Top Headache Doc: Migraine Is Not What You Think

0:00Jonathan Fields: For decades, migraine was explained as a blood vessel problem, swelling, throbbing, treated by shrinking things back down. Turns out, that's mostly a myth. The real explanation is stranger and also a lot more hopeful than the older one ever was. In this conversation, you'll discover why migraine is neuroinflammatory, not vascular, and why some med schools still teach the old version. You learn how your brain can start treating chronic pain as normal, like a broken thermostat convinced a hot room is 72 degrees. We'll talk about why only a fraction of people with migraine ever get aura and how differently it can show up in so many different ways in so many different people.

0:42Jonathan Fields: We'll explore what's happening while you sleep that either clears your brain out or leaves it inflamed and why headache medicine may be entering its golden age. We'll talk a lot about cutting edge treatments as well. Our guide is one of the few physicians in the country trained in both internal medicine and headache medicine, Dr. Fred Cohn. So excited to share this conversation with you. I'm Jonathan Fields, and this is Good Life Project. And we'll jump right in after this short break.

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4:02Yeah. So that's a really great place for because it's still, I would say, a problem if you go today. So first, let me start with the myth and what migraine is still taught us. So migraine, you know, it's actually, there's documentation of migraine since like BC times. And I think it was Aristotle actually has in like a blog or a diary or whatever, him talking about having blinding light in his eyes and a splitting headache, which that sounds like migraine with OR. Yeah, so it's been around for as long as we've been keeping documentation of things. It's not like an occurrence of something new. And the first accepted theory was actually earlier in the 20th century by Dr.

4:49Harold Wolf, who's a very famous forefather of headache medicine, that it was a vascular issue. You know, migraine is that pulsating, pounding thing. But then later on, towards the turn of the century, we know it's not primarily vascular. That's the myth. It's not a vascular thing. And they still teach that, actually, in some parts of med school and whatnot. that it's a vascular problem. It's a neuroinflammatory condition. That's what it is. And again, it's complex. I always tell someone, if you figure out a migraine, 100%, you win the Nobel Prize in Medicine. We understand a good bit what's going on, but there's still more to do.

5:26But it being a vascular blood pressure, so there's a myth, the truth is it's more of a neuroinflammatory condition.

5:34Jonathan Fields: I mean, that's interesting, right? Because I'm somebody who is a migraineur. I have lived with migraines for my entire life since my teens. And I remember hearing early in my doctor visits that this was exactly what you're describing. It's a vascular condition and that a lot of the treatments were designed around that assumption, none of which ever worked for me or helped me in any meaningful way. So you're saying that that was the assumption until not too long ago, but now there's a deeper understanding that there's something different going on here. And that's actually a big fight in, if you will, my great education.

6:08I still have, I meet trainees, med students, et cetera, that they are still learning in their schooling in like the year 2026, that it's a vascular condition. and there's a concern of like oh yeah you know is it make a you know it's a blood pressure thing or something like that and again no like there is a vascular component of it like downstream but the primary aspect thing that's going on a migraine is this release a soup if you will of these inflammatory neuropeptides that are released and then downstream yes they can have vascular effects obviously pain you have the or components like flashing lights the excise weaknesses all this other stuff but it's the vascular parts only one small component so do we know at this point

6:55Jonathan Fields: what causes that release um that leads to all of this inflammation now that's the question because we know what the release is yeah so the way it's described is we know when a migraine starts what's happening but the or most of it i should say but the why that is what we don't know so there's something called the trigeminal vascular system and there is a switch what turns that switch on is it all genetics is it environmental is it dietary is it it's and in my opinion it's not just one thing it's a multitude it's a but anyway you have migraine you have something that predisposes you for the switch that turns on and then there is a release of all these neuropeptides calcetan gene-lated peptides cgrp which there are now treatments that target that and amylin Vip VIP, PayCap, E-C-A-P, Substance P-E-E-C-O, on and on, and all these peptides come out.

7:49We also know there's a concept called cortical spreading depression. And what that is, is this massive release of potassium. Think of if you have a bucket of water, I start shaking it, the wave gets bigger and bigger. That's what sort of is happening. You see this ever so growing wave of potassium released, and that's also happening. Again, we don't know the why per se, but we know that's happening. And that is what, and what that does is it now in your brain, there's no pain receptors. If I was to melt the middle of your brain, you wouldn't necessarily feel it. But what happens is the dura, which is the outside component of our head and brain that becomes super sensitized.

8:26And we believe it's a pulsating pain because the areas where the blood vessels are going through that is now sensitized. And that's why I can feel pulsating. The blood vessels fine, but the area around it is sensitized. And I also going on myth, you know, you brought that up. Everyone commonly thinks a migraine has to be one-sided behind the eye. No, it could be anywhere in the head. Now, one-sided behind the eye is the most common, but I have people who come thinking they have a neck issue or back in the head pain. I go, no, if it's the migraine, you know, criteria. So it really could be anywhere in the head.

8:59It's not just focused behind the eye.

9:01Jonathan Fields: How do we distinguish between a, quote, everyday headache or a tension headache and migraine? Or we hear this other term sometimes, cluster. What are the differences between those things and how do we actually tell? So there are three primary headaches, and you named them also. Tension, which I call, if you will, the regular headache, very broad. It's a mild to moderate pain. They also brought up cluster. Cluster is a very specific kind of headache. Sudden, immediate. That one has to be behind the eye, one-sided, super severe pain for 15 minutes to three hours. And then migraine. So the way we come to diagnosis is the sort of clinical picture of the pain.

9:44Some of the two most important things is duration, the quality. A migraine must be, and I want to stress that this is not black and white. You know, pain is subjective. It's not like, you know, so I have an internal medicine background before I went to headache medicine. You know, when you diagnose a heart attack, you see it. You know, you get a chest x-ray. We can't do that with headache medicine. It's all by feel and pain is subjective. So to those listening, I want to stress this is not completely black and white. You know, this is a discussion with your provider. So the pain generally has to be at least four hours.

