Welcome to the WebMD Health Discovered Podcast. I'm Dr. Neha Bhattak, WebMD's Chief Physician Editor for Health and Lifestyle Medicine. If you've ever canceled your plans or taken a sick day because a throbbing headache has left you nauseous and sensitive to light and sound, you already know migraine is not just a passing discomfort. Maybe you've only thought of migraine as really bad headaches.
But if you've had to barricade yourself in a dark room while your head pounds and your stomach churns, you know firsthand that there's so much more going on. What distinguishes a garden variety headache from the world of migraine? And why do some people endure bouts of vision changes, nausea, or even days of lingering pain? In today's episode, we're going to talk about how migraine can be a big problem for people with
We're tackling these questions head on. We'll explore how migraine develops, why your brain may be more revved up than usual, and why triggers like certain food, stress, or even weather can set off a domino effect of debilitating symptoms.
We'll also dig into the many tools and treatments that can bring real relief from lifestyle tweaks like better sleep routines to targeted medications and emerging approaches like neuromodulation devices. We'll talk about what's safe to try on your own, when you should consider a specialist, and how to create a personalized migraine toolkit that puts you rather than your pain in control.
If you've been struggling to cope with recurring headaches or simply curious about this invisible yet life-altering condition, you won't want to miss this conversation. So first, let me introduce my guest, Dr. Cynthia Armand. Dr. Armand is an associate professor of neurology at Montefiore Medical Center, the university hospital for Albert Einstein College of Medicine, and is also the fellowship director at the Montefiore Headache Center.
She's the current web editor at JAMA Neurology and the host of the JAMA Neurology Author Interviews Podcast. Welcome to the WebMD Health Discovered Podcast, Dr. Armand. Thank you so much, Dr. Pathak. So happy to be here with you. So before we jump into our discussion around migraine, I'd love to ask about your own personal health discovery, whether it's in your research or working with patients.
that really was your aha moment.
Absolutely. I think where this started was me having a fascination with the brain and the nerves, the entire nervous system when I was in medical school. And when I went to residency training, I began to understand the sense of how scared neurologic patients are, especially when you're trying to explain to them something that
doesn't quite necessarily make sense to them because you can't really see it, but they know they're not functioning well and what that means for the rest of their lives, their prognosis and how they can live well. And I began to fall in love with headache medicine because there were two worlds I was seeing. I was seeing the world of devastation for someone living with an invisible disability that
that can't necessarily be seen as a problem. You don't have a broken arm or a leg. You don't have a cast. You don't have a wheelchair in cases. And
And really, they live to prove to the world that something is wrong. And the other part of it is living and finding solutions and management for these individuals and how they were able to triumph and really have a life that's changed and able to be fulfilled.
And I really love the two together. And being a headache specialist has been so rewarding. And what I really like most is the rapport that I have with patients and seeing the same individuals on a regular basis and seeing how they live. Nothing makes me so happy than watching my patients thrive, them showing me their accomplishments and how they live. And that's been amazing for me. So let's take a step back and just sort of define what
what actually is migraine and how is that different from other types of headache?
The first thing I'll say is the term headache, right? It's a catch-all term. It's really a term for meaning pain in the head. And it's a symptom of what can be a signal of what's going on elsewhere in the body or intrinsic to the brain. So that's, in a simplistic version, what headache means. But migraine is much more than that. Migraine is a chronic neurologic disease.
disease. It's a brain disease. The brain cells are vastly hyperactive. This means that there are many more symptoms that happen in addition to head pain. When we diagnose migraine and we utilize diagnostic criteria in the International Classification of Headache Disorders, and what it's described as is it's a recurrent headache disorder.
It's usually unilateral head pain manifesting as pulsating in quality. They're moderate to severe in intensity. They're aggravated by routine physical activity. And there is association with nausea, light sensitivity, which is photophobia, or sound sensitivity, which is phonophobia. And they usually last for about four to 72 hours. This is specific criteria for this.
