Migraine Awareness Webinar

0:03 elizabeth larue
0:04 i’m a neurologist i’m a headache
0:06 specialist
0:08 um and i’m the chair of migraine canada
0:11 so our
0:12 association and our team is very very
0:14 happy to welcome you tonight
0:16 uh during june which is migraine
0:18 awareness month
0:20 to this event uh where we’re going to
0:22 talk about
0:23 migraine prevention but before we
0:27 dive into it and uh we uh we share we
0:30 spilled beans about migraine prevention
0:33 we are going to say
0:34 i’m going to introduce ourselves so who
0:37 we
0:37 are we are a national association
0:40 supporting all canadians
0:42 living with migraine and also other
0:45 headache disorders
0:46 so uh intracranial hypotension cluster
0:49 headache uh
0:50 post-traumatic headache we want to be
0:52 active for everybody
0:54 we are a not-for-profit we are not
0:57 charitable
0:58 yet so hold your donations but very soon
1:01 uh our board is a multi-skilled
1:03 multi-provincial
1:05 diverse board i’ll volunteer and we are
1:08 glad to have wendy
1:09 gerhardt our wonderful executive
1:11 director and randa basil our fantastic
1:14 social media coordinator
1:16 and a lot of people who work with us
1:20 as volunteers so we are a young
1:23 association
1:24 and we really want to help people with
1:27 diff
1:27 with headaches and migraine we are
1:30 supported by the pharmaceutical industry
1:32 and we have numerous partners which
1:34 names are listed here in alphabetical
1:37 order
1:37 and we thank them for their generous
1:39 support
1:42 so one little thing before we get
1:43 started i am a neurologist
1:45 and i’m i’m a doctor but what i’m gonna
1:49 say tonight should not replace
1:51 medical advice from your trading
1:52 physician so we provide
1:54 information facts science um
1:58 but we cannot advise you on your
2:00 particular story
2:02 and your own medical condition so
2:03 whatever you make for medical decision
2:06 please discuss with your personal
2:08 treating healthcare provider
2:10 uh because your story is your own and
2:12 there are things i might say tonight
2:14 uh that might not apply to you
2:18 so tonight we talk about migraine
2:20 prevention the path to relief
2:23 and we know this path can be long and
2:26 arduous
2:27 and sometimes it can be a struggle to
2:29 find a good balance
2:31 in your life and have less migraines
2:35 so the thing is it’s any comfort and i
2:37 always start with this
2:38 because a lot of my patients tell me
2:40 they feel very isolated which is strange
2:43 because migraine is actually one of the
2:44 most
2:45 common diseases of all diseases and this
2:48 is not only in rich countries sometimes
2:50 we have this kind of bias
2:52 it is for the whole planet lives with
2:55 migraine
2:56 there might be a bit less in africa but
2:58 otherwise we think that 11
3:00 of the world’s population lives with
3:02 migraine and one to two percent
3:04 lives with chronic migraine which is
3:07 roughly having
3:08 a headache or migraine more than 15 days
3:11 per month
3:11 so you’re definitely not alone and
3:15 if you live with this i just i just put
3:17 a few sentences
3:18 i’m sure you’ve heard before and with
3:21 different
3:21 you know if you live with migraine
3:23 you’ll meet a lot of good willing
3:24 individuals
3:25 they might be your family your networks
3:28 your coworkers they might be
3:29 someone you’re just meeting um telling
3:32 you a bunch of things
3:34 and sometimes it’s a bit difficult to
3:36 tear you know what makes sense to what
3:38 doesn’t or
3:39 if you’re told that maybe salt and water
3:41 will help you
3:43 for and you’ve been struggling with
3:44 migraine for years sometimes it becomes
3:47 annoying
3:48 so there’s a lot about migraine because
3:50 it is so common and it is
3:52 part of our society so no wonder there’s
3:55 a lot of popular knowledge
3:57 of or miss about migraine and things
4:00 that may be true
4:00 and things that may be not true or
4:03 partially true
4:04 as you know we know happens in science
4:07 but if you’re here tonight
4:08 and if you are logged in um it’s because
4:11 you want to do something you want to get
4:13 better or maybe
4:14 you know someone that you want to help
4:16 and
4:17 you you want to improve your quality of
4:19 life and this is what we’re going
4:21 to talk about tonight so here’s an
4:24 overview of what we’ll talk about
4:26 um when to use prevention right what is
4:29 prevention and when to use it
4:31 um what if you want you would prefer to
4:34 avoid taking medications and you’re
4:36 interested in different lifestyle
4:38 interventions
4:39 and then we’ll talk about medications
4:41 and roughly they go in steps
4:44 first the pills and then we have botox
4:46 and cgrp antibodies
4:48 and then there are what we call third
4:50 line therapies that are usually also
4:52 pills
4:53 um we are an association so we advocate
4:56 for
4:57 access to care and that means we have to
4:59 talk a little bit about
5:00 money cost insurance companies um
5:03 patient support programs and so on
5:07 we’ll also say a few words about the
5:09 neuromodulation devices that can be
5:11 helpful for migraine prevention and
5:13 something you may have heard about
5:15 the g-pants a new class
5:18 for migraine treatment that is probably
5:20 going to come to canada next
5:22 year and end on a bit of advocacy
5:25 a to-do list for you i know you have
5:27 tons of to-do lists but this one
5:29 should be a good one and of course hope
5:32 that there is something out there for
5:33 you
5:35 so our motto as migrant canada is
5:38 no one size fits all this is very
5:41 important because whatever we discuss
5:43 it might be very good for someone it
5:45 might be
5:46 absolutely of no use for other people
5:49 and it might even
5:50 actually cause to cause side effects or
5:52 difficulty
5:53 there’s no unique cause for migraine
5:56 there’s no 100 cure for migraine if
5:59 anybody is telling you that something
6:01 cures migraine in everybody it is not
6:04 true maybe someday but not today not in
6:07 2021
6:09 so migraine is is a it’s a brain disease
6:12 okay it’s a brain disorder
6:14 um and it’s actually something that is
6:16 along a continuum
6:18 so some people have what we call low
6:21 frequency they have
6:22 a few headache days of few migraine
6:24 attacks per month or even sometimes a
6:26 few per year
6:27 lucky people i mean that’s less than
6:30 other people have sometimes
6:31 but still attacks can be disabling some
6:34 people will have
