The Dr Louise Newson Podcast - 76 – Why migraine is so much more than a headache with Dr Eli Sader

Episode Date: June 18, 2026

Migraine is one of the most common causes of disability worldwide, yet it’s still widely misunderstood and often dismissed as “just a headache”.In this episode, Dr Louise Newson is joined by neurologist and migraine specialist Dr Eli Sader to explore what migraine really is, why it happens and why it affects so much more than pain alone. Dr.Elie Sader is a double board-certified neurologist and pain physician. Known online as Dr. Painkiller, he creates evidence-based migraine and pain educationacross platforms, cutting through medical misinformation with clinical rigor and a healthy skepticism toward wellness hype.They discuss the different stages of a migraine attack, common triggers, and why symptoms can vary so much between individuals. Eli explains what is happening in the brain during a migraine and why recognising the early signs is so important.Louise and Eli also explore the powerful connection between hormones and migraine, including why fluctuating hormone levels can worsen symptoms during perimenopause and menopause, and also during the menstrual cycle. They talk about how the right treatment approach can help.We hope you love the podcast. If you enjoyed this episode, please make sure to follow us, leave a 5-star rating and share it with someone who might find it helpful.LET'S CONNECT👉 Subscribe on YouTubehttps://www.youtube.com/@menopause_doctor?utm_source=DLNpodcast+&utm_medium=shownotes&utm_campaign=BAU+👉   Instagramhttps://www.instagram.com/menopause_doctor/?hl=en&utm_source=DLNpodcast+&utm_medium=shownotes&utm_campaign=BAU+👉 LinkedInhttps://www.linkedin.com/in/drlouisenewson/?utm_source=DLNpodcast+&utm_medium=shownotes&utm_campaign=BAU+👉   TikTokhttps://www.tiktok.com/@drlouisenewson?utm_source=DLNpodcast+&utm_medium=shownotes&utm_campaign=BAU+👉 Spotifyhttps://open.spotify.com/show/7dCctfyI9bODGDaFnjfKhg?utm_source=DLNpodcast+&utm_medium=shownotes&utm_campaign=BAU+LEARN MORE👉 Hear more from Dr Elie Sader on YouTubehttps://youtu.be/YI14xTnfMqA👉 Download mybalance apphttps://balance-app.com/?utm_source=DLNpodcast+&utm_medium=shownotes&utm_campaign=BAU+👉 Order my new bookhttps://bio.to/ThePowerofHormones?utm_source=DLNpodcast+&utm_medium=shownotes&utm_campaign=BAU+👉  Speak to NewsonClinichttps://www.newsonhealth.co.uk/?utm_source=louise_podcast&utm_medium=show_notes&utm_campaign=clinic_cross_promotion👉  Visit my websitehttps://www.drlouisenewson.co.uk/?utm_source=DLNpodcast+&utm_medium=shownotes&utm_campaign=BAU+

Hi, welcome to my podcast. Thank you, Louise. I'm honored to be here. Wow, it's great. I've been following you on Instagram, and as many people listening know that I suffer with migraines, my daughter has migraine, my mother has migraine, my maternal grandmother had migraines.

It is often an inherited condition. And it's a long-term, lifelong condition. And it's really high up in the number of, or the most frequent causes of disability, but it's been underrated, underspoken about. So Eli is with me today, who's a neurologist and a specialist in migraines, headaches, pain, and I'm just really keen to talk again about migraine if that's okay with you. Let's do it. No, I'm excited. I think there's a lot of misconceptions to correct and a lot of education needed in the field. Yeah. So as I was saying to you,

I had a migraine recently for three days. And my. husband who I love very dearly said to me, has your headache gone yet? And I nearly lamped him, like, nearly hit him, but he knows it's not just a headache. But so many people think it is just a headache. And most headaches are a nuisance, but you can brush them off. Migraines, I just think differently. I'm a different person. And it's really hard to describe to people because also all migraine sufferers have different experiences. And I've had so many different types of migraines. And sometimes it's hard to know, is it a migraine or is it something else?

