Debunking the myths on types of headache diagnosis

0:00 let’s see all right so welcome everyone
0:02 uh to this webinar called debunking the
0:06 myths on type of headaches and diagnosis
0:09 and um well I added a title what kind of
0:13 migraine are you dealing with
0:17 um and I put this image I love to share
0:19 images and to find images from my
0:22 presentations because I find that images
0:25 often speak a bit more than words
0:28 um and this this photo here this lady we
0:31 can assume maybe is is made of a
0:36 multitude or a little tiny pictures and
0:39 only by looking at the full picture with
0:42 a bit of distance can we actually make
0:44 up of what’s going on and and uh imagine
0:47 or see her face so you’ll understand
0:50 that that a bit more when I go ahead
0:53 when I present for medical conferences
0:56 or a different committees and Boards I
0:59 always present my disclosures this means
1:02 that I have received uh honorary and
1:04 payments from companies pharmaceutical
1:06 companies where I serve either as a
1:09 board member speaker or consultant
1:12 um and all of those might are actually
1:14 related to the new therapies antibodies
1:17 gpans Botox Etc I also have the pleasure
1:21 of course of sharing migraine Canada and
1:23 I really encourage you to look up our
1:25 campaign you wonder I will be boxing uh
1:28 for a migraine I do boxing training for
1:31 five years five years now so I have
1:34 created my little page it’s very easy if
1:35 you want to create your personal event
1:37 so go ahead
1:39 um all right so let’s get started so
1:41 tonight we will discuss definitions so
1:45 first some definitions in the world of
1:48 headache are clear
1:50 others are less clear that means that
1:54 sometimes even doctors even experts even
1:57 the leaders of the international
1:59 classification argue with one another
2:02 okay so I’ll give you an example A lot
2:05 of people argue about the definition of
2:07 vestibular migraine which is something I
2:10 live with and something that I uh have
2:13 interest in
2:14 so quite frankly just be clear sometimes
2:18 there are things that are certain and
2:20 there are things that are uncertain and
2:22 we have to live with that some degree of
2:24 uncertainty and it’s difficult
2:26 especially when sometimes when you live
2:29 with a disease or with symptoms that are
2:31 extremely disabling and we want to find
2:34 a solution so it all starts in theory
2:36 with a proper diagnosis but sometimes
2:39 it’s not that easy so tonight I will not
2:42 cover all the diagnosis I will cover
2:45 empathetic and chronic migraines some
2:47 discussion refractory migraine also
2:50 post-traumatic headache and migraine uh
2:52 the aura so let’s uh let’s start this
2:57 just as an intro okay I like to start
3:00 from very basic concepts before we dig
3:02 into the details so we don’t get lost
3:05 um how medicine has studied disease for
3:08 centuries is that we observe
3:11 symptoms usually problems
3:15 um in a person and we then we find
3:17 people who look aloud look alike who
3:19 have the same set of symptoms and then
3:22 we study them uh and that we have more
3:25 and more techniques now to study uh the
3:28 human beings so MRIs CT scans lab tests
3:31 genetic panels
3:33 electrophysiology EEG EMG because then
3:37 tons of labs but remember at the
3:39 beginning of medicine it was not that
3:40 easy so now we have more tests so for
3:44 example people who live with a thyroid
3:47 issue well they will have a set of
3:49 symptoms not necessarily all of them
3:51 some of them and then the then
3:54 eventually medicine found an
3:56 understanding of the thyroid we found a
3:58 test to test the TSH and we know if the
4:02 TSH is too high or too low there’s a
4:04 problem and then we can treat with a
4:07 levothyroxine very common drug called
4:09 centroit so it’s easy and then we can
4:12 monitor the TSH level to say is it too
4:15 high is it too low and then we adjust
4:16 the treatment so that’s an example of a
4:18 a relatively easy situation
4:21 so what we want is okay we want to
4:24 understand the cause of the disease so
4:27 we say fine there is a lack of the
4:29 thyroid hormone the gland does not work
4:31 so this causes the symptoms of
4:34 hypothyroidism and then we give a
4:36 treatment to correct that a to be easy
4:39 now no offense to the thyroid but the
4:42 brain is way more complicated so in the
4:45 brain it gets really mixed up and so by
4:48 that I mean that the brain has numerous
4:51 system networks neurotransmitters it
4:54 works with chemistry with electricity it
4:57 had it has different zones so it’s not
5:00 easy to to kind of understand those
5:02 networks and plus we still don’t have a
5:04 lot of ways to dig into the brain in the
5:07 electricity and the chemistry of it so
5:11 we can see some of the brain of course
5:13 but not all of it so when someone has a
5:16 headache uh what can be the head the
5:18 neck the sinuses the TMG all of this is
5:21 a bit together well the question is
5:23 where does it come from
5:24 and usually it will come with either
5:27 from something like a sinus or an eye or
5:31 you know a structure of the head or if
5:33 it comes from inside the the skull it
5:36 will come from meninges and blood
5:39 vessels the brain itself it doesn’t feel
5:41 a thing okay there’s no pain fibers
5:44 there’s no pain nerves in the brain what
5:47 makes pain inside the skull is the
5:50 meninges the meninges is like the big
5:52 protection the membrane that protects
5:54 the brain so if you think about
5:56 meningitis and blood vessels arteries
5:59 and veins those are super super
6:01 sensitive with lots of little nerves
6:04 that can cause pain
6:06 so any headache will come somehow from
6:09 an irritation or stimulation of pain
6:12 fibers and and this I explained to
6:15 medical students to doctor this is
6:17 something very important so whatever
6:18 arrives that causes pain will come from
