What happens when a head injury affects the brain, and how do neurologists determine the best path to recovery?
In Episode 4 of The Care Cartography Podcast, host Andrei Tsygankov welcomes Dr. Tamara Greene, a board-certified neurologist and founder of Greene Neurological and Medical Consulting, for an in-depth conversation about traumatic brain injuries, concussions, headaches, and neurological care.
Dr. Greene explains why a traumatic brain injury does not always require a direct blow to the head, how neurological examinations help identify potential problems, and why diagnostic testing should be tailored to each patient’s symptoms.
Guest: Dr. Tamara Greene, M.D. — Board-Certified Neurologist; Founder, Greene Neurological and Medical Consulting, Roswell, Georgia
B.S., Xavier University of Louisiana · M.D., Saint Louis University School of Medicine · Residency, UT Houston (Chief Resident) · Fellowship in Clinical Neurophysiology, UT Houston · Fellowship in Neuromuscular Medicine, Houston Methodist
Host: Andrei Tsygankov, CEO of AP Healthcare
This transcript has been lightly edited for readability.
Andrei Tsygankov: Welcome to The Care Cartography, a show about healthcare and having practical conversations with people who understand the healthcare system from different angles — from doctors and nurses to administrators and operators, to coordinators, advocates, and other healthcare professionals who see where the system works, where it breaks down, and what can be done better. I’m your host, Andrei Tsygankov. Today, we’re going to talk about neurology, traumatic brain injury, headaches, and what really goes into evaluating patients with neurological symptoms.
With us today is Dr. Tamara Greene, a board-certified neurologist with extensive experience in general neurology, traumatic brain injury, concussions, headaches, and neuromuscular medicine. She’s also the founder of Greene Neurological and Medical Consulting in Roswell, Georgia, just north of Atlanta. Dr. Greene, welcome.
Dr. Tamara Greene: Hi, thanks for having me.
Andrei Tsygankov: Great to have you. I think our audience would be especially interested in how much of neurology is detective work. When patients come to see you with headaches, dizziness, or cognitive issues, a lot of it is determining what’s causing their problems. How do you begin evaluating someone like that, and what does it take to get to the root of the problem?
Dr. Tamara Greene: The basics we’re taught in medical school are the history and physical. You collect the history: the symptoms, what’s going on, how long it’s been going on, how severe it is, and whether it affects daily life. Then you get the past medical history to see if there are any diseases the patient is currently dealing with that could be related to their symptoms. Family history is also important, to see if there’s a history of similar symptoms in the family.
Finally, you do a physical exam — specifically, a neurologic exam, which is a bit different from other providers’ exams. You do a thorough neurologic exam, assess any abnormalities, and from there you come up with a game plan: a potential diagnosis, potential treatment options, and diagnostic testing.
Andrei Tsygankov: So there are multiple components, but the core would be the history, the family history, the physical exam, and then perhaps diagnostic testing to triangulate what the issue might be.
Dr. Tamara Greene: Correct.
Andrei Tsygankov: Let’s go back to the beginning. Tell us a little about yourself and how you became interested in medicine.
Dr. Tamara Greene: I entered medical school five years ago. (laughs) I entered medical school uncertain about what I wanted to do. I knew I wanted to be in medicine, and during your third year, you rotate through different specialties. Going through those rotations, a lot of the residents just didn’t seem happy, and I thought, “Great — what am I going to do with my life?”
Then, in the second half of my third year, I did my neurology rotation, and the residents were happy. They were smiling. What I love about neurology is that it’s an ever-growing field. Unfortunately, most of the things we treat don’t have cures — some do, but many don’t — so it’s about making sure patients have a good quality of life as they go through whatever they’re going through.
Talking to those residents, seeing how they evaluated patients and interacted with them — and then, once you actually treat a patient and help them feel better, the patients are so grateful. Smiling residents, smiling patients — I thought, “This would be a good profession for me.” After that, I did a fourth-year away rotation at the UT Houston Health Science Center, which further solidified that this was the field I wanted to go into.
Andrei Tsygankov: In our conversation earlier, you mentioned that neurology is a growing and changing field. What does that mean to you?
Dr. Tamara Greene: I love some of what’s happening in neurology, because it’s giving patients hope. With Alzheimer’s dementia specifically, there used to be only a couple of prescription medications thought to make certain neurotransmitters — chemicals in the brain — more available to help with symptoms. But they didn’t slow the actual progression of the disease. Within roughly the past five years, there are now medications that have been shown to slow the rate of progression of Alzheimer’s dementia. That’s new.
There are also several medications coming out to treat multiple sclerosis, in various categories, as researchers study the mechanisms of the immune factors that affect the disease. Those are two prime examples of diseases where research keeps evolving to give patients hope for a good quality of life. Hopefully, on the horizon, there will be medications for other forms of dementia. Alzheimer’s is the most common, but there are other subtypes people are less familiar with that still don’t have a treatment targeting their specific abnormalities. Hopefully, as research continues, we can give those patients hope too.
Andrei Tsygankov: That’s fascinating, and it seems like it would really improve quality of life for a lot of people.
Dr. Tamara Greene: Absolutely.
Andrei Tsygankov: You did your residency and one of your fellowships in Houston. What was that like, and how did it shape your outlook on medicine and neurology?
Dr. Tamara Greene: Well, Houston was hot. (laughs) These days, I think residencies aren’t as tough on residents, but I trained back before the 80-hour work rule. You’d be in the hospital 36 to 40 hours at a time.
Andrei Tsygankov: That sounds absolutely brutal.
Dr. Tamara Greene: It was brutal, but I’m grateful for it, because during that time you see pathology you’ll probably never see again in your career. With that training, you not only learn the science behind things, you also learn how to interact with patients.
