Migraine Pain and Mental Health

0:00 thanks everyone for attending today
0:02 um I would love it to be as interactive
0:04 as possible so yeah please put some
0:06 questions in the chat or the Q a and
0:08 then we’ll uh we’ll get to them at the
0:12 very end if that’s okay
0:14 um so I’m just going to share my screen
0:15 right now and we will start from there
0:20 um
0:20 so let’s go here so what’s uh I’m going
0:26 to talk about today is the impact of
0:29 headaches on mental health and vice
0:31 versa and so maybe a little bit about
0:34 myself before I get started so my name
0:36 is Mike Butterfield
0:38 um I am a pain specialist and
0:41 psychiatrist
0:42 um I am a clinical assistant professor
0:45 at the University of British Columbia
0:46 and the department of Psychiatry
0:48 anesthesiology pharmacology and
0:50 Therapeutics my
0:53 main focus is on pain management and I
0:55 do in Psychiatry my focus is on
0:57 treatment resistant depression
1:00 um and pain medicine my cell specialty
1:03 focus is actually on headache management
1:04 so I work at the UBC headache Clinic
1:07 with Dr Spacey and I also work at St
1:10 Paul’s Hospital in Vancouver
1:12 um with a focus on headache management
1:14 there as well so
1:16 um hopefully that will be a helpful
1:18 background today so
1:21 um
1:21 this is the general outline of what my
1:24 talk is going to be about obviously you
1:26 can talk about anything related to
1:28 mental health and headaches or pain in
1:31 general
1:33 um at the end of the session but
1:34 hopefully this covers a relatively good
1:37 amount it’s going to be quite an
1:39 overview because this is a huge topic
1:41 with so many different things
1:43 um that are coming out on a daily basis
1:45 about how
1:47 the co-occurrence of this and how we can
1:49 treat these more effectively so
1:52 um so yeah so I’m very happy to answer
1:54 your questions at the end if it’s not
1:55 covered by what we talk about today
1:57 so first we’ll talk about pain and
2:00 mental health so pain in general would
2:01 be very brief we’ll talk about migraine
2:04 and anxiety and depression and the
2:06 co-occurrence and what can happen with
2:07 that the main focus about what the
2:10 presentation today is going to be about
2:11 will be actually about like handling
2:13 anxiety or distress that comes with
2:16 um migraines or headaches and how to
2:18 maybe some practical tips around how to
2:21 manage that
2:23 um how to speak about clinicians about
2:25 mental health because that can be a bit
2:26 of an issue sometimes and when should we
2:29 consider medication or other types of
2:31 treatment for mental health symptoms
2:33 when they do occur and what is available
2:35 and how to access that
2:37 so with the first one which I’m going to
2:39 talk briefly just about chronic pain and
2:42 depression and anxiety so you can see
2:43 here
2:44 and this is a sample of a large sample
2:47 of people that attended a primary care
2:50 clinic or their family doctor’s clinic
2:51 and it looked at people that presented
2:54 with pain as a primary complaint and so
2:57 when they presented the clinic with pain
3:00 it found that about half of them
3:02 actually only had pain but the other
3:04 half so we’re a little bit less than
3:06 half
3:07 um so 46 percent actually had
3:09 co-occurrence of either an anxiety
3:12 disorder or a depressive disorder or
3:14 both
3:15 um so you’ll see that the most common
3:18 one
3:19 um well they’re pretty much equal but
3:21 pain anxiety and depression were quite
3:25 common and then pain and depression was
3:28 the next most common but pain and
3:29 anxiety was only three percent
3:32 and this differs significantly with uh
3:36 actual migraine or headaches so and this
3:39 is because this is chronic pain in
3:40 general so anywhere in the body
3:43 and the main thing that a lot of people
3:45 ask around is the chicken or the egg
3:47 what comes first does the pain come
3:49 first does the headaches come first or
3:50 chronic pain and we know that actually
3:53 for many different studies that looked
3:54 at this in many different ways we found
3:56 that um most of the patients that do
3:59 present with either depression or sort
4:01 of anxiety disorders generally develop
4:04 these pain symptoms first and then that
4:06 sort of feeds into this development of
4:08 these other mental health symptoms which
4:10 is depression anxiety or other types of
4:13 symptoms
4:16 um and similarly with uh when we talk
4:18 about migraine and so just going back
4:21 that was about chronic pain and when
4:23 we’re going to focus specifically more
4:24 on headaches um so migraine in
4:26 particular a major depressive disorder
4:28 we see that there’s a significant
4:30 increase
4:32 um in the lifetime prevalence of uh
4:35 depression when we look at the general
4:37 population which is about one in five
