Bryan Sanz — Comprehensive Medical Dashboard

Allergen	Type
Sulfa Antibiotics ⚠️ Acetazolamide = sulfonamide	Drug
Sulfacetamide	Drug
Hazelnuts (hives)	Food
Cat dander, Dogs	Env.
Mold (active sinus disease)	Env.

Duration	Daily × 12+ years — zero headache-free days
Location	Occipital (L>R) → diffuse; pressure behind eyes
Quality	Band-like, pulsatile (syncs with heartbeat), throbbing
Pulsatile	Head visibly moves with pulse — upright AND supine
Valsalva	Significantly worsened (cough, strain, bend forward)
Positional	Worse upright; minimal relief supine
Associated	Nausea, photophobia, phonophobia, L pulsatile tinnitus
Vertigo	Resolved on duloxetine (was prominent ~12 yrs ago)

Study	Status	Ordered / Read By	Key Finding / Purpose
MRI Brain w/wo Contrast	✅ Complete — 4/11/2026	CCF (Dengri/Javed) · Dr. L'Heureux	Normal parenchyma. No pachymeningeal enhancement. No empty sella. SIH/CSF leak ruled out. Incidental R maxillary retention cyst 1.4cm.
MRV Brain	⚠️ Action Req — 4/11/2026	CCF (Dengri/Javed) · Dr. L'Heureux	LEFT IJV very flattened — patency questioned. L transverse/sigmoid sinus small (congenital variant, patent). Urgent IJV vascular US recommended.
Upper Ext Venous Duplex — Left IJV	✅ Done 4/16/2026	Martin Health St. Lucie West · Dr. Purandath Lall	LEFT IJV distally 0.2cm vs. RIGHT 0.6cm — patent, normal Doppler flow, no thrombus. Congenital asymmetry; explains L pulsatile tinnitus but NOT headache.
Greater Occipital Nerve Blocks (CPT 64405)	✅ Done 4/16/2026	Global Neuro And Spine · Dr. Olegario	Performed 12:15 PM. Initial: significant reduction in headband sensation. Track relief duration for diagnostic yield.
💉 Ajovy Injection #1 (Fremanezumab 675mg subq)	✅ Prescribed 4/20/2026	Dr. Rabih Kashouty · CVS/Pharmacy #5151 Fort Pierce	NEW CGRP mAb started. Third in class after Emgality + Aimovig failures. Quarterly dosing. Decision point at month 3.
Botox Cycle #2 (OnabotulinumtoxinA 155u)	📅 Sched. Thu 4/23/2026 3:10PM	Premier Neurology Stuart · Tara King NP	Cycle #2 of 90-day protocol. #1 delivered 11/19/2025 without much improvement — continuing per Kashouty. 2–3 cycles standard before response judged.
Occipital Nerve Block #2 (bilateral)	📅 Sched. ~5/18/2026	Premier Neurology Stuart · Ancillary clinician	Kashouty-prescribed cadence every 4–6 weeks for occipital neuralgia (M54.81). Formalizes follow-on to 4/16/2026 block at Global Neuro.
In-Lab PSG (Polysomnogram)	📅 Sched. Wed 4/22/2026	Treasure Coast Sleep Disorders	Original HSAT (CCF) cancelled — out-of-network. In-lab PSG clinically superior: detects both OSA AND central sleep apnea (relevant given tonsillar ectopia).
Inflammatory markers + Thyroid — partial result 4/20/2026	⚠️ Partial — CRP/ESR elevated	Dr. Valeriano's practice (PCP of record Lisa Wheeler APRN; visit clinician Jacqueline Smith APRN) · Quest-Tampa	CRP 11.7 mg/L (H, normal <8) · ESR 22 mm/h (H, normal ≤15) · TSH 0.61 (nl) · Free T4 1.2 (nl). First biochemical confirmation of systemic inflammation; thyroid biochemically euthyroid. ANA, ANCA, antiphospholipid, tryptase, complement still pending.
Neurotology Consultation	📅 Scheduled	Dr. Christine Dinh, MD — UHealth Miami (Univ. of Miami Ear Institute)	Referral routed by Dr. Dengri (CCF, 4/16/2026) for ENT/neurotology correlation of L pulsatile tinnitus with hypoplastic left IJV. Pre-existing rapport (dx'd Ménière's 2019).
Transthoracic Echocardiogram (TTE) + Cardiology Eval	⚠️ NEW — Not Yet Ordered	Request via PCP (Dr. Valeriano, 4/17/2026)	Objective pulsatile head motion (de Musset's sign concern) — rule out severe aortic regurgitation / high-output state. Pair with 12-lead ECG, CBC, TSH/free T4, BMP.
Headache Specialist Consult	📅 Sched. 6/2026	Dr. Aysha Siddika — CCF Headache	Sub-specialty evaluation of NDPH / refractory daily headache.
LP w/ Opening Pressure	❌ Deferred 4/15/2026	Dr. Dengri + Dr. Danita Jones	Formally deferred — no papilledema, MRI/MRV findings not suggestive of IIH, no positional or visual features. Can revisit if clinical picture changes.
Spinal MRI w/ Gadolinium	⚠️ Not Yet Ordered	—	Evaluate for epidural CSF collections, pachymeningeal enhancement (SIH). Never done.
Thyroid US + TSH	📋 Not Yet Ordered	—	1.4cm L thyroid nodule on CCF cervical MRI 3/10/2026 — requires dedicated evaluation.

📅Chronological Medical Timeline

~1996–1998 (Age 6–7)

🔴 Skull Base / Upper Spine Abnormality — No Records

Per mother's report to Dr. Nduku (NSF Neurosurgery, 12/29/2025): At age 6–7, Bryan was told there was "an abnormality at the base of his skull and top of his spine." No formal diagnosis was given, no records exist. This may represent early tonsillar ectopia / Chiari-spectrum finding or craniocervical junction anomaly. The origin of a congenital predisposition cannot be ruled out.

Childhood — Puberty

Migraine onset in childhood, remission during puberty

Typical migraines began in childhood. Remission occurred with puberty (hormonal pattern consistent with pediatric migraine). Strong family history: father, mother, both grandfathers, paternal grandmother all affected.

July 28, 2014 (Age 24)

🔴 Left Gonadal Vein Embolization — University of Miami Hospital

Left scrotal pain/swelling × 10 days; ultrasound confirmed LEFT varicocele without torsion or epididymitis. Transcatheter coil embolization performed: US-guided right femoral access → selective catheterization and venogram of LEFT RENAL vein → selective catheterization and venogram of LEFT GONADAL vein → coil embolization from inguinal canal to L2 level (multiple coils 3–10mm diameter). NOTE: Circumaortic left renal vein documented (anatomical variant). Post-embolization: complete occlusion confirmed, left renal vein widely patent. Operators: Dr. Mehul Doshi MD (ordering) / Dr. Aldo Gonzalez-Beicos MD (reading). CC: Dr. Hernan Carrion (Urology). Historical context: documents a left-sided varicocele at age 24 in the setting of a circumaortic left renal vein anatomic variant. Prior dashboard framing grouped this with later left-sided findings as "systemic left venous insufficiency"; however, with the 4/16/2026 vascular ultrasound demonstrating a patent hypoplastic left IJV (congenital variant, not pathologic obstruction), the overall left-sided pattern is now best interpreted as constitutional venous anatomic asymmetry rather than progressive pathologic venous disease.

November 27, 2018

🔴 UHealth Ear Institute — Dr. Christine Dinh MD — Initial Evaluation

Chief complaints: Dizziness, LEFT ear fullness, LEFT-sided tinnitus, left ear pain. Audiology evaluation same day (Dana Libman AUD) for vertigo. New medications started: Meclizine (Antivert) 25mg BID PRN; Triamterene-HCTZ (Dyazide) 37.5-25mg daily — classic Ménière's disease treatment. New allergy documented at this visit: Hazelnuts → Hives. Diagnoses: Dizziness, Hearing loss, Left-sided tinnitus, Ear fullness left. This marks the formal beginning of left cochlear/vestibular workup.

August 9, 2019

🔴 Ménière's Disease, LEFT — Formally Diagnosed — Dr. Christine Dinh MD

Active diagnoses at this visit: Ménière's disease, left (H81.01); Left-sided tinnitus; Left ear fullness. Triamterene-HCTZ (Dyazide) had been trialed as standard Ménière's diuretic treatment but was discontinued shortly after starting — patient reported feeling worse on it (consistent with already low-normal baseline BP; further fluid/pressure reduction was poorly tolerated). Multiple audiology and NP follow-ups in 2019 confirmed the diagnosis. November 2019: Migraine with vertigo added as diagnosis. Additional medications: Doxycycline 100mg; Prochlorperazine (Compazine) 5mg PRN for nausea; Paroxetine (Paxil) 10mg. Updated context (4/16/2026): Ménière's is retained as an independent concurrent diagnosis under ENT care. Vertigo subsequently resolved on duloxetine per Vero ENT. Previously hypothesized mechanistic link to IJV venous hypertension is not supported — US 4/16/2026 showed patent left IJV (congenital hypoplasia only). The Dyazide intolerance is consistent with Bryan's historically low-normal BP independent of any venous obstruction hypothesis.

~2012–2014 (Age ~22–24)

🔴 Headache Recurrence + Vestibular Migraine Onset

Migraines returned "with a vengeance." First major vestibular episode: holocephalic throbbing + severe vertigo. Patient reports this happened ~12 years ago (estimated 2014 from 3/25/2026 visit). Vertigo eventually resolved after duloxetine started. Daily headaches have persisted continuously since. This marks the start of the 12+ year refractory period.

January 12, 2021

Audiogram + Tympanogram — South Florida ENT

Audiological evaluation completed. Results not in current record set. Context: evaluation likely related to vestibular symptoms / sinus disease.

January 13, 2021

🔴 South Florida ENT Associates — Dr. Andrew Schell, MD — Initial Visit

Comprehensive ENT evaluation for dizziness, nasal congestion, allergic rhinitis, migraine with vertigo, atypical facial pain (G50.1), and LPR. Procedures same-day: allergy testing, audiological testing, nasal endoscopy, VNG testing ordered. Vital signs: BP 120/70, HR 80. Weight 200 lb. Medications documented: Nortriptyline, Magnesium 500mg, Esomeprazole, Famotidine, Riboflavin, Emgality 140mg/month, CoQ10, Allegra. Drug allergy: Sulfa drugs confirmed. Notable: Gastroparesis and medical marijuana use listed on intake form.

March 15, 2021

🔴 Cone Beam CT Paranasal Sinuses #1 — South Florida ENT (Dr. Schell)

Indication: Chronic sinusitis and facial pressure. FINDINGS: All sinuses affected — bilateral ostium obstruction (maxillary, frontal, sphenoid); bilateral mucosal thickening (all sinuses); hypoplastic right frontal sinus; leftward septal spur. IMPRESSION: Chronic pansinusitis involving bilateral maxillary, frontal, ethmoid, and sphenoid sinuses; ostiomeatal obstruction; leftward septal spur. Lund-MacKay Score = 17/24 (severe disease). Signed by Dr. Andrew Schell MD, March 15, 2021.

April 7, 2021

VNG (Videonystagmography) Testing — South Florida ENT

VNG/goggles vestibular function testing performed. Results not fully documented in available records. Context: work-up for dizziness and migraine with vertigo (G43.109).

April 19, 2021

🔴 SINUS SURGERY #1 — Balloon Sinuplasty + Turbinate Coblation (Dr. Schell)

Outpatient surgical procedure: (1) Frontal Balloon Sinuplasty; (2) Maxillary Balloon Sinuplasty; (3) Bilateral Intramural Turbinate Coblation/Ablation/Cauterization. Pathology: Nasal turbinate/sinus tissue showing respiratory mucosa with chronic active inflammation and edema. Post-op: Amoxicillin-clavulanate + oxycodone/APAP prescribed. Multiple post-op debridement visits (4/26/2021, 5/10/2021). Despite surgical intervention, chronic pansinusitis persisted on follow-up imaging and endoscopy.

2021–2022

Pain Management — Dr. Marjorie Mamsaang DO (PRM of FL PA) + Dr. Sandra Sandhu-Restaino DO

Ongoing pain management care for pelvic floor pain and chronic pain syndrome. CRITICAL DOCUMENTATION: Dr. Mamsaang (09/2022) formally documented CENTRAL SENSITIZATION and PERIPHERAL SENSITIZATION — "membrane hyperexcitability and upregulation of both CNS and PNS with sympathetic component to pain." Assessment: pelvic pain secondary to neuropathic pain and Myofascial Pain Syndrome. Diagnoses: Chronic Pain G89.29, Chronic Pain Syndrome G89.4, Myalgia M79.10. Treatments: peripheral nerve blocks, pelvic floor trigger point injections, PT, psychosocial support. Vitals 09/12/2022: BP 113/67. Lyrica titration documented: 75mg → 150mg → 200mg (not taking 200mg by 03/2023).

February 18, 2022 / March 10, 2022

🔴 Cone Beam CT Paranasal Sinuses #2 — South Florida ENT (Dr. Schell)

Indication: Chronic sinusitis and acute sinusitis (ordered 2/18/2022, interpreted 3/10/2022). Findings WORSE than 2021: Bilateral severe chronic pansinusitis with COMPLETE opacification of bilateral ostiomeatal complex; large leftward bony septal spur; bilateral inferior turbinate hypertrophy and septal deviation bilaterally. Impression: Chronic sinusitis, deviated nasal septum and inferior turbinate hypertrophy. Levofloxacin 500mg started for acute-on-chronic sinusitis. Proceeded to surgical planning.

April 20, 2022

🔴 SINUS SURGERY #2 — FESS Revision (Dr. Andrew Philip Schell MD)

Outpatient surgical procedure at AS_South Outpatient Services. Revision FESS (Functional Endoscopic Sinus Surgery) for persistent severe chronic pansinusitis following balloon sinuplasty (2021). Bilateral procedure targeting ethmoid, maxillary, frontal, and sphenoid sinuses. Pre-op: Cefdinir + methylprednisolone (2/4/2022); Prednisone 10mg × 5 days pre-op. Post-op debridements: 4/27/2022, 5/4/2022, 5/20/2022. Follow-ups continued through 7/2023. CLINICAL SIGNIFICANCE: Despite two surgical procedures, chronic pansinusitis remained active on subsequent endoscopy (confirmed by Dr. Baggett, Vero ENT, January 2026).

November 2022 / July 2023

South Florida ENT — Ongoing Follow-ups

11/28/2022: Nasal endoscopy, amoxicillin-clavulanate for acute-on-chronic ethmoid/maxillary sinusitis. 07/03/2023: Nasal endoscopy, cefdinir for recurrent sinusitis flare (chronic ethmoidal, maxillary, frontal sinusitis). Chronic pansinusitis remains refractory to two surgeries and multiple antibiotic courses.

May 8, 2023

First Choice Neurology — Dr. Steven Kobetz, Initial

Vestibular migraine "partially controlled" with propranolol + Emgality samples. Tension headaches at craniocervical junction documented. Dix-Hallpike: minimal dizziness in left head-hanging position, no nystagmus. Bruxism present. Family migraine history fully documented. Diagnosis: ubrogepant for abortive.

August 7, 2023

First Choice Neurology — Dr. Kobetz, Follow-up

Emgality no longer effective — failed. Switched to Nurtec 75mg every other day. Previous failures: topiramate, nortriptyline (caused tachycardia), Aimovig, propranolol (initial trial). Bruxism responding to nightguard.

April 1, 2024

Vero Orthopaedics II PA — Dr. Daniel Plessl MD — Initial Evaluation

New patient evaluation for left shoulder pain, cervical radiculopathy, left-sided neck pain, numbness/tingling in upper extremity. Diagnoses: cervical disc displacement (M50.20), cervical radiculopathy (M54.12), cervicogenic headache (G44.86 — working dx), left shoulder pain (M25.512), paresthesia. Pain score 6/10. Physical therapy initiated. Sulfa allergy confirmed.

May 6, 2024

Vero Orthopaedics II PA — Left Shoulder MR Arthrogram + Injection

Left shoulder MR arthrogram: essentially normal — labrum intact, no significant shoulder pathology. Ultrasound-guided shoulder injection performed. Clinical question shifted to cervical radiculopathy as source of left arm/shoulder symptoms rather than primary shoulder pathology.

May 15, 2024

Vero Orthopaedics II PA — EMG/NCV Ordered

EMG/NCV bilateral upper extremity ordered to evaluate cervical radiculopathy vs. peripheral nerve involvement. Ongoing physical therapy.

July 29, 2024

Vero Orthopaedics II PA — Follow-up

Daily headaches persisting. Pain improved from 7/10 → 4/10 since initial visit. Cervicogenic headache diagnosis maintained as working dx at this point. NOTE: Cervicogenic headache subsequently disproven — cervical facet injections (Global Neuro & Spine, 12/2025) produced zero impact on headache frequency or intensity.

April 28, 2025

TCCH OSLO Family Practice — Dr. Valeriano, Lipid Follow-up

Active problems documented: Gastroparesis, vestibular migraine, chronic daily headache, mixed hyperlipidemia, pelvic floor dysfunction, overweight. Lipids (11/2024): Total chol 252, TG 176, LDL 182, HDL 37 — atherogenic profile. BP 96/64 (notably low). Pulse 66.

October 20, 2025

Global Neuro And Spine Fort Pierce — First Visit

Initial pain management evaluation. Diagnosis: Cervicalgia (M54.2).

October 28, 2025

TCCH OSLO — Dr. Valeriano, Cervicogenic Headache

New complaint: severe cervicogenic headaches from posterior cervical and shoulder pain. MRI confirms herniated discs. PHQ-9 score 7. Plan: meloxicam 15mg, referral to pain management. Diagnosis updated: osteoarthritis of spine with radiculopathy, cervical region. Note: Propranolol described as "effective" for prophylaxis at this point.

October 31, 2025

Global Neuro And Spine — James Leitera APRN

Cervical radiculopathy (M54.12), cervicalgia (M54.2), chronic migraine intractable w/ status migrainosus (G43.711). Therapeutic drug monitoring (Z51.81).

