Top Headache Doc: Migraine Is Not What You Think

For decades, migraine was explained to patients as a blood vessel problem: swelling, throbbing, treat it by shrinking things back down. That explanation is mostly a myth, and it may be part of why so many older treatments never worked. Dr. Fred Cohen is medical director of Headache Intervention and an assistant professor of medicine and neurology at the Icahn School of Medicine at Mount Sinai. He's one of the few headache specialists in the country trained in both internal medicine and headache medicine, has over 40 publications in journals including The Lancet and Cephalalgia, and has lived with migraine himself since his teens. In this conversation, you'll explore: Why migraine is a neuroinflammatory condition, not a vascular one, and why some medical schools still teach the outdated versionThe "broken thermostat" phenomenon of chronic sensitization, and how untreated migraine can convince your brain that constant pain is normalWhy only about 30% of people with migraine ever experience aura, and the surprising range of ways it can actually show upThe current treatment landscape, from triptans to CGRP therapies, Botox, neuromodulation devices, and what's coming nextWhy Dr. Cohen calls this the golden age of headache medicine, and what that means if you gave up on treatment years ago If migraine has ever made you feel like your body was working against you, or like you'd already tried everything, this conversation will change how you see both. You can find Fred at: Website https://www.headache123.com/ | Instagram https://www.instagram.com/fredcohenmd/ | Episode Transcript https://www.goodlifeproject.com/podcast/migraine-neuroinflammation-cgrp-fred-cohen Next week, we're sitting down with Marisa Renee Lee to talk about why the tidy stories we tell ourselves about grief and resilience tend to fall apart, and what it actually looks like to build a life around pain instead of waiting to get past it. Be sure to follow Good Life Project wherever you get your podcasts so you don’t miss any upcoming episodes! Check out our sponsors and resources: Visit Our Sponsor Page https://www.goodlifeproject.com/sponsors/ Share your midlife reinvention story with us HERE https://stephanie197.typeform.com/to/BOdLYgvb. Hosted on Acast. See acast.com/privacy https://acast.com/privacy for more information.

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• 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'll 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. We'll explore what's happening

• 0:43Jonathan Fields?

  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 the short break.

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• 2:18Jonathan Fields?

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• 3:00Speaker 05

  Yeah. So, that's a really great place to start, because it's still, I would say, a problem, if you will, today. So first, let me start with the myth, and what migraine has still taught us. So migraine, you know, it's actually, there's documentation of migraine since, like, B.C. times. And I think it was Aristotle actually has in like a log, or a diary, or whatever, him talking about having blinding light in his eyes, then a splitting headache, which, that sounds like migraine with aura, yeah. So, it's been around for as long as we've been keeping documentation of things. It's not like an occurrence of

• 3:39Speaker 05

  something new. And the first accepted theory was actually earlier in the 20th century by Dr. Harold Wolf, who's a very famous forefather of headache medicine, that it was a vascular issue. You know, migraine's 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 like, some parts of like 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

• 4:22Speaker 05

  going on, but there's still more to do. But the, you know, it being a vascular blood pressure, so it's a myth, the truth is, it's more of a neuroinflammatory condition.

• 4:32Jonathan Fields?

  Hmm. 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. Like, there's a, 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?

• 5:03Speaker 05

  And that's actually a big find in, if you will, migraine education. I 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, you know, is it, 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 in 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 aura components, like flashing

• 5:46Speaker 05

  lights, excites, weaknesses, all this other stuff. But it's, the vascular part's only one small component.

• 5:51Jonathan Fields?

  So, do we know at this point, what causes that release that leads to all of this inflammation?

• 5:59Speaker 05

  Now, that's the question. Because we know what the release is.

• 6:02Jonathan Fields?

  Yeah.

• 6:03Speaker 05

  So the way to describe it is, we know when a migraine starts, what's happening? 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, in my opinion, it's not just one thing. It's a multitude. 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. It's calcitonin-gelated peptides, CGRP, which there are now treatments that target that, amylin, VIP, VIP, PCAP, substance pico, on and on. And all these peptides

• 6:47Speaker 05

  come out. We 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. You 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 in 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 supersensitized. And we believe it's a pulsating pain, because the areas where the blood vessels are going

• 7:29Speaker 05

  through, that is now sensitized, and that's why it can feel pulsating. The blood vessel's 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 and the head pain. I go, none of it's the migraine, you know, criteria. So it really could be anywhere in the head. It's not just focus behind the eye.

• 7:59Jonathan Fields?

