The Neurologist’s Guide to Beating Migraines & Headaches

[00:00:00]So, so yes, I'm double-boarded in neurology and interventional pain, which is an anesthesia fellowship with and because of that a lot of the stuff that I'm going to be talking about and that I do generally on a day-to-day is really at that kind of interface between procedures, but also diagnosis and kind of more neurology. Uh so not not necessarily the more kind of classic headache neurology that you might be uh used to just because of that uh different toolbox uh from anesthesia interventional pain.

[00:00:27]So, let's get started by uh talking about uh the case and then we'll base everything on that essentially and then we do the Q&A at the end. I don't have any disclosures. I'm not paid by any of the pharmaceutical companies. So, uh there's really nothing I'm mentioning today that I have any any specific uh bias in from a financial standpoint.

[00:00:47]We're going to talk about Rachel. Uh basically, she's going to be uh an example case that we will build on during this webinar to uh discuss some of the you know topics and migraine and headache in general that I think apply to a lot of people in general, but uh you know, if we if we use Rachel, I think she's a very prototypical headache patient that I see.

[00:01:11]So, in this specific scenario, she's a 32-year-old and she basically has been having sinus headaches or what she calls sinus headaches for a very long time.

[00:01:19]She describes them as pressure and throbbing around her eye and they happen about two or three times a month.

[00:01:26]One thing she mentions also that she yawns a lot. She has some chocolate craving and uh other symptoms that tend to happen before the actual headache.

[00:01:35]And um she gets some vision changes too, which she describes as a shimmering um and that tends to happen about 20 minutes before the actual headache starts.

[00:01:44]She does have other symptoms, but the bottom line is when she gets all of that constellation, uh she ends up going to the dark room so that she can actually um you know, alleviate the symptoms. She takes Excedrin as well every once in a while. Um and uh um she hasn't really seen a neurologist because most of her symptoms seemed more like sinuses. And so, she has seen ENT, she has seen her PCP, but uh they cleared her, nothing really is going on from a from an ENT standpoint that would warrant intervention.

[00:02:15]And so, bottom line is, you know, she hasn't really uh gotten any proper uh treatment. So, what are her options and what should she do at this point when she's having yet another attack of the same type?

[00:02:26]A is she can go to the emergency room. B is she can take a decongestant because of the, you know, sinus involvement.

[00:02:33]Um C is she can basically keep taking the Excedrin like she is now.

[00:02:38]Or D, she can actually go and see a neurologist. Now, obviously, this is a this is a leading question, but uh the answer in this case is that she should probably be seen by either a neurologist or some kind of headache specialist.

[00:02:49]And we'll talk about why in a second.

[00:02:52]Now, before we talk about migraine in in more detail, just to kind of frame it properly and put it in context, when we talk about headaches in general, you have what we call primary headaches, and then you have the secondary headaches.

[00:03:04]The idea behind it is that secondary headaches are going to be things like brain tumors or brain bleeds or infection, meningitis, that kind of stuff. So, these are usually things that are due to the headache is itself due to another uh disorder, either inflammation or infection or blood or or mass structure effect. Primary headaches means that you don't really have any of those. So, it means that there's no easily identifiable cause that is leading to the to the headache. And what I will say is that, generally speaking, based on my practice, but also based on published data, 98% of people who have a headache are going to be primary headaches. Right? And only 2% will be the secondary headaches, which are again the brain tumors and the somewhat kind of scary or stuff, right? But the 98% are going to be primary headaches.

[00:03:51]Within that 98% basically everybody is going to be either a migraine, a tension headache, or a cluster headache. Now, I put under cluster headache as well that, you know, the it belongs to a family of what is known as the TACs or tax, trigeminal autonomic cephalalgias. But basically this is a family of disorders and as you can see from the from the from the picture, those that definitely center more on the eye itself, they tend to be associated with a lot of uh autonomic symptoms like a runny nose or watery eye or red eye.

[00:04:24]And the pain itself is stabbing as opposed to the pain quality in the other headache disorders which tends to be more pulsating or or kind of uh dull or or just kind of pressure. Um but basically 98% of people uh are going to have these primary headaches when it comes to um anybody having headache. And so migraine, tension headache, and cluster headache all fall within those primary headaches and these are going to be the most common ones that we see both in clinic and I'm assuming as well in the emergency room.

