The Dr Louise Newson Podcast - 115 - Migraine and hormones, with specialist Dr Katy Munro

Episode Date: September 7, 2021

Dr Katy Munro was a GP partner in a Hertfordshire practice for many years and developed migraine in her 40s, around the time of her own perimenopause. This led to an interest in migraine and her involvement with the National Migraine Centre, first as a patient and then as a doctor.  Katy now works as a GP Headache Specialist at the National Migraine Centre, a charity that raises awareness on migraine, shares information and advises how to manage it. In this podcast episode, she chats to Louise about what migraine is, dispels myths, and explains why migraine is not just simply a ‘bad headache’. The experts discuss the role of estrogen in migraine, other possible triggers, and ways to help minimise the onset, severity and frequency of migraine. This hugely useful conversation is a must-listen if you or a loved one experiences migraine.  Katy has recently written a book on migraine, ‘Managing Your Migraine’, and it is available to buy now.  Katy's 3 reasons to buy her book:  Educate yourself on migraine and take control of it.  There is hope, no matter what you’ve already tried there will be something else – you’re not at the end of the line.  Migraine is genetic. Think about not just who you got it from, but who you’ll pass it on to. We need to learn more about how to help children who go on to develop migraine and there’s a chapter on this in my book.  National Migraine Centre - www.nationalmigrainecentre.org.uk  ‘Managing Your Migraine’, by Dr Katy Munro, is published by Penguin Life Experts and is out now.  

Welcome to the Newsome Health Menopause podcast. I'm Dr Louise Newsome, a GP and menopause specialist, and I'm also the founder of the Menopause charity. In addition, I run the Newsome Health Menopause and Well-Being clinic here in Stratford-upon-Avon. Today I want to welcome to you Katie Munro, who I've not actually met in real life, but she's a fellow author, so we both authored books, which we'll talk about in a bit. But she is a migraine specialist. And for many of you who know me or have listened to me, probably know that I experience migraines,

and I have a particular interest in migraines, and migraines can get worse with hormone changes. So it seems very pertinent that we welcome. Katie today, so thanks ever so much for joining me, Katie. Thank you for the invitation, Louise. I feel as if it's a great honour to be on your podcast, and there's such an overlap between the conditions that we both see. And personally, I didn't start getting migraine until I was in my 40s and

coming up to perimenopause. So it was sorting out my own HRT that really helped. Amazing, isn't it? I think you learn so much in medicine when it's a lived in experience and either yourself or a family member or a close friend. And there's nothing like having a migraine to be able to really sympathise with people who experience migraines, isn't it? I think I feel very guilty because I've given my migraine genetic predisposition to one of my children, only one hopefully, and my mother feels even more guilty. And my grandmother, if she was alive, would have felt guilty too. But there's a lot of people when you say you have a migraine, oh, right.

It's a bit like saying, I've got a headache. And they're completely different, aren't they? Absolutely, yeah. A migraine is not just a headache. It's kind of the mantra that we're always talking about. You know, there's so many other symptoms that you can get brain fog, dizziness, nausea, vomiting. So yeah, a migraine attack can be very debilitating or can be actually quite mild. And there's lots of myths and misconceptions out there about migraine.

Yes. So we can talk about some of those. But before we start talking too much about migraine, tell me a bit about you and your sort of role and where you work and how you got to there, if you don't mind, Katie. No, that's fine. I started off as a GP and I was a partner in a practice for many, many years. And then I developed migraine. And so that is where my interest came from. As part of my searching for understanding of migraine, I went as a patient to the National Migraine Centre and then as a doctor on a study day and got inspired by the centre and thought that would be a great place to work. The National Migraine Centre is a charity and we offer appointments to people with migraine. But we also do a podcast called Heads Up and our mission really is to try and share

really good quality information about migraine and how to bridge it yourself. And it's also just to raise awareness, I think, because it's one of the commonest and most debilitating conditions and really, really misunderstood. And a lot of people will dismiss it with that awful phrase, oh, it's just a headache. Everybody exists, don't they? And no, everybody doesn't get them. Some people get them really, really badly. And how common are they, Katie? One in seven people get them. And three times as many women get them as men. So globally, there are a huge burden on individuals, on their families and their colleagues at work, and economically, you know, the absenteeism with people being off work with the migraine,