And research has really backed this up of all of these symptoms because how we envision a migraine attack, we know that possibly symptoms start about 48 hours before we even start to feel the pain phase. And we do break down migraine into four phases. There's the premonitory phase.
where individuals can start to feel symptoms leading up to it. And that's when the cells are revved up. After the premonitory phase, then comes another phase that not necessarily is experienced by many people. It's the aura phase. And we know aura to be a transient, reversible neurologic symptom that is experienced most classically prior to the pain phase.
It comes in different forms, but the most classic form is a visual aura where someone can see what we call a scintillating scotoma. There can be kind of shapes and they're moving across the visual field. And then after that comes the pain phase, which is classically what I described in the diagnostic criteria.
And then this pain phase is extremely debilitating. Again, it's moderate to severe, which really separates migraine attacks from something like tension type, among other things, where people can still function when they have a tension type headache, for example. With migraine, you can imagine with everything I'm describing, it's very hard.
function. And after that pain phase, the fourth phase is the post-drome. We see this as a recovery period. The brain was hyperactive. Now it's still recovering and people can be groggy. They can be tired. They can still have this cognitive dysfunction that lingers. And then a lot of us like to think of a fifth phase called the interictal phase. And that's
the period of time where if it's someone with episodic migraine, they have no pain. And I think this part is also debilitating, this phase, because people are anticipating when the next attack can come because they're unpredictable. And they're really, okay, when am I going to have the next attack? Okay, I have a wedding to go to next week. What am I going to do? Oh, I have to anticipate this. And so it can be incredibly crippling to living life to the fullest.
Thank you so much for really sort of walking us through a variety of phases that are all sort of part and parcel of that migraine diagnosis. And it can be different for different people. But I'm curious,
With the MRI studies, the fMRI studies, even if you're not someone that has an aura or that you sort of perceive that you're having an aura, are you still having some of those changes in your brain? So is it always that everyone is going through these different stages? You may just perceive them differently? Or is it that some people just may not have an aura and some people do? Yes, absolutely. We do see these changes.
And this helps to identify the phases, but people experience migraine differently. And this is why we have individualized care. But yes, we do see the changes. And that's why we recognize this as a brain disease disease.
And one in three individuals with migraine experience aura. So not everyone will have the aura phase. And someone who has migraine for quite some time may not experience their first aura until 10 years after they are diagnosed. Or maybe they're experiencing something, but they don't realize it. And again, aura comes in different forms. There's visual, there's sensory, there are brainstem auras. So really, sometimes...
It takes a while after establishing rapport, conversations, keeping a diary for this to be recognized because many patients are afraid to be upfront about what they're experiencing because automatically they may say, but this has nothing to do with it. Because before they seek care, there's this misunderstanding and they're always shot down.
So imagine you're feeling things and someone in your family or someone you confide in says, oh, it's just a headache. Just go take some Tylenol or X, Y, and Z. You'll be fine. But you are experiencing severe nausea, for example, where you can't keep things down. Your belly is cramping. You can't even get a sentence out when you're having this type of pain or even prior to you're having word finding difficulty.
How can you come forth with that information when suddenly you're shot down on a regular basis and we get to the doctor's office, they're like, okay, it's the head pain. It's the classic things. I have migraine. I look this up. What are we going to do about this? Right. So, right.
That's really, really interesting. So let's talk a little bit about how common migraine is. Is this something that you see very frequently in your office? Are there other headache types that people often confuse migraine with? And is there a predominance of one gender versus another or ethnicity or race sort of predilection for migraine?
So, of course, I work at a headache center, so I am seeing migraine much more often than other individuals. However, according to the World Health Organization, migraine is one of the 10 most disabling medical diseases in the world. It's the second leading cause of disability worldwide. About 1 billion people are living with migraine globally.
