Ep 220: Understanding Pediatric Migraines with Dr. Amy Gelfand

In this episode, Dr. Amy Gelfand, a child neurologist specializing in pediatric headaches, discusses the complexities and treatment of migraines in children. Gelfand explains the genetic nature of migraines and their commonality among kids, noting triggers like menstrual cycles and changes in sleep patterns. She elaborates on distinguishing features of migraines and provides insight into preventive and acute treatments, including NSAIDs, triptans, neuromodulation devices, and supplements. The discussion also covers the importance of a regular schedule, the benefits of cognitive behavioral therapy (CBT), and recent advancements in migraine-specific medications. Dr. Gelfand emphasizes the significant progress in migraine treatment and encourages families to consult specialists for personalized care.

About Dr Gelfand:

Dr. Amy Gelfand is a pediatric neurologist who specializes in diagnosing and treating children with a variety of headache disorders, as well as those with childhood periodic syndromes (such as abdominal migraine), which may be precursors to migraine headache later in life. Her research focuses on the epidemiology of pediatric migraine and childhood periodic syndromes.

Gelfand received her medical degree from Harvard Medical School. She completed residencies in pediatrics and child neurology at UCSF.

Gelfand has received a teaching award from the UCSF pediatric residency program and writing awards from the medical journal Neurology. She is a member of the American Academy of Neurology, Child Neurology Society and American Headache Society.

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Transcript

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Welcome back to your child is normal. I'm your host. Dr Jessica Hochman, so if your child gets migraines, you are definitely not alone. Migraines affect about 5% of younger children, and by adolescents, that number climbs up to nearly one in 10 or more. And Migraines aren't just headaches. They can be intensely painful and truly disabling for kids, but the good news is we have more ways than ever to help. So today, I'm joined by Dr Amy Gelfand, one of the leading experts in pediatric migraine. She's a pediatric neurologist and the director of pediatric headache at UC San Francisco, where she specializes in caring for children with migraine and leads research in this area. In our conversation, you'll hear about what migraines really are, why they often run in families, common triggers like sleep changes and hormones, and most importantly, how we treat them. We cover what really helps in the moment, what can prevent migraines over time, and exciting new migraine specific medications that are now approved for kids and teens. And if you listen and find this episode helpful, please take a moment to leave a five star review or share it with another parent. Thank you so much for being here and taking the time to listen to this episode. Now on to my conversation with Dr Amy gelfin. Dr Amy gelfan, thank you so much for coming on the podcast. I've been really looking forward to talking to you. Thank you for having me. So what do you do for work? What is your specialty? I'm a child neurologist, and I specialize in pediatric headache. So I take care of kids who have all different kinds of headache disorders, but most commonly, kids who have migraine, post concussive headaches, other kinds of headache disorders too, and I'm so fortunate to have you back on Dr galphin came on the podcast a few years ago, and I was looking forward to talking to talking to you again, because since we've talked there have been updates with headaches, and also because I find that they are so common and so prevalent. Yeah, they really are very common, unfortunately, out of curiosity, off the top of your head, do you have any statistics on how common they are? So migraine by age 10, 5% of kids have migraine, and then it goes up from there. So I think about that is basically, by fourth grade, there's probably at least one kid with migraine in every classroom in America, and in middle school and high school, it's going to be more than that. So it's, I think, the most common neurologic type problem that kids have, and what does the latest tell us about why they happen? Do we know why kids get migraines? Fundamentally, migraine is genetic, so you inherit some predisposition, some sensitivity. People who have migraine, their brains are wired up to be more sensitive to stimuli, whether that's stimuli that are coming from outside the body, like lights and sound or stimuli that are coming from inside the body, such as your perception of your own movement. But of course, some family members are affected a lot more than others, and sometimes a family member might not realize that the headaches that they experience are, in fact, migraine headaches. It's not entirely unusual to diagnose a parent with migraine in our clinic, too. If someone says, Oh yeah, I just get headaches with my period, and I have to lay down and turn out all the light. And turns out that that parent also has migraine, but it's not necessarily always recognized. And then there's different times of life when migraine gets more active, and it tends to be times when things are changing. Mid childhood and adolescence is a really common time for migraine to start acting up, because there's a lot of change that's going on with preparations for puberty. Puberty itself adolescent development. So there's quite a bit that is changing for kids in that age range, and when kids have headaches, I feel like the term migraine gets thrown