SPEAKER_00 0:00

Your brain is your body's control center, shaping how you think, feel, and move. When something goes wrong, it can affect everything. Welcome to Your Brain, Your Health, a podcast from St. Luke's Neurosciences. We'll explore conditions that impact the brain, spine, and nervous system and how they connect to your overall well-being so you can stay informed and take charge of your health. Thank you for joining us on today's episode, The Truth About Migraines, is it more than just a headache. I'm your host, Dr. Eric Eustace, emergency medicine physician at St. Luke's University Health Network. And with me today is Dr. Daniel Ackerman, Section Chief of Neurology and Director for Stroke and Vascular Neurology here at St. Luke's. Together, we'll explore what migraines really are and how they're often misunderstood, and just find out a ton of information about them. Thank you, Dan, for joining us as always. This is a pleasure.

SPEAKER_01 0:53

So well, thank you so much for having me. And just to answer your question, yes, it's more than just a headache. Let's just start there. As an emergency room physician, how often do you see migraine?

SPEAKER_00 1:03

At least once a shift. So once a shift, I have a patient who comes in with a migraine. For people who are listening, what is exactly a migraine and what makes it different than just a regular old headache?

SPEAKER_01 1:13

So a headache is just pain, right? Like we we can describe headache as head pain or head discomfort, which could mean any number of things. Now, a migraine, so in neurology we say migraine is a complex neurobiological process. But what we're really talking about is migraine is a significant functional change in the brain. It affects multiple regions of the brain. There are multiple neurotransmitters involved, and it actually changes the way the parts of the brain talk to each other to produce a constellation of things, including not only significant awful pain, but changes in the way we think, changes in the way we perceive things around us that produce a lot of hypersensitivity. Migraine can have several phases. Your average migraine can last several hours. Some might be a little shorter, some can last for days on end. Migraine is not only incredibly common, it's a major source for significant disability. And when you talk to migrainers or or people who experience migraine, and if you say they have a headache, immediately you're going to start getting some looks because it is just it is just absolutely so different and impacts so much of what they're able to do, what they're able to accomplish with any given time. It is absolutely not just a matter of gritting your teeth and getting through it.

SPEAKER_00 2:30

You weren't lying. It is not just a headache.

SPEAKER_01 2:33

Correct.

SPEAKER_00 2:35

I mean, I I know a lot of people in my life actually suffer from migraines and um it it it really debilitates that. It interferes with their livelihood, their lives. They can miss days of work in school. I mean, right, you see that in your practice. I'm sure patients have a very difficult time, especially for a newly diagnosed patient.

SPEAKER_01 2:54

Absolutely. Well, there's there's a couple of important points to that. First is that migraine is ultra common. So when you look at it statistically, there's roughly a billion people, billion with a B worldwide. Migraine affects, if I'm remembering the statistics right, one in four women, one in sixteen men, one in eleven children. And people can have migraine beginning as babies, like toddlers can get migraines. And young children can get migraines. So it's extremely common. That's number one. But because migraine is common and headache as something completely separate is also relatively common. People can really have challenges in that when they communicate they're having a migraine, a lot of other individuals may presume they know what someone is going through. Um and people with migraine can often feel judged when they need time, when they need time off, when they need to recover from this thing that has happened. Um there is a stigma around that, you know. Oh, so and so has a headache again.

SPEAKER_00 3:50

Right.

SPEAKER_01 3:50

I mean, that's that is just really not appropriate when we're talking about migraine. Misconception. Oh, yeah.

SPEAKER_00 3:56

Are there any things that trigger migraines for patients? I'm sure there's multiple triggers, but anything like stress, foods, what what in your practice do you commonly see triggers migraines for patients that probably have the propensity to get them?