And in the United States, it's roughly 39 million people with it. We do see that migraine is three times more common in women than men. And it does affect 30% of women in their lifetimes.
So we do see that gender predominance. However, when we think about gender, we think about the nuances of who's more likely to seek care than others, traditional gender roles in society. And are we not seeing as many men coming in with migraine because
Perhaps they are taught not to talk about pain or they're not strong enough. X, Y, and Z, many of these perspectives that come to light when they're in my office. But we do see that difference.
So tell us a little bit then about triggers. What might set this off? When I think about triggers, and I like that you use the term set off, right? Because when you have migraine, it's a chronic brain disease. It's there. The triggers are not the cause of the migraine attack. The triggers are what really lowers the threshold for someone to have that attack, makes it easier, for example. So when I talk about triggers...
I usually start off by saying the migraine brain loves consistency, loves a schedule. Anything that disrupts that causes the schedule to become awry, that is unpredictable, it can make it easier to have a migraine attack. And triggers are highly individualized.
Some groups of people may have similar triggers, but just because one person has one doesn't mean you have to have the other. So I try to counsel my patients on not going to extremes to avoid things because this may not be for you. Let's just keep a diary and figure that out. So when I think about consistency, I think about, okay, in the trigger box, what do we have?
sleep, right? So we know that lack of sleep, too much sleep, change in sleep-wake pattern can trigger migraine. So that's something that is very well known. And we
When we counsel our patients, we think about telling them, try to have consistent, adequate sleep. Many individuals with migraine may have obstructive sleep apnea. So we ask questions about snoring, ask questions about apneic episodes while they're sleeping. And we get them to a sleep specialist to diagnose that because obstructive sleep apnea also has other health implications. Diet is a big one.
And many patients are very quick to go on strict diets because they have migraine and they can't have chocolate. They have to stay away from the coffee. Listen, you can enjoy your latte. You can enjoy your dark chocolate if that's what you like. How about you keep a diary and figure that out first before you go that extreme? So there are individuals who they have gluten insensitivity.
And that's something that can trigger a migraine. Not everyone, though. There are people, chocolate does it. Wine is a common offender, red wine. And these are things that I say keeping a food diary is very helpful. Doing what you do on a regular basis and seeing when something happens and when something can be triggered.
Caffeine is something that's very interesting because someone can regularly have caffeine and use medications that also has caffeine and may not recognize that the amounts are building in the body. And then when they return to their usual, they may have this withdrawal phenomenon where they have worsened headache. So I always ask those questions about different caffeine sources. Many times I say, do you take in caffeine? And the answer is no, not at all. We have to be specific. Red
Red Bull, Coca-Cola, black tea, green tea. And then the answers are, oh, yes. I, oh, sometimes. What sometimes? Every day, five times. So really, we like to keep that just under control. And I say, you can enjoy it.
whatever pleasure you have with that, but really be cognizant of how much of it you're taking in and when you're tailing off. Other triggers that we cannot control, the weather is something that can really do a number on individuals. And that's something that I think is difficult to handle and difficult to deal with. So we guide our patients on maintaining consistent lifestyle and thinking about their migraine action plan. And the final thing is stress.
Stress is unavoidable. There are many things that can happen in our lives that will lead to stress and our pro-inflammatory state will heighten. So I always talk to my patients about thinking about ways to manage stress. And there are validated treatments in migraine that deal with stress management, like mindfulness, meditation practice, cognitive
Cognitive behavioral therapy. So while you practice these things on a regular basis, it's perfect because it's creating a lifestyle where you are arming yourself in the best way possible to handle stressors that may come to you. Because when they do come, you've been practicing them.
