Hormones & Migraines: What Every Woman Needs To Know

Episode summary

In this insightful interview, Dr. Rose Giammarco, a neurologist specializing in headaches, shares expert knowledge on migraines, triggers, treatment options, and how hormonal changes influence headache patterns. Discover practical tips for managing migraines and understanding when to seek medical help.

Key  topics

- Difference between headache and migraine
- Hormonal influence on migraines
- Triggers and lifestyle management
- Medication options and overuse risks
- Pregnancy, postpartum, and menopause considerations

Chapters

00:00 Introduction to Headaches and Migraines
04:36 The Burden of Migraines on Women
05:07 When to Seek Medical Attention for Headaches
07:37 Menstrual Migraines: Causes and Effects
10:57 Preventing Menstrual Migraines
13:35 The Role of Supplements in Migraine Management
14:47 Medication and Treatment Options for Migraines
18:54 Advil vs. Migraine-Specific Medications
22:08 Lifestyle Factors and Migraine Triggers
24:16 Understanding Medication and Migraines
25:06 Pregnancy and Migraine Management
30:43 Postpartum Headaches: What to Watch For
32:11 Birth Control and Migraines
33:00 Stroke Risk and Migraines
34:51 Perimenopause and Migraines
36:15 Hormone Replacement Therapy and Migraines
38:12 Lifestyle Factors in Migraine Management
41:28 The Importance of Headache Diaries
45:20 Natural Approaches to Reducing Migraines
47:03 Key Takeaways for Women Managing Migraines

Resources

International Headache Society - https://www.ihs-headache.org/
Migraine Canada - https://migrainecanada.org/
Ubrelvy (ubrogepant) - https://www.ubrelvy.com/
Botox for Chronic Migraine - https://www.migraines.org/treatment/botox/
Migraine Diary Apps - https://migrainecanada.org/tools/diary/
Dr. Rose Giammarco's Clinic in Hamilton - https://www.hamiltonneurology.com/

Disclaimer

Breast Intentions is intended for informational and entertainment purposes only. The content shared on this podcast is not a substitute for professional medical advice, diagnosis, or treatment. Any views or opinions expressed by the hosts and guests are their own and do not necessarily reflect the views of any affiliated organizations. Always consult with a qualified healthcare provider for medical advice or concerns.

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Transcript

SPEAKER_02 0:00

Yeah, the disability and burden of migraine is beyond what you would imagine. Up to 18% of women suffer from migraine at some point in their life. And of those women who have migraine, about 25% have menstrual migraine. And it's got a huge disability. It's considered one of the top disabling conditions, particularly because it hits women in particular in their childbearing years and in their most productive work years. So between their 20s and their 50s, when they're very productive at work or raising their family, whatever the case may be, that's when the migraines seem to peak the worst. So the disability and burden of disease is huge.

SPEAKER_03 0:39

Welcome to Best Intentions, the podcast where we take off the bra of expectations and dive into honest, empowering conversations. We're your hosts, Nadine and Cynthia, two Canadian girls who swapped snow boots for flip-flops in the Cayman Islands. This is your space to feel seen, supported, and a little less alone. So grab a cup of coffee or a glass of champagne and get ready for your weekly handful of truth, wellness, and empowerment. Welcome back to Breast Intentions. Headaches and migraines in midlife can feel confusing and often misunderstood. So today we're bringing in a true expert. We're joined by Dr. Rose Giamarco, a neurologist with over three decades of experience, trained at McMaster University and actively shaping migraine care. Based in Ontario, Rose is also the visiting neurologist at Health City, right here in the Cayman Islands. And today she's breaking down what every woman needs to know about migraines in midlife.

SPEAKER_00 1:36

So um maybe if you can give our listeners a little bit of an intro on how you ended up specializing in headaches and migraines.

SPEAKER_02 1:45

I started as actually I was a nurse. I was a psychiatric nurse for a long time. I went into medicine and then neurology. I had a practice in general neurology, and as part of my residency, I spent time with my mentor in Toronto, um, Dr. Edmeads, who was one of the first headache specialists in Canada, and he really influenced me in that area. So I have migraines myself. Um I worked with him quite closely, and even though I had a general neurology practice for the first several years, I started to focus more on headache and headache and and basically have an exclusive headache practice over the last 25 years. So yeah.

SPEAKER_00 2:24

Now, for anyone who is listening, by the medical definition, what is the difference between a headache and a and a migraine?

SPEAKER_02 2:32

So headache is more of a descriptive term. Um, and headache really refers to head pain. It's not a diagnosis, it doesn't really fit with any of the criteria that the body called the International Headache Society has, where they go through over 200 different types of headaches. Headache would be anything that describes head pain. So you can have headache from sinus issues and TMJ problems and problems with your eyes and so on and so on. It's not really a diagnosis, it's a description. Migraine is very different. Migraine is a brain disease that's inherited in many situations. It has a very specific set of symptoms that go along with it, and those are sensitivity to light, sensitivity to noise, possibly smell, nausea, potentially vomiting. In a percentage of patients, they have something called an aura, where they have a set of neurological symptoms that include perhaps visual changes, flashing lights, they may lose vision, they may have numbness or speech difficulty. So it's got specific criteria as outlined by the International Headache Society itself. They could be episodic, which means they happen two or three times a month, but then over time, and in some patients they become chronic, so they may have headaches 15 to 25 days in a month. So there are many different subtypes of migraine, but we won't get into that today. So that's essentially the difference.

