Instant Genius - Migraines, with Dr Katy Munro

Episode Date: August 22, 2021

Headache specialist, author and podcast host Dr Katy Munro tells us what goes on in your body during a migraine. Once you’ve mastered the basics with Instant Genius, dive deeper with Instant Genius Extra, where you’ll find longer, richer discussions about the most exciting ideas in the world of science and technology. Only available on Apple Podcasts. Produced by the team behind BBC Science Focus Magazine. Visit our website: sciencefocus.com Hosted on Acast. See acast.com/privacy for more information. Learn more about your ad choices. Visit podcastchoices.com/adchoices

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I'm Sarah Rigby, online assistant at BBC Science Focus magazine. In this episode, I talked to Dr. Katie Monroe, a GP headache specialist. at the National Migraine Centre. She hosts the podcast Heads Up and is the author of the new book, Managing Your Migraine. She tells me all I need to know about migraine headaches, from what's going on in your body during an attack to the up-and-coming treatments her patients describe as life-changing.

First of all, could you please just explain what exactly is a migraine? Oh, a migraine attack. I tend to call the migraine attack. So migraine is the condition, which is part of the... genetic and is partly due to the influence of environmental factors on the brain. So the genes for migraine set the brain of that person to have the vulnerability to have migraine attacks. Whether they have migraine attacks depends on factors throughout their lives that are changing. So the brain seems to be set to be more irritable by changes in sensory inputs. It doesn't

process sensory things as well as it should do, and that irritates the brain and it causes it to release neurochemicals. Other things changing like hormones or even the weather, so internal things and external things, can combine to cause that irritation of the brain. Once neurochemicals build up, they cause an electrical depolarization to roll out over the surface of the brain, and that's what gives people the symptoms that are so commonly felt in a migraine attack. But we can talk a bit more about the phases of a migraine attack because I think often people think that it's just a headache and our clarion call to everybody is migraine is not just a headache. It's a lot more than that. Yeah, so what are the phases? So there are four that are recognized. So the first phase of the

prodromal phase and that's that kind of day or two before the person is aware of the more strong symptoms of the migraine attack and in the prodromal phase people might have things like yawning or fatigue or they get really hungry and they start craving carbohydrates which is where chocolate got its bad rep because people would stuff themselves with chocolate and then get a migraine and go ah it must be the chocolate that's caused the attack whereas in fact craving for carbs is a well-known pro-domal symptom. So that can go on for anything up to two days. The aura phase, only about a third of people get aura, and that is defined as neurological changes that come and go within an hour before the next phase. And the changes then are normally visual, although there

are some other neurological symptoms that people get. So they might smell weird things. Some people get kind of tingling down one side of their body or even heaviness or even unable to move parts of their body during that short aura phase. Then it's what's called the headache phase, but I kind of would like to change the name of that. I think we should be calling it maybe the impact phase because that's when the headache, the brain fog, the vomiting, the dizziness, the gastric upsets, all of those kind of things start to come in. And that can go on for anything. up to three days. And then there's the, what we call the post-dromal or the hangover phase, which is where all of that impact phase is quieting down, but the person just doesn't feel

right. So the headache may have gone, but they feel as if they've been run over by a steam while then they're just not 100%. And that can be another day or even two. So a migrant attack can be quite long, can take up a whole, you know, almost a week. And then if you get another one quite quickly, you're all very rapidly having a great impact on somebody's life. I know a few different people who get migraines, and they all get them differently to how I get them. Like, for example, I know one person who doesn't really get the headache and mainly just gets the aura. I know someone who gets a few attacks, only a few attacks a year, but they're really intense. Why is it that everyone gets them so differently? Well, I think we're all very different

genetically, and also our lives, if you think about it, the factors that I was mentioning in the environment that can change things that irritate the brain are all very, very different from person to person. So one person's hormones, one person's lifestyle can be very different from another person, the impact of the genes can vary, the expression of those throughout somebody's life can change. So we quite often hear from people who say, well, when I was younger, I used to get migraine attacks like this, but now they've changed. So it might be that when they were children, they got recurrent tummy pains and vomiting, may or may not have been recognized as migraine. As they've got older into their teenage, they've had more predominantly

headache attacks, maybe with quite violent vomiting. As they've got older, the vomiting sometimes settles, but they still get the headaches. And with women in particular, as they go into the Menopause, they very often get more dizziness. And vertigo and vestibular migraine is something that we recognize. So people sometimes have symptoms like dizziness or aura and no headache at all. So it's trying to tease that out. But I think, you know, humans are very variable. But migraine is particularly variable from person to person and even throughout life. Sometimes from attack to attack. Yeah, in other people, they'll say, well, it's always exactly the same. I always get this and it moves onto there.

