Joey Wahler (Host): This is Happily Ever After 40, a podcast from ProMedica, where we discuss midlife health and wellbeing. In this episode, we'll talk about recognizing and treating migraines. Our guest, Dr. Selena Nicholas-Bublick. She's a neurologist with ProMedica. Thanks for listening. I'm Joey Wahler. Hi, doctor. Thanks for joining us.

Dr Selena Nicholas-Bublick: Oh, thank you. Pleasure to be here.

Host: Pleasure to have you. So first, just how common are migraines in the first place?

Dr Selena Nicholas-Bublick: Well, if I take a step back and say headaches in general are probably the most common presenting complaints that we see in a general neurology clinic, and just with talking about headaches, I'm going to throw a few statistics out there, there's about 3 billion with a B people worldwide that have headaches. And then, migraines as a subtype is considered a common type of primary headache disorder. And there's about 1 billion, again with a B, worldwide.

If we just focus on the US, there's an estimated 39 million sufferers. And we do know that women are about three times more likely to be affected. And that's thought to be related to fluctuations in ovarian hormones. And we know that menstruation and resulting hormonal changes are considered one of the most common migraine triggers. And I was just going to step back again and say, to clarify, a primary headache disorder, and those are the ones we're talking about today, means that there's no other underlying identifiable cause.

Host: Gotcha. And so, what are some of the things that differentiate migraines from "regular headaches"?

Dr Selena Nicholas-Bublick: Yes, that's a great question, and it's one I get a lot from my patients. And we look at a few of the characteristic features that distinguish migraines from other headaches. In general, we think of these as recurring headaches, and they have a duration of about 4 to 72 hours, and a lot of patients will typically have one side that's worse than the other. And they'll describe that pain with a pulsating or throbbing quality.

Typically, we always listen to hear a moderate to severe intensity of pain that's worsened with just routine physical activity. Often, the patients with migraines will also have nausea. They may or may not have vomiting, but they will frequently also complain of light and sound sensitivity.

 Now, in addition to that, some individuals with migraine attacks will experience something called aura. And commonly, this is related to visual changes that are reversible. We will hear spots in vision, blurriness of vision or tunnel vision. But there are some other types of auras that are more rare and they can occur with speech deficits that again are reversible, transient weakness, numbness and tingling. And so, those features, when we hear those descriptions in the clinic, would cue us into that definition of migraine rather than other types of headaches.

Host: And when you talk about those visual auras as they're called, do those often occur as sort of a prelude to some of the other symptoms?

Dr Selena Nicholas-Bublick: Yes. Some of those auras can precede the pain symptoms that a patient can have, and that can also be a warning for them that they will be having pain. And quite often when we talk about treatments, that's a time period when they start to experience an aura, whether it's visual, whether it's more of the rare form speech or weakness or numbness and tingling that they can take an acute medication to try and abort that migraine attack.

Host: So, that can actually be a good thing, so to speak, kind of a forewarning to be prepared and do something proactively.

Dr Selena Nicholas-Bublick: It can be. But overall, we want to try and reduce the number of those headaches that are associated with aura, and we can talk about the therapeutic treatments later on.

Host: Absolutely. So first, what are some of the causes of migraines?

Dr Selena Nicholas-Bublick: In general, we think about these type of headaches as an inherited disorder of sensory processing. So, we do find that patients that have migraines tend to have other family members that are experiencing similar types of headaches. But unfortunately, there's a lot of aspects of the underlying basis of the headache that is still unknown.

So in a way, we think of this as a dysfunction in the way the body is processing sensory information and regulating itself. And if you just think about a typical migraine attack, that can illustrate that type of dysfunction of sensory processing. The sufferer will commonly describe the difficulty tolerating lights and sounds. They can also feel irritable and have difficulty concentrating and focusing. And there are other symptoms that once we start interviewing, we can hear as well, including altered sleep, yawning and food cravings.

Host: And so, what are some of the treatments that are most commonly used and how effective are they?

