The Whole-Body Systemic Nature of Migraine

Hinzugefügt: 2026-05-14

[00:00:00]here. So, I just want to welcome you all again and this panel is all about the bigger picture of women's health. Like you saw on the screen, understanding that migraine rarely comes alone. Many of us live with more than one condition whether it's autoimmune, cardiovascular, metabolic, and we often find ourselves coordinating.

[00:00:21]Should never have flip pages when you're on a panel. Coordinating uh multiple specialists just to be heard. Today we'll explore how these systems connect and how women can take charge and have better care across the whole body. So let's start by talking about how does migraine connect to the rest of the body. And I'll um start with you Dr. Nahas.

[00:00:46]Migraine connects to the rest of the body in in almost any way that you can imagine. You know, migraine is more than just a headache, as we all know, and it's more than just a neurological disorder, condition, disease, whatever label you want to put upon it. Now, we think that most of the action comes from the brain itself. And in fact, it may start very very deep in the brain in our most primitive neural structures almost reptilian in nature connecting through the rest of the body largely through the autonomic nervous system which you're going to hear a lot more about shortly and then manifesting with not just head pain of certain characteristics but also sensitivity to things in the environment. This is within the criteria of the definition.

[00:01:35]Nausea and vomiting is a primary gastrointestinal symptom. This is also within the definition. But other things that you won't see listed in the definition, but you'll hear from individuals living with migraine that they experience are things like neck pain. And that has to do with the interconnectedness of the nervous system and the rest of the body. We talk about the trigeminal nerve and the trigeminal system and its connections to the vascule, the the cervical structures, the autonomic nervous system and more as really being where all the action sits.

[00:02:11]So you can imagine if you disturb the trigeminal system which is which starts deep in the brain stem then you can activate it in a way that it misbehaves and when that misbehavior occurs you get amplification of symptoms and other biological phenomena. So in addition to this, besides neck pain, you can get sinus symptoms, sinus congestion, you can get a lot of eye pain, you can get primarily more abdominal symptoms. You can start to imagine why folks living with migraine might be steered in the wrong direction to a specialist in the gut, a specialist for the neck, a specialist for the TMJ, the temporalmandibular joint, eye specialists. A lot of these specialists are the first ones to to really see and pay attention to somebody with migraine.

[00:03:02]But really, all clinicians should should be equipped to care for migraine. And everybody living with disease of migraine should feel empowered to seek a team of specialists who can address all of their critical needs. So to summarize, to answer your question, how does migraine connect with the rest of the body in almost every way a way imaginable? and it's rooted in our biology and even our most primitive biology.

[00:03:28]>> I'm just going to ask you, thanks Dr. Nhas to also um touch a little bit. Can you tell us more also about the um overlap of cardiovascular health and also allergy, asthma, MCCAST, EDS, spinal fluid leaks, just I know that's a lot. Yes. But this is how complicated this is. So I'm going to ask you to just to say a little bit more about that. So to to get a little bit more into the wheats, um you you remember the uh the diagram that was uh on display for much of the beginning of of this morning's session.

[00:03:57]And many of those entities listed are merely diagnoses or conditions that we see fairly commonly in the population of people living with migraine which can have effects on migraine itself or can alter the decisions that we as clinicians might make and how to manage the totality of that human's experience.

[00:04:20]But certain of those conditions are actually considered co-orbidities. And what does that mean? That means that someone with more with migraine is more likely to have certain conditions than somebody without migraine. And the ver reverse can also be true. A key example is depression. Uh depression and anxiety. Uh sleep disorders also fall into that category. Asthma falls into that category. And there are a number of of others. And some of these conditions can also serve as risk factors for migraine getting worse. What we call disease progression. Obesity is one of those conditions for example and anytime those coorbidities are not adequately managed in the context of the totality of the human being. We also consider that to be a risk factor for progression of migraine from something that's controllable to something that is highly burdensome and perhaps even totally disabling. So you want to know about cardiovascular health for for number one. I think that was the first one you mentioned.

[00:05:21]Now, cardiovascular health is particularly important for women of middle age who are who predominate the population of individuals with migraine because this is a time when women may be at most risk for having adverse outcomes from cardiovascular disease because it's not looked for. It's not recognized because it may present in different ways with diff different different symptoms or even minimal symptoms compared with what we are as clinicians trained to think of as somebody at risk for heart disease, right? Uh the older man who's got high blood pressure and was a smoker and he gets chest pain when he walks.

