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Category Archives: Neurology

Menstrual Migraine: Revisiting the Relationship Between Hormonal Events and Migraine – Neurology Advisor

In light of important new information reported on menstrual migraine (MM) in recent years, including evidence that has led to a revision of the International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria for MM, a narrative review aimed to summarize recent data on pathophysiology, epidemiology, burden of disease and treatment of MM was published in the Journal of Neurology.

The goal of this review was to provide an updated overview on the topic of MM. Researchers conducted a literature search to identify relevant studies, reviews and abstracts from MEDLINE, PubMed, Cochrane Library and EMBASE databases published between 1972 and October 2019.

According to the ICHD-3 classification, a diagnosis of MM includes both migraine related to menstruation (MRM) and pure menstrual migraine (PMM) and there are criteria for PMM and MRM with and without aura. In both cases, women reported that migraines occur more frequently during menses, and that those are more severe than other migraines. The diagnostic criteria included migraine attacks in a menstruating woman that occur in a range of 2 days before to 3 days after menstruation in 2 of 3 menstrual cycles.

Estrogens play multiple actions in migraine when intense hormonal fluctuations occur leading up to and immediately after menstruation. The estrogen withdrawal hypothesis, described more than 40 years ago, relates to estrogen fluctuations across the menstrual cycle and has been implicated in the initiation of migraine attack. The drop in estrogen levels mid-cycle can lead to a significant increase in prostaglandins, resulting in neurogenic inflammation, release of various neuropeptides, including substance P, neurokinins and calcitonin gene-related peptide (CGRP). Furthermore, estrogens and estrogen receptors are widely expressed in the brain and in

the trigeminovascular system. A clear association between progesterone fluctuations and migraine attacks was not appreciated.

As for the genetic aspects of MM, polymorphisms in tumor necrosis factor alpha (TNF), Spectrin Repeat Containing Nuclear Envelope 1 (SYNE1), and neurophilin 1 (NRP1) gene were found to be associated with MM.

MRM is more common than PMM and studies have reported wide variations in the prevalence MM, with one Norwegian study reporting a prevalence of 7.6%. Of note, a higher occurrence of MM along with menstrual cycle synchrony was evident among women living together, compared with those living alone.

It is noted that MM may change over a womans reproductive life. Higher headache intensity was reported among women with MM during early pregnancy and postpartum period, compared with those without MM. Although serum estradiol levels are low during the perimenopausal period, MM can appear during menopausal transition.

Compared with nonmenstrual migraine, attacks of MM are frequently more debilitating with longer duration, higher recurrence rate and lower response rate to acute treatment. However, there are no specific treatment options for MM approved by the United States Food and Drug Administration or the European Medicine Agency.

The available treatment options for acute migraine including triptans, nonsteroidal anti-inflammatory drugs (NSAID) and ergot derivatives. Triptans have the strongest evidence for acute MM treatment, with positive reports on the use of almotriptan, naratriptan, sumatriptan, and zolmitriptan.

Preventive treatment may be important as the response to acute treatment is frequently limited. Short-term prophylactic therapies administered only during the perimenstrual period include triptans, estrogen, and naproxen. Triptans also have the strongest evidence for preventive MM treatment, including frovatriptan, naratriptan, and zomitriptan.

Continuous prophylactic treatment with hormonal contraceptives may be effective, but there are concerns regarding the risk for vascular disease and stroke associated with these agents. Furthermore, oral contraceptives should not be used for MM with aura, as they may further increase the vascular risk. Limited data are available on the use of phytoestrogens, Vagus Nerve Simulation and Onabotulinium A for MM prophylaxis.

Additional studies have suggested a potential benefit for perimenstrual use of telcagepant, a CGRP receptor antagonist. Several additional antibodies directed against CGRP or CGRP receptor may prove to be useful in these cases. The development of ditans and gepants might represent a major progress, not only in the treatment of migraine, but also in the treatment of MM.

Understanding the mechanisms that contribute to neuroendocrine vulnerability in some women and some menstrual cycles may yield possible marker of the disease opening treatment options specifically targeting MM, concluded the study authors. They also note that, An increased interest for future research on the subject will further elucidate how to manage this debilitating type of migraine.