[00:04:53]And even though they may not be life-threatening, they are extremely disabling, especially migraine.

[00:04:58]So, migraine is indeed the number one cause of disability in people who are under 50. So, during the most productive years of somebody's life. Uh and unfortunately what I find is that a lot of times people really minimize migraine. Um so, in the general population and for people who have migraine, they hear this all the time, right? It's just a headache.

[00:05:19]Um and and that is a very kind of triggering sentence for a lot of migraine patients because when they have migraine and they live with migraine, they're suffering. Um when somebody just tells them that it's just a headache, it's uh it's ultimately very very minimizing.

[00:05:34]>> [snorts] >> Because the symptoms that happen in migraine really affect somebody's life and career and relationships. And so, just calling it a headache and reducing it to the headache phase is doing them a disservice. So, in this talk we're going to talk about the actual symptoms that happen and the treatments, but this is just kind of to to put it in context of how how disabling it is.

[00:05:55]So, that we all understand the impact and the the kind of relevance of the stock.

[00:06:01]So, migraine is definitely, you know, a brain and kind of full body disorder, I would say, because not only does it affect the the brain and kind of the symptoms emerging from the brain, but also people have sometimes gut dysfunction, right? So, they can get gastroparesis, their their vision is affected a lot of times, their speech is affected, they can get allodynia, which is almost like a whole body phenomenon where somebody's skin can hurt, right? So, so all of these are very across the whole body.

[00:06:29]So, we're not just talking about somebody having a headache like tension headache, or even cluster headache, we're talking about a full body event that has a genetic root. So, migraine is definitely genetic and it has a reasonably or at least I would say moderate heritability.

[00:06:48]It's not Mendelian per se. There are a few subsets of migraine like hemiplegic migraine that are due to, let's say, one gene and have a more like, let's say, autosomal dominant inheritance pattern, but generally speaking we think of migraine as being polygenic. So, it's multiple genes that are involved in how the brain is wired and ultimately put somebody at risk for for having migraine.

[00:07:10]And significantly more common in women, runs in families as well, and there's a lot of misconceptions around it. Right? So, one of the misconceptions is what, you know, was essentially what Sarah had, right? So, she's having what sounded like sinus headaches and which basically people either self-diagnose as having sinus headaches or even when they go to primary care or the emergency room, a lot of them are diagnosed as having sinus headaches and then, let's say, referred to ENT, but then ultimately based on the studies we have, 90% of people who have a self-diagnosed or even a formally diagnosed sinus headache by primary care or emergency room, uh, turn out to actually be migraine.

[00:07:53]And unfortunately, some of them spend years. I've heard patients tell me that they've spent 5, 10 years dealing with these kind of, uh, sinus headaches without getting proper migraine treatment. And then ultimately, you know, that's just, uh, you know, so many years wasted and disability, unfortunately.

[00:08:09]So, before we going to talk about the treatment for migraine, I want to make sure that we discuss the different phases. Because usually, when people talk about a headache, and when people try to reduce migraine to just a headache disorder, the focus is obviously on the head pain by definition. When we talk about headache, the, you know, the head is aching.

[00:08:28]Uh, the, the important thing to keep in mind though, is that headache is only one out of the four phases of the, of the migraine. So, we're basically talking about 25%. And some people actually have what we call acephalgic migraine, which is basically also known as silent migraine, which is, the aura and the prodrome without the actual headache.

[00:08:49]So, 36% of people who have migraine will at some point have some episodes that are headache-free, but that are still migraine. Because they're getting the other phases, but not the actual headache or the head pain.

[00:09:01]And then 4% of migraine patients exclusively have acephalgic migraine, which basically means that all of their attacks are purely the aura and let's say the prodrome and postdrome, but they don't really get the actual head pain in any of their episodes. It's a minority, 4%, but those are tricky because they can go their whole life, you know, under the assumption that these are due to a different cause, when they actually are acephalgic migraines, and the treatment for it is obviously going to be migraine treatment. So, so it it changes things from a management standpoint.

[00:09:31]Let's talk about the phases. So, when we are discussing a episodic migraine attack, uh we can think about it this way.