around a lot, but sometimes it's not actually a migraine. What are some of the key distinguishing features when you hear from a kid that you think, Oh, this is likely a migraine. Yeah, that's a really good question. So migraine is so much more than a headache disorder, I think of it as really a disorder of how the brain processes stimuli, so stimuli become amplified or distorted. Lights are perceived as brighter than they really are. Sounds are perceived as louder than they really are. Smells are stronger. Regular movements of the body are troublesome and uncomfortable. There's nausea. Oftentimes people will have vertigo, which is an illusory sensation of movement, like you're on a boat, or like a room is spinning. Oftentimes, people will say, I feel dizzy. And when you dig into that a little more, what they mean is it feels like something is moving. It's really common that people have some kind of visual disturbance as well with migraine, not everybody, but it might be aura, where they get like a little blurry spot that grows over the course of minutes, or a jaggedy shimmery line that moves over the course of minutes. But even if they don't have aura, a lot of times, young people with migraine will say. Just go blurry everywhere, or get a little bit fuzzy on the edges. So a lot of sort of visual sensitivities that is really interesting. I'm thinking last night, my daughter told me, before she went to sleep, she's feeling dizzy. So maybe I need to probe into this a little more, and then out of curiosity, because when I hear about a kid having a migraine, I picture them being in bed for a really long time. Is there any data on how long a typical migraine lasts? So most commonly, it's going to be somewhere in the range of two to 72 hours that's untreated or unsuccessfully treated. So ideally, the kid has a diagnosis and has a good acute treatment that they can take right away and shut it off and not lose their time like that, but if it's untreated or unsuccessfully treated, somewhere in the range of two to 72 hours would be the most common. That is really interesting. So I'm thinking those moms that you see in your clinic that had undiagnosed headaches, they could have been treated and felt better sooner had they been appropriately diagnosed. Yeah, and have less disability, fewer days where you don't get to do what you want to do, less miss school, all those kinds of things. And I'm also curious, is there a typical trajectory for migraines? Do they tend to get better over time? I know you said there's different times of life where there's changes, where you see it happen more frequently, but as someone goes into adulthood, does it tend to get better? Does it tend to stay the same? What should one expect? Yeah, I think sometimes it can at first get a little rockier, especially, say, when girls are first getting their periods and things are still really irregular. It's not unusual for migraine to be a little more active during that time. But then as they get into late teenage years, early 20s, a lot of times it does quiet down, you know, I think about our lives compared to the lives of a 12, 1314, year old. You know, my schedule is much more consistent and predictable than a kid going to school where they have different after school activities depending on the season. They have summer vacation. They have changes in their body, they have changes in their cognitive skills, their social environment. So things are changing so much for them, and then by the time you get to be in your early 20s, a lot of that has settled down, and it's more predictable and it's more consistent, and I think there's just less change coming their way. So I often say time is on your side, that you know it often will quiet down, which isn't to say that it'll go to zero and be gone or cured, but the problem nature of it often quiets down. I love a message of optimism, and I'm also thinking that you must be really busy if migraines are very common and they happen to be pretty intense in childhood. Yes, we have pediatric headache neurologists on our team at UCSF, plus two nurse practitioners and nurses. And I think we could run a clinic 24/7, and probably still have kids, unfortunately, who need to be seen. Wow, that's incredible. The need that there is. It's incredible, and it's too bad. And then I'm curious. You explained how migraines tend to be mostly genetic, but there's also triggers that we talk about. There's things that tend to provoke migraines. You mentioned that predictability is a really good thing for migraine prevention. What are the most common triggers that you notice that provoke migraines? Periods, menstrual periods is probably the most common. About 50% of adolescent girls and women who have migraine will get an attack with their menstrual period. And oftentimes the menstrually associated attacks are worse, they're longer, they're more severe, they're not as responsive to treatment. So that's probably the most common trigger. Some people will also notice jet lag if they go on a trip and their circadian rhythm gets really messed up, that sometimes will set off an attack or changes in their sleep schedule. There's some interesting data that Monday is the most migrant day of the week, and I think a lot of that is you go from Sunday, maybe you stay up late because you slept in, and then you get back onto a weekday schedule and Monday morning, and things get a little bit out of kilter. So change in circadian rhythm can also be an activator. I'm thinking that song manic Monday, we could do a new rendition on migraine Monday, new lyrics, yeah, we can do that. So now let's say somebody comes to see