[00:06:00]You know, that doesn't describe the middle-aged woman living with migraine who's at risk for stroke, heart attack, or other vascular events. Migraine itself we consider to be a risk factor and especially migraine with aura in this population of of younger otherwise healthy women. Now if you add to that other coorbidities which can increase vascular risk it makes it all the trickier and when you consider that one of our best weapons to treat migraine attacks is a tripan which can cause vasoc constriction that can be very risky. So some women as they age and they've been relying on a particular acute treatment for their attacks at some point becomes too risky to use. And then what do we do? Well, do we rely on some sort of garden variety uh like an analesic like an anti-inflammatory agent? Well, those can also have risks not just for vascular health but also for gastrointestinal health. So here we have another connection where if you're using something like ibuprofen excessively, that's going to have a negative effect on the gut. So now you feel kind of stuck. It can be it can be humbling. It can it can make someone feel quite lonely and like they're not in control. Um and sometimes as clinicians, we also feel like our hands are tied that we we know we want to help the patient sitting before us, but we more and more options get taken away.

[00:07:26]And this is why research is so critical to developing more treatments that are designed specifically for migraine that are safer and better tolerated. Now, what was the next one you you asked about? Asthma, allergy, MCCAST.

[00:07:39]>> Yeah. And I think actually maybe we should maybe we'll let Dr. Napony chime in on that because I think we should transition over to the >> Sure. Let's go. I don't need to take the entire first half of this panel.

[00:07:50]>> Amazing educator that you are. Um I'm going to transition though to Dr. Dr. Napony because she does specialize in the autonomic nervous system. So Dr. Napony, can you tell the audience what is the ANS? How does it go haywire? What kind of conditions are coming along with the haywired system?

[00:08:09]>> Yes. Hi everyone. I'm happy to be here over Zoom. I can't see you, but I'm assuming you can see me. Um, so let's talk about the autonomic nervous system.

[00:08:18]It's basically a part of the nervous system that is automatic. So it automatically regulates things like our blood blood pressure, our heart rate, our temperature, our digestion.

[00:08:28]Basically all of the background functions that keep us alive without us thinking about them. It operates through two major branches. The sympathetic, which is the fight or flight. I liken it to if you're being chased by a tiger, your sympathetic nervous system is going to activate. And then we have the parasympathetic nervous system, which is sort of that rest, digest. You had a big Thanksgiving dinner and then you're sort of tired and digesting after. That's the parasympathetic nervous system. And in migraine, as we've talked about, we now understand it's not just a pain disorder, but it really is a disorder of the entire brain body regulation. We actually have functional imaging studies that show that the brain regions that control autonomic functions such as the hypothalamus, the brain stem, they activate before the pain phase of migraine even begins. So that's why you might experience symptoms such as yawning and food cravings, dizziness, nausea, or temperature changes even before the headache starts. So recapping the autonomic nervous system in looking at it, it's not just impacted by migraine, but is really part of the migraine engine and the entire migraine experience. So when it becomes unstable or hyper sensitive, the brain then becomes more reactive to normal inputs and then those in turn become migraine triggers. So you asked next, how does the autonomic nervous system go haywire?

[00:09:54]Well, basically it becomes disregulated when it's constantly trying to compensate for all of these external and internal stressors. So we think about hormonal shifts and blood volume changes and stress or sleep disruption and basically it just becomes oversensitized but knowing that it's not damaged it's just more overreactive and unstable and even in some people the um high alert state that sympathetic overactivation can really become stuck. So I have a lot of patients who say they feel overstimulated like their heart is racing they're wired but tired. So feel like they are so tired but can't sleep and there's difficulty tolerating stress, heat, noise. And then you have others where you're really swinging in the opposite direction. So we're looking at more fatigue, lightadedness, brain fog, and we can say that those are absolutes, but they're really not. A lot of people function and fluctuate between the two states. So I look at the parasympathetic and sympathetic as these scales and they go and they counterbalance each other but one can definitely predominate.

[00:11:03]So like I said before when the autonomic system becomes unstable the pre the brain becomes super sensitive to these normal everyday inputs. So, everyday things that we do, things that we do without thinking, like standing up or eating or going out in the heat or being exposed to bright lights, those can then provoke a migraine attack more easily.