6:35 high frequency so that roughly we define
6:38 this at
6:39 8 to 14 days of migraine per month and
6:42 then some people have what we call
6:44 chronic migraine that’s 15 days and more
6:47 all those limits are arbitrary because
6:50 most people
6:51 actually fluctuate along the spectrum
6:54 but some people remain at the same
6:56 frequency for years and years
6:57 and other transition to chronic other
7:00 revert and they go back to episodic
7:02 so wherever you are on the spectrum um
7:05 migraine prevention could be interesting
7:07 for you and
7:09 tonight i’m sure we have people who have
7:11 tried a lot of things already
7:13 and i’m sure we have some people who
7:15 have not yet started their path
7:17 and they are wondering what’s out there
7:20 on the menu
7:20 so we’ll say a few words for everybody
7:23 and hope we can help
7:25 let’s recall also that you know why are
7:28 we treating migraine with
7:30 prevention so prevention when we talk
7:32 about stroke
7:33 is we don’t want the stroke to happen in
7:36 migraine it’s different it’s like asthma
7:38 you know it’s like attacks
7:39 are happening you live with it already
7:42 um but we want them to be
7:44 less frequent and less severe so the
7:47 migraine brain
7:48 is different i mean by that migraine is
7:50 not imaginary there’s something
7:52 in the brain and it’s something about
7:54 electricity
7:55 and chemistry that leads your brain to
7:58 be hypersensitive to certain
8:00 triggers you know about triggers and
8:03 those triggers build up
8:04 and then trigger the famous migraine
8:07 attack
8:08 and so all of this is addressed in
8:10 another webinar that is on our youtube
8:12 channel which is the science of migraine
8:15 if you want to hear more about that i
8:16 definitely encourage you to look at it
8:18 uh but just to remind that when we try
8:20 to prevent a disease we have to have
8:23 a bit of an idea what this disease is
8:26 and so the migrants brain interacts with
8:30 the environment and when i see the
8:32 environment it’s our
8:33 body environment and it is the
8:35 environment around
8:36 right the lights the sounds the smells
8:39 the weather
8:40 and then the food our emotions our
8:42 hormones
8:43 our pains in the neck and in the sinuses
8:47 so when we want to improve the migraine
8:49 situation
8:50 there’s two things we can do we can
8:52 raise the tolerance
8:54 of the brain to triggers and we can
8:57 decrease the load on the brain or the
9:00 triggers
9:01 stabilizing lifestyle which we’ll talk
9:03 about is good for both
9:05 aspects right it makes the brain more
9:07 resistant and it can also decrease
9:09 the triggers and migraine preventives
9:12 usually will act on the brain chemistry
9:15 to make it
9:16 less prone to attacks more resistant
9:19 that’s what they do
9:20 all of them one way or another
9:23 so when we talk about treating migraine
9:26 it can be
9:27 a mix of different things
9:30 so it’s always three parts and that’s
9:32 another thing that you might be familiar
9:33 with
9:34 but when we talk about migraine
9:36 treatments there’s always a behavioral
9:38 part behavioral part means
9:40 what you do in your life right so
9:42 lifestyle
9:43 and putting your brain in a good place
9:45 in a state in a stable place
9:47 acute therapy we don’t talk about it i
9:49 just release podcasts about this
9:51 um and we can definitely do webinars
9:53 about this so that’s treating the attack
9:56 as needed prevention is lowering attack
9:59 frequency and severity
10:01 so if most of the patients i meet um
10:05 and who are starting their journey they
10:06 say well what can i do if maybe i’d like
10:08 to
10:09 either avoid taking medications or you
10:12 know i’d like to i’m taking medications
10:14 but i like to
10:15 optimize my situation what can i do
10:18 there are two ways to look at this
10:20 one way is to avoid triggers which can
10:23 make a lot of sense
10:24 especially if the triggers are clear but
10:27 sometimes
10:28 when the treat when the migraines are so
10:30 frequent and you have them
10:32 20 days per month well a lot can happen
10:35 on 20 days right the weather can change
10:37 you can eat a lot of things
10:39 a lot of emotions a lot of things and it
10:41 can become a bit stressful to watch for
10:43 the triggers all the time
10:45 so one revert way to look at this is to
10:48 optimize protective behavior so things
10:51 you do that
10:52 protect your brain and the list you know
10:55 it’s
10:55 exercise healthy eating hydration
10:59 pacing your energy uh protecting your
11:02 sleep
11:03 all of this can be difficult or
11:04 complicated especially if you have a lot
11:06 of migraine
11:07 but it’s just a bit of an interesting
11:09 way of you know looking
11:11 triggers versus protective behaviors
11:13 that are more empowering
11:16 than sometimes getting afraid of having
11:17 triggers but of course if you have
11:19 triggers it’s good to be aware of them
11:22 so when we talk about lifestyle and
11:24 about
11:25 non-drug approaches and i’m not going to
11:28 talk tonight about
11:29 all the other non-drug approaches but
11:31 they are important
11:32 massage therapy osteopathy chiropractic
11:35 medicine
11:36 acupuncture all of these can be part of
11:39 your menu to help with migraine
11:42 but those are the seeds so sleep
11:44 exercise
11:45 eat and drink diary and stress
11:48 all of this you can manage in stress
11:52 let’s just say that we stress is not
11:54 always being anxious about what can
11:56 happen it can mean a lot of things so in
11:58 this
11:59 part usually we include dealing with
12:01 emotions
12:03 dealing with energy drains pacing your
12:06 schedule
12:07 planning for buffer time and all the
12:09 relaxation world
12:10 breathing cardiac coherence mindfulness
12:13 there’s lots that can be done there
12:15 that can be extremely effective with
12:17 persistence
12:19 here’s a slide that comes from a deck
12:22 that we
12:23 are soon going to give to doctors right
12:26 so we want to tell doctors how to assist
12:29 you guys
12:30 um in putting these uh these habits and
12:33 these lifestyle things
12:35 in your life uh so here’s let’s look at
12:38 them just for fun
12:39 so um so we want the doctors to validate
12:42 that migraine is a neurological disease
12:44 and can be very disabling
12:45 very important we want them to help you
12:49 setting realistic expectations and we’ll
12:51 say we’ll talk a bit more about that
12:54 we want them to understand and you and
12:56 also you as a person as a patient