4:40 um and the people with migraines so
4:42 episodic or chronic so it actually
4:44 doesn’t seem to matter that much with
4:46 people that have episodic migraine or
4:49 chronic migraine so and that definition
4:51 is just people that have headaches more
4:54 than 15 days per month and that could be
4:56 tension type headacheco or migraine so
4:58 it’s double either way and the other
5:01 thing is that the prognosis seems to
5:03 change significantly
5:05 um when uh we’re talking about
5:09 the incidence of uh when the migraine
5:13 starts so are when the new onset starts
5:16 and migraines in two years so you see
5:18 people with a history of major
5:20 depressive disorder
5:22 um have a much higher degree of new
5:26 onset of a migraine in two years after
5:28 diagnosis of major depressive disorder
5:30 versus people that don’t
5:32 um and then the since a new onset of
5:34 major depressive disorders so people
5:36 have a history of migraine
5:38 um they’re more likely from the
5:41 diagnosis of migraine they’re more
5:44 likely in two years to develop a major
5:46 depressive disorder 10 of them are able
5:49 to versus people that don’t have a
5:50 history of migraine at all so like an
5:53 eight times increase in that in that
5:55 two-year time frame that the study
5:57 looked at so obviously these uh
6:00 disorders both migraine and major
6:03 depressive disorder are highly linked
6:04 and the incidence of one significantly
6:08 impacts the incidence of the other
6:11 and I won’t go to Too Much particularly
6:13 this is a really important one I think
6:15 major depressive disorder migraine very
6:17 closely linked uh so is anxiety as well
6:20 but some of the other
6:22 um disorders we know here kind of talked
6:24 about this already but people with
6:26 migraine or tension type headache
6:29 um have more than twice the incidence of
6:30 developing major depressor which we
6:32 talked about bipolar disorder which is
6:35 very interesting one
6:37 um and I kind of highlighted it here
6:39 with the asterisks and also put it in
6:41 italics it’s only specifically for
6:43 migraine not tension type headaches and
6:46 there is uh not that the incidence is
6:48 that high to begin with it’s only about
6:50 one to two percent in the general
6:52 population but it does seem to there has
6:55 been numerous studies looking at the
6:57 co-occurrence of migraine and bipolar
6:59 disorder and it is almost a double in
7:01 people with migraine
7:03 um and specific types of anxiety
7:05 disorders like panic disorder and social
7:07 anxiety disorder have also shown
7:09 um to have twice the incidence in
7:11 individuals with uh you know headaches
7:16 um we do know though that uh people with
7:18 uh over the age of 65 older adults tend
7:21 to have less common
7:24 co-occurring psychiatric disorders
7:27 um with headaches versus those that are
7:29 younger and again the and then the
7:32 downside obviously is that the health
7:33 outcomes are worse in individuals with
7:35 both headache and psychiatric disorders
7:37 so the co-occurrence of one or more of
7:40 uh psychiatric stores with the migraine
7:43 or tension type headache does tend to
7:45 lead to worse outcomes
7:47 um and also poorer prognosis which is
7:49 why it’s very critical to treat both at
7:52 the same time if if they’re both
7:53 occurring
7:58 um so I want to touch we talked a lot
7:59 about depression so I do want to touch
8:01 base around anxiety disorders and we’ll
8:03 talk a little bit more about this when
8:04 we talk about different coping
8:06 strategies uh But anxiety disorders so
8:09 the ones I talked about before social
8:10 anxiety disorder and panic disorder
8:13 um and another very common one is
8:15 generalized anxiety disorder so these
8:18 are uh diagnoses or disorders of
8:20 excessive fear and anxiety and related
8:23 behaviors or things that happen as a
8:25 result
8:25 so
8:27 um this fear is really an emotional
8:29 response to a real or a perceived threat
8:31 so in when we’re thinking about
8:34 headaches or when we’re thinking about
8:35 migraines you know the fear of actually
8:37 of having another migraine again
8:40 um is this emotion is this emotional
8:43 response to that perceived threat
8:46 um this anxiety is the anticipation of
8:48 that future threat again maybe that
8:50 future headache or migraine
8:53 um and so these this fear and anxiety is
8:55 highly linked and often into those with
8:57 anxiety disorder so having anxiety about
9:01 something is very different than having
9:03 an anxiety disorder because the anxiety
9:05 disorder itself really means that
9:07 there’s that anxiety has taken on a life
9:09 of itself and led to significant
9:12 um functional impact in different
9:14 different parts of their life so it’s
9:17 very normal to have fear and anxiety
9:19 about future events but when it starts