SPEAKER_00 3:58

Okay. You know, throughout all of my years of coaching, um, I had probably a handful of clients that suffered with headaches on a daily basis.

SPEAKER_02 4:08

Yeah, the disability and burden of migraine is beyond what you would imagine. I mean, up to 18% of women suffer from migraine at some point in their life. And of those women who have migraine, about 25% have menstrual migraine. Um and it's got a huge disability. It's considered one of the top disabling conditions, particularly because it hits women in particular in their childbearing years and in their most productive work years. So between their 20s and their 50s, when they're very productive at work or raising their family, whatever the case may be, that's when the migraines seem to peak the worst. So the disability and burden of disease is huge.

SPEAKER_00 4:47

So it's inherited, you were saying, for the most part, the migraine side of things?

SPEAKER_02 4:52

In some cases, yeah, very often there is a family history. And there are some genetic subtypes, like familial hemoplegia, which is a different type of migraine, but there are some specific subtypes that are inherited. Migraine in general is felt to have some genetic um basis to it in some situations. Having said that, there are certainly patients that I see that don't have any family history of migraine at all. Um some patients can develop migraine post-traumatically if they have a head injury preceding history. Oh wow.

SPEAKER_00 5:21

Okay. So for many women that do get the headaches and they push through, when is it something that you should actually get checked out? Like it does it just last a bit longer, or is it like a certain level of pain?

SPEAKER_02 5:43

So there when we in neurology, when we look at headache, we have something called the red flags. Okay. And there's about 10 or 11 different red flags. And essentially, this applies to any kind of headache, but um, women or men in the general population, if someone has worsening headache, the uh escalation in the frequency or the severity, um, if they have associated symptoms, like when they get a headache, they start to get double vision or they start to get periodic paralysis. Um, if their headaches are associated with fever or neck stiffness, we think about more infectious processes like meningitis, for example. If they have ocular symptoms, glaucoma is not headache, but it can certainly present as orbital pain, which sounds very much like headache. Um and if some the one that's most worrisome and troublesome is the thunderclap headache, and it's exactly like thunderclap. Your headache is devastating from the onset, it doesn't build, it comes on very, very quickly. And although there are some migraines that do that, um it's called a benign thunderclap headache, it could also be something that's underlying that's more sinister, such as a ruptured aneurysm or a stroke or a bleed into a tumor or something like that. So those would be the red flags that we consider, and we always ask questions in the history pertaining to those symptoms. Um and in some patients you you if they do have the red flags that warrants further investigation.

SPEAKER_00 7:09

So when do they get sent to you? Like they would get sent to you by their GP.

SPEAKER_02 7:17

Well, it I think I think it would depend on how in Canada or Ontario you need a referral, so they would have to see their GP or other physician who then refers to me. Um many patients get referred to a general neurologist, and that's absolutely fine. And then if the general neurologist is comfortable treating headache, and they should be, um, they will take over. But if there's something unusual about it or problematic with a treatment or they're just not responding to treatment, very often they come to see me.

unknown 7:46

Okay.

SPEAKER_00 7:46

Why do migraines around your period feel so much worse than other headaches? Okay.

SPEAKER_02 7:52

So menstrual migraine or menstrual related migraine, and there are two types very briefly. I'm just going to give you the description. Menstrual-related migraine is when migraine occurs during the menstrual cycle, but the women will have migraines at the other times of the month related to alcohol or weather or whatever the triggers are. Pure menstrual migraine, which is less common, is just migraine around the menstrual cycle. So that's the distinction. The treatment's not going to be that much different, but we'll talk about that as we go along. But um headaches during the menstrual cycle have to do with estrogen stability. And that's the underlying cause we think of menstrual migraine. And these studies were done back in the 70s, and sadly, there's not a whole lot more since that time that's really been looked at in great detail. But they looked at women who had menstrual migraine, measured estrogen levels, and felt that the drop in estrogen just around the menstrual cycle was the trigger. So why does estrogen make headaches more sensitive? Well, you know, for example, when you have a procedure, if you go to the dentist, if you have Botox, if you have something else, pain is more is perceived as more intense during the menstrual cycle. Um and the reason for that is estrogen, when it's depleted or when it drops, the brain becomes more sensitive to painful stimuli. Um and also when you're around the menstrual cycle, prostaglandins are released, and this is a brain chemical that causes inflammatory changes, and that's also why you may get more pain and the headaches may be more painful. Um but they definitely are, and although there haven't been terrific studies in this area, the some of the evidence suggests that menstrual migraines are more severe, they last longer, they don't respond to medication as well as other migraines during the rest of the month, and the rescue medications don't seem to work as well for them overall.

SPEAKER_00 9:44

Oh, okay. So then this is where, and I think we're going to talk about it later anyways, is when women are going through menopause and when the estrogen is dropping, is when they start to notice. It's all about headaches. I yeah, I I've never um struggled with headaches at all um during my life until my hormones started to go a little bit wonky, and now I notice that I actually get a little bit of a headache a couple days before my period.

SPEAKER_02 10:14

Yeah, for sure. And everything changes at the age of 40. Um so even though you you're not physically going into menopause, and we'll talk about that, there are many, many other changes as a result of it.

unknown 10:25

Okay. Okay.

SPEAKER_00 10:27

Is there anything that women can do before their period starts to prevent migraines?