12:58 living with migraine that this is a long
13:00 journey
13:01 some of you might say hey you know i
13:03 know that baby i’ve been there for 25
13:06 years
13:06 but it’s important for those who are
13:08 starting that this can take
13:10 a while and multiple trials before
13:13 finding the right mix um
13:16 lifestyle changes take time patience and
13:18 persistence and it can be
13:21 really sometimes challenging but with
13:23 persistence it can really be helpful
13:25 and even if you do all of it and you are
13:28 a yogi master you meditate you train you
13:30 hydrate you’ve done
13:32 it all or you’re just too sick that you
13:35 cannot do these things
13:36 migraine can be disabling and can
13:38 require
13:39 medications okay so even with the best
13:42 lifestyle
13:43 sometimes just like asthma just like
13:45 diabetes just like
13:46 any other chronic disorder medications
13:49 are needed okay so let’s say you say
13:53 okay i’ve done my lifestyle thing and i
13:55 looked at what i could do
13:56 i would like to try medications so what
13:59 are the goals of preventive therapy
14:01 obviously
14:02 you know getting better you want to have
14:04 less migraines you want to be
14:06 you know to have less severe attacks
14:08 ideally none maybe
14:10 but usually we consider success as a 50
14:13 reduction in frequency if you live with
14:16 chronic migraine a 30
14:18 reduction is actually significant
14:20 because that can be
14:22 going from 20 days per month to 14 days
14:25 per month that’s
14:26 that’s a full week gain so that’s um
14:29 that can be
14:30 that get make a lot of difference for
14:31 you we want the attacks to be easier to
14:34 treat
14:34 to be less intense we want less symptoms
14:38 that are um nausea vomiting ideally you
14:41 don’t have to go to the emergency
14:43 emergency department we want less
14:45 disability
14:46 higher tolerance to triggers so maybe
14:48 you can exercise or maybe you can have a
14:50 little glass of wine or you know go to a
14:52 restaurant or go out
14:54 and we want less anxiety depression and
14:57 irritability because when you live with
14:59 a lot of migraine
15:00 you know that can happen okay
15:04 so before people go to drugs sometimes
15:06 they will say i’d love to try
15:08 supplements there are four official kind
15:11 of supplements that are
15:12 studied for migraine magnesium vitamin
15:15 b2
15:16 coenzyme q10 and butterbur or pedasitis
15:20 hybridized which is a
15:22 kind of a root um this one is a bit less
15:24 recommended now
15:26 because there are concerns about liver
15:27 toxicity but
15:29 there are also safe uh ways to get that
15:32 so
15:32 let’s let’s say that you have to discuss
15:34 this with your healthcare provider
15:36 but the others can all be taken all by
15:38 themselves or in
15:40 supplement pills that combine them all
15:42 and if you want to go that route
15:45 you can my comment about supplements is
15:47 that
15:48 treat them as drugs really because i’ve
15:50 seen patients they take vitamin b2 and
15:52 magnesium
15:53 for like 10 years every day and they’re
15:56 not sure if it did anything
15:58 so if you do a trial do it and see if it
16:01 helps
16:01 and if it doesn’t stop it right there’s
16:04 no point paying and taking
16:06 more pills if they’re not helpful
16:10 so when we start medications for
16:12 migraine prevention
16:14 there are a few things that sometimes
16:15 your doctors will
16:17 you know they will make a few mistakes
16:20 so sometimes the underestimates the the
16:23 real state of things
16:25 because people with migraine tend to
16:27 just look at the worse attacks
16:29 so if you sometimes some of them will
16:31 say i have eight migraines per month
16:33 but they have eight migraines but then
16:35 they have 10 other little normal
16:37 headaches
16:38 which does 18. so underestimating the
16:41 baseline
16:42 is something that doctors do very
16:44 frequently and even my patients
16:46 when i ask them to do a diary they
16:48 realize that the situation
16:50 is a bit different than what they
16:51 thought so it’s nice to have a good
16:53 baseline
16:54 another problem with drugs is i hear my
16:57 patients all the time say this
16:59 i was like i’m just given my doctor just
17:01 gives me drugs and there are not even
17:02 drugs for migraine
17:04 this is true and will present the drugs
17:06 they are for other conditions
17:08 but in the end all of these drugs have a
17:10 way to act on migraine
17:12 and i think it’s very important that
17:15 people understand that so your doctor
17:18 ideally in a world with plenty of time
17:20 would explain to you
17:22 why those drugs are prescribed for
17:24 migraine
17:25 so i think it’s very it’s this is
17:26 something that is lacking in our system
17:28 where time is very short and often
17:31 doctors will say take this take that do
17:33 this do that
17:34 and there’s not really a conversation
17:36 about it
17:37 um if something doesn’t work
17:40 why keep it right and that’s true for
17:42 anything supplements drugs or behavioral
17:45 practices
17:46 and the other thing is that i hear a lot
17:48 from my patients
17:49 when they make it to me or another
17:51 headache specialist
17:53 they’ve been told sometimes by their gp
17:56 or even a neurologist
17:57 there’s nothing else i can do don’t
17:59 accept that i mean
18:01 yes there are people who have really
18:03 tried the whole thing
18:04 um and then we have to find ways to help
18:07 but um often people are told there’s
18:10 nothing else but as you will see
18:11 in two minutes there’s a lot that can be
18:14 done so
18:15 don’t lose hope and ask to be referred
18:17 to a specialist
18:19 when you start a drug another mistake
18:21 that often happens
18:22 is that the trial is not long enough
18:26 and the dose is not high enough
18:29 so i’ve seen quite a few patients who
18:31 tell me
18:32 oh i’ve tried this drug at this dose for
18:34 like two weeks it didn’t do anything
18:36 or a month it didn’t do anything or you
18:39 know i had the side effects for two days
18:41 and i stopped it
18:42 so the side effects come first and then
18:45 comes the benefit
18:46 so try to bear truth on some side
18:48 effects if you can
18:49 if you can and then if um
18:53 once you’re past that that that time
18:55 because usually
18:56 not all the time sometimes side effects
18:59 will get better
19:00 and then the brain chemistry adapts and
19:02 then the migraines
19:04 get better so persistence is important
