Episode 46: Headaches Explained: From Tension to Migraine with Dr. Jaclyn Duvall

Migraines aren’t “just bad headaches” — they’re a disease that can be life-altering.  In this episode, we sit down with headache neurologist Dr. Jaclyn Duvall to explore the world of tension headaches and migraines.  We discuss what causes them, common triggers like food, sleep, and posture, and how to know when over-the-counter medications are enough — and when it’s time to see a doctor.  We also cover social media myths, supplements that may help, and the importance of getting proper treatment.  We also clear up common misconceptions — like why so-called “sinus headaches” often turn out to be migraines.  

Don’t miss this episode — understanding your headaches is the first step to taking back control.

Find Dr. Jacyln Duvall:

Headache Specialists of Oklahoma

Link to Dr. Duvall's book: The Basics of Migraine

Guided meditation/ Relaxation resources recommended by Dr. Duvall

thestartinggatepodcast.com

Email us with questions and topics you want us to cover at
contact@thestartinggatepodcast.com

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The content in this podcast is for general reference and educational purposes only.  It is not meant to be complete or exhaustive, or to be applicable to any
specific individual’s medical condition.   No information provided in this podcast constitutes medical advice and is not an attempt to practice medicine or to provide specific medical advice, diagnosis or treatment.  This podcast does not create a physician- patient relationship and is not a substitute for professional medical advice, diagnosis or treatment.  Please do not rely on this podcast for emergency medical treatment.  Remember that everyone is different so make sure you consult your own healthcare professional before seeking any new treatment and before you alter, suspend, or initiate a new change in your routine.

Transcript

Headaches Explained: From Tension to Migraine with Dr. Jaclyn Duvall

[00:00:00] Before we start today's episode, I would like to quickly read you our podcast disclaimer. The content in this podcast is for general reference and educational purposes only. It is not meant to be complete or exhaustive or to be applicable to any specific individual's medical condition. No information provided in this podcast constitutes medical advice and is not an attempt to practice medicine or to provide specific medical advice, diagnosis, or treatment.

This podcast does not create a physician patient relationship and it's not a substitute for professional medical advice, diagnosis, or treatment. Please do not rely on this podcast for emergency medical treatment. Remember that everyone is different, so make sure you consult your own healthcare professional before seeking any new treatment.

And before you alter, suspend, or initiate a new change in your routine.

Welcome to the starting gate. We're your host, Dr. Kitty Dotson and Dr. Sarah Sheets, two internal medicine doctors who spent years practicing traditional primary care. Over time, we realized something was missing from modern healthcare, a [00:01:00] real understanding of how everyday lifestyle choices impact overall health.

We will help you cut through the noise of the countless health influencers and their conflicting opinions because no matter who you follow, the basics of lifestyle medicine are at the heart of it all.

 Welcome back to the starting gate. We're your host, Dr. Kitty Dotson and Dr. Sarah Schuetz. Hopefully you've enjoyed our latest episodes, all revolving around gut health, but today we're gonna start shifting our focus, which we'll be doing for the next few weeks to our brain, and next week we'll be talking about stroke and the following week, dementia.

But today we're gonna be talking about a problem that so many people deal with, and that is headaches. There are many different types of headaches, but we're gonna focus on the two most common types of headaches today. Tension headache and migraine headache,

and we're really excited to have an expert in the field to help us explain this topic and answer our questions. We have Dr. Jacqueline Duvall, who will be joining us. She's a board certified neurologist and fellowship trained in headaches. It's really hard to find a neurologist [00:02:00] who's had this extra training.

So we are so excited to have her today. She actually practices in Tulsa, Oklahoma, and has also written a book titled The Basics of Migraine. And we'll be sure to have a link to that book in the show notes because after listening to her, you may wanna learn even more. So be sure to check that out.

But Dr. Duvall, can you please tell our listeners a little bit about yourself? 

Yeah, absolutely. Yes, I'm Dr. Jacqueline Duval. I am a neurologist by training, but actually I fell in love with headache medicine as I started practicing in general neurology. The thing about neurology is that typically a win is preventing progression, not necessarily giving people back days of their life.

And so with migraine management, I . Started to find myself looking forward to seeing these individuals where I could truly gift them back days of their life. Like really making a difference, helping and it tends to impact women of our very similar demographics, so women who are busy [00:03:00] having families, careers.

And so for me, I really felt this connection, which, put me to go back and complete my headache fellowship. I didn't necessarily do things in the traditional order. I practiced, then went back to fellowship. But I think it really set the path for me to be able to pursue a dream that I love now.

Oh, that's wonderful. And I know I always felt so empathetic to my patients with migraines or chronic headache of other kinds because I luckily very rarely have a headache. But when I do, it ruins my day. Yeah. And so I feel so much for people that have to deal with that on a regular basis. I cannot imagine what that feels like.

Funny you say this, because my husband had the same reaction. , When I decided I wanted to pursue headache medicine, he's are you sure there's a need for that? Are you gonna have any patience? I'm like, okay. He's not in the healthcare field. No idea. He has gone through two migraines in his lifetime, actually write about it in my book.

And he, after the [00:04:00] first migraine, he was in our closet. Closet doors shut, light out. He's like, your patients go through this more than once in their lifetime, he was in shock. And so the World Health Organization looks at over 300 individual diseases. Migraine ranks a day. Lived with migraine is equated to being quadriplegic.

People can be out of commission. They're afraid to move because movement can exacerbate their pain. They may be vomiting, they light sensitivity sounds. So that day lived with migraine is so debilitating and many people just aren't aware of that. 

And another thing before we get into the nuts and bolts of headaches, can you let our listeners know about how you started your own practice?

So I had the amazing opportunity to do my headache fellowship at Mayo Clinic, and one of the most acclaimed practices in the world and was asked to stay up in Minnesota.

But my passion has been my [00:05:00] community. I'm from Tulsa, Oklahoma. And it was always my goal when I went up there for fellowship to come back and establish a headache clinic within the community. When I moved back to Tulsa, I was employed for a few years here. It's hard to start up a practice. There are a lot of different facets.

You think about starting a business and all of the things it would entail, you add medicine into that equation and it grows like exponentially. And so fortunately I had my husband give me a little push and help alongside, and so he's been able to help me manage the business side of our practice.

