Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
How does topiramate fit into your treatment paradigm for prevention of episodic migraine?
1.) Topiramate has excellent evidence for efficacy, including better than the evidence for beta blockers, amitriptyline, and venlafaxine, which this guideline recommended as first-line. I have a hard time saying these meds should be recommended as first-line over topiramate due to the reliance on ol...
What work-up and treatment do you recommend for exertional headaches?
Primary Exercise Headache Diagnostic Criteria per ICHD-3: At least two headache episodes fulfill criteria B and C Brought on by and occurring only during or after strenuous physical exercise Lasting <48 hours Not better accounted for by another ICHD-3 diagnosis Caveats: Migraine headache worsened o...
What is your preferred first-line treatment for chronic fatigue in patients with long COVID-19?
Assuming that a thorough workup for other causes of fatigue (anemia, thyroid dysfunction, sleep apnea, etc.) has been performed and is negative, no single medication has been proven by a randomized placebo-controlled trial to help chronic fatigue in PASC. Anecdotally, my colleagues who treat PASC ha...
What level of relief do you target with acute migraine treatments before you think there is diminishing returns on trialing a different agent?
My goal in terms of abortive migraine treatment is to provide the patient with a medication that FULLY relieves the headache within 2 hours, does so consistently, and without side effects. It may take several visits and judicious use of a couple of medications to accomplish this. It is of paramount ...
When do you find benefit in sequencing different dopamine receptor blockers for emergency treatment of migraine?
I do not think that intravenous dopamine-receptor antagonists provide a specific migraine-abortive benefit. They either cause drowsiness, which may be helpful to the patient in terms of inducing sleep, or cause akathisia that makes the patient want to leave the emergency room as soon as possible. At...
What is the role of radiation in intra labyrinthine (cochlear) schwannoma?
This is a bit of a tricky question to answer without knowing the size of the lesion, the age of the patient, their current symptoms, and whether they have serviceable hearing.If the tumor is small, and the patient has residual serviceable hearing, it might be best to delay treatment and order a repe...
Do you wait to treat small asymptomatic brain metastases until they reach a certain size?
I typically treat all lesions on MRI that are found to be concerning for brain metastases. This is after a discussion with our neuroradiologist colleagues. If there is uncertainty that a small lesion may not be a brain metastasis, then I will elect to follow with a surveillance MRI and treat in the ...
For which stroke patients, if any, do you recommend implantable loop recorder for long-term cardiac monitoring and why?
Fantastic and pertinent question! I won't pretend that I have an answer, but do have a few thoughts that may help frame further discussion: We derive our evidence for the efficacy of anticoagulation in stroke prevention from older trials designed to answer that specific question (SPAF, etc.). In the...
How do you decide between FcRn inhibitors and complement inhibitors for treatment-refractory AChR-positive myasthenia gravis?
UPDATE (02/2025):In the last two years, there have been few real-world comparative efficacy studies published to address this question. I have attached a selection of them below. Overall the conclusion is that equipoise remains- there is no clear evidence of the superiority of complement inhibitors ...
Do you recommend routine neurosyphilis testing in patients being evaluated for dementia?
Syphilis is a rare cause of dementia without other evidence of neurological disease, at least in the US and most other industrialized countries. Of course, a careful neurological examination is required for all dementia patients, but the absence of other manifestations of neurosyphilis makes testing...