Migraine Diagnosis & Treatment

0:05 the way that I I structured things today
0:07 is really first to to Define and discuss
0:10 the diagnosis of migraine what comes
0:13 with migraine how does migraine actually
0:15 affect an individual and then to launch
0:18 into what is available for treatment and
0:21 how do we decide on what to treat
0:23 someone with and how do we gauge a
0:25 proper response to treatment and what’s
0:27 even available to us in Canada and then
0:30 I also I wanted to end with a bit of
0:33 advice and tidbits and obviously this is
0:36 my own experience but how to chat with
0:39 your healthcare provider about this
0:42 problem to really help you communicate
0:44 your needs and to help us as healthare
0:47 providers to help you better because uh
0:49 all of us who who actively treat migrant
0:52 in Canada our goal really is to help so
0:55 uh if we can improve our communication
0:57 then we’ll be doing an even better job
0:59 so
1:00 so what is migraine and you know there’s
1:03 a lot of fallacies out there about what
1:06 migraine is not but what migraine is is
1:09 it’s what we call a primary headache
1:10 disorder and what I mean when I say a
1:13 primary headache disorder that means the
1:15 type of disorder where we can’t see an
1:17 identifiable cause either on Laboratory
1:20 Testing like blood tests or Imaging
1:22 tests like MRI or CAT scans and the way
1:25 we make a diagnosis of migraine is based
1:28 on the history that someone is able to
1:30 provide us and based on the symptoms
1:32 that someone is able to report so our
1:35 confidence and our ability to diagnose
1:37 someone is is Reliant a little bit on on
1:39 how someone’s able to communicate their
1:41 symptoms to us it is what we call an
1:44 invisible disorder in that even though
1:46 it presents with a ton of symptoms that
1:49 can be very disabling and very very
1:51 important it’s not something that other
1:53 people can see and for that reason it’s
1:55 something that often get gets dismissed
1:58 by other people and often does not
2:00 Garner the attention that it deserves
2:03 and I’m always careful when I’m telling
2:05 somebody that they have migraine that
2:07 that that I’m not telling them that they
2:10 have just migraine because migraine is
2:13 an important organic disorder of the
2:15 brain that can lead to significant
2:17 impairment and in significant impairment
2:19 in quality of life and while migraine is
2:22 not something that limits one’s
2:24 longevity it can definitely limit um the
2:28 quality of one’s life while while there
2:30 living and and migraine affects people
2:33 most during what we would call our Peak
2:35 productive years so the people who are
2:38 most affected by migraine are the people
2:40 who are in their 20s to 50s the people
2:43 who need to be at work the people who
2:45 are trying to have families the people
2:47 who are up for promotions the people who
2:48 are just trying to succeed let alone let
2:51 alone just trying to live their life and
2:53 get some enjoyment out of life so these
2:54 are the people who are most affected
2:56 that’s not to say that it does not occur
2:58 in children that’s not to say that it
3:00 does not occur in older adults but this
3:02 is the bulk of who we deal with and it
3:04 is a condition that occurs throughout
3:06 the life cycle so it may change
3:08 throughout one’s life cycle and um and
3:12 it may change in different phases of
3:13 someone’s life like pregnancy
3:15 menstration all these other things that
3:17 can also affect migraine which I’ll get
3:18 into in a little bit as well what we
3:21 know about why migraine happens so it’s
3:24 caused by a release of what we would
3:25 call neuropeptides so there’s a bunch of
3:28 chemicals that can get released in the
3:30 brain which then activate pain circuits
3:33 in the brain it’s a process that we’ve
3:35 termed neurogenic inflammation and
3:37 there’s a whole lot of these specific
3:39 molecules that we know are important but
3:41 the one that we found over the last few
3:43 decades is probably the most important
3:46 is one called cgrp and that becomes
3:49 important based on some of the
3:50 treatments that I’ll discuss later on so
3:52 just kind of keep that in
3:54 mind so migraine is obviously you know
3:58 very important and disabling and and why
4:00 we’re here today but what what some
4:03 people don’t realize is that while
4:05 migraine is probably the most important
4:07 thing that we see in clinical practice
4:09 it’s not actually the most common type
4:11 of headache the most common type of
4:13 headache would be what we would call
4:14 tension type headache but by def
4:16 definition attension type headache is
4:18 usually what we would consider to be a
4:20 mild or moderate or often non-disabling
4:22 headache so the mere fact is someone is
4:25 asking for help and is finding that
4:27 their headache is disabling enough to
4:29 actually see a practitioner the
4:30 likelihood of it being migraine goes way
4:32 way up so that’s just sort of some
4:34 interesting
4:35 statistics um I will not I will not go
4:39 through this very busy slide but I do
4:41 want to be transparent on how we make
4:43 the diagnosis of migraine and I’m not
4:45 going to go through all of these details
4:47 but I I do want to point out that for
4:49 example if someone has had a headache
4:52 that lasts for four or more hours that
4:55 is bad enough that they have to stop
4:57 what they’re doing so it’s moderate and
4:58 it’s worse when someone moves around and
5:01 then you have some nausea associated
5:02 with it that is sufficient to have a
5:05 diagnosis of an individual migraine
5:07 attack so it is important to kind of
5:09 keep that in mind that a lot of folks
5:12 may come into their doctor and not
5:13 realize that what they’re experiencing
5:15 is migraine and if someone does not
5:17 delve if a healthc care practitioner
5:19 does not delve a little deep enough into
5:20 what they’re experiencing they may also
5:22 miss some of these Cardinal things that
5:25 can make uh can make a diagnosis of
5:27 migraine
5:29 so when it comes to migraine diagnosis
5:32 so we know that it’s a condition that’s
5:35 at least partly related to genetics
5:36 probably vastly related to genetics but
5:39 we haven’t identified all of the
5:41 important genes that we know are passed
5:43 down that lead to migraine however it is
5:45 a condition that while there’s genetic
5:48 what we would call susceptibility it’s
5:50 influenced by the environment so it’s
5:53 not that the chocolate someone just ate
5:56 or the weather that just changed was the
5:58 cause of their migraine migraine is a a
6:01 condition that someone has that is
6:03 influenced by those external factors
6:05 making it more likely for someone to get
