Neurology
Expert perspectives on neurological conditions, stroke management, movement disorders, and neuromuscular disease.
Recent Discussions
What are your preferred second-line medications for trigeminal neuralgia?
My FIRST-LINE medication for trigeminal neuralgia is botulinum toxin. I write about its application in face pain, including trigeminal neuralgia, in Chapter 16 of my book, HEADACHES: Why You Have Them - What You Can Do About Them.
At what lab values (ferritin, TSAT%) would you offer IV iron therapy to patients with restless leg syndrome?
1. I am hopeful that practitioners will start understanding that ferritin alone is not enough to assess iron because of its acute phase reactivity. I like to order iron parameters after a 5-9 hour fast so the serum iron is not speciously elevated and get a ferritin and TSAT. If the ferritin is <30 a...
What clinical features predict visual recovery from optic neuritis in NMOSD?
The main clinical feature associated with outcomes is the severity of vision loss at nadir. The more severe the vision loss, the higher the risk of poor outcomes. However, there can be patients with very severe vision loss (no light perception) who can still recover to 20/20. The correlation with ra...
What are your ACTRIMS 2026 top takeaways?
1. Abstract and presentation CE2.2 from Dr. Dalia Rotstein in Toronto (Rotstein et al., ACTRIMS 2026). With so much press on the role of EBV in MS and data strongly suggesting that exposure is nearly an absolute requirement for having the disease, some people were actually advocating testing a patie...
How does progression independent of relapse activity (PIRMA) influence your decision to change treatment in relapsing remitting multiple sclerosis?
In a patient who is progressing in the absence of relapse activity, I typically do not change DMT and instead focus on managing the symptoms directly. Such as physical therapy or walking aids, physical worsening, cognitive rehab, OT for fatigue issues, or counseling if mood issues are contributing t...
When do you consider testing autoimmune antibodies for axonal polyneuropathies without clear etiology?
Dr. @Dr. First Last gave an excellent summary of the clinical red flags that should trigger antibody testing in polyneuropathies. I would like to highlight that not all antibodies are pathogenic or cause the same phenotypes/clinical syndromes, therefore, I would like to break it down by antibody gro...
How do you approach evaluation of a patient referred for mononeuritis multiplex and +SSB?
Step 1: A clinical syndrome of mononeuropathy multiplex always requires an EMG study. Is the primary mechanism of the MnM axonal or demyelinating? If it is demyelinating, there are only two possible diagnoses: multifocal CIDP (Lewis Sumner syndrome, which can occur in the context of Sjogren's syndro...
When do you find benefit in sequencing different dopamine receptor blockers for emergency treatment of migraine?
I know that these medications given intravenously have been found effective abortively in randomized, double-blinded, placebo-controlled trials. Prior to the advent of the triptans in the early nineties, I often treated migraine headaches abortively with metoclopramide 10 mg orally, in 15 minutes, f...
Do any subgroups of headache patients benefit more from neuromodulation devices compared to pharmacologic treatment?
I think patients with episodic cluster headache benefit greatly from external vagus nerve stimulation (gammaCore) use. This device aborts cluster attacks and has a preventative action as well for future attacks during a cluster bout. It allows for more than 2 treatments per day if the patient is hav...
When do patients with descending paralysis and suspected botulism require inpatient EMG?
If a health care provider suspects botulism in a patient presenting with descending paralysis (beginning from the cranial/bulbar region) and certain clues such as autonomic nerve involvement with dilated poorly reactive pupils, constipation, etc. can help, then treatment must be administered immedia...