Cupini LM, Corbelli I, Sarchelli P. Menstrual migraine: what it is and does it matter? [published online January 28, 2020]. J Neurol. doi:10.1007/s00415-020-09726-2

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Neurology congress goes virtual to give attendees access during COVID-19 pandemic – New Zealand Doctor Online

In the interests of the health, safety and wellbeing of all registered attendees and the wider public, the European Academy of Neurology (EAN) has cancelled all face-to-face activities and in-person attendance at its Annual Congress, scheduled to take place in Paris from May 23-26. Instead, attendees and speakers will have the opportunity to participate from home via the EAN Virtual Congress 2020, which will take place online. This decision has been taken due to the increasing public health burden throughout the world caused by the COVID-19 Coronavirus pandemic and to support public authorities globally in their effort to slow the spread of the disease.

The EAN Virtual Congress 2020 will allow attendees and speakers to participate from their computers without leaving their homes, no matter where they live. Difficult times ask for creative and courageous solutions which may also open new avenues for a better future. says Prof. Claudio Bassetti, Acting President of EAN, who goes on to explain that We must stay positive, strong and united more than ever to come through this crisis, which is why EAN, along with its partners, is playing its part in the fight against the pandemic by offering the online participation in the EAN Virtual Congress free-of-charge.

With conferences across many industries and fields already cancelled without online replacements, the EAN Virtual Congress is set to be one of the few meetings in neurology, as well as the biggest in 2020, as the conventional congress normally attracts more than 6,000 participants each year.

For those who have already registered for the EAN Paris 2020 Congress, fees will be refunded as soon as possible, and EAN is already contacting registered attendees. Registration for the EAN Virtual Congress will open on April 5, 2020 and will be available via the EAN website (

About EAN

The European Academy of Neurology (EAN) is Europes home of neurology. Founded in 2014, through the merger of two European neurological societies, EAN represents the interests of more than 45,000 individual members and 47 national institutional members from across the continent. Each year, EAN brings together more than 6,000 neurologists and related scientists to the biggest general neurology conference in Europe. In addition to its overarching theme of Predict, Prevent, Repair, which are the three main challenges in dealing with neurological diseases, the EAN Virtual Congress 2020 will also cover all neurological diseases and disorders, including the big seven: epilepsy, stroke, headache, multiple sclerosis, dementia, movement disorders, neuromuscular disorders.

For further updates & information:For support regarding registrations & travel bookings for the Paris congress contact:

For information related to the industry exhibition and sponsorship contact:

For general information related to the EAN Virtual Congress see the FAQ page:

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Neurology congress goes virtual to give attendees access during COVID-19 pandemic - New Zealand Doctor Online

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A day in the life of a pharmacist administering botulinum injections – The Pharmaceutical Journal

A day in the life of a pharmacist administering botulinum injections  The Pharmaceutical Journal

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Smartphone Use and Headache: What’s the Link? – Clinical Advisor

Increased smartphoneuse was found to be associated with an increased requirement of acutemedication and less relief from medication for primary headache, but not anincrease in frequency or duration of headaches, according to research publishedin Neurology Clinical Practice.

Smartphonetechnology is advancing at a rapid rate, but excessive engagement with thesedevices is raising health concerns. In a cross-sectional study, researcherssought to determine whether smartphone use was associated with worsening ofprimary headache, including migraine, chronic migraine, and tension-typeheadaches.

The study wasconducted between June 2017 and December 2018 in India, and included patients aged14 years with primary headache. All patients underwent detailed neurologicexamination and relevant investigations; information about headache pattern,severity, frequency, duration of episodes, character, location, and associatedcomplaints were noted. Information was also obtained about new-onset headachesof >3 months.

Each patient wasrequired to answer questions regarding mobile phone use with respect to type ofcell phone, daily usage duration, and type of usage. Questions were scored as 0for no and 1 for yes, with the highest score of thequestionnaire being 11. Patients were divided into non-smartphone users (NSUs; eitherdid not use a cell phone or non-smartphone user) and smartphone users (SUs).

