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Important COVID-19 Announcements HERE

New Alzheimer’s Drug – Aducanumab (Aduhelm) Information HERE

Please note:  NCPA physicians do not prescribe narcotics for the treatment of headaches or migraines. 

Introduction

Headaches are a common health problem and one of the most frequent reasons for neurological consultation. Tension headaches are the most prevalent headache type, and are usually mild, not associated with significant disability, not lateralized, are not throbbing/pulsatile, and are responsive to over-the-counter analgesics. Migraines, on the other hand, are described as throbbing, often lateralized, intense or severe headaches, often associated with nausea, vomiting, sensitivity to light, sound or smell, and exacerbation with movement. In some cases, migraines can be preceded or accompanied by visual or sensory disturbances.

Migraine affects approximately 12% of the United States population and is, in most instances, an inherited disorder. However, they are often incorrectly diagnosed as sinus headaches, tension headaches, cluster headaches, or neck pain. Correct diagnosis is essential so that appropriate treatment can be successfully implemented and improve the patient’s quality of life.

Mechanisms of Migraine

The once popular vascular theory of migraine, which suggested that migraine headache was caused by the dilatation of blood vessels, while the aura of migraine resulted from vasoconstriction (constriction of an artery), is no longer considered accurate.  The current prevailing theory is that dysfunction in certain parts of the brain leads to a sequence of changes intracranially and extracranially that account for migraine, including the four phases of premonitory symptoms (before the onset of migraine episode), aura, headache, and postdrome (after effects of the migraine episode).

The genetic basis of migraine is likely to be complex and in some people may be based on the cumulative effect of more than one genetic source.  People prone to migraine have a genetic threshold that renders them susceptible to an acute migraine attack depending upon the balance between stimulation and inhibition in different parts of the nervous system.  Subtle dysfunction, involving membrane channels, receptor families, and enzyme systems have been linked to migraine in certain groups and individuals which are the targets of migraine therapies.

Diagnosis

Migraine is diagnosed largely based on a consistent clinical history and the absence of atypical features. However, additional testing, such an MRI and vascular imaging (carotid ultrasound and transcranial Doppler scan), may be indicated to exclude conditions that can mimic migraine. It is up to the physician to make a clinical diagnosis of migraine. Features that could cast doubt on the diagnosis include sudden onset severe headache, new onset headaches after age 50, new onset headaches with an underlying medical condition such as cancer or other systemic illness (e.g. HIV), headache with fever, or headache with other neurologic symptoms (e.g. sudden loss of vision, altered awareness, lateralized weakness). In these patients, the diagnosis of migraine should be one of exclusion. Lastly, a headache which is distinctly different from or worse than any previously experienced headache warrants immediate medical attention.

Migraine Subtypes

There are numerous well recognized subtypes of migraine, including migraine with brainstem aura, hemiplegic migraine, retinal migraine, and vestibular migraine.

Migraine with brainstem aura is an uncommon form of migraine with aura where the primary signs and symptoms are localized to the brainstem without weakness. Migraine with brainstem aura was previously called basilar-type migraine. It occurs more often in females than in males. Onset is usually between ages 7 to 20. The auras consist of some combination of vertigo, slurred speech, tinnitus, double vision, ataxia, impaired consciousness, and diminished hearing.

The most significant feature that differentiates hemiplegic migraine from other types of migraine with aura is the presence of muscle weakness as a manifestation of aura in at least some attacks. In addition to weakness during the aura phase, which is typically lateralized to one side of the body, the symptoms of hemiplegic migraine attacks may include severe headache, visual changes, numbness, tingling, and impaired speech/language. Hemiplegic migraine may occur either in families or sporadically.

Retinal migraine is a rare condition that is characterized by repeated attacks of monocular scotomata or blindness lasting less than one hour, associated with or followed by headache.  Irreversible visual loss may be a complication of retinal migraine, although the incidence is uncertain.

