Hemicrania Headache

Hemicrania is a special type of headache that is seldom diagnosed or described.  It is a sharp pain, on one side of the face or head, which may be associated with abnormal sensations and appearance of the face.  The special associated features may be swelling or drooping of the eyelid, a small pupil, tears or nasal congestion, or redness of the eye for example.  Hemicrania is a type of Trigeminal Autonomic Headache.

There are two types of Hemicrania

Paroxysmal Hemicrania

This is a sharp pain that lasts 2-30 minutes.  There are changes in the eye or face on the same side as the pain.  It may occur more than 5 times per day.  There is relief of the symptoms between the attacks.

Hemicrania Continua

This is a dull pain, that occurs every day.  The baseline headache can be punctuated by attacks, lasting 30 minutes to 3 days.  These attacks are associated with a higher level of pain and changes in the face described above.

Hemicrania headaches are sensitive to a medicine called indomethacin.  Sometimes the dose of this medicine must be gradually increased to obtain relief.  Other types of headaches are not normally affected by this medicine.



Prakash 2017  J Pain Res, Jun 29(10) 1493-1510  link

Baraldi 2017  J Headache Pain, Dec 18(1) 71  link

MS medicine cost 2017

These are the updated prices of MS medicines for 2017.  The data were obtained from GoodRx.com.   The date of search is December 17, 2017.

Each listed price is for a one month supply in US $ dollars.  If there are two prices, the first price is the lowest price, the second is the retail average price.


Copaxone / Glatopa    $1953    $4188

Aubagio    $6301

Avonex    $6421   $6574

Betaseron    $6788    $8249

Extavia    $6073

Gilenya   $5558

Plegridy    $6419     $8813

Rebif    $7019    $7782

Tecfidera   $6963   $9524


Why are Tysabri and Ocrelizumab not listed?  They are supplied by a specialty pharmacy, and pricing data are not available.

Osgood Schlatter Syndrome

Osgood Schlatter is a condition that causes knee pain in adolescents.  There is traction of the patellar tendon on the anterior tip of the tibia, at the bottom of the knee.   It is noticeable in children between the ages of 9-14, and it is especially noticeable in children who enjoy sports.  Sports with running or jumping tend to be associated with this condition.    The pain of this condition may be worse with kneeling, running, jumping, squatting, climbing stairs.  It may occur on one side or both sides.  It tends to be noticed after a growth spurt.

Normally the diagnosis can be made without an xray.   The range of motion of the affected knee is not affected.  Tenderness to touching the anterior tibia may be present.  Extending the knee against resistance may be painful, or there may be pain when squatting with the knee flexed.    A similar condition, jumper’s knee, will cause pain in the patellar tendon rather than on the tibia.

Most cases of Osgood Schlatter will resolve with icing and rest over several months.  Avoidance of sports is not necessary, although aggravating activities may be avoided.   Playing with mild pain is normally ok.   Occasional exacerbations may be noticed from time to time.  These should resolve quickly.  Stretching of the quad and hamstrings muscles prevents flare ups of this condition.

Surgery for Osgood Schlatter is not normally needed.  In some cases surgery is performed after growth ceases, since residual bone formation may interfere with knee mechanics.

Sometimes prominence of the anterior tibia is noticed after this condition.  Some people with this condition have a history of knee swelling or pain associated with activity.

Normal F Responses

Normal F wave responses

These are examples of normal F-wave responses from 73 healthy individuals.


Nerve      Site        value (msec)

Median    wrist      28

Ulnar       wrist      29

Peroneal  ankle     54

Tibial       ankle     55



Alavian-Ghavanini MR and Haqhpanah S.

Electromyogr Clin Neurophysiol 2000 Sept 40(6): 375-9

Posterior Cruciate Ligament Injury

The posterior cruciate ligament (PCL) prevents the tibia (shin bone) from moving backwards relative to the femur (thigh bone).  Injuries to this ligament tend to occur when the knee is bent and the upper leg moves forwards relative to the lower leg, such as when it collides with a car dashboard or a person.

Injury to this structure may not cause many symptoms.  There may be pain in the back of the knee with squatting or kneeling, a slight limp, or loss of the full range of knee flexion.  With chronic injury to the PCL, there may be problems using stairs or ramps.

The principles of therapy are rest, ice, compression, elevation, medications and protection.  Often crutches are recommended if weight bearing causes pain, but otherwise crutches are not necessary.  Return to light duty activity is ok soon after an injury.

Most PCL injuries do not occur by themselves.  They are often associated with meniscus injuries or other trauma to the knee.  They are also difficult to distinguish from other ligament injuries to the knee.  When the PCL is injured, there is often no pop sensation, just a vague feeling of discomfort.

Thyroid and myotonia

Very rarely, people with hypothyroidism develop a painful condition of the muscles.  This condition, myotonia, results in pain, cramping, and weakness.  It may affect the proximal muscles of the arms or the legs.

In these conditions, a peculiar exam finding may be made.  Tapping the muscle with a reflex hammer can cause a ridge of muscle contraction, referred to as myoedema.  In some cases, thickening of the muscles occurs due to fluid retention or the deposition of connective tissue.

