The Dr Louise Newson Podcast - 284 - Migraines and menopause: what’s the connection?

Episode Date: November 26, 2024

On this week’s podcast, Dr Louise Newson is joined by Dr Rebecca Walker, a GP who specialises in headache medicine and migraines. In this episode, Dr Rebecca and Dr Louise (who suffers from migraines herself) get back to basics, looking at what migraines are, why they can occur and management approaches, from lifestyle measures to medication. They also talk about how hormone changes during perimenopause and menopause can impact the frequency and severity of migraines, and bust some myths around taking HRT if you have a history of migraines. Follow Dr Rebecca on Instagram @dr_rebeccawalker. For more information on migraines, visit the National Migraine Centre here, and you can find resources about migraine and menopause on the balance website here. You can also listen to an earlier episode of the Dr Louise Newson Podcast with Dr Katy Munro, author of Managing Your Migraine, by clicking here or searching for episode 115 on your favourite streaming app. For more information on Newson Health, click here.

Hello, I'm Dr Louise Newsom. I'm a GP and menopause specialist and I'm also the founder of the Newsom Health Menopause and Wellbeing Centre here in Stratford-Pon-Avon. I'm also the founder of the free balance app. Each week on my podcast, join me and my special guests where we discuss all things perimenopause and menopause. We talk about the latest research,

bust myths on menopause symptoms and treatments, and often share moving and always inspirational personal stories. This podcast is brought to you by the Newsome Health Group, which has clinics across the UK dedicated to providing individualised perimenopause and menopause care for all women. So today on the podcast I've got someone called Dr Rebecca Walker with me, who is a GP with a special interest in migraines, as well as hormones as well.

And as many of you know, the two are very closely linked. So I wanted to dedicate this podcast to really just talking a lot about migraines. I have a big personal interest being a migraine sufferer myself. And it's really shocking. Menopause is neglected, but migraines are really neglected, actually. They're under-recognise, they're under-diagnosed, they're under-treated. And actually, the impact of migraines is just still not recognised. to the extent. So it causes a lot of personal suffering, a lot of professional suffering because people

are able to go to work and a lot of unnecessary costs to the NHS as well because people are not given the right treatments or given inappropriate treatments. So hopefully we can unpick some of what migraines are, how best we can optimise them because us with migraines know we'll never not, we'll never be cured. It's not curable, but it's manageable. And so we just want some really great tips from an expert. So thanks for coming today, Rebecca. That's my pleasure, Louise. Thank you for asking me and putting migraine on your agenda because, yes, it's important to me to for all the reasons that you have said. Yeah, so it's very timely actually. I'm just coming out of a migraine, so I still don't feel completely with it. But, you know, yesterday morning, I had one of these

classic times where I was in a important meeting and I suddenly felt all cold and shivery. And I thought, oh, what's going on? And then the day progressed and I knew that I was developing a migraine and my daughter, who's also a migraine sufferer, had phoned me. And she said, Mommy, have you taken aspirin and Don Peridone? And I was like, no, I'm fine. She goes, no, I can hear by your voice because you're slowing your words. But it's really weird. When you have a migraine, you don't think properly. And you can't actually, you know what you should do, but you can't do it sometimes. And then it makes it worse. And then it's sometimes too late because you have this window. And then I was taking some of my trips in, but I knew it

wasn't right. But I also knew I had to drive and take my daughter to something else. another daughter so I couldn't take the Zomor trip to it and I hadn't eaten properly and it's this spiral of sort of oh it's awful but I mean you have just said so many things in that one but it's one of those that I think a lot of people still don't understand because when I say to people I have a migraine oh do you just have a bad headache I think that's the key and you feel like ripping their head off but actually they don't understand so can we start with just what is migraine So migraine is a complex neurological condition.

It is not just a headache. We know that it has a strong basis in genetics. So most of the time there's a family history there. But the genetics are complex. So there is variable inheritance. So some people will express migraine in one way. And other family members might express migraine in another way. Then that's part of the problem too.