SPEAKER_02 10:33

So we're going to talk about lifestyle, so I won't get into detail here, but as far as medication is concerned, um it really depends on the predictability of the cycle. So I'm going to give you a clinical scenario. So a patient comes in, she's in, she's her mid-30s, she has headaches around the menstrual cycle. The questions that we tend to ask are: are your menstrual cycles predictable? In other words, are they 26, 28 days all the time? And does your headache around the menstrual cycle start on a predictable day? Many women will say it starts the day I start my period, some women will say it starts a day before. And that's helpful. Um it's particularly helpful if they're on the pill and they know their period date and they know when the headache starts. Diaries are also helpful for this because what we can do is we can do a mini preventative approach. So if a woman has her menstrual cycle every 28 days, her headache starts on day 27. There have been studies using several different medications where on the day before the headache, we start them on a migraine medication, such as a tryptan, imotrex, stomatryptan, even neproxin, for example, there's a new class of drug called the GPANs. So we start that the day before in anticipation of the headache coming on, and they take that medication for five days in a row, hoping to prevent the headache from coming on. So that's only if they have a predictable cycle. The more challenging thing is when their cycles are all over the map, there can be 26 days, 28 days. We can't do that. So what we end up doing in that situation is we just give them something that works effectively to take abortively, meaning when the headache comes on, and that's what they do for the three or four days that they have their cycle. If they have headaches other times of the month, so menstrual related migraine, and their headaches are more than five or six a month, we generally look at starting a daily preventative medication and then topping them up around their cycle.

SPEAKER_00 12:32

Now, I don't know if if we're going to get into this later on or not, but from a supplement side, is there anything that a person can do? Or are you at a stage where when people are seeing you, like this is far beyond supplements?

SPEAKER_02 12:47

I wish. You know what? My first appointment with a patient is about education and lifestyle. And that's we can talk about that in a bit more detail, but since you asked about supplements, I'll talk about them here. All of my patients get started on magnesium, um, and the dosage is either 300 milligrams twice a day. If they have sleep issues, I tell them to take it all at bedtime. One of the side effects could be diarrhea. If they have that, they can back down a little bit, but hopefully stay on it. Another one is B2 or riboflavin, again, 200 milligrams twice a day, but taking it all at once improves compliance, so take it all at bedtime, 400 milligrams. Although we do recommend vitamin D, there's really not a lot of evidence for it showing benefit, but it certainly doesn't hurt, particularly in a perimenopausal woman. But then the other one that we tend to start is coQ10, coenzyme Q10. It's good for many different things, including cardiovascular disease, and there's some evidence that it may help with migraine, and that dosage would be 75 to 100 two or three times a day. Um, so those are the supplements that we tend to look at in addition to the other lifestyle issues. And that, you know, that can easily be started before they come to see me, but sadly most most times it's not.

SPEAKER_00 14:04

Okay.

unknown 14:05

Okay.

SPEAKER_00 14:06

So going along that line with the medication, with a lot of women being afraid to take medication, um, are they suffering unnecessarily because of this?

SPEAKER_02 14:16

Yes, you know, the pain of menstrual migraine is not fun.

SPEAKER_00 14:19

Um I'm I'm guessing there's so many women that just kind of, you know, I'm gonna put on my strong hat and I'm just gonna plow through. It's just a headache, or you know, it'll go away. And I can see that.

SPEAKER_02 14:32

And you know, they have it every month and it's short-lived and it lasts two or three days. And but you know, when you think about it, uh the question I ask them is, are you missing work? You're staying home from work on those days once or twice a month. Are you able to look after the kids? Are you missing social functions like your kids' birthday party or Christmas or something like that? And if the answer is yes, then I try to encourage them, just take the medication when your period comes on, take it appropriately, take it early. Um The other problem is that now over time, with many studies that have been done, patients who have migraine who don't treat when they're episodic. In other words, if you have migraines three, four, five days a month, over the years you have a higher chance of developing chronic migraine by not treating them. So you may end up with 15 to 20 headache days a month. So there are advantages to treating aggressively, treating early um when you have the headache to prevent that chronic migraine.

SPEAKER_00 15:30

Okay. I feel so bad for anyone that has to suffer with that. Like again, I've I haven't really had a lot of them. Cynthia, do you get them?

SPEAKER_03 15:41

No. Um in the past, I think I have like probably menstrual related head. I wouldn't even I don't it probably wouldn't even be classified of my grain, I think. It was probably to me just a really bad headache. Yeah. Um, but it it didn't last very long. I think it was actually probably when I was starting perimenopause, like it was several years ago now. Um, but it it is debilitating, like it's yeah, hard to concentrate when you do even have just I don't know, a mild regular disk because I just it's just there, and you're like, oh, I can't get any work done. I can't concentrate, I can't deal with whatever this person needs me to deal with right now. So I yeah, I can't imagine. Some people are dealing with it daily, and I can't even imagine.

SPEAKER_02 16:28

I mean, imagine having a migraine where you can't go out, you're in bed, the lights are out, and you have two children, toddlers, yeah, at home that you have to look after. Um, and then you're never headache free because the other thing that happens is that when you start taking medication more than 10 days a month, and these people have to, then you have the added complication of developing medication overuse headache, which is from the drugs you're taking. So things like Tylenol, neproxin, the tryptans, things that abort the migraine and that we encourage you to take. If you take them more than 10 days a month, you start to develop we call it medication overuse or medication-induced headache as the proper classification, and that's a daily background headache, but then the migraines occur on top of that. So it's a real difficult thing. And these patients are so disabled by them. And many of them, it's amazing to me how they still go to work and work under work conditions with loud noises, fluorescent lights, working shifts, you know, healthcare workers. It's just it's unimaginable. It really is.

