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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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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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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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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As a neurologist who sees many patients with neck, back and various joint pains, I practice an area of medicine known as neuro-orthopedics. As such, I treat patients for their pain without surgical intervention. Many patients with neck, back and joint pain (knee pain, shoulder pain, elbow pain, etc.) can be successfully treated without invasive surgery and the many risk that go along with this. With surgery there is also a prolonged recovery time and need for extensive rehabilitation. The area of medicine that applies to successfully treating patients without surgery or use of narcotic medications is known as regenerative medicine. In this field, platelet rich plasma is injected into the affected joint, tendon, ligament or soft tissue area that has pain and is failing to heal completely. Tendons attach muscle to bone and ligaments attach bones to bones. Platelet rich plasma (PRP) is the concentrated healing components of the blood. Only one percent of the blood contains the bioactive proteins and platelets that are involved in healing. Through a specialized process, we can take the patient’s own blood and concentrate the platelets and bioactive proteins up to 500%. This small amount of concentrated PRP is then injected into the joint or other body area, that needs regeneration, after local anesthetic is administered. The PRP graft is then activated with thrombin and the healing process begins. Using the patient’s own blood eliminates the risk of transmitting disease and prevents graft rejection. PRP also has the benefit of being antimicrobial, killing off bacteria thereby limiting the risk of infection. David Crane, MD published an excellent overview of platelet rich plasma.

Platelet rich plasma works by first being injected into the affected area and activated. The activated platelets attach themselves to the damaged tissue, whether that be tendons, ligaments, muscle or bone. The platelets release alpha granules and dense particles. The small packets contain powerful bioactive proteins that begin the healing process. The alpha granules contain clotting factors, growth factors, cytokines and adhesion molecules. These substances allow the PRP graft to attach to the damaged tissue and start recruiting other healing cells to migrate into the area. The dense particles contain proteins that allow the platelets to clump together, forming the structural matrix of the PRP graft.

(more…)


Posted in Back Pain, General Medicine, Nerve Pain, Pain, Platelet Rich Plasma and tagged , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , by

Parkinson’s disease is the second most common neurodegenerative disorder, just behind Alzheimer’s disease. Parkinson’s disease is characterized by specific clinical symptoms including rigidity (stiffness), slowness of movement, unsteadiness (gait imbalance) and tremor. For the accurate diagnosis of Parkinson’s disease to be made, a patient needs to have 3 of the 4 major symptoms of the disorder. Each patient with Parkinson’s disease is different and may have differing degrees of each component of Parkinsonism. Not all patients with Parkinson’s disease have tremor. Some may have more instability of gait, shuffling or slowness of movement. There are several medications available that neurologists can use to treat Parkinson patients to alleviate their Parkinson symptoms and improve their overall quality of life. Unfortunately, there is a down side to this treatment. Patients who have been on Sinemet for a few years tend to develop motor fluctuations. Motor fluctuations include end-of-dose wearing off, where their functional abilities deteriorate before the next dose of medication is due. Other motor fluctuations include freezing and off time.
Parkinson freezing is simply when a patient becomes “stuck” meaning they cannot move. This occurs more frequently when going through doorways, stepping up onto a curb or stair or when getting up to start walking. Freezing can also occur first thing in the morning, just when getting up out of bed. Freezing episodes can last for a second up to a few minutes. It is the goal of every Parkinson’s disease neurologist to minimize a patient’s amount of freezing, through various medications and dosing schedule changes. Off time can occur in two settings: one is predictable, usually at the end of the dosing interval but the other occurs randomly, without warning. These sudden off time events are more problematic as they tend not to respond as well to medication changes. Off time is troublesome for the patient and caregiver. Affected patients become virtually immobile, essentially frozen in place. There are different degrees of off time, but in all cases, the patient’s mobility and ability to function are severely impaired. Off time may last minutes to hours. For those patients with short duration off time, additional medication or shorter dosing intervals usually will help. Off time may also occur first thing in the morning when waking up. Even if Parkinson patients take their medications, it may be an hour or more before they are functioning normally. For patients with prolonged off times, usually greater than 45 minutes, there is treatment.
Apokyn (apomorphine) is a self administered injectable medication that rapidly relieves off time. Its duration of action is generally less than 2 hours. This is an ideal medication for patients with one or multiple daily freezing episodes. For those affected patients, Apokyn can literally give them their lives back, particularly when more waking hours are spent in the “off time” than in “on time.” For a patient or caregiver to administer Apokyn, some training is required. This is covered by the drug manufacturer and by Medicare. Side effects can include a drop in blood pressure, lightheadedness, nausea or vomiting. When initially starting a patient on Apokyn, medication to prevent nausea is given first. After being on the Apokyn for a few weeks, patients frequently can stop the antinausea medication.
If you are a patient or caregiver and feel that Apokyn may be of benefit, contact your neurologist or Parkinson disease specialist for more information. An excellent information package, with DVD, is available at no cost. The first step is to make the call to improve your quality of life.  For more information, visit the website for Dr. Kassicieh at: www.DrKassicieh.com.


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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.


Posted in Migraines / Headache, Nerve Pain and tagged , , , , , , , , , , , , , , , , , , , , , , , , , , , , , by

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.


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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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