Vestibular migraine symptoms include episodic vertigo in people with a history of migraines or with other typical features of migraine (photophobia, phonophobia, visual aura, etc). The association of headache with vertigo is variable, even in individual patients. Other disorders, specifically Meniere disease and structural and vascular brainstem disease, must be excluded in most cases.

Treatment

Treatment of migraines falls into two broad categories: acute treatment to relieve pain from a migraine, and preventative treatment to reduce the frequency of migraine. The migraine regimen should be individualized to a specific patient's needs.

The following have been reported as common migraine triggers and should be avoided where possible:

  • Emotional stress
  • Hormones in women
  • Irregular meal times/skipped meals
  • Weather
  • Sleep disturbances
  • Odors
  • Neck pain
  • Lights
  • Alcohol
  • Smoke
  • Sleeping late
  • Heat
  • Food
  • Exercise
  • Sexual activity

However, most people with migraine ultimately require medication intervention. Mild migraine with minimal disability often responds to nonspecific over-the-counter simple analgesics including aspirin, acetaminophen and nonsteroidal antiinflammatories (NSAIDs).  Migraine sufferers who experience more disability usually require specific prescription migraine medications, such as triptans, that work by inhibiting the pain pathways in the migraine process.  The combined use of a triptan and a nonsteroidal anti-inflammatory drug (NSAID) to treat acute migraine appears to be more effective than using either drug class alone.  The newest class of medications, gepants, are small molecule calcitonin gene-related peptide (CGRP) receptor antagonists that block the CGRP receptor, inhibiting a pathway known to play a role in the pathophysiology of migraine. In people where nausea and vomiting are early prominent symptoms, there are medications available for self-injection or nasal administration that do not require gastrointestinal absorption.

Acute treatments optimally should not be used more than two days per week. With more frequent use, there is the risk of transforming episodic migraine into a pattern of chronic migraine or chronic daily headache. Sometimes if a patient has entered that cycle, abstinence from analgesics is required.

For some migraine patients, a daily preventative medication is required. These medications are typically used in people who have frequent migraines, or long-lasting severe migraines that cause significant disability. These medications include blood pressure medications, anticonvulsants, certain antidepressants, and the newest class of medications which are calcitonin gene-related peptide (CGRP) inhibitors. Botox injections, which are given every 3 to 6 months, can also be very effective for treatment of migraines that are refractory to the standard preventative therapies.

People with migraines often report a lower quality of life, increased emotional distress, difficulty sleeping, and miss days from work or school due to the migraines. There are now numerous options for treatment of migraines, many of which have minimal side effects. The goal in treatment is to prevent or reduce migraines and their associated disability, and to improve the migraine sufferer’s quality of life.

Treatment is individualized based on many considerations and different physicians within and outside of our practice have different preferences and prioritization for different treatments.

Listed below are commonly prescribed acute treatments for migraine attacks and the most commonly associated side effects:

Triptans

  • Eletriptan: mild dizziness and nausea
  • Naratriptan: mild dizziness and nausea
  • Sumatriptan (oral, nasal spray, nasal powder, and subcutaneous) chest pressure or heaviness, flushing, weakness, drowsiness, dizziness, malaise, a feeling of warmth, and paresthesias
  • Rizatriptan: dizziness, asthenia/fatigue, nausea, and somnolence; in one study these effects were dose dependent
  • Zolmitriptan: (oral and nasal): nausea, dizziness, somnolence, paresthesia, fatigue, and tightness in the throat or chest
  • Almotriptan: nausea and dizziness
  • Frovatriptan: nausea and dizziness

Triptans have proven to be safe and effective for most patients with migraine.  All triptans should be limited to no more than 10 days of use per month to avoid medication overuse headache. Based on limited evidence, it is still recommended that triptans be avoided in patients with hemiplegic migraine, basilar migraine, ischemic stroke, ischemic heart disease, Prinzmetal's angina, uncontrolled hypertension, and pregnancy. 

