Maggie McKay (Host): Welcome to Health Works Here from Emerson Health. Thanks for joining us. I'm Maggie McKay. Our guest is Dr. Agnes Virga, Chief of Neurology at Emerson Health to discuss perimenopausal headaches and migraines. Thank you so much for being here, Dr. Virga.

Agnes Virga, MD: Thank you so much for having me. I've been treating migraines for decades and I have been a migrainer myself, so this subject is very close to my heart and knowledge and expertise. Thank you.

Host: I'm so with you. I also get migraines, so I understand. So what is the difference between a headache and a migraine?

Agnes Virga, MD: Well, migraine is a very complicated neurological disorder. It's not a simple pain like you have a pain in your knee or your hip or your back. It's a very complicated chemical change, and it's usually a recurring severe headache. Can cause throbbing, pulsating pain, usually one side of the head, but location can be different. It's not always one sided. And a very big difference between like a regular headache or a migraine, it's migraines usually come with other symptoms. For example, stomach problems, GI complaints, diarrhea, nausea, vomiting, can be visual disturbance, tingling, numbness on one side of the body or another, feeling dizzy, lightheaded, and sensitivity to light and sound.

And very often people have to lay down in a dark, quiet room and it's affecting their daily activities, their life. So it is not a simple pain. We cannot always differentiate, keep in mind, because there are different migraine types. Sometimes people think it's migraine, which puts you to bed and you have visual disturbance and you throw up, but it's not the case.

There are different type of migraines, which can be very similar to the so-called regular migraines, you know. They can cause neck pain or TMJ pain in your jaw and other symptoms. So I do have patients who come and tell me, oh, I have these headaches for a long time. I have to lay down. I take all this Tylenol, Advil, they don't help.

Or I have these sinus headaches for years and I take antibiotics and don't help. So, one more reason to see a neurologist or seek help because they are different, but they can be misleading. You know, you can mistake migraines as a regular headache or sinus pain.

Host: Definitely. And they are debilitating oftentimes, at least that's what I've experienced. Are there certain points during perimenopause or menopause where women have more headaches or migraines?

Agnes Virga, MD: Oh, definitely. Perimenopause it's a transition time, from life with the regular menstrual migraines and menstrual stages to the menopause. This peri menopausal time can be several years, you know, one year or four years as an average. So this is a problem when the estrogen and other female hormones fluctuate.

So migraines can be very different actually in perimenopause. They can be worse than before. And not only the frequencies, severity can increase, but also how they present. I did have patients who had their first real migraines, first time in the perimenopausal stage, and they can have different symptoms. For example, I see more people with visual migraines, visual auras, when they see flickering lights in front of their eyes or they go numb or weak, other symptoms. These so-called migraine variants or complex migraines when maybe the headache not even so bad, but people will have other neurological symptoms, which scares them that, oh, they have a stroke, but meanwhile it's a migraine.

And perimenopause brings them in much more frequently than even before. The estrogen levels go down in perimenopause slowly. It's not like a switch, like an on and off switch, it's like a dimming kind of switch. So it goes slowly, fluctuates and in perimenopause, just would like to add that other symptoms can play a role in that, which can be confusing because this is when people have other symptoms.

For example, hot flashes start to come, irregular periods. Some emotional changes, sometimes depression or sleep disturbances, they all play additional role.

Host: And what are some effective treatments for headaches or migraines?

Agnes Virga, MD: There are wonderful new treatments for headaches and migraines. This is why I enjoy so much now my job, because in the past we did not have so many things. Just very briefly tell you that even thousands of years ago, they were treating headaches and migraines. And today what we do, actually, many of them are quite similar.

But, the treatments are either medical or medication type of treatment, or of course non-medication, which we always, of course, encourage. We can do special diets, avoid the triggers, healthy lifestyle, sleep hygiene, but people do a lot of things on their own and it's helping, but actually it's a chemical imbalance, so we need some kind of treatment.

There are treatments if the headache's frequent enough, which are preventive therapy and they are different. There can be some of the antidepressants, even anti-seizure medications. But these days there are wonderful new medications. It's a new chemistry discovered about eight years ago. We call them CGRP. Not that you need to remember, but these new treatments are amazing. They can use even as a preventive when you know that hormonal change will come, Nurtec. These are wonderful, no side effects. Then, there are other preventive, even Botox therapy we use for preventive therapy.