And we've grown. I'm so proud to say that not only is it me, but I've now trained two nurse practitioners under me who are extremely passionate about this. And they've taken to it so beautifully. I put together a learning curriculum for them, shadowing practices and it's awesome. So we're helping more people in Tulsa than ever before.

that's great. 

 So to get us started, we would love to touch on tension headaches, and I [00:06:00] know I'm just from us talking before we even started recording migraines is something that is the most common probability that people come to you for, but tension headaches are also very common. Can you give our listeners a definition of what is a tension headache and why it happens?

So tension headache is by far the most common headache type that someone will encounter. It's estimated that about 90% of the population have experienced a tension headache in their lifetime. But on the flip side of that tension headache rarely if ever brings somebody to the doctor's office. And the reason for that is that it's typically so mild and so a common misconception is the pain is pressure, or it's in my neck and it's, it's on both sides, so that's gotta be a tension headache.

It came on with stress or lack of sleep and all those, things are common triggers for tension. Those are ous triggers as well. And in migraine, we have so much neck pain, correlation, the same [00:07:00] nerves that affect the neck, affect the brain and are highly interconnected. And so it's very common for people to think I'm actually having tension when it is migraine.

So I, I tell people, if your pain is reaching moderate intensity. Enough to take you out of your busy life to come see a healthcare professional. Odds are it's migraine and we have a lot of studies to back this. , One of the studies suggested that about 90% of what people came to a clinician's office for thinking it was tension is actually migraine.

Oh, interesting. Yeah. That is fascinating. And I sometimes not talked about enough in, general primary care because a lot of times it's, we're talking about tension headache a lot. 

And so most of the time when people, they have a tension headache, and you mentioned some of that's usually maybe the necks involved or it's both sides of the head feeling that kind of squeezing pain.

Usually people just go take some [00:08:00] ibuprofen or some other over the counter medicine. Is that the best way to handle one of those? 

So that really gets back to the frequency that they're occurring. So your tension headache, to circle back a bit, 'cause I didn't tell you what it is. It typically is this pressure, like quality more mild to moderate intensity, but it tends to be like following a stressful period, perhaps lack of sleep.

Maybe you haven't been taking care of your body the way you should, whether that's nutrition or fluid intake. And so those kind of can bring on or predispose you to having this. If this is happening regularly, you've really gotta look at what these triggers are that are predisposing you. Because taking these over the counter medications, even though they're over the counter, it doesn't necessarily make them safe, especially if used day after day.

So I'll have people coming in, taking daily Advil or daily, [00:09:00] Excedrin and they're going, but it controls my headache. I go but what about the concerns on our liver, on our kidneys? What about the concerns on our blood pressure by being exposed to these medications recurrently? So if I have maybe a tension headache in a month, using an over the counter analgesic, I think would be appropriate.

Those typically resolve the pain you move on with your life. But if these are happening more recurrent, you've gotta focus in on more of these lifestyle interventions, or if they're happening near daily than even a prescription preventive could be considered. 

Great leeway lifestyle interventions, what we love to talk about, what are some things that you notice with patients that have these more frequent tension headaches that they can change within their lifestyle and really see a big impact?

Because I will say getting rid of headaches is a great motivator for people and making change. But I don't think that necessarily many patients get this [00:10:00] aspect of advice when they go to the doctor with recurrent headaches. 

Yeah. I would say the two biggest factors I see that predispose someone to having regular a tension type headaches are inadequate sleep patterns and stress.

And oftentimes, as we know, those two are interconnected as well, right? Yes. I'm stressed, my brain starts to reel. Now I'm not sleeping now I'm more stressed because I didn't sleep and worried about it the next night. And it's this, snowball effect that happens. And so I think as simple as it sounds, stress reduction is one of the biggest things that you can do for helping to manage tension, regular sleep schedules.

And then those things that I mentioned before regular diet. So we know that people predisposed to getting headaches don't like shifts in blood sugar levels. So we typically will suggest like more frequent, even like snacking and avoiding big meals if you're predisposed to headaches. So those blood [00:11:00] sugar levels remain more consistent throughout the day.

Adequate hydration is really important but also posture plays a big role. I experienced this actually at the beginning of COVID. I started doing so many more virtual appointments and I was ending up with chronic neck pain as a result of ergonomics of my computers.

I, I didn't have anything eye level. I was, hunched over typing, talking to everyone. I didn't have my regular clinical practice where I was up moving about stretching. And so most people do have desk jobs, and I think making sure that they've positioned the desk, if they can have a desk that moves where they could be standing at times, sitting at others.

But if they don't, just taking time throughout the day to, to roll the shoulders back, to tuck the chin to get everything in alignment. Or if more severe, really reaching out to physical or occupational therapists to help in meeting those goals. 

I was actually even thinking earlier, I just wonder if we're seeing more tension headaches because we're all [00:12:00] looking down at a device more frequently and have our necks positioned that way.

So in the migraine world, we call that tech neck. And I tell everyone our society is set up to predispose us to headaches. If, literally if you think about sitting in your car now, and you'll never unsee this, the headrests of our cars are just slightly positioned forward. So almost everything we do, has our neck and chin in this coming forward anterior position.

And if we could all, strengthen those little bitty spinal muscles and get our shoulders down and back. But the truth is we all feel so proper. Or maybe that I'm trying to think of the word for this. Like maybe uptight if I'm sitting in this, straight position. But that really is, we've gotta work on that neck strengthening and getting those shoulders rolled down, that scapula twisted in and pulled back to really help with that posture.

Because those nerves that come out [00:13:00] of the upper cervical spine, when the neck goes forward, they're just being strained already. So if they live in this constant straining and then you add in any of these additional triggers or factors that we've mentioned, it just sets everything off in motion. 

with tension headaches, does inflammation have a play in those type headaches?

Inflammation is more so migraine Okay. And that's where this interplay comes from. Most people, when it's inflammatory related from like diet, it truly is migraine and just masquerading as this tension headache. 

And you mentioned hydration as well. While we're still on the nutrition side of things, is there a certain amount of water that you recommend for your patients?

so we use the eight by eight rule, eight glasses of eight ounces of water a day. I will encourage patients to mix some of that with electrolyte supplements. Especially, summer times when they may be dehydrated [00:14:00] or having, excessive sweating, et cetera in the heat or someone who's exercising quite a bit.