So it's just one of those ways that it expresses itself. Why do you think it's important that people who get migraines should understand them as opposed to just recognizing that one's coming and taking a painkiller? I think it's crucially important that people understand what migraine is about. And that's part of the reasons that I've written a book and we do a podcast is to try and explain to people what's happening because it gives them power. It gives them the power to change and control the things that are changing. So they may decide to work on lifestyle. They may decide to take some supplements or they may decide to look at the other options for preventing the migraine.

But it empowers them to go and get really good advice and to help themselves really. So I don't think it's, I don't think you can do without it. I think it's so important. I've noticed a few people who get migraines who, until someone has said to them, that sounds like a migraine, they always thought, oh no, I just get normal headaches. So how can you tell whether what you're getting is migraines or headaches? So that's a bit of a bugbear of mine, just the normal headaches. So I always say to people, you know, you wouldn't say to me, oh, I just get the normal rashes.

or I just get the normal coughs. So headache is a symptom. So it is important to ask them about headaches, but if you've got headaches, then you need to find out why and get a proper diagnosis. So to make the diagnosis of migraine in a person, we would ask, first of all, it's mainly on the history. There's no blood test.

We can't put you through a scanner and say, oh, it's showing up that you've got migraine in your head. It doesn't work like that. So we listen really carefully to the, story. And the history of migraine can start at any time in life. So we sometimes hear that patients have had symptoms, which we know are migranists from when they were children. Sometimes they've started in teenage or later in life. And migraine is characterized by this combination of neurological symptoms like headache, but also sensitivity. So we would ask about,

are you sensitive to light, sound, movement, smells, and even touch during attacks? Do you get nausea and vomiting during attacks? Because we know that the changes in the brain during migraine affect the vagus nerve, which also has an effect on the gut. And looking at the number of attacks they've had, if they've only ever had one attack of headache, then we wouldn't necessarily diagnose migraine. But if they've had repeated attacks and they're following these kind of patterns,

with some of the symptoms that I've just mentioned, then we're pretty confident. What some people have been told is, oh, it's probably tension headaches because you're bit stressed and you've got, you know, tight muscles in your neck and shoulders. So what I would say is, in general, tension headache is greatly overdiagnosed. And if people say to us, well, I get tension headache, but when I move it really hurts, I have to go and lie in a quiet, dark room. and while, you know, and I feel a bit crazy, that isn't tension headache, that's migraine. And I'm kind of trying to clarify the difference.

Migraine has underdiagnosed many times in clinic. I'm talking to patients or maybe parents of children with obvious migraine. And I say, oh, do you get it? And they go, no, no, no. I just get these recurrent headaches and I feel a bit sick. And you're like, well, that is migraine, actually. So we spread the word and the light bulb at moments happen. You mentioned tension headaches there. What's a tension headache?

So tension headache is more of a featureless headache. It's described as a feeling like a pressure around the head, but it's featureless. So it doesn't usually cause sensitivity to light or sound. It doesn't usually cause nausea or vomiting. Most of us in the headache specialist world would say, well, probably a tension headache is actually just a mild migraine that hasn't been diagnosed. But, you know, there are people who get tension and headaches, but migraine is much the most common thing that we see. About one in seven people get migraine. It's really, really common. What are the best treatments for migraines, both in terms of, you know, medications to prevent it

for, you know, lifestyle changes or painkillers? Oh, right. So we're going to be here now for another day and a half talking about that topic. I think I put it under three headaches. So first of all, I always talk to people about lifestyle because if you get your lifestyle things as controlled as you can, that can help. Having said that, I would never blame people if they're still getting attacks and they tell me, oh, I've done all the things you suggested I'm eating

