Neurology Minute

Dr. Halley Alexander and Dr. Abel Sandmann discuss seizure rates and risk factors in patients with cerebral cavernous malformations (CCMs) during long-term follow-up without CCM intervention. 
Show citation: 
Sandmann ACA, Vandertop WP, White PM, Verbaan D, Coutinho JM, Al-Shahi Salman R. Seizures and Epilepsy in Patients With Untreated Cerebral Cavernous Malformations: A Prospective, Population-Based Cohort Study. Neurology. 2025;105(11):e214387. doi:10.1212/WNL.0000000000214387 
Show transcript: 
Dr. Halley Alexander:
Hi, this is Halley Alexander with today's Neurology Minute. I'm here with Abel Sandmann from Amsterdam University Medical Center, and we just finished recording a full-length podcast about some exciting findings related to cerebral cavernous malformations and the risk of seizures and epilepsy.
Abel, can you give our listeners a rundown of the most exciting findings and how it can change practice?
Dr. Abel Sandmann: 
In our paper, we show that patients with a cerebral cavernous malformation who have a first unprovoked seizure should be diagnosed with epilepsy and considered for anti-seizure medication, as most of them achieve long-term seizure freedom with medical therapy alone.
These findings are based on a prospective population-based cohort study in which we analyze long-term follow-up and assess the rates and risk factors for: one, a first-ever epileptic seizure; two, seizure recurrence to evaluate the updated ILAE definition of epilepsy; and three, seizure freedom over two years and five years among patients with epilepsy.
We found that among patients who had never experienced a seizure before, the 10-year risk of a first-ever seizure was only 6%. This supports current recommendations against prophylactic anti-seizure medication in patients who are incidentally diagnosed with a cerebral cavernous malformation. However, following a first unprovoked seizure, the 10-year risk of recurrence was 80%, which exceeds the 60% threshold defined by the ILAE.
This justifies diagnosing epilepsy after the first and provoked seizure in this population. Given that the risk of recurrence was lower in patients treated with anti-seizure medication after the first seizure, this supports early initiation of therapy, although these treatment analyses were non-randomized and should be interpreted cautiously. Most patients who met the definition of epilepsy became two year and five years seizure-free with medical management alone.
But some patients with cerebral cavernous malformations develop medically intractable seizures and might benefit from surgical treatments.
Dr. Halley Alexander:
Excellent. Thank you so much, Abel. You can find the full-length podcast, which is available now on the Neurology Podcast, or you can also find the full article in Neurology at neurology.org, or in the December 2025 print issue.
As always, thanks for tuning in for today's Neurology Minute.

In part one of this series, Dr. Tesha Monteith and Dr. Jennifer Robblee discuss an international consensus definition for refractory migraine and why clearer criteria are needed. 
Show citations:
Robblee J, Minen MT, Friedman BW, Cortel-LeBlanc MA, Cortel-LeBlanc A, Orr SL. 2025 Guideline Update to Acute Treatment of Migraine for Adults in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache. 2026;66(1):53-76. doi:10.1111/head.70016
Robblee J, Khan FA, Marmura MJ, et al. Reaching International Consensus on the Definition of Refractory Migraine Using the Delphi Method. Cephalalgia. 2025;45(9):3331024251367767. doi:10.1177/03331024251367767
Show transcript: 
Dr. Tesha Monteith:
Hi, this is Tesha Monteith with the Neurology Minute. I've just been speaking with Jennifer Robblee about her exciting work defining refractory migraine with an international consensus, as well as her work with the American Headache Society on a guideline update for parental pharmacotherapies for migraine in the emergency department. Hi, Jennifer. Thanks again for coming on our Neurology Minute.
Dr. Jennifer Robblee:
Thank you so much for having me. I'm delighted to be here.
Dr. Tesha Monteith:
You've done a lot of work in the area of refractory migraine. Why don't you tell us why you felt there need to be clarification on the definition?
Dr. Jennifer Robblee:
Well, this is a patient population that I'm really passionate about. There's not enough research out there. We don't really know who these patients are, why they're not responding to treatment, and we don't know how to help them because we have no guidelines, obviously, since they're refractory to what we use for treating. So I thought it was really good to get an international group to standardize our definition and hopefully help move the research forward.
Dr. Tesha Monteith:
Why don't you tell us a little bit about the consensus definition
Dr. Jennifer Robblee:
So we came up with an international consensus definition for refractory migraine that was laid out the same way that migraine is, say, laid out in the ICHD-3 diagnostic manual, if you want to call it that. So we have different criteria on. So criterion A basically allowed for it to be episodic or chronic migraine. Criterion B had three subcriteria, so you needed to have at least two out of three of severe to very severe disability and/or a constant background headache and/or at least eight monthly migraine days.
Criterion C was about the lack of response to treatment. And basically it says that you needed to have failure of all medication categories, and there is an extra one for an other in case any new treatments emerge before the diagnostic criteria get updated. And what we considered a, quote, unquote, failure was that you did not have a 50% improvement in monthly migraine days, or you had intolerable side effects, or you had an absolute contraindication.
There is a caveat that you need to have at least four true lack of efficacies. And then the CGRP monoclonal antibody or gepant category and the onabotulinumtoxin toxin category both had to be a true lack of response. And of course, there's a criterion B to say that this should not be from another diagnosis.
Dr. Tesha Monteith:
Thanks so much, Jennifer.