you they diagnose their child with migraines. What's the first recommendations you give to a family to help their child with their migraines? So I always talk about that there's two sides of treatment. There's the preventive side, which means everything we do to try to decrease the frequency of the attacks, and then there's the acute side of treatment, or the as needed, which is what you do when you get an attack. There's certain things that we can think about, trying to keep to as regular of a sleep schedule as you can, trying to have good hydration, regular meals, regular exercise. But even when people are doing all those things, sometimes they're. Migraine frequency is still too high, and then we think about what kind of pharmacologic treatments or other non pharmacologic treatments, could we offer? And a lot of these are pill based therapies, but not necessarily prescription. Though, there are a number of prescription medications that can be helpful, but certain supplements sometimes can also help with decreasing migraine frequency. I'm thinking about riboflavin, which is vitamin b2 or magnesium, which is an element. Taking a supplement of those things regularly can sometimes help decrease migraine frequency. There's also some things called neuromodulation devices. So this is not pharmacologic therapy. This is something that a kid can put somewhere on their body. Some of them are on the arm. Some of them go on the head, and they stimulate nerves to sort of change how the brain is functioning and help quiet down migraine frequency. So some people are drawn to those options, there's also something called Cognitive Behavioral Therapy, or CBT, that has been studied for helping to bring down migraine frequency in young people. And so that is also an option, and it's usually not long term therapy. It's usually six to eight sessions coaching on techniques around relaxation and how to pace your activities. You know, it's one thing for me to say, have a regular sleep schedule. It's an entirely different thing for a kid in a family to actually operationalize. How are we going to have a regular sleep schedule? And I think that working with a therapist for cognitive behavioral therapy for a headache can help with how you're actually going to do those things in real life, because it's a lot more complicated than it sounds when I say, hey, go do this. And the neuromodulators. Out of curiosity, is that through a pediatric neurologist and is that stimulating the vagus nerve? It depends there. So there are five of them now. One of them is an external vagal nerve stimulator. There is one that goes on the arm and is a remote electrical nerve stimulation device. So it's stimulating peripheral nerves. There's one that goes up on the forehead, there's one that gives a magnetic pulse, and there's one that stimulates in the front and the back at the same time, four of them are by prescription. One of them is actually available over the counter, and so you you could get it without a prescription. I would think child neurologist would mostly be the ones to prescribe them, but they have, generally speaking, good safety records, so I don't think it would be unreasonable if a general pediatrician wanted to prescribe those. I've never actually recommended that to a family, so that's really helpful to know about. I should say that they do tend to have out of pocket costs with them, because oftentimes insurance won't cover the neuromodulation devices. The standard of evidence to get FDA cleared for a device is lower than the standard of evidence for medication to get FDA approved. And so there's a little difference there and how likely a insurance company is to pay for it, but they exist. Okay, all right, so that's good on the on the prevention side, and I also, I love that you pointed out the supplements that are beneficial, because I know there's a lot of supplements that people try to take to see if they'll help with migraines, but the best evidence you're saying is with the riboflavin and with magnesium, I think so. Other ones that we use in our program are Coenzyme Q 10 and melatonin. So there's a handful that can be helpful. And then on the acute side, or the as needed side, there are very simple common things like over the counter medications such as acetaminophen and ibuprofen. But if those things aren't enough, then there's migraine specific medications. The older class of those is called the triptans. There's seven different triptans. They come in lots of different ways. Some of them are pills, some of them are sprays that go in the nose. Some of them are shots. There's a lot of different ways to give a triptan. And then some of those neuromodulation devices can also be used for as needed treatment. And then there is a newer class of treatment called the G pants that act on something called CGRP, calcitonin gene related peptide. It's a little protein that's involved in migraine, and they can help either in the moment as acute treatment. Sometimes they can also be used as a preventive treatment, but that's a newer class that's just come out in the last few years, and that's so exciting that there's a new medication that we can offer people that are suffering from migraines. I absolutely agree. I think it really is a big development, and I should mention back on the preventive side, there are some of these CGRP pathway treatments that are once a month injections that someone can do at home to decrease their migraine frequency. And how does the data look on the cgrps? Does it look like it's making a big difference? Nothing works for everybody. But I think these are really a great new tool, new