SPEAKER_01 4:11

So I will tell you first of all, that is a loaded question. Okay. In a way. And and here is why. Um for many, many people, they do have some migraines that are clearly triggered by something in the environment. However, for many people they do not, or they have some that are triggered and some that aren't. Where people get into trouble is often if they have a migraine or a particularly bad migraine, it's very natural to look at what we were doing at the time. What had we just eaten, where had we gone, what was going on around us, and to associate those things with migraine. And we can start to become very restrictive about our life and our lifestyle because we're trying to avoid those things that we think triggered migraine. The problem is that our physiology is always shifting, always changing. And for someone who is prone to migraine, that can be triggered at any time without an environmental stimulus. Um, common triggers that some people experience, not everyone, can include red wine, can include uh foods that have MSG or that have nitrites in them, um, can include strong smells like cigarette smoke or or other strong colognes and perfumes. Um but really when we're talking about triggers, the key is consistency. What I usually tell people in the office, or what I ask people in the office, is are there specific places you can't go or things you can't do, or things you can't eat, because it absolutely triggers a migraine basically every time. And that's how we try and figure out triggers and use that to our advantage. People with migraine may have sensitivity even when they're not in the middle of a migraine. So being sensitive to bright light or sensitive to loud noises and having those things perhaps bring on a migraine. I don't know if that's as specific a trigger as opposed to just something that is sensitivity, that's part of having a history of migraine. Um but that's where triggers are important, but not the be-all end-all. And with regard to stress, because you said stress. And of course, you know, as physicians, we never experience stresses. That's false. Um but with regard to stress, what I usually teach is that you know, I'm not personally aware of any medical condition for which stress is beneficial. None that I know of. You might know some, but I I don't know any. However, stress is blamed for a lot. And does it help? Probably not. Is it the root cause? And if we could just find a way to get stress under control, it would make it all go away? Probably not. So having good stress control techniques, again, diet, exercise, healthy outlets, you name it, those things are super important for everyone, including people with migraine, but stress is not the be all end-all.

SPEAKER_00 6:54

I think we talk about, we're talking about stress and we're talking about brain, this is all about brain health, right? This podcast. And so there are, you know, living a healthy lifestyle helps minimize your stress, helps improve the brain in whatever capacity. And as we talked about, migraines are that issue with the brain. It's more complex than just a headache. So the brain is affected in migraines. So if we're doing all those things to keep your brain healthy, I'm assuming they're gonna help with our migraines.

SPEAKER_01 7:20

So I hope so. Although it's there are some people for whom those lifestyle things might actually be enough to keep them under pretty good control. There are a lot of people for whom they can, you know, they're doing everything, again, everything right, in quotes, but the migraines are happening anyway.

SPEAKER_00 7:36

Aaron Powell You talked a little bit about women versus men versus children. Why is that? Why do we see maybe a propensity to migraines in women as opposed to men? And then also, too, are there any genetic predispositions that might cause migraines?

SPEAKER_01 7:51

So yes and no. Um when we so taking that in reverse order, when we talk about predisposition, I would say there is clearly an inherited predisposition as opposed to genetic. So people who have genetic syndromes that include migraine, a lot of the times we're talking about specific genes and specific diagnoses that that cause progressive damage in the brain over time and are causing migraine. And that is exceptionally, exceptionally rare. That is like the less than 0.00 whatever percent of people with migraine. Um however, migraine does run in families. Having one parent with migraine gives you a 50-50 shot.

SPEAKER_02 8:31

Wow.

SPEAKER_01 8:31

Having two parents with migraine, you've got a 75% chance. And so when I'm seeing patients in the office, I usually ask who else in their family has migraine, and then we squarely blame that person, whether it's the you know, mom, grandma, father, whatever. Um with regard to the difference between genders, that's a little tougher to discern. Um we know that some migraines can be hormone sensitive. Uh we can tell that because for women who have a cycle of hormone changes, their migraines may reliably track with those hormone changes. Although, again, just because some of their migraines are hormone sensitive doesn't mean that all of them are. Um however, it seems to be more complex than that. I don't know if we fully understand the neurobiology of why that's different between the two genders. We can make we can make educated guesses that it has to do with the difference between the two genders themselves somehow. Um, because yes, it turns out men and women or males and females are different, right? We I you know that that took a lot of medical school to to be able to recognize that. But we know it's true. Um do we really understand all the ways that we're different? You know, we're we're still getting that figured out.

SPEAKER_00 9:41

Aaron Powell Tell me a little bit, what are some of the other symptoms that patients can experience with migraines, more than just the pain they're experiencing? What other things that they can see?