[00:11:24]And I think it's key to know that's why migraine often feels so random and so unpredictable. We try to control all of these triggers and we're like, why? Why can't we just get a handle on it? Well, it really is a reflection of the nervous system and how it is trying so hard to regulate the entire internal environment and sometimes it just has a really difficult time doing that.

[00:11:45]>> Yeah, thank you for explaining that. And u maybe you can also touch on the alphabet soup of what I I understand is called the trifecta of MCCAST POTS and EDS. I know that's a big part of your practice. So maybe you can break that down a little for us.

[00:12:02]>> Absolutely. So we know that the coorbidities of EDS or Eer's down low syndrome or even just hypermobility not necessarily the syndrome but just being more hyper mobile is more common in people with migraine as is MCAST mass cell activation syndrome and then autonomic dysfunction which can be POTS it can be orthostatic hypotension or it could just be a general sense of autonomic instability. So I see a lot in young women who, as we have said, are told that they're anxious and that nothing is really wrong. But these disorders go together and they're very difficult because they span different specialties. I will say nobody has taken control of POTS. I try to take control of POTS and and own it, but it really is something that crosses different specialties and really hard to get diagnosis and proper treatment.

[00:12:56]>> Can you talk to both I want to ask both of you this question. um the fragmentation of care that feels so overwhelming. If you're seeing multiple specialists, what are some strategies women can use to help their clinicians connect the dots instead of treating each symptom in isolation? I'll start with you, Dr. Nihas.

[00:13:16]>> Yeah, Dr. Kempner touched on this and I I think this is going to be a recurring theme for today and you know, and in fact, I think it was really a major driving factor in bringing all of this together and having this initiative and this conference.

[00:13:29]Um, it's true when you have multiple diagnoses, multiple different symptoms, often you will need to see multiple specialists and it can feel extraordinarily overwhelming, can also be quite costly in terms of your time as well as your money and getting everybody to be on your team and to collaborate though I I think is the greatest challenge of all. Staying within a single health system helps with that a little bit. I know that I always find it easier when one of my patients is seeing another specialist within my health system or at least that's connected to my electronic medical record. We all like to bash these electronic medical records that have taken our attention to a a computer screen and a keyboard and a bunch of whizzing electrons and directing our attention away from the patient, which is an unfortunate reality that we have to deal with. But it also makes our jobs easier to integrate massive amounts of information all at once. And so we can in in a way be a little bit more efficient. Now that's not always possible. Some of the best specialists don't use EMRs in the way that are that are connected to large university systems. And obviously for those who don't live in a major metropolitan area, it can be even more challenging to find a set of specialists all in one area. So having that be a priority at every single visit with your clinician, no matter who they are, reminding them who your care team consists of, what they are managing, what they have recommended, be that medications or other therapies, lifestyle modification, etc. Making sure that everybody is on the same page because number one, that will help with safety. It'll it'll help prevent the pitfalls of too many cooks in the kitchen spoiling the soup. Right? If you have ingredients that don't go well together, that could be unpleasant. It could actually even be dangerous. What we're looking for though is the opportunity for synergistic collaboration where we can make not just some alphabet soup to to borrow a term, but the finest of all bullyabases.

[00:15:35]And sorry to those who don't like shellfish or seafood, but uh you know me, I'm all about analogies. So, how's that one? I'd like Dr. Nat. I love food.

[00:15:44]Yeah, >> I'd like to hear Dr. Nat Bon's take on this, though.

[00:15:48]>> Yeah, thank you. I I agree with your take. I think as someone who practices not within right now, I did practice in an academic institution, but is now in a private practice setting. We can't see everything. So, we can see what you bring us. Um, I can see what connects maybe to care quality or some of the the larger systems, but the most valuable thing for me is really bringing a timeline, a very big overview of when things started, how they've progressed, and what treatments have been put in at what time. So bringing a list of medications that you're currently on, what you've been on in the past, how they were tolerated, and what dose, and what has worked, even if it wasn't tolerated or stopped working is really helpful for me. And I think having a list of the clinicians that you're seeing, what they're each responsible for, and who is prescribing what is helpful. I know we all want to be able to talk to each other and be able to I loved that word, Dr. in a house synergistically coordinate um care, but it's sometimes more complex than than anybody realizes. But as a patient, really taking control of you have basically a printed out resource of your history, the names of the other doctors, the medications that you're taking, your diagnostic tests, and being able to hand those over to your doctor at each visit does help streamline the process.