Dr. Tamara Greene: My neurophysiology fellowship focused primarily on patients with seizure disorders, as well as certain rarer diseases — muscle and nerve diseases. During that first fellowship, my mom was diagnosed with myasthenia gravis. It’s an autoimmune disease where your body makes antibodies that attack the muscles. It just so happened that I was in the middle of that fellowship, and myasthenia gravis was one of the diseases we focused on. Having that knowledge really helped me tell my mom, “This is new, it’s autoimmune, but it’s very treatable.” And that’s another disease where new medications on the horizon are giving patients hope.
Andrei Tsygankov: That must have been surreal — studying something and then having your own family affected by it.
Dr. Tamara Greene: It was. She had seen a couple of neurologists, and when she started describing her symptoms, I said, “Mom, it sounds like you have myasthenia gravis.” My mom was living outside Kansas City, Missouri, and one of the mentors who trained me during residency had taken a position in Kansas. He is so kind — I’m eternally grateful to him. I sent him a simple email: “I think this is what’s going on with my mom. They can’t get her in for six months.” He called me and said, “Have her come into my office on Monday.”
Andrei Tsygankov: I’m sure your mom was relieved to get that appointment right away.
Dr. Tamara Greene: She absolutely loves him — Dr. Dabatsky. He’s watching. (laughs)
Andrei Tsygankov: Solid plug.
Andrei Tsygankov: You mentioned clinical neurophysiology. Can you explain in layman’s terms what that means?
Dr. Tamara Greene: Physiology here refers to the electrical dynamics of the nervous system — the brain and the spinal cord. One of the major diagnostic tests we use is the EEG, or electroencephalogram, which is common for patients who have seizures. You assess the brain waves to see whether they’re having seizures and what type.
The second major test is the EMG and nerve conduction study — electromyography and nerve conduction, often abbreviated NCS. That assesses the peripheral nervous system: the muscles and the nerves. The brain and spinal cord make up the central nervous system, and all the nerves and muscles that extend from it make up the peripheral nervous system. So my fellowship focused on seizure disorders, brain waves, and diseases associated with epilepsy, as well as muscle and nerve disorders of the peripheral nervous system.
Andrei Tsygankov: What’s one of the most common misunderstandings patients have about working with neurologists?
Dr. Tamara Greene: It’s kind of hilarious when I tell people I’m a neurologist and they say, “Oh, you deal with the nerves — well, my nerves are bad.” And I say, “No, that’s more psychiatry.” (laughs) If you have MS, seizures, migraines — that’s neurology. A lot of people don’t know what neurologists treat, and that’s fine. It’s just a matter of educating patients about the disorders we focus on.
Another misconception is confusing neurology with neurosurgery. I’ll sometimes get referrals for neurosurgical cases — the referral says “brain tumor” — and I’m like, “No, you need to see a surgeon.” Their malpractice insurance is a lot higher than mine, and they make more money than me. (laughs) But we’ll get you to the right place.
Andrei Tsygankov: So how does your practice differ from a neurosurgeon’s?
Dr. Tamara Greene: Again — lower malpractice, and they make more money. (laughs) But neurosurgeons do surgery, and most neurologists don’t. Some neurologists do minor procedures. I do a few procedures, and during the second year of my fellowship training I did a lot of muscle and nerve biopsies. But if you need a brain tumor resection or spinal surgery for disc degeneration, those are the big things neurosurgeons focus on.
Andrei Tsygankov: I guess the word “surgery” in “neurosurgeon” should have tipped everyone off.
Dr. Tamara Greene: Ideally, but that’s not always the case.
Andrei Tsygankov: You touched on how important the physical exam is. How does your exam differ from, say, a general practitioner’s?
Dr. Tamara Greene: The neurologic exam has seven main components. First is the mental status exam: Are they awake and alert? Are they talking? How is their speech? Can they answer questions appropriately? Then there’s the cranial nerve exam, which focuses on the function of the muscles, the eyes, and everything in the head. Then the motor exam: How is their strength? Is there asymmetry — are they weaker on one side than the other? The sensory exam assesses sensation: Do they have neuropathy, numbness in the feet or hands?
Then reflexes: you tap the elbows, knees, and ankles to see whether reflexes are present, whether there’s asymmetry, or whether someone is hyperreflexic. That tells you a lot about where the lesion is. Then coordination and fine motor movements: When they do finger-to-nose, do they have a tremor? Are they missing the target? In Parkinson’s disease, do they have bradykinesia — slow movements? And finally, gait: How are they walking? Are they stumbling? Can they do tandem gait — some of my patients call it “the drunk walk” — one foot in front of the other? Can they stand with their eyes closed?
Those are the major components of the neurologic exam, and that sets us apart from pretty much every other specialty. Some neurosurgeons incorporate it into their exams too, but for neurology, these are the core components.
Andrei Tsygankov: That seems very different from what most people are used to. And that’s where the detective work starts.
Dr. Tamara Greene: Absolutely.
Andrei Tsygankov: You said something interesting: “Where is the lesion?” Can you explain that?
Dr. Tamara Greene: The nervous system is divided into the central nervous system — the brain and spinal cord — and the peripheral nervous system. As you go through your exam, you look for findings that point to certain areas. Facial asymmetry, for example, can tell you something is wrong with a cranial nerve. Stroke patients will have a lower facial droop, which points to a central nervous system lesion — something in the brain. With Bell’s palsy, the entire side of the face is paralyzed, which indicates a peripheral nerve lesion — the seventh cranial nerve is damaged.
If someone is hyperreflexic — you tap the reflexes and they’re very active — that could indicate a lesion in the brain. If it’s on one side, the lesion is likely on the opposite side of the brain. If they’re hyperreflexic throughout, that could indicate a spinal cord lesion. A patient with neuropathy may have numbness or sensory changes past a certain point in their arms and legs. So once you do the neurologic exam and see those abnormalities, you can say, “Their lesion is likely here,” or “likely there.” Or, hopefully in many cases, the exam is normal and you can give them some reassurance.