Dr. Stacey Clardy reviews biotin deficiency and biotin-related lab interference.
Show transcript: 
Dr. Stacey Clardy:
Hi, this is Stacey Clardy from the Salt Lake City VA and the University of Utah, and I'm back with you for another lab minute. Today, let's talk about Biotin or vitamin B7, because the Biotin story in neurology has two very different aspects. The first is a real deficiency, which is uncommon, but clinically really important. And the second is the modern problem of biotin supplementation that's quietly wrecking our lab interpretation.
So first, true biotin deficiency in adults is less common, but it can look like a multi-system neurologic syndrome. The classic teaching is dermatitis and alopecia, so keep those in your mind. But neurologists end up seeing the downstream features. So lethargy, depression, paresthesias and sometimes ataxia. Now, in infants and children, the bigger higher stakes entity is biotinidase deficiency, which is fortunately screened in many newborn programs in the US. Untreated, it can produce seizures, developmental delay, optic atrophy, and hearing loss. And the key point is that these neurologic injuries can be prevented if biotin is started early enough.
Also, remember, there are numerous reports now in the literature of it mimicking the clinical and radiological features of neuromyelitis optica spectrum disorder or multiple sclerosis. So if you have one of those diagnoses and you're not quite sure that it's right, keep biotinidase deficiency in the back of your mind. Now, what most of us clinicians are living with is the biotin supplement era. So high dose biotin, taken by a lot of people, either knowingly or unknowingly, can interfere with biotin streptavidin immunoassay platforms. And the direction of error depends on the assay design, but the practical pitfalls are simple. You can be handed a lab pattern that screams something like hyperthyroidism or other endocrine pathology, and it can actually be purely analytical artifact. Thyroid testing is the most common example, and troponin and other assays can also be affected depending on the assay platform.
So a common clinical misstep is to treat the lab burnout rather than the patient. So if your patient symptoms don't match this new endocrine emergency that the lab appears to be showing, ask, are they taking biotin? This is commonly in hair and nail supplements or buried in the myriad ingredients of another fix all supplement. So you need to find out if it's in any of those. The easiest thing is to say, tell me all of the supplements and the brands you're taking. And then I usually do a quick internet search right there to find out if biotin's in there.
And so the lowest friction fix is generally to repeat the test after holding biotin for an appropriate interval. At least a week is usually a safe time to guess about. The key is coordination with the laboratory. Not every lab behaves the same and some systems now actually have evolved mitigations, which is quite helpful. So that's the biotin update. So remember, biotin deficiency is treatable and sometimes urgent. And also, biotin supplementation is now a common lab confounder that can trigger avoidable diagnostic and therapeutic errors. Thanks for spending a few minutes with me. This is Stacey Clardy, and that's your lab minute.