But let's just unpick it a bit. Like, what is it? Some people say migraine or migraine and it's a bit US or UK. But what is it, Eli? Just tell us a bit more. Yeah, no, great points. I personally like to define migraine as being a sensory processing disorder. I think that that potentially might be a better way to define it,

obviously because the headache itself is not going to be the only. thing that is involved in a migraine. And sometimes it's actually absent from the migraine in general. So the way to think about migraine is that basically the brain becomes hyper-excitable. And I think that there is an element of sensory amplification where any kind of sensory stimulation,

whether it's light or sound or smell or touch for some people, all of those essentially become amplified. and the threshold at the neuronal level in the brain becomes lower for the person who's having the migraine to experience essentially pain from any of these stimuli, which is unusual. Oh. In normal people. However, when you have migraine, unfortunately, any kind of stimulation, including light, can be perceived as being painful inside the brain of a migraineer.

And as you mentioned, basically the headache part is only one of the four states. stages of a migraine. So unfortunately, migraurs go through a prodrome, sometimes an aura phase for one-third of patients, and then you have the post-dromb phase. And for some of the patients, the actual headache is not even the worst part, right? Because they essentially get the proodrome where they feel tired or they have appetite changes. They become, you know, potentially hungry or they're eating more. And then you have changes in mood, changes in sleep that can happen. And all of that is even before the headache has started. And then you have the aura, which is very disabling when it's a visual aura and people

cannot see properly. And then you obviously have the post-drome phase where people are tired and they just feel drained after the headache itself. And so the headache is only one of the, you know, 25%. So one-fourth of the actual migraine. And just, you know, thinking and reducing a migraine to simply the headache part is just minimizing it. And unfortunately people do that because you can't really see all the other parts of a migraine as easily, right?

Usually pain is a little bit more perceptible and people can talk about it and quantify it and can rate it out of 10 as opposed to the other features. But that's a big part I think that people need to recognize. And that's also why sometimes the duration of a migraine should not really be reduced to only the duration of the headache. So when people ask you how many migraine episodes have you had in a month or how many days of migraine have you had on a month, unfortunately, a lot of people underestimate that number. Right. So they might tell you that they've only had five migraines in a month when it's actually potentially 15 migraine days. Because if you take into account the prodrome and the postrome, then it's significantly longer. And then you're morphing into the domain of a chronic migraine, which is an entity in itself, where the pain essentially becomes noceplastic at the brain level.

and it is significantly more disabling and harder to treat for a lot of patients. Right. So going back to your question, I would say that migraine is really defined by that hyper-excitability at the brain level. And the treatment for it will also have to take that into account, right? And so that's why a lot of the treatments will target that cortical spreading depression, that usually accounts for the aura for a lot of people. But then we have to keep in mind all the different triggers, right?

Because migraine, and that's actually the very interesting thing about migraine, is that there's so many different things involved, right? So obviously you have a hormonal component. Stress has a huge impact on migraine, right? It's actually the number one trigger for most people who are surveyed. And then you have other factors that are beyond people's control. So weather changes, barometric pressure changes, certain, you know, fasting, food items, right? There's just so many different things that are involved that make it such a complex,

neurological disorder. Yeah, and you're right. Everyone is so different, and it can make it sometimes difficult to make the diagnosis. If someone has the barn door aura and the flashing lights, then it can be very obvious.

But I know certainly just personally and with my daughter, I don't have any, I've never had any flashing lights. Before, I have the head pain. I often feel very hungry. I feel very shivery. I feel cold.

but I sort of overthink and catastrophes and I sometimes feel very low in myself and I find it hard to recognise myself whereas my husband can recognise just by the way I look he'll go and take us on my chipped-in and I can make it on my daughter often will text me and say I'm no good at the trombone I'm rubbish and I'm like hang on

I think and I can hear on her speech because she gets slowing on her speech as well And sometimes she'll say, I don't think I've got a migraine, but it feel really not right. And I can hear her speech is fine and I can reassure her. So it's actually other people sometimes that need to understand because I think when you're suffering, you just don't think in the same way. It sounds really obvious, but it can be very hard. And I often don't know whether to take, because the early you take, you know, a medication often the better.