10:14So when someone says, oh, it's only last 30 minutes, I'm not as inclined for a migraine. It needs to be moderate to severe. And usually the way I define it is it impedes you. You have trouble focusing. You've got to leave work. You can't keep going about your day. It's bothering you. Versus a tension headache more mild. Yeah, it bothers, but you could persevere. You don't have to stop working. and lastly that it also can be usually pulsating throbby but again it doesn't have to be but really that duration and the quality is what hones me in now again we don't have a test to prove this and it's actually a big popular area of research but usually these are conditions of exclusions means we make sure it's not something else you know if you have certain concerning signs.

11:05We may get an MRI, make sure that's fine. Or if there's a reason to get a blood test, something like that. But again, there's no blood test to prove it. It's really by clinical picture.

11:17Jonathan Fields: So it sounds like of those three that you just described, probably the most clearly discerned one is cluster. It comes on really fast and incredibly intense. Cluster is one that usually, yeah, there's no confusion about it because it's so specific. and so unique than the others i'll give an example like it's a severe pain so typically you know the way i i the way i bring me up is like if a patient tells you i think i'm in cluster i'm like how is it yeah okay i don't want to come off like i don't believe the patient but speak this on a cluster they're like they're on the ground they can't talk like so and again not like not to sound dramatic but it has you know this sometimes it could do this it has a nickname name up the suicide headache because people, you know, it's so severe that it has historically brought people to that, you know, when they haven't got adequate treatment.

12:13So it's a very different picture than tension and migraine, which could, those have a lot more overlap.

12:19Jonathan Fields: Yeah. I guess maybe there's a little confusion just in popular understanding because of the name, because the name itself, Cluster, it kind of makes it sound like, well, if I have a four days in a row. That sounds like a cluster to me. Whereas like, so the common understanding of that word is very different than the medical understanding of the name. And yeah, it gets, I understand the nomenclature of the term. A lot of patients go, yeah, but it's happening in clusters. Sure. Migraine can do that. Yeah. My people could, you know, it's very common. Women can have only migraine attacks around their menstrual cycle.

12:52That's a, that is a very common thing. And I've had patients come, Oh, I have cluster because they're happening in this grouping. And again, migraine attacks can happen in groupings. Cluster, again, it has to have that specific severe pain.

13:05Jonathan Fields: Let's zoom the lens out just for a minute because I'm curious too about the prevalence of this just across large numbers of people. What are some of the general numbers, like the big picture numbers and stats? For migraine? Yeah, for migraine. Sure. So migraine, you know, our epidemiology suggests it affects anywhere from 40, 60 million Americans. So that's one out of six Americans. More common in women, so about 18 % of American women, 6 % American men. So about one out of five almost American women. So very, very common. common. Now, chronic migraine, which for those who are having eight or more migraine attacks a month and 15 total headache days, we think that's around 1 % of the population.

13:56So, you know, not as much as migraine, but that's still quite a bit. And think of having that many migraine attacks a month, that could be pretty, you know, disabling.

14:07Jonathan Fields: Yeah. And you just described, and I've heard this mentioned also in the past that there seems to be a much higher prevalence in women than in men. Yep. Do we know what that's about? So there's some suggestions. The most common one believed is we know estrogen is related to migraine attacks. And it's not the level, it's fluctuation. Because I've had patients ask, should I take an estrogen replacement? I go, hold on, no, that might not solve this. Most women notice their first migraine attack if they get one around their first menstrual cycle. We notice that in the first trimester of pregnancy, there's increased frequency of migraine attacks.

14:48And for a lot of women, when they go through menopause, there's no more migraine. And that was the case with my mother and my grandmother. Which my mom, when I complain about my migraine, just goes, oh yeah, wait till you get older. I'm like, well, there's a phenomenon. I'm not going through menopause.

15:01Jonathan Fields: The other fact that I've heard, which is more gender specific, is that, and I don't know how you measure this. I'm curious whether there's data on this, is that not only is it more common in women, but that it can also be more painful, more intense. Is that true or is there data around that? I don't know if there's data really behind it. Again, it's really hard to quantify pain. Yeah. Because so we have battles, if you will, for migraine in both sexes. You know, there's unfortunately a lot of women's health issues, you know, don't get as high a focus as they deserve and need to be. So there's always this fighting stigma around migraine and raising awareness of migraine.

15:46But the other side of the aisle, that migraine is a woman's disease. And again, where there are many men who I've met, patients of mine who just dealt with it, thinking it's headache, and didn't see treatment just, oh, I don't have migraine. I'm not a woman. And again, no, like, well, yes, it's more common in women. Sure, men can still get it, and a good amount of men get it. So, you know, that's actually been a reason to shed light that, hey, you're a male having a headache attack. Speak with your doctor, that could be migraine. As far as which gender has more pain, you know, there's no data behind that.

16:26And I never like to compare. I tell my patients, never compare your headache or pain with someone else. It's because pain is subjected. You know, how someone expresses pain differs by person, by culture, by so many factors. So that's why I never like comparing, oh, that's more painful than this, et cetera. But that's also why in my patient interactions, I don't just ask about pain. I think the best indicator for the impact of someone's migraine or headache is asking about their function. How many days have you missed work in the past month? How many days have you not been able to do like an activity, go out, spend time with friends?

17:01How many days could you not interact with your child? How many days are you taking medication, et cetera? Those could go like for someone who I've had patients, especially, you know, being in New York City, I have a good deal of immigrant patients. They come from areas that don't really have health care infrastructure. So they're not used to discussing or bringing these up with a doctor. And they come because their family member brings them and they're like, yeah, I don't really have pain. But these are asking the questions. How many days have you not been asked to be a doctor at work? Oh, yeah.

17:28Like two or three times a week. Well, you're having two to three headache attacks a week. So that's why I don't always focus on the pain number, but these other metrics as well.

17:36Jonathan Fields: Yeah, it's such a good point. And I have had in my own experience over many, many, many years, there have been windows where the headaches are so frequent that you kind of forget what it's like to move through the day without them. and it almost becomes normalized where it actually really does become hard to understand. Like if you were going to rate the pain, it's kind of hard to do that because you're comparing it to sometimes a window that is hard to almost relate back to. But if you said like, how is this affecting you? You know, like, is it stopping you from doing X, Y, or Z? A patient of mine who had headaches every day for years.