but also presenteism where people go into work staggering in. I don't know about you, Louise, but I've definitely done surgeries where I've been sitting really, really still with I've got a headache, you know, and it really has an impact on all of us in society. Absolutely, but it's so underestimated, and it's actually, I feel quite sad. actually, hearing that it's a charity offering consultation because it should be routine care, shouldn't it? Not just in the NHS, but other health centres and health systems across the world, because of something that affects one in seven, it's not a weird genetic disorder

where sometimes you do need to really seek a specialist. It can be very difficult. But one in seven, I mean, that's more common than hypertension, isn't it? And so as a GP or any sort of physician actually, surely we should all know about migraines as a priority, shouldn't we, if it's that common? I absolutely agree. And that's one of our missions is to educate anybody who is looking after people with migraine. But if you think back over medical training, there's so much trying to be crammed in. So very little training about migraine is given generally.

Also, when I'm seeing patients in my clinic, I have more time to listen to them and speak to them and work out a plan together. And sometimes patients have a long and complicated history. And with the best will in the world, a GP with 10-minute consultation isn't going to have the time to go into it in that much detail. I'm very aware that GPs have to be generalists and know a little bit about everything.

But the more that we can upskill everybody to understand migraine, the better, I think. And I think it all starts with the patients as well, actually, doesn't it? So, as you say, there's so much misinformation out there about headaches, about migraines, about what they are, what the treatments are available, what triggers are. So I feel it's a bit like that with the menopause. And one of the things I'm trying to do, and certainly with the charity that I founded, is about awareness and about empowerment, actually, so that we can take control of our bodies, either as a menopause or

as a woman or as a woman with migraine, I am both, thankfully. But I should be able to have as much information. So then I can go to my doctor, nurse, health care provider and say, I have migraines because I have this, this, this and this. I have tried these treatments over the counter and often people have spent fortunes, haven't they, buying things over the counters, but it's really impacting on me. And I read about this drug or that drug and can we talk about it? Because then actually it makes that consultation more focused and targeted if I've done my homework. And also if I, which I have done actually, I've given up alcohol, I've given up caffeine, I don't eat chocolate, I'm very routine in a way that I eat. Many of people know that I like yoga and I did yoga this morning

before I came to work, but I have to get up an hour earlier so I can eat, waiting out, and then I do yoga. All these people that can get up and do yoga. If I did that, I would get a migraine. But if I do my homework, then it makes it easier for the doctor done, doesn't it? Because you haven't got to then say to me, what do we use, how much alcohol do you drink or have you try giving up chocolate or whatever. So it has to be a partnership, doesn't it, to really maximize. I agree. I think speaking in my book about how to prepare for going to the doctor, what to do first, but also about getting your team. I think migraine care needs to be part of a team. You need to understand it yourself first. People who are around you need to understand it. It's your partner or your children, you know, to understand that a lot of noise and a lot of bright lights are going to likely make you worse and support and help you with understanding and empathy.

The local pharmacists might be somebody who can give you good. advice about helping yourself. But once it gets to the stage where your migraines are coming more frequently, then I think it's a time to seek specialist advice. Now, your GP may be a headache specialist. There are a few around, and we're trying to upscale even more, but it may be that you need to be referred on to a neurologist and a neurologist who has an interest in headaches and migraines because I think it's just such a variable condition and there are lots of things that can be done but sometimes people have been told oh well you've that's it you know you've got migraine off go and dismissed and I think that's when I start to think no no that's not the message we need to be

giving patients there's always something else we can find to help which is so unfortunate is it because I think there's two really things I suppose mainly with migraine is about the actual migraines how to get on top of those when you have them and you feel like your head's being ripped apart or you've got a sledgehammer in it. And then the other side is how to reduce the frequency of them as well. Because if I was told I would only have one migraine a year and it would be really bad, that'd be fine.

I wouldn't mind at all. But actually it's when you have a three-day migraine that isn't nearly as severe as what I've just described, but actually it impacts me more. Yeah. So it's the combination and there are different treatments, are there for both types, you know, before reducing the number and also helping the acute situation.