6:06 an individual migraine attack and as I
6:09 mentioned before the frequency or how
6:11 much migraine affects someone can vary
6:14 significantly throughout one’s life and
6:16 for some people there might be many
6:17 years where they don’t experience
6:20 attacks at all and then it may come
6:22 roaring back um and and one of the more
6:24 common times we see that especially for
6:26 women is in the per menopausal period so
6:29 it may that someone doesn’t understand
6:31 gez why am I getting headaches now in my
6:33 in my 50s when I haven’t really had one
6:36 since I was 17 and a lot of it really is
6:38 just changes in in people’s environment
6:41 and environment in the case of migraine
6:43 can relate to the internal environment
6:45 so what’s happening within you other
6:47 health conditions you name it or the
6:49 external environment triggers Foods
6:51 weather you name it and uh even though
6:55 these things can lead to an attack they
6:57 are not the cause of migraine and un
6:59 fortunately when someone has migraine
7:02 they will always have migraine it’s
7:04 really about how much it’s active versus
7:07 inactive the way that we then further
7:10 categorize migraine um is in a couple of
7:13 different ways based on the symptoms
7:15 that come with it and then also based on
7:17 its frequency the frequency of attacks
7:19 that people report so we we look for
7:23 something called Aura and I’ll talk a
7:25 little bit about what Aura is but
7:27 basically what an aura is is
7:30 something that can occur like a
7:31 neurological symptom that can occur
7:33 either before or during or some time
7:36 association with a migraine attack and
7:38 I’ll again I’ll talk a little bit more
7:39 about that as we go so we categorize it
7:41 as migraine with aura or migraine
7:43 without Aura and then depending on how
7:46 often these attacks occur then we may
7:48 either term it chronic migraine or
7:50 episodic migraine
7:52 and to put it in the simplest terms if
7:55 there’s something there some kind of
7:57 headache there at least 15 days in a
7:59 month so half the time or more we call
8:01 it chronic migraine and if it’s less
8:04 than this we term it episodic migraine
8:06 and and the reason that can be important
8:08 is not only for you know proper
8:10 diagnosis but also because there are
8:12 certain treatments that may have
8:14 evidence or have an indication for one
8:17 but not the other so that’s why it’s
8:19 important to get a specific diagnosis
8:21 not just a diagnosis of migraine in
8:23 general but we do know that chronic
8:26 migraine is the more severe form of
8:29 migraine and that it affects people more
8:31 it affects people’s quality of life more
8:33 than episodic migraine does and there
8:35 are some risk factors that we know like
8:38 let’s say someone has episodic migraine
8:40 but what puts them at risk for then
8:42 going on to develop a more severe form
8:44 of migraine and some of these things are
8:46 things we can modify and some of these
8:48 things are things that we cannot modify
8:50 but they’re things that we may look for
8:52 as healthc care providers to say geese
8:55 if someone has all of these things I
8:56 might be more likely to offer them
8:58 treatment earlier on in their course to
9:00 prevent a more severe form of a disorder
9:03 so we know that if someone has four or
9:05 more monthly migraine days at their
9:08 Baseline that is in and of itself a risk
9:10 factor for them developing more migraine
9:12 down the road we know that if people
9:15 have psychiatric disorders like anxiety
9:17 or depression while those are not the
9:19 cause of migraine they can be the reason
9:21 why migraine gets worse or can be the
9:23 reason why migraine does not improve so
9:26 if those are also there that might make
9:29 us more likely to want to address it
9:31 earlier we know that if people are above
9:34 an optimal body weight it also puts them
9:36 at a higher risk for developing chronic
9:38 migraine and of course things we can’t
9:40 affect is lower level of education and
9:42 being
9:43 female so really what we want to do is
9:46 like we have to think about migraine as
9:48 as a Continuum um
9:51 so someone who has what we call episodic
9:53 migraine may fall to the left on this
9:56 chart and someone who has chronic
9:57 migraine might be towards the right
9:59 where there’s sort of some degree of
10:01 attack all the time or or a near daily
10:04 headache or very minimal recovery
10:07 between individual migraine attacks and
10:09 if we let migraine go untreated then it
10:13 can turn into the chronic form and
10:14 really what we what we hope for with
10:16 proper treatment is we take we take
10:18 severe impairment and we turn it into
10:20 mild impairment if we’re able to and
10:22 we’ll talk more about a little bit about
10:23 what those treatment objectives are
10:25 later so Aura which I mentioned before
10:29 so an aura is is a neurological syndrome
10:32 that occurs at some point in
10:34 relationship to a migraine attack only
10:37 about 20 to 30% of people who have
10:38 migraine actually have an aura and
10:41 generally speaking in terms of diagnosis
10:44 the M that aura should last between five
10:46 and 60 minutes and occur within close
10:48 proximity to a migraine attack there is
10:50 some Nuance to that that’s a little bit
10:53 um a little bit beyond what what our
10:55 time to discuss is today but uh
10:57 something to keep in mind some people
10:59 have Aura may not have Aura with every
11:01 single headache so some people may have
11:02 migraine with aura and and migraine
11:05 without Aura in the same individual and
11:07 what we think about Aura as being is
11:10 it’s a it’s a symptom that’s represented
11:13 from um that’s caused by altered
11:16 Electric electrical activity in the
11:17 brain that we call cortical spreading
11:20 depolarization or CSD and this is this
11:24 is what we’ve learned over the past few
11:25 decades which has really allowed us to
11:27 study migraine a little bit more and and
11:29 really learn about a lot more about why
11:31 migraine happens and which eventually L
11:33 us down the pathway of finding more
11:36 treatments so what else happens with
11:39 migraine besides Aura because there’s a
11:41 lot we don’t talk about that the phase
11:43 of when someone is in pain and having
11:45 you know a severe or moderate headache
11:47 with light sensitivity and nausea that
11:49 part’s a little bit easier for us to
11:51 tell but there are sort sort of hidden
11:54 phases of migraine that people won’t
11:55 always recognize and I’ll show you a
11:57 little schematic of that in a moment but
11:59 but what I think is really important to
12:00 note is that there’s both a prod Drome
12:03 and a post Drome and some people will be
12:05 able to clearly identify this and some