SPEAKER_03 17:35

I would also be worried about taking that much medication. Like I I know the headache overuse a headache can happen, but also like other parts of your body, like I feel like I don't know, your liver, your gut, your liver.

SPEAKER_02 17:48

Like, yeah, depending on what it is, you know. I mean, the tryptans um aren't typically a problem. The long-term use of tryptans hasn't been shown to do anything, but and these newer medications have only been around for about five years, so stay tuned. But right now they look to be fairly safe. The ones you want into trouble with are the over-the-counters, you know?

SPEAKER_03 18:07

Yeah, right, like the Advil and the Yeah, and Tylenol. Yeah.

SPEAKER_02 18:10

People think, oh, it's just Advil, but you know, you get gut problems and GI issues, and with the Tylenol, you get into things like liver toxicity. So yeah, there are problems.

SPEAKER_00 18:21

Yeah. So going along that line, Advil versus migraine-specific medications, what's the difference?

SPEAKER_02 18:29

There is a difference. I mean, Advil is something that treats the pain, basically. And Advil blocks that chemical called prostaglandin. So any inflammatory pain, even if it's your back or your leg or whatever, your tooth, the advil will work. So it's not a specific target. It's simply treating the pain. Um, as opposed to migraine-specific medication, and there are two, um, three, but one's not around much anymore. So the tryptans, and you know, for people who have had migraines, imitrex, maxalt, rhizotriptin, elotryptin, there's about seven of them. Um, and they're essentially the same with minor differences, but those are targeted towards the transmitters and chemicals that affect migraine. And the newer class of drug called the GPANs, called Ubrel V, um, I believe that's available now in Cayman. Um, so those medications are migraine-specific. They target certain chemicals and transmitters in the brain that will stop the process. So instead of chasing it with pain relief, you are stopping the process from progressing. So that's the major difference.

SPEAKER_00 19:39

Okay. Can they use can they be used hand in hand? Together, yeah. Or would do you yeah.

SPEAKER_02 19:45

I mean, I less is better. So if I'm giving them a prescription one, I'll tell them to try it. But then they may come back and say, well, your prescription medication worked well, but I still had a little bit of a headache and it was much more tolerable. Then I might tell them to combine that my medication with the over-the-counter one, as long as they're documenting what they're taking, so I can see how often that is.

SPEAKER_00 20:06

Okay. I feel like I remember many years ago Advil coming out with like a migraine pill that had caffeine in it.

SPEAKER_02 20:15

So there's one, we don't have it in Canada. Um, but in the US, there's something called excedrin migraine. Works great.

SPEAKER_00 20:22

Yes, that's what it was.

SPEAKER_02 20:23

I mean, it's a combo of Tylenol, an anti-inflammatory, which is Motrin, um, and a bit of caffeine. So it works very, very well for people that may not have extremely severe migraine. Um, and in Canada, what I'd basically do is tell patients to take an extra strength advil, a Tylenol extra strength, and they are hit of caffeine, whichever their choice is, and take that all at the same time.

SPEAKER_00 20:47

So you like down it with your coffee? That kind of thing? Like you down it with your coffee, or really. Is there a certain amount of caffeine?

SPEAKER_02 20:55

Is it a coke or something like that? Because you're getting that caffeine, and that caffeine helps with the absorption of the drugs, too.

SPEAKER_00 21:02

Is that what the caffeine is there for?

SPEAKER_02 21:04

It does a lot of stuff.

SPEAKER_00 21:05

For quicker absorption.

SPEAKER_02 21:06

It does a lot. I mean, caffeine and migraine is a very hot issue. I mean, too much coffee is not good. Um, too little coffee causes caffeine withdrawal in someone who drinks on a regular basis. Um, if you have a hit of caffeine when you have a migraine, it may actually help. Like some migrainers will get up in the morning. I know I sometimes I get up in the morning and I feel like my migraine is coming. After I have my morning coffee, it's gone. So it's like sleep, you know. I I was going to get into this, but we might as well talk about it. Not enough sleep will cause migraine. Having a nap in the afternoon sometimes triggers a migraine in someone who has migraines. Sleeping in or changing your sleep cycle will cause a migraine, which is why many patients wake up Saturday morning and say, I have a headache every single Saturday morning. It's because they've slept in an hour or two. So migraine brains are very sensitive to change. So, you know, if you change your sleep routine. If you change your diet. God forbid you fast and your blood sugar goes down when you're a migraine sufferer. Those are all triggers. You know, stress is another trigger to migraine. People, and it's and it's paradoxical because people can function at a very high stress level from Monday to Friday. On Saturday and Sunday, or even on the first couple of days of vacation, their headaches will go over the top. And it's, you know, you think, why? I'm not stressed. My stress was last week. I'm better now. Why am I getting a headache now? It's because of that stress release phenomena. We don't fully understand physiologically how that all works, but I mean you'll definitely see it in some migraine patients.

SPEAKER_03 22:41

It's almost like you're, I don't know, running on adrenaline or you're just like, go, go, go, go, go. And then when your body relaxes and lets go of all that, exactly right.