Definitely. I tend to talk to people about the acute phase and rescue treatment, if you like. And that's great. If you've got that sorted and you only get occasional migraine attacks, then you've got the power in your own hands to deal with it. That really helps people's anxiety reduce because very, very commonly, migraine is associated with anxiety and sometimes depression. But once you're getting more than about five attacks a month, or if you can't find a recipe for

rescuing you from that attack, that's when we need to probably sooner than it often happens be speaking to patients about preventative medications. And those come on under three headings. I would count lifestyle as preventative as well. But when you're talking about more medically based interventions, there are medications of people take by mouth, there are injection techniques, and there are neuromodulation. devices. So there's a wide range of things. Of course, the medications are usually what people are put onto first, and a lot of those are borrowed from other conditions like hypertension,

high blood pressure, or epilepsy or maybe antidepressant medications, which if there isn't an explanation about why those are still being used for migraine, then people get put off and worry, well, they've put me on an antidepressant, and why do I have that? And because they come a bunch of side effects. So I think that having somebody who understands exactly about all of these different options and what the pros and cons are, helping you towards your own personalised plan is really, really helpful. Yeah, it's so important actually when you use medications off licence, because a lot of medication actually we prescribe, especially to children, is off licence, but it really scares people. And as you know, even HRT is only,

license for menopausal women who have not had a period for at least a year. We prescribe it for perimenopausal women because there's good evidence that the earlier you take it, you top up the missing hormones, improve future health. Testosterone isn't licensed for women in the UK at all, but we prescribe it, but a regulated product. But some people think if it's off license, therefore it's dangerous. Yeah. It's quite different. There's still regulated medications you're giving these people, aren't you? Yeah, they're often licensed for other things, aren't they? And been widely used. Sometimes they've got licenses in other parts of the world, but we over here have dragged our heels for whatever reason. So yeah, I think some

explanation about that is often necessary. And these things can be very, very useful and effective. So let's go back to talking about what I only really think and talk about is perimenopause and menopause. So how is that associated with migraine? So we know that when girls start their periods, they often have fluctuating hormones and my brain can manifest itself often then, can't it? And then it seems to go down. Pregnancy can be a time when migraines can worsen, again, hormones change. And then like you say, yourself, in the 40, you're doing the perimenopholes or menopause, there's a lot of women who have quite crippling migraines. They might start new or it might be an extension of worsen. So how does that, can you explain how that happens? Yeah, so we know that estrogen is the key hormone in migraine aggravating. and women. So fluctuations in estrogen seem to be really important. So if you have migraine without aura, and aura being that sort of hour of flickering visual disturbances, usually that's the most common,

then if you have migraine without that, it's the falling estrogen levels that seem to trigger worsening of migraine. And we see this on a monthly cycle. So when people are taking the pill for three weeks, then coming off it for a week, they often get a migraine then. And in the perimenopause, of course, estrogen levels don't just smoothly decline to zero. They go up and down like a flipping roller coaster. So on the times for people with migraine without aura, as their estrogen levels fall, they can get more attacks. For people with migraine with aura, rising levels of estrogen seem to aggravate attacks. And so that still can happen in the perimenopause. We can have some weeks where estrogen's dipping down, other weeks where it's

back up again. And so it's a very common time. We see so many women who are getting worseing of attacks. And they seem to become sometimes more tricky to treat. The other thing we hear is that the migraine changes over a person's life. So they may come and say to me, well, I used to get these really bad headache attacks with vomiting. It was really intense. But as I'm getting into the perimenopause, I'm now getting more vertigo or dizziness with my migraines. And I don't get aura so much, oh, I've started getting it. So things are really changeable. And that makes people worried as well. Of course, if you add in the fact that in the perimenopals, women are often feeling that they can't sleep so well. It may have a much poor quality sleep. They may have

other life stresses. They may be feeling, you know, a lot of emotional ups and downs. Anything that causes change irritates the brain of a person with migraine. And it's the combining of these changing things that seems to cause the problems. Yeah, and it's so common, but it's often people don't associate it. I mean, I think back, and I must have missed hundreds, if not thousands of women who have presented with migraines in their 40s, and I've concentrated just on the migraine as a GP. I, you know, would always ask if anything changed in their lifestyle or their job or any stresses, but I didn't even think about hormones because no one taught me.