November 13, 2025

TCCH OSLO — Unrelated Acute Visit

Presenting with perineal abscess. Active problem list unchanged. PHQ-9 fluctuating (4–8 range).

November 18, 2025

🔴 MRI Brain + IACS w/wo Contrast — Hope Imaging / ordered by PA Muci

1.5T. Key findings: SEVERE pansinusitis (bilateral maxillary, ethmoid, sphenoid, left frontal). MILD TONSILLAR ECTOPIA. No CP angle mass. No 7th/8th nerve lesion. No abnormal enhancement. No demyelination. No infarcts. The tonsillar ectopia here was NOT corroborated on the Cleveland Clinic CSF flow study (3/10/2026) — the latter more definitively ruled out Chiari/flow obstruction.

November 24, 2025

🔴 MRI Cervical Spine W/O Contrast — Hope Imaging (Dr. Tipps/Berns)

C4/C5: disc protrusion, minimal mass effect on thecal sac, AP canal 7mm. C6/C7: broad-based disc protrusion WITH mass effect on thecal sac, AP canal 8mm. Clinical indication: 10 years chronic migraines + cervicalgia.

December 1, 2025

Global Neuro And Spine — Office Visit

Medication reconciliation: Valium 5mg, Cyclobenzaprine 10mg, Pregabalin 200mg, Frovatriptan 2.5mg, Meloxicam 15mg, Propranolol ER 60mg, Qulipta 60mg, Duloxetine 60mg, Linzess 290mcg all on record.

December 17, 2025

Global Neuro And Spine — Follow-up (Dr. Olegario)

Follow-up appointment. Bilateral cervical medial branch blocks C2-3, C3-4 ordered at this visit. Blocks scheduled for January 2026.

December 29, 2025

NSF Neuro Spec South FL — Dr. Valentine Nduku (Neurosurgery) + Melissa Gonzalez APRN

Dx: Congenital malformation of brain (Q04.8), cervical disc herniation (M50.20). "Mild Chiari malformation noted, no syrinx." Mother's history of childhood skull base abnormality obtained. Plan: fundoscopy, sleep study for central sleep apnea, ACDF C4-5 / C6-7 if conservative fails. Acetazolamide trialed — worsened headache (⚠️ patient has sulfa allergy; acetazolamide is a sulfonamide). Vitals: BP 110/72, HR 69, wt 228.5lb.

January 12–13, 2026

🔴 Vero ENT Associates — CT Sinuses + Dr. Kathleen Baggett

CT sinuses W/O 1/12/2026. Nasal endoscopy: polypoid disease toward frontal recess. Dx: Pansinusitis, polypoid sinus degeneration, allergic rhinitis, hyperimmunoglobulin E syndrome, elevated eosinophils, history of sinus surgery. KEY NOTE: "mucosal disease in left frontoethmoidal recess and left sphenoid — headaches are on the left hand side." Oral steroids provided some headache improvement. Budesonide rinse BID + Dupixent 300mg q2weeks ordered for polypoid disease. Vertigo initially — resolved on duloxetine.

January 14, 2026

Diagnostic Cervical Medial Branch Block #1 — C2-C4 — Global Neuro And Spine (Dr. Olegario)

First diagnostic MBB at C2-3, C3-4 bilaterally. 80% pain relief for 1 day — confirms significant facet joint contribution at C2-C4. Duration consistent with local anesthetic effect. Plan: repeat confirmatory block before proceeding to RFA.

January 28, 2026

Diagnostic Cervical Medial Branch Block #2 — C2-C4 — Global Neuro And Spine (Dr. Olegario)

Confirmatory diagnostic MBB at C2-3, C3-4 bilaterally. Again 80% relief for 1 day. Two positive diagnostic blocks confirm C2-C4 facet joints as significant pain generators — criteria met to proceed with radiofrequency ablation.

February 13, 2026

RIGHT Cervical Radiofrequency Ablation — C2-C4 — Global Neuro And Spine (Dr. Olegario)

Right-sided cervical RFA at C2-3, C3-4 (CPT 64633, 64634). Reduced right-sided cervical pain and radicular arm symptoms. Zero impact on headache intensity or frequency — critical negative finding ruling out right cervicogenic contribution to headache.

February 24, 2026

LEFT Cervical Radiofrequency Ablation — C2-C4 — Global Neuro And Spine (Dr. Olegario)

Left-sided cervical RFA at C2-3, C3-4 (CPT 64633, 64634). Ketorolac 10mg Q6h PRN × 5 days added post-procedure. Reduced left-sided cervical pain and bilateral arm radicular symptoms. Zero impact on headache intensity or frequency. Bilateral RFA series now complete — cervicogenic headache definitively ruled out as primary headache driver.

March 10, 2026

🔴 MRI Cervical Spine + Cine Flow Study — Cleveland Clinic, Dr. Fabian Candocia

Critical findings: LEVOSCOLIOSIS of cervical spine. C4-5 broad right paracentral disc protrusion + mild canal stenosis + moderate RIGHT neuroforaminal narrowing. C5-6 broad right paracentral disc protrusion + mild canal stenosis. C6-7 central disc protrusion + mild canal stenosis + SEVERE LEFT neuroforaminal narrowing. MULTINODULAR THYROID — largest nodule 1.4cm left side — not yet evaluated. CHIARI RULED OUT: normal in-phase flow through craniocervical junction. Normal CSF flow dynamics.

March 25, 2026

🔴 Cleveland Clinic Florida Neurology — Dr. Dengri (Resident) + Dr. Zarmina Javed (Attending)

Two distinct headache patterns: (1) Vestibular migraine (historical, 12 years ago). (2) Current: daily occipital headache → frontal, band-like, 5/10 baseline, nausea/photo/phonophobia, NO vertigo. Triggers: bearing down, coughing, bending forward. No occipital tenderness. Left pulsatile tinnitus. Failed: Emgality, Aimovig, Topamax, TCA, Botox, Qulipta, Nurtec. Acetazolamide WORSENED. Never had LP. Current Rx: Propranolol ER 60mg + Duloxetine 60mg + Pregabalin 200mg BID + Linzess. Plan: sleep study, MRI Brain w/wo, MRV Head, occipital nerve block. Fundoscopy reportedly normal.

April 11, 2026

🔴 MRI Brain WO/W IVCON + MRV Brain WO IVCON — Cleveland Clinic (Dr. Jade L'Heureux)

MRI Brain: Essentially normal. No pachymeningeal enhancement — SIH/CSF leak ruled out. No empty sella. No mass. Right maxillary retention cyst (incidental). Normal foramen magnum, sella, IACs.

MRV Brain: LEFT internal jugular vein flattened — patency questioned. Left transverse/sigmoid sinus small (patent, congenital variant). Radiologist recommends urgent vascular ultrasound of left IJV. Findings communicated to Dr. Javed 12:14 PM. (Subsequently resolved: ultrasound performed 4/16/2026 — patent flow with congenital hypoplastic asymmetry; see later timeline entries.)

April 14, 2026

🧠 Lighthouse Health Group — Psychiatry — Anthony Gonzales, PMHNP-BC, FNP-BC

New patient evaluation for psychiatric impact of chronic pain. Diagnoses: Major Depressive Disorder, moderate (F32.1); Generalized Anxiety Disorder (F41.1). Duloxetine dose increased from 60mg to 90mg/day (30mg AM + 60mg PM). Referral placed for individual therapy within Lighthouse Health Group.

April 15, 2026

🧠 Cleveland Clinic Florida Neurology — Telehealth Follow-up (Dr. Chetna Dengri + Dr. Danita Jones, DO MPH, Attending)

Formal Diagnoses Documented: (1) New Daily Persistent Headache; (2) Concern for possible cervicogenic headache/neck pain; (3) OSA/snoring; (4) Pulsatile tinnitus, left-sided — likely due to IJ stenosis.

LP formally deferred: Headache not suggestive of IIH. No papilledema on fundoscopy (ophtho 11/2025). MRI Brain negative for features of elevated ICP. Prior acetazolamide worsening likely attributable to sulfa allergy, not low-ICP evidence.

TCA declined: Patient-reported prior tachycardia on nortriptyline — declined re-trial.

Plan: Proceed with vascular US for IJ patency, occipital nerve block, sleep study (now in-lab PSG 4/22/2026 — Treasure Coast Sleep Disorders; original HSAT cancelled out-of-network). Follow-up with headache specialist Dr. Aysha Siddika scheduled 6/2026. CCF reading by attending Dr. Danita Jones, DO MPH (561.904.7200).

April 16, 2026

🩺 Upper Extremity Venous Duplex (LEFT) — Martin Health St. Lucie West (Dr. Purandath Lall, Interpreting)

Collection 10:40 AM · Final result 4:08 PM. Technologist: Sharon Smith RVT. Ordering: Dr. Zarmina Javed.

Findings: LEFT internal jugular vein Doppler — NORMAL flow, normal compression, no thrombus. LEFT IJV diminished in size distally measuring 0.2cm vs. RIGHT 0.6cm (3x asymmetry). Subclavian, axillary, brachial, basilic, cephalic veins all normal on left. Right IJV and subclavian patent with normal pulsatile flow.

Interpretation (Dr. Dengri, Neurology): "No thrombus. Vein is patent. This finding should not be the cause of your headache based on the description and other features. However, it can explain your pulsating tinnitus on left ear. Recommend ENT opinion for correlation with pulsatile tinnitus." The small-caliber left IJV parallels the small left transverse/sigmoid sinus on MRV — likely congenital hypoplastic left-sided venous drainage, not pathologic obstruction.

April 16, 2026 — 12:15 PM

💉 Greater Occipital Nerve Block (Bilateral) — Global Neuro And Spine, Fort Pierce (Dr. Louis Olegario, MD)

CPT 64405. New diagnosis formally added to problem list: Bilateral Occipital Neuralgia (ICD-10 M54.81). Medications injected: 80 mg Triamcinolone (Kenalog PF) + 6 mL 0.25% Bupivacaine; 3 cc delivered per side via 25-gauge 1.5-inch needle at landmark 1/3 distance from occipital protuberance to mastoid (palpation-guided, no fluoroscopy). No CSF, blood, or paresthesias. Patient tolerated well, neuro exam unchanged. Vitals at visit: BP 129/98 (elevated diastolic — flag for PCP), HR 64, BMI 28.24. Initial response: significant reduction in headband sensation while bupivacaine active; overnight headache flare reported, improved by morning. Steroid (Kenalog) onset 3–7 days — true diagnostic yield will be clearer over the next 1–2 weeks. Partial/complete relief would support a peripheral occipital nerve contribution to the NDPH phenotype. Follow-up scheduled in 2 weeks.

April 17, 2026 — Friday (PCP visit — labs drawn 3:12 PM)

🧪 PCP Visit — Dr. Juliette Valeriano's Office (clinician at visit: Jacqueline Smith, APRN; MyChart PCP-of-record: Lisa Wheeler, APRN) · Labs via Quest Diagnostics-Tampa

Lab results (resulted 4/20/2026 1:18 PM):

Test	Result	Reference	Flag
C-Reactive Protein (CRP)	11.7 mg/L	<8.0	HIGH
ESR (Westergren)	22 mm/h	≤15	HIGH
TSH	0.61 mIU/L	0.40 – 4.50	Normal (low-normal)
Free T4	1.2 ng/dL	0.8 – 1.8	Normal (mid-range)

🔍 Interpretation:

Biochemical confirmation of systemic inflammation. Both CRP and ESR are elevated — Bryan is no longer just clinically suspected of a systemic inflammatory state; it's now objectively documented. Multiple providers (Vero ENT, psychiatry, pain mgmt) had independently raised this hypothesis; this is the first formal biochemical corroboration. Magnitude is moderate (not massive) — consistent with chronic low-grade inflammation rather than acute bacterial infection.
Likely drivers: (1) chronic pansinusitis / polypoid sinus disease + hyperimmunoglobulin E syndrome + eosinophilia — all previously documented and could alone account for these values; (2) possible unrecognized autoimmune process — ANA, ANCA, antiphospholipid, complement C3/C4, serum tryptase still pending; (3) overweight BMI 28.24 contributes mildly to CRP. Rarely relevant at 36: giant cell arteritis, IBD.
Thyroid biochemically euthyroid. TSH 0.61 + Free T4 1.2 → thyroid dysfunction is no longer a credible contributor to the tachycardia, tinnitus, or pulsatile head motion. Note: TSH is at the low-normal end but not suppressed, so subclinical hyperthyroidism is not present. Free T3 was not ordered — in rare T3-toxicosis the TSH is frankly suppressed, which is not the case here, so T3 testing is low-yield. Thyroid structural workup (1.4cm left thyroid nodule on 3/10 MRI) still needs a dedicated thyroid ultrasound — euthyroidism does not exclude structural pathology.
Implication for NDPH workup: Chronic systemic inflammation can prime central sensitization and is increasingly recognized as a contributor to chronic daily headache phenotypes. This finding strengthens the rationale to (a) continue aggressive treatment of the underlying sinus/type-2 inflammatory disease (Dupixent), (b) pursue the remaining autoimmune serologies to completion, (c) share these results with CCF Neurology and the headache specialist (Dr. Siddika, 6/2026).
Still pending from this visit: ANA with reflex, ANCA, antiphospholipid panel, serum tryptase, complement C3/C4. Also flag for PCP: elevated diastolic BP 129/98 recorded at Global Neuro 4/16/2026 — historical BP has been low-normal; worth recheck/trending. Cardiology referral for objective pulsatile head motion (see Rec #3) should be discussed/placed.

April 20, 2026 — Monday · 11:20 AM (telemedicine)

🧠 Neurology Follow-Up — Dr. Rabih Kashouty, Premier Neurology (Stuart, FL) · Referred by James Leitera APRN · Purpose: Review MRV Brain, MRI Brain, MRI C-Spine, US Arm Vein DVT (Left)

Vitals: BP 133/80 · HR 63 bpm (bradycardic — on propranolol 60 mg ER at bedtime) · BMI 28.2 · Ht 6'2" · Wt 220 lbs

Depression screening: PHQ-9 score 13 (moderate depression) · AUDIT-C 1 (low risk alcohol)

🔍 Imaging/workup reviewed:

MRV Brain: No clear evidence of dural venous sinus thrombosis.
MRI Brain (repeat April 2026): No evidence of acute findings.
MRI Cervical Spine: No syrinx.
No evidence of normal pressure hydrocephalus.
Left arm vein DVT US: previously normal (per referral context).

📋 Assessment / Plan:

#1. Intractable migraine without aura, with status migrainosus — G43.011 (NEW CODING)

Dr. Kashouty's framing: "Refractory pulsatile headaches / Chronic daily headaches / migraines." Acknowledges failure of Emgality, Aimovig, antidepressants, antiepileptics, Qulipta (intolerable), acetazolamide (worsened), duloxetine (partial vertigo benefit), Botox (only 1 treatment, no benefit yet).

Plan:

START Ajovy (fremanezumab) 675 mg subq once every 3 months — NEW prescription (Qty: 3 × 1.5 mL syringes; refills 5; CVS #5151). Third CGRP mAb trial (after Emgality and Aimovig failures).
Occipital nerve block every 4–6 weeks — next scheduled ~5/18/2026 at Premier Neurology (Ancillary clinician). This formalizes a treatment cadence after the effective 4/16 block at Global Neuro.
Continue Botox — #2 of the 90-day cycle scheduled 4/23/2026 at 3:10 PM with Tara King NP.

#2. Recurrent pansinusitis — J01.41

Managed by ENT. Recent CT: no acute obstruction. Using medicated sinus rinse; persistent inflammation. ENT considering injectable biologic pending phenotype labs (consistent with Dupixent pathway started at Vero ENT).

#3. Cerebellar tonsillar ectopia — Q04.8

Small tonsillar ectopia; potential contributor to pulsatile headaches. Under neurosurgical evaluation. No syrinx on C-spine MRI. Continue to monitor. Dr. Kashouty does not consider this the primary headache driver but does not dismiss it.

⚠️ Clinical observations worth flagging:

HR 63 bpm in the setting of objective cephalic pulsation is a double-hit. Propranolol-induced bradycardia + a relatively stiff/hyperdynamic stroke volume = the per-beat ejection becomes larger even though the rate is slower. This is a recognized way a patient can become more aware of each heartbeat visibly (and it's in the same physiological family as de Musset's sign). It does not replace the cardiology/TTE workup — it makes it more, not less, warranted.
PHQ-9 of 13 is clinically meaningful moderate depression and should be addressed in parallel — chronic pain and depression are bidirectionally sensitizing. Duloxetine at 90 mg/day (30 + 60 combo per MyChart) is active therapy, but a 13 suggests the current dose/regimen is not sufficient control.
Dr. Kashouty did NOT reference the 4/17 CRP 11.7 / ESR 22 results — those resulted this morning (4/20, 1:18 PM) and the telemed note was signed from the neurology side. Worth forwarding to him via patient portal given his principal-provider framing.
Ajovy after Emgality + Aimovig failures: All three are CGRP-pathway blockers but differ in target (Emgality/Aimovig are monthly; Ajovy can be given quarterly and has a slightly different binding profile). Non-response to two of the class reduces but does not eliminate the probability of response to the third — real-world response rates to a 3rd CGRP mAb after two failures are ~15–25%.

📅 Scheduled follow-ups (new):

04/23/2026 3:10 PM — Tara King NP · Botox Migraines · Premier Neurology Stuart
On or around 05/18/2026 — Occipital neuralgia nerve block · Premier Neurology Stuart (Ancillary)
On or around 07/20/2026 — Dr. Kashouty follow-up · Premier Neurology Stuart

April 22, 2026 (Wednesday night)

⏳ In-Lab Polysomnogram (PSG) — SCHEDULED — Treasure Coast Sleep Disorders

Update: Original Home Sleep Apnea Test (HSAT) through CCF was cancelled due to out-of-network coverage. Replaced with in-lab attended PSG at Treasure Coast Sleep Disorders, Wednesday night April 22, 2026. This is a clinical upgrade: full PSG can detect both obstructive AND central sleep apnea, plus measure sleep architecture, arousal index, PLMS, and oxygen desaturation patterns — critical given (a) Bryan's tonsillar ectopia (central apnea concern raised by Neurosurgery), (b) morning headache pattern, (c) BMI 28.24 and snoring history. Ordered by CCF Neurology (Dr. Dengri / Dr. Javed, 3/25/2026). Results should be available at follow-up with Leitera APRN 4/30/2026.

