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.

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


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 19 068

Ocrelizumab (Ocrevus)

Ocrelizumab is a medicine designed to treat multiple sclerosis.  It is indicated for relapsing remitting MS (RRMS) and primary progressive MS (PPMS).  It is made by Genentech.

Ocrelizumab is given by the IV route, 600 mg every 6 months.  The retail cost of the medication is $65000 per year.

Ocrelizumab is an anti CD20 antibody.  It reduces the number of B lymphocytes in the immune system.  It is similar to an older medicine named rituximab.

Clinical trial results

In 480 patients with PPMS treated with ocrelizumab, progression of PPMS was slowed by 24%.   This was assessed over 96 weeks.

For 800 patients with RRMS treated with ocrelizumab, there was a significant reduction in relapses in  over 96 weeks.  Patients treated with ocrelizumab had a 46% reduction in relapses compared to those treated with beta interferon 1a.   About half of the patients had no relapses or new MRI lesions while using ocrelizumab.

Adverse events

Side effects of ocrelizumab are generally reported as mild.  They include infusion site reactions, headache, back pain, fatigue, influenza, upper respiratory tract infection, or depression.

Ocrelizumab should not be used in patients with hepatitis B or other infections.  Ocrelizumab may be associated with a higher rate of new malignancies (cancers) compared to interferon.



Hauser SL, et al.  New Eng J Med.  2017  Jan 19   276(3): 221-234

Montalban X, et al.  New Eng J Med.  2017  Jan 19  376(3): 209-220


HCG is a hormone.  It stands for human chorionic gonadotropin.  It’s biological role is to promote the corpus luteum during early phases of pregnancy and to promote the production of progesterone to prepare the uterus for a fetus.

Pregnancy tests detect levels of this hormone.  The level of this hormone is lower at early stages of pregnancy, 5-50 mIU/mL.  These increase with each week of pregnancy, from levels of 1000 to up to 200000.

HCG is similar to LH, a hormone that affects ovulation.  HCG is often used to help women with infertility.  The injection of HCG is used to promote maturation of eggs and ovulation.  Ovulation normally occurs about 36-40 hours after injection.  During IVF procedures, egg retrieval is normally done about 36 hours after HCG, before natural ovulation.

HCG is sometimes used in men to stimulate testosterone production.  It has also been linked to performance enhancement scandals in professional sports.

Gonal F

Gonal F is a hormone medicine.  It is injected under the skin to stimulate egg production.  It is similar to the hormone FSH (follicle stimulating hormone).

Gonal F is often used to treat infertility, in particular for IVF procedures.

Common side effects of Gonal F include abdominal pain, bloating, pain where the injection is given, or a headache.  Serious side effects are rare but they may be trouble breathing, dizziness, bleeding or swelling.

What is Clomid?

Clomid, clomiphene, or serophene, is a medication that interferes with estrogen receptors in the hypothalamus, a hormone regulator in the brain.  The result of clomid treatment is the release of GnRH, or gonadotropin releasing hormone, and resulting increases in FSH and LH release from the pituitary gland.  The causes growth of ovarian follicles, and often clomid is used to stimulate ovulation.

What is infertility?

Infertility is the inability to have a pregnancy within 12 months of trying.  Some of the causes of this condition are related to males, some are related to females.

Common causes of infertility are:

Problems with ovulation / eggs

Problems with the uterus / endometriosis

Blockage of the fallopian tubes

Changes in hormones / prolactin

Male factors / sperm quality

Evaluation of the causes of infertility require a careful evaluation of medicines and medical history, genetic family history, and testing for sperm count, appearance, uterus and fallopian tube anatomy, hormone testing, and sometimes genetic testing of the blood, sperm or the eggs.