So it often goes unrecognized from family members to family members. But we know that it's not just a headache. headache is one symptom of migraine. Headache might not be a symptom of migraine. So there are people out there who will be experiencing migraine where they don't get headache at all. And that's because we know that migraine, so let's go back to the sort of basics and some biology, a type of migraine starts with an inherited tendency towards the condition.

But we then know that there are environmental, both internal and external environmental factors that push you over your migraine threshold. And once you hit that migraine threshold, you start to get activation. in the hypothalamus part of the brain. So this is the thermostat, if you like, the center that controls our temperature regulation, our sleep-wake cycle, our appetite cycle. So in that part of the brain is being activated, they start to get prodromal symptoms. And they might be feeling hungry, feeling thirsty, going to the loom often,

yawning uncontrollably, a dip in mood, slow thinking processes, neck stiffness. And that might be happening anywhere from a few hours to a few days before you, start to get the more readily recognizable symptoms of migraine, which would be the nausea, the light sensitivity, sound sensitivity, the headache. And then as you are possibly right now in your post-drome, where you're maybe, you know, you're recovering as relief that the unpleasant symptoms are passing, but you're still not back up to functioning at your normal 100, maybe 60 to 70% brain still feels thick and foggy, energy levels are still a bit flat. So that's a typical attack of migraine without aura. There are three and ten people who experience migraine who

get, might have aura as part of their attack. But that just goes to illustrate, firstly, that it can last anywhere from hours to days, but also the myriad of symptoms that a person with migraine can experience during an attack. And that's really difficult because I think that's why so many people it can take a while to be diagnosed, especially we see a lot of people in the clinic who have vestibular migraine. So they might have balanced problems and they've never had. had a headache and they've often been diagnosed as actually having a TIA, a transient ischemic attack and people think that they've had a mini stroke. But when you take the history very clearly, it often isn't, is it? There's a history of migraine. So vestibular migraine is a really

interesting variant of migraine. I see it's so commonly presenting in the perimenopause. It's typically characterized by episodes of vertigo that last for maybe several hours or so, accompanied by other symptoms of migraine, so that light sensitivity. movement sensitivity, sound sensitivity, feeling nauseous, headache doesn't always have to be present. You know, it's usually been there at some point in the past within an attack, but it doesn't always have to be present. And what we often find with vestibular migraine is that headache is there, but it's not the most bothersome symptoms. So in migraine medicine, we're really keen on finding out from people, what is their most bothersome symptom? It might be headache, but it might not be,

it might be balanced disturbance. It might be fatigue. It might be brain fog. Yeah. whole host of different bothersome symptoms. Yeah, and how do you define chronic migraine? Because that's a term that's used quite a lot as well. So what does chronic migraine mean? So I'm pleased that you asked about this because I think part of, again, a migraine awareness and helping people recognize that actually they might be experiencing migraine and not just headaches, no one is born with chronic migraine. There is a point at which migraine, which is episodic, so that means it comes and it goes and you feel well in between your attacks transforms to this chronic, more burdensome, more impactful and potentially life-limiting condition.

It comes down to essentially how impacted an individual feels by their migraine, but our classification systems use a cut-off of 15 days. So if you have migraine days that number more than 15 per month, eight of which really fall into typical migraine-type attack days, then that constitutes chronic migraine. So as I said, that's when it becomes life impactful. But if you look at disabilities through WHO, it's really up there, isn't it, as being one of the commonest causes of disability, because migraine is so common. Yet there's so much we still don't know about it.