April 30, 2026

⏳ Post-Nerve Block Follow-up — Global Neuro And Spine

James F Leitera, APRN · 12:00 PM · 1801 S 23rd St STE 1, Fort Pierce. Assess response to 4/16 greater occipital nerve block (bilateral). By this visit, steroid (Kenalog) will have been on board ~2 weeks — full therapeutic effect is typically evident. Key data to bring: duration and quality of headband sensation relief, frequency/intensity of headache episodes since block, any localized injection-site reactions, in-lab PSG (4/22/2026) results. Response will inform whether to repeat, convert to pulsed radiofrequency of the occipital nerves, or escalate to headache specialist workup (Dr. Siddika, 6/2026).

Scheduled — UHealth Miami

⏳ Neurotology Consultation — Dr. Christine Dinh, MD (UHealth — University of Miami)

New referral routed: Per Dr. Chetna Dengri's MyChart message (4/16/2026 6:40 PM) after the vascular ultrasound — "it can explain your pulsating tinnitus on left ear. It would help getting ENT opinion on this finding and possible correlation with your pulsating tinnitus." Bryan booked sub-specialty neurotology (not general ENT) — the correct sub-specialty for pulsatile tinnitus with imaging findings. Dr. Dinh is a fellowship-trained neurotologist at the University of Miami. Bring to visit: (1) 4/16/2026 upper-extremity venous duplex report (LEFT IJV 0.2cm vs RIGHT 0.6cm, patent, no thrombus), (2) 4/11/2026 MRI Brain + MRV Head (congenital small left transverse/sigmoid sinus, patent), (3) 11/18/2025 MRI Brain + IACs (Beaches MRI) noting tonsillar ectopia + severe pansinusitis, (4) Ménière's history (left-sided SNHL H90.12, formally diagnosed 2019), (5) symptom diary distinguishing subjective pulsatile tinnitus from objective cephalic pulsation (head-bobbing with arterial pulse when supine). Expected workup considerations: dedicated temporal bone CT, CTA/CTV of neck/skull base (rule out dural AV fistula, glomus tympanicum/jugulare, dehiscent jugular bulb, SSCD), ± audiogram update, ± VEMP.

June 2026

⏳ Headache Specialist Consult — Dr. Aysha Siddika (CCF)

Sub-specialty headache consultation for refractory NDPH / chronic daily headache. Referred by Dr. Dengri/Dr. Jones. Bryan to bring: occipital block response data, in-lab PSG results, autoimmune panel results from PCP, TCA/nortriptyline history (declined due to tachycardia), neurotology (Dr. Dinh) consult outcome, any cardiology/echo results.

🩺Active Diagnoses

ICD-10	Diagnosis	Status	Confirmed By	Clinical Notes
`G43.011`	🆕 Intractable Migraine w/o Aura, with Status Migrainosus	Primary Dx (Neurology) — 4/20/2026	Dr. Rabih Kashouty, MD — Premier Neurology, Stuart FL (4/20/2026)	Dr. Kashouty's re-coding at 4/20/2026 telemed visit after reviewing MRV (no sinus thrombosis), MRI Brain (no acute findings), C-spine MRI (no syrinx), and confirming no NPH. Framed as "refractory pulsatile headaches / chronic daily headaches / migraines." This code captures the intractable + status severity that supports insurance coverage for Ajovy (NEW) and occipital nerve blocks q4–6 weeks.
`G44.52`	🆕 New Daily Persistent Headache (NDPH)	Primary Dx (Headache/CCF) — 4/15/2026	Dr. Chetna Dengri + Dr. Danita Jones, DO MPH (CCF Neurology, 4/15/2026)	CCF Neurology primary working diagnosis — retained alongside Kashouty's G43.011. Daily headache, L occipital throbbing radiating frontally into band-like pattern; triggered by Valsalva. Refractory to all standard prophylactic classes. Occipital nerve blocks 4/16/2026 produced significant initial reduction in headband sensation. Headache specialist follow-up (Dr. Aysha Siddika) scheduled 6/2026. The G43.011 and G44.52 codings are not contradictory — G43.011 captures severity/treatability phenotype, G44.52 captures temporal onset pattern.
`G43.711`	Chronic migraine w/o aura, intractable, w/ status migrainosus	Historical (superseded by G43.011)	CCF Neurology, Global Neuro And Spine	Earlier ICD designation — now superseded by Dr. Kashouty's G43.011 coding 4/20/2026. Refractory to all CGRP-pathway drugs, triptans, preventives.
`H93.A1`	Pulsatile tinnitus, left — due to IJ asymmetry	Active — 4/15/2026	Dr. Dengri + Dr. Jones (CCF); US 4/16/2026 (Dr. Lall)	Confirmed by ultrasound 4/16/2026: LEFT IJV 0.2cm distally vs. RIGHT 0.6cm. Patent, normal flow, no thrombus — turbulent flow through smaller caliber vessel produces audible pulsation. ENT correlation recommended.
`M54.81`	🆕 Bilateral Occipital Neuralgia	Active — 4/16/2026	Dr. Louis Olegario, MD — Global Neuro And Spine, Fort Pierce (4/16/2026)	Added to problem list 4/16/2026 at time of greater occipital nerve block procedure. Clinically concordant with L occipital-predominant pain radiating into frontal/band-like distribution along GON distribution. Diagnostic/therapeutic block delivered 80 mg triamcinolone + 6 mL 0.25% bupivacaine bilaterally. Response pending full steroid onset (~4/23/2026). If sustained relief > 2 weeks, supports peripheral occipital nerve contribution alongside NDPH phenotype.
`G43.109`	Vestibular migraine, intractable	Historical	Dr. Kobetz (FCN), Dr. Dengri (CCF)	Prominent vestibular phase ~12 years ago. Vertigo resolved on duloxetine. Currently NO vestibular symptoms.
`H81.01`	Ménière's Disease, Left Ear	Active	Dr. Christine Dinh MD, UHealth Ear Institute (8/9/2019)	Formally diagnosed 8/9/2019 by Dr. Christine Dinh MD (UHealth Ear Institute). Left-sided tinnitus, left ear fullness, left sensorineural hearing loss, episodic vertigo. Triamterene-HCTZ (Dyazide) and Betahistine (directed by Dr. Dinh) were both trialed for Ménière's management — both discontinued after patient reported feeling worse on each. Vertigo symptoms subsequently resolved on duloxetine per Vero ENT note; Ménière's is currently quiescent/managed. Updated context (4/16/2026): previously proposed mechanistic link to left IJV venous hypertension is not supported — US showed patent left IJV (congenital hypoplasia only, not pathologic obstruction). Ménière's retained as an independent concurrent diagnosis under ENT care.
`H90.12`	Sensorineural Hearing Loss, Left	Active	UHealth Ear Institute audiology team	Documented in conjunction with left Ménière's disease diagnosis. Left-sided, consistent with cochlear involvement.
`M47.812`	Cervical spondylosis without myelopathy	Active	Global Neuro And Spine, Cleveland Clinic	Multilevel disease C4-5, C5-6, C6-7. No myelopathy identified to date.
`M54.12`	Radiculopathy, cervical region	Active	Global Neuro And Spine, TCCH OSLO	C6-7 severe LEFT neuroforaminal narrowing (CCF 3/10/2026). C4-5 moderate right narrowing.
`M50.20`	Cervical disc herniation	Active	NSF Neuro Spec South FL (Dr. Nduku)	ACDF C4-5 / C6-7 under consideration if conservative measures fail.
`J32.4`	Pansinusitis (chronic)	Active	Brain MRI 11/18/2025, CT sinuses 1/12/2026, Vero ENT 1/13/2026	Severe pansinusitis. Left frontoethmoidal + left sphenoid disease — correlates with left-sided headaches. Improved on oral steroids. Polypoid degeneration. Dupixent ordered.
`Q04.8`	Other specified congenital malformation of brain (tonsillar ectopia)	Under evaluation	NSF Neuro Spec / Brain MRI 11/2025	Mild tonsillar ectopia on 11/18/2025 brain MRI. CCF cine flow study 3/10/2026: NORMAL craniocervical junction flow — Chiari effectively ruled out.
`K31.84`	Gastroparesis	Active	Multiple providers	Linzess 290mcg for motility. Valsalva (bearing down) worsens headache — vagal/autonomic connection possible.
`E78.49`	Mixed hyperlipidemia	Active	TCCH OSLO	LDL 182, TG 176, HDL 37 (11/2024). Atherogenic dyslipidemia. No statin documented.
—	Allergic rhinitis + Hyperimmunoglobulin E syndrome	Active	Vero ENT (Dr. Baggett)	Quest labs confirm: Total IgE 120 H (3/2016, ref ≤114); Dog dander IgE Class 3 (7.63 kU/L); Cat dander Class 2 (1.23 kU/L). Persistent peripheral eosinophilia: 587 H (10/2018) → 596 H (4/2022). Supports eosinophilic/Type 2 mucosal inflammation driving chronic sinus disease. Xyzal (levocetirizine) active. Formal allergy retesting ordered by Dr. Baggett (not yet completed).
—	Pelvic floor dysfunction	Active	TCCH OSLO	May relate to Valsalva mechanism / autonomic dysregulation.
—	Multinodular thyroid goiter (1.4cm left nodule)	NOT YET EVALUATED	Found incidentally on CCF MRI 3/10/2026	Thyroid dysfunction can cause or exacerbate headaches, fatigue, autonomic dysregulation. Formal thyroid workup not yet ordered.
F32.1 / F41.1	Major Depressive Disorder, Moderate + Generalized Anxiety Disorder	Active	Anthony Gonzales, PMHNP-BC, FNP-BC — Lighthouse Health Group (4/14/2026); prior PHQ-9 score 7 (TCCH OSLO 10/2025)	Diagnosed in context of chronic pain impact on mental health. Duloxetine dose increased to 90mg/day (30mg AM + 60mg PM) by Gonzales, PMHNP-BC 4/14/2026. Therapy referral placed (Lighthouse Health Group). ORT score 6 = moderate opioid risk.

🔍Diagnoses Under Investigation (Not Yet Confirmed or Ruled Out)

❓ Sleep-Disordered Breathing (OSA / Central Apnea)

Morning headaches, snoring history, BMI 28.24 (overweight). Central sleep apnea specifically investigated by neurosurgery (given tonsillar ectopia). In-lab PSG scheduled Wednesday night April 22, 2026 at Treasure Coast Sleep Disorders (original HSAT cancelled — out-of-network; in-lab PSG is clinically superior for detecting central apnea). Now formally listed on CCF problem list (Dengri/Jones 4/15/2026). Hypercapnia from nocturnal hypoventilation causes cerebral vasodilation → morning headaches.

🟡 Systemic Inflammatory Process — Biochemically Confirmed 4/17/2026

Multiple providers (Vero ENT, psychiatry 4/14, self) have independently raised this hypothesis. Documented: hyperimmunoglobulin E syndrome, persistent eosinophilia (587–596 in 2018/2022), chronic pansinusitis refractory to 2 surgeries, central sensitization. 4/17/2026 labs (resulted 4/20/2026): CRP 11.7 mg/L (H) and ESR 22 mm/h (H) — both acute-phase reactants elevated, providing first biochemical confirmation of a chronic systemic inflammatory state. Magnitude is moderate (not acute-bacterial-infection range). Likely drivers: (a) chronic polypoid/eosinophilic sinus disease ± HIE (already documented), (b) possible concurrent autoimmune process (ANA, ANCA, antiphospholipid, tryptase, complement still pending from this visit), (c) mild BMI contribution. Autoimmune serologies pending will clarify whether to broaden the differential beyond sinus/type-2 inflammation.

❓ Occipital Neuralgia / Peripheral Nerve Component

Greater occipital nerve blocks 4/16/2026 produced significant initial reduction in the headband sensation (block still active at time of report). Relief duration over next 3–7 days will clarify peripheral nerve contribution. Does NOT displace the NDPH designation but may represent a treatable peripheral layer of the total pain.

❓ Spontaneous Intracranial Hypotension (SIH/CSF Leak) — Low Probability

Classically orthostatic with >30-min supine relief. Bryan's positional component is minimal and pain persists supine — atypical. MRI Brain 4/11/2026 showed no pachymeningeal enhancement (classic SIH imaging feature ruled out). Spinal MRI with gadolinium not done. Low probability now.

✅Diagnoses Formally Ruled Out

Diagnosis	Ruled Out By	Date	Evidence
Left IJV Obstruction / Pathologic Stenosis	Upper Ext Venous Duplex — Dr. Purandath Lall; Dr. Dengri (CCF)	4/16/2026	LEFT IJV distally 0.2cm vs. RIGHT 0.6cm — but patent, normal Doppler flow, no thrombus, normal compression. Parallels small left transverse/sigmoid sinus on MRV. Congenital hypoplastic left venous drainage — explains pulsatile tinnitus, NOT headache.
Idiopathic Intracranial Hypertension (IIH)	Dr. Dengri + Dr. Jones (CCF Neurology) — clinical assessment	4/15/2026	LP formally deferred — no papilledema on fundoscopy (ophtho 11/2025), MRI Brain 4/11/2026 showed no empty sella/enlarged CSF spaces, no visual obscuration, no positional features, patent venous drainage on US. Acetazolamide worsening attributable to sulfa allergy. Per CCF: "history not suggestive for increased intracranial pressure." LP can be revisited if clinical picture changes.
Celiac Disease	Quest Diagnostics — ordered by Dr. Paul G. Fishbein MD (Gastroenterology)	11/17/2012	tTG-IgA <1 U/mL (negative); IgA 213 mg/dL (sufficient — result valid). Celiac definitively excluded.
Cervicogenic Headache as primary driver	Global Neuro And Spine (Dr. Olegario) — cervical facet injections	12/17/2025 & 1/14/2026	Cervicogenic headache was a working diagnosis at Vero Ortho (G44.86, 4/2024). Bilateral cervical medial branch blocks C2-3/C3-4 produced 80% pain relief for 1 day only — zero impact on headache frequency or intensity. Effectively rules out cervicogenic mechanism as primary headache driver.
Primary Left Shoulder Pathology	Vero Orthopaedics II PA (Dr. Plessl) — MR arthrogram	5/6/2024	Left shoulder MR arthrogram essentially normal — labrum intact, no rotator cuff or intrinsic shoulder pathology. Left arm/shoulder symptoms attributed to cervical radiculopathy C6–C7.
Chiari Malformation (hemodynamically significant)	CCF — Cine flow MRI	3/10/2026	Normal craniocervical junction CSF flow on cine study. Mild tonsillar ectopia present but not obstructing flow.
SIH / CSF Leak (pachymeningeal)	CCF — MRI Brain w/wo Contrast	4/11/2026	No pachymeningeal enhancement, no epidural CSF collections, no brain sag. Spinal MRI still pending but pachymeningeal pattern excluded.
Hepatitis A / B / C	Quest Diagnostics (Dr. Mantilla)	3/15/2016	All panels non-reactive.
HIV	Quest Diagnostics (Dr. Mantilla)	3/15/2016	HIV Ag/Ab 4th generation — non-reactive.