9:21 to take on a life of its own that’s when
9:23 it can become a disorder and so people
9:25 with anxiety disorders typically tend to
9:27 overestimate the danger in situations
9:30 that they fear or avoid
9:33 and
9:35 I want to bring up this because it also
9:37 really highlights this
9:40 different cycles that people can get
9:43 trapped in unfortunately and it happens
9:45 to many of us all of us sometimes is
9:48 that there can be this this injury or if
9:51 or not even injury can be an event like
9:53 a headache or a migraine and people have
9:57 this pain experience and when we look at
10:01 this pain experience they can have it
10:02 can kind of go one of two ways though
10:04 that’s very dichotomous though there are
10:06 can be obviously different variations
10:08 and degrees of where people fit in this
10:11 uh this model but to keep it simple the
10:15 pain people can have the pain experience
10:17 and then have no fear very little
10:19 anxiety about what that means or what
10:22 that means to their body or what they’re
10:24 feeling injured or anything like that
10:25 and so they confront this and then their
10:28 recovery happens or they they get past
10:30 that
10:32 um in some cases for some people we’ll
10:33 have this pain experience and depending
10:35 on a number of different factors
10:37 including you know comorbid anxiety
10:40 Comer depression past experiences
10:43 underlying disorders a number of
10:45 different things can develop
10:47 um this thing called pain
10:49 catastrophizing or these uh these
10:52 feel like the the pain experience is a
10:54 very threatening
10:56 um uh threatening experience that is
10:58 really going to cause specific damage to
11:00 their body and that can lead into this
11:03 this cycle here where it can avoid doing
11:05 things or activities that might bring on
11:07 that type of pain which can lead to more
11:11 disability and potentially depression
11:13 and can lead to this cycle so a lot of
11:15 the times when people do get caught in
11:17 this unfortunately sometimes the thing
11:18 that we try to do and focus on a lot is
11:20 trying to transition out of this cycle
11:22 and getting back into this so decreasing
11:24 this catastrophization or this
11:26 threatening these threatening thoughts
11:29 so it’ll be important in the next thing
11:31 that we talk about which is
11:34 um how to cope with
11:36 um cope with this anxiety or cope with
11:38 uh the stress of having having headaches
11:41 so
11:43 um stress as many people probably in
11:46 this uh webinar where stress is the
11:48 number one trigger for migraine so there
11:50 was a large study that looked at
11:54 um what are the number one triggers for
11:56 migraine so
11:58 um the number one is is stressed by far
12:01 and Far and above so
12:03 um in this study that they looked at
12:06 um the stress a lot of people use deep
12:07 breathing meditation and yoga to try and
12:09 Target that stress response
12:12 um and it was effective or partially
12:14 effective for some of these people but
12:16 this was generally just a study that
12:18 looked at what are triggers and how do
12:20 people try and manage those triggers and
12:22 so it didn’t look at overall
12:23 effectiveness of any of these treatments
12:28 um so going back to the anxiety and
12:30 stress component so when we’re talking
12:32 about this we’re talking about headaches
12:33 we’re talking about migraines and the
12:36 anxiety or stress of having one and so
12:39 um when we think about events or
12:41 anything outside of even headaches um
12:43 what are they caused by they’re almost
12:45 always caused by things that are in the
12:46 future that are unpredictable
12:49 um can be ambiguous and often and
12:52 sometimes new
12:53 and so when we do have this they we have
12:56 this this thought or this anxious
12:58 thought or anxious fear and this can be
13:01 a worry and so what we try and do is we
13:03 try and avoid or control
13:05 um any events that can decrease any of
13:08 these uh these factors here on the right
13:10 so whether it’s new or unpredictable or
13:12 ambiguous and then that can transition
13:14 or that can cause physical Sensations
13:18 um that might be increased muscle
13:20 tension or tightness
13:22 um there could be a lot of different uh
13:24 feelings that can come out of that
13:27 foreign
13:29 and we know that there’s a lot of shared
13:31 mechanisms between headaches and anxiety
13:34 and stress like I mentioned that like
13:36 muscle tension and tightness
13:39 um I’m sure people in this room some
13:40 people in this webinar know that like
13:43 increased muscle tension or tightness in
13:45 their neck can be a trigger for
13:47 migraines as well or even the migraines
13:49 themselves you kind of can feel that
13:50 like muscle tension and tightness in the
13:52 back there