6:22 somewhere something wrong with this
6:24 sensory system
6:26 in the classification so how doctors put
6:29 things together we love to put
6:30 classification so we know what we’re
6:32 talking about always in the spirit of
6:35 research right so we we do criteria we
6:38 make definitions so all around the world
6:41 we all talk about the same thing this is
6:44 important because when we do research
6:46 well we want to be talking about the
6:48 same thing so we can talk together right
6:50 so if someone in Asia and some someone
6:53 in North America don’t have the same
6:55 terms then we’ll all mixed up and it’s
6:57 not good for research so the
6:59 classification has something around 215
7:03 diagnoses okay so it’s a lot of them
7:06 um but roughly if we think about it we
7:10 separate the headaches in headaches that
7:12 are that come from the problem from the
7:14 sensory nerves themselves and headaches
7:17 that come from something wrong with the
7:20 brain or the skull or the arteries so
7:22 those are the usual causes so problem
7:25 with their blood vessels infections
7:27 accidents
7:29 um a medication something wrong with
7:32 anything else in the body something that
7:34 is wrong with the nerves themselves so
7:37 those we call secondary headaches
7:39 headaches that are caused by something
7:41 else the primary headaches are headaches
7:46 that are just part caused by a problem
7:48 in the sensory system itself
7:51 it is not that that easy to understand
7:53 this definition and to be honest there’s
7:55 it’s not perfect but just it’s very
7:58 important and when we talk about
8:00 diagnosis that when we teach doctors
8:02 like family doctors neurologists we
8:05 start there we say there’s primary
8:06 headaches there are secondary headaches
8:09 and they’re all in the classification
8:11 for those of you who are curious and and
8:13 who may feel comfortable going into
8:16 medical resources you can access ichd3
8:19 online
8:20 ichd3.org and you will see all the
8:23 criteria that we the doctors and other
8:25 Healthcare Providers use to diagnose
8:28 headaches okay they’re all there and
8:30 sometimes there are interesting notes as
8:32 well about the different diseases
8:35 so the key here is that to do a
8:37 diagnosis well unfortunately up to this
8:40 day there is no test that can diagnose
8:43 Migraine with any certainty okay so if
8:46 you have a brain tumor okay it’s like
8:48 having the computer on the left that’s
8:50 completely broken nobody would think
8:52 that this computer works it’s it is dead
8:54 uh and so on the MRI we see this big you
8:57 don’t need a medical degree to see that
8:59 something is wrong with this brain
9:01 there’s a big Mass a big ball into it if
9:04 you go below while you look at this
9:06 computer it’s nice it looks pretty good
9:08 but then when you start to open it
9:10 crashes the programs don’t work so it
9:13 looks okay but the the system of it
9:16 don’t work and that’s what we see with
9:18 migraines the problem of systems and
9:20 networks
9:22 so
9:23 so the thing is our society and humans
9:25 love to work with their eyes we like to
9:27 see so that’s why we rely so much on the
9:29 Imaging and that’s why so many of you
9:32 I’m sure have had numerous sitting scans
9:34 and MRIs and other steps to try to
9:36 understand what your diagnosis is
9:38 because we like visual proof so the
9:41 humans are more and more like this
9:42 little guy here you know nobody uh big
9:45 eyes big brain you can remove the
9:47 cigarette ideally and looking at the big
9:50 screen for hours at a time and just
9:52 trying to see and see and see but the
9:55 diagnosis of headache depends on a good
9:57 history and listening to the symptoms so
10:00 we need to listen to what the person is
10:02 saying and try to understand of which
10:06 animal we’re talking about here which
10:07 category
10:09 because migraine is way more than just a
10:11 headache I don’t need to tell you this I
10:13 mean if you live with any headache
10:15 disorder you know it’s not only headache
10:17 but migraine is more than a headache
10:20 there’s I’ve put in blue the light blue
10:22 boxes are the symptoms that are part of
10:25 the diagnostic criteria so if you speak
10:27 to a doctor and you want to clarify
10:30 what’s going on with you well what they
10:32 will ask are you sensitive to light or
10:34 sound
10:35 um do you have nausea and vomiting so
10:37 this is those are all things that that
10:39 help us to diagnose migraine because
10:42 migraine has been defined this way all
10:44 right so we are still a bit in a circle
10:46 here we Define migraine away but since
10:49 we don’t have tests to diagnose it
10:52 we kind of know there are other symptoms
10:54 but those symptoms are the one we use to
10:56 diagnose and I will not go into big
10:59 detail about this tonight
11:01 so one thing it’s that’s important is
11:03 that we know that migraine has very
11:05 numerous causes or mechanisms I prefer
11:08 mechanism because a cause is like
11:10 there’s one reason Like A to B here we
11:12 are not a to B we are in networks and
11:15 chemical and electrical networks and all
11:18 of these are determined by genes
11:20 so what we think is that migraine
11:23 actually is in has different pieces and
11:26 I will not go in depth about this I gave
11:28 another webinar which is called the
11:30 science of migraine where I go into
11:32 great detail but it’s all about
11:34 chemistry and electricity and there are
11:37 numerous substances and networks
11:39 involved in the migraine’s brain
11:41 the inflammation of the migraine attack
11:44 is around the meninges and arteries so
11:46 we we know where the pain comes from and
11:49 also this I I elaborate more in my other
11:52 webinar but I just wanted to tell you
11:54 very importantly it’s not true we don’t
11:57 know what causes migraine it’s just
11:59 there’s many parts to this and just for
12:01 fun okay this is this is part of it I