19:07 um then patients often want to know if i
19:10 take a drug
19:11 am i going to have to take it for all my
19:14 life right of course not
19:17 right so the idea is if you take
19:20 something
19:21 well um the idea is to say okay every
19:24 year or every two year depending on your
19:26 story
19:27 reassess how are you doing are you
19:29 better and if you are so much better
19:31 then maybe you can withdraw the drug
19:33 progressively
19:34 that can be done can be done for
19:36 anything antibodies drugs supplements
19:38 botox
19:39 anything can be withdrawn after a while
19:42 but if you’re starting a drug it’s
19:44 because you want to get better
19:45 and if you do get better well sometimes
19:48 it’s nice to stay that way for a little
19:49 while
19:51 all right so pills so pills for migraine
19:55 there are roughly i’m not going to go
19:57 into deep detail because i want to give
19:59 an
19:59 overview tonight but there are roughly
20:02 three
20:03 main categories of pills for migraine
20:05 prevention
20:07 all of these categories are drugs that
20:09 were designed or prescribed for
20:12 other conditions so there’s the
20:14 anti-depressants that are treating the
20:16 mood
20:16 or anxiety anti-epileptics for epilepsy
20:20 or seizures
20:21 and anti-hypertensive or hypertension
20:24 drugs
20:24 and i’ve put here the brand names and
20:27 the generic names
20:29 because just to make our lives easier
20:31 there are different names for all these
20:33 things
20:34 so for example elevil is the brand name
20:37 for amitriptyline and topamax
20:40 is the brand name for the pyramid
20:43 all right so if we look at all of these
20:45 there are more
20:46 right i didn’t put the whole thing if
20:48 you want to do to see the whole thing
20:50 go on our website there are lists and
20:52 tables with
20:53 everything in there but those are the
20:55 key ones that are used
20:57 so all of these all of these have
21:00 roughly
21:00 ballpark estimate 40 to 50 percent of
21:04 chance
21:04 that you will improve by 50
21:08 right so that means that it’s flipping a
21:11 coin
21:11 if you try one of these drugs it’s kind
21:14 of um
21:14 it’s a hurdle race so you you try one
21:17 and you
21:18 there’s no way at this point to know if
21:20 it’s going to help
21:22 or if you’re going to have side effects
21:25 so pills are not no none of these pills
21:28 are the best
21:29 or favorite some have different side
21:32 effects
21:32 some lead to weight gain or drowsiness
21:35 others might lead to brain fog or memory
21:38 issues and others might lead to low
21:41 blood pressure
21:42 so when you decide for a drug be aware
21:45 that it’s a trial
21:46 you try it you increase the dose you can
21:48 speak with the pharmacist
21:50 hopefully you don’t have side effects if
21:52 you have side effects you stop it
21:54 and then maybe you try something else
21:58 so that’s approximately how it works
22:00 when you want to try drugs for migraine
22:04 that slide is a bit too busy but it’s
22:06 it’s because it comes once again from
22:08 a medical deck but it’s just to
22:10 summarize the current state
22:12 of things right those are not official
22:14 guidelines
22:15 this is just how things are working in
22:18 doctors offices
22:19 across country for migraine prevention
22:21 in 2021
22:23 so first line in purple is what we just
22:26 discussed you know evaluate
22:28 if you want to start a preventive
22:29 approach um
22:31 establish your baseline start a diary
22:34 discuss
22:34 options and then get started then the
22:37 first lines
22:38 are usually oral meds or pills that we
22:41 just presented
22:43 and ideally meds that have good evidence
22:46 for effectiveness and a low or
22:49 relatively low
22:50 side effect risk it doesn’t mean they
22:52 have no side effects but they have
22:54 probably less side effects than other
22:55 drugs and then once you’ve done that you
22:58 will access what we call the second line
23:01 so the second line are drugs like botox
23:03 and cgrp antibody which we’ll talk in a
23:06 minute
23:07 and then if those don’t work then you
23:10 can try
23:10 what we call third line options drugs
23:12 that are effective but usually not that
23:15 well
23:16 tolerated roughly put it looks like this
23:19 a little note botox is indicated in
23:22 canada
23:23 and across the world only for chronic
23:26 migraine
23:27 so people who have 15 days per month
23:29 plus
23:31 okay so let’s say you’ve tried oral
23:34 pills and you’ve tried if like
23:35 let’s say two or three of them well and
23:38 and you’re still struggling with
23:39 disabling migraine
23:41 so cgrp antibodies they are a revolution
23:45 in migraine world um this is 30 years
23:48 of research and i’m not going and
23:51 tonight is not the night to talk only
23:53 about cgrp antibodies
23:55 if you’d like to know about them please
23:57 watch our webinar that’s
23:59 it’s on the youtube channel and i gave a
24:01 two-part webinar
24:02 only on cgrp antibodies how they work
24:06 at their side effects their
24:07 effectiveness um
24:09 so here they are just depicted so you
24:12 know what they are called
24:14 emmavig hov mgality and soon to
24:18 arrive in the in canada vft which is an
24:20 iv
24:21 infusion it’s in a perfusion intravenous
24:24 so cgrp antibodies are all injectables
24:28 uh that’s because you cannot digest
24:30 antibodies they’re not going
24:32 to work and if you want to learn more
24:34 about them
24:35 look at our webinar this being said i
24:37 will just give you
24:38 the ballpark for response so i told you
24:41 for pills
24:42 it was flipping a coin 40 50 chance
24:46 for cgrp antibodies well we look at
24:49 episodic migraine and chronic so for
24:52 episodic
24:53 the ballpark is 50 to 60 percent
24:56 uh response and for chronic it’s 40
25:00 so four people on 10 will have a 50
25:03 response
25:04 and then there are what we call super
25:07 responders
25:08 so people who improve 75 so that’s
25:11 you know means going from 21
25:15 to maybe four or five massive difference
25:18 um so those people maybe one and five
25:21 for chronic migraine will have this and
25:23 one and three for episodic migraine
25:26 so just to give you an idea not
25:28 everybody respond
25:29 but people can can respond partially or
25:32 very well
25:33 and i’m not going to talk about side
25:35 effects and details look at the webinar
25:37 for that
25:38 botox therapy has been approved in
25:40 canada for chronic
25:42 migraine since 2011.