18:13And when I first met this individual, he told me that his headaches were a nine out of 10. We've done a lot of treatment. They're still daily, but they're down to a five out of 10. So I ask him, would you like to keep trying new therapies? He goes, listen, this pain came out from nine to a five. Five is nothing. I don't want new meds. I'm content. And I said, that's up to you. That's fine. So yeah, they're just numbers. And one of the biggest lessons in medicine is treat the patient, not the number. And again, like, yes, I always ask those things, but those numbers are not just specific, finite.

18:45All right. Like, that's all I'm going to work with. No.

18:49Jonathan Fields: Damn. You know, one of the most important things is the history. Remember, you know, it's not just looking at, you know, tests and labs and whatnot, but how the patient is presenting it themselves. Now that makes a lot of sense. And we'll be right back after a word from our sponsors. Hey, so we'd love to share more midlife reinvention stories on the podcast. like the recent one from Sari Baden, who after decades in her career, then being pushed out as she neared 60, launched Oldster Magazine to an incredible reception that even led to a book deal. We love inspiring stories that show how change is not only possible, but often incredible at any age.

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22:12Jonathan Fields: Members get more at Lowe's. $25 minimum and loyalty membership required. Order eligible items by 2 p.m. Subject to weight and size restrictions and availability. Terms at lowes.com slash shipping terms. You mentioned earlier in our conversation that you started out in internal medicine, switched over to headache. This is not just your practice. This is personal for you as well. Oh, yeah. So I always say never trust a headache doctor who doesn't get headaches. Because, you know, there's a lot of them. So my path was I always had a weekly severe headache, since I can remember. It was never thought to be a thing, you know, and this is no complaint.

22:56I'm very close to love my parents very much. Although I do give a little bit of shtick to my mom, my aunt and my grandmother who have migraine and never thought that oh maybe Fred's having that um so I tell him that that's the only mistake he ever made raising me uh but I just dealt with it all the way until residency one day a week pain out of commission now in residency you're not sleeping you know you're working 80 90 hours a week so now the migraine ramped up and you know I take it as a blessing that I trained at Montefiore, a hospital system in the Bronx that has a very well-known headache center.

23:33And I actually got a lecture from one of their providers. And at the end, I said, hey, I think I got that. And she was like, come on down. I went to see them, had a visit. Life-changing completely. Now, these migraines that took a day a week became non-problematic. It's not common for me to lose a day now to the migraine. And I learned from them this is a field. And I said, this is what I want to do. this is the field of medicine I want to pursue. And then I learned that headache medicine is a ward certification you don't have to be a neurologist for. You know, you could be an internist, family medicine, pediatrics, OB.

24:09Now, most headache medicine specialists are neurologists, the vast majority. So I'm like sort of this uncommon one. But it's also what I love about our field, the collaborative nature. A couple of days ago, I just came back from the annual scientific meeting of the American Headache Society. And you meet people of not of just not from different areas, but different backgrounds, physical therapists, occupational therapists, psychologists, you know, of course, internists, family medicine, peds, etc. And, you know, it's such an interesting field that most fields of medicine are just in their own, you know, their area, whereas this, it's different specialties coming together.

24:47Jonathan Fields: I mean, that makes a lot of sense to me. And also, it sounds like tell me if this is accurate or not. as you described, there's neuroinflammation. There's inflammation in the brain. Part of the theory is that it somehow affects the DORA, and that's where a lot of the actual receptors are, which we translate to, oh, this is painful. But I would imagine also that it's systemic. This is not something which is reserved to what happens from the neck up. There's something going on that's more broadly systemic that also influences the entire experience. Does that land? It affects other systems. So for instance, the GI tract is involved.

25:29We know during a migraine attack, there is gashoparesis. Gashoparesis is going with the line in turn, not per se paralysis of the gastric system. So the stomach isn't moving as much. This is why we think there's nausea. There have been studies called a barium swallow. Patients drink a dye and we can see it on x-ray And it is confirmed in migraine attacks, there is a degree of gastroparesis. You know, and my, you know, we know there's also migraine is not just a headache. There's multiple phases. The prodrome, so the beginning can have excessive hunger, fatigue, thirst, irritability. Then we have the headache for the aura phase, then the headache phase.

26:13The prodrome, the postdrome is named the migraine hangover because it's immense fatigue. but yes it does affect other systems yes neuro is the most affected systems but and it also is known for having very common comorbidities anxiety depression we know that asthma is a common you know comorbid condition obesity there's so many things that are involved with it uh that it's not just neuro involved it does affect other systems in more than one way so now i'm curious about two

26:46Jonathan Fields: things you just said there too um one the the early part of it what was the language you used for sort of like the very early projome right you mentioned and you mentioned a couple of times this notion of an aura um and that i think is one of the things that in popular lore is associated with like oh there's a migraine coming and for some people that's true but that's not true for everyone right ready for me to spill another myth yeah what if i told you that most people with migraine don't get aura okay and we think of migraine always or no only 30 of those with migraine get aura the majority don't so that's why when someone's like i don't get aura i'm like okay like okay you don't need to and you don't need to have an aura every attack so aura can be any i describe it as this it's any neurological symptom um that essentially could last anywhere from 15 to 60 minutes.

27:42That timing is very important. Now, some auras can, but an aura should not last longer than 60 minutes. If it is, you have to speak to your provider that has to be evaluated. The most common aura is the visual ones. Zigzag flashing lights, a blind spot that grows, some people subscribe it as kaleidoscope vision, and generally there's no pain during it. It happens, it goes, and then the pain begins. But an aura could present in a lot of other ways. or could present as numbness it could present as weakness there are some who have what's called hemiplegic migraine where it mimics a stroke some who have vestibular migraine giving vertical like symptoms there are those who have difficulty speaking there's a famous video on youtube of a news reporter who's you know on camera giving a report and then she starts saying nonsense like gibberish and they thought she had a stroke they took her to the hospital migraine you know now These have to be assessed to make sure it's not those things.

28:38But my point is, migraine aura is not just the visual symptoms. It really could be any neurological presentation.