12:04 don’t expect to present this and I I
12:06 don’t want to do go into detail I just
12:08 want to show you how much we know about
12:11 those things and and in the uh the
12:13 medical circles
12:15 um now there’s tons you see all those
12:17 zones all this is a brain so we see all
12:20 those zones all those areas all those
12:22 networks if you want even worse than
12:25 that let me show you that’s even worse
12:27 okay so this is all lingo of medical
12:29 stuff that explains what happens during
12:32 a migraine attack I’m not going to talk
12:34 about this but I’m just showing you to
12:36 show you how there’s probably very many
12:39 different types of migraine different
12:41 genes different uh equations and that’s
12:44 why migraine is so complicated to
12:46 diagnose and to put into categories okay
12:50 so now we switch to the Pokemons I don’t
12:52 know if you remember the Pokemons but
12:54 I’ve always been amazed to see how many
12:57 Pokemons there are and they are all you
12:59 know we we describe them by their shape
13:01 their color their capacities and
13:03 um I remember little kids at the time
13:05 they were looking in a book with all the
13:07 categories of Pokemon it’s a bit like
13:09 the international headache
13:10 classification
13:12 so uh we are we like classification so
13:16 here’s something I took for I took from
13:18 the web and I love this page it’s
13:21 completely completely inaccurate from a
13:24 scientific perspective Dr Smith is an
13:26 ENT this is his website Kevin
13:28 smithmd.com and I don’t want to offend
13:31 him but this is completely out of the
13:34 box for a classification but it starts
13:36 the discussion perfectly
13:38 so he says that he treats all types of
13:40 migraine this is a website so obviously
13:42 he’s looking to propose his help to
13:44 different people I put in green the ones
13:47 that
13:48 um well first we removed the s for a
13:50 migraine now we say migraine as a
13:52 disease but so the green ones are the
13:54 one that are kinda in the classification
13:57 the yellow ones are the ones that it’s
14:00 kind of true what is there but uh it’s
14:03 it’s not in the classification and the
14:05 the red ones are terms that are used by
14:09 a lot of people but are not diagnosis
14:12 okay so if we look for example at
14:14 cluster migraines cluster migraine this
14:17 is not a diagnosis cluster migraine is
14:19 something that is usually someone who
14:21 has a cluster headache and a migraine or
14:24 something that is sitting in between
14:26 another thing like ocular migraine uh is
14:30 not a diagnosis silent migraine is not a
14:33 diagnosis sleep migraine is not a
14:35 diagnosis tension migraine is not a
14:37 diagnosis by definition if you have
14:39 Tension Headache or migraine or you can
14:42 have different types of attacks but not
14:44 both so it shows you a bit of daily
14:46 migraine what is that it’s not a
14:48 diagnosis it’s just a description
14:51 um so hormonal migraine well that would
14:54 be migraine influenced by hormones so a
14:57 lot of women lived with that
14:59 um but it’s not a diagnosis either but
15:02 it describes things that do exist though
15:04 so we have to acknowledge that
15:06 so all along the centuries of medical uh
15:09 knowledge well humans try to researchers
15:13 try to classify migraine and just to
15:16 tell you in the 19th century there was
15:18 something we don’t use anymore but it
15:20 was based on once again Vision well
15:23 there were red migraines and white
15:25 migraines so if you have the red
15:27 migraine your face is red and if you
15:28 have the white migraine your face is
15:30 white and they thought that it was
15:32 because the blood vessel dilate or the
15:34 constrict which makes some kind of sense
15:37 but nowadays this is completely gone we
15:39 don’t use this anymore
15:42 um then there are classifications by
15:43 symptom okay you can say migraine with
15:46 aura for example and this is an official
15:48 term vestibular migraine is Migraine
15:51 with dizziness and vertigo we all think
15:54 I I believe it exists but isn’t it is
15:56 not yet an official diagnosis
15:58 triggers so you can say Okay menstrual
16:01 migraine is triggered by hormonal
16:03 changes and there’s a lot of terms in
16:06 the the population like weather
16:08 migraines sinus migraines neck migraines
16:10 those are not official diagnoses but
16:13 they reflect the reality that some
16:15 migraines are triggered by different
16:17 things and then frequency episodic
16:20 versus chronic I’m going to talk about
16:21 it or um is this a spectrum maybe so
16:25 frequency is very important and it is
16:27 getting more and more important as it
16:29 influences how we deal sometimes with
16:31 insurance companies okay
16:34 so my message here is that if you live
16:37 with migraine um and if the migraine
16:39 diagnosis is made it means that all the
16:41 secondary stuff you know other diseases
16:43 have been included well the symptoms
16:46 here that your doctor usually will think
16:49 a bit like this okay they will say what
16:52 are your symptoms okay because migraine
16:54 is very very diverse what are your
16:56 triggers because then we can work on
16:58 them absolutely it makes sense to talk
17:00 about the triggers but it doesn’t change
17:02 the diagnosis the health history so you
17:05 can have Migraine with a bunch of other
17:08 things in your body and mind and mental
17:10 health and surgeries and accidents we’ll
17:13 get back to the accidents and then what
17:15 did you try as for treatment trials and
17:18 sometimes this also influences how we
17:20 think
17:21 so once you’ve said that’s migraine it’s
17:24 migraine well that’s that’s a bit of the
17:26 work that the doctor will make and it
17:28 doesn’t change the diagnosis but it
17:30 tells you how you should treat our
17:31 Orient you
17:33 okay so now we’ll talk about Aura
17:36 episodic chronic refractory and