And I mean, gosh, I'm 55 now. I should know better, but I often take it far too late, and then it doesn't work as well. It's very difficult to know when a given episode has started, right? So obviously, if we're only thinking about the headache, that can be easier to define in terms of the onset. However, the problem is that you have all of that precursor that's happening, right? And all of these changes are happening very gradually, right? So because the onset of the tiredness and the fatigue before the actual migraine and potentially also some of the changes in appetite and the hypothalamic activation and all of the different kind of sensory changes that are happening, they're just happening at a very gradual level, right? So nothing is really going to be suddenly turned on or off.

And so that's why it can be difficult for people to know when a migraine has started. And like you said, if you take the medication early enough, especially for tryptans, they're going to be significantly more effective, right? So the success rate of aborting an actual migraine episode is going to be much higher when the triptans are taken toward the very beginning. But defining that beginning can be difficult because most patients actually assume that the beginning is when the headache is essentially in its early stages. But the beginning is probably 24 hours prior to that.

And so even if you have full insight into the fact that migraine is not just a headache, unfortunately it can still be difficult to delineate the onset, right, which makes it very tricky. And then it becomes a moving target. And like you said, there's a lot of different symptoms that people can tell maybe from the outside, way more than the actual person, right? So for example, when you have the changes in speech, right, so the slurring in the speech and other stroke-like symptoms that can happen in certain migraine subtypes, right? And then when you have the vision changes, when you have, you know, some of the temperature

dysregulation that can happen, right? Some people feel that there are chills or, you know, changes in temperature. So all of those can happen, but people can attribute them to other things, right? So is it that you're maybe getting sick? Is it that, you know, there's something else going on? And unfortunately, they're not consistently present across all migraine episodes for a given person, right? So that's why it can be difficult for the individual migrainer to tell if this is indeed a migraine or not, because not all episodes will obey the same rules. And that unfortunately can also become a way to blame oneself and to essentially have a lack of validation because people are not really confident about what is going on. Yeah, it makes it very,

very difficult. And what was actually going on in the brain? Like, why do they happen? So, I mean, basically, there's a lot of different things involved. But the main one is the involvement of the trigeminovascular your system. So the trigeminal nerve is, you know, one of the main cranial nerves. And the reason why it's a very important nerve when it comes to migraine is because of the way the enervation works. So I just going to, I always have this model in my clinic that I borrow essentially all the time, but it makes life easier to show it to patients. But basically with the trigeminal nerve, we're going to pretend that what you see in yellow right here are actually the branches of the trigeminal nerve. And the important thing to keep in mind is that it has, you know,

a lot of involvement in the face. So it's innervating the skin and a lot of other parts of the face. You have the three different branches of that trigeminal nerve. So the sensation in the face is covered by that. But then also it's innervating the meninges, which is basically the envelope around the brain. So this is the brain right here, and that's essentially we're gonna pretend

that's the envelope around it, which is called the meninges. Part of it is the Dura, right? But the main thing to keep in mind here is that the trigeminal nerve, is actually what innervates that envelope. And so that's why it receives pain and input from that envelope whenever they're stretching, like in extreme cases when you have meningitis, right?

But in migraine as well, obviously, in other conditions, you have all of that input that's coming through the trigeminal nerve and then going into the brain to tell the brain that, you know, there's a pain component going on. And then you end up with a vicious circle where you have essentially an amplification of the signals, between the nerves, such as the trigeminal nerve, and then the brain itself.