SPEAKER_01 9:52

Aaron Powell Well, so let's let's break this down into into phases, okay? So migraines can have three or four different phases. And the first phase is sometimes what we call a prodrome. And that's different from an aura, which we'll talk about in a second. Now, a prodrome, some people can tell their migraines are coming because they have symptoms that precede the pain phase. That can include mood changes, changes in energy level, vision changes, yawning, appetite changes, um cravings, you name it. Okay. Um, separate from that, there is the idea of an aura. Now, an aura is a specific neurologic symptom that comes before a migraine. There are several things that we look at to help us differentiate aura from prodrome because they are different. For many people, uh can be a visual symptom, although it doesn't have to be. Often that visual symptom will start in one region of someone's vision and spread out across their vision. Some people talk about it as zigzag bright lines or what we call reinforcement spectra lines that are around solid objects in their vision. Um for some people it may be uh a dark area or a loss of vision that again will will grow and spread out. Um but there are some important implications for you know what that may place us at risk for in the future and and how we deal with those changes. So there's a prodrome phase, an aura phase, then you hit the pain phase. Now, with the pain phase, um there are some things about the pain itself, how severe it is. Most often it's one side of the head, but it doesn't have to be.

SPEAKER_00 11:27

Okay.

SPEAKER_01 11:28

Most often it's pounding, but it doesn't have to be. Um most often it is in the head, although can it extend down into the neck and shoulders and back? Sure it can, although it doesn't have to. When we talk about additional symptoms, the most common include sensitivity to light, sensitivity to loud noises, sensitivity to strong smells, nausea, with or without vomiting, what we call brain fog. Migraines tend to worsen with physical activity, um, but there can be a whole host of other symptoms. Everything from dizziness to uh even what we call vertigo, like room spinning, loss of coordination, weakness, numbness, you name it. What I often say is anything a stroke can do symptom-wise, a migraine can do. Um so there can be a lot of those things. But most often the ones we mentioned are sort of the most common ones that go with the pain. And the pain may be horribly debilitating, but it can also be moderate. Some people have this vision of migraine in their head of you know, a person stuck in their bedroom with the lights off, with headphones on, with a blanket over their head for 47 hours. And yeah, that happens. But just because someone's symptoms are not entirely debilitating doesn't mean they're not severe, and certainly doesn't mean they're not migraine.

SPEAKER_00 12:50

Okay. Uh what types of medications you use in your practice or other types of different treatments that we might not be aware of?

SPEAKER_01 12:57

Sure. Well, settle in. So there's only about 70 or 80 things that we sometimes recommend. Um but let's let's divide treatment into a couple of different camps here. Okay. So uh one mode of treatment is what we would call abortive treatment or you know, how to kill a migraine. Migraine begins, so what medications can you use to get rid of it? And there's a slew of different types of medicines we use. Um of the main classes of medicine we use, so one are what we call tryptan medicines. So things like sumatryptan, rhizotryptan, we'll try and I'll try and stick with some of the generic names on here. Um but that's a class of medicine that is made for migraine. There's a second class of medicine that are called ergots, dihydroergotamine, um, which comes in. Sounds fancy. Oh, it's very fancy.

SPEAKER_00 13:44

Like a red wine, like a fancy red wine.

SPEAKER_01 13:46

No, that causes migraines. We're staying away from that. That's right. No, we don't none of that here. That's not right. So that also can be used to treat acute migraine. Okay. There's a whole new class of medicine, actually, two of them, uh, they're called G-Pants and Ditans. Um, but they are classes of medicine that were GPants in particular, custom made to treat migraine. They target a very specific protein in the brain, can be super duper effective. And a lot of times these are used in combination with anti-inflammatory medicines, anti-nausea medicines, other medicines that slow down nerve impulses in the brain. So, for a lot of times, it may not be a single medicine you use to kill a migraine, it's a little bit of a combination. Now, there's a second entire group of medicines we use for migraine prevention. And actually, this is a really important point I want people to get. Very, very, very few patients who have migraine ever get appropriate migraine prevention. Okay. We would say anyone that has four or more migraine days per month, or even fewer than that if the migraines are quite debilitating, should be on something for migraine prevention. And I can't tell you how many people I've seen who've had migraine for 10, 20, 30, 40, 50 years, even, and have never really taken anything that helped to prevent it.

SPEAKER_00 15:02

Yeah, that doesn't seem like a lot of instances of migraines to be able to start a preventative medicine. Trevor Burrus, Jr.

SPEAKER_01 15:08

Absolutely right. But that's just how bad migraine is. And of course, you're gonna tailor that to the patient themselves. Now, when we talk about prevention, there are again, there's a boatload of different stuff. But just in terms of painting in broad strokes. So painting in broad strokes.

SPEAKER_00 15:26

Like your tie like your bow tie?