17:39 post-traumatic headache which are a bit
17:40 of the focus for tonight past this
17:43 explanation of how we diagnose and we
17:46 diagnose uh stuff in medicine and how
17:49 migraine is diagnosed
17:52 the aura so the aura remember what I
17:55 said about Vision uh human beings love
17:59 to see stuff vision is the very very
18:01 important sense uh perception so Aura
18:05 has been described since Antiquity even
18:07 the old Greeks have described it and
18:10 here we have an early drawing of the
18:12 typical evolution of the order visual
18:14 Aura so it’s something that people will
18:16 see it usually progresses over a few
18:19 minutes
18:20 sometimes people will have also symptoms
18:23 like Sensations or they may have
18:25 tingling on one side of the body and the
18:27 face that usually will move along the
18:30 arm it will March or progress and um and
18:34 vision wise there’s a lot of different
18:36 symptoms that the aura can come with
18:38 right so this is a study made in Brazil
18:41 and the participants in this study were
18:44 asked to draw their auras and as you can
18:46 see there were a lot of different
18:48 drawings so it can be colored it can be
18:51 flashes it can be light can be a lot of
18:53 different things but the characteristic
18:55 of the aura
18:57 is that it is usually Progressive it is
19:00 not sudden and it will last typically
19:02 five to thirty minutes and typically a
19:05 person with an aura will have different
19:07 like many similar episodes over the
19:10 years the aura very often starts in
19:13 childhood it runs in families
19:16 um and when it is typical it is usually
19:19 as easy enough to diagnose
19:22 here it’s an important Point people say
19:25 very often the migraine Aura the correct
19:28 way is migraine with aura or an aura
19:31 because you can have an aura with no
19:33 migraine at all this is a question I get
19:35 almost every week someone comes and
19:37 you’re sent to me because they had a
19:39 typical visual Aura with squiggly lines
19:42 or kaleidoscopes or colors but they
19:45 didn’t have a headache this is possible
19:47 because the aura is a brain phenomenon
19:50 and migraine is a different brain
19:53 phenomenon so what is happening inside
19:55 the brain during an aura is not the same
19:58 thing at what happens during a migraine
19:59 but those two things are linked
20:02 so the aura has a cause it is cause we
20:06 think almost certainly by something we
20:09 call cortical spreading depression what
20:13 that means is a wave of electric
20:15 disturbance on the surface of the brain
20:18 the cortex okay so cortical
20:20 and where the wave goes the symptoms
20:23 happen
20:24 because the wave moves along the brain
20:27 from neuron to Neuron a bit like
20:29 dominoes or if you put a pebble in a
20:31 pond like the waves will just grow and
20:33 grow well that’s that explains why the
20:36 aura progresses slowly over time and
20:39 then eventually the wave resolves the
20:41 aura stops and then in certain people
20:44 migraine is triggered so I encourage you
20:47 first to stop talking about ophthalmic
20:50 migraine ophthalmic is the eye and it’s
20:53 an old term for migraine with aura so we
20:56 we really try to use the correct term
20:58 which is migraine with aura not a
21:00 stomach migraine anymore and not
21:03 migraine Aura because of this difference
21:05 even if those two things come together
21:07 like salt and pepper but still soft as
21:10 salt and pepper is pepper
21:13 so these are not auras there’s a lot of
21:15 symptoms that actually
21:17 um sometimes people are not too sure
21:19 what they are frodrome is a different
21:22 thing a program is when you start a
21:24 migraine attack and some people will
21:26 have symptoms before they have the
21:29 headache craving for Foods neck pain
21:32 yawning brain fog writability it is
21:35 sometimes a little vague some people
21:37 have no problem at all and for some
21:40 people it is very clear so a pro draw is
21:44 a different thing we think that the
21:45 prodrome comes from a different part of
21:48 their brain than the aura so it’s
21:49 important because then we the aura comes
21:52 from one place the prodrome comes from
21:54 another place some people have both some
21:57 people have neither and they all have
22:00 migraine
22:01 photophobia is when the light hurts so
22:03 sometimes I ask if people have visual
22:05 symptoms with the migraine they will say
22:07 oh yeah sure the light hurts uh but
22:09 that’s not an aura and then there’s a
22:12 ton of visual symptoms I see black dots
22:15 white dots for a few seconds I see
22:17 colors when I close my eyes I see blurry
22:19 I’m not too sure and those are not
22:21 considered Aura especially if they last
22:23 for a few seconds or for many many hours
22:27 at a time and they they are not well
22:29 defined
22:31 it’s not always easy to to put this
22:33 diagnosis into words and it takes a
22:36 neurologist or someone who’s very
22:38 skilled with headache to kind of put
22:40 things in the right boxes and let me
22:42 tell you sometimes it’s not that clear
22:44 okay so that’s one of the parts where
22:46 some auras are super clear and some
22:48 auras not too clear
22:51 it is important to distinguish migraine
22:54 without Aura migraine with aura
22:56 um but the hard truth is that a lot of
22:59 people have both and they will have
23:01 attacks with the aura and some attacks
23:03 without the aura some people have only
23:06 auras with no migraine and some people
23:08 have auras that are caused by completely
23:11 different stuff like for example stroke
23:13 so I told you about the wave of
23:15 electricity well this wave of
23:18 electricity can be triggered by many
23:20 things and sometimes it is not related
23:23 to migraine at all okay so think of the
23:26 aura as its own thing it is a brain
23:29 Phenomenon with different
23:30 characteristics
23:32 you may have heard the term complex