I really feel like needs to look at some of those electrolyte replacements just to make sure that they're not getting too much just straight water. And when you mentioned 

electrolyte replacements, there's such a variety. Now, is there specific when it comes to headache electrolytes that you wanna make sure are in the option that you choose if you're trying to combat the headaches?

So I love anytime that magnesium is added into the equation. Magnesium's my favorite supplement. We'll talk about it whenever we get to migraine. But no, the truth is you really wanna well-balanced. And the other thing is without a lot of additives, so I'll encourage my patients to really try what's best for their body.

You will find that some, whether they're dyes that are added in, like if it's already a liquid mixture or sometimes added sugars can be triggering to certain people and not to others. So it [00:15:00] really is individual. 

 And just hearing you say the rise in the fall of blood sugar being something that can worsen things.

We'll just go back and remember all of that fiber we've been talking about the last few weeks. So, you know, If you are gonna be having sugar pairing it with fiber and protein, it's probably gonna help keep from having those spikes come up and down which may worsen this. Do you have anything specific that you do recommend for stress reduction?

That's such a hard one for all of us, I think. 

Yeah. I think this is just so much easier said than done. The truth is that we all have stress in our life, and in fact, we want a certain amount of stress in our life, right? We call that the target zone, where not too much, not too little.

There is such a thing as a stress letdown headache or stress letdown, migraine, where somebody may go through the work week of stress, and then as soon as that stops Friday, Saturday morning, a [00:16:00] headache breaks through. And that's that shift of cortisol that we can see happen. I think if you're under excessive stress, then it's time to start looking at what things are within your control, the modifiable risk factors that you could do something about.

The number one thing I go to with my patients are smart devices. I think that they are overutilized in our society. We are constantly checking them. We recheck them. We drive down the road and unsafely check them. Some people YouTube, you know why they're driving and it just is terrifying to me. But I start with something as simple as social media.

It's unessential in your life. We think we need it, but the truth is that it probably is increasing anxiety and stress far more than we ever realize. So I think if you could take certain things, and maybe it's even just putting a timer, I will allow my phone to be open and available during these hours.

And then turning it off. I think that [00:17:00] those are little things that you have within your control to try to help with stress, yoga, meditation, I love. I think that these are huge. I realize that not everyone has time, but I do think even at the end of the day, if you can go through deep breathing meditation, all of these are available in like apps I just mentioned.

Don't use your smartphone, but if you're using that sort of for good. And then there's also actually a dear friend of mine, Dr. Dawn Bus she's a neuropsychologist. She has an entirely free website that allows for guided meditation, neurofeedback type exercises to do. And I've had so many patients have success with that.

Oh, we'll be sure to link that as well. 

That's a good one. And it's just 

dawn buse.com. And you had mentioned yoga. Is there any other specific exercise that you find beneficial for patients with tension headaches? 

Yeah, moderate aerobic exercise on most [00:18:00] days of the week has been shown beneficial for really all headache types.

and it doesn't have to all be at the same time. So that can be, parking at the end of the parking lot and taking your way in, maybe trying to move at a more brisk pace. If you have a 15 minute lunch break, could you take a walk around the block to get the heart rate up? So it doesn't have to be a specific type.

Yoga in particular has level A evidence for migraine prevention. And so that's, that's more migraine focused evidence. 

 Before we leave tension headache, you alluded to this already, but if someone is thinking that they're having a tension headache and it's more than that once a month when should they know that they should go see a doctor?

I think if you are taking an over the counter analgesic more than a day or two in a week, I think it would be appropriate to start looking at some of these preventive measures. And then as I mentioned before, we do have prescription preventives for chronic tension [00:19:00] headache also.

So I think that would be appropriate. I think another scenario to consider seeing someone for help is if over the counter medications are not effective. That's what I consider a red flag to say, do we need to take a deeper look and figure out what's really going on? 

are there any over the counter remedies that you see patients taking that worry you or you would really advise avoiding like, I know one thing that's popular here is something called goody powder. any things like that. That you think stay away from?

Yeah, so Excedrin is my pet peeve and I, I have people say, you hate Excedrin Migraine. And it's not that, it's that the concern is. If you are experiencing headache or migraine days more than a day or two a month, that's probably not the right treatment. It has such a high rebound potential to increase headache days, because it's a triple threat.

It's not just Tylenol or just Ibuprofen. And so that caffeine [00:20:00] component as well, you can actually end up with not only a caffeine withdraw headache, but also this analgesic or pain medication overuse headache. So it's a double-edged sword that I really get nervous about. There was actually a time that Excedrin was unavailable and I like had a mini party here in the clinic because that's one that I see people going through bottles at a time.

Goody powder is another one that I just go, oh, and then getting off of these is so difficult. Because you will have a worse headache whenever you try to discontinue use. It's going to worsen. It typically will hang out there for, maybe up to three weeks, which is a long time to go through a bad headache.

And then it'll start trickling down. But you've gotta wipe away those recurrent, as needed medications to be able to open the door for headaches to get better. 

 Okay. So watch out for the medicines that seem to be a combination of multiple drugs together. 

[00:21:00] Absolutely. They're great for once in a while.

I tell people that is what their intention is. My rare, I have one, maybe two in a month, headaches that happen, they'll work beautifully stop pain. But if taken too regularly, they really start to become a culprit. 

 Great advice. 'cause I'm not sure many people realize that. All right. Now let's move into migraine headaches.

I, for any of our listeners who have had a migraine headache, I know that they are ready to hear anything you have to say about this topic. But let's start by actually giving an explanation of what is a migraine headache and how it's distinguished differently from that tension headache. 

So migraine is more complex to answer in that because you actually can have a migraine and not have a headache at all.

So we say that migraine is a brain disease, a neurologic disease of sensory processing disorder. I like to explain it to patients like , it's a hyperactive [00:22:00] or Ferrari type brain. So when I explain migraine or the potential for it , I like to use analogies and one of them I'll use is like this dam where the dam is holding the water back.