Yeah. So I didn't know. And now, obviously, it's so obvious. but even in my mid-forties, my migraines were getting so much worse. And they always occur or they often occur at a weekend or on a holiday when I'm just relaxed. It's quite classic, isn't it? And I remember once we had this Sunday holiday to Morocco. We only went for four nights.

And three nights I was just in bed. And I often get migraines when I'm away. And I think it's also partly because it's quite hard to be so obsessed about food and routines when you're changing or whatever. But it was just so awful because I could see everyone else having a really nice time. And I was just in bed thinking I just want my head to be cut off. I feel so awful. But if someone had just said to me, Louise, your mid-40s, do you think your hormones have changed? Do you think it could be related?

Firstly, that would be very reassuring because it would stop me thinking, have I got a brain tumor or something else causing my headaches. But also it means that I could probably replace my estrogen and improve my migraines. Yes, I think there's a lot of myths and misunderstandings about hormones and migraine. And, you know, we hear people saying, well, my GP wouldn't give me HRT because I've got migraine. Well, that's completely not true. So our goal is basically, once you feel that you're in the perimenopause, is to get a form of migraine treatment that smooths out those estrogen fluctuations. And the transdermal route is the preferred route.

Absolutely. So when we say transdermal, it means the estrogen's given through the skin, isn't it? It's a patched down or there's a spray as well. so it goes straight into the bloodstream. So there's no risk of clot or stroke, which there potentially is with tablet estrogen, especially even the contraceptive pills, with containing estrogen.

But in the insert, it will still tell you there the risk of clot and strokes. Yes. I mean, I've been approaching the MHRA several times, and I know they're looking at changing it because it's very confusing, actually, for women, isn't it, when they look? But it's very safe because it goes straight.

into the bloodstream, doesn't it? So there is no increased risk with women who have migraine, even migraine with aura. So that's a really useful treatment choice that can actually really help. But we do find sometimes that I tend to actually start women with my bones, are very low doses to do. Sometimes a patch and I get them to cut it in the quarter. And then I gradually increase it because sometimes it's not just the level. It's a big change, isn't it? Absolutely. I think you're right. And I think that's probably a good rule have done for anybody with migraine because people do tend to be sensitive to medications if they've got that irritable brain. So going back to what I was saying, we know that it's a genetic neurological

condition. The genes give you the vulnerability for your brain to be irritable when things change, but it's the effect of changing things that irritates the brain. And so going in with low doses and increasing gently, and the same if you're coming off things, I think, as well. Sometimes people have been on medications for a while. And they're going to be in on medications for a while. they're wanting to stop them for whatever reason, and doing things gently, but also being patient. And it's so hard to be patient, isn't it?

Oh, it is. When you're suffering and someone says, well, in three months' time, well, that's a long time, isn't it? That's a lot of work that you've given up for. It's very difficult, actually. And I really look at people that can go on these two, five fasts, and I think, oh, my goodness,

my head would explode. And in fact, a really good friend of mine said to me the other day, his mother was a nurse and said, well, because I'm going to give you some really good advice. Never ever marry someone who has migrants. And he at the time thought, that's a weird thing to say. And actually,

I look at my poor husband. And I get very pale just before I ever had it. My eyes just go and he just looks and this is like, go to bed. And I was just like, no, are we fine? No. You know, and like you say, it affects the whole family. It really does. And it's really tedious because then I think,

oh, so he's, again, got to look after his children, he's got to watch television on his own, and it's boring. It's boring. It's boring for you, but it's boring for everybody else. Oh, another headache. You do hear this, don't you? And I think that what, it's interesting what you were saying, you know, you said to him, oh, it'll be fine.

I think when we're beginning to have a migraine attack, often our brain doesn't work probably. I certainly remember thinking, oh, oh, it'll probably be fine. I won't bother taking anything, leaving it too late by which. time you've missed the boat. And that is a big problem, isn't it? And I think, and also sometimes you get these little warnings, like, sometimes I crave, I need to eat something, or I get very thirsty, and then, like you say, people are very sensitive to light or sound. And then you suddenly think, what's going on? But because your brain isn't working, and my daughter has migraine, and she's been

