PODCAST: What Does a Neurologist Do & When Should You See One?

ZACH MOORE: Welcome to On Health with Houston Methodist. I'm Zach Moore. I'm a photographer and editor here, and I'm also a longtime podcaster.

TODD ACKERMAN: I’m Todd Ackerman, I’m a former medical reporter, currently an editor at Houston Methodist.

ZACH: And, Todd, have you ever been to the neurologist?

TODD: I have seen a neurologist. I had a pinched nerve that caused me a lot of problems that we ultimately resolved. But along the way, I was kind of worried that the effect it could have on me. My mother also had shingles, so I had some experience going with her to the neurologist. She had shingles, not sort of the garden variety people have it for a couple months and it clears. She had it for ten years and died with it, so I’m kind of well aware of neurologists.

ZACH: You know, I’m fortunate enough where I haven’t had the need to go to a neurologist yet for myself or for someone who I’ve been responsible for the care of. So, have your experiences there been beneficial or --

TODD: In the case of my pinched nerve, it was certainly beneficial. It resolved the issue. But I would say that you are definitely fortunate in that. I was struck when I was researching this at the extent of neurological conditions. It is the leading cause of illness and disability globally.

ZACH: Mh-hm.

TODD: One in three people have it. More than three billion. So, that’s more in lower income countries probably, but it’s still in the U.S. It’s one in four to five Americans have it, 75 million Americans they estimate. Which is not as much as heart disease with 120, but, you know, cancer is 17 million. So, it’s pretty widespread out there.

ZACH: Yeah, with a neurologist, it feels like such a specialty. Right? Like such a -- Like, you would think it’s like, “Oh, it’s a niche specialty, I had to go see a neurologist.” But actually, you know, wide variety of things they can help you with.

TODD: Right. Right, I mean, you’re talking the brain, the spinal cord nerves. There’s a lot of people out there, you know, who deal with headaches and who deal with neuropathy, that that’s where they’re going. Some of the other things are more rare or more a factor of older age, but it’s still a lot of people.

ZACH: Yeah, and that’s really what we’re gonna be talking about in today’s podcast. You know, signs that you should go to a neurologist. And who do we talk to today, Todd?

TODD: We talk to Dr. Tanu Garg who’s a neurologist at Houston Methodist.

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TODD:  Hello Dr. Garg. How are you today?

DR. TANU GARG: Good. How are you?

TODD: I’m good. So, for this podcast, we’re gonna do a little different model than we usually do which is talking about a particular condition, and what people can do to prevent it or manage it. Here, we often get a lot of talk from people that they don’t know exactly what a neurologist does. And so, I kind of want this podcast to answer that and to let people know when they should be thinking about seeing a neurologist. So, maybe before we can start to get to any of that, you can just tell me what a neurologist is.

DR. GARG: So, a neurologist is basically a physician that specializes in brain and nerve disorders. So, it’s a very wide field because we see patients with brain issues, spine issues, and also nerve issues. And then, under neurology, there are multiple specialties and subspecialities where they specialize in specific things like one neurologist may only specialize in brain. One may only specialize in the nerve. And so, it depends on what condition you’re having that you should go see a specific neurologist.

TODD: And so, do you mostly see referrals or do an appreciable number of patients come directly to you?

DR. GARG: I usually see referrals. I do get referrals from primary care doctors, neurosurgeons, referrals from other hospitals, other cities, states, since I do a lot of stroke. So, I see a lot of subspecialty stroke patients.

TODD: Besides stroke, neurologists treat a lot of conditions, but what do you most commonly see patients about?

DR. GARG: Since I see a lot of stroke patients in my clinic, a lot of those stroke patients also have other conditions such as seizures, dementia, nerve problems. And so, I end up seeing a wide variety of patients in my clinic.

TODD: Not like headaches? That’s not a common --

DR. GARG: I do see headaches as well. It’s just I see them less commonly than I see seizures and dementia.

TODD: What symptoms are kind of classic signs that someone might need to see a neurologist?

DR. GARG: A lot of times, first of all, you usually go to your primary care doctor because that’s the best person to guide you to the right neurologist. But things that a neurologist you need to look for would be like having severe headaches, migraines. You’re having stroke-like symptoms. You’re having seizures. You’re having nerve problems like neuropathy. Those symptoms prompt you to go see a neurologist. We’re also seeing a lot of patients these days with memory loss. And so, that is another specialty that’s becoming very popular under neurology.