And anyone could have a migraine in their lifetime. Stress levels are too high. Inadequate sleep, as we've talked about. Maybe they get the flu or they drink too much alcohol or they eat the wrong foods and the water height just keeps going up with these triggers and spills over. Someone with the genetic predisposition for migraine starts with a lower dam height, so it takes fewer of these triggers to send the water over.

And so I tell them, your brain is the Ferrari of brains. It is ready to go. You don't have to push hard on the gas. It may just take one trigger. Just I didn't sleep well tonight and you're off. And it really is just this hypersensitive brain disorder. 

And what are those [00:23:00] symptoms , that people see since it isn't just a headache.

And I remember when I learned that as a medical student, I was like, wait, you can have a migraine without actually having a headache. It blew my mind. But what are those symptoms that people will experience with this? 

So migraine is actually has four major phases. The first phase is what we call the pre monetary phase or prodrome, where you can get these warning symptoms before the headache phase ever comes.

This could be heightened light sensitivity, smell sensitivity. It could be food cravings, food aversion. It can be mood changes both like euphoria or feeling down concentration difficulties, maybe it's word finding. These can happen hours to days before the headache ever takes place.

The next phase is what we call aura. And only about a quarter to a third of people with migraine have aura. So that's one of the common myths that I like to tell people. They'll say I don't have [00:24:00] aura, so I can't have migraine. Say well, actually you have the most common type of migraine then because it's more rare to have aura.

But aura are these transient neurologic symptoms that typically last between five to 60 minutes and are followed by the headache phase. Although, as we mentioned, not always but these symptoms, unlike a stroke, tend to be more positive phenomenon. So instead of, I've suddenly lost vision, my vision went black, as we might see with a stroke type symptom, these are typically like bright flickery lights or maybe a smudge in your vision with this halo or surrounding zigzag of color that may grow or progress, or maybe it's sensory phenomenon, these tingly sensations, but with migraine, they tend to start and progress over the course of minutes, so seizure is very fast and fleeting.

It's typically under 60 seconds of these [00:25:00] symptoms that happen. Migraine. Again, you're gonna have patients telling you, this lasts longer, typically 20, 30 minutes on average. Then we have the headache phase. The classic headache, as we've mentioned, is one-sided. It's throbbing or pulsating in character, typically of moderate to severe intensity, and it's aggravated by movement.

You're not gonna go out for a run. You'd rather lay down in bed, recluse. You don't have to have all of those, but you need to have at least two of them to be a migraine. So it used to be part of our criteria that you couldn't have pain on both sides of the head to be migraine. We now know about 40% of migraine is on both sides of the head, and then you need to have either nausea with or without vomiting or light and sound sensitivity.

And what I remind patients is that these things are not a severity scale. So although it can be severe light sensitivity, I need sunglasses on, I need a [00:26:00] dark room I need to recluse. Sometimes it's just those lights bother me. The computer screen glare my phone. I'm still functioning and I'm still making it through the day.

But if given the option, I'd rather not be looking at this screen or in the bright sunlight or I'd rather my kids keep down the noise. It's aggravating to my pain. So either the nausea or light sound sensitivity. And then the last phase of the migraine is called the rum. It's the migraine hangover.

Patients described just feeling absolutely wiped out. They may feel like muscle aches. They may have further cognitive difficulties. So that can sometimes be even as impactful as the headache phase itself, 'cause that can last days at a time. 

And I'm glad you addressed the severity because I do think that if you've never had one before, many's people's conception of a migraine is being in bed.

But that isn't always the case. And it's important as we'll get into to understand if it's a [00:27:00] migraine, because treatments can be different to help you out. 

Absolutely. I just think that idea that migraine is not in this black box. There can be mild migraine attacks, which, many people will go, gosh, that's not a thing.

But you actually can go through the international classification of headache disorders and meet criteria for migraine and have mild pain. So we have this whole scale of what migraine is and really even after residency, before fellowship, I may not have called some of my headache days, migraine days. I know now that they are, they just haven't progressed into that severe level.

So you can start treating those differently than you may have done otherwise. 

what's happening in our brains, that makes us. Nauseous and not wanna look at the light. , Why does that happen? 

so we think that light sensitivity, we call, those sensory phobias, have to do with meningeal irritation.

So the meninges are the [00:28:00] surrounding layers of the brain. I call them like the saran wrap layers of the brain. They are separated and they have different content. But there is something about menal irritation that sort of can set off this pain cascade. Part of that pain cascade involves a very specific area of our brain that is involved in like the nausea area.

And that part doesn't have what's called a blood brain barrier. And so it may be why we can experience those symptoms even before the headache phase has taken place. 

And if you are someone that experiences nausea with your migraines, do you always experience nausea when you have migraines it's highly variable. So I'll tell people, even within an individual there can be multiple different types of migraine attacks. And so I'll have some patients that come in with their list and they'll say, I have four different types of headaches. And I say, actually, you have migraine and you [00:29:00] have four different types of migraine attacks that happen.

and they'll even call tension and I'll say, I wanna start encouraging you to change your tension to mild migraine. Because if you have the genetics of migraine, chances are that is not a tension type headache. That probably is more ness. Again, it just hasn't reached that threshold of severe pain.

 Another type of migraine that I think is tricky for people to get diagnosed is like a vestibular migraine because that one just comes out of outta the blue and many don't even have headache with that one. 

Yeah, so a vestibular migraine is a type of migraine attack that will typically have a sort of vertigo type episode that happens, or this dizziness, as some people will describe it, but it also tends to be in that five to 60 minute phase and followed by head pain, although not always. , and that can be a really challenging one to treat. [00:30:00] Sometimes when those are happening more regularly, we can get them on the right preventive treatments to really have an impact.

But oftentimes those type of symptoms are so short-lived, like the vestibular or vertiginous dizzy aspect of the attack may only be 20 to 30 minutes. Most of the medications, even if given an injection, take about 15 minutes to reach at least their T max. And so it can be very challenging to have a treatment for that if they're happening more rarely.

Can you tell us some of the common triggers or risk factors someone might have to have a migraine. 

 Actually these are very similar to common triggers that you may also see for tension. So we do see quite a lot of overlap, but for migraine, typically we'll see hormonal changes, especially for women as a common trigger.