SPEAKER_01 15:28

Yeah, well, that's a big complex pattern there. That's like this is a migraine-inducing bow tie. You want to be careful there. Um but painting in broad strokes, I would say, first of all, there are things like nutraceuticals, so there are certain legitimate vitamins and supplements that are actually studied. They are legitimately good for migraine prevention. That, in addition to lifestyle changes, diet exercise, and that sort of stuff, that can be an excellent program for migraine prevention. From a medication standpoint, there are, again, like 50 different things that we can use, all of which were originally for something else, but we discovered they are outstanding for migraine. And these are treatments that need to be taken on a daily basis, whether someone has migraine or not, to keep the migraines from happening and to make the migraines that do happen not just less frequent, but less severe. There are certain newer medicines that, again, are custom-made for migraine prevention. They come in oral tablets you take once a day, or once a month uh injections that it's just a pen that you would inject uh at home or in a doctor's office that that's all you need for an entire month. There are IV infusions you do once every three months. Um there are sometimes other injections we do in the office that uh can be used either to treat migraine or to prevent them. And there are even migraine prevention devices. There are nerve stimulators that are not implanted ones, but ones that just stick on the skin. There's one that goes on your forehead, there's one you touch to a spot in your neck, there's one that you wear on your arm, and they can be used, they should be quite painless, just a little tingly.

SPEAKER_02 16:58

Sure.

SPEAKER_01 16:58

And they can be used both to prevent migraine and to treat an acute migraine when it's happening. And then the third class of treatment is what we would call a bridge. So some people who get into a cycle of having migraine again and again and again, they may need a really strong medicine or a specific type of medicine for just a week or two weeks to try and break that cycle and get them back to their normal state. So something where we don't want to make a huge change in their treatment. Okay. We just want to break that cycle and get them back to normal.

SPEAKER_00 17:29

All of these treatments that you mentioned, do they need to be prescribed by a migraine specialist or a neurologist such as yourself? Or can their family physician, general practitioner start some of these medications, or even some of the more complex ones?

SPEAKER_01 17:45

Aaron Powell Absolutely. A lot of these are things that can be started at the level of our primary care colleagues, um family medicine, internal medicine, uh pediatrician, you name it. Uh their comfort level with migraine is going to vary from person to person. Um if we're talking about even some of the stuff that's non-prescription, so the nutraceuticals, perhaps some of the devices, having the guidance of a physician is also very important in that situation. Um of the other things about these treatments that I want people to understand, whether it's started by a primary care physician or a neurologist, remember that for a lot of these, we are what we call titrating to effect. In other words, there's not a single specific dose. We are trying to have someone on the lowest possible dose of medicine that's really effective for them. Okay. Which means the dose that they start on the very at the very beginning, it's probably going to be a low dose, just a little tiny bit, and turned up slowly. So if that initial medicine isn't working, it doesn't mean it won't work. It may just mean we haven't turned it up yet, we haven't adjusted it yet. If someone has a side effect, of course, that's a different story. Um, but I just I want to make sure people have hope. I have so many people who've come to me and said, I've tried everything. I don't think I've ever yet had a patient who came to me where I couldn't offer them something novel that they had not tried before or an approach they hadn't taken before. Um and so there is there is good reason for optimism.

SPEAKER_00 19:11

Okay. Does St. Luke's offer any type of specialist or program for migraines? Do we have a special type of system to make sure that we're treating patients with migraines appropriately?

SPEAKER_01 19:25

Absolutely. So some of that actually does begin with our primary care teams. So as physicians at St. Luke's and in the neurology department in particular, um, actually not just our physicians, but our advanced practice providers, PAs, nurse practitioners, our residents that are in training, we actually put together an entire migraine treatment suite that is in our medical record system and our primary care physicians have access to that to be able to get people started on that treatment. In addition to that, we have an entire group of clinicians in the neurology department who treat migraine very frequently because migraine is that common. When you say you're able to treat migraine, it's kind of like drinking from the fire hose. It's just, you know, there's like a lot of people. Um and so usually a neurologist will be able to take things further than your average primary care physician can. We also have infusion centers throughout the region that can provide both acute migraine treatment, but more commonly preventive treatment on a regular basis. And then we have an inpatient service that allows us for people who have truly horrible refractory migraines to sometimes receive treatment in the hospital to, again, get these cycles broken, get them back to their normal self. So yes, you're absolutely right. It starts with primary care, but we have several systems in place to try and provide several different touches to those patients, make sure that they're getting the treatment they need as best as possible.