So it's an interaction between the peripheral nervous system and the central nervous system, and then they just keep piping each other up, right? And then one thing that a lot of people, unfortunately, you don't really pay attention to is the fact that you have a connection between the neck, right, and the occipical nerve that is basically connecting the neck to the scalp and the actual face.

and the trigeminal nerve, because the two have a landing synaptic connection that's happening inside the brainstem and the upper part of the cervical spine. And so what ends up happening is that people get neck pain during migraine attacks, and then also sometimes people will have referred pain in the face. So I see this very commonly in my patients,

but the pain might actually be coming from the neck. So that interplay between all those different systems is definitely a big component in migraine. The other one is actually the vessels, which you can see right here. So basically the vessel diameter changes during migraine and also changes during the different migraine stages. And that's something that some of the medications like chryptans capitalize on. So they vasoconstrict the vessels and they have an effect on the serotonin receptors

that leads to changes in that blood flow. And that is thought to be definitely an important factor when it comes to pathophysiology of migraine. But there's others too, right? And there's a lot of different things feeding into it, right? So for example, estrogen and hormones will have an impact on the trigeminovascular system, but also things like weather changes and barometric pressure change has been shown to actually activate that trigeminal nerve, right, both in animal models and in humans.

So then you're, you know, kind of thinking about very different parameters that unfortunately all converge onto the same system, but that can have many faces, right? Because to think about a disorder where you have impact coming from the weather change, which a lot of people think, unfortunately, is superstition, right? A lot of migrainerers, you know, don't believe themselves that, you know, the weather is leading to kind of, you know, pain and headaches and migraines. But it's very, it's very legitimate.

And there's a lot of research behind it and a lot of different mechanisms. But, yeah, I mean, a lot of my patients tell me that they are walking barometers. but they don't really believe themselves until you validate them and you tell them that, yeah, this is actually true, right? Yeah, and it's interesting because whenever I have a migraine, I try and work out the trigger

because anything to reduce my migraine frequencies I'll work really hard at because they're so debilitating and really, just such a waste of time really because I can't function when I have them. But often, and the same as my daughter, always like, well, what's triggered it? And sometimes it's really obvious.

It might be that I've eaten a meal, late or something has happened. But when it's a weather change, when we both go, oh, yeah, but look, hang on, it's been raining and it stopped or whatever. It's quite reassuring to know it's something that you haven't done as well, because there's a lot of guilt that can go on. And when we look at sort of non-drug treatment, I think with migraine, you can never cure it, but you can try and reduce the severity and frequency of migraine.

grains, really. I hope you agree with that. Yes, excellent point. And it's really important to work with patients to understand that it's multifactorial as well. So it's not like if you cut your finger, it's very easy. You then have a stitch in it or your plaster on it and it will repair. There's so many different things. Some you can control and some you can't. And everyone's different. And so I've spoken about it before, you know, I don't eat processed foods because I know they trade a migraine. I wouldn't be able to drink a glass of orange juice

because it would trigger a migraine. Whereas my mother has migraine, she drinks orange juice every morning. I can't understand why I can't. And we're different. And you have to work it out, but it can sometimes take quite a long time to make changes.

And you don't want to make too many changes because then you can't work out what it is that's either made it worse or better. Great point, great point. And I think that what's important to mention here And the way I like to think about migraine and the whole kind of trigger thing is basically that you have essentially like a jar or a, you know, a glass of water that you're filling, right, with different triggers. And then you reach a certain stage or a threshold where basically that's going to trigger a migraine. And really every one of those factors are going to contribute, but to a different extent.

So it's almost like each factor is going to have its own coefficient, right? So you have the weather changes for some people. You're going to have the hormonal changes at certain. Sometimes you're going to have maybe if somebody had chocolate or if somebody had caffeine or if they did not sleep properly the night before, right? Or if there's too much stress going on in their life, each and every one of those is going to be its own trigger. And then potentially, you know, up until that stage, even with all of those, they're still compensating and you still don't really have a migraine. But then all of a sudden, if you add on top of it some blue light or bright light or something of that sword, and now you have crossed that threshold and you're going to get your migraine. but each individual factor on its own may not be sufficient.