13:54 um and it’s kind of this reciprocal
13:55 mechanism
13:58 um that can one can trigger the other
14:00 and vice versa and so how do we how do
14:03 we combat that or how do we try to
14:05 address that
14:06 and so these are the types of treatments
14:08 that have been shown to be effective in
14:10 terms of this class we would call like
14:13 psychological or psychotherapeutic
14:14 interventions
14:16 um cognitive behavioral therapy being
14:17 one of them probably the most prominent
14:19 one biofeedback again being probably the
14:22 second most well-stated uh most
14:25 efficacious treatment for headaches
14:29 um deep breathing exercise Progressive
14:30 relaxation Tai Chi Yoga and hypnosis
14:33 actually have also been shown to be
14:35 quite effective
14:36 and this is all for treatment of
14:38 migraines not specifically treatment of
14:40 anxiety or depression this is all
14:42 looking at reducing migraine uh
14:45 frequency
14:47 and so and actually I would like to
14:49 point out that uh in certain studies uh
14:52 biofeedback and cognitive behavioral
14:54 therapy
14:55 um have actually been shown to be as
14:57 effective as some of the most common
15:00 preventative medication treatments for
15:03 migraine such as like Propranolol or
15:07 even Topiramate these treatments have
15:10 actually been shown to decrease the
15:12 migraine frequency to an equal equal
15:14 degree
15:16 so we’re going to talk a little bit
15:18 about
15:19 um sort of what we can do and what how
15:21 do we sort of can we cope with uh or
15:24 what kind of skills can we use to deal
15:26 with the anxiety or stress about like
15:29 having migraines headaches or even just
15:31 daily life in general
15:34 um and this is more of a cognitive
15:36 behavioral approach with some
15:38 mindfulness components to it so
15:41 um again because that cognitive
15:42 behavioral therapy seems to be the most
15:44 effective
15:45 so
15:46 um I I tend to use it as sort of the
15:49 Three B’s
15:51 um and I think these are backwards
15:52 actually so the breathing is the picture
15:55 of the lungs uh balanced thinking would
15:57 be that one and then the third one is
15:59 being so that’s more of the mindfulness
16:01 approach so I like acronyms and things
16:03 that are easy to remember so I think of
16:05 the Three B’s and we’ll go through each
16:07 of these B’s in particular
16:09 so
16:11 um the first one being breathe so
16:14 relaxation so what I there’s been
16:16 there’s actually a recent study that
16:18 came out that looked at different types
16:20 of breathing exercises and which causes
16:24 the most Improvement in terms of
16:25 relaxation and also Improvement in
16:28 depressive symptoms and also Improvement
16:30 in anxiety symptoms and in general when
16:34 we’re thinking about this it’s about the
16:37 inhalation or sorry the x or exhaling to
16:41 be longer than the inhalation so
16:44 inhalation shorter exhalation longer so
16:46 what I would like everyone to do if uh
16:49 if you want to join me if you can um in
16:51 doing this exercise to help us sort of
16:54 do this uh in a
16:57 uh combined fashion
17:00 um is to go through each all three of
17:02 these so and I’m sure people have done
17:04 this before so if you’ve done this
17:05 before and you like it join us if you’ve
17:07 done it before it doesn’t work for you
17:08 then don’t but if you’re dizzy
17:10 lightheaded or any respiratory issues
17:12 that you can’t do these exercises again
17:14 just don’t do that so we start with the
17:16 belly breathing
17:18 um and what I’d like people to do is put
17:20 their hand on their chest
17:22 um and their hand on their belly all
17:23 kind of stand up and so you can kind of
17:25 see so
17:27 um what you want to do is bring your
17:28 head a chest hand on your belly and I
17:30 want you to breathe in through your nose
17:34 so your belly expands
17:36 and then breathe out uh through your
17:39 mouth so that your belly kind of comes
17:41 in
17:42 the and this is different from the like
17:45 chest breathing which is very shallow so
17:47 if you do that to just breathe in and
17:49 move your chest
17:51 I’m sorry
17:55 you can see that and that actually ramps
17:58 up the sympathetic nervous system or the
17:59 nervous system that actually like drives
18:01 a lot of muscle tension tightness
18:03 increases your heart rate increases your
18:04 blood pressure so the belly breathing
18:06 will do that again so
18:08 hand on your chest hand on your belly
18:10 and then
18:11 breathing through your nose
18:13 and then exhale
18:17 through your mouth okay and so as long
18:20 as you’re exhaling longer at least by a
18:22 second or two that seems to be more
18:24 effective than the in and out being
18:25 equal
18:27 um
18:28 and so then the next one is sort of
18:30 peace and calm this is the one that I