23:34 auras so those are auras that last a
23:38 long time may have speech symptoms the
23:41 sensory symptoms or tingling people may
23:44 paralyze even lose completely their
23:46 strength on one side we call that
23:47 hemiplegic migraine confusion basilar or
23:51 brain stem hallucinations even very rare
23:54 uh and Alice in Wonderland which is
23:57 seeing things bigger smaller like the
23:59 Alice and the novel
24:01 and I will not go into great detail
24:03 because all of those should be evaluated
24:06 carefully by a neurologist all right
24:08 because usually GPS are not very
24:10 comfortable with making a diagnosis of
24:13 those symptoms
24:15 silent migraine okay so so this is
24:18 getting very popular online I see it a
24:21 lot on social media I see it on the
24:23 forums the patient forums I even saw a
24:25 post from a migraine again recently
24:29 I advise not to use this term and I’ll
24:33 say why
24:34 so because it is not clear what it is
24:37 okay so some people talk you silent
24:40 migraine to say it’s supposed the
24:43 postdrome so there’s no headache the
24:45 pose drone there’s no headache Aura
24:48 without headache so it’s very confusing
24:50 what does it mean some people even have
24:53 started to use the term silent migraine
24:56 to describe any symptom that is
24:59 unexplained otherwise brain fog
25:02 dizziness
25:03 and then they say well maybe you know
25:06 those symptoms are caused by all those
25:08 mechanisms that cause migraine but
25:11 without the headache to be honest from a
25:14 scientific perspective it’s possible you
25:16 know why not those brain networks could
25:18 cause a lot of symptoms
25:20 but remember that the research on
25:22 migraine was done on people who have
25:24 headache by definition because it’s an
25:26 it’s the way we defined it so we cannot
25:29 apply This research to people who do not
25:31 have headaches so I think if we want to
25:33 study those people and people who have
25:36 those symptoms we should study them like
25:38 they are and I would seriously because
25:41 I’ve seen on social media sometimes
25:43 people saying oh my doctor didn’t know
25:45 that silent migraine exists well because
25:47 it doesn’t
25:48 it doesn’t in the official
25:50 classification so if we want to start
25:52 using this term we have to seriously
25:55 clarify what we are talking about so I’m
25:58 pretty strong about this and I know some
25:59 of you might be a maybe surprised or
26:02 even shocked
26:03 um but I I’m very uh that’s why I’m
26:06 giving this webinar I care about words
26:08 because words are the start for research
26:10 and research is the key to better
26:12 treatments
26:14 now chronic and episodic migraine so we
26:16 talked about the aura now we switch the
26:18 gears we talk about the name of migraine
26:23 let me tell you the story here and it’s
26:25 a story that goes back maybe 20 years or
26:27 30 years ago
26:29 at the time there was Migraine with and
26:31 without Aura it was the big thing nobody
26:33 was talking about chronic migraine but
26:36 headache Specialists they knew because
26:38 they see in their office that some
26:40 people seem to have migraine almost
26:43 every day with kind of attacks little
26:46 headaches you know different headaches
26:48 tactiles and these people were difficult
26:50 to treat they were using a lot of
26:53 medication to treat attacks they
26:55 sometimes had more health issues
26:57 and so Dr Lipton a researcher decided to
27:02 call this transformed migraine by
27:04 transformed he meant well this person
27:06 had migraine attacks in the past like
27:09 once in a while a few times per month
27:11 and then they were in normal in between
27:14 the attacks they were feeling okay
27:15 normal
27:16 and then they morphed they transformed
27:19 so the migraine became more frequent the
27:22 headaches become more frequent and it
27:24 became something more difficult to treat
27:26 so that was a diagnosis that lasted for
27:29 maybe a decade and then well those
27:32 patients they were excluded from
27:34 research studies on treatments because
27:36 they were too sick so usually
27:38 pharmaceutical companies would say nah
27:41 you know they’re not we better exclude
27:43 those guys because they’re not going to
27:44 get better with our treatments so we’ll
27:46 focus on people who have well-defined
27:49 attacks that we can count and in between
27:51 they’re okay
27:53 but then interestingly Botox occurred
27:57 and Botox was studied in at first right
28:00 it was seen in the Cosmetic clinics that
28:02 Botox help with migraine the studies
28:04 were made on people the episodic ones
28:07 the usual ones and they did it didn’t
28:09 work Botox actually was not helpful so
28:13 then the the eye of the company turned
28:16 to the this bunch of people who had very
28:18 frequent attacks and at the same time
28:21 the scientific Community decided that
28:24 maybe it was time to kind of Define this
28:27 this group of people with severe
28:29 migraine and they called it chronic
28:32 migraine and they made the definition
28:34 that is still up to this day valid which
28:38 is 15 days per month of headache or more
28:40 and eight days with migraine symptoms
28:43 that fit the criteria for migraine just
28:46 let me tell you this a lot of GPS are
28:49 not comfortable with this so I’m telling
28:50 you like I’m talking to a fellow doctor
28:52 because if you live with migraine you
28:55 understand all of this
28:56 but this notion that in chronic migraine
28:59 there are different levels of headache
29:01 is not always clear to a certain
29:03 Physicians and then from this definition
29:06 of chronic migraine came the concept of
29:09 chronification or progression you know
29:12 before we had transformation and then we
29:14 started looking at who are these people
29:17 who live with chronic migraine what are
29:20 the risk factors what are their other
29:22 diseases and then what can we do to