SPEAKER_00 20:45

Aaron Powell What type of advice would you give somebody who their loved one has is suffering from migraines? What what advice would you give to that loved one to support that individual?

SPEAKER_01 20:56

So, number one, remember their migraine is not like your headache migraine, whatever else we're talking about, okay? Um the experience of migraine is very unique from person to person. It's a really complex neurobiological problem. Like it really is. So, first of all, support them when they need your help. Second of all, don't let them just live with it, because there are so many treatments that we can use to prevent them, to treat them. Just living with it is not really not what we want to encourage here. Help them to be careful and recognize how frequently they're medicating their migraines. When we talk about over-the-counter treatments, which is what most people start with before they involve their physician, those over-the-counter treatments are not necessarily benign, especially when you're taking them once or twice a day, every day for several weeks. Like they will they will seriously hurt things and can even cause extra migraines just because of the frequency that they're using it. Uh so help them to keep a little bit of perspective on how often they're using that stuff, and even keeping a bit of a migraine journey. There's great apps for this. I usually say find one that is free or simple or just use a note or a calendar. But so, so many patients are shocked when they come see us and we ask them to keep track of their migraines while we're getting them into treatment. And they're shocked at how often their migraines are actually happening. They, you know, that it's something that they are accustomed to living with and working around and they just didn't realize what an impact it has. So doing a little bit to keep track and recognize that impact so that you can encourage people to get help from their physicians is also huge.

SPEAKER_00 22:33

Trevor Burrus, Jr. And it sounds like the advice you're giving for the loved one is the same one as somebody suffering from migraines, I'm assuming, right? Anything different for those individuals? I uh it sounds like making sure that you're getting some sort of treatment because this can be debilitating and no one wants to live in this state of pain and discomfort. Trevor Burrus, Jr.

SPEAKER_01 22:52

Oh, absolutely. Uh I mean I would I would echo that treatment for whether it's someone experiencing migraine, whether it's their loved one, their family, their friends. Um again, especially being understanding.

SPEAKER_00 23:02

Yeah.

SPEAKER_01 23:02

You know, I mean that there it is so hard for someone to explain sometimes, I have migraines and so I can't do X, Y, or Z. Um, we're afraid of being judged. Uh and with good reason, I suppose, because sometimes people are very judgy. Um so yeah, making sure that we approach that with just compassion. Compassion for ourselves if we have migraine, cut ourselves a break, yeah. Um, and compassion for others with migraine and and making sure that we are supportive. Awesome.

SPEAKER_00 23:33

Well, Dan, it's been a pleasure, as always. Thank you so much for explaining migraines for us and diving a little bit deeper. Any last words?

SPEAKER_01 23:41

So I have two last words for you. Yeah, let's go. Number one is remember there is significant hope here. There have been so many new treatments. Migraine, for better or for worse, is extremely common, but as a result, there's a lot of new research, there are a lot of new things. So even if you were treated for migraine in the past, or you've been treated for migraine for many years, don't just live with it the way it is. The other important thing is while most of the time migraine is part of our physiology and is not necessarily dangerous, there are rare times where migraine can be a sign of something else going on in the brain. So, particularly for people who have migraines that are suddenly different, they have migraines with additional neurologic symptoms with them, they have a sudden significant shift in their migraine frequency, they have migraines that are very sensitive to things like body position. These are sometimes red flags that tell us the migraine is a symptom of some other bad thing going on. And so, although most of the time migraine is not, it's just a part of our physiology, making sure that you take changes in your migraine or additional migraine neurologic symptoms very, very seriously. Get your primary care doctor, get to your neurologist, get to see your friendly neighborhood emergency room physician.

SPEAKER_00 24:54

There you go.

SPEAKER_01 24:55

Um, so that we can make sure, as we're working on treating it, make sure that people are safe. Perfect.

SPEAKER_00 25:00

Thank you so much, Dan. It's been a pleasure as always. Until next time, we'll see ya. And that's it for today's episode of Your Brain, Your Health. Thank you for spending the time with us to learn a little bit more about migraines and how you can improve your life. Take care. Your brain health matters, so keep learning and listening. If you found this episode helpful, share it with someone you care about. And for more resources on brain health, visit St. Luke's Neurosciences at Sluh N.org. Until next time, take care of your brain and your health.