25:45 guys if you’d like a webinar on botox
25:47 i’m very happy to do one
25:49 i’ve been injecting it for 10 years and
25:52 in summary everybody
25:54 asks me where did they put the botox
25:56 this is where
25:57 everybody that’s where there are sensory
26:00 nerves
26:00 the forehead the temples the back the
26:03 shoulders you know where the pain is
26:05 um and botox acts mostly on sensory
26:09 nerves
26:10 to kind of quiet down the hypersensitive
26:13 pain system of chronic migraine it’s a
26:16 fascinating toxin really
26:18 and the success rate 50
26:22 you know there’s no 100 in migraine
26:24 world
26:25 um quite well tolerated and like i said
26:28 if you’d like to have a webinar in botox
26:30 therapy i’m happy to do one
26:33 okay so those of you who i i’m 43
26:37 those of you who remember indiana jones
26:40 maybe have seen this
26:41 this the third movie which is in indiana
26:44 jones and the
26:45 is it the the holy grail or the no d
26:48 is that the name yeah so in this movie
26:51 and jenna jones have to uh has to kind
26:53 of um
26:54 uh pick the right cup from a bunch of
26:58 cups
26:58 and if not he’s going to die so
27:02 with this i wanted to say that um it’s a
27:05 struggle
27:06 and i see a lot on social media and
27:08 patient forums
27:10 you know how what is your experience
27:11 with this what is your experience with
27:13 that
27:13 um what is the best thing what if i have
27:17 sinus migraines whether migraines
27:19 menstrual migraines
27:21 can we predict which drug will work
27:24 for me we can’t we can’t
27:28 in psychiatry there are some genetic
27:31 testing that can be done
27:33 hopefully we’ll have that someday in
27:35 migraine but so far
27:37 it’s not possible sometimes your doctor
27:40 will choose according to your
27:42 medical profile so for example if you
27:44 cannot sleep he will give you
27:46 a drug that can promote sleep um or if
27:49 there’s like epilepsy
27:50 obviously you’re gonna have a drug that
27:52 treats both epilepsy and migraine
27:54 but for most of you guys we we just try
27:57 the best we can
27:58 and we try to navigate this without
28:01 knowing
28:02 really what will work
28:05 so now let’s talk a bit about money
28:08 right so okay let’s say you’ve walked
28:10 the path
28:11 and you’ve tried different things and
28:12 then you make it to
28:14 botox or cgrp antibodies
28:17 obviously these treatments are more
28:19 costly than the pills
28:22 um and so the the question is well what
28:25 about my insurance company
28:27 in canada people might have private
28:30 coverage
28:31 that’s approximately sixty percent of
28:32 canadians they might have
28:34 public coverage approximately thirty
28:36 percent and there’s maybe ten percent
28:39 that uh who don’t have coverage they
28:41 have to pay
28:42 out of pocket and that’s a that’s quite
28:44 a difficult situation
28:46 so let’s talk about the private
28:48 insurance first
28:50 so the thing about cgrp antibodies
28:53 and botox is that the criteria for
28:55 coverage
28:56 vary a lot so some plans
29:00 might not cover them and some plans
29:02 might cover them but they will
29:04 ask for you know tickets or tokens or
29:06 things you know proofs criteria
29:09 here is what the criterias are usually
29:12 so this is kind of
29:14 roughly what we see because i feel these
29:16 forms
29:17 every day every week many um so usually
29:20 insurance will ask for this
29:23 you have to have eight days per month of
29:25 headaches or for
29:27 of migraine per month at least you have
29:29 to have tried
29:30 and failed or not tolerated two or three
29:34 or more sometimes
29:35 um oral preventives ideally from
29:38 different families
29:40 or classes your physician will have to
29:42 fill a form to give this information
29:45 and then the patient support program
29:47 which is
29:48 something we see with cgrp antibodies so
29:51 programs
29:52 organized by the um pharmaceutical
29:55 company that sells a product
29:56 will support patients to navigate
29:59 insurance
30:00 uh and answer questions help you with
30:03 the injections
30:04 and sometimes also provide what we call
30:06 a co-pay which is kind of a financial
30:09 assistance
30:10 if you continue the drug and your
30:13 insurance company pays part of it the
30:16 psp will pay
30:17 part of it as well so this is this is
30:20 something that might not apply to you
30:22 but
30:22 it does apply to some people with
30:24 private insurance
30:26 if you try one of the cgrp antibodies or
30:29 botox
30:30 the insurance company will ask for proof
30:34 right so the proof might be a headache
30:36 diary
30:37 numbers of days and questionnaires or
30:40 different scales or
30:42 that you have to fill all of this is
30:44 done with the help of your doctor
30:46 what about public drug plans okay so
30:49 that’s something that is
30:50 quite interesting we could do a full
30:52 webinar on this
30:54 and let me just walk you uh through it
30:57 so how does it work for a drug to be
31:00 covered by
31:01 a public drug plan in canada for the
31:04 record
31:05 i’m a doctor i’m a neurologist i work in
31:08 advocacy
31:08 i didn’t know any of this four or five
31:12 years ago
31:13 and i doubt that all of my colleagues in
31:15 neurology know these things
31:16 right this is not something of common
31:18 knowledge
31:20 okay so let’s say a pharmaceutical
31:21 company puts
31:23 product a and says okay the health
31:25 canada approves it
31:26 it’s safe it’s effective um then they
31:29 can submit
31:30 to cadif so this this is a public agency
31:34 for drugs technologies and health
31:36 so cadif will look at all the results of
31:38 the research about the drug
31:39 and say okay you know it looks like it
31:42 has
31:43 a value to treat people and the cost
31:46 uh could make it it’s possible that the
31:49 cost could be worth it
31:51 so that’s the first step when this
31:53 happens