TODD: How about movement balance problems? Is that pretty common?

DR. GARG: Yes, so there’s like multiple, more than ten, different specialties for neurology, so movement is one of them. So, we do see Parkinson’s patients. We see patients with tremors. We see patients with Parkinson’s and memory loss. The other condition that we see a lot here, just because it’s a tertiary center is, like, ALS, which is a very rare but sad disease. We also see people with other nerve problems as well.

TODD: Changes in smell or taste. Does that sound -- tend to be things that --

DR. GARG: Very rarely. Because of COVID, actually, it became more popular because a lot of people had loss of smell because of COVID. But that is not specifically something we see on a day-to-day basis. I can think of, like, one patient in four years.

TODD: Difficulty swallowing, speaking?

DR. GARG: A lot of that comes with stroke actually. So, when we see patients with stroke they have difficulty with speech, swallowing. Or if they have ALS, that can cause difficulty with speech and swallowing. So, we do see patients with that but it’s because of a certain condition that’s causing those symptoms. So, it’s those symptoms because of something else going on that makes them come to a neurologist.

TODD: And dizziness, did you mention that?

DR. GARG: No. So, dizziness is actually something I see a lot more than you would expect, and because dizziness can be from the brain or from the heart. And so, if it’s coming from the brain, it can be very serious. And so, we do see patients with dizziness, and we worry about a stroke if they’re having dizziness. However, the first person to see would be a primary care doctor because they can tease out, do you need see a cardiologist or a neurologist.

TODD: Let me mention some specific conditions and you can tell me what symptoms a person might first experience that might cause them to think that they have this, and whether they start with the primary care doctor or not, a neurologist might be in their future. Multiple sclerosis.

DR. GARG: So, with multiple sclerosis, symptoms can be very vague. However, it’s usually younger people, they may have first time vision loss, like they just lost vision in one eye. They couldn’t move one side of their body and then it came back. So, those symptoms in a young person would prompt them to see a neurologist.

TODD: Shingles.

DR. GARG: With shingles, usually it starts with the pain and then a rash. Shingles can usually be handled by a primary care doctor. You only see a neurologist if you have severe nerve pain after shingles for a while, and then a neurologist might help you with pain medications for the nerve irritation and pain.

TODD: Are you seeing that less these days?

DR. GARG: Yes, because of the shingles vaccine. Yeah. And this is not something a neurologist sees on a day-to-day basis. I have seen one person in four years with -- Yeah. And so, usually they end up going to a primary care doctor or a pain specialist.

TODD: But that’s something if you see that rash you need to get in right away because the treatment is only good -- effective if you get in right away.

DR. GARG: Correct. And the shingles, the nerve pain is very, very painful.

TODD: Neuropathy.

DR. GARG: So, with neuropathy, usually people say they have numbness and tingling in their feet, or they feel like they just can’t feel their feet anymore. Their balance is off if they close their eyes. They can also get weakness in their arms and their legs if they’re having nerve issues. And so, usually, the most common cause of neuropathy is, in the United States, is diabetes. And so, a lot of times these patients end up going to a primary care doctor first. And we’ll notice if they have diabetes and they’re having nerve problems, and then they’re referred to a neurology for further evaluations.

TODD: Parkinson’s.

DR. GARG: With Parkinson’s, it’s usually, you know, when you talk to people about Parkinson’s, the first thing that goes through people’s head is tremor, like shaking. People say their hand is shaking. We also see people, they have lost emotions. They have flat affect. When you see them, they’re very slow to walk, slow to respond. And so, those conditions can also trigger you to go to a neurologist. And sometimes they’re very hard to detect, like, it’s hard for the family to notice it right away. It takes time over the years, you notice, like, “You know what, your facial expressions are changing, or they’re less,” or, “I’m seeing a tremor in your hand.” And then, they should definitely see a Parkinson’s doctor.

TODD: Meningitis, encephalitis.

DR. GARG: Yes. So, because I do a lot of work in the hospital, we do see many meningitis and encephalitis patients. With meningitis, I usually see patients with herpes meningitis and encephalitis. And so, for that, you know, we think of basically a patient is confused. They are not following commands. They are having seizures. And they come to the hospital just completely out of it -- like, family found them down or something like that. So, those patients are really sick, and they usually come to the emergency room via EMS because they are not cognitively there to answer questions.