regularly, I'm sleeping well, but I'm still getting attacks because we know it's a genetic condition and that's it's not all about lifestyle. We would then talk about acute treatments and that's, That might be simple things. So in kids, it might be just going and having some paracetamol or going lying down and in a dark room, reducing those sensory inputs. But as we get older, we tend to turn more to the over-the-counter painkillers, hopefully not turning to opiates or codeine because those are really bad for migraines and generally for headaches. But things like ibupin or aspirin or paracetamol. Paracetamol's one of the weaker ones, but it can be useful in some people. And then we have the triptans. So those are very useful in an acute attack, and there are seven different ones, which are sometimes news to people. They know that there's one called Sumatryptan or Immigran, which they can buy over the counter, or they can get on prescription. But if that doesn't suit them, there are quite a number of other ones that they can try. And then from a prevention point of view, again, I subdivide that into three headings. So there's medication, which is often borrowed from other conditions like antidepressants, like amatribes,

are very useful for migraine prevention in lower doses usually than we would use them for depression and those sort of things. There's anti-epileptic drugs that we have borrowed that seems to be very useful in preventing migraine. And there's beta blockers and anti-high blood pressure drugs that we use. So those can be one aspect. But then there are also some new things which have been around more recently called neuromodulation devices. And these can work by sending impulses into the brain. So one is by using electrical impulses on the forehead. That's the cephali dual device.

And then there's another one called the STMS Mini, which sends magnetic pulses into the brain. And there's also one coming, which you put on your arm, would you believe? And it seems to ascend electrical impulses that distract the brain. So those are really interesting. And new developments and very well tolerated by people. And then the third is injection therapy. So Botox has been around for many years.

And when it was being used to improve people's facial wrinkles, some of the people that were using it found that their migraine improved. And so then the scientists did some studies and found that, yes, it does actually seem to suppress the sensory inputs from around the scalp. So there's a good regime now of working at how to use Botox in the best way for people with chronic migraine. And then there are other injection techniques and the latest ones, the new kids on the block, are the anti-cGRP monoclonal antibody injections. So these have been hot news in the headache worlds over the last couple of years. And they are now available in this country on the NHS,

although it's, you know, the NHS is under huge strain at the moment. And so that doesn't mean you can just pop along and get them. there's a certain amount of waiting that happens, as I'm sure you understand, especially with the pandemic. So those are the main types of treatments. But which one you should use for which patient is a really personal, individual conversation to have with each person as to whether they've got other medical conditions that would prevent them taking something like, for example, if people have asthma, they can't have beat blockers, or whether they're, They've got depression or anxiety.

They might do better with an antidepressant type of preventer rather than something that we know aggravates mental health issues. So it's really trying to look at that whole picture and work out. I say to people, you know, we're going to make an individual recipe for you. And that will be Plan A. But if Plan A doesn't work, then we'll work on Plan B and Plan C. There's always another plan. That is a really surprising range of possible treatment.

So antidepressants, Botox, electrical stimulation, antibodies even. How do they all work? What is the mechanism behind a migraine that means all of these could possibly stop it? Well, they're all working on neurochemical pathways in the brain, but they're working in different ways. And so the brain is basically a bag of neurochemicals. And there are some that we know are particularly implicated in pain pathways. So research particularly recently has concentrated on the CGRP, which is the calcitonin gene-related peptide. But there are other neurochemicals that scientists are looking at at the moment.

And headache researchers are looking at different ones, all with very complicated acronyms. So the thing I think that we can say with certainty is that everybody's doing. And so nothing works for everybody. And that's a bit of a mantra of mine, really. So not only nothing works for everybody, but a technique or an intervention that works brilliantly for somebody might not work at all for somebody else. And that, I think, is just due to the individual variety of our makeup, you know, of genes and environment and the way that our bodies respond. The pharmacodynamics, pharmacogenetics of the way we process dry. and all of those kind of factors interact.

And the, you know, emotions, what else is going on in our lives, it's all very variable. So sadly, if only we had a magic warn the therapy that we could say, yes, this is it for everybody. It's much, much more complicated than that. When I was preparing for this interview, I was having a quick look at what questions people Google around migraines. And obviously the first one is how do I stop a migraine, how do I treat a migraine? But one that came up over and over again, which I hadn't thought so before, was, is it possible to cure a migraine permanently?