Andrei Tsygankov: So, in lay terms: “Where is the problem?”
Dr. Tamara Greene: Exactly.
Andrei Tsygankov: There are more and more diagnostic tests available. Why is the physical exam still so important?
Dr. Tamara Greene: One of the most important reasons is the patient’s finances. You don’t want patients doing diagnostic testing unnecessarily. You don’t want to order a scan of the entire brain and spinal cord, which could cost several thousand dollars. Once you localize the lesion, you can narrow it down: this person needs an MRI of the brain; if they’re hyperreflexic all over, maybe an MRI of the cervical spine; if they’re hyperreflexic only in the legs, you can stop at the thoracic spine.
It’s also important for reassurance. If a patient’s neurologic exam is normal, you can say, “Your exam is normal; more likely than not, imaging won’t show anything — but we can do it.” Sometimes patients just need that reassurance. Doing the physical exam makes sure you’re not over-ordering tests, putting patients through unnecessary testing and cost, and sometimes unnecessary radiation exposure, which a lot of patients are concerned about.
Andrei Tsygankov: So the exam makes diagnostic testing very pointed, as opposed to general.
Dr. Tamara Greene: Absolutely.
Andrei Tsygankov: What are some neurological symptoms patients may minimize but shouldn’t overlook?
Dr. Tamara Greene: Refractory headaches are an important one. I see a lot of headache patients, and if you start treating a headache and it isn’t going away — especially if it popped up spontaneously, and especially in older patients or patients with a strong family history — high blood pressure is one of the first things I look for. You ask, “What’s your blood pressure?” “I don’t know.” You check it, and it’s in the 200s.
I recently had a patient with recurring headaches. I asked, “What’s your blood pressure?” She hadn’t checked it. Then she called me — I think someone else had checked it for her — and it was literally in the 200s. She was about 36 years old.
Andrei Tsygankov: Oh, wow.
Dr. Tamara Greene: So recurring headaches are one. Another is what we call focal neurologic deficits: if one entire side of your body isn’t moving as well as the other, that could be a sign something is going on in the brain. And with a lot of my retired NFL patients, I see balance problems and stiffness. Those aren’t things you want to ignore, because they could lead to something more serious.
Andrei Tsygankov: When it comes to headaches and high blood pressure, why is that a problem?
Dr. Tamara Greene: Because it can lead to stroke — both types. An ischemic stroke is when a blood clot in an artery inside the brain cuts off the blood supply to an area, resulting in a stroke where you can’t move one side of your body or can’t speak. A hemorrhagic stroke is when a blood vessel actually ruptures and bleeds into the brain, and the most common cause of hemorrhagic stroke is elevated blood pressure. Both are serious, but with hemorrhagic strokes the deficits are often worse, the recovery time is longer, and the mortality risk is much higher than with an ischemic stroke.
Andrei Tsygankov: So if you have a headache that doesn’t go away, take care of it.
Dr. Tamara Greene: Take care of it — and the first thing you do is check your blood pressure to make sure it’s fine.
Andrei Tsygankov: One of your specialties is traumatic brain injury. When someone hears “TBI,” what should they understand?
Dr. Tamara Greene: Traumatic brain injury refers to any external force that causes the brain to move inside the skull and disrupts brain activity — electrical activity or structure. There’s a misconception that it requires direct trauma to the head. That’s not always the case. A rapid acceleration and deceleration can cause it. The skull is a hard surface, and the brain floats in cerebrospinal fluid, or CSF. If the head suddenly stops but the brain keeps moving inside the skull, it can impact that inner surface and create what we call post-concussive symptoms. So one of the most important things to understand is that TBI doesn’t necessarily require a direct impact to the head. It’s any force that causes the brain to shake inside the skull, disrupting its electrical activity and function, which then leads to symptoms.
Andrei Tsygankov: Would a concussion fall into that category?
Dr. Tamara Greene: Yes, and that’s another thing people don’t always understand: a concussion is a type of mild traumatic brain injury. The terms are often used interchangeably.
Andrei Tsygankov: So concussions are mild, but there are more severe types of TBI. What might cause something more serious?
Dr. Tamara Greene: Gunshot wounds, stab wounds to the head, and, not uncommonly, blast injuries — for example, military service members who are physically thrown by a blast. Those are more serious traumatic brain injuries. And, unfortunately, something we saw a lot during my pediatric neurology rotation is shaken baby syndrome, a very serious TBI that can be extremely detrimental to babies.
Andrei Tsygankov: Patients sometimes hear the term “post-concussion syndrome.” What does that mean?
Dr. Tamara Greene: Simply put, post-concussion syndrome refers to the symptoms patients experience after a concussion. The duration varies. Some patients recover after a couple of weeks. The data varies — some studies say six weeks, some say three to six months. About 10 to 15 percent of patients may have symptoms longer than a year, and that’s referred to as permanent post-concussion syndrome.
Andrei Tsygankov: So that can stay with someone for a long time?
Dr. Tamara Greene: For the rest of their life. What the studies show is that if a person is still having post-concussive symptoms a year after the injury, those symptoms are likely permanent — in roughly 10 to 15 percent of patients.
Andrei Tsygankov: Is there a common thread among the people who end up with long-term symptoms?
Dr. Tamara Greene: Honestly, it depends on the cause, but you can’t really tell who’s going to have long-term symptoms. Some patients have what you’d think was a pretty mild accident and have symptoms long-term. Others have something serious — last year I saw the sweetest lady who had an intracranial bleed, bleeding in the brain, and within a couple of months she recovered pretty quickly. You can’t predict who’s going to have what. The big topic people are talking about these days is CTE — that’s a whole other talk show — but that’s also an example of what could be considered a permanent injury.
Andrei Tsygankov: You said something interesting: you don’t treat a syndrome, you treat symptoms. Can you explain?