So it's estimated about 60% of women with migraine will have menstrually associated [00:31:00] migraine. So those drops in estrogen can have a big trigger on migraine. I see sleep disturbances as a major trigger. Also, barometric pressure or weather change, which is not within our control typically can be a common trigger.

Dietary factors. Including caffeine and or alcohol intake can be triggers. 

I just wanna pause for a moment on a couple of these. So the barometric pressure being a trigger for migraine, I feel like many times when that's the case, people call those sinus headaches.

How does that fall into place? Because I do feel like anytime there's weather shifts, they're like, oh, my sinus headache got triggered versus my migraine got triggered.

So recurrent sinus headache in the absence of a structural abnormality is exquisitely rare.

It is so over-diagnosed. I actually think it's one of the most common misdiagnosis that I see, and there's a lot of reasons behind this. So I'll [00:32:00] unpack it. Dr. Richard Lipton, who's one of the world's leading epidemiologists in migraine, did a study in the US with people who thought they had sinus headache.

There were like , 36,000 Americans living with sinus disease or what they thought was sinus disease. 88% of them fulfilled migraine criteria. So I tell people, if you are having recurrent sinus disease, if you have family members that had this, the odds that it is migraine is exquisitely high.

The reason for that, there's a bundle of nerves in our nose called the sphenopalatine ganglion. It's actually a branch of the trigeminal nerve, and that's our major migraine nerve trigeminal nerve. So the pheno palatine ganglion is responsible for what we call autonomic symptoms of a migraine.

This occurs in about 60% of people with migraine. These are things like nasal congestion or runny nose, eyes tearing, turning red, facial flushing, blood [00:33:00] pressure, heart rate changes, body temperature changes, and so when these weather changes happen, which trigger migraine and allergens trigger migraine, and then I get all these sinusy type symptoms.

It's natural and logical to think this is sinus, when in fact this is migraine that's masquerading as sinus symptoms. 

When people do think they're having sinus issues and they're taking antihistamines or other type of allergy medicines, does that help their symptoms at all?

So antihistamines help migraine too. So actually I will prescribe various antihistamine type medications to help with migraine. So that goes into the exquisite inflammatory disease that is migraine and the truth is, we are still missing so much of migraine, which is why we don't have a cure for it.

It's because if you listen to the basic science researchers, even in all of the migraine [00:34:00] education that I have, I've devoted my whole life to this. I feel like I'm well versed on it, but when I start listening to the basic science researchers in my field. I start to think they're speaking German. There are so many aspects of inflammation that's happening in the midst of a single migraine attack.

It's unbelievable to actually think about and it fully helps to explain why it can be challenging to manage everyone's disease, but antihistamines can be beneficial for migraine as well. So oftentimes I'll use that and help with that. 

And you mentioned earlier about thinking about it as if you're someone that has migraine your dam level is lower and it's easier to overflow.

 Why would a person start out that way? Are there specific genetic things or exposures that makes someone even at risk to have a migraine triggered? Yes. 

So migraine is most common, a genetically inherited disease. Typically you'll have kind of this family [00:35:00] lineage that you can trace when the lineage comes through mom's side.

It's a lot easier to trace because boys tend to experience migraine more frequently during adolescence than girls do. And oftentimes they outgrow it. And so if that lineage comes through dad's side, grandma doesn't talk about him having headaches because it was so long ago. Nobody's remembering, nobody's talking about that.

And and then sometimes it's what we call a sporadic inheritance. So you're the first one to get the genetics for it. But that damn height starts because of your genetic makeup, which is what makes our job so challenging because the number one question I get is why I wanna get to the root of it.

And my answer to that is it's like asking, why did I get brown eyes instead of blue eyes? It's part of my genetic makeup. And now I need to look at all of the different fuels, what I call triggers that are exacerbating it. And those are things within my [00:36:00] control. But that root cause, I don't have an explanation for you it's what you were given what the good Lord gave you.

that is a great explanation because I know sometimes, people are wanting to cure it altogether, but when it comes to migraine, it's more important to be like, okay, I need to reduce triggers or reduce the risk factors as much as possible because they can have significant improvement in their headaches by getting to that route.

Absolutely. 

Absolutely. And I always am cautious or leery. In fact, that's one of the common myths that I had to share with you, that there is not a cure for migraine. So if you're hearing somebody, boast a cure, chances are it's, it may be, not legitimate. Our migraine community, we do not boast cures for migraine.

Some people are what we consider super responders. They may have near complete or complete relief, but they still have migraine. And it could come out at [00:37:00] any point. So we don't yet have a cure for this disease. 

Now when it comes to migraine, is there specific nutrition triggers, just like tension headaches?

Is it going to be thinking about your blood sugar just like with the other headache as well? Or is there anything that's more unique to migraines , the migraine brain is even more particular. So I tell people migraine brain wants everything the exact same all the time.

So it doesn't want too much or too little sleep. It doesn't want too high of blood sugar, too low it, it wants everything just right and on a routine. So even caffeine can be like that. I tell people, instead of having just like a big cup of coffee beginning of the day, really spreading that out and having less fluctuations and that caffeine level is probably the best for a migraine brain.

Your dietary impacts are going to be all of the foods that we think of that are pro-inflammatory. So anything with [00:38:00] additives in it, I tell them, if you can't read the back of the box, it's probably not meant to be in your body. Anything that ha like highend, nitrates, tine foods with MSG are particularly susceptible for people living with migraine.

Dairy can be a common and gluten for some, but that's another misconception is some people think if I just control my diet, it fixes it all. And I always tell patients while the dietary changes can have a marked impact, for some people it doesn't for everyone. So I, and I tell them, if you took everyone's recommendations about dietary changes that should happen for migraine, you'd be left with water and like some green leafy vegetables, but not all of them.

And so that probably means that we are all unique and it's finding out your individual triggers. And then sometimes you can make all of the right things and it still [00:39:00] continues. And so I really emphasize you can't blame yourself. You can't, put it on you. If your body is not responsive to these dietary changes, 

how do you recommend someone going about trying to figure that out for themselves?

there are so many different recommendations for the best way to do this. I do talk about this in my book that I think the best way to go about instead of these strict elimination diets that many people have a hard time keeping up with, they may do it for a week or two, or maybe even a month or two.