Yeah. Right? Combine them all together and then you end up with the magic concoction to actually have that excitability in the brain and potentially end up with a migraine. And that's why it's so difficult for patients to keep track of all the different triggers, right? Because they might think that one day the weather may have had an impact, but then the next week, even with the same weather, you know, they didn't really have a migraine. So then is it really that weather has an impact on them or not? but they're not keeping track of all the other factors

what they ate, whether or not they had some red wine potentially, some nitrides, you know, smoked meats, all of the, you know, common triggers, which are different

between different people, right? But even for the same person, I think that one trigger on its own is not going to be sufficient to trigger the migraine. It's really the combo, right? And that's essentially how I like to think about it and why it's so important

to keep a headache diary, right? And to, you know, or these days more of an app, right? So there are apps, you know, that can keep track of your triggers. But that's so important because I think humans usually overestimate their abilities at remembering things, right? So we think that we're going to, you know, remember if, you know, coffee has an impact on our headaches or the chocolate or something, right? But then you actually need to have probably like a month or two of tracking the data to be able to tell.

Absolutely. I mean, it's a bit funny in some ways, but about 20 years ago I was getting palpitations, really awful palpitations, and I'd often get them at night. They'd often wake me up. And sometimes I got chest pain and shortness of breath with them. And a few times I thought, I'm going to have to call an ambulance. I went and saw a cardiologist. I had various tests. Everything was fine. And they said, well, I think you should probably give up caffeine and alcohol. Now, I've never drunk much alcohol.

caffeine I really liked my tenor-clock in the morning, a cup of coffee. But I thought, well, I don't want these palpitations because they're scary. You've only got one heart, right? And it's really quite unnerving. So I gave up alcohol and caffeine. And then after about, it was probably about three to six months, quite a long time, I realized I wasn't getting as many migraines.

And so then I thought, well, I'll do anything to help my migraines. So I haven't drunk alcohol or eaten chocolate since then. But it was probably my whole. hormones that was causing my palpitations. That's the funny part about it. So if I had seen a cardiologist who understood hormones, I'd probably still be eating chocolate and drinking alcohol. And I probably would say to you, well, I don't have much. So therefore, it's not really a trigger. But because I've stopped it completely, you know what? So I think that's the thing. Sometimes people reduce something and say, well, it's not really the alcohol or it's not really

the chocolate or it's not really whatever. But you have to really remove it, I think, for a length of time before you can decide whether it does like a difference or not. It's a process of elimination and I think that it has to be done a very controlled and measured way by taking out one factor at a time, right? Because all of the, there's so much interplay between these factors, right? Let's take caffeine as an example. Caffeine itself has more than one mechanism in terms of how it affects the brain, right? So you have the nitric oxide mechanism where it's going to lead to vasodilation of the vessels, right?

But then you also have the adenosine pathway, right? And the problem is that all of that is going to happen in different ways during the day. So depending on how tired you are, depending on how you slept the day before, right? That's going to influence how caffeine will affect someone, not to mention the dose in itself, right? So caffeine, let's say less than 200 milligrams in a day versus more than 400 milligrams. It's going to have a very different effect. And that's why sometimes we use caffeine as treatment for certain headaches, including migraine. We have a lot of different medications like fioracet and accedrine.

and things of that sort, right? But then also for other people, caffeine can definitely be a trigger. And then for other people, caffeine withdrawal is a huge issue, right? So if you drink a lot of coffee and then you stop drinking. So there's just so many factors that unfortunately, you know, we generally like to make things simple, right? As a humans, we like to simplify and make everything binary. It's like, okay, caffeine is good, caffeine is bad, right? But it's not that simple.

With a lot of these triggers, you know, it's really not that simple in terms of whether or not they're going to be good or bad when it comes to migraine. Yeah. It's also interesting the sex difference, isn't it? Because it is more common in women. Yes. And a lot of people, there's a hormonal change like you've already said, but there's different hormones that we need to think about and people respond quite differently.

And certainly I've got a huge amount of clinical experience because we see thousands of women every month in our clinic. So we really notice that having the right dose and type of hormones can really help. And I know myself, if I'm not on the right dose, it will trigger a migraine. Because I get muscle and joint pains, which is not a migraine thing. It's related to having no hormones. And I use patches of eustradial, which is the only way I can get the estrogen and through my skin. The gel floats off my skin.