TODD: And once they’re stabilized then they would see a neurologist?

DR. GARG: They’ll see a neurologist in the hospital right away because this is a -- this is a very critical condition, and so they do have to see a neurologist in the hospital. And if they recover then they see a neurologist in the clinic as well.

TODD: Is -- They see a neurologist for viral meningitis or encephalitis too?

DR. GARG: Yeah. So, we see all kinds of meningitis. We see viral. We see bacterial meningitis. I have seen autoimmune encephalitis, which is an autoimmune condition that can cause inflammation, so many different kinds of encephalitis, meningitis that neurologists treat.

TODD: Vertigo.

DR. GARG: Yes. So, vertigo, we see -- I see a lot of patients with vertigo. So, we see vertigo coming from the brain and then we see vertigo coming from the ear. So, sometimes it’s hard as a patient to figure out if it’s coming from your brain versus your ear. But usually, if it’s coming from the brain, it’s constant. It doesn’t go away. But if it’s coming from the ear, it’s more position. Like, if you move your head to a certain direction you get dizzy. If you, like, lay down it gets better. So, we see a lot of patients in the hospital and clinic with vertigo. It’s important that if you are feeling dizzy that you reach out to your primary care doctor. And if it’s constant, then you come to the emergency room.

TODD: Pinched nerves.

DR. GARG: For a pinched nerve we do see patients with a condition called radiculopathy which is basically a nerve that gets pinched in your neck or in your leg and that can cause tingling, pain, weakness in your arms and your legs. And for that, the first line treatment we do is therapy. We try medications. And if that doesn’t work, then we’d refer them to neurosurgery, but neurologists do see a lot of patients for pinched nerve.

TODD: And the effect on that is the arm or the back?

DR. GARG: So, it’s more in the -- If it’s a pinched nerve, you feel like almost, like, it starts in your neck and you have this tingling pain that goes down in your arm. And the same thing, it starts in your lower back and then goes down to your leg, you feel like a tingling sensation down your leg. But usually, it can start with just pain, and numbness, and tingling, but sometimes it can progress to weakness, and that’s why it’s important that you see a neurologist for an accurate diagnosis.

TODD: So, I had one in my – in my neck that the first symptom I felt was just overwhelming ache in my arm muscle, and we had no idea what it was and went to a primary care doctor. And we tried different things, and it was only after a little while, I started notice a little numbness, and that kinda tipped me off so I went to a neurologist. Is there usually that tingling, and numbness right away that would tip people off?

DR. GARG: No, sometimes symptoms are very mild in the beginning, like you don’t even notice that you have these symptoms and they progress over time. So, you may reach out to a doctor once symptoms have progressed more, they’re becoming more annoying and more bothersome. But they might not happen right away.

TODD: Tinnitus or Tinnitus, however – there’s two ways to pronounce it?

DR. GARG: I say both ways, depending on what the patient says. But the Tinnitus, the only problem is I do see patients with that sometimes, however the worse thing I say is like, “I don’t have treatment for you.” And so, as of now, like even though patients come in to either our clinic or the ENT clinic, there is no good treatment for Tinnitus. So, even if you have ringing in the ear, I tell people to go to the hospital, if they also have other symptoms. Like they’re feeling dizzy with it, this is brand new for them, this has never happened before. They have hearing loss, ‘cause that can sometimes be stroke symptoms.

TODD: Brain tumors. Neurologists are sometimes involved in the diagnosis and pain management.

DR. GARG: Yeah, so we sadly see a lot of brain tumors. We actually have a Neuro-Oncology center here as well. With brain tumors, we play a big role in diagnoses, so we do see patients who are coming in with stroke-like symptoms or nerve symptoms, and then we do an MRI, and we find brain tumors. And once we do, then we refer them appropriately to either a surgeon or whether, you know, they need like radiation. However, we still follow them. So, they might need help with chemotherapy, they might help with seizures, they might need help with pain. So, the neurologists actually helps manages all those symptoms, while the surgeon is doing the surgery.

TODD: Did you initially mention epilepsy seizure disorders?