SPEAKER_02 22:50

That's exactly right.

SPEAKER_03 22:51

Kind of ramps up, yeah.

SPEAKER_02 22:52

Yeah.

SPEAKER_00 22:53

It's a very fine line then to try to manage migraines.

SPEAKER_02 22:57

Yeah, it's routine, routine, routine. And that's part of the education with patients is try and stick to the routine. Get it's not fun to get up at six o'clock on a Saturday morning and a Sunday morning when you could sleep in, but if you don't, you'll get a headache in some cases. Also, you know, the other thing on a Saturday morning is you don't, you know, and during the weekday, you may grab something to eat for breakfast in the morning, whereas on Saturday morning you have orange juice, bacon, eggs, maybe something else, and those are migraine triggers right there. Plus your trigger of sleeping in. And maybe an extra cup of coffee, which will do it again too.

SPEAKER_03 23:30

Sounds like you have to be very regimented and very structured. You do. Yeah.

SPEAKER_02 23:35

Yeah, you do. You do.

SPEAKER_00 23:38

So is there ever a a case where you may take too much medication and trigger a migraine? I'm guessing so, because it's just such a fine line.

SPEAKER_02 23:47

Well, the tryptans, I mean, the tryptans, when they first came out back in 1991, patients were coming in saying, Oh my, my headache's much, much worse when I take it. But I mean, I've taken these medications and during the f in some of them, during the first 20 minutes after you take it, you get that tightness in your neck, tightness in your jaw, tightness around your scalp. That's the medication working. And it kind of wears off after about 20 minutes as the meds start to kick in. So that can sometimes be perceived as medication making your headache worse. There are some preventative medications that patients find make their headaches worse as well. So it really depends on the individual.

SPEAKER_03 24:27

Okay. Um, we're gonna move into sort of pregnancy and postpartum a little bit. I'm assuming there is a hormonal component here. Um, but yeah, if somebody's trying to get pregnant and they do already suffer from migraines, it is there something they should be thinking about ahead of time?

SPEAKER_02 24:47

So my advice to women when I start them on a preventative and they're thinking of family planning down the line is to speak to me or their physician about what the timing is. Um, have a plan. If they're on a preventative medication, ideally stop it as your planning goes into play. Um if you miss that and you're on, choose a medication with your physician that could be relatively safe if you do become pregnant, and there are some. Ideally, we stop everything once they're pregnant or before when they're planning, and not try and give anything during the first trimester. It's a key time in fetal development. There are medications we can use that have been approved during pregnancy, like the amatriptaline antidepressant class, the beta blockers, propranolol. So those have been approved during pregnancy and are considered relatively safe. There are also acute medications to take, like stubo triptan, for example, and can be taken during pregnancy now, just recently, they've decided that it's okay. So the key is really education planning before. Also, if patients are pl have very bad migraine, chronic migraine, you stop their meds, they get much, much worse. Think about that scenario. What's your plan going to be? You have two kids at home, you have a full-time job, do you have resources? Do you have people you can turn to? Is your work environment something that needs to be addressed during pregnancy? And basically taking it all back to the natural things, hydration and so on and so forth. In terms of medication, um, in terms of the course of migraine, the good news is that 70% of women get better during pregnancy because it's a fairly stable estrogen rise, there's no abrupt changes or fluctuations. So 70% get better and they maintain that while breastfeeding. Sadly, the 30% that don't get better, um, one of them, one group gets worse during the first trimester, and then it improves as it goes on. But then there's one particular group of women, and I'm one of those, both pregnancies where your headaches just went off the rails, the entire pregnancy, and even into breastfeeding. So it can it can do one of three things. It can get worse, it can get better, and it can basically be somewhere in the middle. But we can treat them. There are options for treatment, many more than there used to be, even 10 years ago. So that's the good news. Um and in breastfeeding.

SPEAKER_03 27:19

That's good to know because I think I would have assumed that no, you can't you have to kind of cut it all off and suffer through.

SPEAKER_02 27:26

Yeah. Yeah. There are some that we can use. Um, and and we go things like nerve blocks, for example, and even in some situations, some physicians will give Botox because there's no evidence that it causes harm at this point.

SPEAKER_00 27:38

I forgot about that one. I don't know if we have that on the um on the list. But it is um something that I've heard of a lot of people getting.

SPEAKER_02 27:48

Yeah. So Botox, the indication we have for Botox, and it has to be approved and so on, is for chronic migraine. So chronic migraine is eight migraine days minimum per month, but then another eight or nine headache days. So a total of 15 headache days a month. Um, and you also in Canada, and not so much in Cayman, but in Canada, you need to have failed three of the traditional oral treatments before it's approved by insurance. Um, Botox works quite well in chronic migraine. Um, and just in terms of the procedure, it's given every three months. There's a total of 31 to 35 injection sites given all at the same sitting. Um, not very uncomfortable, it's a very tiny needle. So it's very similar to the cosmetic Botox if anyone has that, except that we have more injections involved and different locations in some cases. It works well. Um, and the big advantage to Botox is the side effect profile. So if I have a patient who has multiple medications, who has multiple medical problems, um the Botox is something that I would generally look to because it's not going to interfere with drugs, it's not going to give them side effects of weight gain, weight loss, cognitive changes, or anything like that. It's very clean in terms of tolerability. So yeah.

SPEAKER_00 29:09

And it's in like the back of the neck, I think some people get it.