31:54 migraine canada gets in right and we
31:57 propose
31:58 a report so we act on your behalf and we
32:00 ask
32:01 you to participate in surveys to send
32:04 cadif and say
32:05 yes people with migraine need new option
32:08 because migraine
32:10 you know is disabling um and here is
32:13 what people with migraine go through
32:15 this is our role this is what we do and
32:17 then this is a public thing the reports
32:19 are public
32:20 um you can find all of this on their
32:22 website once cadet says
32:24 yes yeah we recommend that this is
32:27 covered
32:28 um then it goes confidential it goes to
32:30 something called the pcpa
32:32 where all the um there the
32:34 pharmaceutical companies sit
32:36 and they discuss about what costs would
32:39 be reasonable to price this drug
32:41 in canada right and those those
32:44 discussions can take a while
32:45 and they are confidential then they come
32:48 up with a cost a reasonable cost for our
32:50 country
32:51 and then all of this goes to the health
32:54 ministry
32:55 of your province right and at this level
32:58 this is the final decision to say based
33:00 on what
33:01 khadif says based on the cause that is
33:04 agreed by pcpa
33:05 centrally in canada are we quebec
33:08 ontario
33:09 alberta cover this drug and this is
33:13 where migraine canada can also
33:15 act with advocacy and by actually
33:17 writing to the health ministers and
33:19 saying
33:20 hey migraines common migraine is
33:22 disabling
33:23 and so on right so this may look dry to
33:26 you
33:26 but it is extremely relevant because it
33:29 is actually
33:29 how you can access drugs if you are
33:33 on public coverage and once this is done
33:36 usually the drug the public coverage
33:39 will work exactly the same way
33:41 with criteria and forms that doctors
33:44 will have to fill
33:45 with your information okay
33:49 so so we we covered quite a lot of
33:51 ground so we started from you know when
33:53 to start prevention
33:54 lifestyle supplements and pills and
33:57 botox and cgrp antibodies
33:59 i wanted to just mention and say a few
34:01 words about
34:03 neural modulation devices that’s another
34:06 webinar we could do if you
34:07 uh want one um so these devices are not
34:12 chemical they don’t
34:13 enter your body right they they act
34:15 through stimulating
34:17 the nerves to modulate the pain system
34:20 in your head
34:21 and by doing so they quiet down the
34:23 migraine activity
34:25 so separately has been around for a
34:27 while uh you can
34:28 buy it easily you don’t need a
34:30 prescription for it
34:32 i think to the last minute i checked it
34:34 was 300
34:35 i’m sorry my cat is
34:38 um it was 250
34:42 uh to buy one of these and it sends
34:44 impulses on their forehead
34:46 modulating and decreasing migraine
34:48 frequency so there’s
34:50 reasonable evidence about cephali
34:52 especially for episodic migraine
34:54 gamma corset fire is a vagus nerve
34:58 stimulator
34:58 it the vagus nerve is a nerve that runs
35:00 to the neck it goes
35:02 to the body organs it is a very
35:04 interesting device i think we we should
35:06 soon we’ll have a page on it promise and
35:09 so this device
35:11 has effectiveness also for migraine
35:13 prevention
35:14 the problems with neuromodulation
35:16 devices and i’ll be very honest
35:18 they require you to use them regularly
35:22 and that’s the way it works it it
35:24 doesn’t take like days or even weeks
35:26 it takes multiple weeks of regular used
35:29 to
35:30 actually provide the benefit um and the
35:33 costs can be also prohibitive so gamma
35:35 core will cost for example i think it’s
35:37 around six hundred dollars per month
35:39 and that’s not easy for everybody to
35:41 afford and
35:42 coverage is also difficult to negotiate
35:45 so i think these options can be
35:47 very interesting especially if drugs are
35:49 not an option
35:50 or if someone cannot use medications or
35:54 they want to try something different and
35:56 very well tolerated but there are also
35:58 there are pros but there are cons so we
36:00 can talk more about this
36:01 maybe in a future webinar g-pads
36:04 so if you follow the migraine activity
36:07 you might have seen the names ubrelvi
36:09 and nurtech
36:10 from our neighbors in the u.s so g-pans
36:14 are new drugs so they are actually pills
36:17 that block cgrp
36:19 so we have antibodies for cgrp um but
36:23 these are pills that block the cgrp cgrp
36:26 receptors so
36:28 bradley and nerdtech are approved in the
36:30 u.s they are not yet approved in canada
36:33 uh atoji pant is a preventive drug
36:36 and so here you can see the big change
36:39 the big change
36:41 is that these drugs are acute
36:44 and preventives interesting right
36:47 so if you use acute meds for migraine
36:50 you
36:50 probably know that if you use them too
36:52 often you fall
36:54 into the dreaded medication over you
36:57 situation
36:58 where you have more headaches because
37:00 you’re taking too many
37:01 tylenols or tryptons or opioids or
37:05 whatever
37:06 so this was a dogma and this this is
37:09 something very difficult to deal with
37:11 because the more migraines you get the
37:12 more
37:13 you want to treat and so on with g-pens
37:16 it might actually reverse you might say
37:19 i use a g pen for my attack i block cgrp
37:22 and then the more attacks i have the
37:24 more depend i take
37:25 and i’m not going to go into overuse it
37:28 may
37:28 actually protect me against further
37:31 attacks
37:32 this is not proven this is not yet
37:35 proven but we can just
37:36 deduct that if a gpan can be used for
37:39 prevention
37:40 it’s very unlikely to cause medication
37:43 overuse headache right
37:44 so this is something very new this is
37:47 very interesting
37:48 and they are expected in canada
37:50 hopefully in 2022
37:52 maybe 2023 we will see stay posted
37:56 hey so all this is very new this is very
37:59 new for me