  How do we distinguish between a, quote, "everyday headache," or a tension headache, and migraine? Or we hear this other term sometimes, cluster. Like, what are the differences between those things? And how do we actually tell?

• 8:14Speaker 05

  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.

• 8:22Jonathan Fields?

  Okay.

• 8:23Speaker 05

  Then you also run up cluster. Cluster's a very specific kind of headache. It's 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 a diagnosis is the sort of clinical picture of the pain. Some of the two most important things is duration and 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,

• 9:05Speaker 05

  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. So when someone says, oh, it's only lasts 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, you know, but like, you could persevere, you don't have to stop working. And lastly, that it also can be usually pulsating, throbbing. But again, it doesn't have to be. But really, that duration and the quality is what hones me in.

• 9:48Speaker 05

  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, we may get an MRI. You know, make sure that's fine. Or if you, um, if there's, you know, 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.

• 10:15Jonathan Fields?

  So it sounds like there's three that you just described. Probably the most clearly discerned one is cluster comes on really fast and incredibly intense.

• 10:26Speaker 05

  Cluster is one that usually I'm like, yeah, there's no confusion about it because it's so specific and so unique than the others. I'll give you an example, like it's a severe pain. So typically, you know, the way I, the way I bring me up is like if a patient tells me, 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 to someone clustered. 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 of the suicide headache.

• 11:01Jonathan Fields?

  Right.

• 11:01Speaker 05

  Because people, if, you know, it's so severe that it has historically brought people to that, you know, when they haven't got a good treatment. Um, so, and it's, so it's a very different picture than tension and migraine, which could those have a lot more overlap?

• 11:17Jonathan 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 headache four days in a row, that sounds like a cluster to me. Whereas like, so the co- the common understanding of that word is very different than the medical understanding of the name.

• 11:35Speaker 05

  And yeah, it gets, I, I understand the, the nomenclature of the term. A lot of patients go, yeah, but it's happening in clusters. Sure. Migraine can do that.

• 11:44Jonathan Fields?

  Yeah.

• 11:45Speaker 05

  My people could, you know, it's very common, women can have only migraine attacks around their menstrual cycle. That'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.

• 12:04Jonathan Fields?

  Let's zoom the lens out just for a minute because I'm curious too, um, about the prevalence of this, um, just across large numbers of people. What, what are some of the general numbers, like the big picture numbers and stats?

• 12:19Speaker 05

  For migraine?

• 12:20Jonathan Fields?

  Yeah, for migraine.

• 12:21Speaker 05

  Sure. So migraine, you know, our epidemiology, um, 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 the, of American women, 6% American men. So about one out of five, almost, American women. So very, very, uh, common. Um, 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. So, yeah, 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, uh, disabling.

• 13:05Jonathan Fields?

  Yeah. And you just described, then I've heard this, this mentioned also in the past that there seems to be a much higher prevalence in women than in men.

• 13:15Speaker 05

  Yep.

• 13:15Jonathan Fields?

  Do we know what that's about?

• 13:17Speaker 05

  So there's some, um, suggestions, the most, well, the most common one believed is we know estrogen is related to migraine attacks. And it's not the level, it's fluctuation. Cause I've had patients ask, should I take an estrogen replacement? I go, hold on, no, that might not solve this. Um, most women notice their first migraine attack, if they get one around their first menstrual cycle. We noticed that in the first trimester of pregnancy, there's, uh, increased frequency of migraine attacks. And 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 complained about my migraine, she just goes, oh yeah, wait till you get older. I'm like, well, unless there's a phenomenon, I'm not going through menopause.

• 13:59Jonathan Fields?

  The other fact that I've heard, um, 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, um, in women, but that it can also be more painful, more intense. Is that, is, is that true or is there data around that?

• 14:19Speaker 05

  I would, I don't know if there's data really behind it. Again, it's really hard to quantify pain.

• 14:23Jonathan Fields?

  Yeah.

• 14:24Speaker 05

  Um, 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 higher focus as they deserve and need to be. So there's always this fighting stigma around migraine, um, and raising awareness of migraine. But the other side of the aisle, that migraine is a woman's disease. And again, and where there are, I have, 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.

• 15:08Speaker 05

  So, you know, the, this, that's actually been a reasoning to shed light that, hey, you're a male having, you know, it's a headache attack, speak with your doctor, that could be migraine. As far as which gender has more pain, you know, I, there's no data behind that. And I never like to compare, I tell my pages, never compare your headache or pain with someone else. It's because pain is subjective. You know, how someone expresses pain, uh, differs by person, by culture, um, by, 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.