[00:09:39]Um think of initially about the prodrome phase, which is really what is going to happen in the brain and in the body a few hours to even a few days before the actual headache. So, let's say somebody is having uh the headache phase start today. Based on the studies we have, including functional MRI studies and a lot of kind of other uh investigations that were done, the prodrome phase can start up to 48 hours before the headache.

[00:10:07]In other words, even although the actual head pain may have started, let's say, this morning, the the prodrome part of that same migraine attack actually started basically yesterday or the day before.

[00:10:17]And these are going to be usually things like yawning, there's going to be fatigue, there's going to be brain fog, there's going to be mood changes, a lot of times irritability, but for some patients even euphoria can happen before the actual uh headache. Uh there's going to be language disturbances, uh there's going to be changes in body temperature. So, the hypothalamus is very heavily involved in the prodrome phase, and the thinking is basically that it's almost the migraine generator inside the brain. So, that's where things kind of start before it kind of progresses to involve more and more parts of the brain. Each one will lead to its own uh set of symptoms. But basically, the prodrome is extremely important because when people are able to pick up on their prodrome symptoms, that can make treatment significantly more effective. A lot of the medications we have work better in the prodrome phase as opposed to in the headache phase. So, when patients are just waiting for the head pain to start, a lot of times they're missing the good window.

[00:11:13]Right? Uh but anyway, so the prodrome phase is really kind of the very initial 48 hours before the head pain. And then the aura phase, which happens in about 1/3 of migraine patients, right? So, 1/3 will have an aura at some point. Uh the other 2/3 are what we call migraine without aura. So, they simply don't have uh an aura. And the the migraine types from that sense are actually very different in terms of their physiology and and risk. We know for example that migraine with aura puts people at a higher risk from a stroke standpoint, ischemic stroke standpoint.

[00:11:44]Not so much migraine without aura. So they have very different kind of physiology and and treatment implications.

[00:11:51]But for those who do get an aura, so that's going to be the second phase of the migraine and that tends to happen anywhere between 60 minutes and 5 minutes before the actual head pain.

[00:12:00]Right? So the very kind of imminent right before the actual head pain as opposed to the prodrome which you know we said can be 48 hours prior.

[00:12:08]And the aura for 90% of patients who do get an aura is going to be visual. So there's going to be zigzag, there's going to be some kind of blurry vision, there could potentially be all kinds of there's a 25 described aura visual aura types that can happen and people describe them in different ways, but they can be shimmering like in Rachel's case in the scenario right here or they can be a little bit more like blind dots, they can be flashing white spots. There's just got a lot of different ones. And they are coming from the brain as opposed to the eye itself.

[00:12:42]Which is important in distinguishing if it's a retinal event that's happening or if somebody's having some kind of retinal TIA or retinal stroke or even if somebody's having floaters as opposed to somebody who is actually having an aura, right? Because in this case obviously this is coming from the brain and if it's coming from the brain it means it's going to be in both eyes. All right? But it's going to be just one part of the visual field but but both eyes. So closing one eye is not going to change it. But there's other aura types, right?

[00:13:08]So people can get also what we call a verbal aura and that's going to be one in which you know they have almost like an aphasia picture or like they have word finding difficulty. Or even a speech disturbance. People have a sensory aura so tingling pins and needles sensation.

[00:13:23]So there's different types of aura that can happen for those who do get an aura and usually right after the aura is when you're going to get the actual headache phase.

[00:13:32]Now, once the headache is over, people normally morph into what we call the migraine hangover.

[00:13:37]So, that essentially is what we call the the postdrome.

[00:13:41]And some of the features of the postdrome are similar to the prodrome in the sense that you can get that brain fog, you can get the fatigue, you can get the mood changes, right? You don't really get a lot of the other stuff like the yawning and the food cravings, right? So, but the postdrome is really when, you know, that you can think about it this way. The brain almost went to the to a workout session, you know, for 8 hours at the gym, and now it's just so tired that basically it's uh you know, not functioning properly, and uh it's uh it's buffering.

[00:14:10]Uh so, that's really the postdrome. And e- even though the headache phase is over, the migraine wasn't really uh over yet.