Dr Selena Nicholas-Bublick: And I'll just say, when we start looking at migraines, some patients may say, "Well, I don't need to have these treated." But we do have a few statistical reasons why we like to start considering thinking about the treatments for these type of headaches. When we look at half of the patients, when we look at literature, report symptoms that are severe or significant enough to require bed rest or to impair just their routine daily activities. And about 30% of migraineurs have missed at least one day of work or school within a three-month period. In addition to those statistics, we find that untreated or ineffectively managed migraine attacks can over time lead to greater disability and transform into something called chronic migraines.

So, chronic migraines are headaches that occur on 15 days or more a month with eight of those headache days meeting criteria that we talked about for migraines for about a 3-month period. And so, being able to treat those migraine attacks effectively can help prevent having those chronic migraines over time and also to avoid losing days to headaches.

Host: So, that's how one knows whether they need to go for treatment. And then once they do, what can you and yours do to address this?

Dr Selena Nicholas-Bublick: So, no single one treatment is correct for every patient. Everyone's an individual. It's good to think about having a range of strategies. And so if I break it up, we'll talk about the acute treatments first. And we can divide those into non-pharmacological, so non-medication treatments, non-specific treatments and then migraine-specific treatments. And so, those non-pharmalogical treatments include resting in a dark, quiet space, making sure that they have adequate hydration, using ice packs, deep breathing. Some patients like to do guided meditation, sometimes gentle yoga or biofeedback.

Now, if it's to the point where those types of treatments are not working, there are the non-specific acute therapies, and these can be helpful for more mild to moderate migraine attacks. And most patients will tell you they've tried acetaminophen or Tylenol, which is commonly over-the-counter or other non-steroidal anti-inflammatories, such as ibuprofen or Naproxen types of medications.

Now, after that has been tried and maybe has not been successful, we start looking at acute migraine-specific therapies. And these are prescription medications that we're talking about now. And there's two main types. There's a type of acute medication for migraines that's been around for a while. Those are the tryptans. And then, there's newer classes of medications called CGRP inhibitors. And there's a few different ones that can be used at that point in time.

Now, there is an important caveat with use of these acute medications. Once we start overusing them, for example, patient can start suffering from overuse headaches or rebound headaches. And then, they can have other side effects specifically from these acute medications, commonly gastrointestinal types of upset and issues, and sometimes cardiovascular issues. And that's when we start looking at preventative therapies. So if a patient is noticing that they're taking these acute, non-specific or specific medications more and more. And despite that, they're still having an increasing number of headaches and migraines, such that they're starting to notice that key 15 days a month of headaches with migrainous features, we really want to be looking at preventative therapy. And at that point in time, we should be starting to talk to their physicians or their neurologists to look at that.

And so, that goal of preventative therapy is really the reduction in disability and improvement of quality of life. And as I mentioned with the acute therapy, similarly with the preventative therapies, there's no one single treatment that is correct for all patients. And it may take a few trials of different medications to find the right fit, and that's why it's really important to have either general physician or headache specialist or neurologist to guide those therapeutic trials.

And preventative therapies, there's different types. There's oral medications. Again, these are prescription medications at this time. And then, monthly injections, and there's also even botulinum toxin injections, which are done every three months. So really speaking with the patient, looking at their goals, looking at their other health history is very important to select a really good preventative therapy if it comes to that point.

Host: And so in summary here, doctor, your message for those listening that have migraines and either haven't had them treated or maybe haven't had them effectively treated, your message is that quality of life can indeed improve.

Dr Selena Nicholas-Bublick: Absolutely. And it's one of these disorders where we often see patients suffering through them just because of knowledge and not being aware that there's other therapies available for them. So just taking that one step, reaching out to the general physician and saying, "Hey, I have these headaches. I feel like they're getting worse and worse. They're starting to impair my quality of life. What is the next step?" Just even saying, "What is the next step for these headaches?" I think is helpful.

Host: Indeed. And so, clearly part of the message here too is, "Don't let this go, get it looked into by an expert like yourself and go from there." Well, folks, we trust you're now more familiar with recognizing and treating migraines. Dr. Selina Nicholas-Bublick, thanks so much again.

Dr Selena Nicholas-Bublick: Oh, thank you very much.

Host: Absolutely. And for more information, please visit promedica.org. Again, that's promedia.org. If you found this podcast helpful, please share it on your social media. And thanks again for listening. I'm Joey Wahler. Until next time, stay happily ever after 40.