Michael Smith, MD (Host): Meaningful Medicine is a Novant Health podcast, bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physician offer tips to help navigate medical decisions and build a healthier future.

Today, I'm sitting down with Dr. Megan Donnelly and we're going to be talking about migraines. But before we start there, Dr. Donnelly, I always like to ask my guests how did you choose your specialty? Like what was going on when you were making that decision, you know, back in medical school, getting ready for residency? How did you pick Neurology?

Megan Donnelly, DO: Great question. So, my uncle was a neurosurgeon. He has actually just recently retired. And so from the time I was a very young child, I always said I wanted to be a brain doctor like him. I did not realize what all that entailed until many years into my education. But I think I said that and didn't really mean it at that point. So, it's just ironic that full circle, I ended up in a brain field.

So, I went off to college and knew I wanted to do medicine, so I took pre-med classes, and one of my classes in the intro level was a Neuroscience class, and I loved it and ended up declaring myself a Neuroscience and Psychology double major. So, I'm actually neuroscientist first, and then worked full-time in clinical traumatic brain injury research for three years and then went to medical school, and naturally chose Neurology.

And then, after I finished my Neurology training, I worked as a general neurologist. I was 50% of the time an inpatient neurohospitalist, and 50% of the time outpatient. It actually didn't sing to me. It didn't give me as much joy as I expected, but I realized what I loved were my headache patients.

And so, they were motivated, invested in their care, and we could actually get them doing better. And so, all of that was really, really fun to work with. And so, I went back after a couple of years as an attending to do a headache fellowship. I also, in the meantime, had a complicated pregnancy and realized if there was anything that I could do to make the lives easier of patients who are trying to get pregnant or lactating, I wanted to be able to do that. So, I also then had embedded in my Headache fellowship, an Obstetric Neurology fellowship, of which there's two in the country. So, I was able to fortunately get that training as well. And I haven't looked back.

I absolutely love what I do. I get to see everybody. About 80% of my clinic is headache, head and face pain, so complex facial pain like trigeminal neuralgia and things included. And about 20% of my patients are pregnant, with anything neurologic going on in their pregnancy. And it's great. Every day is a new day and every patient is unique.

Host: That is so great. So, you're one of those physicians that make us other physicians seem like slackers. You've done a lot. That's great.

Megan Donnelly, DO: There's people who are meant to be a generalist and people who are meant to be a subspecialist. So, I was meant to be a subspecialist.

Host: Right. So, we're going to be talking about migraines today. And I'd like for you to help us understand first off, because I think this is like the big first question for people, right? Is my headache a migraine or is it just a really bad headache? How do you tell? Can you help us understand that?

Megan Donnelly, DO: Sure. So, the positive predictive value of if somebody thinks they have migraine, they're probably actually right because there's enough known in pop culture about it. So if you think you have migraine, you're probably correct about it. So, migraine, by definition, is having five or more attacks in one's life that are moderate to severe headache that are more throbbing, more unilateral, but kind of moves back and forth. And there has to be light and sound sensitivity. So, you're kind of wanting to go somewhere quieter and darker if you have the option, and queasiness or nausea. And people are so stoic that I'll ask them, like, "Are you light sensitive?" And they're like, "No. I'm at work and I'm a nurse and I just have to keep going." I'm like, "Okay, but if you had the option to go somewhere quieter and darker, would you?" "Oh, yeah, definitely."

So, I think that it's important, when you're talking to your physician, not to downplay those symptoms. If you're wishing that you could be somewhere quiet and dark, that means you have the light and sound sensitivity. Just because you're stoic and can power through, that's awesome, but it still counts that you would prefer to be somewhere darker, or that you do admit that you have the nausea if you have it.

So, a lot of people who think they have migraine do. Forty-two million Americans who are adult age have migraine. So, it's a massive population and it is the second leading cause of disability worldwide per the World Health Organization.

Host: Are experts like you, are we trying to look at migraine more as a collection of symptoms, not just headache? Is that true? Like some people with migraine might have some of the sensory issues. Maybe the headaches aren't so bad or something like that. It's not just the headache, right?

Megan Donnelly, DO: Correct. It's not just a headache. So, you compare it to, say, tension headache, which is a mild to moderate headache that doesn't have any of those other associated symptoms. And so, that's really what defines migraine is that associated light and sound sensitivity or that associated nausea that goes with it.

And you nailed it, there are some people that it's really only a moderate headache, which is still included in diagnosis, but it's that terrible light and sound sensitivity, or the terrible nausea and vomiting that goes with it. And patients will tell you, "I mean, the pain is bad. But the intractable vomiting, that's what brings me into the emergency department." So, it's not always the pain that's the most bothersome part of the syndrome. It can be that light sensitivity where, you know, "Gosh, I can't even open my eyeballs even in a dark room because I'm so light sensitive," or "I end up in the emergency department." And I hear these stories from patients about those associated symptoms being sometimes the worst part.