SPEAKER_02 29:12

Like, yeah, we basically inject frontally here. These are very similar to the cosmetic ones. We then inject into the temple, into the back, and then across the traps. So in people who have a combination of neck pain and migraine, that's obviously also a very good course to go.

unknown 29:32

Okay. Yeah.

SPEAKER_03 29:33

Oh, that's so neat. I've seen people like get the the trap ones done. Um I do, I have neck pain sometimes, so I'm always interested in that one.

SPEAKER_02 29:42

So we have to look at it. But also TMJ. Yeah, that's off-label. But many patients who have chronic migraine do clench, do grind their teeth. And so sometimes off-label, not part of the protocol, we add a little bit into the jaw as well.

SPEAKER_03 30:02

Alright, back to the postpartum. After having a baby, how do you know if a headache is just a headache or if it's something more serious?

SPEAKER_02 30:13

So the the list of possibilities during pregnancy and in the postpartum period for headache in terms of the differential and other possibilities is very different than it is in the general population of women. Women who deliver babies, women who are pregnant, we have to think of things like eclampsia, toxemia. Women are hypercoagulable, meaning they have more tendency to clot. So we have to think about something like that as a potential process. There are some benign brain tumors, like something called a meningioma or a pituitary tumor, that may be absolutely fine. It's tiny, small, but it grows under the effect of hormone pregnancies, hormones of pregnancy, rather. So those are things to consider. Plus, there are also other very unusual headache syndromes that can be quite devastating that can occur during pregnancy. So our index of suspicion in a pregnant or postpartum woman is much higher for something sinister, especially if this is a new headache presentation.

SPEAKER_03 31:13

Yeah, right. So, what about for birth control? Is that similar to like some women who go on birth control, their migraines disappear, whereas some get worse? Is that sort of like the pregnancy one?

SPEAKER_02 31:28

Well, it's the it's all about estrogen again, right? That's what it comes down to. And when you're on the birth control pill, your estrogen's pretty stable. So your brain is happy. And if it's a low dose pill, many women, their headaches do get better because they don't go off the estrogen and they don't have a menstrual cycle, so they have that smooth estrogen throughout the course of the month. Um, where they run into trouble sometimes is if the estrogen dose is too high. Um, that high estrogen can sensitize the situation and make their headaches worse during the course of the month rather than just associated with the menstrual cycle.

SPEAKER_03 32:02

Oh, okay.

SPEAKER_02 32:03

So it's variable and you can't predict. But my my rule of thumb is always the lowest possible estrogen dose that you can get away with, and preferably continuous rather than placebo during those seven days.

SPEAKER_01 32:15

Yeah.

SPEAKER_03 32:17

Um what is the connection between migraines and stroke risk? And who needs to worry about that?

SPEAKER_02 32:25

Um I mean that's a huge topic, but very simply, women who have migraine, who are otherwise healthy, who have plain migraine without aura, the stroke risk is not significantly different from another woman compared without migraine of childbearing age with no stroke risk factors. Where we run into difficulty, the thing that seems to be the factor is the aura. Um and so if you have a not so much even just a visual flash of light, but if you have a more complicated aura where your speech is affected, or you have numbness down one side of your body, or you have severe vertigo, or you lose your vision, that in itself associated with migraine increases your stroke risk. Um and then if you add other stroke risk factors, so diabetes, hypertension, um, high BMI, uh smoking, for example, all those things increase the risk exponentially. So basically your stroke risk is not significantly higher in a young woman who's healthy, no aura, and no other risk factors. We start to get worried when all these other risk factors are compounding it. And that's when your stroke risk goes up. And those are precisely the kind of women with those stroke risk factors where we would not consider putting them on the birth control pill or hormone replacement therapy.

SPEAKER_03 33:45

Okay. So you had said earlier that everything changes at 40. Um this is um the perimenopause time of our lives. Um for for women that do say that my migraines have changed and I don't recognize my body anymore, what could be what could what's going on?

SPEAKER_02 34:10

So during your 20s and 30s, things are good. Estrogen's stable, hormones are stable, your periods are usually regular. And so what happens in your 40s is even before your blood work reflects it, um, and even before you develop other symptoms, if you think about what causes menstrual migraine, it's that curve of estrogen going up slow and then dropping. If you think about perimenopause, your estrogen is doing this up and down and up and down. And every time it drops, you're prone to getting the symptoms. So that occurs even before your blood work will reflect it. So women who come in and say, Well, my family doctor or whatever, I had my hormones checked, my hormones are fine, you're just catching a little snip of the hormones when they're getting in their blood work. So it doesn't really reflect perimenopausal symptoms. I mean, a lot of things happen perimenopausally before you lose your period, your weight changes, you develop widening of the abdominal girth, you develop cognitive issues or brain fog, for example, hot flashes, restless life, there's a whole list of wonderful things that happen. Um, and it's again because of that fluctuation in estrogen. And so, yeah, it's just part of it, unfortunately. Yeah.

SPEAKER_03 35:22

What role, if any, does hormone replacement therapy or HRT play in managing migraines?