hoiked up by teachers actually thinking that she's on drugs because she says her words, she's chipped up the stairs. And they've, a couple of times said to her, you know, come on, Jessica, where have you been? And because she's 18. And she doesn't actually, she's like me, she's stopped drinking alcohol to help her migraines, but they've not believed her. I thought it was drugs. And actually, when she's better, because you can't even make a sentence. It's really hard sometimes. Sometimes kids also get yawning or adults sometimes get yawning, you know, that can get them into trouble in class too if they're not paying attention. But, I mean, of course, talking about kids, we also know that kids often,

are missed because they get more abdominal migraine symptoms. So a lot of tummy pains. So I love seeing kids with migraine, not because they've got migraine, but because I want to give them the tools at an early age to give them the understanding so they can go forward and get really good plans. She's so important because, like you say,

the amount of time that's lost with work, you know, it could be seen as an easy excuse, isn't it, pharaoh, I've got migraines. And if you don't understand, so I think this is why what you're doing with the two, charity is so important so that we're educating everyone as well because then in the workplace people can be more attuned and it might be ways of helping in the workplace. We have someone that works with us who has migraines and she can't have the artificial lights on because she

knows it's triggered. So we've changed the lighting in the room that she works and actually the other people quite like it as well. It's quite calm in the room she works. But it's acknowledging it and not thinking of all she's a bit weird because she has to sometimes wear dark glasses inside, actually think, goodness me, what must it be like to have this? There are some very simple reasonable adjustments. You know, it is, especially chronic migraine, if it's coming thick and fast, then it is classed as a disability under the Equality Act. And going and having a conversation with the employer about if it's possible to make reasonable adjustments, and I list some of them in the book, then that is something that can just really make

such a difference. I had a patient who used to have to go for a presentation every week, a briefing presentation, and there was a PowerPoint. And she found that the glare of the PowerPoint gave her a migraine. So her employer said, well, instead of going and looking at the PowerPoint, here we are with the printed copies on paper. Simple. So simple. It was made such a difference to her. The Migraine Trust also have a very good work advocacy help line. So if people are struggling at work. The thing that penalises people is if they have multiple short absences with migraine. Often sickness policies are weighted against people with migraine, but that needs a conversation with work. So, well, it can we not count absences which are migraine? Because

you're going to keep getting them and they need to be understood. Really important. So you mentioned your book. Tell us about your book. What's it called, first of all? It's called, funny enough, managing your migraine. Perfect. And it's a series, isn't it, by Penguin Knife excerpts? It is. And my goal was for it to be a very easily accessible source of evidence-based information for people to take control of their own migraine and make a plan, not necessarily avoiding

doctors, but knowing, as we were talking about earlier, how to best arm themselves to go and have a useful conversation with their doctor, knowing all of the variety of treatments that are available, but what they can do to help themselves as well. And have you, is this your first book? Have you written a book before? This is my first book, yes, yes. So it's a huge amount of work. Anyone listening, do not underestimate how hard it is. And I think, I mean, I've been involved in a few websites. In fact, we're just updating a couple of websites at the minute. But the good thing about website is you can change it all the time. And you see it, you think, no, I don't like,

change it words, change this. You cannot do that in the book. And once it comes, out, that's it, you cannot actually think I can't read it because I know I'm going to find things that I want to change. Well, I've got my first hands on a paper copy this morning as it came through my door from the postman and flicked through it thinking, what did I write that I'm going to want to change exactly that? But I'm quite hopeful that it is all evidence-based and it is all practical and nothing greatly will be changing. There are going to be some more medications is coming soon and there are already some new and exciting treatments which are to be available on the NHS.

But that can go in your second edition. So it's going to be available bookstores, Amazon, everywhere that you can get books, audible, Kind of, Amazon. So if people, and do find it useful will be really nice if they wrote a review for me on Amazon because it's about getting the word out there. It's about educating people generally. and the more people that know about it, hopefully the more can be helped. There's probably very few books, are there?

A migraine is not something that I see is a best seller. You know, in Amazon, when you go to health books, I mean, I often look at N for menopause and there's dreadfully few, and then migrainer's, I've not really come across anything that's been that useful. I think quite a number of years ago, there were a couple that were published through people that worked at the National Migraine Centre, and there were kind of tales of people's migraine in books, but nothing quite like this is a sort of handbook for helping yourself.

So, yeah, I'm very delighted that it's out there. You've got given the chance to write it. Brilliant. So that should be something that everyone should be looking at and even, like you say, relatives or family members or even work colleagues of people as well. So maybe it should be that every organisation should buy one as well. Yes.