• 15:53Speaker 05

  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? Are you, how many days could you not interact with your child? How many days are you taking medication, et cetera? Those who 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 healthcare 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 they just ask them questions, how many days have you not been asked for productive at work? Oh yeah, like two or three times a week. Well, okay, 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.

• 16:34Jonathan Fields?

  Yeah. It's such a good point, you know, and, and I, I have had in my own experience over many, many, many years. There've 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, um, 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?

• 17:08Speaker 05

  A patient of mine who had headaches every day for years. And 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 asked him, would you like to, you know, 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, that's up to you. That's fine. So yeah, the, those are, they're, they're just numbers. And one of the biggest lessons in medicine is treat, treat the patient, not the number. And again, like, yes, I always ask those things, but those numbers are not just specific, finite, all right. Like that's all I'm going to work with. No.

• 17:46Jonathan Fields?

  Yeah.

• 17:47Speaker 05

  Um, you know, uh, one of the most important things is the history. Remember, you know, it's not just looking at, you know, um, tests and labs or whatnot, but how the patient is presenting it themselves.

• 17:59Jonathan Fields?

  Hmm. 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 Saribhat, who after decades in her career, then being pushed out as she neared 60, launched Old Street 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. And it's not just about work, it's about relationships, location, health and more. So if you've got a reinvention story you'd love to share, just tap on the link in the show notes and give us a quick summary. And who knows, you might just end up on the podcast.

• 18:43Jonathan Fields?

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• 21:38Jonathan Fields?

  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.

• 21:48Speaker 05

  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. I'm very close and 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. So I tell them that's the only mistake you ever made raising me. But I just dealt with it all the way into a residency. One day a week, pain at a commission. Now, in residency, you're not sleeping. You know,

• 22:29Speaker 05

  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. And 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 board certification you don't have to be a neurologist for. You know, you

• 23:13Speaker 05

  could be an internist, family medicine, pediatrics, OB. Now, most headache medicine specialists are neurologists, the vast majority. We, so I'm like sort of this uncommon one. But it's also what I love about our field, the collaborative nature. Couple of days ago, I just came back from the annual scientific meeting of the American Headache Society, and you meet people of not, just not from different areas, but different backgrounds. Physical therapists, occupational therapists, psychologists, you know, of course, internists, family medicine, peds, et cetera. 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.

• 23:56Jonathan 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, you know, there's, there's neuroinflammation, there's inflammation in the brain. It, 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, like, that it's systemic. Like, there, this is not something which is, you know, like, reserved to what happens from the neck up. Like, there's something going on that's more broadly systemic that also influences the entire experience. Is it, does that?

• 24:33Speaker 05

  It affects other systems. So for instance, the GI tract is involved. We know during a migraine attack, there's gastroparesis. Gastroparesis is, you know, going with the line in term, not per se paralysis of 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, 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 this also. Migraine is not just a headache. There's multiple phases. The prodrome, so the beginning,

• 25:12Speaker 05

  can have excessive hunger, fatigue, thirst, irritability. Then we have the headache, well, the aura phase, then the headache phase. The prodrome, the postrome is nicknamed 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, that it's not just neuro-involved. It does affect other systems in more than one way.

• 25:53Jonathan Fields?

  So now I'm curious about two things you just said there, too. One, the, the early part of it. What was the language you used for sort of like the very early?

• 26:01Speaker 05

  Prodom.

• 26:01Jonathan Fields?

  Prodom, right. You mentioned, and you mentioned a couple of times, this notion of an aura. 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?

• 26:17Speaker 05

  Ready for me to spill another myth?

• 26:19Jonathan Fields?

  Yeah.

• 26:19Speaker 05

  What if I told you that most people with migraine don't get aura?

• 26:26Jonathan Fields?

  Okay.

• 26:26Speaker 05

  And we think of migraine always as aura. 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 aura every attack. So aura can be any, I describe it as this, it's any neurological symptom that essentially could last anywhere from 15 to 60 minutes. That timing is very important. And now, some auras can, but an aura should not last long 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, blind spot that grows. Some people describe it as kaleidoscope

• 27:09Speaker 05

  vision. And generally, there's no pain during it. It happens, it goes, and then the pain begins. But aura could present in a lot of other ways. Aura could present as numbness. It could present as weakness. There are some who have what's called hemiplegic migraine, where it mimics a stroke. There's some who have vestibular migraine, giving vertigo-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. It's migraine. You know, now, these have to be assessed to make sure it's not those things. But my point is migraine aura is not just the visual symptoms. It really could be any neurological presentation.