these tools and you have them in there, you're much better equipped to utilize them when absolutely necessary. What's the first step in treatment? Let's say even before you go to see a physician, are there things that you can do for yourself if you're noticing, okay, I
I have migraine. I've been diagnosed with migraine. I feel like it's coming on. These are my typical symptoms. What can someone do to sort of head it off at the pass if they're someone who suffers from episodic migraine? Right, right. So that's it. That's
key that you say that episodic migraine. And really, if you haven't seen a physician, there are many over-the-counter treatments that are available that have at least two positive randomized controlled trials behind them, which is level A evidence for treatment of migraine. For example, many individuals can take aspirin as needed for migraine attacks. Naproxen, of course, I'm talking about the NSAIDs, right? Non-steroidal anti-inflammatory medications. So
naproxen, ibuprofen, diclofenac, many of these medicines are level A for treating an attack when it happens. And the best way to do this is as soon as you feel it coming on, you want to nip it in the bud right away before all the other millions of neurons come in and become involved. You want to get it when it's at its very start because there are minimal amount starting revving that activity up. So I think that's the
the first way to think about this is,
Do I have something to arm myself with at the time when I'm having the attack? Many people are not into medications and they may think of non-pharmacologic ways of treating. And that's okay too. We just discussed mindfulness, meditation. Some people may put themselves in a dark, quiet room, get some ice packs, meditate. And that may be helpful to them because that is what they prefer. But if you're having attacks and
again, they're disabling and you're not able to function your day-to-day, meet social requirements, meet work demands, you're absent, you're not present, then medications are important and that conversation should be had with your doctor. Now, they are effective, but it's really important to make sure they're not taken too often because there's an entity called medication overuse headache. And so those are rebound headaches that happen if you take too many of these medications.
So again, important to recognize that there's an issue going on, you're trying to treat it, but if you're having to treat more than two to three days per week, get yourself to a provider in order to help with it.
Can you talk us through what you're doing to give someone that official diagnosis? Absolutely. So I talked about the international classification of headache disorders. So I'm really having a conversation with a patient. Migraine is a clinical diagnosis. So I'm getting a history, looking into the nuances of what they're experiencing and seeing if it, A, is
fits into something that we call a secondary headache disorder or primary headache disorder. Primary headache disorder is something that's intrinsic to the brain, tension type headache, migraine, cluster headache, trigeminal autonomic cephalalgias,
But before you get to that, you need to parse out the history in order to rule out any red flags that would determine if what is happening is behaving like something that is mimicking a migraine. Can there be some sort of malignancy there? Is there thyroid disease? Is there anything else going on in the body that is presenting itself this way? With those red flags, if any of them present, common red flags are
Fever, focal neurologic deficits, a certain age, like an age between 50, 65 years old, rapid weight gain, ringing in the ears. All of those things are red flags that lead us to seek ancillary testing at that point in order to rule out a secondary disease. And then that brings me to migraine or any of the primary headache disorders.
And ancillary testing can be a head imaging. It can be labs. It could be a spinal tap, depending on what's going on, right, to figure that out. So you want to be able to determine is this a primary or secondary headache.
Again, ruling out red flags, getting that ancillary testing, and then you're in the primary headache disorder realm. Imaging is not necessary to diagnose migraine. It's really that history, but it's imperative to make sure red flags aren't present so that you're not missing a secondary headache disorder.
So then let's move on to other treatment options if it's not cutting it for you with regard to some of these over-the-counter pain relievers. What else is in your arsenal? So I love this topic because over the past several years, we have had this robust discussion
just improvement in treatments because of our researchers and scientists who've worked so diligently to understand how migraine works. And first of all, we've had what we call triptans, which are serotonergic agonists. There are seven of them and they are used
for acute migraine therapy. The one thing about, two things about triptans is they can have certain side effects that are unpleasant to individuals. They can feel chest tightening, neck tightening, just really unpleasant, flushing. And then there are whole amounts of people who can't take them. People who have cardiovascular risk factors. They've had strokes, myocardial infarctions, uncontrolled hypertension.
So really, with these triptans, they're really tailored to a specific phenotype of individual who doesn't have those risk factors. Now, with the triptans, and we're talking about migraine-specific therapy, there are ergot derivatives that also can be used. They are vasoactive. And also, too, they come with side effects.