DR. GARG: Yes. So, seizures are more common than you think and so a lot of times those seizures, you know, we always think of like the movie, like somebody is shaking full body. But we also see people who have seizures, like they’re just confused. You know, the wife says, “My husband is not paying attention anymore, he’s just staring into space.” But that could be a seizure, not just the husband ignoring the wife.

TODD: That tends to be more of the vascular…

DR. GARG: It could be vascular or non-vascular. So, it could just be you have a seizure problem, or it could be you had a stroke and you’re having seizures, or you have a brain tumor that’s causing seizures. So, there’s multiple different reasons to have seizures. And so, usually, you know, when people have mild seizures, they might not even know they’re having a seizure. But a lot of times people come to the hospital, and something happens dramatic like they were just completely out of it, they got lost, they had shaking on one side of their body and then they end up in the hospital.

TODD: But just having a seizure, by definition, makes them an epileptic?

DR. GARG: Everyone can technically have a one-time seizure, and not be an epileptic. You have to have multiple seizures, you have to have reason to have seizures to be called epileptic.

TODD: Okay. Any conditions there that I left out?

DR. GARG: We see a lot of ALS also here at Methodist. So, ALS is a very devastating disease because it causes weakness over time, and there’s no cure at this point. But for ALS, we do recommend that you see a neurologist, and there’s multiple neurologists that subspecialize in that.

TODD: After the break, we’ll be back with Dr. Garg, who will tell you what you can expect at your neurology appointment.

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TODD: So, I realized we talked about an incredibly wide range of conditions there, but are there common things that someone seeing a neurologist should expect in their first visit with the neurologist? Like what kinda test you’ll do or if you’re seeing a neurologist for the first time, how’s that appointment likely to go?

DR. GARG: So, as a neurologist, the two things we pride ourselves in like taking good history and doing a thorough physical exam. Because your brain controls everything, so on a first visit, you’re gonna get asked a lot of questions, we’re gonna do a full body exam from head to toe. And then, we usually order pictures like CAT scan of the brain or MRI of the brain, and if it’s nerve problem like pinched nerve, then we do something called EMG, which is a nerve study to check how the nerve is working.

TODD: And are there things a patient should be prepared to answer before they see a neurologist for the first time?

DR. GARG: Yes, I think the couple of questions that we ask all patients is basically, when did those symptoms start? What was causing these symptoms? Have they noticed any triggering factors, anything that makes it better or worse? And also if it runs in the family or have they ever had issues with this before. It’s also important to know if there's medications, have they had any testing done before, if they’ve had images done before from somewhere else we’d like to see the discs as well. So, as much information as you can give us as a neurologist, we’d really appreciate it.

TODD: And just because your specialty is stroke, talk a little bit more about that, about the ways patients at risk can prevent it, what they first see that should cause them to come to see their doctor.

DR. GARG: That is actually one of the biggest things I do as part of my work is providing stroke education and basically teaching patients and families what to look out for, if they’re having stroke symptoms. So, things I tell all my patients, all my patients’ family, friends, and family is that if you have weakness on side of your body, your face is drooping, your arm gets paralyzed on one side, or you cannot see from one eye, that same 911 phone call. Because there are certain medications and procedures we can do in the hospital if you come right away, that we cannot do if you come six, seven, eight hours later. And also, vertigo is actually one of the symptoms of stroke that can happen. If it happens all of a sudden and it’s like 24/7, and that gets missed because a lot times people think, oh stroke is someone is drooping or weak on one side. So, those are symptoms I tell all my patients, family, and friends about.

TODD: And what’s the acronym?

DR. GARG: So, there are two acronyms actually, one is called FAST, which is Face, Arm, Speech, and then Time. And then the new one that I really promote is BEFAST, and B stands for Balance and E for Eye. So, those patients who are dizzy, they have lack of balance or their eyes are not doing what they’re supposed to do. So, we actually promote BEFAST more than FAST now.

TODD: Is stroke increasing, decreasing, or staying the same?

DR. GARG: I think we’re seeing more stroke patients because we’re getting better at detecting it. We have really advanced imaging now that was not there even like 15 years ago. So, we are definitely seeing a lot of stroke volume.

TODD: Okay. Is there anything I didn’t cover that you would wanna say? And what people should know about what a neurologist does? When to see them? What symptoms to be on the lookout for that we haven’t already covered or to, just to kinda summarize.