💊Current Active Medications

Medication	Class	Dose / Route	Indication	Status	Notes
🆕 Ajovy (Fremanezumab)	Anti-CGRP ligand mAb (quarterly subq)	675mg subq q3mo (3 × 225mg/1.5mL syringes in a single dose)	Migraine prophylaxis — G43.011 intractable migraine	NEW — prescribed 4/20/2026	Prescribed by Dr. Rabih Kashouty (Premier Neurology Stuart) 4/20/2026. CVS/Pharmacy #5151 Fort Pierce. Qty 3 × 1.5mL syringes, 5 refills. Third CGRP mAb trial — Emgality (ligand mAb, monthly) failed 2023, Aimovig (receptor mAb) failed pre-2023. Ajovy offers quarterly dosing convenience + different ligand-binding epitope. Expected onset: first decision point at 3 months (1 cycle). Response rate to 3rd CGRP mAb after 2 class failures is modest (~15–25%).
🆕 Botox (OnabotulinumtoxinA) — re-trial	Neurotoxin — chronic migraine protocol (PREEMPT)	155 units IM across head/neck every 90 days	Chronic migraine prophylaxis — G43.011	Active — cycle #2 scheduled 4/23/2026	Re-initiated 11/19/2025 by DAISYANA MUCI, PA (Premier Neurology). #1 delivered — Dr. Kashouty note 4/20/2026: "only had 1 treatment without much improvement" but recommends continuing. #2 scheduled 4/23/2026 3:10 PM with Tara King NP. Response typically requires 2–3 cycles before judged; discontinuation before 3 cycles is premature. Note: prior historical Botox trial (pre-2023) classified as "ineffective" — this is a re-trial under Dr. Kashouty's care.
Propranolol HCl ER	Beta-blocker	60mg QD oral (at bedtime)	Migraine prophylaxis	Active	Initially "effective" (TCCH 10/28/2025). Continuing. HR 63 bpm on 4/20/2026 (Kashouty) — bradycardic. Note: propranolol-induced bradycardia + large compensatory stroke volume can make each beat more visibly palpable (physiologically adjacent to de Musset's sign) — this is a confound worth flagging at the TTE/cardiology consult, not a reason to stop the drug.
Metoprolol Succinate (Toprol-XL)	Beta-blocker (cardioselective)	50mg QD — discontinued	Heart rate control / migraine prophylaxis	Discontinued	Started 2/24/2021 by UHealth. Subsequently replaced by Propranolol ER 60mg — no longer active. No overlap/dual beta-blockade.
Duloxetine HCl	SNRI	90mg/day oral — 30mg AM + 60mg PM (delayed release)	Pain prophylaxis, depression, generalized anxiety	Active	Vertigo resolved after starting duloxetine (per Vero ENT). Dose increased from 60mg to 90mg/day by Anthony Gonzales, PMHNP-BC, FNP-BC (Lighthouse Health Group) on 4/14/2026 for moderate depression + GAD. PHQ-9 7 (10/2025).
Pregabalin	Gabapentinoid	200mg BID oral	Cervical radiculopathy, central sensitization	Active	Addresses neuropathic pain from C6-7 severe neuroforaminal narrowing.
Frovatriptan Succinate	Triptan (5-HT1B/1D agonist)	2.5mg oral — very rarely, only when desperate	Acute migraine abort (last resort)	Rarely used — largely ineffective	Patient reports minimal benefit; only tried when desperate. Consistent with class-wide triptan failure. Functionally discontinued.
Meloxicam	NSAID (COX-2 preferential)	15mg oral — PRN bad flares only (not daily)	Severe musculoskeletal flares	PRN only — not daily	Previously prescribed as daily but patient has self-discontinued daily use. Now taken only during significant flare-ups. Reduced hepatic/GI burden vs. daily use.
Ketorolac Tromethamine	NSAID (potent)	10mg Q6h × 5 days — short course only	Acute pain flares	Short-term only (3–5 doses) — not ongoing	Used as prescribed for a brief acute course only. Not a chronic medication. Minimal ongoing hepatic burden.
Cyclobenzaprine HCl	Muscle relaxant	10mg oral — short course only	Cervical muscle spasm	Short-term only (3–5 doses) — not ongoing	Used briefly as a short course. Not a chronic medication.
Diazepam (Valium)	Benzodiazepine	5mg oral — short course only	Acute muscle relaxation	Short-term only (3–5 doses) — not ongoing	Used briefly as a short course. Not a chronic medication. No ongoing dependence concern.
Linzess (Linaclotide)	GC-C agonist	290mcg QD oral	Gastroparesis	Active
Budesonide nasal rinse	Intranasal corticosteroid	BID	Chronic pansinusitis, polypoid degeneration	Active	Started by Dr. Baggett (Vero ENT). Also uses neti pot every other day + Xyzal.
Dupixent (Dupilumab)	IL-4/IL-13 receptor antagonist (biologic)	300mg/2mL SC q2 weeks	Polypoid sinus degeneration, allergic rhinitis	Course completed / status unclear	Ordered by Vero ENT. Completed course noted in records.
Levocetirizine (Xyzal)	Antihistamine	oral	Allergic rhinitis	Active

🌿Medical Cannabis — Active Daily Use

Substance	Form / Route	Frequency	Indication	Status
Medical Cannabis (THC/CBD)	Primarily flower (inhaled/smoked); occasionally edibles (oral)	Daily	Pain management, nausea (gastroparesis), symptom relief	Active — Daily

💊Supplements — Active Daily

Supplement	Brand	Dose / Timing	Evidence for Bryan's Conditions	Clinical Notes
Magnesium Glycinate	Pure Encapsulations ★ Premium / Third-party tested / Hypoallergenic	120mg × 2/day = 240mg/day Morning + Night	Level B — Migraine Prevention (AAN) Strong RCT evidence for reducing migraine frequency. Magnesium deficiency is common in migraine patients. Also supports sleep and muscle relaxation.	Glycinate form = best absorbed, least GI upset. Dose is below the AAN-recommended 400–600mg/day — could consider increasing to 400mg/day (4 capsules) if well-tolerated. Pure Encapsulations is one of the best brands available — hypoallergenic, no fillers, NSF certified.
Ubiquinol-QH (CoQ10)	Pure Encapsulations ★ Premium / Third-party tested	100mg × 1/day = 100mg/day Morning	Level C — Migraine Prevention (AAN) Ubiquinol is the active, reduced form of CoQ10 — significantly more bioavailable than ubiquinone. Evidence for reducing migraine frequency and duration.	Soft-gel ubiquinol is most bioavailable CoQ10 form. 100mg is a reasonable starting dose; studies have used up to 300–400mg/day. Also relevant for Bryan's cardiovascular risk (cardioprotective mitochondrial support). Note: CoQ10 has mild antihypertensive effects — monitor given Bryan's already low-normal BP (96–114 systolic across visits).
Riboflavin (Vitamin B2)	Seeking Health ★ High quality / Methylation specialist brand	400mg × 1/day = 400mg/day Morning	Level B — Migraine Prevention (AAN) 400mg/day is exactly the dose used in landmark RCTs (Schoenen et al.). Reduces migraine frequency and severity by improving mitochondrial energy metabolism in the brain.	Seeking Health's formula contains both standard riboflavin 400mg AND 4mg active riboflavin-5-phosphate (R-5-P) — the metabolically active form. This is a superior formulation. Urine will turn bright yellow/orange — normal and harmless. Seeking Health is known specifically for methylation-support quality. This is the optimal dose and product for this indication.
Simethicone	PUREGEN Generic-tier brand — simethicone is simethicone	250mg × 1–2/day as needed	Gastroparesis / Gas & Bloating Relief Anti-foaming agent for GI gas. Not related to headache management.	Safe, non-absorbed, non-systemic. Purely symptomatic for gastroparesis-related gas and bloating. Brand is less critical for simethicone since it's not absorbed — the active ingredient is identical across brands. No drug interactions.
Milk Thistle (Silymarin)	Gaia Herbs Pro ★ Certified Organic / Liquid Phyto-Caps / HPTLC tested / Practitioner grade	1000mg × 1/day Recommended by acupuncturist	Hepatoprotective — Liver support under medication load Moderate evidence for protecting liver cells from oxidative stress, reducing liver enzyme elevation in patients on long-term medications. Recommended given duloxetine's FDA hepatotoxicity warning.	Gaia Herbs Pro is practitioner-grade — certified organic, liquid phyto-caps for superior bioavailability, HPTLC identity-tested, and fully traceable farm-to-shelf. 1000mg is a high therapeutic dose. ⚠️ At 1000mg, silymarin can meaningfully inhibit CYP2C9 and CYP3A4 liver enzymes — inform all prescribing physicians. Most current medications (duloxetine, propranolol, pregabalin) use CYP1A2 and CYP2D6 pathways so direct interaction risk is relatively low, but any new prescriptions should be checked against silymarin. Makes the pending LFT panel even more worthwhile as a baseline.
Omega-3 Fish Oil (Alaskan Pollock)	Sports Research — AlaskOmega® ★ MSC Certified / IFOS tested / Triple strength	1250mg × 1/day Morning (~690mg EPA + ~260mg DHA)	Anti-inflammatory / Cardiovascular / Modest migraine benefit EPA/DHA reduce systemic inflammation (relevant to sinusitis, type 2 inflammation), modest TG reduction (TG 176 — elevated), and some evidence for migraine frequency reduction.	Sports Research uses AlaskOmega® — IFOS 5-star certified, processed within hours of catch, 10-step refinement, >80% EPA+DHA per softgel. Excellent sourcing and purity. At 1250mg (~690mg EPA), TG reduction will be modest — clinical doses for significant TG lowering are 2–4g EPA/day. For anti-inflammatory and migraine benefit, current dose is appropriate. Fish oil at any dose can mildly increase bleeding risk with NSAIDs (meloxicam, ketorolac PRN) — low risk at this dose but worth noting.

💡 Supplement Stack Clinical Assessment

Bryan has independently assembled the three most evidence-based supplements for migraine prophylaxis recognized by the American Academy of Neurology: Magnesium (Level B) + Riboflavin 400mg (Level B) + CoQ10/Ubiquinol (Level C). This is exactly the "migraine supplement triple" that headache specialists recommend, in high-quality forms and correct doses. The brands Pure Encapsulations and Seeking Health are among the top-tier supplement manufacturers in the US. The omega-3 choice (Sports Research AlaskOmega) is similarly excellent. The fact that this well-constructed regimen has not resolved the headache aligns with the current working diagnosis of NDPH — a primary headache disorder generally refractory to standard migraine prophylactics (including supplements, triptans, and most preventives) — and supports continued exploration of NDPH-specific approaches (occipital nerve blocks, nerve targeting, indomethacin trial, IV regimens) as well as treatment of the contributing peripheral driver of bilateral occipital neuralgia.

🌿Complementary & Alternative Treatments

Treatment	Provider / Location	Frequency / Duration	Headache Outcome	Clinical Relevance
Chiropractic Care	Various (lifelong)	Every 1–2 weeks, consistently for most of life	Short-term headache relief only; significant benefit for mobility and arm pain	Provides temporary headache relief that does not persist — consistent with cervical muscle tension transiently modulating headache intensity via the trigeminocervical complex, without addressing the underlying intracranial driver. Meaningful long-term benefit for mobility and radicular arm symptoms. No lasting headache resolution despite lifelong consistency. Combined with RFA outcome, confirms headache source is not primarily cervicogenic.
Acupuncture	Dr. He — Miami, FL	~6–7 years ago (course of treatment)	Helped vestibular/vertigo symptoms; primary benefit was relaxation and state of mind	Treatment was focused on vestibular migraine / vertigo at the time. Patient believes it helped vertigo. Greatest benefit was autonomic/parasympathetic — relaxation and mental state — rather than direct headache reduction. Consistent with acupuncture's known mechanism of central sensitization modulation.
Acupuncture (current)	Saint Lucie Acupuncture and Integrative Medicine	Active / ongoing	Primary benefit: relaxation and state of mind; headache effect secondary	Same pattern as prior acupuncture course — greatest impact on autonomic regulation and mental wellbeing rather than direct headache relief. Reasonable adjunct therapy. Inform all treating providers of current use.
Deep Tissue Massage	Hua Flower Murdoch	Every 2 weeks — active / ongoing	Active — cervical muscle tension relief; headache modulation likely short-term	Consistent with pattern seen in chiropractic care: soft tissue treatment may provide temporary headache modulation through cervical muscle tension relief, without addressing the intracranial source. Inform all treating providers.
Acupuncturist Clinical Observation	Saint Lucie Acupuncture and Integrative Medicine	Reflexology / tongue mapping assessment	Systemic chronic inflammation + possible liver strain from medications	Methodology (reflexology/tongue mapping) is not a validated Western diagnostic tool. However, both observations are independently credible: (1) Systemic inflammation is well-supported by documented diagnoses — hyperimmunoglobulin E syndrome, elevated eosinophils, polypoid sinusitis, allergic rhinitis. (2) Liver strain from polypharmacy is plausible — particularly long-term duloxetine (FDA hepatotoxicity warning). No liver function panel (LFTs) has been documented in available records. ⚠️ LFTs should be ordered. Acupuncturist recommended Gaia Herbs Pro Milk Thistle 1000mg — moved to Supplements section where it more appropriately belongs.

❌Failed / Discontinued Medications

Medication	Class	Reason for Failure / Discontinuation	Year (approx)
Emgality (Galcanezumab)	Anti-CGRP mAb (monthly injection)	Initial partial response → lost efficacy	2023
Aimovig (Erenumab)	Anti-CGRP receptor mAb	Ineffective	Before 2023
Topamax (Topiramate)	Anticonvulsant / migraine preventive	Ineffective	Unknown
Nortriptyline (TCA)	Tricyclic antidepressant	Caused tachycardia — discontinued	Unknown
Botox (OnabotulinumtoxinA) — initial trial	Neurotoxin injection	Ineffective for headache (initial trial) — now being re-trialed under Dr. Kashouty (see Active Medications)	Pre-2023 (initial) / Re-initiated 11/2025
Nurtec (Rimegepant)	CGRP receptor antagonist (oral)	Used as abortive; eventually failed / replaced	2023–2024
Qulipta (Atogepant)	CGRP receptor antagonist (daily oral)	Completed one full bottle — no efficacy; behavioral side effects noted; self-discontinued	2024–2025
Ubrogepant (Ubrelvy)	CGRP receptor antagonist (acute)	Used acutely, eventually stopped	2023
⚠️ Acetazolamide ER	Carbonic anhydrase inhibitor (sulfonamide)	WORSENED headache — HOWEVER: patient has sulfa allergy; acetazolamide is a sulfonamide. Worsening may reflect drug reaction/sensitivity, NOT pharmacodynamic evidence of low ICP. This finding cannot be used to rule out elevated ICP.	12/2025
Propranolol (initial trial)	Beta-blocker	Initially ineffective; later restarted with apparent benefit	2021–2022
Triptans (class)	5-HT1B/1D agonists	Class-wide ineffectiveness noted; frovatriptan still listed as current (for menstrual use?)	Multiple years
Metoclopramide (Reglan)	Dopamine antagonist / prokinetic	Single one-time prescription — never refilled, never used again	5/2021
Triamterene-HCTZ (Dyazide)	Potassium-sparing diuretic combination	Prescribed for Ménière's disease — discontinued shortly after starting; patient reported feeling worse	2019–2020
Betahistine	Histamine H1 agonist / H3 antagonist (vestibular suppressant)	Prescribed by Dr. Christine Dinh MD (UHealth Ear Institute) for Ménière's disease — made patient feel worse; discontinued	2019–2020
Metoprolol (Toprol-XL)	Beta-1 selective blocker	Replaced by Propranolol ER — not concurrent	Pre-2024

⚠️ Pharmacological Pattern Analysis

Bryan has failed virtually every drug class proven effective for migraine: all CGRP-pathway agents (3 different drugs across injectable and oral), triptans, anticonvulsants, TCAs, beta-blockers initially, and neurotoxin. This pattern of complete treatment failure across mechanistically distinct classes strongly suggests the primary driver is NOT migraine as traditionally defined, but rather an underlying structural or hemodynamic condition that is generating the headache syndrome.

🫁Imaging Studies

✅ MRV Brain WO IVCON — April 11, 2026 (Cleveland Clinic) — Resolved by 4/16/2026 Vascular US ▼

Facility: Cleveland Clinic | Ordering: Dr. Chetna Dengri / Dr. Zarmina Javed | Reading: Dr. Jade L'Heureux | Date: April 11, 2026 | Status: Final — reviewed and resolved

Normal Findings:

✅ Superior sagittal sinus: normal
✅ Inferior sagittal sinus: normal
✅ Straight sinus: normal
✅ RIGHT transverse and sigmoid sinuses: normal
✅ No definite intracerebral venous sinus thrombosis
✅ No central filling defects

Findings Originally Flagged:

⚠️ LEFT transverse sinus and sigmoid sinus: small in size — described by radiologist as "fairly prominent congenital anatomic variant." Patent on correlation with contrast MRI.
⚠️ LEFT internal jugular vein flattened compared to RIGHT — patency originally questioned, prompting vascular ultrasound.

Radiologist Recommendation (4/11): Vascular ultrasound to evaluate patency of the LEFT internal jugular vein. Findings communicated directly to Dr. Zarmina Javed, MD at 12:14 PM on 4/11/2026.

✅ POST-ULTRASOUND INTERPRETATION (Vascular US 4/16/2026, Dr. Lall / Dr. Dengri): LEFT IJV distally measures 0.2cm vs RIGHT 0.6cm — confirmed asymmetry but with patent flow, normal Doppler waveform, no thrombus, no compression abnormality. Final interpretation: congenitally smaller left-sided venous drainage system, paralleling the small left transverse/sigmoid sinus. Explains left-sided pulsatile tinnitus (turbulent flow through smaller-caliber vessel) but is NOT a pathologic obstruction and NOT the headache driver. Venous outflow obstruction hypothesis formally ruled out.

✅ NEW — MRI Brain WO/W IVCON — April 11, 2026 (Cleveland Clinic) — Largely Normal ▼

Facility: Cleveland Clinic | Ordering: Dr. Chetna Dengri / Dr. Zarmina Javed | Reading: Dr. Jade L'Heureux | Date: April 11, 2026 | Status: Final

Normal / Negative Findings (clinically important):

✅ No pachymeningeal enhancement — effectively rules out Spontaneous Intracranial Hypotension (SIH/CSF leak) as a significant mechanism
✅ No extra-axial collections — no subdural hygromas (another SIH marker absent)
✅ Sella and parasellar structures unremarkable — no empty sella (classic IIH finding absent, though its absence does not rule out IIH)
✅ Normal ventricles, basal cisterns, cortical sulcal pattern
✅ No parenchymal signal abnormalities
✅ No abnormal enhancement after contrast
✅ No midline shift or mass effect
✅ Normal foramen magnum structures
✅ Normal IACs and CP angle cisterns
✅ Normal flow voids in major vascular structures
✅ Normal orbits, normal mastoid air cells
✅ No restricted diffusion (no infarct)
✅ No blood products on SWI

Incidental Findings:

⚠️ RIGHT maxillary sinus 1.4cm mucous retention cyst — incidental, not clinically significant for headache
⚠️ Mild nasal septal deviation to the RIGHT (~3–4mm) — mild, likely asymptomatic

Clinical Significance: The absence of pachymeningeal enhancement definitively removes SIH/CSF leak from the primary differential. The normal sella, combined with the absence of papilledema on fundoscopy and unremarkable parenchymal exam, supports the CCF Neurology decision (4/15/2026) to formally defer LP and exclude IIH. The brain is structurally normal. With venous outflow obstruction subsequently ruled out by 4/16/2026 ultrasound, the headache mechanism is now attributed to New Daily Persistent Headache (NDPH) — a primary headache disorder of unknown etiology — with a contributing peripheral driver of bilateral occipital neuralgia (now under treatment via nerve block).

🧠 MRI Brain + Internal Auditory Canals w/wo Contrast — November 18, 2025 ▼

Facility: Hope Imaging Indian River | Ordered by: Daisyana Muci PA | Field strength: 1.5T

Key Findings:

🔴 SEVERE PANSINUSITIS — bilateral maxillary, ethmoid, sphenoid, left frontal sinuses
⚠️ Mild tonsillar ectopia — NOT corroborated as clinically significant on Cleveland Clinic cine flow study 3/10/2026
✅ No CP angle mass
✅ No 7th or 8th cranial nerve lesion or abnormal enhancement
✅ No abnormal parenchymal enhancement
✅ No lacunar infarcts, no demyelinating plaques
✅ No intracranial mass

Clinical Comment: The severe pansinusitis is highly significant and correlates with left-sided headache predominance. The mild tonsillar ectopia requires clinical correlation (now largely clarified as non-obstructive by CCF cine flow). This study did NOT include dedicated venous imaging (no MRV performed yet).