• 27:53Jonathan Fields?

  Yeah. I mean, that's so helpful because I had heard that, like, this is much more common than you're describing. But also understanding that aura is not just the classic, you know, spot division or, or shift in what you see, but it can show up in so many different ways in your body.

• 28:07Speaker 05

  It really can.

• 28:09Jonathan Fields?

  Yeah. I mean, that-

• 28:09Speaker 05

  There are those who, you know, lose sense of smell, those getting, I have one that they get tingliness on their tongue for 30 minutes. It really, what I care about is the duration. That's the key thing.

• 28:18Jonathan Fields?

  Yeah.

• 28:19Speaker 05

  That it's last, it's, because 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. Now, it comes back normal, cool. We'll say it's that, that's your aura. But it really could present in any way it wants.

• 28:35Jonathan Fields?

  So my other question was about the sort of like the, the post phase. And you mentioned that fatigue can be one of the, 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 would just, like, went through this intense, you know, like, maybe like it just did a 10-mile, like, hike or something like that.

• 29:00Speaker 05

  That's why we call it the hangover. It's like when you had too much to drink.

• 29:03Jonathan Fields?

  What's going on there? Why, why the fatigue?

• 29:06Speaker 05

  Our thought, why? And, you know, we don't have 100%, you know, what this is. But we talked about a migraine when it's happening, all these neuropeptides are firing, right? What happens if you, you're running for a while? You know, 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-

• 29:43Speaker 05

  That's how I sort of visualize in a way that your brain just spent so much fuel and it's like recovering.

• 29:51Jonathan Fields?

  Let's switch gears a little bit and talk about what we do. So 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, like, this is not medical advice, like, 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,

• 30:35Jonathan Fields?

  intervention and prevention, because it seems like those are two different things, maybe with some overlap. So if you are, 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?

• 30:54Speaker 05

  Sure. So I just want to make one point, because this is sort of another myth.

• 30:57Jonathan Fields?

  Yeah.

• 30:58Speaker 05

  If you're not, if you don't have a neurologist, start with your primary care. You'd be surprised, because a lot of people wait to see a neurologist. You might need to see a neurologist, but if, you know, if someone's having tension or migraine, PCP is the place to start. 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, it's like a scale, if you will.

• 31:36Speaker 05

  Anywhere from at least four to six or more, headache, 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. If 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 tryptan family and the GPAN family. The tryptan family has been around since, I believe, the, yeah, the early 90s. You might have heard of these, assume a tryptan, risatriptan, et cetera.

• 32:21Speaker 05

  There are seven flavors of tryptan. They all have their differences, of course. They're available as oral, intranasal, even injection, and they work actually on a, it's 5-HT serotonin receptor, and that actually causes vasoconstriction. But wait, Dr. Cohen, you said migraine's not a vascular problem?

• 32:42Jonathan Fields?

  Right.

• 32:43Speaker 05

  No, no, we'll get, so, yes, the drug itself does cause vasoconstriction, but that causes a decrease in release of CGRP, capsulonchymalated peptide, which is a neuropeptide we know in the migraine cycle. That's how it achieves it. Then there's the GPAN class. You might have heard of these as remidipant, nertec, ubrojapant, ubrowve, zavspren, 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.

• 33:19Jonathan Fields?

  How effective are these? And are they universally effective for everyone? Is it completely different for everyone?

• 33:26Speaker 05

  I wouldn't call any migraine treatment universal. If there was, well, we'd cure it. But these are first-line, and they usually are quite effective. I would say, you know, 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 that those two classes are all, that doesn't mean there's anything wrong with you. Again, everyone's migraine's unique, but those generally are pretty effective.

• 33:51Jonathan Fields?

  So, let's talk about the tryptans for a minute, because I think that was sort of like the earlier class of drugs, and then the things which are, use a different word. I've commonly heard of them described as anti-CGRP meds. It's a, that's a newer class.

• 34:06Speaker 05

  GPANS are anti-CGRP meds, yes.

• 34:08Jonathan Fields?

  Yeah, GPANS, right. That's a newer class than the tryptans, right?

• 34:12Speaker 05

  GPAN's released at the end of 2020.

• 34:14Jonathan Fields?

  Okay, so fairly new, that's, you know, like, six years old at this point, as we're having this conversation.

• 34:20Speaker 05

  Mm-hmm.

• 34:21Jonathan Fields?

  And it sounds like what we know now, and tell me if this is right, is that the tryptans 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, is that right?