To have a really good understanding as well. And I think this goes back to what I was saying at the beginning about patients being empowered. And I think it's really important that we share our decision-making with patients. We have some new guidance that came out from Nice in June 2020, shared decision-making guidance. And I think these are so crucial for everything we do as doctors, that we listen to patients,

we take understanding of what they want to get out of their consultation, and what they know already about their condition, their illness or whatever. But they have to do homework as well. One of the days where people just rock up and expect the doctors to do everything. And I'm not saying that I think doctors are lazy or whatever. But actually we want to target and help people to the best of our ability, helping take into consideration what's going on. And you don't always know to us the right questions,

but if patients know more, they can really help us. And I think doing some homework, you'll get the most out of your consultation because I don't know the figures, Katie, but you might, the number of people that go repeated times with migraines to doctors must be huge. Oh, yeah. So if we could reduce that by half, because patients were empowered by, for example, reading your book, that would free up doctors' time, which would then make it a win-win

because we want to, you know, there are some consultations as a doctor you know are going to be more difficult than others and actually seeing a mind going, you know, oh my goodness, it's not the same. For everyone, it might be quite difficult and if someone's come three or four times, your treatment choices have reduced.

But it might be like you say, as simple as asking, well, what triggers is it at work? You know, do you know the triggers rather than treatment, treatment, treatment? And certainly, I mean, I'm sure you have, we've seen a lot of people who have just been given pain killers, pain killers, pain killers. And then they get headaches because of their pain killers.

And it's just going to be this vicious cycle. So we have to unpick it all and start almost over again. So I think even anyone listening who's had migraines for years should still be considering buying your book to start all over again maybe because things have changed. Definitely. It's only when mine got worse, actually, I was so desperate to keep my job that I thought, right, how else can I improve? And it's, you're on this conveyor about all the time, one's busy. But when you take a step back and think, right, what are my real triggers?

What can I do? What about my lifestyle? I can't blame anyone else other than me if I've not eaten breakfast or I had a mid-afternoon snack or if I've drunk a cup of tea instead of some herbal tea. You know, it's me. But I have to have the information to know how to make those changes. I think that's absolutely right. I'm fully, fully on board with different. shared decision making, I think that's crucial because there's no point. If a patient comes into me and I say, oh, just try this medication, then, you know, that's often what they've had before. And so I'm picking it right from the beginning and saying, right, do you know what migraine is? Did you know it's a genetic neurological disease? Do you understand about the irritability and the

change? Do you understand about the importance of just things like eating regularly, having low carbohydrate, low-G-I diet, having possibly a bedtime snack. A lot of women are waking with migraine in the morning and simply putting in something to keep their brain fed overnight can be really helpful. So there are some very simple basic things that often people say, nobody's ever told me that before. And they go off and make some changes themselves.

And they're so happy. You know, I think people with migraine, and probably it's the same with menables or symptoms, they want information. They are searching. They will try anything. When you've got, you know, these horrible recurrent attacks, you really do want to have a range of options and find the right recipe for yourself.

Which is so important. It's such a great way to end is about having some control and learning. So before we end, I always ask for three, we're putting you on the spot here, Katie, three take home tips about something that I'd like to ask you three reasons why someone should buy your book, either for them or for someone else. What were the three main reasons to buy your book? Well, first of all, it is what we've been banging on about. It's about educating yourself and taking control and understanding what's going on. Secondly, I want everybody to realise that there is hope. You're not at the end of the line. There is almost invariably something else that you

will not have tried. And thirdly, it's a bit of a passion of mine. There's a big chapter on children. I want us to be looking at our children because it's genetic. So when I'm asking about family history, I'm saying, what about your descendants as well as your ancestors, not just who have you got it from, but who might have got it from you? No blame attached. But if we can help children to be understood better,

then I think that's really, really worthwhile. So brilliant. So we'll put a link to the book at the end of the podcast notes and also a link to the charity as well. So thank you so much for your great work, Katie. and thanks for joining me today. It's been really good. That's a great pleasure.

For more information about the perimenopause and menopause, you can go to my website, menopausedoctor.com. Or you can download our free app called Balance, available through the App Store and Google Play.