28:44Jonathan Fields: Yeah. I mean, that's so helpful because I had heard that this is much more common than you're describing. But also understanding that aura is not just the classic spotty vision or shift in what you see, but it can show up in so many different ways in your body. It really can. Yeah. I mean, those who, you know, lose sense of smell, those getting, I want that, they get tinglyness on their tongue for 30 minutes. It really, what I care about is the duration. That's the key thing. Yeah. That it's the last, it's because the, that is like the one I would say, per se absolute. When someone's like, it lasts an hour and a half, we need to get neurological testing to make sure that's not that.

29:20Now it comes back normal. Cool. We'll say it's that, that's your aura.

29:24Jonathan Fields: Got it. But it really could present in any way it wants. So my other question was about this sort of like the, the post phase. And you mentioned that fatigue can be one of the things that we feel. That's certainly something that I have felt. And I've always been curious about that because it's not just like my head is really tired and my eyes are tired, which often they are. But my whole body feels like I just went through this intense, maybe I just did a 10-mile hike or something like that. That's why we call it the hangover. It's like when you had too much to drink. What's going on there? Why is it fatigue?

29:57Our thought why, and we don't have 100 % what this is, but we talked about a migraine when it's happening, all these neuropeptides are firing, right? What happens if you're running for a while? You push your body, you get tired. And I like to think of it like that. You have all your brain. It's just neuropeptides are fuel. and when you, you know, just like when you're running a lot, it makes, you know, the engine wear down. And it's that sort of, that's how I sort of, you know, visualize in a way that your brain just spent so much fuel and it's like recovering.

30:43Jonathan Fields: Let's switch gears a little bit and talk about what we do. So if somebody's joining us and they've had headaches, maybe they're new, maybe they've had them on and off for a long time, they weren't sure, are these tension headaches? Are these migraine? Are they clustered? Maybe now through this conversation, they've got a lot more clarity and they're pretty convinced they have migraine. And as always, we make clear, this is not medical advice, see your qualified healthcare provider. But I want to zoom the lens out and just explore options that probably a lot of people haven't known about. Let's start with this distinction between prevention and sort of like immediate treatment, intervention and prevention, because it seems like those are two different things, maybe with some overlap.

31:32Jonathan Fields: So if you feel like something's coming on or you're in the middle of something, what are the common available sort of like main mechanisms that you look to now to try and stop it in its tracks as much as we can? Sure. So I just want to make one point because this is sort of another myth. If you don't have a neurologist, start with your primary care. You'll be surprised because a lot of people wait to see a neurologist. You might need to see a neurologist, but if someone's having tension or migraine, PCP is the place to start. it so you know you said it correct we have acute and preventive so there's two different schools of thought of when starting a treatment there's so no everyone needs acute the migraine attack happens but does everyone need prevention and that's a bit of a gray area so these are guidelines set forth by the american headache society there's no 100 like this is the where you start it's sort of a scale, if you will.

32:28Anywhere from at least four to six or more, how to get migraine attacks a month, but also how much the burden is. For instance, if someone tells me they have four attacks a month, but they're not that burdened from it, I might just do rescue medication. Someone has three attacks a month, but also they're really impactful. The day after the hangover is really bad. You know what? Okay, let me start preventative therapy. So that's generally how we pick it. So starting with acute therapy, there are two really common treatments, classes, the triptan family and the g-pant family. The triptan family has been around since I believe the early 90s.

33:09You might have heard of these as sumatriptan, risotriptan, etc. There are seven flavors of triptan. They all have their differences, of course. They're available as oral intranasal even injection um and they work actually on a um this 5ht serotonergic receptor and that actually causes vasoconstriction but wait dr cohen you said migraine's not a vascular problem no no we'll get so yes the drug itself does cause vasoconstriction but that causes a decrease in release of cgrp calcium gene related peptide which is a neuropeptide we know in the migraine cycle. That's how it achieves it. Then there's the G-Pan class.

33:51You might've heard of these as Remigipant, Nerdtech, Eubrogipant, Eubralve, Zavspra, and those are antagonists of CGRP. So they're targeting directly. There's other therapies as well, but those are the two typically first line therapies I go to for acute treatment.

34:12Jonathan Fields: How effective are these? And are they universally effective for everyone? Or is it completely different for everyone? I wouldn't call any migraine treatment universal. If there was, well, we cured it. But these are first line and they usually are quite effective. I would say more than often, I don't need to go to a different class, that those two classes take care of the job. Now, I want to stress if you're someone who had those two classes to help, that doesn't mean there's anything wrong with you. Again, everyone's migraine is unique, but those generally are pretty effect. So let's talk about the triptans for a minute, because I think that was sort of like the earlier class of drugs.

34:49Jonathan Fields: And then the things which are, use a different word. I've commonly heard of them described as anti-CGRP meds. That's a newer class of drugs. So G-Pants are anti-CGRP meds, yes. Yeah, G-Pants, right? That's a newer class than the triptans, right? G-Pants were released at the end of 2020. Okay, so fairly new. That's like six years old at this point as we're having this conversation. And it sounds like what we know now, and tell me if this is right, is that the triptans work by a secondary effect in tamping down or limiting CGRP, whereas the newer class goes directly there. But at the end of the day, it's sort of like a similar mechanism.

35:34Jonathan Fields: Is that right? So, yes, it's not as concise as that because, well, yes, triptans, in my view, are this sort of secondary effect. They also work quicker. The mechanism of G-pans, what we see is they, on average, take a bit longer to get their effect than the triptans do. So I don't like – like I get a saltine which one's better. Unless – until we do a superiority test, there aren't. I never like to put a claim on which one's better. They have their uses. It's the individual patient, if I pick, if they're getting a G-Pan, a Triptan first. Yes, in theory, Triptan's having a secondary effect, but that's a common thing in medicine.

36:17In a lot of conditions, we don't always get something that goes right to the area of concern that it takes a bit of other things to get there. So I never like to sort of diminish that of its thing. um but yeah triptans on average actually have a quicker onset so about about how long is the difference between those two classes now i want to stress this is averages and yeah yeah yeah anecdotally this is anecdotally right you know meaning i like i don't want you know this is not you know a clinical trial whatever what i see is triptans are anywhere from 30 minutes to an hour per se uh g pants are an hour to two hours but that is my anecdotal answer i've had patients that the G-Pants work very quickly.

37:00It all depends on the individual. There's a lot of things going on in the body that sort of dictates that.