18:32 tend to like the most because it’s very
18:33 easy and you don’t have to put your hand
18:35 on your chest and your belly when you’re
18:37 in like a meeting or you’re in some
18:38 other sort of situation where it might
18:39 be a bit awkward to do so
18:41 so
18:43 um so when you breathe in again
18:45 breathing through your nose think peace
18:47 and then breathe in breathe out through
18:49 your mouth and think calm and longer as
18:52 well so
18:54 peace
18:58 um all right and then the last one is
19:01 the rectangle again easier to to time
19:04 this out but breathe in one two three
19:09 four
19:10 hold for two seconds and then
19:13 breathe out one two three four five six
19:17 and we’ll do it again breathe in one two
19:21 three hold and breathe out one two three
19:26 four five six
19:28 all right great so hopefully uh for me
19:32 myself definitely that makes me feel
19:34 more relaxed and makes you know I don’t
19:37 know if you noticed maybe you did but my
19:39 shoulders are probably up a little bit
19:40 higher now they’re a little bit more
19:41 relaxed so this definitely is a very
19:43 immediate effect and doing this for even
19:45 five minutes every day
19:47 um has been shown to uh sort of decrease
19:51 um or sorry increase our level of
19:53 relaxation and decrease any depression
19:55 or anxiety symptoms
19:58 um so the next thing we’ll go to is sort
20:02 of the imagery
20:03 so when you are doing these breathing
20:05 exercises it’s really really important
20:07 to
20:09 um obviously be in a safe space where
20:11 you’re able to do that but also
20:13 sometimes just imagining in a different
20:15 scenario different place and if you
20:16 think of a place that’s you know is a
20:19 very pleasant experience someplace
20:21 that’s a very comfortable someplace
20:23 that’s very relaxing and some place
20:24 that’s very safe for you
20:26 um that can even augment any of the
20:28 benefits that you get from the deep
20:30 breathing as well so
20:32 um if you think about different You Know
20:33 Places you’ve been or places that you
20:34 would like to be that you can imagine
20:36 that can amplify the effects that you’re
20:38 having
20:40 and sort of going back to this model of
20:42 thoughts actions feelings
20:44 um the feelings is very difficult to
20:47 modify but our actions we can and that’s
20:50 how we do it through the breath
20:51 um that those are the sort of actions
20:53 that we can take or behaviors that we
20:56 can do to uh modify this model or impact
21:01 this model in a certain way and then the
21:03 next thing we’re going to do is do is uh
21:05 do the uh Target the thoughts so that
21:08 the fear or the anxiety so there’s this
21:11 thing called thinking traps
21:13 um and another term that’s often used as
21:15 a thinking or is a cognitive distortion
21:18 I don’t like that word as much as
21:19 thinking traps because cognitive
21:21 distortion has a very negative
21:22 connotation to it
21:24 um and also I’d like to put like read
21:27 this disclaimer down at the bottom so
21:29 when we talk about this this is not
21:31 meant in any way to like minimize
21:34 um the legitimacy of concerns about
21:35 headaches headaches are very severe very
21:39 challenging um to treat and obviously
21:42 have a significant impact on many
21:43 people’s lives so it’s not to minimize
21:45 any the you know things that happen or
21:47 the experiences that people have when
21:48 they have headaches
21:50 um it’s just just a different way to
21:52 think about
21:53 um about when we have these and factors
21:55 that can amplify that or cause our
21:57 headaches happen more frequently and a
21:59 negative thought isn’t necessarily A
22:00 thinking trap or Distortion it just is
22:03 is a thought so
22:05 some of the traps that we can get
22:07 involved in is things called like all or
22:09 nothing thinking so and these are some
22:11 some thoughts or automatic thoughts that
22:13 can come uh come into our brain so
22:16 um the only thing that can help me is
22:17 medication nothing helps with my pain so
22:19 either one thing or the other and that’s
22:21 it that’s another one thing that’s
22:22 called Black or White thinking is
22:23 another one uh catastrophizing so a lot
22:26 of like amplification or my headache
22:29 will never get better better I won’t
22:31 recover
22:32 um really a lot of strong negative
22:34 associations with that
22:36 um negative filtering so filter on
22:38 anything else that’s positive and only
22:39 taking the negative so nothing there’s
22:41 nothing but problems with my body and
22:43 over generalization this pain management
22:46 or headache management strategy didn’t
22:47 work before so it won’t work now or ever
22:50 um underestimating coping or
22:52 overestimating danger you can see that
22:54 there and then should statements I think
22:56 are are you know in general bad because