Dr. Tamara Greene: There’s a misconception that post-concussive syndrome can be treated with one thing, and it can’t. Many specialties have their own syndromes, and they often require a multidisciplinary approach. It’s not neurology, but take Down syndrome: patients may have cognitive delay, cardiac defects, sometimes hormonal abnormalities — so you need a neurologist, a cardiologist, and an endocrinologist on board. You don’t treat a syndrome; you treat the patient’s symptoms.
So when I talk to a patient and hear their symptoms, I try to address each one. Not uncommonly, you’re treating everything at the same time, because the symptoms can interfere with activities of daily living. You don’t want to say, “Let’s do the headaches first. Okay, those are better — now the dizziness. Okay, that’s gone — now the memory.” You want to address everything at once to help accelerate the patient’s recovery.
Andrei Tsygankov: What role do physical therapy, occupational therapy, or vestibular therapy play in TBI recovery?
Dr. Tamara Greene: I often refer for vestibular therapy, because patients have inner ear symptoms. Not only does the brain hit the inner surface of the skull — in the inner ear, there are small crystals called otoconia. So you can have central nervous system dysfunction when the brain is affected, and the inner ear can be affected too. Those crystals can be dislodged into the semicircular canals — there’s a set on each side — which are very important for balance and equilibrium.
A very common symptom patients describe is positional dizziness: they bend over and get dizzy, stand up and get dizzy, turn their head and get dizzy. Unfortunately, there are no FDA-approved medications for post-concussive vestibular symptoms, so we often refer for vestibular therapy. A good vestibular therapist will teach exercises to get that equilibrium back and improve balance so the dizziness isn’t so bothersome.
Andrei Tsygankov: In layman’s terms, what does vestibular therapy do?
Dr. Tamara Greene: They do passive range-of-motion maneuvers with the patient’s head to move those inner ear crystals back where they belong. They also assess balance, since patients not uncommonly complain of balance issues, identify the abnormalities, and teach exercises to do at home. Occasionally, patients get vestibular therapy for ringing in the ears. Tinnitus can be very difficult to treat; depending on the cause, vestibular therapy sometimes helps and sometimes is less effective. In essence, the goal is to get the patient’s vestibular function back.
Andrei Tsygankov: When it comes to head injuries, why is getting an evaluation early so important?
Dr. Tamara Greene: The most important thing is to help you recover sooner. Sometimes patients minimize their symptoms — “This isn’t a big deal, I’ll be okay” — and then three or four months later they’re still having symptoms. Some patients also don’t know about small lifestyle changes they can make. Stay well hydrated. I tell my teenagers and twenty-somethings — for whatever reason, they don’t like drinking water these days — “You have to hydrate. Dehydration can aggravate your headaches and your dizziness.” Avoid prolonged fasting, because that can aggravate headaches and dizziness too.
And you want to make sure they don’t do anything to aggravate their symptoms. I had one patient — such a sweet kid, bless his heart — who had an accident on a Thursday or Friday and then decided to go to Six Flags and ride the roller coasters. So not only is the brain shaking around inside the skull, now you’re whipping the neck too. It’s those little things patients don’t know to avoid that can make symptoms worse.
Andrei Tsygankov: So — no roller coasters after a head injury.
Dr. Tamara Greene: Absolutely not.
Andrei Tsygankov: What are some red flags after a head injury, big or small, that someone shouldn’t ignore?
Dr. Tamara Greene: Headaches are a big one. Another is cognitive deficits, especially when they start to interfere with daily activities and work. I have a patient now who’s an accountant, and she told me it’s hard for her to remember numbers — she finds herself repeating numbers in her head and then forgetting them immediately. When deficits start to interfere with your livelihood — and of course, no one wants an accountant who can’t count their money — (laughs) — those are things you don’t want to ignore, because they affect your quality of life.
Andrei Tsygankov: With accidents that result in head injuries, headaches seem to be a very common complaint.
Dr. Tamara Greene: Actually, the most common complaint.
Andrei Tsygankov: How do you think about headaches in that context?
Dr. Tamara Greene: You talk to the patient and assess the specifics. Where is the headache located? Is it sharp? Throbbing? Does it radiate? How bad is it on a scale of 1 to 10? Are there medications that help or don’t help? Are there associated symptoms — sensitivity to light or sound, blurry vision, floaters? You take all of that into consideration before coming up with a treatment plan.
If the headaches are in the back of the head, that’s most often associated with occipital neuralgia. A common scenario is patients hitting their head on the headrest. This week, I literally had two patients who were wearing hair clips, and when they hit their heads, the clips struck the back of the head — one patient’s clip actually broke — and now their headaches are primarily in the back of the head.
Other patients, because they’re in pain, grit their teeth. The temporalis muscles on the sides of the head are among the muscles of mastication, so gritting your teeth can cause tenderness or irritation in the temporalis muscles. If the headaches are more diffuse, you’ll probably focus more on prescription medical management, because occipital neuralgia and temporalis headaches can be treated with simple injections, but with a diffuse headache — short of Botox — you can’t inject all over the head. So you collect the history and look at associated symptoms. One patient of mine had floaters, and she responded well to one of the medications we often use for headache prevention.
Andrei Tsygankov: You mentioned Botox for headaches. What other procedures or injections might you recommend for someone suffering from headaches?
Dr. Tamara Greene: The three most common are occipital nerve blocks for headaches in the back of the head; temporalis trigger point injections for temporalis headaches — not uncommonly, you can actually feel a trigger point or spasm in the temporalis muscle; and Botox injections. Botox for headaches is a series of 31 injections into the muscles around the head and neck, usually reserved for patients whose headaches don’t respond to medication or to the simpler injections.
Andrei Tsygankov: What does an occipital nerve block do, and what’s the benefit?