There's so little research that's done. And there's very few specialist migraine clinics as well, isn't it? I think that probably comes back to it being maybe a women's issue. It's predominantly a condition of women, so it affects three times more women than it does men. It affects women disproportionately and men too, but it affects us disproportionately in our midlife. So during most productive years, working age, and that's largely in women due to the impact of hormonal influences. And I think it is stigmatized, it's hugely stigmatized, and it comes down to this lack of understanding. It comes down to thinking of it as just being a headache, something that people should take a paracetamol for.

and get over and get back into the office for, which means that people are sometimes anxious or nervous about coming forward to volunteer that they have an issue that they need support and attention for. And equally, perhaps as healthcare professionals, we carry our own stigma related to migrate as well because of a lack of training. I think you're absolutely right. There is a real lack of training. And it's always difficult in medicine when you're dealing with a condition that there isn't a diagnostic test for. So if I thought you had diabetes, I could do a blood test.

test and I could say yes or no, Rebecca, you've got diabetes or you haven't. With something like migraine, there isn't a test. We sometimes do test to make sure there isn't a brain tumour or something else causing some symptoms. Not always. Most people don't need a scan, of course. So then you're going with a really good history and story, but you have to be trained to ask the right questions because if you don't ask the right questions as a healthcare professional, you're not going to get the whole story. And sometimes people don't think something's relevant because like me, the beginning saying I suddenly felt cold at a meeting. I know that my headaches, the migraines are going to start at some stage, but I try and ignore it. But if I didn't know

it was associated, why on earth would I tell a doctor that I feel cold sometimes? You know, so patients have to have more knowledge so they can give the good history. But doctors and healthcare professionals need to be asking the right questions. Because so often in medicine, when we don't know the answers, it's easy to say, oh, maybe it's because you're stressed. And the number of times that I have been told, but certainly my daughter has, oh, it's maybe because you're a bit anxious. Well, no, you might be stressed because you're in so much pain and disability and you're not being listened to and you don't know how to help. And you're really worried it's going to happen at a time when you are doing something public facing or you're doing something that you can't get out of. Of course that's going to make you worried, but the worry hasn't caused you to have migraine, if you see what I mean.

And that's really hard for patients, isn't it? It's a real thing. The fear or the apprehension of experiencing migraine is a real thing. And I mean, it is a vicious cycle. We know that the more migraine you experience, the more it does impact on your mental health and your well-being. And the more that makes you more predisposed or vulnerable to experience in migraine. So it is a bitter cycle.

And our stress hormones, adrenaline, and cortisol definitely have a role to play, but they are never the only answer. And I hear it all the time that people, well, I wouldn't be feeling anxious. if I didn't, if I wasn't worried about migraine or I wouldn't be feeling low if I didn't wake up with a headache every day of the month in all of these sorts of things that we hear so commonly in clinics. Now, I'm just going to say it's very interesting about mood because there's the anxiety that

you can have thinking, oh gosh, I'm going to have a migraine at a bad situation, what am I going to do? But the other thing is, and it's taken me 53 years to realize that actually sometimes when people have migraine or just before it comes, you can get very low in your mood. So I often have feelings of really low self-worth, really low self-value. I really think that I'm no good as a person. I'm no good as a doctor.

And it's a downward spiral. And it's only been the last year that I realize that quite soon after I have these feelings, then the migraine occurs. And I've also learnt through my daughter because she has this as well. And it's like, where's this come from? Why are you suddenly so negative? And then I realized I sit on the phone. I can hear this learned speech.

And so now we can reassure each other. And I think that's really important because I wonder how many people make the wrong decisions because they're having migraines, if you see what I mean. Or because they can't acknowledge that they have an attack, that they need to take a step back. Do you mean that they need to take some time out, recover, give themselves space? They need – but I think, again, it comes down to validation, you know, almost being given to me. I mean, it's not your fault that you have migraine. It is the genetic lottery that we are, you know, given.