12:07 people will not and some people will
12:10 only notice that it happens or you you
12:12 may be talking to someone about it and
12:13 you’ll kind of see the light bulb go off
12:16 whe when you tell them about it because
12:17 they think oh wow I have experienced
12:19 that and why this is so important is is
12:22 I want you to think about what a
12:24 migraine attack can really be so let’s
12:27 say someone has one migraine a week
12:30 you know that that may not seem so bad
12:32 on the surface but if that pain phase
12:34 that we talk about is lasting for two
12:37 days and then on either end you have a
12:39 prod Drome and a postdrome that can be
12:42 the better part of a work week and what
12:44 a prodrome is is sort of a it’s a state
12:47 of being more susceptible to a severe
12:50 pain attack where your brain is more
12:52 hypers sensitized to that people might
12:54 feel irritable maybe their mood is
12:57 affected sometimes they yawn more
12:59 sometimes they pee more and this is the
13:01 phase where someone might be susceptible
13:04 to a trigger where they ordinarily would
13:06 not and this is why I sometimes have
13:08 people say you know sometimes I can have
13:10 a glass of wine and be fine and then
13:12 other times I have a glass of wine and
13:14 boom I have a migraine attack and there
13:17 is some evidence now mounting that
13:19 suggests that prodrome might actually
13:22 cause food cravings or may actually
13:24 alter our Behavior so it might not be
13:27 that that food you ate caused a migraine
13:30 attack it might be that the migraine
13:32 attack caused the behavior that led to
13:34 it so it’s it’s a very fascinating field
13:37 of research that we’re learning more and
13:38 more about and then when the sort of
13:41 pain phase is over is when you have a
13:43 pro Drome or post Drome pardon me and
13:46 people who experience a postr almost
13:49 liken this to a hangover without the fun
13:51 the night before so this again can last
13:54 for hours or days so if you have hours
13:55 or days on either end of that migraine
13:57 attack this could be an entire work week
13:59 with one single attack and then if you
14:01 take someone with chronic migraine who’s
14:03 having a ton of migraine attacks they
14:06 may never fully recover and even when
14:08 they’re not in a pain phase they may be
14:10 in sort of a Perpetual state of either
14:12 being in their prodrome or postdrome or
14:14 some mixture of the two and this is why
14:16 there’s so much invisible disability
14:19 that comes with migraine because nobody
14:20 can tell when someone is is is
14:22 experiencing these symptoms so what we
14:27 know is during a migraine attack it’s
14:29 PE first of all it’s
14:31 undertreated it’s underdiagnosed it’s
14:34 not accurately diagnosed a lot of the
14:36 time and people are often left to try to
14:38 deal with this on their own without
14:40 appropriate education as to what they’re
14:42 dealing with or exactly how they can
14:44 access proper treatment and why this is
14:46 so important is that almost everybody
14:48 reports impairment during a migraine
14:50 attack with over half of people
14:52 reporting severe impairment or requiring
14:55 bed rest during a migraine attack now
14:57 how is someone supposed to be at work or
15:00 raise children or be successful
15:02 advancing their careers if they’re
15:03 needing to go to bed to deal with their
15:05 headache attack so I think these are all
15:08 important things to to think about and
15:10 and it also we’re looking more and more
15:13 um in terms of when we research migraine
15:16 about what we call presentism when
15:19 people are at work but they’re not
15:21 really at work you know they’re
15:22 physically present but they’re really
15:24 not functioning to at a at a normal
15:26 degree and these are things that we
15:28 think about as Healthcare Providers too
15:30 because this is sort of again how how
15:33 much migraine is affecting someone’s
15:35 life so unfortunately despite despite us
15:39 knowing more and more about migraine it
15:41 does still carry an Associated stigma
15:43 it’s often poorly understood by people’s
15:45 families people’s employers and it’s
15:48 often perceived as being just a headache
15:50 despite the fact that we know migraine
15:52 is a disabling neurological disease and
15:55 and it also can impact important life
15:57 decisions so if someone is dealing with
15:59 really you know disabling or frequent
16:02 migraine they may put off Family
16:03 Planning they may choose not to go for a
16:06 promotion that they’re wanting to go
16:07 ahead with they might limit travel they
16:09 may realize gez whenever I go to a new
16:11 time zone I get just this god- awful
16:13 attack and I can’t enjoy my vacation so
16:16 it it it may seem like not such a big
16:18 deal but if if people are putting off
16:21 things that make them otherwise happy
16:23 then that is a way that migraine causes
16:25 another sort of IND in invisible symptom
16:29 so what else occurs with migraine
16:31 because what I haven’t mentioned is how
16:33 common migraine is so migraine affects
16:36 depending on what study you read you
16:37 know 12 to 15% of the entire population
16:40 more women than men but you know an
16:43 enormous amount of people in Canada are
16:44 affected by migraine and they we like to
16:46 say about one in four households has at
16:49 least one member who has migraine in it
16:52 and because of that so many other
16:54 conditions can occur with migraine and
16:56 and of course this is a limited amount
16:57 and many people that have more
16:59 conditions associated with migraine but
17:00 the most Commons common ones we see are
17:03 anxiety depression childhood adversity
17:06 and all of those while none of them are
17:09 the cause of migraine all of them can
17:11 influence the severity of the disease
17:14 and then what we see as well is other
17:16 things that can make migraine worse are
17:17 what we call medication overuse headache
17:20 which I’ll talk to you a little bit
17:21 later on and then affected by sex
17:23 hormones so menstruation ovulation
17:26 menopause pregnancy all of these things
17:29 can impact how much migraine affects
17:32 somebody so with that said I want to
17:35 launch into a little bit about the ways
17:37 in which we treat migraine so by and
17:40 large there are two types of strategies
17:43 that we think about and some people will
17:46 require one some people will require
17:48 both unfortunately treatment is not
17:51 Curative so there is no cure for
17:52 migraine what we really try to do is to
17:55 reduce the symptom burden and try to
17:57 improve function and the two types of
18:00 treatments that we have are acute
18:02 treatment which you may have heard