The primary objective was to determine the association between mobile phone usage and new-onset headache or increases severity of primary headache. Chronic migraine was defined as headache for >15 days a month for >3 months. Worsening headache was defined as 2-fold increase in severity and/or intensity. Secondary outcomes included the association of smartphone use in patients with primary headache who required medication, as well as the dosage, type of analgesic taken, pill count of acute medications per month, number of prophylactic drugs, duration of prophylactic drug use, and dosage.

A total of 400patients were included in the study (194 NSU; 206 SU). Of the 194 NSU patients,76 were not using any phone and 130 were using non-smartphones. NSU patientswere older compared with SU patients. The majority of patients with headachewere women (269/400); however, more men were in the SU group compared with theNSU group (39.3% vs 25.8%).

The most commonheadache type was migraine, followed by chronic migraine and chronictension-type headache. More patients in the SU group reported more aurascompared with the NSU group (17.5% vs 7.7%), but the course of headache wassimilar in both groups (worsened: NSUs, 71.6% vs SUs, 71.8%).

Patients in the NSU grouphad similar duration of episodes compared with SU patients, as well as thenumber of episodes of headache per month (NSU, 7.3 vs SU, 7.1). Patients in theSU group took a higher number of pills for acute treatment with a median pillintake of 8 per month compared with 5 per month in the NSU group. A higherproportion of patients in the NSU group had relief with acute medicationscompared with the SU group, but the proportions of patients taking prophylacticmedication and the median duration of prophylaxis were similar in both groups.

Although thecourse of headache, frequency of episodes, and the pain scores were similar inNSUs and SUs, the SU group had higher frequency of medications for acuteattacks with poor response to analgesics, the authors concluded.


Uttarwar P, Vibha D, Prasad K, Srivastava AK, Pandit AK, Dwivedi SN. Smartphone use and primary headache: a cross-sectional hospital-based study Neurol Clin Pract. doi:10.1212/CPJ.0000000000000816

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Neurology EMR Software Market Growth and key Industry Players 2020 Analysis and Forecasts to 2025 – Express Journal

The new Neurology EMR Software market report offers a thorough assessment of this industry vertical, thereby outlining various segments of the market. The report provides vital information concerning the total renumeration and key industry trends prevailing in the market. Also, crucial insights regarding the regional dominance and the competitive scenario have been mentioned in the research report.

Underlining the main elements of the Neurology EMR Software market report:

In-depth analysis of the geographical landscape of Neurology EMR Software market:

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Emphasizing on the competitive hierarchy of Neurology EMR Software market:

Additional insights from the Neurology EMR Software market research report:

Table of Contents:

Executive Summary: It includes key trends of the Neurology EMR Software market related to products, applications, and other crucial factors. It also provides analysis of the competitive landscape and CAGR and market size of the Neurology EMR Software market based on production and revenue.

Production and Consumption by Region: It covers all regional markets to which the research study relates. Prices and key players in addition to production and consumption in each regional market are discussed.

Key Players: Here, the report throws light on financial ratios, pricing structure, production cost, gross profit, sales volume, revenue, and gross margin of leading and prominent companies competing in the Neurology EMR Software market.

Market Segments: This part of the report discusses about product type and application segments of the Neurology EMR Software market based on market share, CAGR, market size, and various other factors.

Research Methodology: This section discusses about the research methodology and approach used to prepare the report. It covers data triangulation, market breakdown, market size estimation, and research design and/or programs.

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Dr. Michael Wong on confidence, career, and the importance of family – Jill Lopez

With his Miami practice, Southeast Veterinary Neurology, thriving, a daily commitment to health that keeps him centered, and a tight family bond, Dr. Michael Wong is feeling psyched for the future.

Dr. Michael Wong is one of fewer than 300 board-certified veterinary neurologists practicing in North America. He graduated magna cum laude from the University of Florida (UF) College of Veterinary Medicine and while there, founded the Universitys Veterinary Business Management Association.

He went on to complete a medical and surgical internship at Red Bank Veterinary Hospital in New Jersey and he received his neurology and neurosurgery training at North Florida Neurology.