I would rather see long-term lifestyle changes. So I recommend looking through my list of top triggers and saying, Ooh. Maybe that one's mine. Take it away for a couple of months at a time. If you're not so sure that was a trigger, maybe you haven't seen improvement, introduce it back at that point, but choose one or maybe two of these that you could sustain over the long term.

And just do those so you can get a clear [00:40:00] picture of, what can I eat and what can't. I, instead of being so strict or regimented with this, 

I love that kitty. And I always like to tell people to do self experiments. Because you're gonna learn the most by doing the experiment on yourself, especially in this situation, since it is so individualized.

So I think about a friend of mine who's a dietician, and she commonly goes back to this, that if we look at food sensitivity testing, somebody's body may not like asparagus. And we go, gosh, asparagus is so great for you, for all of these different reasons. But if your body is inflamed as a result of that, then that's not the right food for you.

And it's so highly individual that you really do have to make this your path. 

And what about the role of alcohol in triggering migraines? 

 Obviously excessive alcohol you're going to get headaches following most common. And generally we will see more of like a tension or migraine combo type headache that [00:41:00] follows that hangover headache.

But alcohol in and of itself is typically pro-inflammatory as well, you really have to look at like more clean versions. Very limited. I'll tell people if they're looking for wines you're wanting to avoid them that are very high in additives as well. So it's typically gonna be more expensive bottles that are gonna be more favorable in that.

A lot of your, malt beers or things that are very dark or thick are typically going to be more pro-inflammatory than like a lagger for a beer, although not always. So it's always gonna be my, disclaimer. And then same thing with liquors. Typically, like you're more clear are going to be less pro-inflammatory.

And does nicotine have an impact? Are you seeing, especially with the rise in vaping, is that. Impacting migraine frequency at all? 

absolutely. I think that one of the best things that you can do is not have nicotine [00:42:00] in your system, period. Not only do I see it typically increase anxiety despite claims to help calm you, it's this rebound effect that we'll see that I think, does lead to spiraling of headaches also not to mention vasoconstrictive effects that can have on blood vessels in the brain.

 when it comes to specific vitamins or minerals, is there anything that you think tends to be a common deficiency that you see in patients with migraines? Magnesium, as I mentioned earlier, is my favorite supplement.

I feel like anyone with really a pain disorder at all should be on magnesium. It has an impact on glutamate levels, which are an excitatory neurotransmitter that we see. And so magnesium can just be a great I call it nerve calming supplement in general. So if you have back pain, neck pain, migraine pain, joint pain, I think that magnesium is a good option to consider.

It's not necessarily a deficiency of this though. [00:43:00] So that's been studied. Is it only people with low magnesium that get benefit from magnesium and migraine? And the answer is no. So regardless of your level of magnesium, it can be beneficial for you. Vitamin D is one that we tend to see deficient in neurologic disorders in general.

And I do think we see a higher percentage of this in migraine, but studies have not necessarily shown benefit of repletion from a migraine standpoint. I recommended it in anyone, especially females and repleting, vitamin D if low. But the supplement in addition to magnesium, which has the most evidence, vitamin B two or riboflavin, has level A evidence for migraine prevention.

And again, it's not necessarily a depletion. And it's a high dose. So people say, can I just take a B supplement? No, it's like a 400 milligram a day dose of riboflavin. 

is there anything specific about the magnesium that you recommend? There's a [00:44:00] lot of varieties out there. 

There's so much variety of magnesium.

And this can be tough because as the supplement world is like a multimillion dollar, industry and just because it's a supplement and over the counter doesn't make it safe as well. Magnesium in the form of magnesium oxide has a lot of data behind it, but many people can't tolerate that form 'cause it may give them some gi upset or diarrhea.

And so magnesium threonate is one that we'll commonly recommend is having more impact on the brain More crossing into the brain, if you will. We also, in our practice, we have this triple combination supplement that includes what's called magnesium bis glycinate. So it's call it a fancy form of magnesium.

It has B two, it has coq 10, and then it also has what's called l methylfolate calcium. So it allows more of the product to, to get into the [00:45:00] brain and not be broken down in the gut. But ultimately if I'm having someone start out on magnesium, if they're concerned about cost, I may encourage them to try the oxide and see how it impacts them.

And then if not tolerating or not getting enough benefit, stair step up into fancier forms of magnesium. 

What about your thoughts on creatine? This has been popular lately for lots of reasons and a lot of people. Talk about the impact on the brain, and I've seen some people say that it can reduce headaches.

Is there anything to support that at this point? No. So that's 

still all anecdotal at this point. There's more data with pro-inflammatory supplements. Boswellia is an anti-inflammatory supplement. Butter Bur is one. It actually got pulled at one point because some formulations were causing liver toxicity.

It appears that newer formulations it [00:46:00] seems safer in this regard, but I do tell patients if they're starting on a supplement, especially Butter bur that they're having routine labs checked every few months to make sure they aren't seeing any issues with the supplement, but. Back to your creatine.

No, I don't have any data other than anecdotal for migraine at this point. 

I hadn't heard of Butter Bird. No, I, that is, that one is new. But I had one more I wanted to ask you about and that is omega threes. 

omega threes are great for the brain. They have so much more data for memory than they do for migraine.

Studies for migraine have been mixed and so we don't have like routine guidelines surrounding Omega-3. Same goes for coq 10, much more evidence in memory than for migraine. But I tell people, those things are generally good and safe and so I don't think that they could hurt. 

So you mentioned earlier about yoga. Are there any other specific exercise recommendations you [00:47:00] have for people that suffer with migraine? 

The moderate aerobic exercise most days of the week can also be beneficial.

But those are going to be your big things. Like any sort of consistent cardiovascular can be helpful in prevention. So those are 

the same for both tension and migraine headaches, correct? Yes. Okay. 

Can exercise trigger a migraine? I know I felt like sometimes I had patients fearful of doing certain things that they thought it might bring a headache on.

Yes, so it can, this is typically if you've gone over strenuous exercise or if you're not accustomed to exercising and you go all in on these plans. So I recommend patients that have not exercised in a while, that they start with maybe three to five minutes of getting their heart rate up. The other thing that I'll see that can be commonly triggering to migraine.