• 34:43Speaker 05

  So, yes, it's not as concise as that, because while, yes, tryptans, in my view, are this sort of secondary effect, they also work quicker.

• 34:53Jonathan Fields?

  Ah, okay.

• 34:54Speaker 05

  You know, the mechanism of GPANs, what we see is they, they on average, take a bit longer to get their effect than the tryptans do. So I don't like, like, I get asked all the time which one's better. There, unless, until we do a superiority test, there aren't. You know, I never like to put a claim of which one's better, there, they have their uses, you know, they're, you know, there are some, you know, it's the individual patient, if I pick, if they're getting a GPAN, a tryptan first. Yes, in theory, tryptan's having a secondary effect, but that's a common thing in medicine. We, in 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, but yeah, tryptans on average,

• 35:39Speaker 05

  actually have a quicker onset.

• 35:41Jonathan Fields?

  So about, about how long's the difference between those two classes?

• 35:44Speaker 05

  Now, I want to stress, this is averages and.

• 35:47Jonathan Fields?

  Yeah, yeah, yeah.

• 35:48Speaker 05

  Anecdotally, this is anecdotally.

• 35:49Jonathan Fields?

  Right.

• 35:50Speaker 05

  You know, meaning, I, like, I don't want, you know, this is not, you know, a clinical trial, whatever. What I see is tryptans are anywhere from 30 minutes to an hour per se, GPANs are an hour to two hours. But that is my anecdotal answer. I've had patients that GPANs work very quickly. It all depends on the individual. There's a lot of things going on in the body that sort of dictates that.

• 36:13Jonathan Fields?

  Yeah. Does it also depend to a certain extent on the delivery mechanism? You mentioned oral, nasal, and injection.

• 36:18Speaker 05

  Yeah, definitely. So we have oral, intranasal, and injections. Generally, injection's the fastest, so sumatriptan injectable. We also have sumatriptan and zolmitriptan intranasal, and intranasal zavspren. And yes, there's, that one is a quicker onset than the oral GPANs.

• 36:39Jonathan Fields?

  Got it.

• 36:40Speaker 05

  Now, nasal, again, there's, there's no right or wrong for each individual person. I'll give you an example. I personally love intranasal, but, you know, I use myself. They got a nasty taste. It's not fun getting something, you know, sprays, but again, to each their own, they're all useful things.

• 36:57Jonathan Fields?

  Yeah.

• 36:58Speaker 05

  So there's not like, I don't just, you know, sumatriptan injectable 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.

• 37:12Jonathan Fields?

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• 39:43Jonathan Fields?

  So what about this idea also of medication rebounds? Like I've, 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, migraine for a second day. And then I've heard, well, don't take it for the third day because then you're, you know, you have a likelihood of having a rebound. What's, what's true and what's not true with this?

• 40:04Speaker 05

  So medication adapted headache or medication overuse headache, they're interchangeable terms. I, this actually, I just gave a talk at the American Headache Society meeting last week on this specifically. So yes, uh, what, I guess, let me first define what is a medication overuse headache. It is using a rescue, certain rescue medication.

• 40:24Speaker 05

  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 use the triptan three times in a, like 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. You know, that short span is not going to do it. It takes time. It takes, it's, it's a repeating pattern. That's why like when I meet with a patient, let's say for three months, I'm looking at

• 41:08Speaker 05

  their overall use, not one week. It's not like if you take a triptan 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, we, you know, we have a couple of theories that it's going through this 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.

• 41:36Jonathan 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.

• 41:43Speaker 05

  So great. Think about, we were talking about medication overuse headache, right? Well, if you're having eight, 10, 12, 15, et cetera, headache days a month, you can't use a rescue man 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. That's why I always prescribe acute medications, 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.

• 42:25Speaker 05

  We have what we call the legacy drugs, which have been around for decades. The three legacy drugs are anti-seizure drugs such as still Purimate, um, beta blockers such as propanolol, and tricyclic antidepressants such as amitriptylin or tryptamine. Their evidence is great, but they are work, you know, their original design was for something else and also found to be effective for treating migraine. Then 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 orinumab, chondrazumab, phiminizumab, and eptinizumab.

• 43:09Speaker 05

  These are monoclonal antibodies, which are once a month injections, you know? Think of it like, you know, a lot of people are familiar with like Ozempic or Zepbound, like that kind of applicator, but for your migraine, or once every three months infusions. And there's also, um, atodipine, culeptir, which is take it back to that nirteki, brovy, right? The GPAN, you could take it every day and that's for prevention instead of acute. We 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.