Treatment of hypothyroidism with thyroid supplements is normally helpful for thyroid-related muscle diseases.

Other illnesses that may affect the muscles include:

Adrenal gland, pituitary gland, parathyroid gland problems, exposure to toxins or certain medicines, and diseases of nutrition or metabolism

Meniscus injury

The meniscus is a piece of cartilage in the knee.  It looks like a contact lens holder, a pair of cups facing up at the top of the lower leg, where the bony prominences  of the upper leg bone (femur) slide back and forth.  The meniscus can be injured when the knee is twisted or bent, in particular when the knee is flexed.  Injuries to the meniscus are common in people who play sports such as soccer, basketball and football, but they can occur in anyone who twists their knee.

When the meniscus is injured, there is often swelling, pain, and decreased range of motion.

Treatment of the injured meniscus is best with the following:

Avoid positions and activities that irritate the knee, such as kneeling, squatting, twisting, or taking steps.

Elevation of the leg

Ice packs to the knee to reduce swelling and soreness

Using crutches if the pain is severe

Using a brace if the knee is unstable

As the pain improves, straight leg raising without resistance is recommended, as well as working with a physical therapist.

MRI studies and possibly a referral to orthopedic surgery are recommended when the above treatments are not helpful, or when the range of motion of the knee does not recover.

Sometimes a meniscus injury occurs with minimal trauma.  This tends to happen in people who are older.  Normally physical therapy is sufficient for improving this condition, and surgery is not needed.


Tinnitus is an abnormal sound that we hear.  Tinnitus is caused by a disruption of the sound sense, anywhere from the brain to the cochlea.   It may be a hum, ring, roar, whoosh, click or other sound.  Normally tinnitus can be heard only by the person who has this condition.  There are many possible causes of tinnitus.

A spasm of a muscle in the inner ear

An injury to the cochlea, the organ that conducts hearing

The sound of blood passing through a nearby blood vessel, especially a deformed blood vessel

Increases in the pressure inside the head

Clicking noises can arise from the muscles of the palate

Ocean-like noises can arise from the eustachian tube

Medicine side effects – some medicines are toxic to the inner ear

Small tumors of the acoustic nerve

Certain infections

50 million people in the US have chronic tinnitus, which is a sound symptom lasting longer than 5 months.  People with tinnitus may experience symptoms of anxiety or depression.  Trouble sleeping is often associated with tinnitus.

Testing that is important for evaluating the causes of tinnitus.

Hearing tests

MRI or CT studies to look at the blood vessels

Exam by an ENT specialist

Splinting for Carpal Tunnel Syndrome

Splinting for carpal tunnel syndrome is often effective for mild cases.  Splinting regimens for 24 / 7 or just while sleeping have both been shown to be helpful.

There are several forms of carpal tunnel wrist splints available, from simple generic versions to custom fitted models.  Make sure the one you use is comfortable.

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iphone ppictures July 19 069

iphone ppictures July 19 068

PFO and Stroke

PFO and stroke

PFO is a patent foramen ovale, a small hole connecting the atria chambers of the heart.  A PFO is found in about 25% of people.

Many cases of stroke are not explained, and are therefore labeled as cryptogenic stroke.  This means they are not found to be associated with narrowing of the cerebral arteries, abnormal heart rhythm, high cholesterol, smoking or high blood pressure.

It has been attractive to consider whether having a PFO increases the risk of stroke.  Perhaps a blood clot forms in a low flow vein, after a long plane trip.  It finds its way back to heart, with the other venous blood, then crosses the PFO, into the arterial system, and makes its way directly to the brain?  This mechanism of stroke is often speculated, but rarely proven.

Following most cases of stroke, patients are treated with antiplatelet medicines aspirin or Plavix to prevent a future stroke.  Studies have shown that patients treated with anticoagulation medicine or surgical PFO closure have not had better stroke prevention than patients treated with aspirin.  Although other studies are in progress, the results we have to date support the idea that most PFOs are not relevant to stroke risk.



Carroll JD et al.  RESPECT Investigators. Closure of patent foramen ovale versus medical therapy after cryptogenic stroke. N Engl J Med 2013;368:1092–1100.

Furlan AJ et al. CLOSURE I Investigators. Closure or medical therapy for cryptogenic stroke with patent foramen ovale. N Engl J Med 2012;366:991–999.

Homma S et al. ; PFO in Cryptogenic Stroke Study (PICSS) Investigators.Effect of medical treatment in stroke patients with patent foramen ovale: Patent Foramen Ovale in Cryptogenic Stroke Study.Circulation 2002;105:2625–2631.

Meier B et al.  PC Trial Investigators. Percutaneous closure of patent foramen ovale in cryptogenic embolism. N Engl J Med 2013;368:1083–1091

Shariat A et al. . Comparison of medical treatments in cryptogenic stroke patients with patent foramen ovale: a randomized clinical trial. J Res Med Sci 2013;18:94–98