Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What is your preferred VMAT2 inhibitor to treat tardive dyskinesia; tetrabenazine, valbenazine, or deutetrabenazine?
The base cost of tetrabenazine is much lower than valbenazine or deutetrabenazine, so I generally prefer it. However, due to insurance factors, valbenazine or deutetrabenazine can have lower out-of-pocket costs for some patients. From a purely clinical management perspective, tetrabenazine is much ...
Among patients with secured subarachnoid hemorrhage who are receiving daily TCDs, what is the appropriate frequency of post operative neurological assessments?
I think a textbook might state something like "every 1-2 hours in the acute setting." However, in my opinion, the frequency of neurological examinations should be tailored to the individual patient and involves considerable clinical judgement. Factors that might influence this decision include a) se...
How do you approach a patient who develops a rest tremor after chemotherapy?
Like many questions in Neurology, this question can be simple or rather complex to answer. If the patient is felt to have a drug-induced tremor, withdrawal of the offending drug or drugs should be the first choice whenever possible. In the chemotherapy setting, a common scenario would be when a dopa...
What treatments options may be considered in patients with POTS who also need daily diuretics to treat heart failure and are already wearing compression garments?
Given the epidemiology of POTS and congestive heart failure, you are far more likely to see a patient with neurogenic orthostatic hypotension and CHF than POTS and CHF. I have an article on NOH and CHF in Autonomic Neuroscience 2020. The principals are basically the same however because the managem...
Do you recommend lumbar puncture for suspected early GBS without motor involvement?
If purely for the confirmation of a GBS diagnosis, then no.CSF testing has limited utility for Guillain-Barré syndrome (GBS) diagnosis early in the disease course. Cytoalbuminologic dissociation is only present in 50% of patients in the first four days and rises to ~80% after the first week (Al-Hake...
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...