• 43:50Speaker 05

  And it's 155 to 200 units of Botox injected over the entire head once every three months. So, and, 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.

• 44:12Jonathan Fields?

  Yeah. How does, I mean, you sort of described the mechanism for some of the earlier ones. How does Botox actually work in this particular context?

• 44:22Speaker 05

  So Botox, and you know what? I'll give a good demonstration here. Botox is given.

• 44:30Speaker 05

  31 to 40 injections are on the head. So both by the brow, the forehead, the side of the head, the occipital, it's 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 onabotolatum toxin aid, which is what Botox is. Uh, 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

• 45:13Speaker 05

  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 GPAN with Botox. That was one of the first migraine projects I was, 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 there's, 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 thinking is unique, because I've had people come up and 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.

• 45:56Speaker 05

  So, you know, there's no one true treatment for them all.

• 45:59Jonathan Fields?

  So what I'm hearing really is that even on the prevention side, there are a range of different treatments. 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, the optimal effect. Is that right?

• 46:24Speaker 05

  There's a lot. There's, I could keep going. There are sort of antidepressants, the SNRI's, the loxotin and effexor have evidence, blood pressure, blood pressure medications like candisartan or lisinopril have evidence. You have neuromodulation, which is becoming a popular thing, which are these devices you wear, like cefalies goes on your forehead, gamma cores on the neck, um, nirivios on the shoulders, savdis, you know, back of the, and they're, they, they work by sort of, it feels like a vibration, but they're altering your pain pathways. And therefore you're not taking a, you know, you're not, you're not taking a med. There's so many different, uh, treatments is of course off-label uses of, like for patients who are really, really refractory, believe it or not, ketamine.

• 47:09Speaker 05

  Now that's very uncommon, but there are some people who wore at that level of therapy and have done very well.

• 47:15Jonathan Fields?

  Yeah. Define refractory for me, just like what's a common term?

• 47:19Speaker 05

  Sure. Refractory, um, 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.

• 47:33Jonathan Fields?

  Class of drugs that you mentioned earlier, that I'm curious whether they play any role in this, um, GLP-1 agonist.

• 47:42Speaker 05

  Sure. This is actually a really popular thing that was actually discussed also at this past American Headache Society meeting. So the GLP-1 agonist, these are your Ozempics, these are your, you know, Wegovy, Zepbound, Monjaro, et cetera. It was seen in those trials that those who had headaches or migraines started reporting less. And anecdotally, we, a lot of providers saw it too. So the question is how? Is it, and it goes to, is it direct or is it indirect? Because for instance, we know with migraine or chronic migraine, obesity is a, is a very important risk factor in worsening things. And we, and the reason why we, uh, that we think the GLP-1s work at that, of course, it's reducing weight. So is it that it's making headaches better because we're reducing weight?

• 48:27Speaker 05

  Or is it having a neuroprotective, um, capability? There's a proposed mechanism that GLP-1s actually get 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 hyper, uh, intracranial,

• 48:49Speaker 05

  uh, hypertension, IAH, is too much, you know, pressure in the head and that's can lead to headache, et cetera. So it's a question of is the GLP-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, we, is an auto, 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 GLP-1s? Absolutely. But I view it as, do you warrant weight loss?

• 49:35Speaker 05

  I, because I don't prescribe it specifically for only migraine, um, in mind, because again, it will, you know, GLP-1s 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. It has had a, they're very popular and have a tremendous effect on bringing weight down and helping, um, resolve obesity. But that doesn't mean that non-obese people should be taking it, you know, like, because they, there, there are known side effects. There's a talk about, are they causing hair loss, you know, affecting endocrine issues?

• 50:20Speaker 05

  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 your migraine.

• 50:34Jonathan 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.

• 51:04Jonathan Fields?

  Do the basics work like nutrition, you know, like exercise, sleep, hydration? Do they make meaningful difference?

• 51:10Speaker 05

  Because I don't want to ever come up like, oh, yeah, well, the biggest stigma in migraine, if I had a nickel for 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, it, there's definitely a component of it. Because what I was saying before, migraine is an inflammatory condition. Treatments 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 heading diaries are paramount, because that allows me to track data. I tell patients, don't worry what's in a heading diary. That's my job to be worried about it.

• 51:54Speaker 05

  And that's when I can start finding things that may be interfering on a lifestyle level. I have found patients, certain foods affecting it. I had a patient, her eggs could trigger migraines and other 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 information. There's no one true migraine diet, but I've had patients who have, you know, improved heading frequency, gluten free, ketogenic, um, et cetera. And again, it's not because, oh yeah, that's it. And I won't ever say that's not work for you, uh, from 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, what's called the glymphatic system. Don't ask me why it's called that. We have lymphatic, okay, when we sleep, add the G, I don't know.