SPEAKER_02 35:30

Okay, so again, keeping in mind the whole stroke risk that we talked about, but as a neurologist, um, I tend not to delve into HRT, but it doesn't mean that it doesn't help. So what I try to do from my perspective is manage their headaches. So I give them acute treatment, I give them preventative treatments if their migraines are occurring frequently. I really focus on lifestyle issues like sleep hygiene, diet, exercise, um the vitamins that we had talked about, um, and I put them on prevention if I need to. If I think that hormone replacement therapy may help, not because of just their headaches, the only time that I would suggest hormone replacement therapy if they've developed these other symptoms like restless legs or hot flashes or cognitive issues, dry skin, and so on, that's when I would get in touch with my gynee and say, help me out with this, and what's the best thing to take? Um, preferably low dose, continuous um progesterone only if you're worried about the estrogen, but we make that decision together. Yeah.

SPEAKER_01 36:37

Okay.

SPEAKER_03 36:38

Is it true that migraines get better after menopause, or is that just a myth?

SPEAKER_02 36:45

No, it's not a myth, um, but it's unpredictable. You know, if a woman says to me, so are they going to get better after menopause? Unfortunately, there are no studies to say these women get better, these women don't. Um, so the answer to that would be possibly. Uh, many women do. And just anecdotally, in my own practice, I tend to find that women who have a hormonal pattern to their headache, so did they start when they were 14, when their periods began, were the headaches associated with their periods, did were they affected by pregnancy in one way, or the birth control pill? That woman, I very often will see, may get better post-menopausally. But then it goes out the window because sometimes women absolutely don't change after menopause.

SPEAKER_03 37:29

Right.

SPEAKER_02 37:31

Wait and see, unfortunately.

SPEAKER_03 37:33

Yeah. Okay, so we've talked a little bit, we've kind of alluded to things like sleep, stress, diet. What are the biggest everyday mistakes that women make that could trigger migraines?

SPEAKER_02 37:47

So I think that um, you know, let's talk a little bit about diet. Um, diet, again, regularity, um, monitoring triggers. We always recommend protein first thing in the morning and some form of glucose or something to get your glucose up because you slept all night, your glucose is down, and that the brain doesn't like that. The glucose is required for brain energy and production of these um transmitters and so on. So, diet would be the one thing. Many women don't eat breakfast, many women um don't eat three regular meals a day. Fasting for a diet is the worst thing you can do for migraine. Um, so that would be one of the three things that needs to be addressed. Exercise, huge factor in migraine. Um, exercising three to four days a week makes a huge difference. Um, and I think that that's another one. Um we're all busy, you know, and so the one thing that goes when we're busy is our exercise routine. And I always tell them I don't need you to spend money and join a gym. Even if you walk 30, 40 minutes three or four days a week, that's one thing that you can do. And then the other thing is sleep hygiene. You know, I mean, again, regularity, trying to get to bed at the same time, waking up at the same time. And sometimes it's beyond their control. You know, they're either working shifts, they have young babies that are waking up at night, they don't sleep well, they have stress, they don't sleep well. So those would be the three biggest, I think.

SPEAKER_00 39:12

I'm sure it can be really hard. Um, and and I've seen this in my work with my clients where when you are struggling on a daily basis with a headache or um, you know, a really bad migraine, it can be so hard to get yourself to eat well or to get outside and to walk and to go to the gym. And um that can be a good thing.

SPEAKER_03 39:36

You definitely don't want to be standing by the stove cooking meals or even exercising if I have if you have a headache, yeah.

SPEAKER_00 39:43

Yeah, probably just be curled up in bed. Right.

SPEAKER_02 39:46

So it's you know, it's that multi it's that multimodal approach to headache where it's not just about you know lifestyle, it's not just about acute medication, it's not just about prevention, it's really the whole thing that has to happen together. And there's small steps.

SPEAKER_00 40:01

Um out of curiosity, how long do you spend with your clients when um when you're meeting with them? Because you must have to learn everything about their lifestyle and yeah, we talk about all those things.

SPEAKER_02 40:13

So 45 minutes, sometimes an hour, depends on the complexity, you know. Um so it really varies. There are patients that I see that have been on five or six preventatives and have been on all the abortives I can give them, um, and have had a 40-year history of migraine, throw in a post-traumatic headache. So some of them are very complex, and it's a matter of sorting through. Um, thankfully, there's a whole new class of medication that came out in the last five years that has really made a big difference in migraine treatment. But the problem with that is accessibility. Hugely expensive. Some people, particularly in Ontario, don't have coverage for this sort of thing. Um, so you're back to treating migraines in the 90s with some of these people that can't afford them or have no coverage for these treatments. Um headache diaries. Go ahead.

SPEAKER_03 41:05

No, no, go ahead. Headache diaries, yeah. Headache diaries, yeah. They do they actually help, or is it is it tricky because people might forget to use them?

SPEAKER_02 41:15

Yes, and yes. They do help, but the problem is people don't bring them back or people don't keep the diary. And I have some great patients who come in with a diary the first time I see them. Um, and then I have patients who come in with a diary that's four pages long that has everything on it. And so the key things with the diary, the reason we use the diary, and this is what I tell my patients from the beginning, is that I want to know when you get your headaches, um, mark when your menstrual cycle occurs, when it starts, when it finishes, so that I can see if there's a correlation. Potential triggers, I always give them a list, it's a four-page list of food triggers. I ask them if they can to keep a food diary on the days that they get their headache to start to see if there's a connection with that. What medications did they take and write those down as well. Um, and so typically when they come into my office, I ask them to keep a three-month diary. It can be a paper diary, it can be an app, whatever you prefer. I prefer paper because I can see it right in front of me rather than have to scroll through their phone. But the younger folks prefer the apps, and you can get many different apps, and you can also get download paper diaries from Migraine Canada or the International Headache Society in the US. So diaries are critical, you know, because the other thing is, for example, for menstrual migraine, you can see it right there when their headache starts, when their period starts. But you can also track them for medication overuse headache. Because I can look at that one-month diary and say, you know, you took your med 12 to 14 days every month. We need to do something about that. It's not a judgment by any means, it's just we need to refocus our treatment and try and bring down those number of headache days. So the head the diaries are really a critical part. I would say they're step one of treatment.