But recently, over the past 10 to 15 years, there are a whole new class of medications. And talking about acute therapy first, there are a class of medicines called GPANs. They target calcitonin gene-related peptide receptors. They're antagonists.
And calcitonin gene-related peptide is really shown to be prevalent in migraine pathophysiology. It's released by nerve endings during migraine attacks. It's shown to be in higher levels in individuals living with migraine. And it responds to treatment of migraine during an attack. Those levels of the CGRP go lower. So many medications have come out over the past several years targeting calcitonin gene-related peptide. And what's wonderful about these medicines
is that people with cardiovascular risk factor can take them. And so in acute therapy, there are several options. There is ubrogepant, there is remegepant, and then there is vegepant, which is a nasal spray. So these are several options that are available that are migraine specific that individuals can take.
if other classes are not cutting it. Other options, there is another medicine class called DITANS. They are serotonergic agonists. Also can be used for migraine attacks, migraine specific, but there was a driving restriction with that class of medicines.
Other things in your arsenal, anti-nausea medicine. People can have nausea. You have to treat that. And there are many nausea medicines that are very specific to treating headache as well. They have headache healing properties like metoclopramide, proclopirazine. Those are helpful in the migraine toolkit of treating as well. That's really exciting. Is there anything else on the horizon that is exciting to you?
So other things that I haven't discussed here is treatment of carotic migraine, which 15 or more headache days per month, people have intractable migraine. There are CGRP targeting medications available. They come in the form of injectables or infusions. There are four of them that are available that have been out for quite some time.
And they have really revolutionized the lives of individuals with migraine attacks that happen more often than not. And then I think what's really important to discuss is people who do not prefer pharmacologic therapy, there is something called neuromodulation. And that's basically therapies that are targeting the pathophysiology of migraine and altering the pain signals.
And there are five devices that have been FDA cleared. Five, I'm talking five that are useful for this. And they range from where they're utilized in the body. There are two that go in the head that kind of attach. There's another one that gives magnetic pulsation in the back of the head. There's one that you place on the arm. There's one that's placed on the neck.
And they're used differently. They can be used regularly for preventive treatment and also during an attack. So I think that's something that has been out and recently improving. And scientists are still in the lab looking at the pathophysiology of migraine, identifying other peptides, and really looking at, hmm, what else can we come up with that can really target this disease better?
especially of individuals who may not have response to what just came out. And then can you talk a little bit about something that a lot of my patients ask about acupuncture and then also Botox since we're on the topic of needles. Can you talk a little bit about where you use them when you think about these two ingredients?
interventions? So Botox, that's anabotulinum toxin A. And that is a toxin that is injected into the muscles around the head, neck, and shoulders. It's utilized via the preempt protocol. And really how this was discovered was patients who were getting cosmetic procedures with anabotulinum toxin noticed that their headaches were going away while they had it in their system.
And so this led to the development of what we call the PREEMPT protocol, which is a series of 31 injections for prevention of chronic migraine, FDA approved. And really, the way we think about onoboxylinum toxin A is individuals who have chronic migraine and really insurance companies will not pay for it if you haven't tried onoboxylinum
other first-line therapies for migraine, meaning oral therapies. There has been a lot of movement with these medications, especially because the American Headache Society put out a position statement on the new castor and gene-related peptide targeting medication stating that, you know what, you don't need to use the nonspecific treatments anymore. You can go straight to these new medications.
They have been out. They are safe. They are effective and they're changing lives. So you can start with them right away. So there's where classically we think of Botox as we use a nonspecific preventives and then they have to try, fail or not tolerate and move on to that. There's starting to be a shift on when we utilize it. And it's really a conversation of,
Again, is insurance going to pay for it? And also what the patient is comfortable with, because we really want this individualized care, especially if we know they're diagnosed correctly with chronic migraine. Now, in the story of acupuncture, acupuncture is wonderful because there, again, this is another non-pharmacologic option for individuals. And we do know that there's evidence behind it.