It's no one's fault that they experience migraine. And I think that's also really important. Yeah. It's not something you've called. No, and that is so important. And for others to understand. So recently for my daughter, I actually helped her write a definition of what migraine is

and things that other people can do for her when she has a migraine because she's only young and a lot of people, do think, oh, it's just a headache, just a bit of stress or whatever. And then because her coordination goes, because her speech goes, because her mind doesn't work, it's very hard then to get the right help. But I've sort of wrote this list about things that are worth thinking about for her friends who are with her. So if she starts to yawn, feel cold, is very hungry. Then offer her and make sure she has some aspirin, domperidone,

so this treatment that could have brought an attack. and also, you know, tell her that it's likely that she's going to have a migraine. Sometimes my husband can see it in my eyes before anything else he can see. You know what? I think you're absolutely right. I'm very pleased you shared that because I think you're right. I think it's maybe as people I experience migraine too, there is this element of denial that happens and you do need somebody who's objective who can say, I can see the change, I can see the tail, I can hear it in your voice. Yes. is what we do. And I must admit, again, I'm going to take that away for my adult patients, too, that I have for children, so young people who are at school, I have a migraine action plan that

they can share with their educational environment. That means that this is what I need to take when I have my attack of migraine. This is what helps me. This is what, you know, helps me get through my migraine attack. Yeah. And actually that's important for everyone who experience that in the brain. It is really important. My daughter always has medication with her, but so often she'll phone me and I'll say, right, have you taken? And then she's clumsy so she can't open the purse and then she can't see the tablets and then she's, oh, no, I've run out. So even just the other day, she got a tiny purse and it's just got one of everything she needs in. And then she knows that she's got enough for one attack. And it sounds really simplistic. And we were both saying,

when your mind's on it, you think that's so obvious. But when you can't think it's too much to open a drawer to look through other tablets. And it's really hard to describe to people. But again, to make it easier because there are treatments that often, they don't always work, but can reduce, even can stop sometimes a migraine attack occurring, but they can reduce the severity as well, can't they? They can. So when I'm thinking about looking after people with migraine, the first port of call is always migraine friendly living. So that's good routines. Migraine is inherently sensitive to change. So keeping good sleep hours, hydration, regular healthy meals is important. But a lot of people who've been living with migraine get to the point where they say to me,

if anyone else tells me to drink more fluid, I'm going to, you know, dog than one, because don't they think that I've thought at that already. Then when you move on from living your migraine-friendly life, it's important to have a rescue treatment to hand so that you can abort that attack as soon as as possible. And sometimes it can take trial and error to find the right combination of treatments. But actually, as you say, a combination of treatments, it might be an anti-inflammatory, it might be paracetamol if you can't take anti-inflammatories with a triptan. It's shocking how many people with migraine haven't been offered or haven't sought advice on migraine-specific treatment. Maybe one in four people with migraine have been offered at triptan. So this is a migraine-specific

medication to abort an attack. Having a combination of those, sometimes taking these medicines with a small kind of colon can be helpful. I have a kind of Coke in the bridge with my name on that no one touches just in case for those times when that's because of the caffeine, is that and the sugar or how does that? Yeah, absolutely. I mean, I think from, as you will, from your description, I think going through migraine these genes that essentially mean that you perhaps are more vigilant or more sensitive to the world around you.

Being in that condition demands a lot of energy. And so when you're entering a migraine attack, actually that's what your brain is. craving, it's craving, restoration, good energy levels. And so the caffeine and the sugar boost with the migraine rescue treatment can be helpful.

Obviously we need to be mindful that it's not too much. Too much cholera is a bad thing. But it can be helpful now and again. Yes, and you can get pain killers that contain caffeine as well, can't you, that sometimes people find. And taking an antisickness can sometimes help, too, can't it with the medication? Yeah.

Absolutely. The stomach goes into a state of paralysis in migraine. So taking medicine into your stomach, sometimes it just sits there. And a lot of people feel that and describe that. I feel like my system just stops. Some people who do vomit feel like actually the action of vomiting in some ways goes to relieve or bring respite from their migraine attack. But taking an anti-sickness tablet that also works to move medicine into the intestine

can also be very helpful too. It's all about getting that medication into the system as quickly as you can. We use an analogy at the National Migraine Centre likening an attack to a fire starting in the waste paper bin in your office room. You know, you don't want to go at it with a plant spritz. You want to go at it with a great big bucket of water, put it out quickly, but it doesn't take hold and burn everything down. Yeah, it's a really good analogy, isn't it? And there's also some of the triptans who can have as a nasal spray or they can melt in the mouth, which again is really good if people bind that they're feeling sick or they're not