Dr. Tamara Greene: I love occipital nerve blocks because they’re quick, they’re simple, and they typically knock out the headache like that. In the back of the head, there’s an occipital nerve on each side where it exits the skull, and it gives off branches that supply sensation to the scalp. A telltale sign is tenderness when you press at the craniocervical junction — where the head and neck meet. I jokingly call it the “heifer, stop!” sign, because when you press there, the patient wants to say, “Heifer, stop!” (laughs) If you have that positive sign, you know that’s your target. Patients literally walk into your office with a headache and walk out saying, “Man, my headache’s gone.”
Andrei Tsygankov: How do trigger point injections differ, and who might benefit?
Dr. Tamara Greene: There are different trigger point injections — they can be done in larger muscles like the trapezius and some of the neck muscles. Temporalis trigger point injections work on a similar premise: you press on the side of the head, and sometimes you can feel a trigger point or spasm in the temporalis muscle. Not uncommonly, a patient says, “My headaches are across here,” you press on the temporalis, and the headache radiates forward. The temporalis muscles sit like bands on each side of the skull. You find the area of maximal tenderness — likely the trigger point — inject it, and again, it knocks the headache out.
The main difference is the target. With a trigger point injection, you’re typically targeting the muscle or the muscle spasm itself. With an occipital nerve block, you’re targeting the occipital nerve at the area of irritation where it exits the skull. Because there are occipitalis muscles lying on top of that nerve, those muscles can be tight and tense, and when you put the needle in, you can sometimes hear a crunching sound. Muscle is soft tissue — it’s not supposed to crunch. That tells you there’s likely a spasm sitting on top of the occipital nerve, irritating it and causing the occipital headaches.
Andrei Tsygankov: Would a nerve block help the patient longer term?
Dr. Tamara Greene: Often, yes. I jokingly tell my patients, “If you come in and get an injection, the next time I’d rather see you is at Kroger or Publix. If I see you in my office again for headaches, that means I haven’t done my job.” (laughs) In my career, I’ve only had to repeat it a handful of times. Depending on the medications you use — I use a short-acting anesthetic, a long-acting anesthetic, and a mild steroid that acts locally, so it doesn’t go systemic and patients don’t have to worry about the side effects of oral steroids — you do it and make sure you hit the target area.
That’s really important, because patients are often nervous: “You’re putting a needle in my head,” and they equate head with brain. I’m not putting a needle in your brain — your skull is there to protect it. My goal is to target the muscles that are compressing and irritating the sensory nerves of the scalp, get rid of the pain, and see you out and about in public.
Andrei Tsygankov: So those procedures are very effective.
Dr. Tamara Greene: Yes, very much so.
Andrei Tsygankov: A lot of people might be surprised to hear “Botox” in your line of work, since most associate it with beauty spas. Why is Botox so effective for certain types of headaches?
Dr. Tamara Greene: Especially when patients have diffuse headaches that don’t respond to prescription medications, Botox targets all the muscles in the head and neck — the temporalis, frontalis, and occipitalis muscles — and since patients often have tension in the neck, the neck and trapezius muscles as well. You’re relieving a lot of the tension in the muscles surrounding the head, and many times, when Botox is done effectively, it knocks the headaches out.
Compare that with cosmetic Botox, which is only a few units in certain muscles of the face. Botox for migraines is a series of 31 injections around the head and neck — a lot more injections. And the goal is different: with cosmetic Botox, you’re trying to get rid of wrinkles; with medical Botox, you’re trying to get rid of headaches. There are other indications too, like cervical dystonia and hyperhidrosis, but I won’t get into those.
A lot of times, when my female patients come in for Botox for migraines, I’ll say, “We’re going to take care of your migraines — anything else you want to take care of?” And they’ll say, “Well, do this and do that,” and I’ll throw that in for free. (laughs)
Andrei Tsygankov: I’m sure your patients love you.
Dr. Tamara Greene: And I try to make sure it lasts long enough — mine lasts around six months, whereas at some places the effects wear off in four to six weeks, which isn’t supposed to happen. So I try to kill two birds with one stone: the headaches and the wrinkles.
Andrei Tsygankov: Talk about a tremendous selling point.
Andrei Tsygankov: What should patients know about the timeline for Botox treatment on the headache side?
Dr. Tamara Greene: If you listen to the commercials, they’ll tell you it’s indicated for chronic migraines, with treatment recommended every three months. With Botox, you have to reconstitute it — mix it — and I try to mix it so my patients don’t have to see me that often. Some providers may over-dilute it so patients come back sooner and they can charge more. But again, I’d rather see my patients smiling at Kroger or Publix. The goal is for the Botox to really knock out the headaches and be effective.
Andrei Tsygankov: Is it a one-time procedure, or does it require multiple sessions?
Dr. Tamara Greene: It’s usually once every three months, but sometimes I have patients who stretch it out to four to six months.
Andrei Tsygankov: What about CGRP-blocking agents? Can you talk about those?
Dr. Tamara Greene: CGRP stands for calcitonin gene-related peptide. CGRP inhibitors are newer medications that have come to market within roughly the past five to ten years. The CGRP protein is targeted because it’s thought to cause vasodilation — blood vessels in the brain expanding — which is a primary part of the pathophysiology of migraines. CGRP inhibitors block that expansion, limiting the headache — some are used for prevention, some taken as needed.
The main issue with CGRP inhibitors is that they’re very expensive. If a patient is uninsured or has limited insurance, I typically won’t start there, because they can cost upwards of thousands of dollars per dose. I have a patient on one that’s an infusion, and if you Google the cost, it’s something like $12,000 per infusion. There are also pills and injections — different types of CGRP inhibitors. So I reserve them, because these days it’s important to help the patient in multiple ways: help their headaches and help their pockets. No one wants to pay thousands of dollars for a medication if they don’t have to.
Andrei Tsygankov: In your opinion, are they effective?