There's a 2016 Cochrane review that showed that 41% of patients who received acupuncture had at least 50% reduction in headache frequency as compared to 17% of those who did not. And it was well tolerated. And so I view acupuncture as an adjunctive therapy, especially if someone is debilitated and we have migraine specific treatments.
We have patients who really hold true to holistic therapies. And I always talk about this to add on in order to just be a part of the lifestyle, right? Lifestyle of exercise, living healthy and diet. Why not add acupuncture, something that is evidence-based to help with migraine disease that you're living with?
So, you know, as we come to the close of our time together, I'd love it if we could end the episode by helping someone listening today think about what should be in their migraine toolkit or the toolkit for someone they love today.
so that they're doing this in a step-by-step manner to best take care of their symptoms. When I think about that toolbox, I think about, okay, let me think about my lifestyle. What do I need to maintain a balanced state as much as possible? And I know we talked about living well and the lifestyle parameters. Then I think about what do I need when I'm not in a balanced state or in case of an emergency?
And a part of that toolkit is keeping a diary, right? And recognizing when that's not happening and what happens when you're not in a balanced state, whether
Whether it's stress, what do I do for my stress relievers? And then what happens when I have a migraine attack? Am I taking my prevention? What do I have for that? What do I have for my acute attacks? If it's not working, then what do I do? I have my doctor's number ready. When I go to the emergency room, what do I have to communicate to the individuals that are taking care of me in the best way possible? That is communication.
Efficient and good for everyone. Do I have what we call a migraine action plan, which is simply a document that states what your diagnosis is, what medicines you take, and what works when you are in what we call status migranosis, which means having headache for three or more days continuously. And that's something that can tremendously be helpful at that time.
Other parts of that toolkit is anything and everything that you need when you are in that decompensated state, what your family needs to do. They need to put you in a dark, quiet room, get the ice pack, have your nausea medicine close to you, get you some tea, things of that sort, I think. And it's really individualized for each person. That's what I think about a migraine toolkit for someone in general.
Thank you so much, Dr. Armand. I so, so, so appreciate your time. You have talked us through all things migraine. So just really appreciate you taking the time to talk to us today. Thank you so much. It was wonderful to be here, Dr. Pathak. Lovely to talk to you about this topic that's near and dear to my heart. Today, we spoke with Dr. Cynthia Armand and learned that
Migraine is not just a headache, but a chronic neurologic condition with multiple phases. It often involves an aura, severe head pain, usually on one side, and lingering after effects. We also explored the importance of consistency in daily routines from keeping a regular sleep schedule to
to being mindful of triggers like certain foods, caffeine, and even the weather. We also recognize that one person's trigger might not be somebody else's trigger. So we really need to get to know ourselves
and our own personal triggers. We discussed the benefits of tracking symptoms in a headache diary, which can provide essential clues for both diagnosis and treatment, helping you and your healthcare team create a plan that's right for you. We also covered a wide range of treatment options, from over-the-counter pain medications to migraine-specific medicines, injectables, and cutting-edge neuromodulation devices. Over
Ultimately, the key is to build a personalized migraine toolkit that includes not only medications and therapies, but also practical lifestyle strategies to keep us feeling our best. By recognizing migraine as the complex disease it is and giving our brain the balance it needs, we can take meaningful steps towards relief and a healthier, more fulfilling life.
To find out more information about Dr. Cynthia Armand and her work, make sure to check out our show notes. Thank you so much for listening. Please take a moment to follow, rate, and review this podcast on your favorite listening platform. If you'd like to send me an email about topics you're interested in or questions for future guests, please send me a note at webmdpodcasts at webmd.net. This is Dr. Neha Pathak for the WebMD Health Discovered Podcast. ♪