absorbing properly. And there are different triptans as well. So what suits one isn't going to to someone else. Sometimes people have side effects with one and not with others. And it's like anything in medicine, isn't there, Rebecca? You just try something else. So it's really important if people are suffering not to feel bad, know that you can go back and ask for an alternative treatment. It doesn't agree with me. This isn't the right thing for me. We, I was listening to a professor of neurology talking about how we define triptan intolerance. And he said, well, you know, perhaps we shouldn't be defining it. Our patient should be defining it for us. That's how it should be people coming back to us saying, this isn't working for me.

Is there anything else I can try? Yeah, I think knowing that we're all individuals, because, you know, how I manage or try and reduce my migraine frequency, I have a very routiney life because I know my brain dykes homestasis. So if I skip a meal, I'm guaranteed to have a migraine. If I eat processed foods, I'm guaranteed to have a migraine. So if I had a can of Coke and a Mars bar, I know I'd get a migraine. so I don't have it.

And I don't have caffeine at all. I don't have alcohol. I'm really regimented the way I exercise. If I know if I do more than 20 minutes of yoga in a morning before I've had breakfast, I'll get a migraine. 20 minutes, I'll get a migraine. But that's fine. 20 minutes, most mornings is good enough for me.

Yeah. But if I go for a long cycle ride, I'll get a migraine. I'm really, it's really restrictive to the way that I live. But it's actually quite good because it means I have to be healthier because I otherwise would eat, probably far worse. I probably would drink alcohol. I probably would go to bed far too late and try and have a line at the weekends. But I can't because the last thing I want is migraines because they affect me so badly. Some people makes no difference. So if it doesn't make a difference, what you don't want to do is restrict your lifestyle. But I do know also, and I hopefully you'll

agree that any changes in lifestyle, you have to wait a good sort of three to six months to see it's made a difference. So giving up drinking for one day and then getting a migraine two days later doesn't mean that alcohol is something that you can continue drinking. So you've got to try changing things and waiting. Yeah. Absolutely. I think you're totally right. And it's the same with medical interventions too. So the treatments that we use, it seems to take that amount of time for the brain to recalibrate and to adjust to a new way of being, as it were. So yes, give any intervention long enough and that usually is about three months. Yeah, I agree with you. It can feel very restrictive, but I think as you've experienced, for most people, the benefits outweigh the restrictions that don't post online.

Often people find that once you've got good migraine control, it affords you a little bit more flexibility. So you can push the boat a little bit. You can go out and enjoy that concert or that meal out. It just might mean that you pay a bit of catch up the next day. Or I think another thing about migraine is, I don't know how you feel about the war. word trigger, but the more I do migraine medicine, the more I'm becoming less keen on using the word trigger, I think trigger sort of invokes avoidance behaviour. And actually what we find with migraine is that people retreat from their lives and stop living the lives that they want to lead because they're avoiding triggers. I think it's perhaps kinder to ourselves to think

of these things as conditions that make us more vulnerable to migraine. And we can prepare conditions. It needs to sort of create a more proactive approach. We have some autonomy over migraine rather than dictating how we live our lives. I think that's really important. Yeah. And you do have to be prepared and you do have to, I think you're right, think about alternative. So even some of the tube lines, my daughter can't go on because the noise of the tube, some of them are really noise in trigger, whereas some of the other, like the Elizabeth line, she said it's beautiful because it's really quiet. But she's got And it's really interesting, but once you're aware of it, you think, like, okay, so she plans her journey differently and, you know, and looking at what noise protection you can wear.