Dr. Tamara Greene: Oh yes, absolutely. For the patient I mentioned, it’s been a game changer, because she’d been on so many medications that either didn’t help her migraines or gave her side effects. You have to document, “We tried this, this, this, and this,” because if you’re going to a medication that costs $12,000, you have to show you tried everything else first. Since we got her on it, she’s been maintained beautifully. She’s actually on a combination — Botox plus one of the CGRP inhibitors — because oral medications didn’t work for her or caused side effects.
Andrei Tsygankov: Let’s talk diagnostic testing. What are the most common tests you use?
Dr. Tamara Greene: I see a lot of traumatic brain injury, so I order a lot of MRIs, depending on symptoms. If a patient says they’re improving, you may not necessarily need imaging. But if certain red flags or symptoms stand out — especially if they haven’t had any imaging — like cognitive issues, visual symptoms, or balance problems, you want to make sure there’s no bleeding or structural lesion in the brain.
Sometimes I’ll order an EMG and nerve conduction study. If patients have numbness in their hands — often in accidents, their hands are on the steering wheel and the sudden impact affects the median nerve — you may get an EMG and nerve conduction study. There are also other concussion tests I may order depending on the patient and symptoms. Sometimes patients have already had videonystagmography or EyeBOX testing, the test is positive, and they’re referred to me.
Andrei Tsygankov: What is EyeBOX, and what does it test?
Dr. Tamara Greene: EyeBOX is one of the few FDA-cleared diagnostic tests specifically for concussion. It’s really simple: you sit down and watch a video for about four minutes while your eye movements are monitored. You can tell a lot from eye movements — after a concussion, the eyes don’t move the same. We look at saccades, nystagmus or jerky eye movements, whether the eyes move smoothly, and whether there are interruptions. Even as a neurologist, a patient’s eye movements may look normal to me, but EyeBOX will detect minute abnormalities you just can’t see with the naked eye.
Andrei Tsygankov: And that becomes another data point to continue your investigation as a detective.
Dr. Tamara Greene: Correct.
Andrei Tsygankov: What about a VNG? What does it do, and when is it useful?
Dr. Tamara Greene: VNG, or videonystagmography, works on a similar premise. The patient wears special goggles and follows tracings while their eye movements are monitored for abnormalities like abnormal saccades or nystagmus. VNG is commonly used when patients have vestibular symptoms — dizziness, ringing in the ears, balance issues. The goal is to see whether the vestibular system is affected. Parts of the brain are responsible for the vestibular system, and so are the inner ear structures, so a VNG can tell you whether there’s an abnormality in the brain, the inner ear, or both. Not uncommonly, the VNG is abnormal while the brain MRI is normal — it picks up minute abnormalities that aren’t visible on a structural scan. So patients with dizziness, ringing in the ears, or balance issues would be good candidates for a VNG.
Andrei Tsygankov: Are there other diagnostic tests coming down the pipeline that you find interesting?
Dr. Tamara Greene: There’s a test out now, typically used in the emergency room: a blood test for two main proteins, GFAP and, I believe, UCH-L1. It’s reserved for the emergency room because those levels are highest within the first 24 hours and then taper off. It helps determine whether a patient needs neuroimaging. If levels are high, they may be sent for a CT scan to make sure there’s no intracranial lesion or bleeding. If levels are normal — especially within the first 24 hours after the injury — more likely than not the patient is fine, and you don’t necessarily need to rush to scan them.
Other blood tests are in the works, with researchers trying to determine the best time to test, so patients don’t necessarily have to go through anything invasive — just a simple blood test.
Andrei Tsygankov: And a blood test would be a lot less costly.
Dr. Tamara Greene: Absolutely. The unfortunate thing is that by the time patients see me, they’re already a few days out from their injury, so that test wouldn’t be useful. But research is ongoing to find proteins released after traumatic brain injury that could be measured longer term.
Andrei Tsygankov: We spoke earlier about your NFL-related evaluations and your work with retired NFL players. What has that experience been like?
Dr. Tamara Greene: It’s been eye-opening. I’m a football fan, I admit it — a Tennessee Titans fan. I remember the Super Bowl years ago when the Rams were in St. Louis and played the Titans, and I’ve seen a couple of those St. Louis players and a couple of the Titans players. Seeing players you grew up watching come into your office is surreal. It’s also humbling, and I don’t take it for granted.
These men were strong. I’m only five-one, and you’ve got a guy who’s 6’7″ coming into your office, but he’s not who he used to be. You feel for him, going from seeing him on the screen to seeing him in your office, and you genuinely want to do what you can: “Let’s see what we can do to help you feel better.”
Andrei Tsygankov: What are some unique challenges in evaluating retired professional athletes?
Dr. Tamara Greene: I was raised by my dad — I’m a daddy’s girl — and my dad has two brothers, and I have three brothers of my own. So I’m used to men who are rough and rugged: “I’m not taking a pill unless a limb is falling off.”
Andrei Tsygankov: That seems very common for men in general.
Dr. Tamara Greene: Yeah — the Y chromosome is interesting. (laughs) These men are used to toughing it out. So you try to tell them, “You don’t have to be so tough. Let’s talk as a team about how to get you feeling better. You’re going through this, we can’t change that, but let’s see what we can do.”
Parkinson’s is one diagnosis quite a few retired players receive. They’ll say, “I don’t want to take anything.” “Okay, you don’t have to.” A couple of months later, his wife says, “He fell.” “Okay — are we ready now?” It can be humbling, for me and for them. And some of these men are still in the public eye — football season is coming up, they do tailgates, some of their sons play college football. My goal is: if you’re in the public eye, I don’t want anyone looking at you and feeling sorry for you. I want you to present yourself as normally as possible, so the only people who know what’s going on are your wife, you, and me. No one else has to know.
Andrei Tsygankov: What has that taught you about vulnerability?