37:05Jonathan Fields: Yeah. Does it also depend to a certain extent on the delivery mechanism? You mentioned oral, nasal, and injection. Yeah, definitely. So we have oral, intranasal, and injections. Generally, injection is the fastest, so suetriptin injectable. We also have suetriptin and zolmatriptin intranasal, and intranasal saveja pants, salve spray. And yes, that one is a quicker onset than the oral G pants. Got it. Now, nasal, again, there's no right or wrong for each individual person. I'll give you an example. I personally love intranasal. You know, I use myself. They got a nasty taste. It's not fun getting something you know, spray your nose.

37:45But again, to each their own, they're all useful things.

37:49Jonathan Fields: Yeah. So there's not like I don't just, you know, assume a tryptin and gentle is the highest, the fastest onset. I don't prescribe it to everyone. It doesn't mean that's the, that's it. That's the one for you. There's different reasons why one would get a certain route. And we'll be right back after a word from our sponsors. This episode is brought to you by Best Western Hotels and Resorts. So, you know, one of the things I have come to believe pretty deeply is that some of the best moments in life happen when you actually go somewhere. When you leave the familiar and let the world just surprise you a little.

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40:45Jonathan Fields: So what about this idea also of medication rebounds? Like I've heard that like with certain types of medication, let's say you have like a migraine for one day and you take it, a migraine for a second. And then I've heard, well, don't take it for the third day because then you have a likelihood of having a rebound. What's true and what's not true with this? So medication adapted headache or medication overuse headache, they're interchangeable terms. I just gave a talk at the American Headed Society meeting last week on this specifically. So yes, I guess let me first define what is a medication overuse headache.

41:22It is using a certain rescue medication. In this case, triptans, opiates, or combination drugs that you're excedrin more than 10 times a month. or over the counter, Advil, Tylenol, et cetera, more than 15 times a month. Over three months. Meaning if you have one week of taking Advil every day, that's not necessarily going to give you a rebound headache. This takes time. And it's averages. For example, I've faced this, oh, I used the Triptin three times for three days in a row. Am I screwed? And I go, well, how am I using it before that? Oh, once a week. Okay. That short span is not going to do it.

42:03it takes time it takes it's it's a repeating pattern that's why like when i meet with a patient let's say every three months i'm looking at their overall use not one week it's not like if you take a trip down three or four times in just one week that's it you're it's all over no it's you know it takes time for this because what's happening in a medication overuse headache is your body is good we you know we have a couple of theories that it's going through the sensitization if you will. And the brain doesn't go through that so quickly, it takes time. But that's why whenever I prescribe these things, and when I have follow-ups, I always ask about its use, because we want to prevent that from happening.

42:39Jonathan Fields: Let's move on to prevention. What are the main things that we look at here? And actually, what is prevention? Let's define that a little bit more. So great. Think about, we were talking about medication overuse headache, right? Well, if you're having 8, 10, 12, 15, et cetera, headache days a month, you can't use a rescue men every day, right? So that's where prevention comes in, reduces the frequency. I never like setting the goal as curative. I think that's misleading. Migraine typically isn't per se curative. Breakthrough attacks will happen. I think it's a very important distinction to not be misleading to someone.

43:12That's why I always prescribe acute medications. Because it will still happen. So prevention is to do that, prevent the migraine attack from happening and there's now a lot of medications so i'll do it i guess in a chronological order we have what we call the legacy drugs which have been around for decades the three legacy drugs are anti-seizure drugs such as topiramate beta blockers such as propanolol and tricyclic antidepressants just as amitriptyline and nortriptyline the evidence is great but they They are, you know, their original design was for something else and also found to be effective for treating migraine.

43:55Then in the late 2010s, we had the first use, first FDA approved use, I should say, of CGRP based medications, the CGRP monoclonal antibodies, which is erenumab, calcinizumab, feminizumab, and eptinizumab. These are monoclonal antibodies, which are once a month injections. Think of it like a lot of people are familiar with like, oh, Zempic or Zepbam, like that kind of applicator, but for your migraine or once every three months infusions. And there's also a tojapan, Q-Lipter, which is take it back to that Nertek Ubrelvie, right? The G-Pan, you could take it every day. And that's for prevention instead of acute.

44:38We also have Botox. Botox, believe it or not, is FDA approved for chronic migraine, meaning this isn't for everyone. This is for someone who's having 15 headache days a month, eight of which are migraine attacks. And it's 155 to 200 units of Botox injected over the entire head once every three months. So, and those are, you know, First lines, then there's a lot of other possible treatments. Again, what goes to me choosing what a patient gets is not only their headache frequency, their comorbidities and what else is going on in their life.

45:15Jonathan Fields: Yeah. You sort of described the mechanism for some of the earlier ones. How does Botox actually work in this particular context? So Botox, and you know what? I'll give a good demonstration here. Botox is given 31 to 40 injections around the head. So both by the brow, the forehead, the side of the head, the occipitalis back of the head, upper part of the neck and trapezius. And that is how it's given every three months. And the mechanism is on a botulinum toxin aid, which is what Botox is. when it's injected it gets into the neuromuscular junction and what that's doing is preventing the release of neuropeptides at that level so for cosmetic purposes because of that muscles don't move as much but for pain for migraine it interferes with the release of neuropeptides related to migraine like cgrp which is why i'm actually and i'm biased but i'm a big fan for those who have refractory migraine of one of the CGRP drugs, either the monoclonal antibodies or a G-PAN with Botox.

46:30That was one of the first migraine projects I ever did. Back when I was at Montefiore, we had the first paper showing that together it has a synergistic effect than just by itself are reducing monthly migraine days. Again, I want to stress that I never like coming off as, oh, there's one great treatment or that's the best treatment. There's many treatments. you know everyone's i think is unique because i've had people come to my office saying i want a i want b and i'm like let's talk and then i'm like hey i think c is actually a better fit so you know there's no one true treatment for them all so what i'm hearing really is that even

47:05Jonathan Fields: on the prevention side there are a range of different treatments um it's really important that you work with somebody who is skilled at understanding what is the best approach for you And also what I'm hearing you say is that sometimes it's not a matter of just working with one, but sometimes you may weave different things together for the optimal effect. There's a lot. I could keep going. There are certain antidepressants, the SNRIs, the loxatine and Effexor have evidence. Blood pressure medications like Candesartan or Lisinopril have evidence. You have neuromodulation, which is becoming a popular thing, which are these devices you wear, like cephaly goes on your forehead, gamma cores on the neck, nervios on the shoulders, savdys, you know, back and they work by sort of, it feels like a vibration, but they're altering your pain pathways.