class of tools to have. And. Just earlier this month, actually, big trial was published in the New England Journal of Medicine, a very big journal, showing that one of these monoclonal antibodies, one of these injectables that you can do at home called feminismab, that it works for migraine prevention in six to 17 year olds. So the medication you can use as young as six year olds. Yes, it is FDA approved down to age six, and that approval came out in August of 2025 but it took a little longer for the paper to ultimately be published. So it was just published a couple of weeks ago. But yes, it's actually the only migraine preventive label down to age six, feminism, AB, yes, wow. Okay, hot off the press. You heard it here on your child is normal. That's right, it is hot off the press. Yeah, that's really exciting. I'm really happy to hear that, because I feel like people that suffer from migraines, it is such a bummer. It is so it is so hard on the families. It's so hard on the child. I'm so glad that our tool belt has expanded. Me too. We need every tool we can get our hands on, honestly, given how common migraine is and how much missed school and missed activities and how much burden it can create by this time, by 2026 we should really have like 20 plus migraine specific preventives. It's wild to me that we only have one class of migraine specific preventive everything else has been borrowed for something else in medicine. We borrow medications from treating high blood pressure, we borrow medications from treating anxiety and depression, we borrow medications from treating epilepsy, but now we do have a class of medications that's migraine specific for prevention. Like I said, Nothing works for everybody, and we should really have 20 classes at this point. So there's still a lot of work to be done. There's still a lot of work to be done, but that's exciting. And then, out of curiosity, because it's a monoclonal antibody, do the injectables have to be given once a month, or is it something that you take when you're having a migraine? The injectables are once a month. They have what's called a long half life, meaning how long it takes to break down half of them. That's why they can be given once a month, and you don't have to do it every day, and people can do them at home. There is one that can be given in an infusion center, but the other three you could do at home. Amazing. And so these are strictly approved for migraines. Yes, one of them is approved for another headache disorder called cluster headache, but, but only one of them. And then I know we haven't touched upon this, but there's a different category of migraines, abdominal migraines. And I know we treat abdominal migraines similarly to migraines. Are these monoclonal antibodies approved as well for abdominal migraines? So that's a really good question. There's so few actual trials done for abdominal migraine. And so to the best of my knowledge, they have not been formally studied for abdominal migraine pediatrics. A lot of times we use things off label. They may not have an official FDA approval for a particular use, but sometimes doctors will use them because we need a treatment a patient has a problem. If somebody is an otherwise appropriate candidate, I think it would be reasonable to treat abdominal migraine with these medications as well. That's great, very exciting. Yeah, it's progress. Okay. Now, you've talked to me before about migraines, and I've gotten some great tips from you. And so what I wanted to ask you about when it comes to treating migraines acutely, when symptoms present, you told me that one trick is to take your NSA at the very same time as your triptan. I just thought that was a really nice pearl. So let me know if there's anything to elaborate on there. Yes. So we know this mostly from data that come from adults. But specifically, this was done with one of the tryptans called sumatriptan and an NSAID medicine, non steroidal, anti inflammatory drug called naproxen. If people took both medicines together, they were more likely to be headache free at the two hour mark and less likely to have that headache come back in the following 24 hours than if they took either medication alone, so than if they took the sumo trippin alone, or they took the Naproxen alone. And I tend to extrapolate that to kids, first of all, and then also to triptans generally and NSAIDs generally. And the combination of sumatriptin with naproxen has been studied in 12 to 17 year olds, and is FDA approved for acute treatment in 12 to 17 year old. Oh, and then my personal question is, when you dose NSAIDs or acetaminophen, do you have a recommendation on how much to give? Yes, so for acetaminophen, it's 15 milligrams per kilo, for kids under 40 kilos, and then usually for an adult sized adolescent, I'd be thinking about 1000 milligrams for ibuprofen, 10 milligrams per kilogram for an adult sized adolescent, I'd be thinking about 600 which is three of the over the counter. Or you could do one prescription ibuprofen tablet, which is 600 milligrams, but that is sometimes a little bit more than is written on the box or the bottle. Talk to your doctor. Of course, but those would be pretty standard doses. Okay, great. All right. So just to summarize, there's the preventive arm of migraines. But if somebody presents with a migraine, the first thing you would give them would be either aceta, acetaminophen or Tylenol or an NSAID or a combination of an NSAID plus a triptan, if they're prescribed a triptan, yes, usually if they're coming to talk to us in our child neurology clinic, they've already tried some of the over the counter