Is heavy weights on the shoulders or [00:48:00] the back muscles. A lot of these, what I call swimsuit muscle exercises are starting to pull muscles in and forward in the head and chin region. And again, that puts traction on the cervical sensory nerves, which can induce a migraine. So you have to be cautious about weightlifting and the upper extremities, making sure you're doing that with the right posture and that you're balancing it with getting these little bitty muscles along the center of the spine balanced to get the shoulders back, that you're not just beefing up and the frontal al or shoulder region, which can sort of cause this concave.

Are you seeing any 

positive or negative effects of weighted face?

So I will tell you my personal experience, it put traction on my neck and I had to reduce weight when I started using a weighted vest. I think that's going to be the key is starting out low and slow and seeing how your body adapts to this.

'cause I do [00:49:00] think that we're recognizing the benefit of adding weights, especially for females. And so there, there are positivities, but if it's putting traction on the neck, there is a high likelihood it's gonna increase migraine as well. 

People that are using these, it's like, there's lots of options out there, trying to figure out what feels good because if it feels bad, it's probably going to cause a negative effect and tension on your body.

That's something to keep in mind. 'cause I know we, we do like to promote those at times. Yeah. Yeah. 

speaking from experience with that the number of choices is overwhelming. And then you know the question of what weight do you start with is also confusing. I think although it could be financially disincentive to start low and then you're gonna need to potentially buy another one.

I think that if you're experiencing migraine and you have to do that, you have to start low weight. Even if you are a infrequent, episodic migraine suffer. I think that the [00:50:00] risk of wearing these could potentially increase your frequency.

If you have patients that are experiencing migraine and have dealt with it for a long time and really didn't seek care, when do you recommend that a patient come and actually assess their migraine status with their doctor? 

I firmly believe, and again, I can talk migraine all day, it's my passion, but I think that everyone living with migraine, whether you have, multiple in a week or one in a year, deserve a migraine stopper medication.

So I think everyone should be talking with a healthcare professional about having the right acute or as needed medication for when those attacks come on, even if they're more infrequent. But definitely time that you should maybe be seeing a headache specialist or neurologist or someone is when migraines are occurring like a day, a week or more.

That's the point that we start to see a process that we call [00:51:00] trigeminal sensitization that can actually. Increase your risk of having more and more headaches. So a common thing I'll see is someone maybe starts with one to two migraine attacks in a month and then they've recognized they're closer to four to six a month or two later.

And now, gosh, I'm at 10 days out of the month of some headache pain. Not all migraine, but it's kind of like this process is growing. And so what we wanna do is capture the disease state earlier, so early on I'm more likely to be able to extinguish it and really calm down the trigeminal system.

But if they start to happen back to back, the system is almost primed and ready to go for the next one. And it's less responsive to medications as that happens. 

 . So this is definitely something you want to get ahead of if you're noticing your migraines escalate. 

Absolutely.

Also, if you are experiencing aura symptoms, especially as a female, I recommend [00:52:00] consulting with a healthcare professional. We know women living with aura should not be on estrogen supplements due to a potential increase in stroke risk. And so I think it's just always worthwhile, especially if you have new onset aura symptoms, consult with someone and make sure they really are aura.

And I think that's particularly important to bring up, given that in the world of treating menopause, we are starting to put more women on estrogen. So something to be aware of if you are someone that suffers from migraines. Now, if you're someone that has a migraine once a year, once every other year, and you have an aura, would you still recommend that person be leery of estrogen replacement?

 This is so hard, right? Because the data we have are old formulations of estrogen that are not equivocal to what we have today. But the problem is lack of evidence doesn't mean we have evidence. And so technically it [00:53:00] is still a contraindication. I have many colleagues that are much more familiar with measuring hormone levels and will introduce it, recognizing that risk that I am exquisitely cautious.

And it would also depend on the degree, like the type of aura symptoms that someone's experiencing, I think would be important to keep in mind. , 

Hopefully they're researching and getting us a better answer because we finally are paying more attention to this literature.

So hopefully we'll have a better, clearer answer to come. Yes. 

While we're on the topic of medicines, can you tell us a little bit about someone that does suffer with migraines? What type of therapies are available for them? 

when we manage migraine we typically will start with lifestyle intervention, which we've talked a lot about.

Now, what are the things within my control that I could adjust within my lifestyle to help manage? But when migraine is happening more regularly and we need to [00:54:00] introduce pharmaceutical treatments, we have two major categories of those. We have our acute or as needed medications and we have prevention.

And so those are really the major ways that we'll manage. And I tell people if they are experiencing more than one to two days a week of head pain prevention is really necessary to get the overall impact of migraine reduced so that you can use those as needed meds just as soon as symptoms come on.

are you ever able to get off of preventive medications once you start 'em? 

Very much so not everyone, but oftentimes what we'll see is when we calm the system, it's less irritable. So my analogy for this is like trying to wrangle a bear back in the cave, right? I am. I'm trying to find a way. I get him in, I've got the door on, okay, if I take the door away too quickly and he comes raging back [00:55:00] out, sometimes that door I used is less effective to get him back in.

But if I can keep him there and allow him to just calm down, go to sleep, when I take that door away, he comes out. He may not be angry anymore. And so that timeframe is typically between six to 12 months of control. And then we start pulling away very slowly. So for many people, especially if we're able to control less frequent migraine attacks early on, they are able to come off of medications.

And that's where maybe having time to enact those lifestyle changes that can help calm things down might then allow you to come off down the road. Absolutely. 

 one thing that can be really challenging is if you're starting at a high frequency of headache days, generally the lifestyle interventions just may not be enough.

So you might find yourself down this spiral of frustration where I go, gosh, if we could reign it in and get more [00:56:00] control where maybe you could more effectively track your migraine days and identify what your individual triggers are, it might be less frustrating, less chasing the wind because as I mentioned, that whole span of a single migraine attack, just one could span up to seven days at a time and that trigger that happened could have been, even before that pro drum starting.

And so if you're having more than a day or two a week trying to figure out what caused what can be incredibly confusing for people. 

 , That is so true. I feel like you've given us so much knowledge. But I wanted to have some time for this. Are there any myths that are going around on social media?