So the patch isn't the only way I can use it, but. Every sort of you might see if you follow me on Instagram, I put a picture of one of my patches that's literally flapping in the wind. And a few days ago, I was doing some yoga and I could hear this crinkling. I'm like, what's going on? And then I realized it was my patch. It was just making a noise. And actually before that time, I was getting some migraine.

And I thought, oh, it's probably because I'm getting an intermittent absorption of the Easter diet. It's like being perimenopausal again. It's not constant. And I've went through another three patches before I've found one. It's every so often I think the glue changes. But it's really important because anything small that changes. The brain likes homeostasis, especially if it's a migrainer's brain, isn't it? And, you know, when hormone levels are fluctuating, whether it's eustodal, whether it's progesterone or low testosterone, all of those hormones can really have an important role.

And I see a lot of people who are told by very, especially it can't be your hormones because you're still having periods. And I'm like, no, you still can have hormonal changes. And it's worse, actually, when the hormones are fluctuating. It is. It is 100%. And that's, I think, one of the biggest misconceptions about migraine. And I think we have so much evidence when it comes to estrogen, right? At different stages in a woman's life, so whether we're talking about puberty or whether we're talking.

talking about pregnancy and the postpartum phase, but especially for petty menopause and menopause, I think that's where we have a lot of the evidence about the impact that estrogen fluctuations will have on migraine, right? So with pregnancy, for example, usually about 70% of women will actually have an improvement and their migraines, right? And that's because of the fact that you have more steady levels. But then as soon as they drop in the postpartum phase, that's when things going to happen again, unfortunately, right? And same with the pedimenopause period, right? So you have a lot of irregularities that happen. And that in itself usually brings about a couple of years of, you know, a lot of trouble for many patients because they are suddenly having that resurgence of

their migraines, which they were sort of, you know, somewhat managing over the past 10, 20 years, but then they come back with full force, right, during perimenopause. And unfortunately, because of the stigma around hormones and HRT and some of the misconceptions that were, you know, that still exists, unfortunately, right? In terms of the stroke risk and the other risks of hormones, a lot of women have that fear in terms of being on hormones. And sometimes even their doctors are telling them that they shouldn't be, but not for the valid reasons, right?

So I think it's important to educate ourselves and educate our patients. Absolutely. So that they know what is safe, what is not, and also what forms. So what you mentioned earlier was actually a great point because with the transdermal estrogen, the idea is that you're having less fluctuations as opposed to taking an oral estrogen every day

where you're going to have the ups and downs. And so that's why usually that's what I recommend to a lot of my payment of paupazal women who have migraines, and I tell them that the transdermal is going to be the best option from a headache standpoint, right? Because that's going to minimize the fluctuations.

transdermal HRT is safer than oral when it comes to stroke risk. Yeah. And so that, you know, I think a lot of people need to change the way they think about the risk and benefit ratio when it comes to that. Absolutely. And also the progesterone, making sure it's the natural body identical progesterone because the synthetic progestogens have a clock risk or stroke risk, but they can also worsen migraines too. Yeah, 100%. And there's increasing evidence that testosterone can have a role as well.

It's very anti-inflammatory. But all these hormones can have effects on other neurotransmitters in the brain. And they can also modulate the pain receptors, which is important because they are a natural analgesic as well. Yeah, exactly. And so anything that's going to help our brain function reduce pain as well, it's got to be a good thing. but it's working with the right practitioner and some of you who are listening and might have listened to the podcast I did with my daughter Jess

and you know it's a long journey often to get the right treatment and you know making those lifestyle changes can be a lot harder often than taking a tablet but with migraine we have to be looking at lots of different adjustments as well to really get the most out of our health but it's such a big disability and I'm always very sad to read how little funding there is for research and for even clinics. It's a nightmare over here.

