The Neurology Lounge

In this episode, I explore the diverse clinical and pathogenic dimensions of migraine with neurologist Mark Weatherall whose interests are the diagnosis and management of chronic migraine, facial pain, visual snow syndrome, and secondary headaches associated with systemic disorders.

Our discussion covered the distinction between primary and secondary headaches, the distinctive features of the migraine aura and headache, and the non-headache manifestations of migraine. Mark Weatherall also traced the history of the development, and of the use, of the current acute and preventative migraine treatments, and highlighting the role of the CGRP pathway. He also explores the research into emerging drugs that work via the PACAP pathway.

Mark is former Chair of the British Association for the Study of Headache and Trustee of The Migraine Trust, and who was a highly regarded historian of medicine before studying clinical medicine at Cambridge. His other interests are the historical, social, and cultural aspects of headache and facial pain disorders.

I am joined in this podcast by Danielle Newport Fancher to explore the patient perspective of migraine as portrayed in her illness memoir titled 10: A Memoir of Migraine Survival.

Danielle Fancher is a writer, migraine advocate, and speaker who has received awards from the National Headache Foundation and The Association of Migraine Disorders for her writing and advocacy. She is also a member of the Patient Leadership Council for the National Headache Foundation and a Board Member for the Migraine Science Collaborative.

Our discussion traces the onset of her migraine at the age if 16 and how it evolved to become recalcitrant. Danielle narrates how her migraines manifest, from prodrome through aura to headache.

She also explores the unusual symptoms she experiences, from heaviness to numbness, which makes her remark that migraine is more than just a headache.

We also review the various medications she has tried in her desperate attempt to overcome the disease that she has eventually had to come to terms with it, particularly finding solace in the company of her large community of migraine sufferers.

In this episode, I review the pathological and clinical dimensions of migraine, the most common disabling neurological disorder. I tried to capture migraine’s diverse disabling recurrent symptoms, from its risk factors, triggers and prodrome to the aura, the headache, and multiple heightened sensitivities.

To illustrate the lived experience of migraine, its classical manifestations, and its curious variants, I refer to such vivid patient memoirs as those of Monica Nelson titled Mere Sense, and Abby Reed titled The Color of Pain. I also cited Oliver Sacks classical book titled 'Migraine'.

I also flavour the podcast with historical migraine patient anecdotes, such as those of Ann Conway, the enlightenment writer who was treated by the great physicians William Harvey and Thomas Willis, of Annie, who was treated with an astounding number of therapies by the famous Queen Square neurologist William Gowers, and of Alexander Pope who treated his migraines in a most unconventional way.

In this regard, I relied on Migraine: A History, Katherine Foxhall’s magnificent historical account of the medieval ideas and treatments of the disorder, and Soul Made Flesh, Carl Zimmer's exhilarating biography of Thomas Willis.

The podcast also explores and the evolution of migraine's acute and preventative treatments, and how a better understanding of its pathology is leading to treatments such as those that influence the CGRP pathway.

In this episode, I am joined by Nicholas Silvestri, Professor of Neurology at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, where he is also Associate Dean for Student and Academic Affairs. He is board-certified in neurology, neuromuscular medicine, and electrodiagnostic medicine.

Over the past several years, Nicholas Silvestri’s research interests have included myasthenia gravis and inflammatory neuropathies, and he has authored over 60 peer-reviewed articles, book chapters, and textbooks.

Our conversation covers the full spectrum of myasthenia gravis – from its pathology and pathogenesis to its clinical features, investigations and treatments. He explains such tricky areas of myasthenia gravis, such as why the antibody levels do not correlate with clinical severity of the disease, and why the disease frequently starts in the ocular muscles.

We also explored such themes as why anti MUSK myasthenia gravis favours Black people and those living around the equator, and why steroid treatment may worsen myasthenic symptoms.

Nicholas Silvestri also discussed the newer and more effective treatments of refractory myasthenia gravis, and how he manages the different facets of the disease.

In this episode I explore the autoimmune neurological disorder, myasthenia gravis. I review its classical manifestations as ocular and generalised myasthenia, and I highlight its complications such as refractory myasthenia and myasthenic crisis.

The podcast also discusses the pathogenesis and triggers of the disease, its various mimics, and its indispensable investigations. I also review its treatments which include acetylcholine esterase inhibitors, steroids, immunosuppressants, IVIg and plasma exchange.

I complement the podcast with historical anecdotes regarding the discoveries, frequently serendipitous, of the various treatments of myasthenia gravis. This narrative includes such stories as Mary Walker’s miracle of Alfege’s, the dream insight of Otto Loewi, the mystery of the headless torso in the Thames, and the role played by the Calabar bean in the history of myasthenia gravis. Other relevant historical themes were the role played by Alfred Blalock in introducing thymectomy for myasthenia gravis, and the first serendipitous self-treatment of myasthenia gravis by medical student Harriet Edgeworth.