47:58And therefore, you're not taking a med. There's so many different treatments. There's, of course, off-label uses. for patients who are really, really refractory, believe it or not, ketamine. Now, that's very uncommon, but there are some people who warrant that level of therapy and have done very well. Yeah.

48:18Jonathan Fields: Define refractory for me, just like what's a common term? Sure. Refractory, I use the same definition that the European Headache Federation uses, which is a headache that has become not responsive to at least three or more treatments on average in the span of three months. Class of drugs that you mentioned earlier that I'm curious whether they play any role in this. GLP-1 agonists. Sure. This is actually a really popular thing that was actually discussed also at this past American Head-X-City meeting. So the GLP-1 agonists, these are your Ozempics, these are your Ogovi, Zep-Bound, Mondreno, etc.

48:59It was seen in those trials that those who had headaches or migraines started reporting less. And anecdotally, a lot of providers saw it too. So the question is how? Is it direct or is it indirect? Because for instance, we know with migraine or chronic migraine, obesity is a very important risk factor in worsening things. and we and the reason why we uh that we think the GOP ones work on that is of course it's reducing weight so is it that it's making headaches better because we're reducing weight or is it having a neuroprotective um capability there's a proposed mechanism that GOP ones actually can help reduce cerebral uh cerebral spinal fluid pressure so our brains are like a goldfish in a tank this cerebral spinal fluid, you know, increased pressure, intracranial hypertension, IH, is too much, you know, pressure in the head, and that's lead to headache, etc.

49:59So it's a question of is the GLV-1 actually reducing it directly? Is that the mechanism? Is it suppressing CGRP in some mediated pathway down the road? Or is it just as simple as you reduce obesity, and therefore we know. So obesity is an inflammatory state. Adipose tissue, we know when there's excess adipose tissue, that releases inflammatory markers. So is it just as simple as, hey, there's less weight, there's less adipose tissue, therefore there's less of an inflamed state. So then what's my take on it? What do I use? Have I prescribed GP1s? Absolutely. But I view it as, do you warrant weight loss?

50:38Because I don't prescribe it specifically for only migraine in mind because again it will you know GOP1s will have an effect on weight that's what they're designed to do if someone comes to me who has a BMI of you know they're not obese they're 28 or 27 or less then I don't really recommend it because it might have other consequences you know I wouldn't call this as a wonder pill is had a term they're very popular and have a tremendous effect on bringing weight down and helping resolve obesity. But that doesn't mean that non-obese people should be taking it, you know, like, because there are known side effects.

51:17There's a talk about, are they causing hair loss, you know, affecting endocrine issues? There's a lot of safety data, like I'm always reading about. So I don't directly prescribe it to treat migraine. I prescribe it to those who have those risk factors, diabetes, obesity, et cetera, with the thought of my, hey, this will also hopefully help you migraine.

51:37Jonathan Fields: And that kind of brings us to lifestyle also. You know, because, yes, so here are a whole bunch of, you know, like medical interventions of, you know, pharmaceutical interventions to a certain extent, or you brought up, you know, this growing field of tech and devices, which work in a variety of different ways, interrupting pain pathways, stimulating the vagus nerve. And I think we're really early days from what I've seen in that. but when we bring it just down to basic lifestyle modification um do the basics work like nutrition you know like exercise sleep hydration do they make a meaningful difference because i don't want to ever come up like oh yeah well the biggest stigma in migraine if i had a nickel every time someone said have you tried drinking more water uh like it's not you know it is a neurological condition that, you know, it's not just a lifestyle issue, but it goes, there's definitely a component of it because what I was saying before, migraine is an inflammatory condition.

52:36Treatments involve reducing inflammation. So proper hydration, proper meals, you know, maybe the food's having an effect. So everyone's body reacts differently to different foods. So, you know, when I meet with a patient, the most important, so headache diaries are paramount because that allows me to track data. I tell patients, don't worry what's in a headache diary. That's my job to be worried about it. And that's when I can start finding things that may be interfering on a lifestyle level. I have found patients with certain foods affecting it. I had a patient who had eggs could trigger migraines.

53:05I know they're no spicy foods. It's not common. Why does it happen to them? I don't know. But that's how their body is responding to that inflammation. There's no one true migraine diet. But I've had patients who have improved headache frequency, gluten-free, ketogenic, et cetera. And again, it's not because, oh, yeah, that's it. I don't want to ever say that's going to work for you, but for themselves, they found that that's effective. Sleep is probably the most important thing. I can't stress that enough. When we sleep, when we hit REM, stage four, what happens is our brain activates what's called the glymphatic system.

53:38Don't ask me why it's called that. We have lymphatic. Okay, when we sleep, add the G. I don't know. So we have the glymphatic system. And remember what I was talking about before with like that migraine hangover and because all those neuropeptides. Well, the glyphatic system cleans up the waste from neuropeptides. That's why when you don't sleep, what's groggy? That's what groggy is. Your brain didn't get to clean itself. So it's inflamed. It's in this tired state. So if you don't achieve proper stage four sleep, your brain is not cleansing itself and it's in a pro-inflammatory state of mind. And that's why it's every single new patient visit I do, I do a sleep assessment.

54:14For those who I think there's obstructive sleep apnea, I'm getting them a sleep test. I've diagnosed the late sleep rhythm, insomnia, but sleep is so important. Caffeine gets asked all the time. Caffeine is a double-edged sword. For most people, it helps. For some, it makes it worse. I drink coffee myself. Caffeine is fine in moderation. Don't exceed three or four cups a day. Sort of a no-brainer with tobacco. Tobacco is known to cause migraine attacks. We do know that one of the biggest risk factors for cluster headache is tobacco. Alcohol is a really common treatment for migraine and cluster headaches.