[00:17:13]>> Yeah. And maybe could you just make a mention, Dr. Napony about why it's important to come with the history of medications and about step care therapy, step edits and explain to the audience what that is and how to make sure that they can get on those therapies much more quickly.

[00:17:31]>> Yeah, I'll point out two two points here. So, a lot of our newer medications require that you quote try and fail or that the medication fails you. I won't get into that, but that you've tried other medications in order to get other ones approved. So, having a list of that that the clinician can then document and then be able to get approval for the medications is really important. So, a lot of times we're spent sort of digging, have you tried this, have you tried that? Putting a list together of what you have tried, whether or not they worked can be really helpful for us to get prior authorization. The other thing I want to mention is having a list of what you tried and the doses that you've tried is helpful because sometimes something didn't work because the dose wasn't optimized and sometimes something there's a side effect but maybe there's another medication in the similar class that we can try that might be better tolerated. So there's a lot of nuances within the medication prescribing it really is not a one-sizefits-all. So being able to have that history is really helpful when going to your provider.

[00:18:35]>> Great. Thank you. Let's um transition a little bit over Dr. Nhas to what are some lifestyle changes that patients can start making right now that you recommend to your patients?

[00:18:46]>> I recommend lifestyle approaches to all of my patients because number one that requires no prescription that doesn't require necessarily a a trip to the drugstore or to anywhere really. Plus, it can empower the individual to start to take some of the control back. We call that shifting the locus of control and you will hear a lot more about this later. But a lot of it is common sense and many of you are are probably already doing these things already, which is great. Now, how can you build upon them?

[00:19:20]Right? So, one way to to think of migraine is almost like a diva. Uh the brain is a diva. That was one of the first things I was taught in medical school by my biochemistry professor. The brain is a diva because it relies on nutrients that are unique. It it doesn't accept just any kind of nutrient, right?

[00:19:39]It must have glucose, pure sugar, right?

[00:19:42]That sugar rush to the brain. And the brain is largely responsible for generating the symptoms of migraine and connecting to the rest of the body leading to all that symptomatology.

[00:19:51]Right? So we have to treat the brain like the div.a It is like Goldilocks. If you don't like the word diva, Goldilocks is another way I like to describe. It can't be too much of this. It can't be too much of that. It can't be too little of another thing. It's got to be just right and it's got to be consistent and stable, whatever that means for you. So, not everybody needs eight hours of sleep per night. Some are okay with six as long as it stays constant. Some people need nine or 10. You find what's right for you, what's right for your brain, and you try to stick to it. It can be challenging knowing that sleep disturbances are common with migraine, right? But there are ways around it, and largely they're behavioral. They're not taking drugs. They're not putting band-aids on the problem to knock you out at night and then wake you up in the morning. Having a biobehavioral routine from the start of your day until the end trains and primes your div.a a brain, your Goldilocks brain to stay in this rhythm and it gets easier over time.

[00:20:55]Other things that help to support brain and body health are nutrition and hydration.

[00:21:01]Many of you, how many of you have rolled your eyes when your clinicians have been grilling you about how much do you sleep at night, how much caffeine do you drink, how much water do you drink? All of you, right? Don't be afraid to raise your hands. It makes you really annoyed, right? We try to ask about this and counsel this in non-judgmental ways. It can sound very judgy when you're on the receiving end. If you feel that way, let your clinician know. We're not necessarily trying to We're not I will take that necessarily word out. We're necessarily not trying to berate you or belittle you. We're really trying to assess what kind of millu your brain is having to live in daytoday and what you can do to calm those waters and to and to take it from a storm to you know whatever kind of weather you like. I was going to say bright sunny day. Some of you hate that, right? So there they are really simple things. exercise. No matter how you get your physical activity or movement, it doesn't have to mean going to the gym five days a week for an hour and a half and really pumping iron and breaking out a, you know, a deep sweat. Just getting up and moving for a half an hour a day is a great place to start. So, it takes time. You we don't expect and you shouldn't expect to fix everything instantly. It takes weeks, months, sometimes even years, but it's achievable. And instituting these lifestyle changes can help you get off of medications, which can medications we all know, can drag you down and make these lifestyle changes more difficult, but stick with it and make sure you've got a good coach and a good partner in your clinical care team to help you be successful.