I rely on such illustrative patient memoirs as those of Kemi Olawaiye-Dampson titled Living with Myasthenia Gravis, of Howard Caras titled Permanent Detour, and of Ronald Henderson titled Attacking Myasthenia Gravis.

I also cited such enlightening academic sources as Coping with Myasthenia Gravis, by Aziz Shaibani and colleagues, and The Spark of Life by Frances Ashcroft.

I am joined in this episode by neurologist Thomas Bird to discuss his long professional experience of managing Huntington's disease.

Thomas Bird is Professor Emeritus of Neurology and Medical Genetics at the University of Washington in Seattle. He was previously Chief of Neurology at the Seattle VA Medical Center, and founder of the Neurogenetics Clinic at the University of Washington. He was also former director of the Huntington’s disease Centre at University of Washington

We discussed the diverse manifestations of the disease, from chorea to impaired judgement to psychosis. With anecdotes from the book, we also reviewed the links between the disease and criminality, and with increased socioeconomic vulnerability and trauma. Dr Bird also highlighted the unusual manifestations of the disease in children, and the similarity of the pathogenesis to other neurodegenerative diseases such as motor neurone disease and Alzheimer’s disease.

Our discussion also covered the genetic testing of the disease, particularly highlighting the ethical conundrums leading up to the testing, and the uncertainties that the test result throws up. Other themes we covered are the therapeutic and preventative prospects for Huntington’s disease, and the need for society to understand and support people with the disease.

In this short podcast, I count down 10 clinical features that accompany tremors which indicate that the tremor is not the result of Parkinson’s disease.

In this episode, I explore one of the most visually dramatic neurological disorders, along with its diverse and debilitating symptoms. I explored the history of the disease, describing how George Huntington came to know about it, and how his paper documenting the involvement of a Long Island pedigree in New York served as a landmark in the documentation of the disease. The podcast also used this pedigree to illustrate the strong familial tendency of Huntington’s disease. I

use graphic patient anecdotes, including that of musician Woody Guthrie, to illustrate the onset and progression of the disease, its strongly familial inheritance, and the disruption it causes to relationships and families. I similarly explore such patient memoirs as that of Melanie Pearson, titled Somebody Up There Likes Me, of Sandy Sulaiman, titled Learning to Live with Huntington's Disease, and of Erin Paterson titled All Good Things, to demonstrate the transformation in personality that the disease brings about, it impact on individuals, families and the healthcare system, and the turmoil of undergoing genetic screening to determine the risk of the disease, and the aftermath of this.

I also trace the history of its scientific understanding, from its first documentation by neurologist George Huntington, to the efforts of people such as psychologist Nancy Wexler who led the efforts to identify the gene responsible, a quest that started by investigating a large pedigree in several Venezuelan villages around Lake Maracaibo. I explore the characteristics of the gene, and the unusually transmission of the genetic mutation.

The clinical perspective of the podcast explores the motor manifestations of the disease which go beyond chorea to include a host of other movement disorders such as dystonia and myoclonus. It also highlighted the disease’s varied psychiatric manifestations, from paranoia to aggression, and its cognitive difficulties, from perseveration to executive dysfunction.

The podcast also highlights the neurological mimics of Huntington disease, such as Wilson’s disease and Friedreich’s ataxia, and a host of other causes of chorea, such as systemic lupus erythematosus, infections, and medications. I also review the treatments of the disorder.

I am joined in this podcast by Anne Fadiman to discuss her classical book The Spirit Catches You and You Fall Down, her account of the cross-cultural conflicts between a Hmong family and the American medical system. The book won a National Book Critics Circle Award, a Los Angeles Times Book Prize, and a Salon Book Award.

Published in 1997, the book has attained classic status within medicine. Its contents and lessons remain relevant for contemporary medical practice, and this is why I listed it amongst the important book’s this podcast explores.

Anne explored the tragedy that evolved when Hmong refugees in the United States interacted with their health centre. At the centre of the saga is their young daughter with refractory epilepsy. Anne explores the transcultural failures that marred the interactions between the two sides, and almost fatally compromised the girl’s life.

Anne Fadiman is Professor in the Practice of Creative Writing, and Francis Writer-in-Residence at Yale University. The former editor of The American Scholar and a fellow of the American Academy of Arts and Sciences, Fadiman is also the author of two essay collections, Ex Libris and At Large and At Small, and a memoir, The Wine Lover's Daughter.

In this episode, I trace the history of the development of EEG and MRI, the two key investigation tools of epilepsy. This explores the roles played by neuroscientists Hans Berger and Edgar Adrian, and physicists Paul Lauterbur, Peter Mansfield, and Raymond Damadian.

I also use the fascinating memoir, The Letter E, to demonstrate the importance of the genetic diagnosis of epilepsy, and A Mind Unravelled to demonstrate the complications of anti-seizure medications.

I also trace the history of the use of chemical treatments of epilepsy, from chance discoveries to rational approaches.

The podcast also covers the interventional treatments of epilepsy, such as vagus nerve stimulation and epilepsy brain surgery.