22:59 it kind of has a negative connotation of
23:01 what you did at that time and I think
23:03 it’s very good for ourselves to have
23:05 compassion for what we did at the time
23:07 or how we’re feeling at that time and
23:08 should statements are usually
23:11 um unhelpful in general
23:14 so when we do catch ourselves uh with
23:17 these in these thinking traps we try to
23:19 balance our thinking to decrease the
23:22 anxiety decrease the sympathetic Drive
23:24 decrease the negative connotations with
23:27 them so we try and catch these things
23:28 that’s why we talk about these thinking
23:30 traps so that we can at least start to
23:31 recognize them we can check them and
23:33 then we can change potentially change
23:35 them and also give ourselves some
23:37 compassion so when we think about the
23:40 checking
23:41 um we check the facts the pros and cons
23:44 and other things that may be impacting
23:47 um or like whether or not those
23:49 statements are true or not
23:51 um and the pros and cons of that
23:52 statement being true and then once we
23:55 sort of and this is a very brief
23:56 overview of cognitive part of cognitive
23:58 behavioral therapy because there’s a lot
23:59 of things that go into this but
24:01 um this is how we kind of do that and
24:03 then we can change those thoughts so an
24:06 example of that would be so if we’re
24:08 using even though
24:10 um say for example
24:13 um
24:14 will use a pain management strategy so
24:17 it’s over generalization so even though
24:19 this headache management strategy didn’t
24:20 work before it might work
24:23 it might work in the future or it might
24:25 work now so starting to change the
24:28 narrative a bit and as you change the
24:30 narrative if you think about it once
24:32 you’ve done that you think about it
24:33 usually that does create a change in
24:35 your overall level of emotion or anxiety
24:39 that’s connected with with these
24:41 thoughts so in that way it can really
24:44 enter or can really change
24:46 um change your that level of depression
24:49 or anxiety
24:51 and then compassion statements
24:53 um so you know it’s very very important
24:56 for us to give ourselves up compassion
24:58 especially in the context of different
25:00 um
25:01 medical illnesses
25:03 including migraines or headaches
25:07 um you know these types of statements
25:09 like I have a headache now and it will
25:11 pass I’ve had this before
25:13 and I’ve gone through it thought is just
25:16 a thought I can think of one way I
25:18 overcame this before you know anxiety or
25:21 these thoughts are not bad or dangerous
25:23 they’re just thoughts there’s a lot of
25:25 different types of statements and you
25:26 can look up online different
25:27 self-compassion statements or different
25:30 ways to provide yourself with that old
25:33 self-compassion which I think is
25:34 critically important
25:35 and then finally uh being so the last B
25:38 uh being his uh mindfulness or some
25:42 level of mindfulness so paying attention
25:44 being present purposeful and also being
25:46 non-judgmental so
25:49 um I put put some uh websites here that
25:52 you can access different types of
25:54 um mindfulness-based therapies
25:56 um I really like this mind shift app
25:58 that’s very helpful
26:00 um and all of these uh don’t have no
26:02 cost associated with them
26:04 um and so
26:06 um one of the ways you can start doing
26:07 this or which is really easy that you
26:09 can use at any point in time is this uh
26:12 using the breath so the deep breathing
26:14 that we did and also like uh the five
26:17 senses which is another really a good
26:19 one to do so you can always just if
26:21 you’re feeling you know you’re caught up
26:23 in these uh thoughts around you know
26:26 this is going to happen or is it going
26:27 to happen or you’re kind of you know not
26:29 spiraling but you know those thoughts
26:31 that you’re really having time grounding
26:32 yourself or getting overwhelmed you
26:35 could always just take the take two
26:37 seconds and bring yourself into this
26:38 five senses exercise and that really
26:41 grounds you in the present so
26:43 um you kind of think what are the five
26:44 things that I can see at this time what
26:46 are the four things that I can hear what
26:48 are the three things I can touch and
26:50 what are the two things that I can smell
26:51 and what’s the one thing that I can
26:53 taste so it’s it’s a good exercise it
26:57 really brings you to the present it
26:59 makes things purposeful it allows you to
27:01 pay attention to what’s happening and is
27:03 also very non-judgmental
27:07 so
27:09 um we’ll get into
27:11 um the last uh section of my
27:14 presentation today and then we’ll have a
27:16 lot of time for questions hopefully at
27:17 least like 20 minutes or so uh 15.