18:04 referred to as rescue treatment or
18:06 abortive treatment they all mean the
18:07 same thing or and or preventative
18:10 treatment or preventive treatment um
18:12 which will talk about the specifics of
18:14 both and about what’s sort of available
18:16 and how to navigate how to navigate both
18:19 to the best of your ability so acute
18:21 treatment is really aimed at treating an
18:23 individual attack and the way that I
18:25 like to say this is what can we do to
18:27 get you your day back so that you’re not
18:29 in bed suffering with a migraine attack
18:32 what we aim for is a reversal of pain or
18:36 Improvement in pain if we can’t get full
18:37 reversible reversal uh improvement with
18:41 their most bothersome symptoms so not
18:43 just pain relief but if someone has
18:45 light sensitivity that is the most
18:47 bothersome symptom we also need to try
18:48 to aim for that or if nausea is the most
18:51 bothersome symptom we also may need to
18:53 try to aim for that and I can’t stress
18:55 this part enough but a return a return
18:57 to normal function so if someone has a
19:00 treatment of an individual attack but it
19:02 makes them feel like garbage then it’s
19:04 probably not the right treatment for
19:06 them so we also want to see no
19:09 recurrence of that migraine attack and
19:10 we also want to see something that can
19:13 either produce no or minimal side
19:15 effects doesn’t that sound great I mean
19:17 unfortunately not every treatment is
19:19 perfect and there is a little bit of a
19:21 trial and error process to find the
19:23 right thing for the right person and
19:25 what we often see is being issues or
19:27 barriers to acute treatment are side
19:30 effects of treatment which are common
19:32 access to treatment so either provider
19:34 Healthcare Providers not knowing what is
19:36 appropriate or patients not knowing what
19:37 to ask or both uh cost some people don’t
19:40 have coverage for medications efficacy
19:43 not everything works for every
19:44 individual and when you have a disease
19:47 as far-reaching as migraine there’s an
19:49 enormous amount of um differences
19:52 between people so what worked for you
19:54 know your friend down the road who has
19:55 migraine may not work at all for you um
19:58 and then you know some we have newer
20:00 agents so we don’t have as much
20:01 long-term safety data um which might
20:04 complicate which treatment decisions we
20:05 can make and then as I mentioned I’ll
20:08 mention later issues that come with
20:10 overusing acute treatment which you know
20:12 a lot of people are also not educated on
20:14 so how can you how can you be aware that
20:18 using something too often is causing you
20:20 harm unless someone tells you and
20:22 unfortunately it’s not something that’s
20:24 listed on medication bottles when it
20:26 should
20:27 be so
20:29 what medication overuse really occurs
20:32 when a medication is int that’s intended
20:34 to treat an individual attack leads to
20:37 worsening headache over time and
20:39 generally speaking we like to say that
20:41 it occurs with a a pattern of overuse
20:43 that LE that lasts for about three
20:45 months and different medications have
20:48 different thresholds for causing
20:49 medication overuse headache so certain
20:52 like typical to give you an example um
20:55 typical over-the-counter type pain
20:57 relieving medication
20:59 often can lead to medication overuse
21:01 with about 15 days of use per month
21:04 whereas some of the other treatments are
21:05 more like 10 days a month but there’s
21:08 you know of course there’s variance
21:09 between individuals these are these are
21:11 guidelines that we use and we don’t
21:13 punish people for you know having a bad
21:15 month here and there it really is about
21:16 a pattern and and really if someone is
21:19 needing to to treat an individual attack
21:22 that often that is also a symptom of a
21:24 poorly treated disorder that needs more
21:27 attention from a preventative standpoint
21:28 point which will which will come to
21:30 later so how do we choose because
21:33 there’s so many things to choose from so
21:35 one of the things that I look for uh and
21:38 many and many people who treat headache
21:39 look for is what are some Associated
21:41 symptoms with that you have with your
21:42 migraine attack if you have nausea or
21:45 vomiting very very early in your in your
21:47 migraine attack using an oral medication
21:49 is probably not going to be the best
21:51 answer especially if you’re going to
21:52 bring it right back up if the headache
21:54 escalates extremely quickly again we
21:57 might need a non-oral medic because if
21:59 you think about how a medication has to
22:01 become effective someone has to swallow
22:03 it it then has to be absorbed into the
22:05 stomach and then into the bloodstream to
22:07 exert its effects at you know at a
22:09 remote Target so you know most oral
22:12 medications take many minutes or even an
22:14 hour or two to really kick in to their
22:15 to their optimal degree so we might need
22:18 to think about nasal sprays or
22:20 injections for people who have very
22:22 rapid onset attacks or people who wake
22:24 up with an attack already in play
22:27 certain medications May last longer so
22:29 if someone has a headache that typically
22:32 lasts for several days using one that
22:34 has a short duration of action might not
22:37 be the best answer and relationship to
22:39 menstruation so we know that for some
22:42 people who have a very very obvious
22:44 relationship to their menstruation there
22:46 may be specific differences and
22:48 different types of treatments we may use
22:50 in that specific indication and and I
22:52 can’t stress this part enough but Family
22:54 Planning you know the bulk of our
22:55 patients are women and are people who
22:58 who may be able to become pregnant and
23:00 we want to make sure that we’re doing
23:02 things safely so I always make sure that
23:03 we tell everybody that if if this is
23:05 something that’s in your plans to make
23:07 sure that that gets communicated to your
23:08 healthcare provider so we can do things
23:10 safely and then unfortunately certain
23:13 coexisting medical conditions can make
23:15 it make it so that we can’t use certain
23:18 treatments and that we have to just be
23:19 more careful if someone has a lot of
23:21 other medical conditions and of course
23:23 that becomes more and more important as
23:25 people get less
23:27 young so uh what do we have in our
23:29 armamentarium in in our tool belt so we
23:32 have some migraine specific treatments
23:34 which we call there’s two classes of
23:36 migraine specific treatments one is
23:38 called trip Tans the other is called