But you've got to be one step ahead all the time. But you can only get that step ahead. You've recognised it to start with. And I think, again, that's why, well, it's so lovely to be here to say, you know, please, if you're having recurrent headaches and, you know, headache is a symptom. It's not a diagnosis. Do seek advice. it's really important. I totally agree. And I think that's where using other people to recognize what did you do differently. Was there anything that sort of brought it on? But sometimes it can just

happen. And so like you say, these triggers, sometimes you do feel like, oh, I shouldn't have gone to that concert or I shouldn't have done whatever, but actually it could have happened anyway. And so we really need to be careful that we're not just blaming everything that we do because they will happen regardless. And sometimes we don't know why. I think you're right. And different things at different times. So often people come in to see me and they're really frustrated that they haven't found that one single trigger that flicks their migraine switch. And that's because migraine is complex and it's rarely one thing. It's usually a combination of things. And that combination of things might be hormones and a mismeal one month and it might be a late night and a work deadline the next month. It's just really one of those kind of conditions. And so, well, obviously you can't come on to a podcast about menopoles and not talk about hormones. And we said at the beginning it's more common in women. And there are people who it definitely, we know it can be triggered by changing hormones.

There are some people that have migraines just before their periods, which is when their hormone levels are lower. But especially in the perimenopals, when hormone levels really fluctuate, that can be quite a difficult time for some people who suffer with migraines. because again the brain is exposed to changing levels of hormones, isn't that? So I think the combination of perimenopause, migraine and midlife is just a recipe for turmoil for some women. I mean, it's a really, really awfully challenging time due to the reasons that many of your listeners will be familiar with already. So we have menstrual migraine, which is essentially our thinking is that it's driven to a large extent and it's complex. This is unlikely to the only thing, but to a large extent by the drop in estrogen levels coming up to the period after a period of relatively sustained levels of estrogen.

So it's the brain, again, adjusting to a changing environment, predisposes to migraine. But then we see these biological changes happening to the cycle, to the menstrual cycle, cycles, and the early perimenopals start to get shorter. So you have these long-lasting attacks, menstrual attacks of migraine, tend to be these longer-lasting, more intense, more disabling, more painful, more painful, more nausea, less treatment-responsive attacks. And because the cycle length is changing, they're coming thick and fast, and the recovery phase in between attacks is getting less, and that drives medication use up.

So lots and lots of things are happening to lead to migraine becoming a really big issue during the perimenopause, on top of which you have all the other symptoms of menopause to deal with potentially low mood, sleeplessness, hot flush it, anxiety. Which can then make migraines worse as well, of course. So it is important that, yes, that we're helping women spot these things so that we can put together really comprehensive, holistic, individualised care plan that supports them with all of these symptoms. Yeah. And I still, most days I have somebody who messages me through my social media to say, I have migraine, I've been told I cannot have HRT, what can I do? So we can still have HRT when we have migraines, can't we, or some types of HRT. Yes, we can. That's a big myth.

Buster. So yes, of course, women with migraine and women with migraine with aura can also have hormone replacement therapy. I think making the distinction about whether women have migraine with or without aura is important. Women with migraine with aura have an elevated background risk of stroke. It's still very small, but it's higher than women who don't experience migraine or who don't experience migraine with aura. For those women, then estrogen is still okay to give. It's just it should be given through the skin because that means that it doesn't lead to it. the risk of stroke or blood clots. Women without my brain with aura potentially have more options in terms of their hormone therapy or the regimens of hormone therapy they could use. But again,

that's going to be something that's decided on an individual basis with the clinician who's looking after you, looking at your wider lifestyle factors, so body mass index, smoking all that stuff. Yeah, and it's really important with hormones because, as I've said many times before, there's the three main hormones that we consider estrogen, which is in eustodial, the body identical estrogen that's anti-inflammatory, progesterone and testosterone. And actually we work really hard often to individualise dosage and types because some people, even if they're on a cyclical regime,

so they're having periods, they have two weeks of progesterone and two weeks without, that can sometimes trigger their migraine. So then we give progesterone all the time, because again it's about the brain having the same, and that can be a lot better. Or sometimes we change oral progesterone to vaginal. or if it gets absorbed differently and they feel better. And testosterone, again, some people find when they're on testosterone,

