Melanie Cole, MS (Host): Welcome to Back to Health, your source for the latest in health, wellness, and medical care, keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine.

I'm Melanie Cole, and joining me today to talk about migraines and headaches is Dr. Moises Dominguez. He's an assistant attending neurologist at New York Presbyterian Hospital, Weill Cornell Medical Center, and an Assistant Professor of Clinical Neurology at Weill Cornell Medical College Cornell University.

Dr. Dominguez, thank you so much for joining us today. As we get into this topic, and I find headaches just so interesting, I'd like you to tell the listeners what really are migraines. Why is it important to manage them and even prevent them from worsening? Do we even know what headaches and migraines are?

Dr. Moises Dominguez: Thank you so much for having me. So, to answer your first question, what is a migraine? So, you know, migraine is considered a complex neurological disorder. It can also be thought of as like a disorder of sensitivity, where someone will go ahead and experience a pretty severe headache associated with sensitivities to light and noise. And people can also experience nausea and vomiting. So really, it shows you that migraine is actually more than just a headache. So, that's one part of the definition.

But the other way to think about migraine is that it's considered a disabling neurological disorder. And it's recognized as amongst one of the most common ones in the world, actually. And the reality is that when people have a migraine, they develop this terrible headache. And then unfortunately, they start to miss work. So, it's considered a pretty expensive disease when you think about it that way. And also, it's very limiting in a person's life, so they may not be able to go to family events, or go, you know, to events with their children, or anything like that. So, it really takes a toll onto the person's life.

So because of how disabling it is, it also speaks to how important it is to manage them. And the truth is that there's two ways of managing migraine. One thing that you want to do is you want to reduce the disability associated with the migraine, and that's done with migraine prevention. And then, you treat the attacks as they come, and that's called migraine acute treatment or rescue treatment. So, it's important to manage them and prevent them because as the brain continues to be exposed to more migraine attacks, then later on it becomes, unfortunately, a little bit harder to treat. And in fact, when people have, let's say, two or three headache attacks a month, if it doesn't really get treated, eventually it could evolve to become even more frequent throughout the month. And it even further adds to the disability associated with it.

So then, the last question is why do we even get headaches? The truth is there's still more to be learned about that. That's just the reality about this. What we think about right now is that maybe it's an interplay between what's happening in our environment and also what's in our genetics. Commonly, migraine tends to run in families, and there could be a number of environmental factors that can contribute to the development of migraine, whether that be some sort of head injury in the past, whether that be an infection of some sort. So, It's still complex, it's still unclear, but still more to be learned about that.

Melanie Cole, MS: Thank you so much for such a comprehensive answer and explaining it all so well. And it certainly is, I mean, any kind of headache, but really severe ones are such quality of life limiting, really, as you say, disabling, and hard to even pick your head up off the pillow. So, speak about triggers. You talked about prevention in your answer, Dr. Dominguez. Speak a little bit about triggers. Can overmedication, taking too many NSAIDs or other medications contribute to them? Light, noise? Tell us a little bit about anything we know that can set one off.

Dr. Moises Dominguez: One of the most common triggers for pretty much a lot of these headache disorders is stress, so that can be a very common trigger. Other triggers can include things where there is some irregularity in a person's life. For example, let's say if they had a terrible night's sleep, you know, the night prior, or if they're sleeping much more than usual, that could be a trigger. If someone is used to eating three meals a day with some snacks. And then for some reason, because of how busy life can be and you miss a meal, that can certainly become a trigger too. Other triggers that people have reported to me is like, if they start seeing bright flashing lights, that can definitely tip them over and have a migraine attack. The truth is that a lot of these triggers are pretty unique to a person because everyone's migraine experience is pretty unique. And what's interesting also about triggers is that what could be a trigger one day may not be the same trigger the next day. So, that adds further to the complexity about migraine.

The thing about taking too many NSAIDs, you know, these non-steroidal anti inflammatory medications like ibuprofen or naproxen, what's interesting is that in people who have a history of migraine, if they treat a little bit too much, it can lead to a phenomenon called medication overuse headache, it's like the formal term. Other people have called it rebound headache. For some reason, people who have migraine, they're sort of predisposed to if they treat, let's say, with, acetaminophen more than three days a week and they do that continuously for at least three months, they can have more headaches. Even the tryptan medications that we often prescribe for migraine, if you take that a little bit too frequently, more specifically more than two days a week consistently for at least three months, that can also predispose a person to develop more headache.