[00:14:17]And the In this specific scenario, let's say the headache itself maybe was 8 hours, right? The problem is that if you were to add the prodrome to it and the postdrome to it, then now we're talking about a like a 3 days of somebody's uh somebody's life, right? And uh you know, more episodes in a given month, then you're talking basically now about, you know, 10 days or even 15 days a month, even though it was only, let's say, three actual headache attacks.

[00:14:40]And that's unfortunately what creates a lot of misconceptions about migraine is that when people are only thinking about the headache phase and you're only counting the headache hours in a given day, but you're not taking into account the other, you know, the prodrome, the aura, or the postdrome, which are equally disabling and sometimes even more disabling for some patients, then you're really uh misrepresenting what my what migraine is.

[00:15:02]Uh so, I kind of touched on those already, but just to uh emphasize that again, you know, the probably the number one myth is that, you know, migraine is is just a headache when it's not, right? Uh and then another thing uh relates to triggers.

[00:15:16]We're going to talk about the triggers one by one, but basically in a nutshell, one thing that has been really uh uh almost like a revolution or like a mindset shift in the in the few in the last few years about migraine.

[00:15:29]It's basically that a lot of the things we used to think about as being migraine triggers, now we think are simply part of the prodrome. In other words, chocolate had a reputation for being, you know, one of the most common migraine triggers.

[00:15:42]Uh but then based on the studies we have, including provocation studies in which they would, let's say, give migraine patients who theoretically say that chocolate is their trigger, they would give them chocolate and then see what percentage of those people actually end up getting migraine attack. All right? Uh what they found was that uh that chocolate wasn't actually triggering migraine. It was basically the other way around. So, people were already having the prodrome phase and the food cravings that happen in the prodrome phase.

[00:16:10]And and so essentially the migraine itself is what ordered the chocolate in a way, right? And and so the prodrome made them get the chocolate as opposed to, you know, the chocolate kind of triggering the migraine cuz it had already started prior. And [snorts] that's based on a lot of the studies we have that show that hypothalamic activation that was already happening at the 48-hour mark before the head pain, right? And then let's say the chocolate might happen, you know, 36 hours or 24 hours before the head pain, but there was already the yawning, there was already the other kind of prodrome symptoms, which basically say that, okay, the migraine had already begun.

[00:16:46]Uh so, that's important because unfortunately a lot of patients go through their life uh avoiding all these triggers, right? So, they're like, "Okay, I'm not eating chocolate anymore." Or or I'm not eating cheese anymore. And uh this kind of elimination uh diet and and complete kind of very strict avoidance of triggers unfortunately can be counterproductive based on the studies we have.

[00:17:09]A lot of patients are told that it's just stress that's causing their migraine. Stress is a trigger for sure and it can, you know, change the threshold for migraine, but usually on its own stress is not going to be the the reason why people are having migraine. There's a lot of different things that stack.

[00:17:25]Um and one last misconception also that I want to touch on here is a lot of times uh people almost attribute migraine to somebody being weak or having some kind of personality or kind of character flaw, and they tell them to push through it. They tell them to basically manifest kind of, you know, the migraine ending or something of that sort. Uh but but now that we have so much data on migraine being a complex neurological disorder, uh a lot of people unfortunately were were hurt by these uh these kind of uh attitudes and statements um because they are dealing with something that they did not choose that is very much genetic.

[00:18:01]And and yet uh because of the misconceptions about migraine, uh people unfortunately assume that it's in their hands and that they can basically just kind of will the migraine away.

[00:18:11]Let's talk about the triggers briefly.

[00:18:13]So, there's a lot of different triggers, and everybody's triggers are going to be different. But, the most important thing that I want you to take away from this talk is basically that uh triggers are not going to trigger by themselves, right? So, in other words, whether we're talking about alcohol like red wine or we're talking about bright lights, that by itself is not going to be sufficient to actually lead to a migraine.

[00:18:37]What happens is what we call the threshold theory of migraine, which is essentially that the triggers are going to stack on top of each other, right?

[00:18:44]So, if you only have one of these by itself, that's not going to be enough to actually, you know, lead to a migraine attack. But then if you have two or three stacking on top of each other, then suddenly now, you know, you're basically getting closer to your your threshold, and that might, you know, tip you over the edge, and then you actually morph into a full-blown migraine attack.