things, and so usually we're moving on to a trip 10 at that point. And I think it's very you know, whenever I get the opportunity to talk with pediatricians, I'm always encouraging prescribing sumo triptan or whatever makes the most sense for the kid in the primary care environment, because I think it's a really helpful treatment, and can get a lot of kids moving in the right direction. And I'm curious, out of all the formulations of the trip dance, do you have a favorite? Well, it's a tricky question, because it sometimes comes back to insurance, and sumatriptan is the oldest. It's usually generic. It's usually covered. So I don't necessarily have a favorite, but I often start with sumatriptan, just because it's a good starting point, and then you can figure out what to do going from there. However, sometimes kids are either too young to swallow a pill, so they might use a nasal spray form of sumatriptan, or there is another tryptan called rhizotriptan that has a dissolving melt so they don't have to be able to swallow a pill. And rhizotriptin is actually labeled all the way down to age six. Sometimes kids have a lot of nausea vomiting as part of their attack, and they can't hold down a pill. And so in that situation, again, we might think about a nose spray or even a shot for delivering a triptan, though, most kids usually would rather try the nose spray first. My son uses the nasal spray from time to time, and he complains of the taste. Yes, it tastes terrible. So I try to remind them to do a little lean forward and just breathe normally, because if you do a big sniff, then a lot of it goes down your esophagus and it does taste awful, so ideally, you just breathe normally, and the medicine stays in the nose and gets absorbed in the tiny little blood vessels that line our nose. That's a really great tip. Thank you. Yeah, and then is time of the essence. How long does somebody have to take these medications for them to be the maximum benefit for a child? Sooner the better. It's if you can treat while the pain is still mild, that's better than waiting until it's gotten to be severe. You don't always get that chance. Sometimes a kid will wake up with a migraine attack already well underway, it's already severe, and they just didn't get that chance, and they should still treat. But ideally, if you can treat as early as possible, ideally, while the pain is still mild, some people even get symptoms before the headache part. It's called The premonitory phase, where it's not quite the headache part yet, but they might be starting to get the light sensitivity or the sound sensitivity, or their neck feels stiff or sore, or they feel really tired, and they might experience those premonitory symptoms for even hours or a day before the headache phase. If someone can identify those treat even, even before the headache phase, because if you can treat during the premonitory phase, you might head the headache off entirely, so before the pain gets out of the bag, before it's become a problem, take it and stop in its tracks Exactly. Now, are there any other supplements, or any other treatments for migraines that you recommend, aside from what we've talked about, and the things I'm thinking about are like, what I hear my practice, for example, acupuncture comes up a lot. Going to a chiropractor comes up a lot. And then I hear a lot of people talk about supplements from Asia, for example. Do any of those make a difference in your experience. You know, there are some products, some proprietary products, that combine some of the things we were talking about earlier. So they might combine Coenzyme Q 10 and magnesium, or combine riboflavin and magnesium, or something like that. And I think that that's okay to do. Oftentimes, I find that kids get better from just one of them. So I don't know that you have to take the combined product. And there is some evidence for another kind of supplement called fever few. So some of those combined products will have fever few in them. There's also another herbal product called pedicites or butter bur that one sometimes makes me a little bit nervous, because there can be a toxic alkaloid, a toxin in there that can be damaging to the liver if it's not reliably removed. So that one I personally don't usually recommend, and it's hard to know about things that are either mixed products or not labeled, or have something in there that I don't necessarily know what it is, so I tend to get a little hesitant with those like to know what's in the bottle. It makes sense. You want to know what you're prescribing to your families? Yeah, exactly. Thank you so much for for all of this. This is so helpful. I guess a few other questions that come to mind are, are there any surprising features of migraines? I'm thinking, Are there any. Pictures of migraines and kids that are different than adults, or any any other symptoms that you want people to be aware of that are atypical. I would say one thing that certainly happens in migraine, but is more rare, is getting weakness with it, weakness on one side of the body. We call that a special kind of migraine, hemiplegic migraine, which means half the body going weak, and especially the first time that happens, that's a good reason to go to an emergency department. If somebody gets suddenly weak on one side of their body, you go to the emergency department and get checked out, because we want to make sure that there's not something else going on. It's very rare for a child to have a stroke, but it is not impossible. So the first time that something like that happens, it would certainly get my attention, and I'd have somebody go and get