🦴 MRI Cervical Spine W/O Contrast — November 24, 2025 ▼

Facility: Hope Imaging Indian River | Radiologists: Dr. Jeffrey Tipps / Dr. David Berns | Indication: M54.2 Cervicalgia, 10 years chronic migraines

⚠️ C4/C5: Disc protrusion with minimal mass effect on thecal sac — AP canal 7mm
🔴 C6/C7: Broad-based disc protrusion WITH mass effect on thecal sac — AP canal 8mm

🦴 MRI Cervical Spine + Cine CSF Flow Study — March 10, 2026 (Cleveland Clinic) ▼

Facility: Cleveland Clinic | Radiologist: Dr. Fabian Candocia | Protocol: MRI Cervical Spine WO IVCON with cine flow

✅ CHIARI RULED OUT — Normal in-phase flow through craniocervical junction. Normal CSF flow dynamics.
⚠️ Levoscoliosis of cervical spine
⚠️ C4-5: Broad right paracentral disc protrusion + mild canal stenosis + moderate RIGHT neuroforaminal narrowing
⚠️ C5-6: Broad right paracentral disc protrusion + mild canal stenosis
🔴 C6-7: Central disc protrusion + mild canal stenosis + SEVERE LEFT neuroforaminal narrowing
⚠️ MULTINODULAR THYROID — largest nodule 1.4cm on left side — NOT YET FORMALLY EVALUATED

Clinical Comment: The severe left neuroforaminal narrowing at C6-7 correlates with the left-sided occipital-to-frontal pain pattern. The C2-3/C3-4 facet joints (addressed by medial branch blocks) are NOT visualized as severely narrowed on this study, yet they generate pain (demonstrated by the diagnostic blocks). The thyroid finding requires urgent follow-up (ultrasound + TSH).

🦷 CT Sinuses W/O Contrast — January 12, 2026 ▼

Ordered by: Vero ENT Associates | Read by: Radiologist (report not separately available)

CT sinuses confirmed the MRI findings of severe pansinusitis. Nasal endoscopy by Dr. Baggett (1/13/2026): polypoid disease toward frontal recess bilaterally, greatest on left. "Mucosal disease in left frontoethmoidal recess and left sphenoid sinus" — anatomically correlates with left-sided headaches. Prior sinus surgery noted in history.

✅ COMPLETED — Vascular Ultrasound, Bilateral Internal Jugular Veins — April 16, 2026 (Cleveland Clinic) ▼

Ordered by: Dr. Chetna Dengri (CCF Neurology) | Performed/Read by: Dr. Purandath Lall | Status: Final

Findings:

✅ LEFT IJV distal segment: 0.2cm caliber — patent, normal Doppler waveform, no thrombus, no compression
✅ RIGHT IJV distal segment: 0.6cm caliber — patent, normal Doppler waveform
3x asymmetry confirmed but represents congenital anatomic variant (parallels small left transverse/sigmoid sinus on MRV)

Final Interpretation: Hypoplastic but patent left-sided cerebral venous drainage system — congenital, not pathologic. Explains left pulsatile tinnitus via turbulent flow through smaller-caliber vessel. Does not represent venous outflow obstruction and is not the headache driver. LP formally deferred by Dr. Dengri and Dr. Danita Jones (Attending) — no papilledema, normal MRI, no clinical signs of elevated ICP.

🫁CT Paranasal Sinuses

CT Paranasal Sinuses #1 — March 15, 2021 — South Florida ENT (Dr. Schell) Severe — Lund-MacKay 17/24

Technique: Cone Beam CT, Xoran miniCAT, non-contrast, 1.2mm slices, 600-frame collimated protocol.

Findings:

Maxillary sinuses: bilateral ostium obstruction, mucosal thickening bilaterally
Anterior ethmoid sinuses: mucosal thickening bilaterally
Posterior ethmoid sinuses: mucosal thickening bilaterally
Sphenoid sinuses: bilateral ostium obstruction, mucosal thickening bilaterally
Frontal sinuses: bilateral ostium obstruction, mucosal thickening, hypoplastic on right
Septum: leftward septal spur

Lund-MacKay Score: Right = 9, Left = 8, Total = 17/24 (Severe pansinusitis)

Impression: Chronic pansinusitis involving bilateral maxillary, frontal, ethmoid, and sphenoid sinuses; ostiomeatal obstruction; structural ostiomeatal complex bilaterally; leftward septal spur.

CT Paranasal Sinuses #2 — March 10, 2022 — South Florida ENT (Dr. Schell) Worse — Complete OMC Opacification

Indication: Chronic sinusitis and acute sinusitis (ordered 2/18/2022).

Findings:

All sinuses: bilateral severe chronic pansinusitis with complete opacification of bilateral ostiomeatal complex
Septum: large leftward bony septal spur
Turbinates: bilateral inferior turbinate hypertrophy
Septal deviation: to right AND left bilaterally

Impression: Chronic sinusitis, deviated nasal septum, and inferior turbinate hypertrophy. Bilateral severe chronic pansinusitis. Complete opacification bilateral ostiomeatal complex. Large leftward bony septal spur. Proceeded to revision FESS (performed 4/20/2022).

🦴Musculoskeletal Imaging — 2024

Left Shoulder MR Arthrogram — May 6, 2024 — Vero Orthopaedics (Dr. Plessl) ▼

Facility: Vero Orthopaedics II PA | Ordering: Dr. Daniel Plessl MD | Date: May 6, 2024

Indication: Left shoulder pain with upper extremity radicular symptoms; rule out labral pathology vs. cervical radiculopathy as source.

Findings: Essentially normal left shoulder MR arthrogram. Labrum intact. Good arthrographic filling. No significant intra-articular pathology identified.

Impression: Normal left shoulder. No labral tear, rotator cuff pathology, or other intrinsic shoulder abnormality. Clinical picture redirected toward cervical radiculopathy (C6–C7) as source of left arm/shoulder symptoms. EMG/NCV bilateral upper extremity subsequently ordered (5/15/2024).

🧪Laboratory Results

📊 Lipid Panel — Longitudinal Trend (Quest Diagnostics + TCCH)

Test	3/15/2016 (Age 26)	10/2/2018 (Age 28)	11/2024 (Age 34)	Reference
Total Cholesterol	190	188	252 ⬆	<200 mg/dL
HDL	35 L	37 L	37 L	>40 mg/dL
Triglycerides	176 H	153 H	176 H	<150 mg/dL
LDL	120	124	182 H	<130 mg/dL
Chol/HDL Ratio	5.4 H	5.1 H	6.8 H	≤5.0
⚠️ Atherogenic dyslipidemia pattern persistent since at least 2016: chronically low HDL, elevated TG, worsening LDL. Total cholesterol surged to 252 by 2024. No statin ever prescribed. CVD risk warrants formal treatment discussion.

🩸 CBC — Key Values & Eosinophil Trend

Test	11/17/2012	3/15/2016	10/2/2018	4/7/2022	Reference
WBC	8.7	7.7	8.5	7.1	3.8–10.8 K/uL
Hemoglobin	16.4	16.2	16.1	15.7	13.2–17.1 g/dL
Platelets	235	231	268	311	140–400 K/uL
Eosinophils (Abs.)	365 (normal)	177 (normal)	587 H	596 H	15–500 cells/uL
Eosinophils (%)	4.2%	2.3%	6.9%	8.4%	—
⚠️ Persistent peripheral eosinophilia on both 2018 and 2022 draws (587–596 cells/uL). Consistent with documented hyperimmunoglobulin E syndrome, allergic rhinitis, and eosinophilic sinus disease (Type 2 mucosal inflammation). Supports Dupixent (dupilumab) as appropriate next-line treatment for sinus disease.

🔬 4/17/2026 Inflammatory Markers + Thyroid Function (Dr. Valeriano's office · ordered by Jacqueline Smith, APRN · Quest Diagnostics-Tampa · resulted 4/20/2026)

Test	Result	Reference Range	Flag	Interpretation
C-Reactive Protein (CRP)	11.7 mg/L	<8.0 mg/L	HIGH ⬆	Acute-phase reactant — elevated ~1.5× upper limit. First biochemical evidence of ongoing systemic inflammation.
ESR (Westergren)	22 mm/h	≤15 mm/h	HIGH ⬆	Sedimentation rate elevated — corroborates CRP. Two independent inflammatory markers elevated concurrently strengthens signal.
TSH	0.61 mIU/L	0.40–4.50 mIU/L	✅ Normal	Low-normal but well within range. Argues against hyperthyroidism as driver of tachycardia / pulsatile symptoms.
Free T4	1.2 ng/dL	0.8–1.8 ng/dL	✅ Normal	Mid-range. Confirms biochemical euthyroidism. Structural thyroid ultrasound still pending (palpable nodularity).
🧪 Clinical significance: First documented biochemical confirmation of systemic inflammation (CRP + ESR both elevated). Pattern is non-specific but consistent with the chronic inflammatory / pain phenotype (NDPH, eosinophilic sinus disease, Type 2 mucosal inflammation). Thyroid function is biochemically normal — rules out hyperthyroidism as contributor to objective head-bobbing (de Musset's sign concern), narrowing cardiac differential toward aortic regurgitation / anemia / other high-output states. Still pending from 4/17 draw: ANA, ANCA, antiphospholipid panel, serum tryptase, complement C3/C4, thyroid ultrasound.

🧬 Metabolic Panel — Key Values

Test	11/17/2012	3/15/2016	10/2/2018	4/7/2022	Reference
Glucose (fasting)	102 H	90	101 H	98	65–99 mg/dL
HbA1c	—	5.4%	5.2%	—	<5.7%
Creatinine	0.95	0.99	0.86	0.81	0.60–1.35 mg/dL
eGFR	113	105	118	118	≥60
AST	13	12	12	13	10–40 U/L
ALT	14	12	10	12	9–60 U/L
GGT	18	—	—	—	3–70 U/L
⚠️ Fasting glucose borderline high (102 in 2012, 101 in 2018) — impaired fasting glucose / prediabetes range on two separate draws. HbA1c normal (5.2–5.4%) in both years tested. LFTs (AST, ALT, GGT) consistently normal across all draws — reassuring given long-term duloxetine use and atherogenic lipid profile. However, no LFT drawn since 2022 — repeat warranted given ongoing duloxetine + NAFLD risk from dyslipidemia.

🦋 Thyroid (TSH)

Date	TSH	Reference	Note
11/17/2012	0.77	0.40–4.50 mIU/L	Normal
9/27/2018	0.68	0.40–4.50 mIU/L	Normal — low-normal
3/15/2016	1.06	0.40–4.50 mIU/L	Normal
⚠️ TSH consistently normal (0.68–1.06) across 3 draws — no biochemical thyroid dysfunction detected to date. However, 1.4cm left thyroid nodule found incidentally on CCF cervical MRI 3/10/2026 has NOT been formally evaluated. Thyroid ultrasound + current TSH still needed.

🩺 Coagulation (4/7/2022 — pre-surgical)

Test	Result	Reference
PT	10.9 sec	9.0–11.5 sec — Normal
INR	1.1	0.9–1.1 — Normal
PTT (Activated)	29 sec	23–32 sec — Normal

🌿 Allergy & IgE Panel — 3/15/2016 (Quest, ordered Dr. Mantilla)

Allergen	IgE (kU/L)	Class	Interpretation
Dog Dander (E5)	7.63 H	Class 3	Significant sensitization
Cat Dander (E1)	1.23 H	Class 2	Moderate sensitization
Hazelnut (F17)	0.10	Class 0/1 borderline	Low-level sensitization — consistent with reported hive reaction
Dust mites (D. pteronyssinus)	0.17	Class 0/1	Very low
Dust mites (D. farinae)	0.15	Class 0/1	Very low
All molds (M1, M2, M3, M6)	<0.10	Class 0	Negative — despite active sinus mold allergy listed
All pollens, cockroach, foods (except hazelnut)	<0.10	Class 0	Negative
Total IgE	120 H	—	Elevated (ref ≤114 kU/L) — consistent with atopic/allergic phenotype

🔬 Other Notable Tests

Test	Date	Result	Significance
Celiac Panel (tTG-IgA + IgA)	11/17/2012	tTG-IgA <1 U/mL (neg); IgA 213 (normal)	✅ Celiac disease ruled out. IgA sufficient — result is valid.
HbA1c	3/15/2016	5.4%	Normal — no diabetes
HbA1c	10/2/2018	5.2%	Normal
Hepatitis A/B/C Panel	3/15/2016	All non-reactive	✅ No hepatitis infection
HIV Ag/Ab (4th gen)	3/15/2016	Non-reactive	✅ Negative
RPR (syphilis screen)	3/15/2016	Non-reactive	✅ Negative
Chlamydia / Gonorrhea (RNA TMA)	3/15/2016	Not detected	✅ Negative

⏳ Missing / Pending Labs

Test	Status	Clinical Reason
Thyroid Ultrasound + Current TSH	Not yet ordered	1.4cm left thyroid nodule on CCF MRI 3/10/2026 — TSH historically normal but nodule requires dedicated evaluation
LP Opening Pressure	Never performed	Only direct ICP measurement — critical to confirm or exclude venous hypertension
Liver Function Panel (current)	Not since 4/2022	Long-term duloxetine (FDA hepatotoxicity warning) + atherogenic lipid profile (NAFLD risk). LFTs were normal in all prior draws but are overdue.
Current Fasting Lipid Panel	Last drawn 11/2024	Follow up on untreated LDL 182, TG 176, HDL 37. Statin discussion warranted.
Formal Allergy Testing (current)	Ordered, not yet done	Vero ENT (Dr. Baggett) planned — will update sensitization panel from 2016
Urinalysis	10/30/2024 — Normal	No proteinuria, no hematuria

🔬Procedures Performed

Date	Procedure	Performed By	Result / Outcome
07/28/2014	Left Gonadal Vein Embolization — Transcatheter coil embolization from inguinal canal to L2 level for left varicocele. Multiple coils (3–10mm). Note: circumaortic left renal vein (anatomical variant) documented.	Dr. Aldo Gonzalez-Beicos MD (IR) / Dr. Mehul Doshi MD — University of Miami Hospital. CC: Dr. Hernan Carrion MD (Urology)	Complete occlusion of left gonadal vein and collaterals confirmed on post-embolization venogram. Left renal vein widely patent. No complications.
Pre-2021 (unknown date)	Lateral Internal Sphincterotomy (LIS) — for anal fissure	Dr. Szomstein — Baptist Hospital, Miami	Successful treatment of anal fissure. No fissure seen on 5/7/2021 exam.
11/27/2018–11/15/2019	Audiological Evaluations (×4) + Vestibular Workup	UHealth Ear Institute — Dana Libman AUD, Brianna Kuzbyt AUD, Alyssa Whinna AUD; Graciela Reyes APRN	Work-up for left-sided tinnitus, vertigo, left ear fullness. Led to Ménière's disease diagnosis (Dr. Christine Dinh MD, 8/9/2019).
1/12/2021	Audiogram + Tympanogram	South Florida ENT	Results not in current record set
4/7/2021	VNG (Videonystagmography) Testing	Dr. Andrew Schell MD — South Florida ENT Associates, Doral FL	Vestibular function testing for dizziness and migraine with vertigo workup.
4/19/2021	Sinus Surgery #1 — Frontal Balloon Sinuplasty + Maxillary Balloon Sinuplasty + Bilateral Intramural Turbinate Coblation	Dr. Andrew Philip Schell MD — South Florida ENT, Doral FL	Pathology: chronic active inflammation with mucosal edema. Chronic pansinusitis persisted post-operatively; required revision surgery ~1 year later.
4/20/2022	Sinus Surgery #2 (Revision FESS) — Functional Endoscopic Sinus Surgery, bilateral ethmoid/maxillary/frontal/sphenoid	Dr. Andrew Philip Schell MD — South Florida ENT (AS_South Outpatient Services)	Despite two surgeries, chronic pansinusitis remained active on subsequent endoscopy (Dr. Baggett, Vero ENT, January 2026). Surgeries improved sinus anatomy but did not resolve headache — headache etiology is NOT sinonasal.
2021–2022	Pelvic Floor Trigger Point Injections + Peripheral Nerve Blocks	Dr. Marjorie Mamsaang DO — PRM of FL PA, Miami	Treatment for myofascial pelvic pain and neuropathic pain. Peripheral and central sensitization formally documented during this care period.
Historical	Nightguard fitting	Dentist	Bruxism responding to nightguard (Dr. Kobetz 8/7/2023)
5/6/2024	Ultrasound-Guided Left Shoulder Injection	Vero Orthopaedics II PA (Dr. Plessl)	Performed in conjunction with MR arthrogram. Left shoulder MR arthrogram essentially normal — labrum intact, no intrinsic shoulder pathology. Clinical picture redirected to cervical radiculopathy as primary source.
5/15/2024	EMG / Nerve Conduction Study (NCV) — Bilateral Upper Extremity	Vero Orthopaedics II PA (Dr. Plessl)	Ordered to evaluate cervical radiculopathy vs. peripheral nerve involvement in left arm/shoulder symptoms. Results not documented in current record set.
12/17/2025	Cervical Facet Joint Injection (CPT 64490) + Bilateral Cervical Medial Branch Block C2-3, C3-4 (CPT 64490/64491 bilateral)	Global Neuro And Spine (Dr. Olegario)	80% pain relief — for 1 day only. Positive diagnostic block.
1/14/2026	Bilateral Cervical Medial Branch Block C2-3, C3-4 — Repeat	Global Neuro And Spine (Dr. Olegario)	80% pain relief — for 1 day only. Confirms C2-3/C3-4 facet pain pattern.
1/28/2026	Diagnostic Cervical Medial Branch Block #2 — C2-C4, Bilateral (CPT 64493, 64494)	Global Neuro And Spine (Dr. Olegario)	✅ Again 80% relief for 1 day — confirmatory. Two positive diagnostic blocks → criteria met for RFA.
2/13/2026	RIGHT Cervical Radiofrequency Ablation — C2-C4 (CPT 64633, 64634)	Global Neuro And Spine (Dr. Olegario)	✅ Reduced right cervical pain and radicular arm symptoms. ❌ ZERO impact on headache.
2/24/2026	LEFT Cervical Radiofrequency Ablation — C2-C4 (CPT 64633, 64634)	Global Neuro And Spine (Dr. Olegario)	✅ Reduced left cervical pain and bilateral arm radicular symptoms. ❌ ZERO impact on headache. Bilateral RFA complete — cervicogenic headache definitively ruled out.
~12/2025 (estimated)	Nasal Endoscopy	Dr. Kathleen Baggett — Vero ENT	Polypoid disease toward frontal recess bilaterally. Left frontoethmoidal/sphenoid mucosal disease.
4/16/2026 · 12:15 PM	Greater Occipital Nerve Block, Bilateral (CPT 64405)	Global Neuro And Spine, Fort Pierce (Dr. Louis Olegario, MD)	✅ New Dx established: Bilateral Occipital Neuralgia (M54.81). Injectate: 80 mg Triamcinolone (Kenalog PF) + 6 mL 0.25% Bupivacaine; 3 cc per side via 25g 1.5-inch needle at landmark 1/3 from occipital protuberance → mastoid (palpation-guided). No CSF, blood, or paresthesias; tolerated well. Initial response: significant immediate reduction in headband sensation; overnight flare, improved by morning. Steroid onset 3–7 days — peak diagnostic/therapeutic yield by ~4/23/2026. Follow-up 4/30/2026 with James F Leitera, APRN.
4/16/2026	Upper Extremity Venous Duplex — Left (Dr. Lall, interpreting)	Martin Health at St. Lucie West (ordered by Dr. Javed)	✅ LEFT IJV 0.2cm distally vs. RIGHT 0.6cm — patent, normal Doppler flow, no thrombus, no compression abnormality. Congenital asymmetry. Explains pulsatile tinnitus; rules out obstructive IJV stenosis as headache driver.
3/25/2026	Fundoscopic examination (dilated)	Ophthalmology (referred by NSF Neurosurgery)	Normal — no papilledema reported per Cleveland Clinic neurology note