Dr. Tamara Greene: That it’s okay to be vulnerable. I grew up a tomboy — climbing trees, roughhousing with my cousin and his friends. I grew up tough. But as you get older and things happen, you learn it’s okay to be vulnerable and humble, because people are more willing to help you if you accept that help. And a lot of these men are amazed at how much a little intervention here and there can make a difference in their lives.
Andrei Tsygankov: How do you help these literal giants heal, both mentally and physically?
Dr. Tamara Greene: First, you talk to them as human beings. Being raised around men, I know you don’t want to belittle them, and you don’t want to baby them. You talk to them directly: “Here’s what’s going on.” Straightforward, to the point. And you make it a team effort. I can’t tell a 6’7″, 350-pound man, “You’re going to do this.” They’re used to being on teams, so you talk to them as part of their team: “Here are your options. What sounds good to you? What are you willing to do? What can we do together? What can I do to help?”
Andrei Tsygankov: As a neurologist, what should the public understand about the long-term impact of repeated head trauma?
Dr. Tamara Greene: That’s a big question. A study was just published — some retired players have donated their brains to science — and one in four were found to have CTE, chronic traumatic encephalopathy, which results from repeated head trauma. It’s serious, and it’s real. If you choose that profession, that’s a risk you take. There’s research coming through the pipeline attempting to lessen that risk, which is awesome. For the men who already have it, it’s about making them feel better and helping them through it.
With football season coming — high school, college, and beyond — it’s a risk you have to be willing to take. But it’s important to take care of yourself, your brain, and your body: do cognitive exercises, read, do things that are stimulating, and stay active. I encourage my retired NFL players to stay as active as they can. Bless their hearts — many have had several surgeries on their knees, backs, and joints, and everything aches. You work as a team to help them feel better so they can stay active and get through the pain. It’s not easy, but you give them strategies to cope.
Andrei Tsygankov: Let’s talk about dementia. What’s the difference between dementia and Alzheimer’s disease?
Dr. Tamara Greene: That’s a common misconception — that they’re two different things. Dementia is a broad category, and underneath it there are different subtypes. The one people know best is Alzheimer’s dementia. There’s also vascular dementia, which can result from multiple strokes. There’s FTD, frontotemporal dementia, which affects the frontal and temporal lobes and causes disinhibition, while the person can still be fairly functional. Part of the frontal lobe’s job is to keep you from acting impulsively, so patients with frontotemporal dementia are very impulsive. Years ago, I treated a patient with frontotemporal dementia who would walk in and curse me out — I was a lot of B-words. (laughs) You can’t take it personally, because they’re disinhibited. Her daughter, her staff — everyone was a B-word.
Then there’s Lewy body dementia. There was a show years ago that I loved, Boss, where Kelsey Grammer played the mayor of Chicago, who had Lewy body dementia — he had hallucinations and a tremor. It can have some Parkinsonian features, but the hallucinations are typically what set it apart from Parkinson’s disease. So there are many types of dementia, and Alzheimer’s is just the most common.
Andrei Tsygankov: What are some early signs families and patients shouldn’t ignore?
Dr. Tamara Greene: The most important is when cognitive issues interfere with daily living: leaving the stove on and walking away, getting lost while driving to a familiar place. If you go to the same Kroger every day and suddenly can’t find your way home — those are definite red flags. Or, with cooking, putting ingredients in food that don’t belong. There’s a commercial where a grandmother puts salt in a pie she’s making.
People joke about word-finding difficulty or forgetting names. My grandmother is 89, and often when I come home she says, “Hey, girl.”
Andrei Tsygankov: That must hurt. (laughs)
Dr. Tamara Greene: She’s 89 — I’ll give her that. But she still cooks, she still cleans, and she’s still extremely functional, so I don’t take offense at being “girl” occasionally. There’s a precursor called mild cognitive impairment, where you may have some word-finding difficulty. The transition from mild cognitive impairment to dementia happens when it starts to interfere with activities of daily living — like patients forgetting to take their medications and their blood pressure going up. Those are the warning signs that it’s time to intervene.
Andrei Tsygankov: And by “intervene,” you mean see a specialist.
Dr. Tamara Greene: See a specialist, absolutely.
Andrei Tsygankov: What should families do if they’re worried about memory changes in a loved one?
Dr. Tamara Greene: That’s a hard conversation — I say that because I’ve seen it as a provider and in my own family. Not uncommonly, the family member isn’t receptive. I encourage families: you don’t have to sugarcoat it, but don’t be rough. You can’t fuss, you can’t be demeaning, you can’t be forceful. Sit down and have a conversation. Remember the show Intervention, where the whole family comes together and everyone shares what they’ve seen? I think the affected person will be much more receptive to that than to finger-pointing or being talked to like a child.
Andrei Tsygankov: Constructive and gentle.
Dr. Tamara Greene: Absolutely.
Andrei Tsygankov: What lifestyle choices might help decrease the chances of dementia?
Dr. Tamara Greene: Conservative management — controlling risk factors like diabetes and high blood pressure. If you’ve been diagnosed with those conditions, make sure your numbers are controlled: blood pressure, A1C, cholesterol. Studies have shown that higher LDL increases your risk not only for stroke but also for dementia. Stay active: studies have shown that 30 to 45 minutes of cardio three to four days a week can help lessen your chances of dementia and, if you’re diagnosed, slow the rate of progression. Smoking is another modifiable risk factor, along with high blood pressure and high cholesterol.
Cognitive exercises and reading help too. I encourage patients to do Sudoku or Lumosity — those little brain-game apps you can download on your phone — to stimulate the brain. As the saying goes, if you don’t use it, you lose it. Those little things help keep neurons active so they don’t degenerate.
I love talking about my retired football players, because they’ll spend an hour in the gym lifting weights, and I’ll ask, “What about your cardio?” “I hate cardio.” “Well, you’re bulky, but you still need cardio.” I know you hate it, but cardio has been shown to slow the rate of cognitive decline. So you incorporate it in baby steps — start with 10 minutes, 15 minutes. And a lot of their arms are bigger than my whole body. (laughs) A daily multivitamin and antioxidants are neuroprotective. All of these are conservative, everyday lifestyle steps that may lessen the chances of developing the disease and help slow progression if signs appear.