• 52:40Speaker 05

  Um, so we have the glymphatic system. And remember what I was talking before with like that migraine hangover and because all those neuropeptides? Well, the glymphatic 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, um, state of mind. And that's why it's, it's every single new patient visit I do, I do a sleep assessment. For those who I think there's obstructive sleep apnea, I'm getting them a sleep test. I've diagnosed delayed sleep rhythm, insomnia, there's, but sleep is so important. Um, caffeine gets asked all the time. Caffeine is a double edged sword for most people.

• 53:25Speaker 05

  It helps, uh, for some, it makes it worse. I drink coffee myself. Caffeine is fine in moderation. Don't exceed three or four cups a day. You know, sort of a no brainer with tobacco. Tobacco is known to, uh, cause migraine attacks. We do know that some of the big, the one of the biggest risk factors, uh, for cluster headache is tobacco. Alcohol is a really common treatment for migraine and cluster headaches. Some people makes it better. For me, like I abstain from alcohol, it will give me no matter what, uh, you know, that's actually my trigger. But speaking of triggers, you don't necessarily have to have triggers. Cause 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.

• 54:08Speaker 05

  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, uh, looked at clinical trial data that at the same time, weather metrics were taken. Where, uh, 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. Same thing, if there's a point two for a 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.

• 54:49Jonathan Fields?

  Right.

• 54:50Speaker 05

  There's going to be a storm happening and have your triptonyujiman or whatever on you. So if it happens, you, uh, uh, you take that. And that's sort of why I don't like getting too lost in weeds of triggers. Because some is just, that's the world. Some is just the environment that, you know, the horse you could move a lot now, but some things that you're unable to adjust. But that's where other treatments come in.

• 55:11Jonathan Fields?

  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 pays, makes sense to focus on that. And for others, could be a wide range of things that do or do not trigger, um, a migraine, completely dependent on the individual. Um, you brought up ketamine before also, which I think is really interesting because now, you know, psychedelics in all sorts of forms, um, you know, the, 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, some people debate whether ketamine actually should even be in the class of psychedelics, but.

• 55:55Speaker 05

  I don't think ketamine is classified psychedelics. Ketamine is an M D A. And again, I want to stress, this is not a first line treatment.

• 56:03Jonathan Fields?

  Yeah.

• 56:04Speaker 05

  You know, this is where others, this is for those who are very effective headaches. But we believe that ketamine functions to help reverse this concept of central sensitization. So central sensitization is, you know, sort of the, you know, you can think of it in a very simple way of how like the, the brain is adapting to migraine and more, um, 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. So, you know, and therefore bringing those down produces how many transmissions are going and reducing the headache. We're not fully sure, of course, what it is.

• 56:47Speaker 05

  This is, you know, there's no test to prove it, but that's the general understanding. Um, psychedelics, you know, I, I want there to 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. Um, I, uh, because of its effect with, um, cluster, it makes it hopefully a promising treatment. Um, but I guess all the topic of illicit, you know, treatments.

• 57:31Speaker 05

  Marijuana does have a lot of evidence. There's been many, there's been two or three major trials done. Um, so it does have a, a medical medicinal purpose. Um, but it has been shown that marijuana can be an effective migraine abortive medication.

• 57:48Jonathan Fields?

  These are things that are just kind of on, we're on the edge of knowing. There's 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 do you, what are you seeing in the research pipeline now? That really made you excited, that's not yet available?

• 58:07Speaker 05

  The impact and success of the CGP drugs have flung the doors wide open, which is great. Because again, those were the first treatments that were specifically involved with treating migraine. And the fact that they were so successful, uh, that now there's a lot of attention. For instance, right now we have, there's ongoing trials for a neuropeptide called PACAP. So 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. Um, there is, uh, I also saw a presentation at the American headache society about one that targets histamine. Cause we have histamines involved.

• 58:45Speaker 05

  There's a lot of different potential, um, neuropeptide and other, and, uh, and, 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 a kind of thing gets brought up for, there are people who have migraine that the CGP drugs didn't help at all. What, what does that mean? I thought CGP was involved in migraine. But I believe, because 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 CGP driven. Maybe they're driven by a different neuropeptide.