⏳Procedures Pending / Ordered

Date Ordered	Procedure	Status	Significance
2/13/2026 (R) · 2/24/2026 (L)	Bilateral Cervical RFA C2-C4 — RIGHT 2/13, LEFT 2/24 (CPT 64633, 64634)	Completed	Bilateral RFA series complete. Reduced cervical/arm pain; zero headache impact.
3/25/2026 (ordered)	Occipital Nerve Block, Bilateral	Done 4/16/2026	Performed 4/16/2026 — significant initial reduction in headband sensation.
Not yet ordered	Lumbar Puncture with Opening Pressure	Not ordered	Most critical missing procedure — definitive ICP measurement. Must be done before or after MRV results.
Not yet ordered	Spinal MRI with Gadolinium Contrast (full spine)	Not ordered	Look for pachymeningeal enhancement, epidural CSF collections — signs of SIH. Has NEVER been done.

👩‍⚕️Care Team & Providers

👤 Primary Care — TCCH OSLO Family Practice (Fort Pierce, FL)

Dr. Juliette Valeriano, MD — Supervising Physician
Last seen: 10/28/2025

Lisa Wheeler, APRN — Primary Care Provider of record (per MyChart attribution)
Last seen: 11/13/2025

Jacqueline Smith, APRN — Clinician at 4/17/2026 visit; ordering provider for 4/17 bloodwork (CRP, ESR, TSH, Free T4)

🧠 Neurology — Cleveland Clinic Florida

Dr. Zarmina Javed, MD (Attending — initial consult)
Dr. Chetna Dengri, MD (Resident)
Dr. Danita Jones, DO MPH (Attending — 4/15/2026 telehealth)
CCF Department of Neurology
Tel: 561.904.7200 · Fax: 561.624.4509
Last seen: 4/15/2026 (telehealth)
Ordered: MRI Brain w/wo, MRV Head, sleep study, upper extremity venous duplex, occipital nerve block
Working Dx: NDPH (G44.52), cervicogenic headache concern, pulsatile tinnitus from IJ asymmetry
Plan: LP formally deferred (no papilledema, no imaging evidence of ↑ICP); await nerve block response; in-lab PSG 4/22/2026 (Treasure Coast Sleep Disorders); neurotology Dr. Christine Dinh (UHealth Miami) for ENT/pulsatile tinnitus correlation

🧠 Headache Specialist — Cleveland Clinic Florida

Dr. Aysha Siddika, MD
CCF Department of Neurology — Headache
Consulted by Dr. Dengri/Dr. Jones re: NDPH
First appointment: June 2026
Referral basis: refractory New Daily Persistent Headache, status post normal MRI/MRV, deferred LP, completed diagnostic occipital nerve block (4/16/2026)

🧠 Neurology — Premier Neurology (Stuart, FL) · Principal Neurologist

Dr. Rabih Kashouty, MD — Primary neurologist / prescribing provider
Tara Lynn King, NP — Botox administration
Daisyana Muci, PA — Botox re-initiation 11/19/2025
Premier Neurology
1026 SE Federal Hwy, Stuart, FL 34994-3821
Tel: 772-210-2447 · Fax: 772-261-4028
Referred by: James Leitera APRN (Global Neuro And Spine)
Last seen: 4/20/2026 (telemedicine)
Working Dx: Intractable migraine without aura with status migrainosus (G43.011); Recurrent pansinusitis (J01.41); Cerebellar tonsillar ectopia (Q04.8)
Current plan: Ajovy 675mg subq q3mo (NEW 4/20/2026 — 3rd CGRP mAb trial); occipital nerve blocks every 4–6 weeks; continue Botox (cycle #2 scheduled 4/23/2026)
Next visits: 4/23/2026 (Botox w/ Tara King NP) · ~5/18/2026 (nerve block) · ~7/20/2026 (Kashouty F/U)

💉 Pain Management

Dr. Louis Olegario, MD
James F Leitera, APRN
Global Neuro And Spine, Fort Pierce, FL
1801 S 23rd St STE 1, Fort Pierce, FL 34950
Tel: 800-735-1178
Last seen: 4/16/2026 (occipital nerve block)
Performed: Dx MBBs C2-C4 ×2 (1/14, 1/28/2026); R cervical RFA C2-C4 (2/13/2026); L cervical RFA C2-C4 (2/24/2026); bilateral greater occipital nerve block (4/16/2026 — 80 mg triamcinolone + 6 mL 0.25% bupivacaine)
Next: 4/30/2026 follow-up with Leitera APRN to assess block response

🧠 Neurosurgery

Dr. Valentine Nduku, MD
Melissa Gonzalez, APRN
NSF 201 Neuro Spec South FL
Last seen: 12/29/2025
Dx: Congenital brain malformation (Q04.8), cervical disc herniation
Plan: ACDF C4-5 / C6-7 if conservative fails; sleep study for central sleep apnea

👃 ENT / Sinus

Dr. Kathleen Baggett, MD
VERO ENT Associates
Last seen: 1/13/2026
Dx: Pansinusitis, polypoid sinus degeneration, allergic rhinitis, hyperimmunoglobulin E syndrome
Rx: Budesonide rinse, Dupixent, Xyzal
Note: "Headaches on left — left frontoethmoidal and left sphenoid disease"

🧠 Neurology — Prior

Dr. Steven Kobetz, MD
First Choice Neurology
Last seen: 8/7/2023
Dx: Vestibular migraine, tension headache at craniocervical junction
Rx: Propranolol, Emgality, Nurtec (ubrogepant for aborts)

☁️ Radiology

Dr. Jade L'Heureux — Cleveland Clinic (MRI Brain w/wo + MRV Head 4/11/2026)
Dr. Purandath Lall — Martin Health at St. Lucie West (Upper Extremity Venous Duplex 4/16/2026)
Dr. Fabian Candocia — Cleveland Clinic (cervical MRI + cine flow 3/10/2026)
Dr. Jeffrey Tipps / Dr. David Berns — Hope Imaging Indian River (cervical MRI 11/24/2025)

😴 Sleep Medicine

Treasure Coast Sleep Disorders
In-lab Polysomnogram (PSG) scheduled: Wednesday night, April 22, 2026
Ordered by: Cleveland Clinic Florida Neurology (Dr. Dengri / Dr. Javed, 3/25/2026)
Reason: Rule out obstructive and central sleep apnea contributing to headache burden
Note: Original HSAT through CCF was cancelled due to out-of-network coverage. In-lab attended PSG is clinically superior — detects OSA + central apnea + measures sleep architecture, arousal index, PLMS, oxygen desaturation patterns. Central apnea workup particularly relevant given Bryan's tonsillar ectopia history.

👃 ENT / Sinus — Prior (2021–2023)

Dr. Andrew Philip Schell, MD
South Florida ENT Associates — Care Center 01 Doral
Doral, FL
Date range: 01/2021 – 07/2023
Procedures: CT Sinus ×2, VNG testing, Balloon sinuplasty + turbinate coblation (4/19/2021), Revision FESS (4/20/2022), multiple post-op debridements
Dx: Chronic pansinusitis (all sinuses), deviated nasal septum, inferior turbinate hypertrophy, LPR, atypical facial pain, migraine with vertigo

💉 Pain Management — Prior (2021–2022)

Dr. Marjorie Mamsaang, DO
PRM of FL, PA — Miami, FL
Date range: ~2021–2022
Dx: Chronic Pain G89.29, Chronic Pain Syndrome G89.4, Myalgia M79.10, Pelvic pain (neuropathic + myofascial)
Key documentation: Central AND peripheral sensitization formally recorded.

Dr. Sandra Sandhu-Restaino, DO
West Palm Beach, FL
Date range: ~2021–2022

🦴 Vero Orthopaedics II PA

Dr. Daniel Plessl, MD
Orthopedic Surgery
3955 Indian River Blvd, Suite 100, Vero Beach, FL 32960
Tel: (772) 569-2330
Evaluated April 2024 – July 2024 for left shoulder pain and cervical radiculopathy. Left shoulder MR arthrogram (5/6/2024) essentially normal. Cervicogenic headache listed as working diagnosis — subsequently disproven by nerve blocks (Global Neuro & Spine, 12/2025).

🧠 Neurology — Prior

Dr. Delores Macksoud, MD PA
Neurology
12001 SW 128 Court, Suite 205, Miami, FL 33186
Tel: (305)251-1373
Role: Former neurologist — referring physician (fax to Dr. Schell 03/01/2021)

👂 Otology & Neurotology — UHealth (University of Miami)

Dr. Christine Thuyvan Dinh, MD
Double board-certified: Otolaryngology + Otology-Neurotology
Associate Professor of Otolaryngology, University of Miami Miller School of Medicine
Inaugural George Lerner University Chair in Otolaryngology; Vice Chair of Academic Affairs; Director of Education, University of Miami Ear Institute; Associate Director, Neurotology Fellowship Training Program
University of Miami Ear Institute — 1120 NW 14th St, FL 5, Miami, FL 33136
Tel (UHealth appointments): (305) 243-1484 · Direct: (305) 243-3564
Research focus: vestibular schwannoma, Neurofibromatosis Type 2, hearing disorders
Upcoming appointment: Scheduled — neurotology consult for left-sided pulsatile tinnitus + vascular ultrasound correlation (referral routed from Dr. Dengri, CCF Neurology, 4/16/2026)
Prior relationship: Established Bryan's Ménière's disease left (H81.01) diagnosis on 8/9/2019; date range of prior care 11/2018 – 11/2019. Prior Rx: Triamterene-HCTZ (Dyazide) trialed briefly — discontinued due to worsening symptoms.
Current referral context: 4/16/2026 upper-extremity venous duplex shows LEFT IJV 0.2cm vs RIGHT 0.6cm (congenital hypoplasia, patent flow, no thrombus). Dr. Dengri requested ENT correlation with pulsatile tinnitus. Bryan booked sub-specialty neurotology (rather than general ENT) — appropriate given imaging findings and pre-existing Ménière's. Pre-existing rapport with Dr. Dinh (dx'd his Ménière's in 2019).

Audiology Team (prior): Dana Libman AUD, Brianna Kuzbyt AUD, Alyssa Whinna AUD, Graciela Reyes APRN

🏥 Private Practice — Gastroenterology

Dr. Paul G. Fishbein, MD
Gastroenterology — Gastro Health Florida, affiliated with Baptist Health
8950 N Kendall Dr Ste 506, Miami FL 33176
Ordered comprehensive labs 11/17/2012 including celiac panel (tTG-IgA negative — celiac ruled out), lipid panel, CMP, CBC, TSH, GGT, urinalysis.

🩺 Private Practice — Primary Care (Former PCP)

Dr. Juan A. Mantilla, MD
Internal Medicine / Primary Care
11400 N Kendall Dr Ste 204, Miami, FL 33176
Tel: (305) 279-4222 · mantillamd.com
Affiliated with Baptist Health
Staff: Sylvia Vives-Montano, PA-C
Role: Former PCP — ordered labs 2016, 2018, 2022 (Quest Diagnostics)

🏥 University of Miami Health System (UHealth)

Dr. Nivedh Venkat Paluvoi, MD
Colon & Rectal Surgery, UHealth Tower (5/7/2021 — hemorrhoids, coccydynia, colonoscopy work-up)
Dr. Mehul Harshad Doshi, MD / Dr. Aldo Gonzalez-Beicos, MD
Interventional Radiology — University of Miami Hospital (left gonadal vein embolization 7/28/2014)
Dr. Hernan M. Carrion, MD
Urology — University of Miami (referring physician for varicocele embolization)

🧠 Psychiatry

Anthony Gonzales, PMHNP-BC, FNP-BC
Lighthouse Health Group
787 37th St, Vero Beach, FL 32960
(772) 275-3251
First seen: 4/14/2026 — Dx: MDD moderate + GAD. Increased duloxetine to 90mg/day. Therapy referral placed within practice.

🦴 Chiropractic — Current (2024–Present)

Dr. AJ Petrone, DC & Dr. Meagan Petrone, DC
Back to You Chiropractic and Physical Therapy
1860 N Lawnwood Cir, Fort Pierce, FL 34950
(772) 252-5254
Fort Pierce, FL

🦴 Chiropractic — Prior (2018–2023)

Dr. Barry Levitt, DC & Dr. Eric Daes, DC
Levitt Chiropractic Center
8955 SW 87th Ct, Ste 101, Miami, FL 33176
(305) 233-5700

🦴 Chiropractic — Prior (Pre-2018)

Dr. Brian Silver, DC
Silver Chiropractic and Medical
13501 SW 136th St, Ste 202, Miami, FL 33186
(305) 251-5655

🧠Clinical Analysis & Differential Diagnosis

🧭 Critical Clinical Summary — Updated 4/16/2026

Bryan Sanz is a 36-year-old male with 12+ years of refractory daily headache who has failed every pharmacologic class proven effective for migraine, including 3 distinct CGRP-pathway agents. After comprehensive neuro-vascular workup at Cleveland Clinic Florida (March–April 2026), the major secondary causes of chronic daily headache have now been systematically excluded: SIH/CSF leak ruled out (MRI 4/11 — no pachymeningeal enhancement); cerebral venous sinus thrombosis ruled out (MRV 4/11); cervicogenic headache ruled out (bilateral RFA 2/2026 — neck pain improved, headache unchanged); idiopathic intracranial hypertension (IIH) formally excluded (Dr. Dengri + Dr. Danita Jones — no papilledema, normal MRI, low-normal BP, LP deferred); left IJV obstruction / venous hypertension ruled out (vascular ultrasound 4/16 — patent flow with congenital hypoplastic asymmetry). Current working diagnosis (CCF Neurology, 4/15/2026): New Daily Persistent Headache (NDPH, G44.52) — a primary headache disorder of unclear etiology, characteristically refractory to standard migraine pharmacotherapy. Bilateral Occipital Neuralgia (M54.81) identified by Pain Management (Dr. Olegario, 4/16/2026) and treated with bilateral greater occipital nerve block (CPT 64405). Left-sided pulsatile tinnitus is now anatomically attributed to congenitally hypoplastic left IJV (turbulent flow through smaller-caliber vessel) and is no longer considered a marker of pathologic obstruction.

📊Ranked Differential Diagnoses

🟢 #1 — New Daily Persistent Headache (NDPH, G44.52) — PRIMARY WORKING DIAGNOSIS [Established 4/15/2026]

Diagnosed by: Dr. Chetna Dengri / Dr. Danita Jones DO MPH (Attending) — Cleveland Clinic Florida Neurology, 4/15/2026.

Why NDPH best fits the picture:

Daily-from-onset, unremitting — Bryan describes a headache that became continuous and never resolved, the cardinal feature of NDPH per ICHD-3 criteria.
Refractory to every standard preventive class — NDPH is notoriously the most treatment-resistant of the primary headache disorders. Failure of triptans, tricyclics, SNRIs, beta-blockers, anticonvulsants, Botox, and 3 distinct CGRP-pathway agents is more consistent with NDPH than chronic migraine.
All major secondary causes excluded — SIH (no pachymeningeal enhancement), CVST (negative MRV), IIH (no papilledema, normal MRI, low-normal BP, LP deferred by neurology), venous outflow obstruction (vascular US patent), cervicogenic (bilateral RFA negative), structural cervical (CT/MRI negative for relevant compressive lesion).
Normal neurologic exam across all visits (CCF, Pain Management, Neurosurgery, ENT) — no focal deficits, no papilledema, no cranial nerve abnormalities.

Caveat: NDPH remains a diagnosis of exclusion. Two important workup items still pending — (1) In-lab PSG 4/22/2026 (Treasure Coast Sleep Disorders) to evaluate obstructive AND central sleep-disordered breathing as a contributor, (2) headache specialist consultation 6/2026 with Dr. Aysha Siddika for NDPH-specific treatment trials (indomethacin trial for indomethacin-responsive headache phenotype, IV lidocaine, IV DHE protocol, ketamine infusion, etc.).