SPEAKER_03 43:01

Yeah.

SPEAKER_00 43:03

That's for anything too, for people trying to understand uh themselves and you have to be accountable to like doing your part as well, because you can't do your job to the best of your ability if they're not doing theirs with like tracking for you.

SPEAKER_02 43:20

But the other thing that it's good for is that if I start a patient on a preventative medication and they come back after three months with their diary and they say this isn't working, and they push it across the desk and say it's not doing anything. But I look at their diary and I say, Well, like you know what? You didn't take your your rescue medication as often. You were taking it 15 days a week. You're now taking it eight days a week. And your headache didn't go on for three days. Your headaches are there, but they're only lasting a day. So it's not the number of headaches, it's not the number of days, it's are they responding better to medication? Is their quality of life better? Is their absenteeism from work better? So there's so many factors to look at for For results in medication and treatment.

unknown 44:02

Right.

SPEAKER_02 44:02

Not just the number of headache days.

SPEAKER_01 44:04

Mm-hmm.

SPEAKER_03 44:05

And it's one thing to sort of think like, oh, I think it's getting better, or I th I I think I just have them randomly throughout the month. But then seeing it written down and seeing these patterns or seeing if there was a food that triggered it or lack of sleep, whatever it is, seeing it, seeing the pattern helps, I think, for everything for headaches and other things as well. So if someone wanted to start today to reduce migraines naturally, what the what are the top three things that you would tell her to do?

SPEAKER_02 44:37

Um so I'll break that into categories. One is um lifestyle and thing addressing things like sleep hygiene, um, exercise, diet, not skipping meals, minimizing their caffeine to no more than one or two in a day, um, and keeping track of potential triggers. So those are sort of the usual lifestyle things and stress management, obviously. Um then I would say the vitamins, those are easy things to start, and we talked about that, so I would start the vitamins as well. Um and then the other thing that I would encourage them is if they're prescribed medication, to give it at least three months, because the preventative medications don't start to work until it's about three months. And don't be disappointed if the first one doesn't work the first time. I always tell them, you know, with high blood pressure, fit family dogs will start you on two or three things before they find the best one for you. Migraine's no different. We may have to do two or three trials of a different medication before we find the right one, and it's important for you to stick with it, right? So many will say, That didn't work, I'm not going back to see her. Or she's given me vitamins, she doesn't know what she's talking about, she didn't give me any medications. So there are so many things that come into play. So you have to have that discussion up front about waiting three months. If it doesn't work, I'm gonna be giving you something different. Um, so those would be the things.

SPEAKER_03 46:03

All right, and one last question for you What's something you wish every woman knew, every woman knew about migraines that could completely change how she manages them?

SPEAKER_02 46:15

Lifestyle.

SPEAKER_03 46:16

Yeah.

SPEAKER_02 46:16

Lifestyle? Lifestyle and treating and sticking with your treatment program. Those are the three. All right.

SPEAKER_03 46:24

It can make that much of a difference.

SPEAKER_02 46:27

Oh, for sure. I have patients who come in and I don't touch them with medication just because they're all over the map in terms of not not recognizing when they occur and triggers. So for the first visit for three months, I give them no medication other than maybe a rescue to take when they have the bad headache with instructions not to overuse it. And they come back and they've started the vitamins and they've changed some of their lifestyle. And I do have patients that go from 15 headache days a month down to three or four just by monitoring those things. So it does help.

SPEAKER_00 46:59

That's great.

SPEAKER_03 47:00

Yeah, that's amazing. Well, this was really interesting. Um, and I'm glad like it sounds like there are things that that women can do if they are suffering. Um which is great. I mean, I'm sure when you're in it, it doesn't feel like you can do anything to help. Um but this was a very interesting conversation. Thank you so much for joining us today.

SPEAKER_00 47:22

You're welcome. My pleasure. Yes. Um, you are based once a month in the Cayman Islands out of Helsinki. Every six weeks, yep. Every six weeks. Okay. And then you also have a clinic out of Hamilton, Ontario. My office is in Hamilton, right. Yes. Okay.

unknown 47:42

Okay.

SPEAKER_00 47:42

So just for any of our listeners, especially people who are based in the Cayman Islands that do um now. Can they just book an appointment with you or do they need to go through a referral from their doctor?

SPEAKER_02 47:53

No, I think there um they just contact the um Health City at Cayman Bay and tell them they want to see the see Dr. Rose at the headache clinic and they book right through Health City.

SPEAKER_00 48:04

Okay.

SPEAKER_02 48:04

Perfect.

SPEAKER_03 48:05

That's wonderful.

SPEAKER_00 48:07

All right. Well, thank you very much. We really appreciate it. My pleasure. Thank you. Yeah. Thank you.

SPEAKER_02 48:13

All righty.

SPEAKER_00 48:14

Bye.

SPEAKER_02 48:15

Enjoy your day.

SPEAKER_03 48:16

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