23:40 gepants I’ll talk to you a little bit
23:41 about both then we have non-specific
23:44 treatments these are things that were
23:46 designed sort of as more non-specific
23:48 pain relieving medications but they
23:49 still can be very effective for certain
23:52 migraine attacks and then something we
23:54 have that we may call adjunctive
23:56 treatments that again not necessarily
23:58 devel for migraine but can be really
24:00 important and some of those can include
24:02 anti-nausea medications which may
24:04 actually be quite helpful for migraine
24:06 so this is a list of sort of what’s
24:08 available for uh in our you know in our
24:12 Canadian space at the moment I won’t go
24:13 through each individual one of these
24:16 medications but but I just wanted to
24:18 show this to everyone because there’s
24:20 there’s names that people may recognize
24:22 and one of the important things that I
24:24 that I want to hear as a headache
24:25 provider when someone comes to me is
24:27 what have they tried before they come
24:29 because I you know I don’t want to
24:30 recycle and go back to something that
24:32 someone has found to be ineffective so
24:35 um these trip Tans there are seven of
24:37 them some of them come in oral
24:39 intranasal injectable formulations I
24:42 will just say as just a little you know
24:44 hint of advice to everyone listening
24:46 that the word ODT means oral dissolving
24:49 tablet unfortunately because it’s being
24:52 absorbed in the mouth does not mean that
24:54 it’s being absorbed in in the mucosa in
24:56 the mouth it still needs to be swallowed
24:58 so people who have a lot of nausea that
25:00 still may not be the best answer and
25:02 something like an inasal formulation may
25:04 still be better and then we have what we
25:07 call gpants gpants are interesting if
25:09 you recall I mentioned earlier that that
25:11 important chemical called cgrp we know
25:14 plays a very important role in why
25:15 migraine happens and these gpants are
25:19 things that actually have an action
25:21 against cgrp so they are ENT essentially
25:24 designer drugs aimed at treating
25:27 migraine attacks so what we have in
25:29 Canada we have one called ubro depand
25:31 and just very newly released we have one
25:34 called rapand this just was released in
25:36 Canada last week so the new kit on the
25:39 Block if you will and then some that are
25:41 coming some that are still in the United
25:43 States but have yet to be approved by
25:44 Health Canada um and then we have
25:46 non-specific treatments so the truth is
25:49 um non-steroidal anti-inflammatory drugs
25:51 or IDs for lots of people are excellent
25:55 uh are excellent at at being efficacious
25:57 for for reminding um the truth is you
26:00 know someone’s probably not Dawning my
26:02 door if Advil is helping them so I guess
26:05 I don’t see that quite as commonly but I
26:07 I make sure I put all of these on here
26:09 because even if you can get it over the
26:11 counter it doesn’t mean it’s not a
26:12 medication so if you are you know asking
26:17 someone for help with your migraine then
26:19 it is important to make sure you
26:20 document both prescription and non-med
26:23 and non-prescription uses of things that
26:25 you’re using so that we can help tweak
26:27 your strategy better and get you feeling
26:29 better and then there are some
26:31 formulations that are specific
26:33 combination um combination therapies
26:36 specifically trip Tans and nids can
26:38 sometimes be combined and there’s at
26:39 least one in Canada now that that comes
26:42 as a single pill so all of these may be
26:45 appropriate or inappropriate for an
26:47 individual depending on the ACT
26:48 individual scenario what things to avoid
26:52 so unfortunately you know these kinds of
26:55 things still do get prescribed more
26:57 commonly than we like opioid containing
27:00 medications like morphine Hydromorphone
27:02 Codine tramol unfortunately all of them
27:06 have very poor evidence that they can
27:08 help with migraine and in fact more and
27:10 more mounting evidence that they may be
27:12 harmful for people who have migraine and
27:15 the same thing is true of of a
27:17 medication called butalbital which
27:18 luckily is not used very often in Canada
27:20 any longer so it’s less of a problem
27:22 here than it is in our neighbors the
27:24 South um but with all that being said in
27:27 all of these things that we have to use
27:29 in our
27:30 armamentarium one thing that that I we
27:33 make sure that we try to hammer home as
27:34 much as we can is when you treat a
27:37 migraine attack the best time to treat
27:39 it is at the earliest possible sign so
27:42 as soon as someone can identify I’m
27:44 having an exacerbation of migraine is
27:46 ideally the best time to treat their
27:48 headache so that can present a bit of a
27:51 problem because I’ve just told you that
27:53 certain medications if taken too often
27:56 can then lead to what we call medication
27:57 over use headaches so how do you how do
28:01 you avoid overusing and still treating
28:04 early it can be very very challenging
28:06 for someone who has a lot of headache
28:08 but there’s just a couple of things I
28:09 like to point out if I can so if someone
28:12 treats early and that agent is very
28:16 effective then you’re less likely to
28:18 have a recurrence within 24 hours and
28:21 you’re less likely need to need to
28:22 redose a medication because if you treat
28:25 it at the optimal time you might
28:27 actually should be using less medication
28:29 and if somebody Waits until they’re
28:31 already at their Peak intensity or until
28:34 it’s been going on for hours or days
28:36 you’re more likely to need to treat on
28:37 multiple subsequent days so treating
28:40 early might actually reduce your need
28:43 for more medication days so that’s just
28:45 one thing that I like to kind of put out
28:47 there in The Ether and there is some
28:49 exciting evidence that some of our newer
28:52 agents specifically the uboa pant that I
28:54 mentioned earlier um might actually be
28:57 helpful if people take it during their
28:59 prod Drome phase so if someone can
29:01 clearly identify you know what every
29:04 time before I get a migraine I feel
29:07 foggy and I pee more and I’m yawning
29:10 like crazy and I just don’t feel like
29:11 myself and they’ve been able to identify
29:13 that that always happens before a
29:15 migraine attack it might be entirely
29:17 appropriate to treat early with a
29:19 medicine like ubro jaapan which is the
29:21 only one that has that specific evidence
29:23 for this indication it may end up
29:25 expanding to further treatments down the
29:27 road but that’s still is remains to be
29:29 seen so with that said you know we we’ve