Oh, is it possible to take the genes out of a person so they don't have a tendency to have migraine? The answer is a big fact, no. Is it possible to control migraine? Yes, very much so. is it possible that migraine will settle down and not be a bother in the future? Also, very much so. So I think, yeah, we would never say that we can cure anybody. And anybody who's searching for a cure is going to be sadly disappointed.

And it's actually more frustrating and leads people up the wrong path, really. So it's about finding a way to control the impact of migraine attacks. Well, there are more and more sort of gene therapies coming into the world of medicine. Do you think that might ever be applied to migraines? Well, that would be amazing, wouldn't it? And that is something that then I would have to eat my words and say, well, yes, we can actually get rid of those genes in your body. At the moment, there's no prospect of that, and I don't see that happening in the future.

Do you know of any exciting research that could not necessarily cure migraines? but any exciting new treatments that are coming in the near future? Well, I think in the UK there are still some treatments that we haven't got available yet, but they have been out in the US. So again, going back to the CGRP, so they've had the CGRP monocular antibody drugs for a bit longer than we have, but we have now got those, we've got three of those over here. There's another one which is used intravenously, which is not quite approved yet.

There are also some drugs called, in a class of drugs called G-Pants or diatans, there are two different ones. And those are being used quite widely in the States and going through those processes are being approved here. And they're more for acute attacks. So they're quite handy in people who can't take the triptans that I mentioned earlier. So you can't really use triptans in people who've got any kind of cardiovascular concerns like heart disease, angina, have had heart attacks, that kind of thing. because they constrict blood vessels. And so if you've got a precarious blood supply to the heart, then that would be a risk factor.

Whereas the dytans, Lasamitadan, and Ramegrapant and Eurajapant, they all have lovely names that you can trip over quite easily. They seem to be much safer from that point of view. So we're hoping that we'll get those available soon. And then, you know, neuromodulation devices, I think there's research going on into that area. I hadn't mentioned, but there are devices that can be implanted. So if people have really got chronic intractable migraine,

then they can go into specialist centres and have oxytle nerve stimulators implanted to give electrical impulses and they wear them all the time. So that's not something we would do in our clinic at the National Migraine Centre, but it is something that is done. And then, you know, other intravenous, things like dihydrogotamina sometimes used. That's not a new treatment that's been around for a while. But yeah, I think it's working in headache and, you know, with migrant sufferers at the moment, is an exciting area to be in because I think there is more awareness.

And when you get something that seems, you know, we hear the words life changing in clinic now with some of these new medications, it's really a wonderful thing. thing to hear from patients because the impact is so huge. We see patients who've lost their careers, who have had to cut down their work or lost their jobs, who may be on benefits, you can't interact with their families. It's a horrible condition. I think more that people are aware of it than hopefully the more research we can get done. But it's huge, considering the frequency of the condition is hugely underfunded in terms of research. You said something earlier, quite a bit earlier, that really took me by surprise,

which is that the start of the migraine process can happen a day or two before the pain starts, which is really surprising. So if the process has started that long before, when is the best time for me to take a painkiller to make sure I don't get a painful attack? That's a really good question. and that's something that patients haven't been told very often. So if you think about migraine being a threshold condition, if you imagine that one thing changes and your brain is fine,

two things changes, your brain is beginning to be irritable, three or four things changing, and your brain hits a threshold above which it's going to go into a migraine attack. The more control those changing things, the less likely you are to get to that threshold. But if you do get to that threshold, than a migraine attack is starting to roll, the quicker you can squash it.

I have the analogy of a snowball rolling down a mountain. So if you were wanting to squash that snowball so that you stopped it rolling down and knocking people over, you do that when it's small. And you're much more successful to squash it when it's small, the same as with migraine attacks. So if you get in there quickly with medication, you're much more likely for it to be effective.