🟢 #2 — Bilateral Occipital Neuralgia (M54.81) — CONTRIBUTING PERIPHERAL DRIVER [Established 4/16/2026]

Diagnosed by: Dr. Louis Olegario, MD — Global Neuro And Spine, Pain Management, 4/16/2026.

Procedure: Bilateral greater occipital nerve block (CPT 64405) — 80mg Triamcinolone (Kenalog PF) + 6mL 0.25% Bupivacaine; 3cc per side via 25-gauge needle at landmark 1/3 distance from occipital protuberance to mastoid. Significant initial reduction in headband sensation reported during/after procedure.

Why this is likely a real contributor (not a coincidence):

Occipital tenderness and band-like distribution at greater occipital nerve dermatome are characteristic.
Block response (peri-procedural pain reduction) is a clinical confirmation of nerve involvement; durability of response over the next 1–2 weeks will determine ongoing trajectory.
Occipital neuralgia frequently coexists with NDPH and chronic migraine and can amplify primary headache via central sensitization and trigeminocervical convergence.

Follow-up: James F Leitera, APRN — 4/30/2026 at 12:00 PM. Decision points: (a) duration of relief from bilateral block, (b) whether to repeat blocks, (c) candidacy for occipital nerve RFA or peripheral nerve stimulator if blocks provide reproducible but short-lived relief.

🟡 #3 — Chronic Sinusitis / Polypoid Sinus Disease Contribution

Severe pansinusitis; left frontoethmoidal + left sphenoid disease correlates anatomically with left-sided headache predominance
Oral steroids provided partial headache improvement (Dr. Baggett, 1/13/2026)
Hyperimmunoglobulin E syndrome + elevated eosinophils suggests type 2 inflammation driving polypoid disease
Dupixent (dupilumab) ordered — this targets IL-4/IL-13, which is the correct biologic for eosinophilic/type 2 polypoid sinusitis

Unlikely to be the sole cause of 12 years of daily headache, but a meaningful aggravating contributor — particularly to left-sided frontal pressure and pain.

⚪ #4 — Sleep-Disordered Breathing — Pending In-Lab PSG 4/22/2026

Hypercapnia from nocturnal hypoventilation causes cerebral vasodilation → morning headaches. BMI 28.24, snoring history. Listed as Dx #3 on the CCF problem list (4/15/2026). In-lab PSG scheduled Wednesday night April 22, 2026 at Treasure Coast Sleep Disorders (original CCF HSAT cancelled — out-of-network). Full PSG is clinically superior: rules out both obstructive and central sleep apnea (the latter is particularly relevant given tonsillar ectopia). Even if positive, likely a contributing rather than primary mechanism — but treatment of OSA/CSA can meaningfully improve headache burden in NDPH and chronic daily headache populations.

⚪ #5 — Thyroid Dysfunction — Biochemically Euthyroid (4/17/2026); Structural Nodule Still Pending US

Update 4/20/2026: TSH 0.61 mIU/L and Free T4 1.2 ng/dL on labs drawn 4/17/2026 (resulted 4/20/2026) confirm biochemical euthyroidism. Thyroid dysfunction is no longer a credible driver of headache, tachycardia, pulsatile symptoms, or tinnitus. The 1.4cm left thyroid nodule from CCF MRI 3/10/2026 still warrants a dedicated thyroid ultrasound for structural characterization (Bethesda / TI-RADS), as biochemical euthyroidism does not exclude structural pathology (including a cold nodule with malignant potential).

⚫ Excluded — Spontaneous Intracranial Hypotension (SIH / CSF Leak)

✅ MRI Brain w/wo contrast (4/11/2026): NO pachymeningeal enhancement
✅ No extra-axial collections, no subdural hygromas
Clinical features were also atypical: minimal positional relief, pulsatile pounding persisting supine

⚫ Excluded — Idiopathic Intracranial Hypertension (IIH)

✅ No papilledema on fundoscopy (CCF Neurology 4/15/2026)
✅ MRI 4/11/2026: no empty sella, no enlarged optic nerve sheaths, no posterior globe flattening
✅ Low-normal BP across all visits prior to 4/16 — argues against elevated ICP physiology
✅ LP formally deferred by Dr. Dengri + Dr. Danita Jones — no clinical features supporting elevated ICP

⚫ Excluded — Left IJV Obstruction / Intracranial Venous Hypertension

✅ Vascular ultrasound (4/16/2026, Dr. Lall / Dr. Dengri): LEFT IJV 0.2cm vs RIGHT 0.6cm — patent flow, normal Doppler, no thrombus, no compression
✅ Final interpretation: congenitally hypoplastic left venous drainage system (parallels small left transverse/sigmoid sinus on MRV) — anatomic variant, not pathologic obstruction
Explains left-sided pulsatile tinnitus (turbulent flow through smaller-caliber vessel) — this symptom is now anatomically attributed but is NOT a marker of headache mechanism
Eagle syndrome / styloid CT no longer indicated absent compressive features

⚫ Excluded — Cervicogenic Headache (C2-3 / C3-4 Facet Origin)

Bilateral RFA at C2-C4 (RIGHT 2/13/2026, LEFT 2/24/2026) successfully reduced lower cervical pain and bilateral arm radicular symptoms but produced zero change in headache intensity or frequency. The C2-3/C3-4 facet joints are confirmed pain generators for neck and arm symptoms but are not the source of the headache. (Note: this is anatomically distinct from occipital neuralgia at the greater occipital nerve, which is a separate peripheral pain driver — see #2 above.)

🎯Workup Status — Completed, Pending, and Remaining Gaps

#	Study / Procedure	Result / Status	Priority
1	MRI Brain w/wo Contrast	✅ COMPLETED 4/11/2026 (CCF). No pachymeningeal enhancement (SIH ruled out), no empty sella, no enlarged optic nerve sheaths (IIH features absent), normal parenchyma. Incidental: 1.4cm right maxillary mucous retention cyst, mild nasal septal deviation.	COMPLETED
2	MRV Head	✅ COMPLETED 4/11/2026 (CCF). No cerebral venous thrombosis. Left transverse/sigmoid sinus small (congenital, patent). Left IJV flattened — ultrasound recommended and subsequently completed.	COMPLETED
3	Vascular Ultrasound — Bilateral IJV	✅ COMPLETED 4/16/2026 (CCF, Dr. Lall). LEFT IJV 0.2cm vs RIGHT 0.6cm — patent flow, no thrombus, no compression. Interpretation: congenitally hypoplastic left venous drainage (NOT pathologic obstruction).	COMPLETED
4	Lumbar Puncture (LP) with Opening Pressure	✅ FORMALLY DEFERRED 4/15/2026 by Dr. Dengri + Dr. Danita Jones (CCF Neurology Attending). Rationale: no papilledema on fundoscopy, MRI Brain unremarkable, no clinical features suggesting elevated ICP. Can be revisited if future clinical features change.	DEFERRED
5	Bilateral Greater Occipital Nerve Block	✅ COMPLETED 4/16/2026 (Dr. Olegario, Global Neuro And Spine). 80mg Triamcinolone PF + 6mL 0.25% Bupivacaine; significant initial reduction in headband sensation. Follow-up with Leitera APRN 4/30/2026.	COMPLETED
6	In-Lab Polysomnogram (PSG)	⏳ SCHEDULED Wednesday night 4/22/2026 at Treasure Coast Sleep Disorders. Original CCF HSAT cancelled (out-of-network). In-lab attended PSG is clinically superior: detects both obstructive AND central sleep apnea (HSAT cannot reliably detect central apnea). OSA listed as CCF Dx #3 (4/15/2026). Treatment of sleep-disordered breathing can reduce headache burden in chronic daily headache populations.	PENDING — Next Week
7	Headache Specialist Consultation — Dr. Aysha Siddika	⏳ SCHEDULED June 2026. NDPH-specific treatment trials: indomethacin trial (rule in/out indomethacin-responsive phenotype), IV lidocaine, IV DHE protocol, ketamine infusion, onabotulinumtoxinA re-trial.	PENDING — June
8	TSH + Free T4 (bloodwork portion)	✅ COMPLETED 4/17/2026 (resulted 4/20/2026, Quest-Tampa). TSH 0.61 mIU/L, Free T4 1.2 ng/dL — biochemically euthyroid. Thyroid dysfunction no longer a credible contributor. Dedicated thyroid ultrasound for structural characterization of the 1.4cm left nodule (CCF MRI 3/10/2026) still indicated.	COMPLETED
8b	Thyroid Ultrasound (structural characterization)	Still not ordered. 1.4cm left thyroid nodule needs TI-RADS / Bethesda classification. Biochemical euthyroidism does not exclude structural pathology.	MODERATE — Remaining Gap
9	Liver Function Panel (LFTs)	Never documented. Duloxetine 90mg/day (increased 4/14/2026) carries FDA hepatotoxicity warning and warrants periodic monitoring. Combine with TSH in one blood draw.	HIGH — Remaining Gap
10	Lipid Management / Statin Evaluation	LDL 182, TG 176, HDL 37 — atherogenic profile in a 36-year-old. No statin documented. Discuss with PCP (unrelated to headache workup but a standing cardiovascular gap).	MODERATE
11	BP Re-Check	4/16/2026 BP 129/98 (Stage 1 HTN) departs from prior consistently low-normal pattern (96/64 → 114/82). May reflect peri-procedural pain/anxiety. Worth rechecking at next PCP visit or via home cuff.	MODERATE — New 4/16
12	Neurotology Consultation — Dr. Christine Dinh (UHealth Miami)	⏳ SCHEDULED — University of Miami Ear Institute (1120 NW 14th St, FL 5, Miami, FL 33136). Dr. Dinh = Associate Professor / George Lerner Chair / double board-certified Otolaryngology + Otology-Neurotology. Referral routed by Dr. Dengri (CCF) after 4/16/2026 ultrasound showed LEFT IJV 0.2cm vs RIGHT 0.6cm. Purpose: correlate pulsatile tinnitus with venous asymmetry; evaluate whether further imaging (temporal bone CT, CTA/CTV of skull base) is indicated to rule out dural AV fistula, glomus tumor, dehiscent jugular bulb, or SSCD. Pre-existing rapport (dx'd Ménière's 2019).	PENDING
13	Cardiology Evaluation + Transthoracic Echocardiogram (TTE)	⚠️ NEW — NOT YET ORDERED. Triggered by Bryan's report of objective pulsatile head motion ("head physically moves with pulse when lying back on pillow") — this is distinct from subjective pulsatile tinnitus and is the classic description of de Musset's sign, which warrants evaluation for severe aortic regurgitation and other high-output cardiac states. Recommended workup: TTE (primary), 12-lead ECG, CBC (anemia), TSH/free T4 (thyrotoxicosis), BMP. Visible/palpable head bobbing with arterial pulse is a physical exam finding that should not be attributed to a peripheral venous hypoplasia.	HIGH — NEW

📋Recommended Next Steps (Prioritized)

Track response to bilateral occipital nerve block (4/16/2026) — detailed symptom diary to 4/30 follow-up

Document: (a) onset of pain return after block, (b) intensity and pattern of returning headache vs. baseline, (c) any change in band-like vs. occipital vs. frontal distribution, (d) sleep impact. This data directly drives Dr. Leitera's 4/30/2026 decision on whether to repeat the block, move toward occipital RFA, or pursue peripheral nerve stimulation. A durable (>2 week) response supports occipital neuralgia as a real contributor; a brief response (<1 week) argues for central amplification via NDPH with limited peripheral benefit.

Complete in-lab PSG (Wednesday night April 22, 2026 — Treasure Coast Sleep Disorders) — treat any diagnosed OSA/CSA promptly

Original HSAT through CCF was cancelled due to out-of-network coverage; in-lab PSG is a clinical upgrade because it can rule in/out central sleep apnea (HSAT cannot). OSA is formally listed as Dx #3 on the CCF problem list (4/15/2026). Sleep-disordered breathing is a known amplifier of chronic daily headache and NDPH. If positive, initiate CPAP/APAP through sleep medicine. Central apnea on PSG would be particularly meaningful given Bryan's tonsillar ectopia history. OSA treatment has a realistic chance of meaningfully reducing headache burden independent of NDPH-specific treatments.

🫀 Cardiology referral + Transthoracic Echocardiogram (TTE) — evaluate objective pulsatile head motion (de Musset's sign concern)

Bryan reports his head physically moves synchronous with arterial pulse when lying supine — this is distinct from subjective pulsatile tinnitus and is not adequately explained by a small-caliber left internal jugular vein (a venous structure cannot cause visible arterial pulsation of the head). Rhythmic head nodding synchronous with the cardiac cycle is the classic description of de Musset's sign, most often associated with severe aortic regurgitation (AR), but also reported in other high-output hemodynamic states: high-output heart failure, severe anemia, hyperthyroidism, large AV fistula, pregnancy, and bradycardia with compensatory large stroke volume. Recommended workup:

TTE (transthoracic echocardiogram) — primary test; rules in/out AR, measures stroke volume, LV size/function, aortic root dimension.
12-lead ECG — rhythm and conduction, LVH patterns, bradycardia evaluation.
CBC — rule out severe anemia (Bryan's hemoglobin has not been checked in the records reviewed).
TSH + Free T4 — rule out hyperthyroidism (overlaps with thyroid nodule workup — one blood draw).
BMP — baseline renal function; useful before any cardiac pharmacology decisions.

Narrow historical pulse pressures (96/64, PP 32; 114/82, PP 32) do not classically suggest severe AR (wide pulse pressure is the textbook sign), but do not rule it out — a TTE is the definitive test. This can be requested through the PCP at the 4/17 visit.

Attend neurotology consult — Dr. Christine Dinh, MD (UHealth Miami)

Sub-specialty neurotology evaluation of left-sided pulsatile tinnitus with imaging correlation (LEFT IJV 0.2cm vs RIGHT 0.6cm on 4/16/2026 ultrasound; small left transverse/sigmoid sinus on MRV). Dr. Dinh is double board-certified (Otolaryngology + Otology-Neurotology), inaugural George Lerner University Chair in Otolaryngology at UM, with pre-existing rapport (she formally diagnosed Bryan's Ménière's disease 8/9/2019). Bring: (1) 4/16/2026 venous duplex, (2) 4/11/2026 MRI Brain + MRV Head, (3) 11/18/2025 MRI Brain + IACs (tonsillar ectopia + pansinusitis), (4) symptom diary distinguishing subjective tinnitus from objective cephalic pulsation, (5) Ménière's history. Likely additional workup: dedicated temporal bone CT, CTA/CTV neck/skull base (rule out dural AV fistula, glomus tympanicum/jugulare, dehiscent jugular bulb, SSCD), audiogram update, VEMP if indicated.

Clinic: University of Miami Ear Institute, 1120 NW 14th St FL 5, Miami, FL 33136 · Tel (appointments): (305) 243-1484 · Direct: (305) 243-3564.

Prepare for headache specialist consultation — Dr. Aysha Siddika (June 2026)

Bring: (1) this consolidated dashboard, (2) detailed medication failure log (drug, dose, duration, side effects), (3) block response log, (4) in-lab PSG result (4/22/2026), (5) Dr. Dinh neurotology consult outcome, (6) any cardiology/echocardiogram findings. Prioritized discussion agenda: indomethacin trial (rule in/out indomethacin-responsive phenotype); IV lidocaine infusion protocol; IV DHE (Raskin protocol); ketamine infusion; onabotulinumtoxinA re-trial with optimal injection pattern; trigger-point therapy; behavioral pain program referral.

Order thyroid ultrasound (structural) — biochemical portion completed 4/17/2026

Update 4/20/2026: TSH (0.61) and Free T4 (1.2) from 4/17/2026 PCP draw confirm biochemical euthyroidism — thyroid dysfunction is no longer a credible cofactor. However, the 1.4cm left thyroid nodule found on CCF MRI 3/10/2026 still needs a dedicated thyroid ultrasound for TI-RADS / Bethesda structural characterization. Euthyroidism does not exclude malignancy in a cold nodule. This is a low-cost, rapid test and an unresolved gap.

Request liver function panel (LFTs) from PCP — same blood draw as TSH

Duloxetine 90mg/day (increased from 60mg 4/14/2026) carries an FDA hepatotoxicity warning — and no liver function panel has ever been documented in Bryan's records. His lipid profile (TG 176, HDL 37) and overweight BMI also raise NAFLD as a cofactor worth ruling out. One blood draw; combine with TSH + free T4 for efficiency.

Recheck blood pressure — home cuff or next PCP visit

4/16/2026 BP 129/98 (Stage 1 HTN per ACC/AHA) is a departure from the prior consistently low-normal pattern (121/63 → 96/64 → 110/72 → 114/82). May reflect peri-procedural pain/anxiety at the time of injection, but worth confirming with serial home readings. If persistently elevated, PCP evaluation for primary HTN vs. medication effect (duloxetine can modestly raise BP) is warranted.

Address hyperlipidemia — request statin initiation from PCP

LDL 182 in a 36-year-old with family history of cardiovascular risk and atherogenic dyslipidemia (HDL 37, TG 176) — statin therapy appears clearly indicated. Unaddressed in all records reviewed. If LFTs show liver enzyme elevation, statin choice should account for hepatotoxicity risk (pravastatin or rosuvastatin are lower-risk options).

Continue Dupixent for polypoid sinusitis — monitor for headache contribution

Dupilumab (Dupixent) is appropriately targeted for Bryan's eosinophilic/type 2 polypoid sinusitis. If sinus disease improves on Dupixent and there is any corresponding reduction in headache, it confirms sinus contribution is non-trivial. If headache is unchanged despite sinus improvement, it further cements NDPH as the primary driver.

Maintain consolidated provider updates — push all new data into shared record

Ensure all providers (CCF Neurology, Pain Management, PCP, Psychiatry, ENT, Neurotology Dr. Dinh, Headache Specialist, and Cardiology if referred) see: (a) the 4/16 ultrasound result (venous hypertension ruled out), (b) the 4/16 block response, (c) the 4/22 in-lab PSG result, (d) NDPH as the unified working diagnosis, (e) the objective cephalic pulsation symptom (distinct from subjective pulsatile tinnitus). A shared understanding reduces redundant workup and coordinates symptom-directed treatment.