Lasmiditan (Reyvow) is a selective serotonin 1F receptor agonist that lacks vasoconstrictor activity. It is probably best suited for people with relative contraindications to triptans due to cardiovascular risk factors.  Side effects include dizziness; other relatively frequent adverse events are paresthesia, somnolence, fatigue, and nausea.

CGRP Blockers

  • Rimegepant (Nurtec): nausea, somnolence, and dry mouth
  • Ubrogebant (Ubrelvy): nausea, somnolence, and dry mouth

Ergots

  • Dihydroergotamine: Chest tightness and dizziness
  • Ergotamaine: May worsen the nausea and vomiting associated with migraine and chronic use can increase risk of valvular heart disease.  Ergots should be avoided in people with coronary artery disease because they cause sustained coronary artery constriction, peripheral vascular disease, hypertension, and liver or kidney disease.

Other non-pharmacologic options for acute migraine treatment:

Neuromodulation

  • Transcutaneous supraorbital nerve stimulation (Cefaly)

Nerve Blocks

  • Occipital nerve block
  • Sphenopalatine Ganglion Block

Some indications for preventative therapy:

  • Frequent or long lasting migraine headaches
  • Migraine attacks that cause significant disability or diminished quality of life despite appropriate acute treatment
  • Contraindication to acute therapies
  • Failure of acute therapies
  • Serious adverse effects of acute therapies
  • Risk of medication overuse headache
  • Menstrual migraine

Listed below are commonly prescribed preventative treatments for migraine attacks and the most commonly associated side effects (in parentheses):

Beta Blockers: (light headedness, dizziness, low blood pressure, low heart rate, sexual dysfunction)

  • Metoprolol
  • Atenolol
  • Propranolol

Calcium Channel Blockers: (constipation, light headedness, dizziness)

  • Verapamil

Anti-depressants: (dry mouth, sedation, constipation, weight gain, palpitations)

  • Amitriptyline
  • Nortriptyline
  • Lexapro
  • Venlafaxine

Anticonvulsants:

  • Valproate (weight gain, tremor, hair loss)
  • Topiramate (tingling/parethesia, fatigue, anorexia, diarrhea, weight loss, hypesthesia/reduced sensation, memory difficulty, language problems, difficulty with concentration, nausea, and taste changes)
  • Gabapentin (sedation, dizziness)

CGRP antagoniststs (brand name in parentheses as generics not available):

  • Eerenumab (Aimovig)
  • Fremanezumab (Ajovy)
  • Galcanezumab (Emgality)
  • Eptinezumab (Vyepti)

Non-pharmacologic preventative therapies:

  • Transcutaneous supraorbital nerve stimulation
  • Botulinum Toxin (e.g. Botox)

Useful links:

American Headache Society

Patient Testimonials









"Just wanted to thank you and your staff for creating such a safe environment at your K Street office. I was reassured to see everyone wearing their masks properly yesterday! When a patient's mask started to slip in the reception area, someone IMMEDIATELY came out to ask him to pull it up. It was so reassuring!”

“I am happy to let everyone know how great the Neurology Center/Chevy Chase is. My primary care doctor referred me there because of neuropathy symptoms. He advised that every doctor there is first class, and any will serve me well. I was assigned to Dr. Nabil Altememi, and how fortunate for me. He is brilliant, thorough, experienced, confident and a great communicator. After two appointments now, I am confident in my experience and my judgment. I commend the Neurology Center to you, and I specifically commend Dr. Altememi. Good luck.” –TM
 
“I like the fact that there is very little waiting to see the doctor. Dr. Stephanie Block takes time to hear questions and answer them. I don't feel rushed. And there's plenty of parking.” –NF
 
“Dr. Ezra Cohen takes the time to go through my health issue and concerns on my first visit. He is really great and I just recommended him to one of my friends who is looking for good neurologist. Other staff members are pleasant and the waiting time is reasonable. Overall experience was great.” –MMM
 
“The Neurology Center is awesome and particularly Dr. Eric Jeffries. He’d been tracking an issue with my health for a few years. He sent me to a surgeon this past fall because he didn’t like what he saw. I had surgery in December and the issue has been resolved. Not only is Dr. Jeffries top notch, but the staff is always friendly and helpful. I’d recommend them to anyone.” – LK
 