29:33 talked a bit about how we treat an
29:35 individual attack but but the truth is
29:39 you know many providers have offered
29:41 people some kind of acute treatment but
29:45 where we see people have less access or
29:47 get offered less treatment is with
29:50 prevention and prevention is tough and
29:53 the reason it’s tough is because
29:55 migraine affects young people a lot who
29:58 who often don’t wish to be on medication
30:01 so it’s it’s sometimes a bit of a no pun
30:03 intended a hard pill to swallow but but
30:06 what we really aim for when we’re
30:08 treating someone with prevention is
30:10 ideally to reduce the frequency of
30:12 migraine attacks reduce the severity of
30:14 the headache reduce the need for acute
30:17 medication so remember Advil Tylenol
30:21 these things are medications even if
30:23 they’re available over the counter with
30:24 their own risks and side effects so
30:26 being on a safe preventive medication
30:29 might actually reduce someone’s need for
30:31 taking acute medication and one thing
30:34 that’s become very very important and
30:36 we’re realizing more and more as we
30:38 study migraine is is there’s this
30:41 concept called the interial burden which
30:44 means how much does migraine affect you
30:46 when you’re not actually having a
30:47 migraine attack so people who say I
30:50 can’t go out because I may get a
30:52 migraine I can’t take a trip because I
30:55 may get a migraine how the heck am I
30:56 going to give an oral present
30:58 because the stress of it is going to
30:59 give me a migraine so we know that when
31:02 an effective preventative medication is
31:05 on board that that burden between
31:08 migraine attacks can actually also start
31:10 to improve and and ultimately the most
31:12 important metric as to whether something
31:15 is helpful is whether someone has an
31:17 improved function their day-to-day
31:19 function and unfortunately again
31:22 prevention is not a cure there’s no
31:25 right number of migraine days per month
31:28 when we start prevention But ultimately
31:31 we know that people don’t get offered
31:33 prevention often enough or or off or
31:35 early enough but here are some things
31:38 that we think about so if acute
31:40 treatment is being used too often if
31:43 acute treatment stops working that might
31:46 be an indication that the migraine is
31:48 poorly controlled if your migraine
31:51 starts to affect your life even when you
31:53 don’t have a migraine attack that can be
31:55 a reason why we need to think about
31:56 starting migraine or you know to put it
31:59 simply when migraine affects someone’s
32:02 life when someone is is changing their
32:05 life changing their function because of
32:07 their migraine that probably is an
32:08 indication that we need to think about
32:11 prevention so because someone needs to
32:14 be prevention and this is something that
32:15 I’m always that I always try to impart
32:18 on upon people when I’m when I’m
32:19 introducing the concept of prevention is
32:21 that it’s not a life sentence you know
32:23 some people once we settle the fire it
32:25 may stay settled and we may be able to
32:27 success get people off of medications in
32:30 my experience most people generally
32:32 require it for at least 6 to 12 months
32:35 when we find an effective strategy
32:36 before we try to withdraw and and and
32:39 ultimately you know migraine is
32:41 something that affects people for many
32:42 many many many many years so to have
32:45 someone on something for only a few
32:47 weeks is probably insufficient to really
32:50 kind of settle that fire so so that’s
32:52 the reason why we do that um and
32:55 sometimes we can also use medication for
32:58 other conditions you know to our
32:59 advantage so there are some overlapping
33:02 treatments for anxiety for depression
33:04 for high blood pressure that if someone
33:06 also has those problems we may be able
33:09 to kind of choose an agent that will
33:11 treat more than one condition to reduce
33:13 the overall pill burden and this is
33:15 particularly true in older adults where
33:17 we might be able to take a long
33:19 medication list and make it shorter to
33:21 use things to our
33:23 advantage this is an enormous list so
33:25 again I’m not going to go go through
33:27 everything but but I put it here to show
33:29 you that a lot of what we would term our
33:32 first line treatments or the things that
33:34 have been around for many many years
33:37 they weren’t designed for migraine so
33:39 there are certain blood pressure
33:40 medications certain anti-depressants
33:43 certain seizure medications and other
33:45 sort of oddballs um that all of these
33:48 have evidence that they can help and
33:51 treat migraine and and sometimes if this
33:54 is not presented to somebody
33:56 appropriately like let’s say I I I don’t
33:59 properly counsel someone about the
34:00 diagnosis of migraine and I send them
34:02 away with an anti-depressant to help
34:04 treat their migraine then that may send
34:06 a message that I think someone is
34:08 depressed and that’s why they have
34:09 migraine and and that’s not the case the
34:11 truth is we use even anti-depressant
34:13 medications in people who have no
34:15 clinical depression because we know it
34:16 has evidence for migraine but it really
34:18 is there’s no one siiz fits-all measure
34:21 for an individual person and this really
34:23 has to be a decision that’s made
34:26 together with your healthcare provider
34:28 so we have more migraine specific
34:30 treatments we have our injectable
34:32 treatments uh all but one of these four
34:34 that I’ve listed are once monthly
34:37 injectable treatments um that can be
34:39 highly efficacious for some people um
34:42 and are targeted again towards the
34:44 migraine so these are things that affect
34:46 that cgrp protein that I mentioned here
34:48 earlier in the talk and one of them um
34:51 is an every 3mon IV infusion and then we
34:54 have botolinum toxin or Botox that’s
34:56 delivered every 3 months and again
34:58 there’s specific evidence for prevention
35:00 of what we call chronic migraine so if
35:02 there’s a headache there more than half
35:04 the time and then there are some oral
35:06 agents uh specifically you know if an
35:08 injectable is something that’s you know
35:10 a little a little scary to you or you
35:12 you don’t want to deal with how long it
35:14 may stay in someone’s system um then a
35:16 medicine called a toip pant is a daily
35:19 preventative medication that again is
35:20 aimed at treating that cgrp excess um
35:24 similar to the medicines that I
35:25 mentioned before but it’s meant as a
35:27 daily preventative um and I did put
35:29 another one here remed pant this has
35:32 evidence it does have some evidence that