38:00 a headache specialist this is very new
38:02 for my
38:03 neurology colleagues this is extremely
38:05 new to family practitioners
38:07 so the truth is that doctors in general
38:10 in in this country particularly don’t
38:13 have a lot of training on headache
38:15 medicine
38:16 so the last three years since the
38:18 arrival of
38:19 emmavig in 2018 have been
38:23 a show of new things of new science of
38:26 new data
38:27 so things are evolving quickly you know
38:29 insurance companies
38:30 advocacy policies um
38:34 and science of course so all of this
38:36 moves so fast
38:37 that for some doctors you know that you
38:40 cannot expect them to be on top of
38:42 everything especially family
38:44 practitioners so more
38:46 options also lead to more questions and
38:48 more complexity
38:49 for you when you make your decisions
38:53 and so you might say okay i want to see
38:55 a headache specialist now
38:56 but if you you probably know that
38:58 waiting lists to see
39:00 headache specialists are very long one
39:02 of the reasons for this
39:03 it’s because there’s not a lot of
39:05 incentives
39:06 for young neurologists to become
39:08 headache specialists in this country
39:10 i’m making a political point here
39:12 something dear to my heart
39:14 i think headache medicine should be
39:15 taught way more during residency
39:17 programs and neurology
39:19 so your neurologists are better trained
39:21 and more neurologists
39:23 decide to take up headache medicine as a
39:26 specialty or
39:27 as a you know something that they want
39:29 to be good at
39:30 so that’s a problem that we will address
39:32 hopefully in the future
39:34 okay so i look at the time perfect so i
39:37 have a few more minutes and then you can
39:39 ask
39:39 questions um you’re here because you’re
39:43 interested because you want to do
39:44 something
39:45 because you want to get better right or
39:48 maybe help someone you love
39:49 getting better so here’s a little
39:53 list of things you might decide to do
39:55 after this webinar
39:58 you might go and explore our information
40:00 resource
40:01 the the web is a fantastic tool but
40:04 there’s a lot out there
40:06 that might be great there are very good
40:08 sources you know migraine world summit
40:10 is one
40:11 the american migraine foundation is one
40:13 but
40:14 migraine canada is your canadian source
40:17 of migraine information
40:19 so the migraine tree is our our way of
40:21 putting this
40:22 out right and to you um so this is
40:26 a library of 120 pages on different
40:29 topics
40:30 the way it’s organized is that if you
40:32 look at roots
40:33 of the tree roots are all about the
40:36 types of migraine
40:37 the types of headache the interaction
40:40 between
40:40 migraine and other health conditions a
40:43 hormone issue
40:44 children issue so the roots are really
40:47 where you start from
40:49 then we go to the trunk so the trunk or
40:51 the core
40:52 is basics what what everybody with
40:55 migraine should read and should know
40:57 right so this is very uh is to be
40:59 explored by virtually anybody with
41:01 migraine
41:02 and the branches as you can see they’re
41:04 all equal
41:05 there’s not one bigger there’s not one
41:07 smaller they’re all equal because if you
41:10 live with migraine
41:11 you will have to look at different
41:13 options
41:14 so all branches are about lifestyle as
41:17 we discussed
41:18 uh social life is to be um built up and
41:21 we want to have to have actually your
41:23 input about this how to
41:24 organize your life with your friend your
41:26 family or colleagues
41:28 acute therapy preventive therapy
41:31 devices and neuromodulation and and
41:33 procedures and injections
41:35 so i encourage you to explore this and
41:38 for example
41:38 if you want to read about prevention um
41:41 this is the branch of prevention with
41:43 all the leaves so the leaves are the
41:45 articles um and then you go and you can
41:47 go and read about you know how to try
41:49 preventive
41:51 lists of preventives long-term risks
41:53 cgrp antibodies botox and so on
41:56 so this is how the migraine tree is
41:59 organized so
42:01 we hope that the tree is helpful to you
42:04 the second thing you can do is use a
42:06 headache diary
42:08 maybe your doctor is not asking for one
42:10 maybe your doctor doesn’t know
42:12 he or she should be asking for one but
42:14 we recommend you to do a diary
42:16 you can do paper you can do an app if
42:19 you do an app
42:20 please try the canadian migraine tracker
42:22 once again this is a canadian resource
42:24 it’s been designed by the canadian
42:26 headache society and
42:28 it’s designed to be simple stay tuned
42:30 for more videos on
42:32 about how to use this um because this is
42:35 really
42:36 you know migraine migraine cannot be
42:39 seen on an mri
42:41 but it can be seen on a headache diary
42:43 right so the mris and
42:45 the ct scans are not very helpful to
42:47 manage migraine
42:48 a headache diary is a headache diary is
42:50 like
42:51 the tsh if you have thyroid problems you
42:53 know or creatinine or glucose if you
42:55 have diabetes
42:56 so it’s really something just gives you
42:58 an idea how things are
43:00 and it can help okay so we hear a lot
43:04 from you
43:04 that gps don’t know a lot about migraine
43:07 we hear it
43:08 we know it um luckily the canadian
43:11 headache society which i’m very
43:13 privileged to be the president of
43:15 um has designed a program to teach gps
43:18 about migraine this is a full-fledged
43:20 program
43:21 accredited which means that they can get
43:23 credits
43:25 and this is going to be launched in july
43:27 just very very soon we’re just finishing
43:29 the last little
43:30 pieces so stay tuned because you might
43:33 actually we will give you more
43:35 information and you might go to your gp
43:37 and say hey you know i heard there’s