So that we have another saying that, you know, when you're treating a migraine attack, you need to treat it with the right medication in the right place at the right time. The right medication is the one that works effectively for you. In the right place means that it may be very helpful and important to have an anti-sickness medication so that it goes to where it's absorbed quickly and doesn't just sit in the stomach where it's not a disease. absorbed and at the right time early in the attack. So people sometimes have been told, well, here's your triptan, it's really strong. Don't take that unless you're desperate. So what they do is they go through that prodromal phase into the more of the headache impact phase and they wait until it's really bad. And then they take their triptan and they say, well, it didn't work. And it's because they've left it too late. So if the other thing I say to people is, so nip it in the bud as

quick as you know about it, but also if you know that you're likely to get a migraine attack, and that often it's times like traveling, not that we can do much of that these days, but if you think about catching an airplane to go on holiday, in the day or two before that, you will have stress because you need to get all your work sorted, you'll have excitement because you're going on holiday at last, hooray, hooray, you may well get up in the middle of the night to go and catch that cheap flight. So your sleep's disrupted. Your eating patterns are disrupted. The airport is full of light and sound and noise and stuffiness possibly. You then go to a different time zone in a stuffy airplane and you relax. All of those things can trigger a migraine

attacks be more likely. So if you know that, you can start taking simple painkilers in that pro-dromal phase or the day that you're traveling, it's not so useful to take the trip turns before the pain kicks in, but some of the more simple painklers can help suppress it even in the prodromal phase. So yeah, don't hang about, it's the message. I've read, I think it's on the NHS website that they say, try not to take too many painkillers because it can make them less effective for when you really do need them. So how do you balance that with making sure you always nip it in the bud? That's again about education. So that's really true. And a lot of patients have got the message. A lot of doctors have heard the message you mustn't

take painkillers too often. And this is true for all of the things that we take for acute headache or acute rescue treatments. So what we would say as a guideline, and it slightly depends on who you ask, is try and keep treating your acute attack with acute medications. to less than eight to ten days in a month. Now, if you are taking opiates, then I would say, first of all, stop, because it's a really bad idea. But those are very likely to push the brain into that hyper irritable state and cause it to transfer from episodic to chronic migraine or medication overuse caused by codeine.

But with the other medications, if you are using them on more than about five days in a month, then I would say you need to be talking to your doctor about having a preventative medication quicker. So I think often people leave it too late. They say, well, I'm managing it. It does work. So I'm taking it on 10, 12, 14 days in the month. But then we hear them saying, but now I've got this background, old headache.

And it's there every day. And I can't think straight. And my normal medication isn't working so well. And that's because they've got that medication overuse transformation. And so then the answer is to take away those acute medications and let the brain detox and then use them in a better way going forward. And that's scary because people are dealing with really bad headaches and they don't want a worsening and they feel scared to have a period of time where they haven't got anything to take. So we have to do a lot of discussion around how to support them through that. But if you do stop taking those medications, especially the trip turns for just a few weeks,

often people then start saying, gosh, I'm not getting so many attacks now. I feel a lot better. My medication is working again. So being aware of it is really helpful, I think. Right. I see. Thank you. And just to round off, what would you say are the three things that we really need to know about migraines?

Okay, three things. I would say, first of all, know that there isn't such a thing as just a problem. a normal headache and get a diagnosis. So if you're getting headaches, go and see somebody, preferably a headache specialist, who knows about headaches. The second thing is to know that there are lots of things available. I think sometimes people put up with migraine. They think that nothing much can be done.

And there's lots of things can be done. And the third thing is just to mention that there is a thing called cluster headache and sometimes it takes ages for people to be diagnosed with cluster headache because they've thought that it was migraine. So again, you know, getting good advice, educating yourself around it. People with cluster headache much more likely to want to walk up and down and bang their heads and get very agitated. People with migraine want to stay still.

They want to be still and quiet. So finding somebody who will diagnose that, I think. is part of the journey. So yeah, those are my three top ones. Thank you for listening to this episode of Instant Genius. That was Dr. Katie Monroe. If you want to know more about migraines, check out her book, Managing Your Migraines, which is out this week. Or listen to her podcast, Heads Up.

To hear her debunk the biggest migraine myths, head over to the Instant Genius Extra podcast. The August issue of BBC Science Focus magazine is out now. Pick up a coffee in store. or visit sciencefocus.com. This podcast is sponsored by Name, Audio and Focal. The texture and emotional depth of music can be lost through digital sources or poor signal.

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