35:34 it can be used as a preventative
35:36 officially by Health Canada regulations
35:38 it does not have that that official use
35:41 yet in Canada um but it may be coming so
35:44 it’s it’s something to just be aware of
35:46 so how the heck do we choose with this
35:48 massive landscape so first of all is
35:50 there something we can use for multiple
35:52 reasons like I mentioned before if
35:53 someone also has mild blood pressure
35:56 elevation and we need to treat both why
35:58 wouldn’t we use something that can treat
36:00 both that makes sense certain health
36:02 conditions might exclude certain drugs
36:04 as well as previous allergies What
36:06 treatments have been tried before what
36:08 has been someone’s experience with drugs
36:10 you know I may not choose to choose a
36:13 medication that has a higher likelihood
36:15 of side effects if someone has had a
36:17 really tough time with medications in
36:19 the past and I hate to say it but cost
36:21 and coverage unfortunately plays more of
36:23 a role than we would like it to I don’t
36:25 think any of us um I think all of us
36:27 that this was not a barrier but the sad
36:29 truth is this is the world that we’re
36:31 living in and and we don’t want to give
36:33 something that may break the bank
36:34 unnecessarily so you know this really is
36:37 you know again an individual person
36:40 discussion and luckily because of
36:42 efforts like people like Wendy and
36:44 migrating Canada um what has been
36:46 available on public formularies and
36:49 people who who have coverage through
36:50 their provincial plans has gone up
36:52 significantly in the last few years so
36:55 access in Canada I will say like having
36:57 worked with uh colleagues across the
37:00 world access in Canada is among the best
37:02 that there is so we’re lucky we’re not
37:06 perfect we still have lots of room to
37:07 grow but we are lucky um with what we
37:10 have and then of course Family Planning
37:12 we don’t want to give somebody a
37:13 medication that will be in their system
37:16 for many many many months if if they’re
37:18 planning to get pregnant or they may get
37:20 pregnant you know in a week or two so we
37:22 always ask people you know about their
37:25 plans not to be not to be invasive but
37:27 just to make sure we’re being safe and
37:29 then of course there’s preference and
37:30 comfort you someone may have a friend or
37:33 a family member who’s on a specific
37:35 medication and that might make them more
37:38 comfortable with it and us and make us
37:39 more likely to use it so when we’re
37:42 talking with someone when me as a
37:44 healthcare provider when I’m speaking
37:45 with somebody about how someone’s doing
37:47 there’s some things that I want to know
37:49 to see if this is helpful first of all
37:51 has it been used long enough and has it
37:53 been used as an adequate dose most of
37:56 our data suggest that we won’t really
37:59 know if an individual medicine is
38:01 effective unless it’s tried for long
38:02 enough at the right dose which is
38:05 annoying you know all of us wish we had
38:06 a treatment that would work right away
38:09 um you know patients and healthc care
38:10 providers alike I think all of us wish
38:12 that that was that was the case but the
38:14 truth is we do have to give it time and
38:16 then with injectable treatments some
38:18 people some lucky folks may have very
38:20 very quick responses and that is
38:23 reflected in in our in the data and the
38:24 research about these drugs but people
38:27 who had a very high burden of migraine
38:29 for many many years we may not know
38:31 their full response until they’ve been
38:33 on it for four five six months so
38:35 usually when we’re recommending drugs
38:38 like that we do suggest that people stay
38:40 on them for at least six months unless
38:42 there’s an unexpected problem and then
38:44 with botolinum toxin we usually say
38:47 doing it at least three times separated
38:49 by 12 Weeks lets us know what the
38:52 optimal response is going to be because
38:54 some people who have had again have had
38:56 this for 20 30 years it may not be till
38:59 that third Administration where they
39:01 start to see wow this is really helped
39:03 me and then I think the most important
39:06 is is it worthwhile like if do you want
39:08 to be on this is it helping you enough
39:10 that it’s worthwhile that that’s the
39:12 most important question that I asked
39:13 somebody because really what we look at
39:16 as something being effective
39:18 Effectiveness really is efficacy of the
39:20 medication plus tolerability so if
39:22 something really helps you but makes you
39:23 feel like garbage it’s not useful if
39:26 something has side effects but doesn’t
39:28 really help you it’s not helpful so we
39:30 really have to take both of these things
39:32 into account so with all of that said
39:35 how how does someone prepare how does
39:37 someone navigate how to prepare for an
39:39 deployment how to talk to your
39:40 healthcare provider about migraine
39:42 because because this is a disease that
39:45 has whose treatment is so and diagnosis
39:48 is so contingent upon communication it
39:51 is really important for us to know how
39:53 you’re doing so um if we don’t know how
39:55 someone’s doing it’s really difficult
39:57 for us to make informed decisions so
39:59 this is one of the scenarios where
40:01 keeping a diary can be extremely
40:03 effective and and honestly it can it
40:06 shows us a visual representation of how
40:08 you’re doing when I say a diary I don’t
40:10 mean pages and pages of binders of
40:12 things that you bring into a doctor’s
40:14 office because that might scare us a
40:16 little bit um but you know we want to
40:19 make sure a we’ve got the diagnosis
40:20 right B how are you doing and see you
40:23 know what’s the trend been like and a
40:25 diary can tell us all of that and also
40:27 if they’re if someone believes they may
40:29 have a component of of a menstruation
40:31 that may affect their migraine we can’t
40:34 appropriately make that diagnosis unless
40:35 it’s been a reliable trend on a diary so
40:38 this is where um we have a resource in
40:41 Canada which we’re very lucky to have
40:43 it’s free it’s so easy to use it’s
40:45 called the Canadian migraine tracker
40:47 it’s an app uh you can just download
40:49 from the App Store and this is exactly
40:51 how I tell my patients to track their
40:53 their headaches as well it’s not
40:55 terribly useful to say well this is my
40:58 you know right-sided headache and this
40:59 is my nausea headache and this is my
41:01 headache that starts with my neck pain
41:03 because and within an individual M
41:06 different migraine attacks can feel