“The staff at each office over many years have been AWESOME!! My heart goes to Dr. Taryn Fortune. She is so thorough and has been diligent in helping me with my discomfort. I recommend that anyone who is wants a kind, caring, and thorough Neurologist Don't walk to Dr Fortune, Run!! She is the best!!!” – SM
 
“Thank you Dr. Stephanie Chen Block for your professional manner, your personal concern and your thorough description of my medical situation. Your advice and counsel were invaluable and I would highly recommend you to friends and family.” – DS
 
“Everyone at the Leisure World Office was very professional and courteous. We were taken on time.” – TJA
 
“The Providence staff and Dr. Moore were very pleasant. Dr. Moore was very detailed and he took his time explaining each step of the EMG so I was aware what to expect. The technician was pleasant and made me feel comfortable.” – CL
 
“Dr. Cohen was patient and thorough. I felt like he really cared. I would recommend this practice very highly.” – MB
 
“The White Oak staff is polite and made me feel welcome. My procedure was explained to lessen feelings of anxiety.” – MC

“I’ve been going here for years, and compare to the other doctor’s offices, this practice is great! Dr. Hari Hall is wonderful, very knowledgeable and cares about her patients. I highly recommend the practice!” -RJ

“The kindness and responsiveness of the staff are admired and appreciated!” -GG

“Dr. Rhanni Herzfeld is a hero. She was so great to me that my mom is actually going to move down from Michigan, partly to have access to such great resources like Neurology Center.” -ET

“Dr. Stephanie Block is a wonderful practitioner who listens carefully and always has good suggestions to offer. I would highly recommend her.” –RO

“Met with Dr. Neal Kurzrok for my diagnosis and Dr. Moore for my testing for peripheral neuropathy. I found Dr. Kurzrok to be a no nonsense but heavily qualified physician. He is straight to the point and I like that. I wanted to know just what my issues were and my options. Dr. David Moore knows how to do the professional testing phase and has an easy going bedside manner. He is qualified and very likeable. The Providence office space is very clean and the check in staff efficient.” –AG

“I truly loved the center. The staff was welcoming and attentive. I enjoyed visiting with Dr. Melissa Carswell who was very friendly, patient and professional. Thank you.” – MG

“Honestly, my experience with this practice has been nothing short of stellar. The doctors are thorough and caring. They listen and are eager to help. Dr. Taryn Fortune is amazing at what she does, and is generally a very cool person.”- DS

“The staff and doctors at the Neurology Center have been fantastic....very informative and supportive. I have full trust in their recommendations.” -BT

“The physicians and staff are great. Everything runs smoothly and stress free. Their objectives are scientific.” -JS

“I’ve never written a review before, but I feel compelled to after my excellent experience here. Dr. Philip Pulaski was fantastic - he explained everything very clearly and was very caring. Additionally, the staff are wonderful (Tammy in particular). They’ve gone above and beyond to ensure a very smooth client experience. All around this is a fantastic practice and I would recommend them to anyone in need of a neurologist.” -ST

“Good experience. Dr. David Taragin showed empathy and concern towards my husband who was not feeling well.” -CM

“Dr. Debbie Lin is amazing, very knowledgeable and caring, also very honest and direct. I first spoke with her PA, Ashley Holt today on a telemedicine appointment. She was also extremely helpful, knowledgeable and very clear. She was happy to answer any and all questions. This is a wonderful practice.” – HL

“I love everything about this practice. Easy location. Ample parking. Ease in making appointments. Immaculate office. Professional and kind administrative staff. The doctors and assistants I’ve seen have been top notch (and I come from a family of doctors!) I’ve raved about them to anyone who’ll listen- so glad I found this neurology group. I trust them implicitly.” – HG

“The Neurology Center is a highly professional and very caring practice. The doctors and staff are all friendly and helpful, and they opt for conservative rather than aggressive treatments while being fully pragmatic. Highly recommended.” - BB