29:26 prevent chronification so this was
29:28 something that occurred over the past 20
29:31 years
29:33 but now we know that it’s not cookie
29:35 cutter like this it’s not that clear
29:37 migraine is a spectrum and some people
29:40 will have months 20 days per month some
29:43 people will have months eight days
29:47 over their lifetime a person with
29:49 migraine will have different frequency
29:51 and this is a bit what we call a roller
29:53 coaster of migraine so you see here the
29:55 frequency from 0 to 30 over months and
29:59 you see people vary a lot some people
30:01 don’t vary some people all their lives
30:03 they will have four attack four migraine
30:06 attacks per month maybe around their
30:07 period and that’s gonna be it but some
30:10 people chronify or transform or
30:13 deteriorate over time
30:15 so maybe we should actually be more
30:17 clear that episodic and chronic is not
30:20 the best way maybe we should look at the
30:22 frequency to be more precise is is what
30:25 is the frequency per month so that
30:27 present time this is not official at all
30:30 this is a concept that is discussed by
30:32 doctors but that maybe we should just
30:34 drop this episodic and chronic business
30:36 and just say you have migraine two to
30:39 four days per month eight days per month
30:41 20 days per month 30 days per month and
30:44 so we are more precise
30:47 because that’s the story usually you
30:49 know when when quantification does
30:50 happen and when why should we wait for
30:53 that to happen why can’t we just treat
30:55 people before they get chronic before
30:57 they are in this bad migraine State how
31:00 can we do that I think that’s still a
31:02 very very important question and this
31:05 illustrates a little bit the life of a
31:07 person with migraine starting with you
31:09 know sometimes in childhood puberty
31:11 hormonal changes especially for women
31:14 but also stressors accidents you know
31:17 life happens to you as we say and then a
31:20 lot of other things can happen you can
31:22 fall into medication overuse and then
31:25 pass your 40 50 and you have chronic
31:27 migraine
31:29 I want to just say one thing is that the
31:31 term chronic is not good because chronic
31:35 in Canada there’s a list of chronic
31:37 diseases chronic diseases are diseases
31:40 that last for the lifetime of a person
31:42 okay and they they come with a lot of
31:46 programs funding research statistics at
31:51 present time migraine is luck listed as
31:53 a chronic disease and it’s a partly
31:55 because of our own fault because we
31:57 decided to name chronic only
32:00 or the people who have this famous 15
32:04 days plus which is as I’ve shown you not
32:07 really good because it’s a Continuum
32:09 it’s not like a cookie cutter approach
32:12 so I think at the end of the day we
32:14 should start but what that’s not that’s
32:17 the future I believe we should have all
32:20 migraine listed as a chronic disease and
32:22 then talk about the exact frequency of a
32:24 person but as to this day insurance
32:27 companies classification we’re still
32:30 with episodic and chronic I just wanted
32:32 to share with you the limitations of
32:35 this way of categorizing
32:38 and then there’s another word you will
32:40 see refractory refractory it means that
32:43 it’s difficult to treat this is the
32:45 definition of the dictionary but how do
32:48 we Define that you know is it a number
32:50 of treatments tried how many are you
32:52 refractory if you tried one preventive
32:55 two preventive four preventive I have
32:57 patients they have tried 15 preventives
32:59 what if you started with an antibody
33:02 right-of-way versus trying other meds
33:05 what if your treatment is Botox and then
33:08 you have to try five treatments before
33:10 so I’m not too sure about about this
33:12 definition of refractory
33:15 um refractory can would that mean maybe
33:17 that you don’t respond to an antibody
33:19 ever since European type body so the
33:21 refractory term is not still completely
33:24 officially defined and I think it will
33:26 evolve over time
33:28 uh I will skip over this one just to see
33:32 that chronic migraine rare as they find
33:34 severe migraine rarely comes alone and a
33:37 lot of people actually have other
33:39 conditions playing a role in their
33:42 disease so here you have a little graph
33:45 showing all some diseases on the left if
33:48 you look on the top you will see
33:50 insomnia depression anxiety so they very
33:54 often come with a chronic migraine
33:57 um and then you have other things so
33:59 with migraine in general sorry so
34:01 allergies arthritis vitamin D deficiency
34:04 osteoarthritis hypertension so all of
34:08 these other diseases come with migraine
34:11 and this is another table and I’ll just
34:13 look at the colors don’t try to look at
34:15 the numbers here the point here
34:18 is that if you live with chronic
34:20 migraine especially refractory and
34:22 difficult to treat and for years there’s
34:24 usually not only migraines some people
34:26 have no other issues the one on the the
34:30 right side of the graft well it’s all
34:32 almost all green so these people have no
34:34 other problems on the left side of the
34:37 graph these people have a lot of other
34:40 problems from different categories so in
34:43 my practice I often see chronic binary
34:45 patients and they will have problems
34:48 with the blood vessels with the lungs
34:50 with their GI system their
34:52 gastrointestinal they will have mental
34:54 health issues they will have other pains
34:57 they will have other brain diseases so
35:00 you cannot at this stage just talk about
35:02 migraine you have to also look at the
35:04 rest of the the the condition
35:07 because chronic migraine when it
35:09 transforms we think that’s what happened
35:12 um is that something the person usually
35:15 will start with occasional migraine not