[00:19:03]And and so, for everybody the the the actual threshold is going to be different.

[00:19:08]Uh medications will change the threshold. So, even with the same triggers around, if somebody, let's say, is on a preventative medication for migraine, then potentially, you know, even with these triggers being present, they are going to be less likely to have a migraine attack, right? So, it all has to be taken into context. And we can't really look at the triggers one by one and assume that they are the the the the villain in the whole story.

[00:19:32]However, the most common triggers that people identify and that, you know, are present in pretty much all the the studies on migraine are are these ones that are kind of listed right here. So, stress and I mentioned as well over here stress let down. So, this is definitely not as well known in terms of being a you know, an important factor and it can surprise some patients and people in general. And the idea is basically that people usually assume that, okay, well, I'm you know, when I'm stressed out at the peak of my stress, I'm going to be more likely to have a migraine attack.

[00:20:04]Well, it turns out that actually it's significantly more likely to have it when the stress is over, right? So, for example, during the week, right? If you were to guess which day of the week is the most likely for somebody to have a migraine attack, a lot of people will say probably Monday, right? It's start of the week, it's the work week, it's a lot of stress. But based on a lot of the studies we have, it's actually Saturday.

[00:20:25]And the reason for it is that your stress during the week, Monday through Friday, and then by Friday afternoon, the stress is kind of going down. And that sudden change in stress, right?

[00:20:36]Is basically what leads to to the migraine. We call it the stress let down effect. And that's why people tend to have more migraine attacks on Saturday or weekends and on vacations. Also again, during that transition.

[00:20:50]As a common theme, the migraine brain doesn't really like deviations from routine. It really likes things to be consistent, whether we're talking about sleep, whether we're talking about stress, whether we're talking about your eating and meal kind of schedule. All of those have to be very consistent, otherwise any deviation is basically going to trigger the migraine brain and send somebody into an attack. And it can't really make the the difference or distinction between positive and negative. So in other words, whether it is you know, stress itself which is technically negative, right? If it's high stress, or if it's you know, the fact that the stress is now going down.

[00:21:27]So it doesn't matter the direction if it's like going up or going down.

[00:21:30]But basically the brain interprets that as a change or deviation from norm and that makes it more likely to actually go into a full-blown migraine attack. Um so that's one of them. That's a common one.

[00:21:40]Sleep disturbances, which again, you might think that it's only sleep deprivation, but as it turns out based on the studies, even if you were to sleep in a little bit more on a Saturday or on weekends, that in itself can be a trigger for migraine. Right? Um hormonal changes, you know, so for for women uh especially uh the estrogen withdrawal is a big factor. That's why we have things like menstrual migraine. That's why also migraine has a very different uh mechanics in pregnancy and menopause and puberty, right? Uh so hormones are very important and with more and more data now, we feel that all the other hormones are implicated too, right? So testosterone, for example, now we think is very protective when it comes to migraine. Uh progesterone [snorts] is also protective. Right? So so uh more more and more data is coming on this. Uh skipping meals. So when it comes to specific food triggers for migraine, uh based on what we know so far, uh the number one thing really is going to be fasting or skipping meals. Significantly more of a trigger than any of the specific foods combined.

[00:22:41]Uh weather changes are a big one.

[00:22:43]Barometric pressure changes, humidity, temperature, all that has been shown to actually lead to changes in the firing pattern of the trigeminal nucleus in the brain, which is kind of the big player in migraine. And so uh migraine patients usually perceive themselves to be walking barometers. And that's uh pretty accurate because of the fact that you know, any change in barometric pressure is actually going to trigger the trigeminal nerve. So, so that kind of stuff is very legit.

[00:23:08]Alcohol and not all alcohols are the same. So, red wine and champagne are pretty, you know, high up in terms of how triggering they can be. Things like vodka, gin, and tequila are definitely lower on the list. Bright lights are a big one. Caffeine for some people, but caffeine withdrawal tends to be more of an issue than caffeine itself.

[00:23:26]So, what can patients do at home when they're having a migraine attack?

[00:23:29]Usually, being in a kind of less stimulating environment >> To watch the rest of this webinar, explore our growing library of expert-led sessions, and attend live events where you can ask leading health experts your questions directly, click the link below to join Medical School.

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