• 59:27Speaker 05

  So by, what I really hope to see is when in a couple of years, we hopefully have a PACAP drug that's out. For those people who CGPs didn't help, this can be, hopefully be an effective measure. And then that brings the question, what do you combine stuff? What do we target both PACAP 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. Um, but there's been no contraindications, nothing's been polled, you know?

• 1:00:11Speaker 05

  So they're relatively pretty safe drugs and we're at the eight year mark. Uh, and again, um, it's only one peptide class we targeted. What if we reach a world, we have three or four? So it's very exciting stuff happening.

• 1:00:26Jonathan 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, of opportunities, of offerings to draw upon and maybe even like bring together.

• 1:00:37Speaker 05

  I can't tell you how many patients who said they last saw a provider about their headache, let's say in the nineties. And they're like, I was reluctant to come back because what am I going to do? I'm like, let me tell you, it is a dip, we're in the golden age. Like, you know, 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.

• 1:00:58Jonathan Fields?

  Last question about, um,

• 1:01:01Jonathan Fields?

  Maybe less conventional 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, you know, like, theory around TMS. And then, more recently, Howard Schubner with MBS, Mind Body Syndrome. And it's this notion of, I recently spoke with a researcher from Stanford who used the phrase bio-psycho-social in reference to just generalized pain or chronic pain. Is there a, is there something potentially bigger going on that can lead to migraine,

• 1:01:40Jonathan Fields?

  whether it's relational, or social, or psychological, that manifests in pain, in migraine?

• 1:01:47Speaker 05

  Pain is a concept, if you will, a creation of the brain. Your body doesn't feel pain. Pain is a warning that something is wrong in this area. Like, 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, if someone has 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, 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.

• 1:02:31Speaker 05

  If I cut your foot off, the pain's in your head. You know? It'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's 72. It thinks it's room temperature, but it's really 82. Okay, the house is hot. But the thermostat says, forget it. Think of it like that. When you've had untreated migraine for so long, your brain thinks this is normal. This is a normal way to feel. I'm supposed to feel this way. And that's where things like biofeedback therapy and other psychological therapies come in.

• 1:03:15Speaker 05

  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, 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, you know, that could work on numerous different pathways. But the point being is that it's not like, it's not as simple as migraine is, you know, brain has pain. It's more complex than that. And again, it comes to your brain, how your brain handles certain stimuli.

• 1:03:57Speaker 05

  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 down, I'm saying this simplistically, I'm not trying to downplay any of the depression. Why would that cause pain? Well, depression, anxiety, that's stimulus. It's also noxious stimulus. And 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 it's in a state of danger, and now we're having a painful syndrome. And this is a big oversimplification, you know? Very oversimplification. And while we don't fully understand, we don't. If we knew exactly causes and whatnot, we would cure migraine.

• 1:04:40Speaker 05

  But this is what we theoretically, like, have a theory of how it's sort of interacting.

• 1:04:45Jonathan Fields?

  Yeah. So for someone who's been joining us this conversation, you just went through just incredible depth in what migraine is, and 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 they're 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. What would you tell them? Like, where do they step into this?

• 1:05:25Speaker 05

  Your primary 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 shugging you off, sounds like you need a new primary care doctor. You know, headache medicine specialists exist. You can always go to general neurologist. There's people like me who are board-certified in headache medicine. You could use resources online, like at the National Headache Foundation, and the American Migraine Foundation. They have resources to connect you with a board-certified headache specialist. I run a headache, like, 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 see if there's a headache specialist in your area.

• 1:06:09Speaker 05

  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, up to 60 million Americans are thought to have migraine, who, and many more are untreated or unknown that they have it. It's super common, and there's things we could do.

• 1:06:29Jonathan Fields?

  Hmm. I love that. It makes 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 out.

• 1:06:45Speaker 05

  I can't say it enough. I'm feeling very fortunate. I love my job. You know, there's so much we could do in headache medicine.

• 1:06:50Jonathan Fields?

  Hmm, love that. 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 Good Life Project. If I offer up the phrase "to live a good life," what comes up?

• 1:07:02Speaker 05

  To live a good life is, you know, finding ways to not let chronic conditions, you know, beat you down. And that's harder, that's easier said than done. But, you know, your medical, your patient medical journey never ends, and always finding the best care you can get.

• 1:07:20Jonathan Fields?

  Hmm, 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. Cohen's phrase, not mine, for where headache medicine actually is and is going right now. So here's the concrete thing for you this week to think about.

• 1:08:03Jonathan Fields?

  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 Marisa 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. 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.

• 1:08:48Jonathan Fields?

  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. 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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