checked out right away. But once it's happened a few times, and they've had appropriate testing, and we know, okay, you have this unusual kind of aura and this unusual kind of migraine called hemiplegic migraine, then we can manage it in terms of looking different from what migraine looks like in adults. Sometimes migraine attacks are a bit shorter in kids. So in adults, it's usually four to 72 hours untreated or unsuccessfully treated. In kids, it's two to 72 hours. Sometimes kids, younger kids, might have trouble saying that they they're bothered by lights and sound, and so we might have to figure it out from watching their behavior. Maybe they're pulling the blankets up over their head, or they're asking for people to leave the room, and you can infer that they're having light sensitivity or sound sensitivity. And migraine headache tends to be bilateral both sides in kids all the way through late teens, really, so they don't have to have that one side of the head pain a parent or an older adult might say I get a unilateral, one sided headache when I get migraine, but for kids, it's very often both sides. That's something I didn't realize, because I always learned that a migraine is more likely to be unilateral, and I always think of tension headaches as crossing both sides of the body, so I really appreciate learning that so that I don't mistake the diagnosis for being a tension headache when it's truly a migraine. So I appreciate that. Yep, that is one thing that tends to be a little different for kids. I really appreciate all of these tips and all of your knowledge shared with my listeners. I was wondering, could we go through just some quick lightning round questions just to get your thoughts, if that's okay? Do I give like a one word answer or whatever you want. Okay, cool, okay. Are there any migraine myths that you want to dispel? Yes, but now I have to pick which one. Okay, I would say that to a certain extent, triggers are a little bit of they're not a myth because they're a real ones. We were talking we talked about them earlier in our conversation, menses and jet lag and things like this. But sometimes I think they're overwrought, because, in part, because of that premonitory phase thing we were talking about. Some people in their premonitory phase will get food cravings, and then they'll go and eat chocolate, and then the headache comes afterwards, and they think, oh, chocolate caused my headache. But really, migraine was already underway. The premonitory phase really caused the chocolate eating. And chocolate has actually been studied. It is not more likely to trigger a migraine attack than the control substance, so there's no particular reason that people with migraine need to avoid chocolate. So that in itself, I think, is a myth. And then another one would be this is, again, not a myth, but there's a lot of concern about something called medication overuse headache. You might also hear that called rebound headache, where people will worry that if you use certain acute medicines too often, it might drive up the headache frequency. That certainly can happen with certain medicines, but it doesn't happen to everybody, and it's there's some medicines where it's very unlikely to happen. For example, naproxen, it's very unlikely to happen. So I think that we sometimes restrict people from being able to use their as needed medicines unnecessarily, and we make it more anxiety provoking because they think, Oh, I can only use this twice a week, and what if I get a worse headache later? And so then they wait to treat, and now their pain is severe and their treatment won't work as well. And so it's just we set people up into a kind of a catch 22 crazy loop. I love learning that, because that's what I learned in residency, was that if a child needs Tylenol or ibuprofen more than three days in a row. We should caution the family to not do it more than that, because they could get more pain on the other side for having a rebound headache. But this is great news, because, as you said, we don't want our patients to be in pain. So if this is not a real concern, or if this is an over emphasized concern, over emphasized concern, the data are about are come from days per month. So that's a one little shift that I think can be helpful in counseling. Is if you're going to talk about this, talk about it in days per month. So trip chance, I do usually recommend you try to use them nine days per month or fewer on average, if you have one bad month. You need to use your trip to in 10 or 11 days, the sky is not going to fall. It's going to be okay. But just try not to do that month after month after month, and with the NSAIDs and the acetaminophen on average, ideally, you're using it fewer than 15 days per month. But again, if you have one bad month and you need to use it a little bit more, nothing is going to completely fall apart. So it's really about days per month over time, rather than days per week over just a couple of weeks. This is very helpful. It's not a good lightning round answer, though I went on and off. Sorry. All right, ready, coffee, friend or a foe. Coffee is okay. It seems like one or two caffeine containing drinks per day does not provoke migraine attack, at least in adults, three or more, maybe so, but one or two is probably okay. Cheese, friend or foe, totally fine. Thank goodness I know for adults, wine, friend or foe. It's really interesting. You know, when people track all these dietary things over time, prospectively, it's very rare that they found that it's actually associated with triggering a migraine attack. Some people do, few percentage of people do have