54:52Some people make it better. For me, I abstain from alcohol. It will give me no matter what. That's actually my trigger. But speaking of triggers, you don't necessarily have to have triggers because people get sort of and rightfully so sensitive about it because then when you start talking about triggers, it means you did this. You triggered it. some things in life are unavoidable like weather weather is a very common trigger and people i have patients who feel like their doctors call them crazy for thinking that you talked about lightning before yes we like that's actually a working group i'm part of where we looked at clinical trial data that at the same time weather metrics were taken where we have spoken at headache conferences that we found that if there's a 10 degree fahrenheit change within 24 hours, you have an increased risk of headache.

55:39Same thing if there's a 0.24 barometric change in 24 hours, you have increased risk of headache. Headache changes are real. No, you're not crazy. So some triggers are just unavoidable. What do you do then? That's where acute medication comes in.

55:53Jonathan Fields: Right. There's going to be a storm happening. You have your tryptone or your genement or whatever on you. So if it happens, you take that. And that's sort of why I don't like getting too lost in leads or triggers because some is just, that's the world. Some is just the environment that, you know, the horse, you can move a lot now, but some things that you're unable to adjust, but that's where other treatments come in. Yeah. So lifestyle matters for some people matters more than for others. There are things that are probably fairly universal, like sleep, where it really makes sense to focus on that.

56:25Jonathan Fields: And for others could be a wide range of things that do or do not trigger a migraine completely dependent on the individual. You brought up ketamine before also, which I think is really interesting because psychedelics in all sorts of forms, the volume of research that's going into them for a variety of different conditions is kind of incredible over the last 10 years or so. Talk to me about ketamine or just the general class of psychedelics. And I know some people debate whether ketamine actually should even be in the class of psychedelics. I don't think ketamine is classified in psychedelics.

57:01Ketamine is NMDA. And again, I want to stress, this is not a first-line treatment. This is for others, this is for those who are very refractory headaches. But we believe that ketamine functions to help reverse this concept of central sensitization. So central sensitization is sort of, you can think of it in a very simple way of how the brain is adapting to migraine and more susceptible to migraine attacks. We know it works on a variety of different receptors in the brain, one being GABA. GABA is brain injury. GABA glutamate, like we view these as brain energy. So the brain doing a lot of signals.

57:39So, you know, and therefore bringing those down reduces how many transmissions are going and reducing the headache. We're not fully sure, of course, what it is. This is, you know, there's no test to prove it, but that's the general understanding. Um, psychedelics, you know, uh, I want there to more, be more research in psychedelics for migraine. There's been evidence in other countries of psychedelics for the treatment, like LSD for the treatment of cluster. You know, I know some groups are beginning to underway, um, with looking at it at migraine and cluster in this country. Um, I believe the federal administration recently did an executive order to sort of, you know, speed that up.

58:22Um, I, because of its effect with cluster, it makes it hopefully a promising treatment. But I guess all the topic of illicit treatments, marijuana does have a lot of evidence. There's been many, there's been two or three major trials done. So it does have a medical medicinal purpose, but it has been shown that marijuana can be an effective migraine abortive medication.

58:50Jonathan Fields: These are things which are kind of on, We're on the edge of knowing. They're kind of like, and some you could call them fringe, but maybe further research is really going to prove them out. When you look five, 10 years out, what are you seeing in the research pipeline now that really makes you excited that's not yet available? The impact and success of the CGB drugs have flung the doors wide open, which is great because again, those were the first treatments that were specifically involved for treating migraine and the fact that they were so successful that now there's a lot of attention. For instance, right now we have this ongoing trials for a neuropeptide called PACAP, P-A-C-A-P.

59:31So it's another neuropeptide related to migraine. There are ongoing trials right now. So I hope within the next two years, we have a whole new treatment class. I also saw a presentation of the American Medical Society about one that targets histamine because we have histamines involved there's a lot of different potential um neuropeptide and other and uh and enzyme targets that i think if we did this video 10 years from now there'll be a lot more treatments to talk about and a lot more success because the comment gets brought up for there are people who have migraine that the cgrp drugs didn't help at all what does that mean i thought cgrp was involved the migraine.

1:00:15But I believe, again, migraine is complex and that if we know there's a bunch of neuropeptides involved, I think there are individuals who have migraine attacks that aren't super seizure P driven. Maybe they're driven by a different neuropeptide. So what I really hope to see is when in a couple of years, we hopefully have a pay cap drug that's out for those people whose seizure P's didn't help, this can hopefully be an effective measure. and then that breaks the question what do you combine stuff what do we target both pay cap and cgp what does that do now this is why we need clinical trials like you know to make sure we're not scrambling brains but i will say the cgp drugs uh the monoclonals have been out since 2018 and there's not really been uh a vast increased signal seen in concerns there's the fda released post-marketing warnings that they may uh lead to increased blood pressure anecdotally i've really not seen it that much.

1:01:10But there's been no contraindications, nothing's been polled. So they're relatively pretty safe drugs and we're at the eight-year mark. And again, it's only one peptide class we targeted. What do we reach a world we have three or four? So it's very exciting stuff happening.

1:01:29Jonathan Fields: Yeah. I mean, it sounds like you just described, if we have this conversation again in 10 years, we could have a whole new suite of opportunities of offerings to draw upon and maybe even bring together. I can't tell you how many patients who said they last saw a provider about their headache, let's say, in the 90s, and they're like, I was reluctant to come back because what am I going to do? I'm like, let me tell you, we're in the golden age. There's a lot of things we could do. I can't say it enough. If you're suffering from really any kind of headache, speak with your provider, there's a lot that can be done.

1:02:01Last question about maybe less conventional

1:02:05Jonathan Fields: approaches. I have read, and I'm sure a lot of people have read, like years ago, guys like Dr. John Sarno came out with his theory around TMS. And then more recently, Howard Schubiner with MBS, mind-body syndrome. And it's this notion of, I recently spoke with the researcher from Stanford who used the phrase biopsychosocial in reference to just generalized pain or chronic pain. Is there something potentially bigger going on that can lead to migraine, whether it's relational or social or psychological, that manifests in pain in migraine? Pain is a concept, if you will, a creation of the brain. Your body doesn't feel pain.