After completing his residency, Dr. Wong successfully passed his examination and became board-certified in veterinary neurology in the same year. He founded Southeast Veterinary Neurology (SEVN) in 2010.

We caught up with cool dad of three to learn more:

If I wasnt a veterinarian what would I be:

Ive always wanted to be a veterinarian, so I havent put much thought into that question.Prior to veterinary school I was a life guard at the beach and really enjoyed that.Maybe something with the ocean?Marine biologist?Tour guide?Not sure.

Best career advice I ever received:

Its a marathon, not a sprint.My first year out of veterinary school, Dr. Rick Glass, the neurologist at my internship used to say this.The particular context he used it in was with reference to another veterinarian who didnt think about the effects her decision had on referring vets wanting to refer to her in the future.

Its really shaped the way I view things.I have a long view.I think in the macro.I try to see the big picture.I make decisions based on the effects they will have in the long term as opposed to just the short term gain.I give up lots of short-term wins (profit, awards, etc) knowing that Ive made the right decision for my team and the pets and people that care for them.

How it felt becoming board certified:

Most people hated taking boards.Its a 2-day, five part test that has around a 30% pass rate.But for me, it wasnt stressful it was exciting.I was just putting down on paper all the knowledge I had been acquiring as part of living my dream of becoming a neurologist.

In between sections of the exam, I would head back to my room at the hotel.I remember thinking the lyrics from a song:Ive waited for this moment.Dreamed it every day.This is my one true purpose.It sounds cheesy, and Im sure many people had a very different experience around taking boards and are probably rolling their eyes at me right now.Its just my experience and a happy memory.

Easiest career decision I made

I wont call it the easiest, but certainly the best career decision I made was to open Southeast Veterinary Neurology.Practice ownership, entrepreneurship and leadership have opened up avenues in my life and career that I never would have had without them.

Related, Id say another best decision I made was to surround myself with people that share the vision of bringing hope to people and their pets.

Interesting way I made extra cash in vet school:

In vet school, I would make sushi at home and sell it to my classmates for lunch.Id take orders earlier in the week, buy the ingredients, make the rice, roll the sushi, then deliver at class.

Book that left a lasting impression on me:

Simon Sineks Leaders Eat Lastthis book is for those who want to feel they and their work matter and for those who want to inspire others to feel the same.

How I clear my head after a stressful day

Tennis.Family.Orangetheory.Orangetheoryis a science-backed, technology-tracked, coach-inspired group workout designed to produce results from the inside out.

What adventure most changed my life:

Meeting my wife, Myri-Ann. She was a St. Georges student, doing her clinical year of veterinary school at the University of Florida.Her first rotation was neurology, and we were on together.

I remember seeing her for the first time: she was the first person to the neurology rounds room, sitting nervously with her books on her lap, reviewing her notes.The neurology service was slow for those two weeks.Id come in early to help with neuro exams on her patients, since I didnt have any myself.I wasnt much of a help, as I still knew nothing about neurology at the time.She ended up getting an A and I got a B+.She likes to remind me of that.

We started off as friends.She was very hesitant to get romantically involved with someone from the mainland.Her plan was to go back to Puerto Rico and start a practice after finishing up school.

But, one day I walked her home after clinics were finished and we came across an earthworm struggling to cross the sidewalk in the Florida heat.She told me that her perspective on our romance changed when I picked the earthworm up and moved it to the grass.Im still indebted to that worm, because everything I have in my life right now (kids, family, house, business, etc) is because of this worm.

Whats my favorite way of spending a day off from work:

My perfect day would spending the day with my wife and then later picking up our kids and stopping by a park together on the way home.Play with Disney princesses, build Thomas the Train playset tracks, run around the back yard, exploring the dirt and hiding in the bushes.Jump in the pool.Cook dinner while the kids get a bath.Talk about the day at the dinner table: what we learned at school, who we sat with the lunch table, who we met, who we made smile, who we played with.Have the kids FaceTime with grandparents.Brush teeth.Read stories.Get ready for bed.

Connect with Dr. Michael on Linked in

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Dr. Michael Wong on confidence, career, and the importance of family - Jill Lopez

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