41:08 completely different but they can all
41:09 still be migraine and that’s usually the
41:10 case so what I want to know is how did
41:13 that attack affect your function so red
41:17 yellow green the stop light system this
41:19 is exactly how you see it visualized on
41:21 the Canadian migraine tracker or severe
41:23 moderate mild think about it like this a
41:26 red day so bad you need to stop a yellow
41:29 day is bad enough that you should slow
41:31 down and prioritize something some
41:32 things but you are not functioning at a
41:34 normal at a normal capacity and Mild is
41:38 a nuisance so you can still go so stop
41:41 slow down go so what we sometimes see
41:44 when someone actually gives us I wish I
41:45 had a I wish I had a screenshot of what
41:47 the migraine tracker actually looked
41:49 like this is just one that I kind of
41:50 came up with that I drew up on my own at
41:52 the end but this tells me so much
41:54 information so right away when I look at
41:57 this calendar I
42:00 see I see 13 I see 13 headache days but
42:04 what I see also
42:07 importantly I see four attacks so 13
42:10 headache days but only four attacks so
42:12 right away I want to know this doesn’t
42:15 seem like that their acute medication is
42:16 helping them enough and we may need to
42:19 actually make sure someone is treating
42:20 early with an effective agent because
42:23 all of these days are occurring in
42:24 succession so this shows me a of
42:27 information and also if the next month
42:31 we see some of those red days turn into
42:32 yellow days some of those yellow yellow
42:34 days turn into green days some of those
42:36 green days disappear that to me tells us
42:39 that what we’re doing is starting to
42:40 work so this is the kind of information
42:43 that this can that it can be really
42:45 helpful so I know I’ve spoken an an
42:48 awful lot about medications you know
42:50 migraine is a condition like I mentioned
42:52 that’s influenced by the environment so
42:54 we can throw all the medicine in the
42:56 world at a problem like Mig
42:57 but if we don’t also address lifestyle
42:59 and other things that are going on in
43:01 someone’s life we will only be so
43:03 successful so sleep schedules are
43:06 important so what you’ll probably see as
43:08 a theme Here is that migraine loves
43:10 routine you take yourself out of a
43:12 routine you’re more likely to get a
43:14 migraine attack so regular sleep
43:16 schedule quality of your sleep making
43:19 sure you don’t have other disorders like
43:21 sleep apnea that can impact migraine
43:23 diet there is no specifically approved
43:26 migraine diet that has ever been shown
43:27 to be effective but we know you know
43:30 something like the Mediterranean diet or
43:32 high protein relatively healthy diet it
43:34 generally tends to be more helpful um
43:37 not skipping meals intermittent fasting
43:38 is often bad for people with migraine
43:40 that’s not a cardinal rule some people
43:42 do still say it’s effective but it’s a
43:44 it varies a lot hydration you know you
43:46 have to be making sure you’re adequately
43:48 hydrated and drinking more on days that
43:50 your uh drinking or in days that you’re
43:53 exercising and we have learned recently
43:55 that exercise is probably the most
43:57 important uh lifestyle feature that we
44:00 have in terms of uh of improvement so
44:03 that can be difficult for people who
44:06 have really frequent migraine but this
44:08 is where moderation is important so on a
44:10 bad day maybe pushing yourself a touch
44:13 and on a good day raining it in a bit a
44:15 bit because if you do everything you
44:16 need to possibly do on a good day you
44:18 may pay for it for a few days afterwards
44:21 and then we have some evidence for some
44:23 non-medicinal treatments like cognitive
44:25 behavioral therapy uh for pain control
44:27 that may be helpful for some people and
44:29 there’s evidence to suggest that it is
44:31 and mindfulness-based stress reduction
44:33 strategies um what what our evidence has
44:36 shown us and what our research Studies
44:38 have shown us is that mindfulness and
44:39 the practice of mindfulness reduces the
44:42 impact that migraine has on one’s life
44:44 so even if it doesn’t reduce the number
44:46 of days that people have of migraine it
44:48 may reduce how it affects them and then
44:51 it’s important to treat the conditions
44:53 that come along with migraine so there’s
44:55 no doubt that having poorly controlled
44:57 migraine can start to affect mood um and
45:01 if we don’t also address mood once again
45:04 we will only be so successful at getting
45:06 migraine appropriately treated so it is
45:09 important that all things that come with
45:11 it are also addressed in
45:13 kind so you know for people who are just
45:16 not ready for medications and that’s
45:18 that’s true of lots of people there
45:19 there are things that we can do so what
45:22 we term our neutral prophylaxis so
45:24 there’s some evidence for magnesium
45:27 vitamin B2 co-enzyme Q10 melatonin all
45:31 of these have actual studies that
45:32 suggest that they may be helpful for
45:34 migraine and then a device called the
45:36 seph device which can be obtained online
45:39 uh again quite safe to use um and maybe
45:42 a good choice for people who who are not
45:44 so keen on medication or who have had
45:46 bad experiences with
45:48 medication if you’re not diagnosed or
45:50 you’re needing more help you know one of
45:52 the one of the one of the important
45:55 piece of advice that I’ll give you is to
45:58 if you’re talking about headache don’t
46:00 tack it on to another visit that you’re
46:01 there for another reason and say oh by
46:03 the way it’s important to try to make a
46:05 visit specifically to discuss that issue
46:07 so that it gets the proper attention
46:09 that it needs um you know bring a diary
46:12 to show how much migraine has affected
46:15 your life if your family family doctor
46:18 nurse practitioner healthcare provider
46:20 is not comfortable with your diagnosis
46:21 or treatment to advocate for a referral
46:23 to someone who can help like a local
46:25 neurologist a headaches Clinic a
46:27 headache nurse practitioner all of these
46:29 exist in Canada um in in most provinces
46:32 so access to to these folks is and and
46:35 it’s growing you know uh our our
46:37 initiatives you know are we’re trying to
46:39 train more and more headache Specialists
46:41 across the country and if I was having
46:43 this talk with you uh you know when I
46:46 started you know seven seven years ago I
46:48 would say there’s there was probably
46:49 only about half as many headache
46:51 specialist in Canada as there is now so
46:53 we’re making some grounds at improving
46:55 access as well for