It's unclear why this is the case. Probably the whole communication system within the brain is a little bit different in people with migraine. And when people overtreat, it causes it to change it even further. The truth is that it's also pretty unclear, but that's something to be really aware about because that can be a common reason to see a neurologist too.

Melanie Cole, MS: Doctor, I imagine for people who this is beginning or are new to getting headaches, of course, all of us and so many people that get headaches, the first thing that goes through our mind is brain tumor and we think that. When do people concern themselves enough about a headache that they come to see a neurologist and then what do you do? How do you diagnose that it's not a sinus issue or a tooth issue or an eye something? How do you know what it is?

Dr. Moises Dominguez: Right. That's a very good question. The reality is that unfortunately there is no blood test to say you have this headache disorder or that headache disorder. The way to make the diagnosis really is by first having and performing and conducting a thorough headache history and neurological examination and then, seeing if a person fits the diagnostic criteria that was set forth by the international classification of headache disorders. And to be brief, basically, if someone is having a headache attack that lasts anywhere between four hours to three days, that is at least moderate in intensity, but can be severe, can be one-sided and can worsen with physical activity. And in addition to that, you can also have sensitivity to light and noise and/or nausea, then you're more likely to have migraine. In fact, you meet the diagnostic criteria for migraine if you meet a certain number of the things that I've mentioned previously.

The next thing also, and this is why it's important to do a thorough headache history, is to see if there's anything else that could be going on. And in fact, there's like a helpful mnemonic that people use to just make sure that there isn't anything going on. But to be brief, basically, like, let's say if someone is developing fevers, or they have a personal history of cancer, or if they start having any impairments in their neurologic function, things like that, that can sort of raise some red flags in our head and to say, "Okay, does this person need imaging?" And that would be the next phase of the headache visit. And that will definitely tell us if there's something else that's going on.

What differentiates migraine from let's say a sinus issue or a toothache or an eye issue is those sensitivities that we talked about before. Typically speaking, if someone is having sinus issues, yeah, they'll have discomfort in their sinus area, but they typically wouldn't have the sensitivity to light and noise and the nausea. And if they did, then that points more towards migraine. In fact, when people have sinus issues and they go to the ENT and then they see that, "Oh, I have nothing wrong with my sinus," it ends up being migraine eventually. Because when you do the thorough headache history, you realize, "Ah, they have light and noise sensitivity. They get nauseous. This is pretty disabling. They have to disengage from their environment." So, that basically on the clinical history is what separates a migraine from sinus issues or a toothache or anything like that.

Melanie Cole, MS: Let's talk about some approaches to treating them. And before we speak about medical intervention, what do you tell people that are suffering an acute headache? You spoke at the beginning about management, as a part of dealing with them when they happen. But we also mentioned that those NSAIDs that people typically use for the headaches, they can also start that rebound effect. So, what do you tell people to do at the moment, because that's when it's so disabling? And what are some of the treatment strategies that you give people to use when they're at home?

Dr. Moises Dominguez: Right. So, I think that if someone is having a headache attack at the moment, the best thing to do is to treat as soon as possible. The reality is that the sooner you treat, the more likely you are to get out of this disabling episode that a person may experience when the migraine develops into full force.

The second thing you want to do too is sort of to track exactly what happened. Was there any change? You know, did I sleep Not the best last night? Did I not have enough water? Did something go on that could potentially be triggering this? And then taking a note of that. And then, maintaining a headache diary. So that way, when you see your provider, whether that be a headache neurologist, a primary care physician or neurologist, then you have all of that data. And then, you can start to see, "Okay, this person is having, let's say frequent disabling episodes, or they're having many headache attacks a month that are pretty migrainous. I have to decide, do I want to start some sort of preventive treatment?" And the goal of prevention is to reduce how long, how bad, how severe and how frequent these headache attacks are. And this can be done through a myriad of ways, whether that be through a blood pressure medication class or an antidepressant or an anti-seizure medication. And even the newer migraine treatments that have relatively recently been out, that's been pretty effective to prevent the migraine attacks too, and even treat them as they come.

So, I think in summary, it's like when you feel the migraine is happening, treat immediately. Do not wait and see, "Well, maybe this will go away if I rest." No, just treat right away, because then you expose the brain less to any migraine episodes. Take note of when it happened, how often it occurred and what probably triggered it. And then, with your provider, decide do we need some sort of preventive needed to prevent how often these things are happening to you?