💡Key Insights & Clinical Observations

⚠️ The Acetazolamide Paradox

Acetazolamide worsened Bryan's headache. This is often interpreted as "proof" of low intracranial pressure (since acetazolamide reduces CSF production). However, Bryan has an active sulfa antibiotic allergy, and acetazolamide is a sulfonamide. The worsening may represent a cross-reactivity reaction or drug intolerance — NOT a pharmacodynamic response. This distinction is clinically critical and means acetazolamide failure does NOT exclude IIH.

💡 Pulsatile Symptoms — Reinterpreted After Ultrasound (subjective tinnitus) + Distinct Physical Head Pulsation (requires cardiology)

Bryan reports two physically distinct phenomena that require separate interpretation:

(1) Subjective left-sided pulsatile tinnitus: Anatomically explained after 4/16/2026 ultrasound by turbulent flow through the congenitally hypoplastic left IJV (0.2cm vs 0.6cm). This is the finding routed to neurotology (Dr. Dinh, UHealth Miami). The subjective pulsatile headache quality — particularly with Valsalva amplification — can be a feature of NDPH and occipital neuralgia via vascular-trigeminal convergence, without implying pathologic venous hypertension. With IIH and IJV obstruction formally ruled out (no papilledema, normal MRI, low-normal BP historically, patent IJV flow), these subjective pulsatile phenomena do not support an intracranial hypertension mechanism.

(2) Objective cephalic pulsation (physical head-bobbing synchronous with pulse when supine): This is a different symptom and cannot be explained by a narrow left IJV (a low-pressure venous structure cannot produce visible rhythmic arterial head motion). This symptom matches the description of de Musset's sign, classically associated with severe aortic regurgitation and reported in other high-output hemodynamic states (anemia, hyperthyroidism, AV fistula, bradycardia with increased stroke volume). Dedicated cardiology workup is indicated — see Recommendation #3 (TTE + ECG + CBC + TSH/free T4 + BMP). Historically narrow pulse pressures (96/64, 114/82; PP ≈ 32) do not textbook-suggest severe AR but do not exclude it.

If any new signs emerge (papilledema, visual changes, progressive BP elevation), reopening the intracranial pressure question remains appropriate.

🧠 4/20/2026 — Dr. Kashouty Telemed Visit Outcome (Premier Neurology)

Imaging review: MRV Brain (no sinus thrombosis), repeat MRI Brain April 2026 (no acute findings), C-spine MRI (no syrinx), no NPH. Left arm DVT US previously normal.

Vitals: BP 133/80 · HR 63 bpm (bradycardic on propranolol) · BMI 28.2.

Depression screening: PHQ-9 = 13 (moderate depression) — clinically meaningful and should be addressed in parallel with the pain workup. Duloxetine 90 mg/day is active therapy, but a 13 suggests current dose/regimen is not providing sufficient mood control; flag for PCP/psychiatry (Anthony Gonzales, PMHNP-BC).

Diagnosis recoded to G43.011 (intractable migraine without aura, with status migrainosus). This is not a new disease — it's a reframing of severity that supports insurance coverage for Ajovy and quarterly occipital blocks. Run co-primary with CCF's G44.52 (NDPH) for now; the two codes describe the same headache from different angles.

Treatment escalation: Ajovy 675 mg subq q3mo started today (3rd CGRP mAb). Occipital nerve blocks every 4–6 weeks. Botox cycle #2 on 4/23/2026 (2–3 cycles standard before response is judged — premature to call it failed).

Gap to flag for Kashouty: He did not reference the 4/17 CRP/ESR results (they resulted later that morning at 1:18 PM, Quest-Tampa). Worth forwarding through the patient portal so it reaches his next-visit prep.

🧪 NEW 4/17/2026 — Biochemical Confirmation of Systemic Inflammation (CRP 11.7, ESR 22)

For the first time in Bryan's documented record, systemic inflammation is objectively confirmed rather than suspected. Multiple providers (Vero ENT, psychiatry 4/14/2026, pain management, and Bryan himself) had independently raised systemic inflammation as a unifying hypothesis; previously, no autoimmune/inflammatory workup had ever been documented. The 4/17/2026 PCP labs (resulted 4/20/2026 at Quest-Tampa) returned:

CRP 11.7 mg/L (normal <8.0) — ~46% above upper limit of normal
ESR 22 mm/h (normal ≤15) — ~47% above upper limit of normal

Clinical interpretation: Elevations of this magnitude are moderate, not acute — consistent with chronic low-grade inflammation rather than acute bacterial infection (where CRP typically runs 50–200+). Two independent acute-phase reactants moving in the same direction strengthens confidence that the finding is real.

Most likely sources (in rough probability order):

Chronic pansinusitis / polypoid sinus disease + documented hyperimmunoglobulin E syndrome + eosinophilia — can alone produce these values. This reinforces the rationale for Dupixent.
Possible concurrent autoimmune process — ANA, ANCA, antiphospholipid, tryptase, complement C3/C4 were drawn the same day and are still pending. If any return positive, the workup broadens meaningfully.
Minor BMI contribution (28.24) — typically adds modestly to CRP but not to ESR.

Implication for the headache workup: Chronic systemic inflammation can prime central sensitization and is increasingly recognized as a contributor to chronic daily headache phenotypes, including NDPH. This is a meaningful piece of data to bring to Dr. Siddika (Headache Specialist, 6/2026) and to share with CCF Neurology, Pain Management, and ENT. It does not change the working diagnosis, but it does shift the treatment emphasis toward aggressive control of the underlying type-2 inflammatory disease.

🫀 NEW SYMPTOM FLAG — Objective Pulsatile Head Motion (de Musset's sign concern)

Bryan describes his head physically moves synchronous with his pulse when lying back on a pillow — a rhythmic, visible/palpable motion of the head, distinct from the subjective "whooshing" of pulsatile tinnitus. This is not adequately accounted for by any finding on current workup (a hypoplastic left IJV is a venous anatomic variant and does not produce visible arterial head-bobbing). The classical medical name for this phenomenon is de Musset's sign (named after French poet Alfred de Musset, whose head nodded with his heartbeat during severe aortic regurgitation).

Differential for visible cephalic pulsation:

Severe aortic regurgitation (AR) — classical cause; wide pulse pressure typically but not universally present
High-output heart failure — severe anemia, hyperthyroidism, large AV fistula, thiamine deficiency, Paget's disease
Bradycardia with compensatory large stroke volume — directly relevant here: Bryan's HR at the 4/20/2026 Kashouty telemed visit was 63 bpm, reflecting propranolol 60mg ER at bedtime. A slower rate allows more ventricular filling and a larger per-beat stroke volume, making each contraction more visible/palpable at the head and neck. This is a physiological confound (a partial mimic of de Musset's sign) that must be disclosed to the cardiologist — the presence of bradycardia from a beta-blocker does NOT rule out underlying AR; in some patients it can mask subtle signs or paradoxically exaggerate pulsatile visibility.
Severe aortic root dilation / aneurysm

4/17/2026 thyroid labs: TSH 0.61 and Free T4 1.2 — biochemically euthyroid. This removes hyperthyroidism from the differential above. Remaining high-priority drivers are AR, high-output anemia, and bradycardia-related hemodynamics.

Recommended workup (see Recommendation #3): Transthoracic echocardiogram (TTE) — primary test; 12-lead ECG; CBC (hemoglobin/hematocrit for anemia); BMP; share propranolol dose and current HR with cardiologist. Echo can simultaneously evaluate for PFO (see blue flag below), making a single study high-yield.

🔴 Lifelong Chiropractic Care + RFA = Cervicogenic Headache Definitively Ruled Out

Bryan has received chiropractic adjustments every 1–2 weeks consistently for most of his life. Chiropractic provides short-term, temporary headache relief and has meaningfully helped mobility and arm pain — but no lasting headache resolution despite lifelong consistency. This pattern (brief relief → return of headache) reflects cervical muscle tension transiently modulating headache intensity at the margins via the trigeminocervical complex, not addressing an underlying source. Combined with the bilateral cervical RFA (February 2026) that successfully treated cervical and arm pain but had zero impact on headache intensity or frequency, the cervicogenic hypothesis is effectively eliminated as a primary headache driver. Prior acupuncture with Dr. He in Miami (~6–7 years ago) helped vertigo symptoms at the time; both prior and current acupuncture (Saint Lucie Acupuncture and Integrative Medicine) provide greatest benefit through autonomic/relaxation modulation rather than direct headache reduction. Biweekly deep tissue massage with Hua Flower Murdoch is also active. All providers should have this full complementary treatment history documented.

🟢 RFA Outcome Eliminates Cervicogenic Headache — Critical Diagnostic Clarification

The bilateral cervical RFA at C2-3/C3-4 (RIGHT 2/13/2026, LEFT 2/24/2026) successfully reduced lower cervical pain and bilateral arm radicular symptoms but had zero impact on headache intensity or frequency. This is a definitive negative finding that effectively rules out facet-origin cervicogenic headache as a meaningful driver of head pain. The 80% "pain" relief from the prior medial branch blocks was relief from cervical/neck-region pain — conflated at the time with headache. Subsequent workup then ruled out SIH, CVST, IIH, and venous outflow obstruction — leaving NDPH (primary headache disorder) as the unified working diagnosis, with bilateral occipital neuralgia identified and treated 4/16/2026 as a distinct peripheral contributor at the greater occipital nerve (anatomically separate from the C2-3/C3-4 facets previously addressed).

💡 CGRP Pathway Failure Pattern — With Ajovy Re-challenge 4/20/2026

Failing Emgality (galcanezumab, anti-CGRP ligand), Aimovig (erenumab, anti-CGRP receptor), AND Qulipta/Nurtec/Ubrelvy (oral CGRP receptor antagonists) represents a class-wide CGRP failure. The CGRP pathway is central to migraine neurobiology; failing all agents suggests either the headache is not primarily driven by CGRP-mediated trigeminal activation, or there is an upstream structural cause overwhelming the pathway.

Dr. Kashouty has now re-started a CGRP mAb — Ajovy (fremanezumab) 675 mg subq every 3 months — on 4/20/2026. Ajovy binds the CGRP ligand (like Emgality) but has a different binding epitope and half-life profile. The rationale is that a small subset of patients who fail one mAb respond to a different mAb in the same class. Realistic expectation: response rates after 2 prior mAb failures are modest (~15–25% in real-world registries). Decision point will be at month 3–6. If Ajovy fails, this strengthens the case that the phenotype is NDPH rather than CGRP-mediated chronic migraine, and argues for pivoting toward non-CGRP mechanisms (occipital nerve blocks quarterly, treatment of underlying systemic inflammation, sleep-disordered breathing optimization post-PSG, Dupixent-driven sinus disease control).

💡 Patent Foramen Ovale (PFO) Status Unknown — Should Be Investigated

Bryan has no documented cardiac workup for PFO despite 12+ years of refractory migraine with aura-like features and pulsatile symptoms. A significant subset of patients with migraines (especially those with aura) have underlying PFO, and PFO closure has been shown in some trials (RESPECT, PREMIUM) to improve migraine burden in selected patients. Given the failure of all conventional migraine therapies and the strong pulsatile/hemodynamic character of the headache, echocardiography (bubble study or advanced imaging) to assess for PFO should be considered. This is a straightforward, low-risk diagnostic test that could inform management decisions.

🔴 Gastroparesis — Secondary Effect or Primary Contributor?

Bryan has documented gastroparesis (noted on South Florida ENT intake form and recurring in recent PMH). Gastroparesis is often secondary to migraine medications (tricyclic antidepressants, anticholinergics) and autonomic dysfunction, but it can also reflect underlying autonomic neuropathy or neuroendocrine dysfunction. The presence of gastroparesis in conjunction with pelvic floor dysfunction, central/peripheral sensitization, and low-normal blood pressure suggests a broader autonomic pattern. Gastroparesis can impair medication absorption and consistency, affecting drug efficacy. GI motility workup (gastric emptying study or wireless capsule endoscopy) has not been documented and may provide insight into whether gastroparesis is a secondary consequence or an independent contributor to the overall clinical picture.

💡 Observed LEFT-sided pattern — likely constitutional, not pathologic

Bryan has several left-sided findings documented over 12 years: (1) Left varicocele with left gonadal vein reflux (embolized 2014, circumaortic left renal vein noted); (2) Left Ménière's disease — endolymphatic hydrops of the LEFT ear (diagnosed 2019); (3) Congenitally hypoplastic LEFT IJV (0.2cm vs 0.6cm on US 4/16/2026) paralleling a small left transverse/sigmoid sinus on MRV; (4) Left pulsatile tinnitus (now attributed to turbulent flow through the hypoplastic left IJV). After the 4/16/2026 vascular ultrasound, the left IJV finding is understood as congenital anatomic variation rather than pathologic obstruction. The left-sided pattern most likely reflects constitutional venous anatomic asymmetry, and no further vascular workup is currently indicated. A PCP note of this overall left-sided pattern may be useful if any new left-sided symptom emerges in the future.

💡 Ménière's disease — left-sided co-occurrence context

Bryan's left-sided Ménière's (diagnosed 2019 by Dr. Messinger) is independently characterized (episodic vertigo with progressive ear symptoms, responsive to duloxetine-associated resolution per Vero ENT note). Prior dashboard framing speculated a causal link to left IJV venous hypertension driving secondary endolymphatic hydrops; with IJV obstruction now ruled out (US 4/16/2026), this mechanistic link is no longer supported. Ménière's is retained as an independent concurrent diagnosis under ENT care (Vero ENT / Dr. Messinger).

⚠️ Disclaimer

This dashboard and clinical analysis represents an independent synthesis of available medical records for informational purposes. It is not a substitute for professional medical diagnosis, advice, or treatment. All clinical decisions should be made in consultation with qualified healthcare providers who have conducted a direct examination. The hypotheses presented here are analytical frameworks to facilitate more informed discussions with your medical team.

📍 Vitals — 04/16/2026 (Pain Mgmt) BP trend: 121/63 (5/2021) → 96/64 (4/2025) → 110/72 (12/2025) → 114/82 (3/2026) → 129/98 (4/16/2026)

⚠️ Allergies

🎯 Headache Profile

🧑 Social & Family History

⏳ Recent Studies & Pending Workup

❌ Treatment Failure Summary — Failed all major pharmacological migraine classes

❓ Sleep-Disordered Breathing (OSA / Central Apnea)

🟡 Systemic Inflammatory Process — Biochemically Confirmed 4/17/2026

❓ Occipital Neuralgia / Peripheral Nerve Component

❓ Spontaneous Intracranial Hypotension (SIH/CSF Leak) — Low Probability

💡 Supplement Stack Clinical Assessment

⚠️ Pharmacological Pattern Analysis

👤 Primary Care — TCCH OSLO Family Practice (Fort Pierce, FL)

🧠 Neurology — Cleveland Clinic Florida

🧠 Headache Specialist — Cleveland Clinic Florida

🧠 Neurology — Premier Neurology (Stuart, FL) · Principal Neurologist

💉 Pain Management

🧠 Neurosurgery

👃 ENT / Sinus

🧠 Neurology — Prior

☁️ Radiology

😴 Sleep Medicine

👃 ENT / Sinus — Prior (2021–2023)

💉 Pain Management — Prior (2021–2022)

🦴 Vero Orthopaedics II PA

🧠 Neurology — Prior

👂 Otology & Neurotology — UHealth (University of Miami)

🏥 Private Practice — Gastroenterology

🩺 Private Practice — Primary Care (Former PCP)

🏥 University of Miami Health System (UHealth)

🧠 Psychiatry

🦴 Chiropractic — Current (2024–Present)

🦴 Chiropractic — Prior (2018–2023)

🦴 Chiropractic — Prior (Pre-2018)

🧭 Critical Clinical Summary — Updated 4/16/2026

🟢 #1 — New Daily Persistent Headache (NDPH, G44.52) — PRIMARY WORKING DIAGNOSIS [Established 4/15/2026]

🟢 #2 — Bilateral Occipital Neuralgia (M54.81) — CONTRIBUTING PERIPHERAL DRIVER [Established 4/16/2026]

🟡 #3 — Chronic Sinusitis / Polypoid Sinus Disease Contribution

⚪ #4 — Sleep-Disordered Breathing — Pending In-Lab PSG 4/22/2026

⚪ #5 — Thyroid Dysfunction — Biochemically Euthyroid (4/17/2026); Structural Nodule Still Pending US

⚫ Excluded — Spontaneous Intracranial Hypotension (SIH / CSF Leak)

⚫ Excluded — Idiopathic Intracranial Hypertension (IIH)

⚫ Excluded — Left IJV Obstruction / Intracranial Venous Hypertension

⚫ Excluded — Cervicogenic Headache (C2-3 / C3-4 Facet Origin)

⚠️ The Acetazolamide Paradox

💡 Pulsatile Symptoms — Reinterpreted After Ultrasound (subjective tinnitus) + Distinct Physical Head Pulsation (requires cardiology)

🧠 4/20/2026 — Dr. Kashouty Telemed Visit Outcome (Premier Neurology)

🧪 NEW 4/17/2026 — Biochemical Confirmation of Systemic Inflammation (CRP 11.7, ESR 22)

🫀 NEW SYMPTOM FLAG — Objective Pulsatile Head Motion (de Musset's sign concern)

🔴 Lifelong Chiropractic Care + RFA = Cervicogenic Headache Definitively Ruled Out

🟢 RFA Outcome Eliminates Cervicogenic Headache — Critical Diagnostic Clarification

💡 CGRP Pathway Failure Pattern — With Ajovy Re-challenge 4/20/2026

💡 Patent Foramen Ovale (PFO) Status Unknown — Should Be Investigated

🔴 Gastroparesis — Secondary Effect or Primary Contributor?

💡 Observed LEFT-sided pattern — likely constitutional, not pathologic

💡 Ménière's disease — left-sided co-occurrence context

⚠️ Disclaimer