You know, the clinics over subscribe. My daughter has Botox regularly as well and it's really difficult to have that on the NHS and when I ever take her to an appointment, the nurses are really stretched. there's long waiting list. And for my mind, like, I don't understand because Botox isn't a systemic treatment. And if it works, then that's really good, isn't it? It is. And I think that's important to keep in mind that you need to have a multimodal approach to migraine. So I think that, you know, hormones play a really big role, right? But unfortunately, they're not sufficient for a lot of patients. So we have to always think about whether or not a given patient needs preventative therapy, right, with a prophylactic migraine, such as the Botox that you mentioned, right, which can help a lot of

patients or some of the newer CGRP medications, whether we're talking about the injectables or the G-pants. But essentially, a lot of those will be needed in addition to the lifestyle modifications, right? Sometimes supplements can help, but usually none of those factors on their own is going to be sufficient. You need all of them at the same time to be able to have a profound change and the disability coming from migraine. Yeah, absolutely. And we are all different. But it's great to have this discussion. So people can just think differently, hopefully, and not just for themselves, but for others, whether it's at home or at work or wherever. So before we end, I always ask for three take-home tips. So three things. If someone's listening here and they are either

migraine sufferer or they know someone, what are the three things that you would say initially to someone who has migraines that might help? So one thing I would definitely say is basically not to take their doctor's opinion for granted, right? So I see this a lot. Unfortunately, patients sometimes think that their doctors, you know, have that, you know, 100% certainty rate in terms of, you know, whatever they say. But we make mistakes, right? As I'm sure you No, right? So we're not always right. And especially when it comes to complex disorders, we don't really have all the answers. So assuming that we do can often do more harm to patients. And so usually what I tell patients is that they have every right to second guess their doctors

and to basically seek a second or a third or even a tenth opinion if needed, right, if they feel that they're not getting the proper treatment. So if they are, let's say, with a physician who is telling them that hormones have no impact on their migraine and that they should maybe stay away from HRT, right, for the wrong reasons. Yeah. Right. Then in that case, they should probably go and, you know, talk to somebody else, right? And I think that can be life-changing for some patients,

but they need to have that change and mentality and that mindset shift because otherwise they're going to have the guilt and blame themselves, right? And unfortunately, that can do a lot of harm, right, for disorders like migraine. So that definitely would be the number one thing. to get a second and a third opinion. And then a second recommendation that I have is to pay very close attention to the triggers and the lifestyle changes

and to be very patient with them too, right? So when a given change is made, right, whether that's stopping coffee or stopping cheese or whatever it is, I think that you need to give yourself at least a month, I would say, to know whether or not this is having a meaningful impact, right? Because you have to keep in mind all the other factors that are also having some kind of effect. And so doing it over a month by a process of elimination is probably a more scientific way to

test it out. And then the third recommendation that I would have for migraine patients is to basically remember that migraine is way more than just the headache phase. And so because of the impact that the prodrome and the postrome can have, especially on disability, right? Because when you're having all of those sensory changes, whether they are before or after the headache, that's unfortunately affecting your way to be able to think, to be able to work. You're going to have some brain fog, right? There's going to be changes in the temperature in your body. You're going to feel fatigued. Sometimes you feel like you need to be in a dark room and sleep. So a lot of those unfortunately affect somebody's ability to function even at basic mode. We're not talking about competing in the Olympics. We're just talking about being able to survive on a day to day. and do your usual job, which two days prior would have been very doable. But then now all of a sudden, because of the migraine and the other, you know, the different stages is becoming insurmountable. So I think it's important to keep in mind that there's way more to migraine than the headache

and to also try to appreciate the fact that the onset itself is often several hours before the actual onset of the headache. And because of that, the timing of when to be able to be able to be a headache. to take the rescue medication should potentially be earlier. So at the very first stage, whether it's the visual aura or the prodrome or whatever it is before the actual headache, that's gonna be the highest impact in terms of taking the rescue medication.

And potentially for a lot of patients, if they're having more than five headache days or migraine days in a month, I would say that being on a preventative option, whether that's a CGRP or whether it's a Botox injections or occipital nerve blocks. There's a lot of different prevention options. But then that becomes essentially paramount because otherwise you'd run into medication overuse headache.

Yeah. Which is a real thing in itself with all the rebound you can get from taking too many rescue medications. Great advice from such a wonderful expert. So thank you so much for your time today. It's been brilliant. Thank you for having you.