These impulses are magnified to a much greater degree in FM patient as compared to the general population.

Treatment of FM can be difficult. Over-the-counter analgesics such as aspirin, ibuprofen, naproxen or Tylenol-like products may provide some temporary relief. Some patients may get benefit from a non-narcotic analgesic tramadol. Narcotics should be avoided due to the risk of abuse and addiction. Currently the state-of-the-art treatment in FM is using one of the three agents: Lyrica, Cymbalta or Savella. Lyrica is an antiseizure drug that also has proven effects in certain painful conditions, including FM. Cymbalta and Savella are both antidepressants that elevate the levels of norepinephrine in the brain. Norepinephrine is a major brain neurotransmitter. Higher levels of this transmitter somehow suppress the pain signals in the brain. These are nonnarcotic, nonaddictive medications. They also have added benefit in that they are antidepressants and can treat the depression that so often accompanies the pain of FM. Certainly some type of regular exercise can benefit patients. Each patient needs to find the particular exercise program that they can do without triggering worsening of their fibro pain. Water based or other nontraumatic exercises are the best in this regard.

Fibromyalgia can also be managed by appropriate, well balanced diet. Eat regularly with adequate daily intake of fruits and vegetables. In some patients, a dietary consultation can be helpful in designing a more appropriate diet. Adequate, restorative sleep is critical in controlling and improving the quality of life in fibro patients. If necessary, a mild sleeping agent can be employed. Despite these measures, FM patients will still have good and bad days. On the bad days, one must recognize this and have a more restful, less stressed day.

The first step in getting better, is to see a physician that specializes in treating fibromyalgia. Adequate laboratory testing should be performed to rule out more serious conditions such as thyroid disease, other muscle diseases, rheumatoid arthritis or other connective tissue disorders.


Posted in Back Pain, General Medicine, Memory Loss / Alzheimer's Disease / Dementia, Migraines / Headache, Nerve Pain and tagged , by

Living in Florida is difficult for individual who have migraines and other types of headaches. This is because drops in the barometric pressure can trigger a migraine attack. During the hurricane season in Florida, there are many tropical storms, thundershowers and rarely a hurricane (or hurricanes.) There can just be low pressure weather systems sitting over Florida with no actual “bad” weather. It is not so much the rain that triggers the migraine attack as it is the lower barometric pressure. During the recent string of six different tropical storm and hurricane fronts that lasted six weeks, many patients who normal have perfectly good control of their migraines had their worst attacks ever.

It has been studied extensively as to why changes in barometric pressure, temperature and humidity have such a profound triggering effect on migraine but no definite conclusion has been reached. The effects on the outdoor environment by these weather systems, in Florida, have a profound effect on headache suffers. Not only does the change in weather trigger headache attacks but so does the increase in pollen, mold and fungus spores.

Patients will often claim that they have “sinus headaches.” True sinus headaches belong in the same category as chances of winning the lottery: 1 in 14 million. Why? Because true sinus headaches are rare. What patients are actually feeling is a milder form of their migraine headache, triggered by weather, pollen and molds. Migraine headache symptoms include: nasal congestion, sinus pressure, sensitivity to light and nasal drainage. While these are sinus symptoms, they are part of the migraine syndrome, which is a collection of symptoms associated with migraine. Patients frequently will take sinus medications that will help or stop their headache. This, unfortunately, reinforces the mistaken belief that they are suffering from “sinus headaches.” The fact is, is that sinus medications have a similar effect in relieving headaches as do those of the more specific migraine drugs.

In conclusion, more Florida patients suffer from more headache and migraine attacks during hurricane season (June 1 – November 30) than at other times of the year. About fifty percent of migraine suffers find that changes in weather will trigger their headaches. The best thing to do, if you suffer from migraines or recurrent headaches, is to seek out a neurologist headache specialist and get started on preventative headache treatment as well as migraine treatment specific medication to stop an attack. If you do suffer from allergies, there are many medications to help control this as well.


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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 – a type of facial pain.)

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. These can all result in occipital neuralgia (also called occipital headache or occipital neuropathy).

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 muscles. 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.


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Migraine headaches are one of the most common neurological problems seen. There are an estimated 30 million affected American patients. Despite its common occurrence, fifty percent of affected individuals remain untreated. Why are there so many patients with migraine? A new report in Neurology Reviews has shed some light on migraine risk factors and how they progress.

In this study, conducted by neurologist and headache specialist Dr. Richard Lipton, they found that patients with chronic daily headaches were more likely to be female, overweight and depressed. Other risk factors for daily headaches include head injuries and snoring. Patients also contribute to developing daily headaches by overusing analgesics such as aspirin, ibuprofen or acetomenophen containing compounds – particularly those containing caffeine. Prescription medications containing narcotics, barbiturates and caffeine for migraine treatment also increased risk of more headaches. The overuse of all pain relievers results in rebound headaches. The more headaches you have the more medication you take – the more medication you take the more headaches you have. This cycle must be broken by stopping regular analgesic consumption.

Dietary factors play an important role migraine progression. Excessive caffeine or regular soda consumption constitute significantly to increased number of headaches. Major stress events clearly contribute to migraine progression. Obesity, defined by having a Body Mass Index (BMI) of greater than 30 was associated with a five times greater risk of developing chronic daily headache. The triptan medications, such as Imitrex, Maxalt and others, are excellent choices for treating acute migraine attacks. When they are overused, they can put a patient with frequent headaches at risk for progression to chronic daily headaches. In general, individuals with four headache days per month or less, who take any of the above medications, are not at risk for progression of their headaches to daily headache. If you have more that 4 headache days per month or frequently take pain relievers for headaches, you should see a neurologist headache specialist for evaluation and treatment. The first step to improve your quality of life is to pick up the phone and call.