35:17 always but usually and then something or
35:20 many things happen and then it starts
35:23 vicious circles
35:26 um sleep issues Stress and Anxiety
35:28 muscle tension jaw tension and then the
35:32 person starts to lose its ground right
35:34 life is becoming more and more stressful
35:37 you start avoiding more and more things
35:39 there’s tension at work and then you
35:41 start drinking more coffee you cannot
35:43 exercise you take more and more pills
35:45 more and more analgesics and all of this
35:48 just circles and circles around until uh
35:52 the situation is worse and worse so
35:54 treatment of migraine and chronic
35:56 migraine is important because we want to
35:58 revert all of this back to normal
36:01 so this part was the one about episodic
36:04 and chronic migraine refractory migraine
36:06 why are some people struggling this is a
36:10 slide for doctors but I wanted to show
36:12 you and it actually just explains a few
36:14 things well it can be maybe there’s
36:16 different types of chemicals involved
36:18 maybe there’s a mental health issue
36:20 medical issues maybe neck issues there’s
36:23 a lot of stuff and just to tell you that
36:25 the research is going on
36:27 now last part of our discussion tonight
36:31 is post-traumatic headache so okay you
36:36 had an accident you had a brain or a
36:38 head a head or neck injury what we call
36:40 sometimes a traumatic brain injury TBI
36:42 or concussion concussion by the way is
36:45 not something that is very well defined
36:47 it’s a very common term but even in
36:50 conferences to this day I asked the
36:52 question all the time and say what’s the
36:54 difference between a mild traumatic
36:56 brain injury or mtbi and concussion
36:59 it’s not that clear okay so you have a
37:02 headache now what is your diagnosis
37:05 this little graph here puts all the
37:07 scenarios that can happen in the person
37:10 who had a concussion or many well this
37:13 person can maybe have no headache before
37:15 ever right so then this person has
37:18 post-traumatic headache and then will it
37:20 persist over a long time let’s say it
37:22 does but what if this person had
37:25 migraine before what if this person had
37:27 chronic migraine before what if this
37:30 person had tension type headache before
37:32 but now has neck pain plus migraine
37:34 symptoms
37:36 so it’s it is there are many different
37:39 different scenarios and sometimes the
37:42 best is once again to really look at the
37:44 different parts and put them together
37:47 because usually when a trauma occurs
37:49 it’s a little bit like the graph I
37:51 showed you about the vicious circles
37:53 there’s an accident there might be some
37:56 lesions right and I showed you about
37:58 thought talk to you about the nerves
38:00 there might be some lesions there might
38:01 be some crushed bone crushed nerves
38:04 crushed or or stretched neck or whatever
38:07 something that happens in the flesh
38:09 right and that causes symptoms that
38:12 might heal very well or there might be
38:15 also some trauma to the brain that we
38:17 cannot see so that’s very difficult you
38:20 know how do we look at this in
38:22 concussion and then there is all the
38:24 stress from the trauma and the child the
38:26 changes in someone’s lives right there
38:28 can be a lot of litigation with
38:31 insurance company there can be impact on
38:33 your work impact on on the relationships
38:36 with others
38:37 and then all of this can cycle to a very
38:40 very difficult situation and I see a lot
38:43 of people who struggle with
38:44 post-traumatic headache over months and
38:48 sometimes many years
38:51 the worst case well the worst case a
38:53 difficult scenario is or what I call the
38:56 perfect storm is when someone who has
38:59 migraine who was born or who developed
39:02 migraine at a young age so has a bit of
39:05 you know biological genetic migraine
39:07 migraine is brain all I’ve showed you
39:09 before with all the mechanisms and then
39:12 this person has maybe one first trauma
39:15 maybe a whiplash maybe another and maybe
39:19 another or maybe just one big one who
39:21 cares a story of accidents and then it
39:25 builds up and builds up and builds up
39:26 and then move this person to a state of
39:30 chronic migraine or chronic
39:32 post-traumatic headache
39:34 and then all of these guests get mixed
39:37 up it becomes uh difficult with
39:39 insurance company because they will say
39:41 oh you had migraine before so the trauma
39:43 has nothing to do with it
39:45 and remember that insurance companies
39:47 usually will do what they can to say
39:49 that you know they don’t have to pay so
39:51 it’s not it’s not the uh they will deny
39:54 that the trauma was the initial cause
39:56 for the problem and they have interest
39:58 in doing this on the other side well
40:01 sometimes the trauma is the problem but
40:04 there’s also sometimes other factors it
40:07 can be for example the worst thing is
40:09 when a person with migraine has a trauma
40:12 during a very stressful period so their
40:14 brain during a stressful period is
40:17 sensitive more sensitive and sometimes
40:20 this will cause symptoms to persist over
40:23 time that’s what I see in my practice
40:25 there’s no special name for that but
40:28 this is what I call The Perfect Storm
40:29 but this from a diagnostic perspective
40:32 is complicated
40:34 okay so look at the Pretty Horses here
40:37 and look at the zebra zebra is different
40:40 but kinda looks like the horses right
40:43 so
40:44 if you come in my office and you had a
40:46 story of migraine and then you had a
40:48 whiplash and then a trauma and then now
40:50 you have a chronic headache with other
40:53 symptoms I will probably diagnose you
40:55 with migraine and post-traumatic
40:57 headache because it’s not true that if
41:01 you never had migraine before it’s the
41:03 same story that if you did
41:05 um so we have to start making a