Host: So, what stigmas around, you know, migraine, migraine treatments do you most frequently see?

Megan Donnelly, DO: Well, because it is one of those silent illnesses, somebody can be having migraine, and because they are stoic, they look fine. And so, that can be a stigma that people look fine. And rarely does this happen. I think the vast majority of people are not malingerers, but I think that employers will think, "Oh, they just said they had a migraine." And I'm like, "Well, if they said they did, they probably really do." So, that idea that people are making it up or that they're exaggerating their symptoms, all of that is where the stigma comes in.

And it used to be that we didn't have any way of knowing whether somebody was telling the truth about migraine. And so, historically, we're talking like, you know, 1930s, '40s, '50s, there was this sort of idea of like, "Oh, well, maybe it's just mental health or whatever." In the '90s, they realized that there's a big surge of multiple neuropeptides and neurotransmitters that happen at the onset of migraine. In clinical practice, we don't test for those, but we know that there is a true neurobiological underpinning to migraine. This is a real disease.

Host: Oh, absolutely, 100%. So, I'm glad we've come from the '40s. '50s, and '60s to where we're at today and understanding this. And I know there's still a lot more to understand without a doubt. I want to talk about the triggers or what some people call trigger behavior. So, is it really true that a migraine episode is often triggered by something for some of these patients, maybe it's food, maybe it's a sound, a smell? How important is it for your patients to understand maybe what those triggers are?

Megan Donnelly, DO: Triggers matter because some of them are avoidable. And so, if somebody knows consistently that every time they have. more than 200 milligrams of caffeine in a day, or they know that when they're only getting five or six hours of sleep instead of their usual or missing meals, they're going to get a migraine. Those are ones that correctable. Those are behaviors that can be changed. And it's important to do everything we can to live our healthiest life. And so, a lot of the advice that we give in terms of staying hydrated, limiting caffeine to 100 milligrams or less per day, eating healthfully, not missing meals, managing stress, that stuff is really important.

There are some triggers that we can't do anything about, and we can't live in a bubble. And so, one of them that comes to mind is weather change. You can't do anything about whether you are affected by barometric pressure changes. And so, knowing those things, though, is still helpful because there are some treatments that we can even recommend almost preemptively. So if somebody knows that there's a big storm front coming in or they know that their menses is a trigger and their period is coming in another couple of days, we can think about doing things to preemptively treat in that setting, or if they know that a flight, going on flights is a trigger and they have a flight coming up.

So, some things we can correct, some things we can't, but lifestyle changes that we can make, it's important to try our best to make them, but also not to blame the victim, because there are some people who are doing all the things right, and they're still getting migraines, and it's not because they should "try harder." they're probably doing their absolute best to reduce their frequency already.

Host: Yeah. I'm glad you brought up the missing meals. I have a friend that struggles with migraine and she swears and no one listened to her at first that she was linking it to, you know, if she didn't eat, she's kind of a snacker. And if she didn't have some food every three or four hours, that was her trigger. And it took a while for some of her physicians to accept that. So, I'm glad you brought that up. A hundred milligrams of caffeine, is that about a cup of coffee, one?

Megan Donnelly, DO: That's about a cup of coffee, a normal size cup of coffee, that is not a Starbucks cup of coffee. However, I am actually a Starbucks fan. And so, before Starbucks comes after me, if you have, like, one latte, that's one shot of espresso is only, I think, 60 to 70 milligrams of caffeine. And a big latte actually still only has one shot in it, so you're fine, depending on what you're having, but I'm not anti-caffeine. I think that consistency with caffeine from one day to the next matters the same way that sleep consistency matters. Our bodies like homeostasis, and so they don't like changes in our schedule. And so, that's our caffeine schedule, our eating schedule, our sleeping schedule.

Host: That makes sense. So, what about, you know, to minimize then the impact of chronic or sporadic migraine, because I know you see both of those cases. Are there protocols that you teach to your patients to kind of help to follow to minimize those? Are there some steps that you could offer us now?

Megan Donnelly, DO: Yes. In terms of who we want prevention for, like a preventative prescription medication, American Headache Society says that if somebody is getting four or more migraine days per month, we should be thinking about a preventative. And anybody with any number of migraines should be given as needed medication that they can take to treat it when it occurs. Even if that's one bad attack every six months, they should still be able to treat it when they need to.

And then, I do talk to my patients about all the lifestyle things that we talked about. I have an after-visit summary that includes that. I talk about vitamins and nutraceuticals that have been shown to have some evidence because not everybody wants to go straight to a prescription medication, and I want to honor that. There's a lot of room for improvement that's before there's even medications, but there are treatment guidelines and algorithms for when we should be starting preventatives and when we should be recommending the as-needed medications. But short answer for who needs an as needed is everybody.