27:21 um and so last part is about seeking uh
27:23 for assessment and treatment of any
27:25 mental health symptoms when they come up
27:27 um and so the first thing I want to talk
27:29 about was when should I consider
27:32 treatment for mental health symptoms or
27:33 when you know when is it appropriate to
27:35 to seek out seagull care so I definitely
27:40 believe that like when any mental health
27:43 symptoms anxiety depression whatever it
27:45 may be are causing significant distress
27:47 and impacting your life negatively in
27:49 any domain the main ones I sort of think
27:51 of are like in relationships in your
27:54 work
27:55 um in your leisure activities any
27:58 important areas that the symptoms that
28:00 you’re having are causing significant
28:01 distress that is a time to sort of reach
28:03 out and see you know is there something
28:05 there that can be treated or is there
28:08 something there that I might need help
28:10 with
28:11 the other time would be when these
28:14 symptoms are really impacting your other
28:16 medical conditions so in in the context
28:18 of what we’re talking about today if you
28:21 really start to notice that you’re
28:24 starting to develop a lot more anxiety
28:25 or depressive symptoms and that’s
28:27 causing an increase in your migraine
28:29 frequency that is a time to to seek out
28:33 seek out care because if it is impacting
28:36 other medical conditions that’s that’s
28:38 something that should be treated and
28:40 doesn’t have to be migraine freaks it
28:41 can be any other types of symptoms that
28:42 you’re having
28:43 if the symptoms are really worrying or
28:46 something to people that are close to
28:49 you or care about you
28:51 um that’s another time that I would
28:52 definitely seek out treatments because
28:53 sometimes we have a hard time
28:54 recognizing those symptoms in ourself
28:57 and other people loved ones people that
28:59 care about us
29:01 um can be a good sounding board for you
29:03 know what our symptoms may be and then
29:06 the other most
29:07 um obviously a very clear one would be
29:09 is if safety is a concern in any way
29:11 then that’s definitely a time when we
29:12 should reach out
29:14 and where to access treatment so there’s
29:17 usually a number of different ways in
29:19 which you can access it
29:21 um your primary care professional that
29:24 could be a nurse practitioner that could
29:25 be a family doctor or whoever your
29:27 Healthcare professional is that you’d
29:29 normally go to to seek care that’s
29:31 someone you can definitely go to to
29:33 access them in almost every city across
29:37 Canada there’s a Canadian Mental Health
29:38 Association
29:40 um
29:41 uh not clinic but
29:43 um you know site where you can actually
29:45 you can contact them they will give you
29:48 information around where you can access
29:49 treatment
29:51 um there’s in numerous places there’s
29:53 local community mental health clinics
29:55 oftentimes they don’t usually require a
29:57 referral and people can either contact
29:59 usually call a number or even just walk
30:02 into the clinic and seek treatment from
30:05 from that perspective or they’ll give
30:07 you the resources to be able to seek
30:08 that treatment and then there’s a lot of
30:10 online
30:11 programs that are available
30:13 and we can talk about that at the end
30:16 um some other thing and there’s a lot of
30:18 like online programs though
30:20 um obviously if that’s not something
30:22 that you’re able to access or that you
30:25 find online system just not helpful
30:27 um then these local community mental
30:29 health clinics or Canadian Mental Health
30:30 Association can refer you to some
30:31 in-person resources
30:35 and so what I try to recommend people to
30:39 do uh when they are talking to their
30:42 health care professional whoever that
30:43 might be regarding their mental health
30:46 and how it’s sort of impacting their
30:47 life
30:48 um you know it’s uh it’s really key to
30:52 be prepared uh for those appointments um
30:55 sometimes especially if you know
30:58 uh the symptoms of depression or anxiety
31:01 or the migraines are becoming very
31:04 overwhelming you can have a lot of
31:05 difficulty with
31:07 um thinking clearly like cognition and
31:09 our cognitive dysfunction is a very very
31:12 common one of the key features in a lot
31:14 of
31:14 um mental health disorders so getting to
31:18 an appointment that sometimes you know
31:20 is very limited in time or scope
31:23 um can feel very overwhelming and people
31:25 can get very
31:26 um you know I don’t know uh have
31:30 troubles in sort of organizing their
31:31 thoughts so being prepared for your
31:32 appointment is is key so in doing that I
31:35 often recommend people sort of bring
31:36 written
31:38 um or documented questions
31:40 um or topics to their appointment so you
31:43 know when you get to your appointment
31:44 you can say you know these are the three
31:47 things that I really want to talk about
31:48 today or these are the main concerns or
31:51 you know this is what I’d like to talk
31:52 about if there’s not enough time we can
31:55 reschedule another appointment or
31:56 something but bringing that ahead of