“Highly recommend Dr. Hari-Hall. Have been a patient for a few years, and always receive excellent service. Toye and other technical staff are also always thorough and efficient.” -MM

“Great office atmosphere, the doctor was very informative and seemed genuinely concerned. The K Street office staff worked well together.” –AC

“The Leisure World office staff was helpful and friendly. The doctor we saw was caring and through.” –KBB

“The Providence staff was very professional and the doctor was on time and very thorough and listened to my concerns. I am glad The Neurology Center was recommended to me.” -GW

“Ashley Holt and Dr. Stephanie Block have helped me so much with my migraines. Ashley is a pro at giving Botox injections- always on time and efficient. This office has been a lifesaver for me!” – DB

“They are all very professional, courteous and handle appointments in a timely manner. I have never had to wait after my appointment time to be seen . Dr. Eric Jeffries is the best. He's honest and keeps it real with you. I recommend The Neurology Center in White Oak who is looking for neurological services.” – JC

“Everyone was extremely helpful and warm. Dr. Aman Savani was highly knowledgeable, gladly listened to me, answered my questions, welcomed my adult daughter who came with me and had support staff to provide the additional diagnosing necessities.” -CH

“Dr. Rhanni Herzfeld is everything you want a doctor to be: highly knowledgeable, attentive, inquisitive, sincere — and prompt! In short, she cares.” –CA

“Administrative Staff are competent and courteous and Clinical Staff are highly qualified and conduct themselves so that it is clear they have the patient’s best interests in mind.” – BS

“Physically, the Sleep Center resembles that which you would expect if staying at a very nice motel/hotel, a comfortable double bed, closet space, and a clean bathroom with towels, soap, and shampoo, plus TV. The staff were also very professional from the time of check-in, to showing you around your assigned room, and explaining the process for attaching the requisite electrodes on your body. If you awaken during the night in need of the bathroom, just say your assigned staff member’s name out loud and she will quickly appear to unhook your electrodes from the monitoring station. You are awoken early, around 5am, released from your electrodes and told you may now shower, get dressed, and go home. If, in my case, the testing resolves my sleep disorder, I will upgrade the facility’s rating to the highest level.” -PL

“A very professional yet friendly atmosphere that welcomes you at once, and a staff of very confident and competent caregivers. What more can I ask for? Dr. David Taragin is an extraordinary neurologist, and I know I am lucky to have him for my doctor.” -JK

“Very friendly and helpful staff. My doctor is very caring and has a lot of experience. I would recommend her to family and friends, as my daughter was very happy with the Neurology Center in Rockville.” – BG

“My daughter needed a sleep study to be done. I was contacted before hand, all questions were answered, staff could not have been more friendly, knowledgeable. They explained what was going on and when and what would happen. If I or someone in my family needs a study done, we will be coming here. First class all the way.” -ES

“The Neurology Center has a friendly front office staff always providing outstanding professional customer service with a smile. Dr. Philip Pulaski is the “BEST.” He is kind, compassionate, knowledgeable and really knows his stuff. He has always provided guidance and excellent medical advice throughout the years. Dr. Pulaski is my favorite “Doctor/Friend.” -Ms. M

“Great front desk presence (I don’t get to say that elsewhere). Professional and positive. That sets the tone for the appointment and the importance of this is frequently overlooked. Well done staff! Dr. Nadia Yusuf was warm and genuine and (most importantly) knowledgeable and communicative. Great visit. Keep up the great experience and work!” - MD

“Dr. Nabil Altememi listened to our concerns and took into a count all of my Mom’s issues before recommending the next step. He also let us choose how fast and how far to take the work up, because her issue did not require immediate neurological action. It was very reassuring.” -AB

“The K Street office staff was super kind and helpful, my neurologist was also incredibly kind and personable. One of the best private medical experiences I’ve ever had.” -AM

“Very clean and positive environment. Everyone was very professional. I was impressed with Dr. Nadia Yusuf.” - PL