Host: Right, right. I get that. Mentioning some of the nutrients and stuff, magnesium, you know, doing some additional magnesium every day was a big recommendation years and years ago. Is that still the same? 

Megan Donnelly, DO: It's still one of the recommendations. Magnesium glycinate probably has a little bit better evidence than other forms of magnesium. And it's cheap, it's over-the-counter, helps with kind of digestive systems. So, it's one of those kind of low hanging fruit, easy options. You should still talk to your physician before starting anything because there are certain health conditions that even benign old magnesium can be a problem with, like myasthenia. But the vast majority of people would have no issue with magnesium.

Host: And if it doesn't help you with the migraine, it's still good anyways, right? So, it's okay for you. It's not, you know, anything crazy. I like that. So, here's where I want to drill down to a few more of your favorite-- I don't know if I want to call them tips, Dr. Donnelly-- but three or four, I'm going to call it that, three or four tips, your biggest advice for someone who's suffering migraine. Like what do you really go to? What are your go-to things that you tell

Megan Donnelly, DO: So I think we underestimate the importance of sleep, especially in the American hustle work culture. So, that would be tip number one, is to prioritize sleep. If you are not getting good sleep, or are a snorer, talk to your physician about, "Do I need to have a sleep study to look for sleep apnea because that's going to cause a lot of increased headaches if you do.

Maintaining normal body weight also really, really matters. We know that increased weight increases the rate of headaches because our adipose cells, our fat cells release estrogen, which drives up the pressures of our cerebrospinal fluid. So, that in itself can cause headaches.

Other important things, I already mentioned a couple of them, but staying nice and hydrated, trying to eat well rounded, healthy meals. Not skipping meals. Limiting caffeine to a consistent lower amount on a daily basis. Oh, and exercise. How could I forget exercise? So, everybody should be giving 30 minutes of-- it doesn't have to be vigorous exercise. And I, and not, people don't have to join a gym, but to do a brisk walk around your neighborhood for 30 minutes every single day is really, really important. There was an article that came out of one of the socialized medicine countries, I can't remember if it was Denmark or where it was, but they looked at the importance of exercise in reducing pain. It wasn't just about headache, it was about pain even in other parts of the body. And across the board, there was decreased pain response in people who were exercising because it increases endorphins, which helps, which are kind of an endogenous opiate. And it also teaches your body that healthy pain happens. So, I used to run half marathons and marathons, like, you know what pain feels like when you do those things. And so, then, that down regulates your pain response to other things.

Host: Yeah. I like the idea of just, you know, being physically active. Pickleball, tennis, swim, walk,. You know, let's don't put everybody into like a gym box, right? There's so many other things that you can do, but I'm so glad that you brought that up. Now, here's a big question for you. You know, when you look at all the new research that's going on and you look at all the potential new medications, et cetera, what are you most excited about? Looking into the future for migraine treatment.

Megan Donnelly, DO: So, in the last six years, we've had a big breakthrough where a lot of the medications that have come out target a certain neuropeptide that we know there's a big influx of at the start of migraine called calcitonin gene-related peptide. That's really cool because it's migraine-specific. Everything else that we used prior to that were antidepressants and blood pressure medicines and anti-seizure medications that were kind of repurposed as headache preventatives. So, to have something migraine-specific has been really cool.

CGRP does not account for migraine in everybody. There are other neurotransmitters and neuropeptides that also increase that might be the main pathway to migraine for somebody else. And so, picture migraine town and the roads that go to it is the pathophysiology. So if you block CGRP to migraine town, but that wasn't your main highway there, it's not going to do anything for you.

I can't wait until there are targeted treatments for the other pathways so that when we have somebody who their migraines are caused by a surge of PACAP or MOG, these other ones, there'll be medications that are specific for those and so that we will really be entering that realm of targeted therapy for each patient. And we see that with other fields, like breast cancer with HER2 receptors and ER/PR receptors and other things and knowing what variants there are and having targeted chemo for those things. I think that that's the future of medicine, is to have targeted therapy for various different conditions, but migraine's going to be one of them.

Host: Yeah. It's more personalized that way, because I think we all have to recognize that, you know, most of the chronic diseases that we deal with are multifactorial, right? There's not just this one thing often. And so, yeah, that's fascinating to see more of those, what did you call them, roads into migraineville? Is that what you said?

Megan Donnelly, DO: Migraine town, it's the roads to migraine town.

Host: Migraine town. Yeah, if we could block those, that would be fantastic. So, hey, wonderful conversation, Dr. Donnelly. Thank you so much.

Megan Donnelly, DO: Thank you so much for having me.

Host: To find a physician, you can visit novanthealth.org. And for more health and wellness information from our experts, you can visit healthyheadlines.org. I'm Dr. Mike. Hey, thanks for listening.