they have less migraines as well. And there's some small data to show that probably has an effect. But certainly clinically we see that it does for some women. Some women, if they're not on the right dose of estrogen, it's too high or too low, depending on whereabouts they are. Yeah. That can even, so some people say, well, I can't take HRT because I felt so awful when I was on it. and then you see what they were on and maybe it was a synthetic progestogen,

or maybe it was a really low dose of estrogen, and they needed slightly more or different progesterone. So again, it's, and in the perimenopause, we often have to change it as well because their own hormones are changing, aren't they? So I think when we're thinking about hormones and the perimenopause, there will be plenty of women out there who have migraine, but it isn't hugely impactful, and they will may fare perfectly well with standard regimens of hormone replacement therapy.

Making a diagnosis of menstrually related migraine, so you're having really good diary evidence that shows that there is a real link between periods and attacks of migraine can be a really helpful tool in terms of working out who's going to benefit from what type of hormone replacement therapy. So women with that type of menstrual migraine sometimes benefit from measures that essentially switch off background ovulation. So you get rid of all those crazy hormonal fluctuations. You have nice, constant levels of hormones. That can be really helpful. Looking at diaries, again, if you've got a woman with really disabling chronic migraine, she may well be having attacks of migraine around her periods too.

But actually when migraine is that burdensome, sometimes hormones aren't the answer. And we really do need to be thinking about adding in additional migraine care. And I think that, again, it's about managing expectations and knowing when we need to step things up. Totally. And like we said, it's often a combination of treatments. There's not going to be usually one single treatment. whether it's a hormone or non-hormonal that's going to do it for you. And you might just think, great, I've got the right balance and then something happens. And sometimes people find that

having a good quality magnesium supplement can help. Other people find it makes no difference. Some people find having, there are other treatments that are available, some on the NHS and some not, or in certain areas or by certain specialists that can help reduce frequency of migraines. So it's really important that everything is explored if someone's struggling. Yeah, and that people feel that they can come back and that I think diaries can feel like just an additional admin task, but actually they're really helpful. They are a really key tool for helping guide treatment response, but also working out what the right treatment is worthwhile to give a go. So I would strongly recommend diaries too. I often, I said to a patient recently that I think living

with migraine, and perhaps it's the same with living with menopause as well, managing migraine in the perimenopause. It's like raising a baby or raising a toddler. You know, once you think you've got it cracked, they change, although it's change. And it's because this is a constantly changing environment. Absolutely. And there's still so much that we don't know. We certainly need to do more research and have more evidence and really look so that it is a condition that is managed more appropriately with less suffering. Yeah. So there's lots more. I think I'm going to have to invite you back for another podcast, Rebecca, because we, Still so much more that we can talk about about other treatments, but we will share some resources with a podcast notes.

So I'm very grateful for your time. But before we finish, I always ask for three take-home tips. So three things that you think people could do if they are migraine sufferers and just want to be more empowered about treatment choices. What are the three things that they could do? I think so recognition is the first thing. So I'm going to take it back just a step in saying because I think, think there are so many women out there who are living with headaches who haven't had a diagnosis of migraine and who actually could do with recognizing they have migraine. So that would be the

first thing. Think get a diagnosis. Headache is a symptom. It's not a diagnosis. What's driving those headaches? I think keeping a diary is key because I think again that shows us what's going on, recognizing that headache is a symptom that warrants or is worthwhile the time and attention of your healthcare professional and then getting advice from reliable. resources. So my top resources, obviously I'm going to say the National Migraine Center is a good resource. Katie Monroe's book, Managing your migraine is fantastic. These are all resources for empowering yourself to know more about your condition and what treatment options are available. Great advice. So thank you so much for your time and sharing so much of your fantastic knowledge.

So thank you. Thank you for asking me. You can find out more about Newsome Health Group by visiting www.newsonhealth.co.uk. And you can download the free balance app on the App Store or Google Play.