[00:22:48]>> Great. Thank you. And Dr. Sure. Napony, what about um any lifestyle changes you or recommendations you have regarding the ANS and especially around POTS or you know what we talked about uh Eller's Danlo syndrome, hypermobility, etc. >> I'm glad that you asked that. I also want to point out that autonomic dysfunction is also more common in people with chronic migraine. And with chronic migraine, these lifestyle changes I find are a lot more challenging to do cuz we're always feeling kind of not great. Um, but with the autonomic nervous system or and I I sort of look at it through that lens. So the lens of is there more parasympathetic overactivation or is there more sympathetic overactivation and then how to adjust the lifestyle in order to sort of fix those imbalances.

[00:23:39]So the first thing is I look at okay if somebody is very weak deconditioned is hydration or electrolytes salt trying to get that blood volume up going to be helpful to improve blood flow to the brain. So salt is not good for everyone but in someone who does have more blood pooling autonomic dysfunction I find that that can be very helpful with energy and getting someone to be able to get up and move around.

[00:24:05]The second thing is actually working on feedback to your autonomic nervous system. So paying attention to your posture, your breathing. If you have trouble going from laying down to standing up, definitely avoiding these sudden movements and these sudden changes, avoiding standing for long periods of time, holding your breath for long periods of time, and trying to practice nasal brea breathing or there are different breathing techniques that we can build in there to help feedback on the autonomic nervous system. And in terms of exercise, I feel like exercise is something that is that double-edged sword, but that is so important for both the autonomic nervous system and for migraine. But it really is building strength gradually, not jumping into this highintensity cardiovascular routine that's just going to wipe you out the next day. It really is a few minutes one day building up gradually and gradually to improve vascular tone and autonomic stability over time.

[00:25:02]Again, is it is time. And I sometimes say that like time is our best friend but also our greatest enemy because things take time to get better and to build up. We know that lifestyle at least I believe it is the foundational piece that sort of builds the core of everything else that is put on top of it. So if we can get that lifestyle to be regulated constant consistent and to support the body everything that we do on top of it will just be more beneficial and then like Dr. Dr. Neha said we're able to remove perhaps some of the medications or treatments and still be okay because that foundational piece is there.

[00:25:40]>> Thank you. Let's um transition now.

[00:25:42]Let's talk about the gut brain connection. I'm going to ask both of you. So I'll um the alphabet soup is IBS and GIRD which is irable bowel syndrome, gastrointestinal reflux disease, gastroparasis.

[00:25:56]What are the potential avenues to have these evaluated and treated? Dr. Neiha, start with you.

[00:26:02]>> Yes. Where to begin? I I guess we'll we'll start from the top and sort of work our way our way down. So, I mentioned earlier that anti-inflammatory drugs like aspirin and ibuprofen are commonly used to treat migraine attacks, even though they're not specific for migraine treatment, but they can be irritating to the stomach. they can reduce our body's natural ability to have that protective lining, the mucous lining of the stomach that protects from the acid that's necessary to digest our food. And if you take away some of that lining, which is an unfortunate side effect of anti-inflammatory agents, that can increase acid buildup leading to reflux. That's where the acid kind of comes up into the esophagus, causes heartburn. That's the, you know, colloquial common term for it. And moreover, that damage might not be perceived because what do anti-inflammatory medications also do?

[00:27:00]They dampen pain. So now you can get into an unknowing vicious cycle of utilizing anti-inflammatory agents to manage pain. They're causing damage to the stomach and to the esophagus, but you can't feel it because you've got anti-inflammatory agents in your system masking the pain. Then if we go a little bit uh right into the stomach itself during migraine attacks for many individuals the stomach shuts down. We call that gastroparasis and this may be a reason why nausea can be so amplified during attacks. Uh even in the absence of gastroparasis there's often nausea but gastroparasis makes it worse. Furthermore with gastroparasis in play no matter what you take by mouth it's just going to sit in the stomach.

[00:27:45]It's not going anywhere. Generally speaking, our nutrients and medications don't get absorbed in the stomach. Many people think they do, but by and large, most of it does not happen there with a few exceptions. In fact, some drugs are designed to be absorbed in the stomach.

[00:28:00]Most of it happens in the first part of the intestines. You've got the douadinum or dadum, however you want to pronounce it, is the first short segment of the small intestine. Uh, and then the proximal ilium. That's that means the next part of the intestine that's closest to the douadum, closest to the stomach. That's where most of medications get absorbed. So if the stomach is not letting the medication out, it's not going to get absorbed. It just kind of sits there and you have to wait until the attack is over and the stomach wakes up again. Now the medication comes through, but it's too late and all you may feel is the side effects of that medication. So I've done that that first third of the gut. Let me turn the rest of the gut over to Dr. or not.