DR. GARG: I think the only thing I can think of, just to add to what we discussed before is that, if you do have headaches, like chronic headaches like migraines, it’s always good to see a neurologist, because there’s a lot of new medications out there that might not be given to you by your primary care doctor. And so, if you’re having a lot of headaches, it’s good to see a neurologist. You should never hesitate to see a neurologist if you are having any issues that you think are coming from your brain or your nerves. It’s okay to ask for a referral to see a neurologist. And the things that will prompt you to see a neurologist would be headaches, any nerve problems, any balance issues, any weakness on one side. And those are the main things that we see patients for.

TODD: Alright, very good, I appreciate your taking time to talking with us, I learned a lot from this.

DR. GARG: Oh, thank you, I appreciate it too.

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ZACH: So, Todd, what were some of your takeaways from talking to Dr. Garg?

TODD: Well, my main takeaway was that I really hope that I don’t have to – I don’t have any of the conditions that would cause me to see neurologist. Because none of them are any fun or sound any fun. Just my experience with the – with my pinched nerve, ultimately seeing a neurologist, he directed me to a neurosurgeon and I had surgery to take care of it, and it resolved the issue. Until we figured it out, you know, that was the case, I was -- seriously thought I would, at some point, develop clinical depression, ‘cause it was – the pain was so bad. And I saw no end to it.

ZACH: So, a pinched nerve, just for the listeners who don’t know that is. Is that when a bone kinda grows over a nerve? Is that correct?

TODD: Yeah, pinches it.

ZACH: Okay yeah, ‘cause I know my mom had one of those and had a lot of pain as well. So…

TODD: Yeah, it was very painful. And just watching what my mom went through with Shingles, those are – that was incredibly painful. And you know, you’re ranging from other things like ALS, or Parkinson’s, or Dementia, also don’t seem like any picnic. And ALS is one of the most devasting things you’ve could have diagnosed.

ZACH: Yeah, I found the – just to kind of walk through what Dr. Garg gave us about what to expect from going to a neurologist. I find it beneficial because I think a lot of times you – like, “What is this even gonna be, right?” I mean, you – you go to a primary care physician first, obviously as she reiterated and then you get recommended to the neurologist and then, you know, they kinda – they tests to expect, that sorta thing. Which I think, whenever you go in that – ‘cause it’s scary, right? You get diagnosed with something like this, you don’t know what you’re walking into. And I think having those expectations kinda laid out is kind of a sense of comfort.

TODD: Yeah, she did a nice job, I thought, of previewing for just any illness you can have just because these are, as we say, so wide ranging, and she mentioned, neurologists tend to specialize in different ones. One appointment could be really different than another appointment. Can you remember what BEFAST stands for?

ZACH: Oh, yes. I can. I can.

[Laughing]

No, the stroke thing, yeah.

TODD: Yes.

ZACH: Why don’t you run us through the letters, just to be safe, ‘cause you probably know it better than me.

TODD: Okay, B stands for balance, if you’re having any balance issues. E for your eyes, if you’re having any vision issues. F is for your face drooping. A is for arm weakness. S is for speech difficulties. And T is for time, meaning if you see any of those symptoms, it – time is of the essence to call 911.

ZACH: We did a video series recently for that, on the video department, they are teaching this in schools for children. And I know like we – we had – we did a story about how like a young soccer player, like recognized this, that one their coaches was having a stroke and they remember the BEFAST thing. And it definitely helped save the coach from, you know, having a much worse end result because they were able to identify it and treat it so quickly. So, this – and important acronym to learn. You know, BEFAST, it kinda makes sense too, ‘cause you wanna respond quickly, and so the acronyms kinda play into the word itself.

TODD: Yeah, it’s actually finally emblazoned in my mind, right? Used to hear the term a lot and never really thought about it that much. But as I get older now, I’ve actually taken stock of all those -- all those letters. Any of – I think my takeaway from this was any symptoms that we talked about that you see, you need to make an appointment ‘cause these potentially devastating conditions. And the earlier you treat them, the better.

ZACH: Alright, well that’s gonna do it for this episode of On Health with Houston Methodist. We drop episodes Tuesday mornings, so be sure to share, like, and subscribe wherever you get your podcasts. But until then, stay tuned, and stay healthy.

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