that. But for most people, it's okay. That's so interesting, because I talked to so many people that are convinced that certain foods provoke headache. Yeah, it's really hard to recognize the headache that doesn't come. You know, when you eat something or you drink something and nothing happens, it's really hard to remember that. It's really easy to remember the instances where it did come. And so I think part of that is the ones where the headache follows stand out more than the other eight times where the headache didn't follow. But there are some apps where you can track these things every day for 90 days, and you can find out for your individual self whether it's associated with attacks for you or not. And it's really interesting, because a lot of times things that people thought were don't actually bear out when they prospectively keep track of it is dehydration a common cause of being a migraine trigger. Is that overrated? I think it's probably overrated. I do think that taking good care of your body, you know, regularity, all these things are good. Regular sleep, regular exercise, trying to, you know, be thoughtful about hydration. But I think people might blame themselves too much if they're focusing too much on hydration. All right. Screen time is this overly implicated as a cause of migraines? I think so. I mean, there's lots of issues that screens might bring up, but I don't think it's causing migraine any more than if you went and played soccer for six hours straight, then that would probably set you up for being more likely to have an attack anything done in excess might be an issue, but I don't think there's anything specific to screens, your favorite non medication tool to help with migraines, cognitive behavioral therapy, interesting. I thought you were going to say sleep. Oh I Yeah. I mean, sleep is fantastic, but CBT for the win. Yeah, I think so it's just so hard sometimes to access the CBT that maybe I'm focused on it. Okay, any fun facts that you want to share about migraines? Fun Facts, they're not fun. You know that I think food triggers in particular are not something to worry about. So I think kids with migraine should go ahead, have chocolate, cheese, one or two caffeinated beverages. It's going to be okay. What would you say is the most surprising headache trigger that you see in practice? Think it's what surprises me most is the absence of some of the trigger ability that it doesn't necessarily bear out beyond our control. Yeah, sometimes or it's just complicated and we can't quite detect whatever combination of things might be doing it. Can you offer a message of positivity for anybody who has migraines? Yes, we have so much more now available to help treat migraine than ever before. When I finished residency just about 14 years ago, my practice today is radically different than it was even five years ago. In terms of all these new medications, these new devices, we just have so much more available than there ever was. And so I don't think there's any reason to be pessimistic or to think that there's nothing that can be done. There's every likelihood that we can find a good treatment or combination of treatments, for every person, it might take a little bit of trial and error. Might take a little bit of time. That's definitely true, but in the vast majority of situations, we're going to find something that is going to be helpful. There are things that can be done to improve your migraines. Yep, you don't have to just deal with it. Amazing. I love a message of positivity. So thank you. Yes. So if people are listening to you and they want to schedule an appointment with you, is that possible? How do they reach out to you? How do they find a headache specialist? How can people seek more help? Yes, so our pediatric headache program is at UCSF, the University of California San Francisco. If you just put into Google pediatric headache UCSF, you will find us. If you live somewhere else, you could certainly talk to your pediatrician about who they refer to in your area. There are also websites that sometimes help. If you go to the American headache society or the American migraine Foundation, those are reputable sources that could help you find a good clinician in your area. And can people that don't live in San Francisco see you via television, or do they have to see you in person first? How is how does that work? Right now in our program, we can see a new patient if they're in the state of California. We could do it by telemedicine. They don't have to be physically in San Francisco. Certainly more than welcome to come and visit us in San Francisco, but we can see a new patient in the state of California right now, we can't see a new patient outside the state of California unless they come physically to see us in the clinic, but for any families in California, we can do a telemedicine visit for an initial visit. That's amazing, because that's that's evolved from when you first started practicing. Yes, that's a wonderful silver lining that came out of the covid pandemic, is that now we have a lot more telemedicine capacity and just more flexibility about how that happens. Dr Amy Gelfand, you are such a gem, and I'm so appreciative that you came on the podcast. And thank you again. Thank you. Dr Hochman, it was a pleasure. Thank you for listening, and I hope you enjoyed this week's episode of your child is normal. Also, if you could take a moment and leave a five star review, wherever it is you listen to podcasts, I would greatly appreciate it. It It really makes a difference to help this podcast grow. You can also follow me on Instagram at ask Dr Jessica.