Andrei Tsygankov: And cardio doesn’t have to mean hours of hill sprints. You can start with a light jog or a walk.
Dr. Tamara Greene: Baby steps. When I started working out, I did a little cardio, and I’ve increased it over time. As long as you stick with it, be consistent. You can’t do two miles one day and then not do your next two miles for four or five months. You have to be consistent, three or four days a week.
Andrei Tsygankov: Earlier, you said something very interesting: you are the gatekeeper of your own care and your own health. What do you mean by that?
Dr. Tamara Greene: When it comes to your health, you have to be responsible for how you get better. We’re physicians, not dictators. We can give recommendations until we turn blue in the face, but if a patient isn’t willing to follow them, it’s futile. That’s why, when I talk to patients about their care, I give them options. I don’t say, “You’re going to do this.” You listen to your patients. If someone says, “I don’t like taking medicine,” I’m not going to prescribe anything, because I know they won’t take it.
When a patient comes in with headaches, for example, I’ll say: there’s non-prescription management, there are supplements I often recommend, and there’s prescription management. For patients with multiple symptoms — headaches, insomnia, anxiety — there are a couple of medications that are my go-tos: “We can potentially treat three or four of these symptoms with one medication, if you’re willing to try it.” If you don’t want to take any pills, that’s when we talk about injections — the simple occipital nerve block or temporalis trigger point injection. You give patients options, and since the patient is the gatekeeper, you let them make an informed decision about what they’re comfortable with — within reason.
Sometimes a patient will say, “I’m going to go do this,” and a couple of weeks later, “That didn’t work.” Okay — you don’t judge. You let them try it. It’s like being a parent whose kid is learning to walk: you let them fall a couple of times, and eventually they get it — as long as they’re not bumping their head.
Andrei Tsygankov: As a parent, I can definitely relate to that.
Dr. Tamara Greene: When my daughter learned to walk, her grandparents would run to get her: “No, no, no!” With me, she’d fall and I’d say, “Shake it off.” And she learned to get up and shake it off.
Andrei Tsygankov: So you adjust your recommendations to the patient in front of you?
Dr. Tamara Greene: Absolutely. You have to work as a team with your patient. If they say, “I don’t want to take medications,” okay — we don’t have to, especially if there are other options. Let’s try the injections or the non-prescription options and see if they give relief, and we’ll go from there. Sometimes it helps, sometimes it doesn’t, and if it doesn’t, you revisit it. But you don’t force options on patients who aren’t comfortable with them.
Andrei Tsygankov: What can a patient, especially a new one, do to prepare for an appointment with a neurologist?
Dr. Tamara Greene: That’s simple: know your history and know your medications. If you have symptoms and there are potential treatment options, but you don’t know what medications you’re on, I can’t prescribe something, because there’s a risk of drug-drug interactions, which in certain cases can be lethal. So be in tune with yourself and your body. Know what happened, know your history, know what medications you’re taking — and then, as a team, we can make an informed decision about what you’re comfortable with.
Andrei Tsygankov: If you could change just one thing about healthcare in America, what would it be?
Dr. Tamara Greene: Oh, Lord. (laughs) I really wish everyone in healthcare could get on one accord. It often seems like everyone is fighting against each other. Health insurance companies deny medications from pharmaceutical companies; pharmaceutical companies may price medications too high; insurance companies deny the treatments doctors recommend; hospital systems have prices that can be very expensive; and those of us who are treating doctors are saying, “That’s too expensive,” or “That shouldn’t happen.” There’s a lot of division in healthcare, which is unfortunate.
I wish all of us in the American healthcare system could meet in a room and come up with a solution. The country would be such a healthy place if we could find a way to let patients be healthy, live long lives, and still be productive members of society. Of course, everyone has their business, and I understand that, but financial gain shouldn’t be the ultimate goal. Healthy Americans should be the ultimate goal.
Andrei Tsygankov: That’s a very noble goal. Do you think aligning all those constituencies is possible?
Dr. Tamara Greene: Maybe not in our lifetime.
Andrei Tsygankov: It would be a wonderful goal.
Andrei Tsygankov: If someone could take home just one thing from this conversation, what would it be?
Dr. Tamara Greene: Neurology is an ever-growing field. Unfortunately, patients are often scared to see a neurologist, because it’s their brain, and they may know someone who’s been affected by a neurologic disorder. It’s not something to fear. If you’re having neurologic symptoms, don’t be afraid. There’s a vast range of options to help you get through whatever you’re going through. If you notice something, talk to someone. And if you’re scared to make the phone call, have someone else make it for you — and start the process of preserving your brain and your body.
This podcast is for educational and informational purposes only and does not constitute medical or legal advice. Treatments, procedures, medications, and costs mentioned reflect the guest’s clinical experience and may not be appropriate for every patient. Always consult a qualified healthcare provider about your specific situation. AP Healthcare is a care coordination service and does not provide medical care.
Dr. Tamara Greene is a board-certified neurologist and the founder of Greene Neurological and Medical Consulting in Roswell, Georgia.
She has extensive experience in general neurology, traumatic brain injury, concussions, headaches, and neuromuscular medicine.
Her clinical background includes residency and fellowship training in Houston, with specialized experience in clinical neurophysiology and the evaluation of neurological and neuromuscular disorders.
Dr. Greene also works with retired professional football players, helping address neurological symptoms and the long-term effects of head injuries.
Her approach emphasizes careful neurological examinations, appropriate diagnostic testing, individualized treatment, and collaborative relationships with patients.
In this episode, she shares her experience diagnosing complex neurological conditions, managing headaches, supporting recovery after traumatic brain injuries, and helping patients improve their quality of life.