I know you've done a couple, but are there any more that you really feel like our listeners should hear? 

Yeah, so we talked about if I don't have aura, it's not a migraine, that common myth, actually that's the most common form of migraine. We talked about the cure for migraine and that we don't have a cure. [00:57:00] So if they're seeing that, I really would be skeptical. But it's just a headache is something that we commonly see that we need to reduce stigma.

As we've mentioned, migraine is so much more than just a headache. And so recognizing that these neurologic symptoms that can happen with it can mimic stroke type symptoms, that can be incredibly worrisome to individuals that can be incredibly debilitating. And so it is not just a headache and also that it's not in your head.

For so long we didn't have adequate treatment for migraine, or we didn't understand the pathophysiology or what makes it happen. And we're still figuring that out. And so women in particular were told you're just stressed, or you're just anxious, or you're just depressed and everything's gonna be fine if you can just calm down.

It's not just in your head. This is a neurologic disease with genetic basis. And so being aware of [00:58:00] that. And then sinus headache is the most common myth, right? So if you're having recurrent sinus headache, stop the antibiotics, please try some migraine treatment.

If I'm wrong, I'm wrong. The 88% chance I'm right, and so it could change your life. Lastly, the caffeine always causes a headache. The truth is that for some caffeine can relieve a headache, and so especially if you have more rare migraine, pairing it , with an amount of caffeine, like equivalent to a cup of coffee or even slightly more for that attack could be beneficial for you.

And that is something I felt like I learned is it's more about keeping your caffeine consistent than anything. Is that correct? That's 

correct. And that's more so for somebody who has more regular headaches. , If you're the once a month or once every few months, then it's probably not your fluctuations in caffeine unless you had an excessive amount [00:59:00] right day.

And so those are the situations that I'm talking about where you could introduce caffeine as a treatment. But if you're prone to more regular headache attacks, that one to two a week or more, that's where you wanna keep levels consistent and generally lower, because trying to consistently keep these higher levels is nearly impossible.

 And I hope I emphasize 'cause this is another social media myth, is everyone should clean out gluten or dairy. And again, it's highly individual that eliminating these for some may not have an impact. And so not to be discouraged with that. 

Dr. Duvall, before you leave us, I would love for you just to give a little spiel about your book and who may benefit from it.

Yes, absolutely. So I call my book a Labor of Love because I'm not an author, and for anyone who is not writing a book is just a big feat.

And so for me, my book was that I cannot have [01:00:00] a two hour conversation with every. Person. and migraine is so comprehensive. So in fact my 9-year-old that hears me talk about this all the time, if you ask him what causes migraine, he'll tell you everything. Everything in anything. There's so many different factors.

And so my book really goes through all of this, number one, that you're not alone. And I think that this can be helpful even for family members who may not be understanding. I like to have these things written down so that when my patient says it, I can say, look, this was already in writing.

This is something I hear over and over again. I talk about sinus headache and the common, misconceptions, keeping a migraine calendar, the various treatment options, dietary lifestyle. the purpose is really to be in the voice of a patient and trying to provide helpful, practical, day-to-day advice.

There are typos in it. Please don't tell me about those, because [01:01:00] again, I'm not an author, but my hope is that it'll be empowering for somebody living with migraine and or allow them to share with colleagues or family members to know what they're going through. 

No, that's great. 'cause that's one of the reasons we wanted to do a podcast is be able to give more time for education for patients because it's hard to do in clinic visits at this time.

I love what you all are doing. In fact, as I mentioned, I've been listening to the podcast and it's great to have these practical tools and I think it's also important to recognize that medicine is still an art form. And so we're still learning and developing so much of this and we may not have all of the answers.

So figuring out, what the general recommendations are, but tailoring it to every individual is so important. And that's the same concept in migraine management. 

 Thank you so much and I know your patients appreciate you so much for treating something that can be so difficult, but like you said, so life changing.

 I appreciate you guys. It's so nice to meet 

you. 

[01:02:00] This has been so helpful. Dealing with headache can be so problematic for so many people. And so I think you've given us so much good advice Tension headache, you really wanna think about how is your day going?

How are you positioning yourself at work? Are you getting tech neck and looking down at your phone all the time? So really making sure that you're not constantly pushing your head and face forward and trying to strengthen your neck and have good posture. You also need to watch for lack of sleep and stress as both of these can be triggers.

And then make sure you are staying well hydrated in the realm of migraine. You really think of that as having a brain that is hypersensitive to things. And so the best thing you can do when you're thinking about aspects of lifestyle is to try to have consistency. And so when you're thinking about nutrition, you wanna have.

Good, consistent nutrition, not having spikes of blood sugar up and [01:03:00] down. You wanna make sure that you're staying well hydrated and you wanna try to avoid foods that are going to increase inflammation in your body. But we also need to remember that that is going to be different for everyone. So you need to see what things affect you and try to do that in a methodical manner.

May wanna think about adding magnesium and riboflavin to your supplement list if you are someone that suffers with migraines. And then of course, trying to avoid alcohol and nicotine. Again, you wanna try to keep your stress level as low as possible. We know that's easier said than done, but working on understanding your triggers for stress and seeing what you can do to modify that, really working on getting consistent sleep is another thing that's really important.

But I think we also took away. From you today, understanding that many headaches are migraines, even though you may think there's something else. So understanding [01:04:00] that might help you with what triggers you have and how to avoid getting headaches down the road. 

Hopefully you all found all of this information helpful, especially you can take some of it and have a conversation with your primary care doctor or your neurologist if you see one for headaches and have an educated discussion on how to get better control over your headaches.

We're gonna continue on this theme , and talk about strokes next week. We have Theresa Avili. She is a neurologist. With tele specialists and manages strokes on a regular basis. So we're gonna talk about stroke prevention and I know this is something that many people have had, family members who have experienced this and definitely want to do anything to prevent that in their own lives.

And we'll talk about those lifestyle factors that have a big role in it as well next week. If you have enjoyed today's show, please be sure to like our podcast, leave us a review, share the show with others who may be suffering from headaches. [01:05:00] If you have other topic ideas, please click send us a text, send us a message on any topics that you would be excited to hear about on our show as we continue to plan out the shows for the rest of 2025.

We'll see you next time.