In this episode, Dr. Stacey Clardy reviews the March 9 Capitol Hill Report, recapping key takeaways from Neurology on the Hill.
Stay updated with what's happening on the hill by visiting aan.com/chr. 
Learn how you can get involved with AAN advocacy. 
Show transcript: 
Dr. Stacey Clardy:
Hi, this is Stacey Clardy with today's Neurology Minute. It's an advocacy update from the AAN's Capitol Hill Report. More than 200 AAN members came to Washington, DC, last week for the AAN's annual advocacy fly-in, Neurology on the Hill. As you probably know, this is the annual chance for neurologists to get some face-to-face time with members of Congress or their aides in the US right on Capitol Hill. AAN members had three asks for this year's event. We did cover them last week individually on the Neurology Minute, so have a listen if you want more detail, but I'll review them quickly. 
First, we asked for a permanent inflationary update to physician reimbursement based on the Medicare Economic Index and to raise the outdated budget neutrality triggers in the Medicare physician fee schedule. Under the current system, the AAN needs to ask Congress nearly every year to fix a proposed cut to physician payment under Medicare, so it's time for a better solution.
The second ask, AAN members requested their legislators to co-sponsor the Connect for Health Act in the US. This legislation would support patient access to care by making those old COVID era telehealth flexibilities now permanent rather than requiring repeated extensions. And the need to make these flexibilities permanent was especially clear in the US during the 2025 government shutdown when Medicare recipients' access to telehealth lapsed for about 45 days.
And finally, the third ask was for the BRAIN Initiative at the National Institutes of Health, it's a very important program funding basic research into the brain and it's losing a key funding stream that was previously provided through the 21st Century Cures Act, so the AAN members asked their legislators to close the gap by supporting $468 million in funding for the BRAIN Initiative in 2027. If you didn't go to Neurology on the Hill but want to support these causes, check the AAN's Advocacy Action Center, and you could contact your representative that way.
Outside of DC news, a number of state legislators are considering bills that positively or negatively affect neurology. The AAN has weighed in on several of those bills with advocacy letters. The bills it supported include later school start times in Pennsylvania, restricting AI prior authorization denials in Florida and Hawaii, mandating coverage for telehealth services in Massachusetts, and reducing prior authorization burdens in Arizona and Kansas. The AAN opposed a New York bill, however, that would give chiropractors the ability to evaluate and diagnose neuromusculoskeletal conditions and provide consultation advice and recommendations on neurology.
So you can find links and more in the Capitol Hill Report. It's available on aan.com/CHR, that's short for Capitol Hill Report, and in US members' email inboxes. That's it for this time. Thanks. I'm Stacey Clardy for The Minute.

In this episode, Dr. Stacey Clardy reviews the February 23rd Capitol Hill Report, recapping key takeaways from Neurology on the Hill.
Stay updated with what's happening on the hill by visiting aan.com/chr. 
Learn how you can get involved with AAN advocacy. 
Show transcript: 
Dr. Stacey Clardy:
Hi, this is Stacey Clardy with today's Neurology Minute. It's an advocacy update from the AAN's Capitol Hill Report. More than 200 AAN members came to Washington, DC, last week for the AAN's annual advocacy fly-in, Neurology on the Hill. As you probably know, this is the annual chance for neurologists to get some face-to-face time with members of Congress or their aides in the US right on Capitol Hill. AAN members had three asks for this year's event. We did cover them last week individually on the Neurology Minute, so have a listen if you want more detail, but I'll review them quickly. 
First, we asked for a permanent inflationary update to physician reimbursement based on the Medicare Economic Index and to raise the outdated budget neutrality triggers in the Medicare physician fee schedule. Under the current system, the AAN needs to ask Congress nearly every year to fix a proposed cut to physician payment under Medicare, so it's time for a better solution.
The second ask, AAN members requested their legislators to co-sponsor the Connect for Health Act in the US. This legislation would support patient access to care by making those old COVID era telehealth flexibilities now permanent rather than requiring repeated extensions. And the need to make these flexibilities permanent was especially clear in the US during the 2025 government shutdown when Medicare recipients' access to telehealth lapsed for about 45 days.
And finally, the third ask was for the BRAIN Initiative at the National Institutes of Health, it's a very important program funding basic research into the brain and it's losing a key funding stream that was previously provided through the 21st Century Cures Act, so the AAN members asked their legislators to close the gap by supporting $468 million in funding for the BRAIN Initiative in 2027. If you didn't go to Neurology on the Hill but want to support these causes, check the AAN's Advocacy Action Center, and you could contact your representative that way.
Outside of DC news, a number of state legislators are considering bills that positively or negatively affect neurology. The AAN has weighed in on several of those bills with advocacy letters. The bills it supported include later school start times in Pennsylvania, restricting AI prior authorization denials in Florida and Hawaii, mandating coverage for telehealth services in Massachusetts, and reducing prior authorization burdens in Arizona and Kansas. The AAN opposed a New York bill, however, that would give chiropractors the ability to evaluate and diagnose neuromusculoskeletal conditions and provide consultation advice and recommendations on neurology.
So you can find links and more in the Capitol Hill Report. It's available on aan.com/CHR, that's short for Capitol Hill Report, and in US members' email inboxes. That's it for this time. Thanks. I'm Stacey Clardy for The Minute.