43:38 this great program by the canadian
43:40 headache society
43:41 um about migraine and maybe you know you
43:45 can you can have a look at that
43:47 we all know doctors might not you know
43:49 might be sensitive about being told what
43:50 to do from patients but
43:52 you know advocate for yourself if you
43:54 find that your doctor doesn’t know or
43:55 your doctor says that oh i’m not sure i
43:57 don’t know
43:58 here’s where they can find training
44:02 another thing you can do is involve your
44:04 pharmacists so
44:05 pharmacists are great people they know
44:07 tons about medications
44:09 and i want to share with you a resource
44:11 that is led by the mckesson group which
44:14 is a
44:14 pharmacy distributor group in canada
44:17 it’s called
44:18 the migraine pharmacy network this is
44:21 this is actually a great program i had
44:23 the privilege of working on it
44:25 um and this allows you to book an
44:28 appointment for migraine assessment
44:30 with a trained pharmacist you can do
44:32 this online
44:33 on the weld.ca platform so you go at
44:36 welded ca
44:37 and you just type migraine um and then
44:40 you’ll find
44:41 this uh this uh this website
44:44 and of course it’s you know it’s
44:46 commercial website you will see
44:47 different things
44:48 about migraine that could interest you
44:50 supplements pillows and so on
44:52 but you can book this assessment and
44:54 then the pharmacist will go over your
44:56 migraine situation
44:58 which you design a global care plan
45:01 involving
45:02 everything and then sending to your
45:03 treating physician
45:05 so this can actually help you revising
45:08 your migraine story
45:09 and checking what you’ve tried so far
45:12 what happened
45:13 and the pharmacist can then make
45:15 recommendations about maybe this person
45:17 should try this or this or that
45:19 right so that’s a very interesting
45:20 option
45:22 we know it’s very difficult to find
45:24 headache clinics and we just
45:26 put up a headache clinic locator this is
45:29 a bit of a challenge because there’s no
45:31 clear definition of what a headache
45:34 clinic
45:34 is but we are working very hard to add
45:38 more clinics um and soon we’ll have also
45:42 pediatric
45:42 headache clinics in there so have a look
45:45 but it’s not
45:46 yet complete and we really hope to
45:48 develop it
45:49 so you can find uh access to a headache
45:52 specialist in canada
45:54 if you want to find a botox injector so
45:57 once again this is a website that
45:59 belongs
46:00 with it is managed by otergan canada or
46:02 avi now
46:03 this is a very useful resource if you
46:06 are looking for a botox
46:08 injector some of these injectors are
46:10 also headache specialists or pain
46:12 specialists but
46:14 some are you know people cosmetic
46:16 surgeons who do like
46:18 who have been trained to treat a
46:21 migraine with botox
46:22 but not all of these injectors will
46:25 provide
46:25 a global management of migraine right
46:28 but if you have someone who says yes i
46:31 think botox is good for you when you’re
46:32 looking for
46:33 for someone and you want to look by
46:35 postcode my chronic migraine.ca
46:38 uh can be a very good resource and i
46:40 think the website is going to be soon
46:42 updated in an improved version
46:45 so we’re close to finished now we’ll
46:48 have time for questions
46:50 um i’ve been dealing with people with
46:52 migraine for
46:54 12 years now plus my fellowship um
46:57 and all the team of migraine canada is
46:59 like me we want people to get
47:01 better okay so we really want to help
47:04 you um
47:05 but to help you we need your voice and
47:07 support because this
47:08 is a public health care system in canada
47:11 and this is not a system led by money it
47:14 is led
47:15 by our people and you who are voters
47:18 so here’s our petition and here’s what
47:20 we’re working on
47:22 we want people with migraine not to be
47:24 blamed or shamed or stigmatized
47:27 we want healthcare providers to be
47:29 educated
47:30 about migraine diagnosis and treatment
47:32 very important
47:34 we want that treatments evidence based
47:37 if the effective and science-based
47:39 treatments
47:40 whatever treatments these are are
47:42 accessible
47:43 that includes drugs behavioral
47:46 neuromodulation
47:47 anything we want employers to be
47:50 informed
47:51 about the impact of migraine in the
47:53 workplace so
47:54 you can get accommodations and you can
47:56 be recognized
47:58 as a worker you know in the workplace
48:00 and not be stigmatized
48:02 we want teachers and school personnel to
48:05 be educated
48:06 to better support children with migraine
48:08 so we’re working on all of this
48:10 there’s more we want that people with
48:13 migraine
48:14 are protected from financial abuse by a
48:17 group
48:18 who sell sell you cures right sell you
48:20 stuff
48:21 and that’s that’s not proven effective
48:24 we want that migraine will be recognized
48:26 as a cause of disability how many
48:29 patients you know are off work because
48:30 of migraine and struggle
48:32 to actually find to have their
48:35 disability recognized
48:37 we want headache medicine to be
48:39 supported in departments of neurology
48:41 and family medicine and any other
48:43 department
48:44 so doctors are trained properly and
48:46 research is being
48:48 done also which in canada is really
48:50 lacking
48:51 and finally we want associations to
48:53 support people with migraine to find
48:55 information
48:56 find support and advocate for a better
48:57 quality of life so this is really our
49:00 dream this is what we’re going to do
49:02 and uh if you want to lend us your
49:04 support well go on our website
49:06 facebook instagram instagram um
49:09 linkedin wherever you want to go listen
49:11 to our podcasts
49:12 whatever uh you prefer videos
49:15 podcasts pdfs website we hope we can
49:18 help