It's once in three months, and it's wonderful new treatment. There are new injection therapies which people use once a month. And so they don't have to think about taking a pill every day. But there are also the treatments when you have a breakthrough migraines. So there are different ones. They act on different chemistry, like serotonin. It's a pesky little protein in the brain and in the body, which starts this whole process. You know, inflammation, electric changing blood vessels, dilating pulsating. So there are medications which work on that chemistry, like the older type, the triptans, we call them sumatriptan. rizatriptan, eletriptan. And there are the new ones which use in the different chemistry, which work beautifully. The important thing is that you have to take them immediately when people feel the headache's coming, you don't have to wait. Oh, maybe just a little headache. Maybe will go away.

No, you have to take them right away. Unfortunately with migraines, the over the counter medications like Advil, Tylenol, they don't really work that well because migraine is different. It's not a simple pain like inflammation. Of course narcotics were used in the past. Some other treatments, like there are these electric treatments, electromagnetic therapies, carefully you put it over the head or which people put on their upper arm, electromagnetic treatments. The results are a little bit different with that, with each person, but there are all these new treatments.

I have to tell you that even the most difficult chronic intractable headaches, which people used to have, now can be treated and it is a very great news for people.

Host: That's such good news. That's such good news, and I can attest to it because my doctor prescribed me. I think it starts with riz and it's under your tongue.

Agnes Virga, MD: Yes. Mm-hmm. Yes.

Host: That is like a miracle, a game changer.

Agnes Virga, MD: There are under the tongue medications also, sometimes nasal spray medications as well.

Host: Oh, it sounds like there are a lot of options that's really encouraging. Dr. Virga, when should women get medical help for headaches? Migraines? Should they first contact their PCP or first contact a neurologist?

Agnes Virga, MD: In my opinion, in my long practice, I think they should contact both. The reason, if you want to urgently check because of change of headache, for example. Abrupt, severe headaches like a thunder clap, or you have fever, stiff neck, confusion, visual changes, loss of vision, weakness, numbness, worsening if you have exercise or they wake you up from sleep.

New type of headaches, especially after 50. Now, it's important to check with your primary care because there might be other reasons for the headache, medical problems, anemia, infection, inflammation, other medical issues, medication side effects, which can do it, but at the same time, I see that sometimes because of the perimenopausal symptoms, the headache part is not really addressed so frequently.

It's very often underdiagnosed or not really diagnosed, and people go take over the counter medications on a regular basis more and more. They get rebound headache from it. So I suggest to contact both because you talk to your medical doctor, they do basic tests, blood work or even imaging, but then you have an appointment with your neurologist, which unfortunately will not happen next day when you have a headache.

So it's better to have, in my opinion both, because we have so incredible amount of great treatments now, and availability, and also resources, samples. So I think that both.

Host: That makes a lot of sense. Do headaches and migraines go away during menopause or post menopause? What can women look forward to?

Agnes Virga, MD: Well, I think the outlook is very positive because almost 80% of cases, the headaches get much less frequent and even go away as the hormones change. It's a little bit different if it's like a chemical or surgical menopause where you had to have your uterus or ovaries removed, it's a little bit different.

But if it's not, then the headaches usually go away, much less frequent. And lifestyle changes play a role too. Women often have less of a family responsibilities. Maybe children are gone. Work is like easing up. People are more in control about their headaches, their triggers. They have more time to spend for themselves, to notice what really triggers and more time for ourselves, seeing friends, exercise, yoga, all this and the headaches are better. So I think it's a very positive change people can look for with the menopause and the bodily symptoms also will ease up the fluctuation.

You know, you stand with the more equal hormone level or it's going down so it's not going up and down, more predictable. I really think that it's a positive change we can look forward to.

Host: That's so encouraging between that positive outlook and also all the treatments and the medications that are available now, I think it's a game changer, like we said earlier, compared to maybe even 10 years ago. Would you say that's right?

Agnes Virga, MD: Oh, definitely. I enjoy being a neurologist so much now because sometimes people told me that, oh, your neurologists are so smart, you just cannot even treat a bad migraine. I cannot say it now because it's different and you work with your doctor as a team, you get more control. Already people tell me that they feel more control and it's already great, and then you start to see all those support groups and friends to go out and they enjoy. Your family will enjoy you, your friend. If you are headache free, activities change. So I think it's very important and very positive.

Host: Absolutely. Well, that's a great note to end on. Thank you so much for sharing your expertise. We so appreciate your time and the positive outlook on migraines and all the things available to take care of it.

Agnes Virga, MD: Thank you so much for this and I'm really hoping it helps a lot of people out in the community. Thank you.

Host: Thank you. I'm sure it will. Again, that's Dr. Agnes Virga. Call 978-263-2898 to make an appointment with Dr. Virga or visit emersondocs.org to find a provider. Thanks for listening to Emerson's Health Works Here podcast. Make sure to catch the next episode by subscribing to the Health Works Here podcast on Apple Podcast, Pandora, Spotify, or wherever podcasts can be heard.