41:07 difference between post-traumatic
41:09 headache and migraine I say this because
41:12 on the forums I follow them a lot of
41:15 people will talk about their migraine
41:17 and it’s okay they will say my migraine
41:20 or the migraine or they treat migraine
41:22 um but I never had headaches before my
41:24 accident
41:25 so people who never had headaches before
41:28 their accidents and then develop severe
41:31 lasting persistent headaches we should
41:33 call we should diagnose post-traumatic
41:36 headache because these people are
41:38 different from people with migraine
41:40 before they have different Imaging they
41:43 have different symptoms they have
41:44 different prognosis usually it’s more
41:46 difficult to treat and they have
41:48 different responses to antibodies cgrp
41:51 antibodies do not work very well for
41:53 people who have post-traumatic headache
41:55 with no migraine so I think it’s okay we
41:59 do what we can we use the migraine
42:00 treatments for people with
42:01 post-traumatic headache but we have to
42:03 be clear about what the story is and
42:06 what happens really and what was the
42:09 state before the trauma and after the
42:11 trauma and clarify stuff
42:14 if you look at the X-Men story you will
42:17 probably uh recognize this little blue
42:20 lady here uh I hear that Jennifer
42:22 Lawrence spent a lot of time in makeup
42:25 for this movie so the result is pretty
42:27 striking but if you know this lady here
42:29 about you know that she can change shape
42:31 as she wishes uh Mystic I think she’s a
42:34 Mystique I think she’s called so
42:37 post-traumatic headache has different
42:38 faces it can look like pretty much
42:41 anything I’ve seen people with trauma
42:43 they look like cluster headache I saw
42:45 one today I I see some patients they
42:48 have Tension Headache they have no
42:49 migrant symptoms the majority though
42:52 will have a headache sensitivity to
42:55 light sensitivity to effort sensitivity
42:58 to sound some some tinnitus you know
43:00 some sounds in their ears some of them
43:03 even will have electric shocks in
43:06 different places and lots of them will
43:08 have neck pain especially if they had
43:10 whiplash
43:11 so how do you diagnose that in order you
43:14 put all of this in the same mixed buffet
43:17 or do you just call it post-traumatic
43:19 headache but then there’s a lot of
43:22 different symptoms to treat here and
43:23 different pieces to address
43:25 so I think the best here is really to
43:28 stick to classification but a knowledge
43:30 that post-traumatic headache can look
43:32 like a lot of different things and
43:34 depending on what it looks like we
43:37 usually what we teach to our doctors is
43:39 that well if a post-traumatic headache
43:41 look like migraine you treat like
43:43 migraine and that’s I show this little
43:45 kids game then to say well you put you
43:47 know the right shape in the right hole
43:49 and you try to kind of do your best with
43:52 what you have
43:54 all right so my conclusion before I take
43:57 a few questions is
43:59 um well when we we see a person who
44:02 consults for a headache what should we
44:04 do and maybe my suggestion and actually
44:07 it’s a suggestion from a colleague from
44:09 Montreal Dr Manu is we should use a
44:12 multi-actional classification of
44:14 migraine and of headache actually
44:17 altogether because just using a big red
44:20 stamp and say migraine or not migraine
44:23 you know or post-traumatic headache or
44:25 no post-traumatic headache it’s a good
44:27 start but it’s not enough
44:29 so what I usually teach my residents is
44:31 you have to first list that the
44:34 diagnosis that are accurate according to
44:37 the classification as much as possible
44:39 uh or at least a little bit you know you
44:42 have some idea of what you’re talking
44:44 about so you you start with that and
44:47 then you describe who the person is what
44:50 are the medical issues of this person
44:52 what are the mental health issues of
44:54 this person what are the social factors
44:57 of this person
44:58 and what is the impact of the headache
45:01 condition on this person and based on
45:04 that then we can build a good
45:06 therapeutic plan so if this person has
45:09 migraine neck pain fibromyalgia let’s
45:13 see sleep apnea hypertension and
45:16 medicational overuse then you called all
45:19 of this and then you adapt your
45:21 treatment plan and sometimes as I said
45:23 at the beginning it’s not that clear
45:25 sometimes I sometimes take one or two or
45:28 three visits before I have a clear idea
45:31 of what is going on
45:34 so in conclusion Dr Smith
45:37 um was completely wrong on many things
45:39 but he’s showing the reality of what we
45:42 hear in real life and I hope that I have
45:44 showed you and explained to you that
45:46 terms matter that words matter and but
45:50 sometimes there are realities in the
45:53 headache world that generate those terms
45:55 that are maybe not diagnosis but still
45:58 we should mention if they are triggers
46:00 if they are symptoms if they are
46:02 comorbidities but just keep things clear
46:05 about what we are talking about
46:08 so sometimes there are too many
46:10 diagnoses sometimes the diagnosis is not
46:13 clear and description of symptoms is
46:16 best until we know what’s going on and
46:18 treatments can always be tried anyway
46:20 right we don’t have official tests so
46:23 sometimes we try an error it’s uh it’s
46:26 the usual way
46:27 um but let’s try to clarify the
46:30 diagnosis as best as best as we can so I
46:33 will finish now on the welcoming you to
46:36 our move for migraine Canada campaign
46:38 you can donate to us you can check our
46:41 different teams you can create your own
46:42 team and join us and support us and I
46:46 have my bracelet here I wear it proudly
46:49 and I uh I’m always glad to talk about
46:51 migraine thank you and