[00:28:44]>> Okay. So, I'm thinking now the rest of the gut. Um, also I'm going to look more from the sort of the IBS angle and that brain gut connection of constipation.

[00:28:54]So, even I feel like everyone is constipated and how much that affects us when we're constipated and we're sort of feeding back on on our brain. It just doesn't work as well. We do know like the gastroparesis the gut slows both during attacks but even as part of the autonomic nervous system the gut can slow down even between attacks. So looking at someone who has IBS treating the IBS the constipation part of it and a good bowel regimen will go a really long way can actually help the overall migraine symptoms by helping with digestion and helping with the passage of nutrients throughout the gut. So, I really recommend that everyone who does struggle with constipation to talk to your doctor about going on an appropriate bowel regimen to re-eregulate things.

[00:29:40]Um, trying to think about the rest of the gut. Um, I think we talk also about the concept of leaky gut and that's become more of a question over time and the focus a lot on this overall comprehensive health and I think that we're still trying to figure out what exactly that means and how to treat that in migraine. And we know a lot about the gut microbiome. And like Dr. Nay has said about NSAIDs can also destroy or interfere with um the processes of that gut microbiome. And we know that certain exposures to other medications to antibiotics can have an influence on gut symptoms and migraine alike and the whole body. So I think to answer the question of what we do about the gut, it is a very complicated question and I think that it does require these interactions between neurology, between gastroenterenterology.

[00:30:31]Um but h it's definitely a challenge in terms of how it should be treated. We need to treat it in terms of thinking about migraine and thinking about how the gut interacts with migraine and the medications also that we use and how they interact with the gut are important.

[00:30:48]>> Yeah. And actually we're hoping in the future uh Dr. Napony is going to join us again with uh Dr. Zack Spirittos which hopefully we'll be announcing in the near future um to talk more in depth about the gutbrain connection and what this all means and how complicated it is. And uh I just want to uh ask you both now also do you have anything maybe we didn't cover yet this morning in our questions? Any last comments you want to say before we close? I know you could talk forever, but >> we could talk forever and we don't want to steal the thunder at any of our of our future panelists. So, I will I will just, you know, double down and reiterate what Dr. Napony said about the leaky gut. How many of you have heard of this concept before? The I'm glad that the that the word is spreading. There's intense interest in this from a number of different angles. And basically what this means is that uh one way that this can happen is the the microbiome becomes disturbed. those bacteria actually start to destroy the barrier of the gut that protects our body from certain toxins that we want to keep inside the gut and then flush out. So you may be wondering what's up with my brain fog. It might not be your brain. It might be your leaky gut and those toxins affecting your brain. So you are what you eat.

[00:32:07]This is really important in the mic in the microbiome. You need to enrich your diet with good foods that are good for the good bacteria. Those are called prebiotics. You can take them as a supplement. And then foods that are rich in good probiotics or even a supplement of probiotics. I even heard postbiotics brought brought up by somebody. I don't know what that is yet. I've got to look it up.

[00:32:27]>> I'm going to have interbiotics, uh, extrabiotics, apply whatever Latin prefix you want to it, but um, yeah, that's all I'll say about that because I think we're running out of time.

[00:32:37]>> Well, we have a couple more minutes. Dr. Nathan, you want to add anything else before we >> want to thank Dr. Nah, for for delving into that a little bit more. I just want to clarify one point about autonomic dysfunction and then what is a diagnosible autonomic disorder because having autonomic dysfunction does not mean that somebody has an autonomic disorder such as POTS or orthostatic hypotension. Many many people with chronic migraine have this autonomic instability where you'll have symptoms between attacks that may look like POTS or orthostatic hypertension. The dizziness, the heart racing, the exercise intolerance, brain fog, all very very common. But there are specific diagnostic criteria for POTS and orthostatic hypotension. And you can have dysotonomia or dautonomic symptoms without having the full-fledged syndrome. And I think that's just important because we can feel invalidated when we have these symptoms and everyone around us is telling us, but you don't actually have an autonomic disease. True, but migraine does impact the autonomic nervous system. So, you can still have all of these symptoms and they are real. They are happening and I want to make sure that we validate that.

[00:33:48]>> Thank you. Well, this has been very informative. Thanks to both of you and uh we are actually now going to take a 20 minute break. So, please come back at 45 before the hour and we'll see you.

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