1:02:57Pain is a warning that something is wrong in this area. If I cut your foot, it's pain to make you look at your foot. Oh, there's injury. I need to do something about it. Pain in my stomach. I ate something bad. I'll give an example. IBS. if you do a colonoscopy, endoscopy of someone IBS, it usually comes out clean. But then why is their stomach acting like this? The brain controls all. With that said, it's not just going as, oh, it's in your head. The symptom is real. The symptom is very real. We're going to treat the symptom. Just saying it's in your head. Every pain is in your head. If I cut your foot off, the pain is in your head.

1:03:37It's a manifestation of the brain, if you will. So yes, that's what goes back to this concept of chronic sensitization. When the migraine goes untreated for a while, your brain enters this sort of, you know, new environment. This is where things like, let's say you have a thermostat at home, but it's broken. Well, room temperature 72. It thinks it's room temperature, but it's really 82. The house is hot. But the thermostat says, we're good. Think of it like that. When you've had untreated migraines so long, your brain thinks this is normal. This is a normal way to feel. I'm supposed to feel this way.

1:04:13And that's where things like biofeedback therapy and other psychological therapies come in. And it's again, not saying that, oh, it's in your mind, your brain is thinking of pain wrong. And it doesn't mean that everyone needs that kind of thing. But yes, those get involved. You brought up TMS. And TMS can also have its purpose as well. There's ones that are given in an office setting and some that are going to be given in a home setting. And that could work on numerous different pathways. But the point being is that it's not as simple as my goodness, brain has pain. It's more complex than that.

1:04:55And again, it comes to your brain, how your brain handles certain stimuli. Another example or thing to bring up is so depression is the most common comorbidity for migraine why why is your mood if you will i'm not doubt i'm saying this simplistically i'm not sure i'm downplaying with depression why would that cause pain well depression anxiety that's stimulus it's also noxious stimulus then it's not good stimulus the brain starts seeing that as bad stimulus again what do we say pain is so there's bad and therefore the brain thinks in a state of danger and now we're having a painful syndrome. And this is a big oversimplification, very oversimplification.

1:05:37And what we don't fully understand, we don't. If we knew exactly causes and whatnot, we would cure migraine. But this is what we, have a theory of how it's sort of interacting.

1:05:48Jonathan Fields: Yeah. So for someone who's been joining us, this conversation, you just went through just incredible depth in what migraine is, is in how we start to distinguish these from different types of headaches and the different ways that you think about acute versus preventative and also lifestyle and beyond and what's coming down the pipeline. So somebody's joining us, kind of nodding along, fascinated by this, and maybe there's somebody who's been dealing with migraine. Maybe they've just realized for the first time in this conversation, oh, wait, this actually, I think, may be migraine, and maybe there's actually something that I can do about this, but they don't know where to start.

1:06:25Jonathan Fields: What would you tell them? Where do they step into? this. Your private care doctor is always your first place. And, you know, I always say patients are their own best advocate. If you're a primary doctor, you know, make sure you're making the case that how it's affecting you. If they're shutting you off, it sounds like you need a new primary care doctor. You know, headache medicine specialists exist. You can always go to general neurologists. There's people like me who are board-certifying in headache medicine. You can use resources online, like at the National Headache Foundation and the American Migraine Foundation, the resources to connect you with a board certified headache specialist.

1:06:58I run a headache education blog on my website, headache123.com. So I would summarize it again as, you know, be your best advocate, bring them to your primary care doctor, and then just seeing if there's a headache specialist in your area. It could take a while to see when they typically have long wait lists, then that's why starting with your primary care doctor. But you feel this is affecting you. You're not alone. you know i up to 60 million americans are thought to have migraine who in many more are untreated or unknown that they have it it's super common and there's things we could do i love that it it makes

1:07:35Jonathan Fields: the person who maybe has felt a little bit hopeless realize even if maybe they'd seen somebody a long time ago times have changed and there's probably a lot more that can be done to help you i can't say it enough. I feel I'm very fortunate. I love my job. There's so much we could do in headache medicine. Love that. It feels like a good place for us to come full circle as well. So I always wrap these conversations with the same question in this container of a good life project. If I offer up the phrase to live a good life, what comes up? To live a good life is finding ways to not let chronic conditions beat you down.

1:08:13And that's harder. That's easier said than done. But your patient medical journey never ends and always finding the best care you can get.

1:08:24Jonathan Fields: Thank you. So the thing I'm sitting with from this conversation is how long that the blood vessel story stuck around and how many treatments, including some that I've tried myself over decades, were built on it. A few things I don't want you to lose also, the broken thermostat idea. This notion that untreated pain can quietly convince your brain that this is just normal now, or the migraine hangover, that whole body exhaustion after an attack that's actually your brain running out of fuel, and the golden age, Dr. Cohn's phrase, not mine, for where headache medicine actually is and is going right now.

1:09:02Jonathan Fields: So here's the concrete thing for you this week to think about. If you or somebody you love has been living with head pain, with migraine, or headache and assuming there's nothing left to try or hasn't seen anyone about it since it felt hopeless years ago, that assumption is probably out of date. Start with your primary care physician or your closest qualified healthcare provider. That's it. The whole first step. And hey, before you leave next week, we're sitting down with Marissa Renee Lee to talk about why the tidy stories we tell ourselves about grief and resilience, they tend to fall apart and what it actually looks like to build a life around pain instead of just waiting to get past it.

1:09:42Jonathan Fields: So be sure to follow Good Life Project wherever you get your podcasts so you don't miss that or any upcoming episodes. And do me a quick favor while we're here. Share this episode, especially anyone who is either personally suffering with or knows people, has people around them that deal with these things called headaches or migraines. This can be incredibly helpful and eye-opening for them. And while you're at it, if you have three extra seconds, go ahead and leave us a quick review wherever you get your podcasts. This episode of Good Life Project was produced by executive producers, Lindsay Fox and me, Jonathan Fields.

1:10:15Jonathan Fields: Editing help by Troy Young, Chris Carter crafted our theme music. And of course, if you haven't already done so, go ahead and follow us wherever you get your podcasts so you never miss a conversation. Until next time, I'm Jonathan Fields signing off for Good Life Project.

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