Melanie Cole, MS: Do you advocate for some home remedies, like cool compress, dark room, no noise? Any of those kinds of things that can help?

Dr. Moises Dominguez: Yeah. That actually falls into the non-medication aspects of managing migraine. I think that, how I mentioned before, everyone's migraine experience is unique and sometimes what works for one person may not work for another. If some people find it that putting a cold compress over their head, disengaging from their environment, and relaxing after taking some sort of rescue treatment, then absolutely, I mean, I would say do that. Whatever it is the person has noticed that has been most helpful for them to get them through this migraine experience, I would totally advocate as long as it's not harmful in some way, like treating too often, for example.

Melanie Cole, MS: Well then, tell us about some exciting therapies in your field, Dr. Dominguez, things that you use to help patients manage recurrent migraines. Are there any game changers? What's exciting to you?

Dr. Moises Dominguez: Yeah. So, I think that after 2018 or so, the headache community has really evolved, especially with treatments that target calcitonin gene-related peptide or CGRP. And in fact, the American Headache Society, they're actually pushing for these CGRP antagonists to be used first line in the preventive treatment of migraine, which is massive and huge because these are mostly migraine-specific.

Previously, I mentioned, you know, preventives could be done through a blood pressure medication or an antidepressant or an anti-seizure. So, you notice that they were initially designed for something else, but they just so happened to help with migraine. But now since the 2017-2018 period, now we have migraine-specific medications. They typically come in three flavors from a preventive standpoint. One is something that you get as an infusion once every three months, something that you inject to yourself once a month, and in one of the injections you can inject yourself once every three months. And then lastly, a medication that you can take daily or every other day as a preventive. And that is actually very exciting. And because they're so specific for migraine, the side effect profile as you could imagine could be relatively better than the other ones. So, this is extremely exciting. The one thing we have to realize of course is that there are some insurance barriers we have to be aware of. But at least, it's great to know that these treatments exist and it does help a lot of people, which is exciting.

Melanie Cole, MS: Your best advice, Dr. Dominguez. This has been a very informative podcast and a great discussion, and you really explain everything so well. Now, offer your best advice to people that do suffer headaches and indeed migraines and what you'd like them to know about yourself, the services that you offer at Weill Cornell Medical Center and what they can do to help possibly prevent them.

Dr. Moises Dominguez: I would say the first thing is that you're not alone. Migraine is a very common neurological disorder that affects people no matter the race or socioeconomic status or whatever. Many people experience migraine. The second thing I want folks to know is that, unfortunately, there is a stigma associated with migraine, because some people may not see the burden that it has on the person. And sometimes people may say things like, "Oh, maybe just have some water or drink a cup of coffee" or something like that. And that can I further add to the frustrating aspect of the migraine experience. I want you to know that you're not alone. And this is a real thing that people experience.

The other thing I want folks to know is that like the saying goes, the migraine brain likes everything the same. So, things that a person can do outside of medication is figuring out like, "Huh, what are some things that could be triggering or contributing to the burden of my migraine attack and what can I do to actively change that? Whether that be improving my sleep, exercising, eating healthier, making sure I'm hydrated and things like that."

And then, the other thing too is to also know that there is help. There are fellowship-trained headache neurologists, you know, they're neurologists, primary care physicians, people like these are all equipped to help treat people with this type of neurological disorders. And there are many, many treatments that have evolved since the beginning of, medications being created and realized to manage migraine. And there will soon be more to come. So, this is also a very exciting thing.

And I guess the last thing I'll say, even outside of medications, even devices too, can be pretty helpful. And that provides another option for some people as well. So, you're not alone and there are treatments.

Melanie Cole, MS: Well, there certainly are. And thank you so much, Dr. Dominguez, for joining us today and sharing your most incredible expertise on this topic. And Weill Cornell Medicine continues to see our patients in person as well as through video visits. And you can be confident of the safety of your appointments at Weill Cornell Medicine.

That concludes today's episode of Back to Health. We'd like to invite our audience to download, subscribe, rate, and review Back to Health on Apple Podcasts, Spotify, iHeart, and Pandora. For more health tips, please visit weillcornell.org and search podcasts. And parents, don't forget to check out our Kids Health Cast. So many great podcasts there. I'm Melanie Cole. Thanks so much for joining us today.

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