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How many times have you had an appointment in your doctor’s office, gotten there on time and then had to wait 30 minutes, an hour or even more? We all have. It is one of the frustrating aspects of visiting your doctor’s office. Dr. Kassicieh, at Sarasota Neurology, understands that. He respects patients’ time and makes every effort to see patients at their scheduled appointment time. Dr. Kassicieh does not want his patients waiting for more than a few minutes after they check in, to be seen. He values their time as much as they do and understands his patients have other commitments and time constraints.
Dr. Kassicieh and his staff strive to make sure that his patients are seen in time, tests scheduled and they can leave within a reasonable amount of time. The availability of his website, www.DrKassicieh.com, patients can read about Dr. Kassicieh’s background and learn about the neurological problems he treats. These include neurological problems such as migraine headaches, neck and back pain, Parkinson’s disease, Botox medical therapy and many others. New patients have the availability to download all the required forms, allowing them the freedom to complete these accurately in the comfort of their own home. This saves a tremendous time for the patient in filling out paperwork in the office.
Once the patient comes into Sarasota Neurology, they are pleasantly greeted by our front office manager. Insurance is verified and the patient is brought back for their appointment in a very short time. With the state of the art electronic medical record keeping, Dr. Kassicieh is able to provide better, more efficient care to his patients. Consultations, lab and x-ray as well as other tests and referrals are generated electronically. Once your visit is completed, the completed office visit is immediately faxed to your primary care physician and any consulting physicians you request. Your prescriptions are already printed and waiting for you at check out.
In summary, we here at Sarasota Neurology strive to make the patient comfortable and have a pleasurable experience. You are provided with timely, state-of-the-art medical and neurological care – based on evidence based medicine.  We look forward to seeing our patients and treat them with the respect they deserve. Thank you for visiting our blog site and would invite you to visit Dr. Kassicieh’s website for more information.


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Post-concussion syndrome (PCS) results from injuries to the head. This can range from mild concussions (being struck on the head) to severe head injuries. Not always does the degree of head trauma correlate with the degree and symptoms of PCS. It is estimated that approximately 60-80% of patients suffering a moderate to severe concussion, traumatic brain injury (TBI), will develop PCS. In milder head injuries, PCS will develop up in up to 40-50% of injured individuals. Loss of consciousness is not a requirement for development of PCS. It is not even a requirement that there be a direct head injury. Patients who have sudden jerking movements of the head, particularly in car accidents, with out direct head trauma can suffer from PCS. Risk factors for development of PCS can include lower education level, drug or alcohol abuse, prior head injuries, or preexisting depression or anxiety. The recognition and diagnosis of the symptoms of PCS are important in helping affected patients to return to normal a quickly as possible.

The symptoms of PCS may develop immediately or make take days to several weeks to become apparent. Headaches and dizziness are the most common complaints in patients with PCS. These however are not the only symptoms that can be associated with PCS. Varying degrees of memory loss, concentration difficulty, anxiety, depression, irritability, emotional and behavioral disturbances, insomnia and personality changes. The headaches can vary from mild, dull, generalized headache to severe migraine like headaches. These headaches usually occur daily and can be quite debilitating. Dizziness can be anywhere from lightheadedness to a spinning type of dizziness known as vertigo. Patient can have irritability, anxiety and depression, partly due to the head injury but also from the persistence of their symptoms. Insomnia frequently accompanies these other psychological symptoms. In more severe case, behavioral changes can occur. Patients can become impulsive and irrational in their behavior. Psychological changes are more apparent later in the course of PCS. Decreased ability to concentrate and slowness in mental function can occur, particularly in higher functioning individuals.

Treatment for PCS is primarily time. Many of the symptoms of PCS will clear within days to a few weeks. A typical time for clearing of symptoms is usually 3 months and as much as 6 months. In 10-15% of the cases it can take a year or more for improvement. The earlier the diagnosis is made, generally the better the outcome. Headaches and dizziness complaints most commonly bring the patient to a doctor’s office. Patients may have tension headaches, migraine headaches or a condition known as occipital neuralgia. The latter is an injury to the occipital nerve at the base of the skull. The most effective treatment for this condition is an occipital nerve block. Other headache conditions are treated with the usual preventative migraine medications protocols. As anxiety, irritability and depression are common symptoms of PCS, the antidepressant medications are the most effective treatment for both the headaches and psychological symptoms. Antidepressant medications have been used for decades in controlling migraine and other headache disorders. Over-the-counter analgesics can be used to relieve headache and neck pains. Narcotics should be avoided as they are addictive and do not help the overall patient outcome.  Mayo Clinic has an excellent, comprehensive summary of post-concussion syndrome.

In patients who have persistent complaints of memory loss, concentration difficulties, forgetfulness, anxiety and depression, neuropsychological testing followed by counseling can be helpful in patient management and improvement of symptoms. Testing is usually not done for at least 3-6 months following the head injury. This is because so many patients will spontaneously improve over this time period. Once testing is completed, the psychologist can help the patient through counseling to improve their overall well being. Other diagnostic tests may be performed and can include MRI brain studies, EEG or PET scan.

Prognosis for patients with PCS is excellent in the majority of the cases. Most patients are back to their normal baseline within a few weeks, with a few taking as long a 3 months. It is far less common for patients to continue having symptoms beyond this. It is estimated that only about 15% of patients with PCS will have symptoms a year or more. Early treatment by experienced neurologists or other physicians who have training in treatment of concussion, traumatic brain injuries and post-concussion syndrome are important in improving a patient’s quality of life in as short of period of time as possible.


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