31:57 time so that both you and the healthcare
31:59 professional know what you can
32:00 accomplish during that meeting or if
32:02 there’s other if you need to set up
32:03 another appointment afterwards and then
32:05 because then that really helps you keep
32:06 organized you could consider contact
32:09 your Healthcare professional if that’s
32:10 at all possible ahead of time and kind
32:12 of send that list of what you would like
32:15 to discuss because that can also help
32:18 that communication
32:21 um be more effective if the person is
32:24 aware of what you want to talk about
32:25 they can they can also prepare as well
32:28 um and the other thing that I would
32:29 recommend would be considering to
32:30 Bringing um your own sort of documents
32:33 that you might have that would sort of
32:35 be helpful or supportive in the
32:39 treatment or assessment that you would
32:42 like so say for example if you’re
32:44 worried that anxiety is starting to
32:46 impact your migraines in particular
32:48 bringing a headache diary and showing
32:50 that you know this is the increase in
32:52 the headaches that I’ve had ever since
32:54 I’ve started to become more anxious
32:57 um
32:57 or even do an online scale for anxiety
33:02 so like one of those is called like a
33:04 gad7
33:06 um is a very prominent or normal scale
33:09 that we give to people uh to screen for
33:12 anxiety so bring that or the results
33:14 from that and your headache diary that
33:16 could be very very helpful
33:17 um and and or any other documents that
33:20 you’ve had seen other Specialists
33:21 anything like that would be very helpful
33:25 um so then move on briefly to treatment
33:28 of depressive and anxiety disorder so
33:32 um there’s two main forms of treatment
33:33 one is called one is psychotherapy and
33:35 the other one is medications and there’s
33:37 a few other things that we’ll not
33:38 mention at the end
33:40 um but the main treatments uh involve
33:42 are very similar to some of the things
33:44 that we already talked about for
33:45 treatment of headaches so relaxation
33:48 therapy increased physical activity
33:50 distraction uh complementary and
33:53 alternative medicines such as
33:54 acupuncture yoga Tai Chi meditation and
33:58 um other treatment like cognitive
34:00 behavioral therapy again that’s probably
34:02 the most common
34:03 um and most highly recommended because
34:05 it is the most efficacious treatment
34:07 for a number of psychiatric disorders
34:10 including depressive disorders or
34:12 anxiety disorders and exposures uh
34:15 therapy is another one for trauma
34:16 related therapies so a lot of different
34:19 non-pharmacological treatment options
34:21 which I think is key to start before
34:23 anything else
34:24 and again this is the
34:27 um the model of cognitive behavioral
34:29 therapy which we talked about this
34:30 thoughts behaviors uh moods feelings and
34:33 physical reactions
34:36 um about antidepressants
34:37 um so I just wanted to highlight this
34:40 um or this slide I want to put in here
34:42 there’s been a number of studies that
34:44 look at the efficacy of antidepressants
34:47 and overall there’s been a number of
34:49 studies that show that antidepressant
34:51 medicines are effective I would say that
34:55 antidepressant medications seem to be
34:57 more effective the more severe the
35:00 depression or anxiety is so when anxiety
35:05 or depressive symptoms are more in the
35:06 mild range
35:08 the efficacy of the antidepressants seem
35:11 to be less so so they start to become
35:14 very similar to Placebo at those when
35:17 the severity is low but when the
35:19 severity is high it really starts to
35:21 separate and it’s much more clear that
35:23 antidepressants are effective
35:25 uh and the next slide is a bit busy but
35:29 um it brings home a couple points that I
35:30 want to talk about just in terms of the
35:32 different types of medications
35:34 um and when medications might be
35:36 effective so if the symptoms are pretty
35:38 severe
35:40 um and there’s a number of different
35:42 medications and this is from a it’s
35:44 called a network meta-analysis where
35:45 they take all of the
35:48 um
35:48 studies that have looked at comparisons
35:51 between different medications
35:52 antidepressant medications and Placebo
35:54 and they map it all out in this big
35:56 statistical analysis so
35:59 um and what you can see here is that
36:02 there’s a significant response with and
36:04 it kind of goes from lower to better so
36:06 flight favors active drug is here on the
36:08 on the bottom here so all the ones that
36:10 are on the right side kind of show that
36:12 these um are more effective so you’ll
36:15 see a few of these that are things that
36:18 we use for treatment of headache quite
36:20 frequently so one is amitriptyline which
36:23 is the one at the very top here
36:25 venlafaxine is another one that’s a
36:27 second line treatment for migraine for
36:29 chronic migraine
36:31 um but the there’s a couple here that I
36:33 would also sorry like to point out
36:37 um is that this one right here so
36:39 escitalopram and Sertraline
36:42 um seem to be the most so in hero kind
36:44 of looked at the bottom here there’s
36:45 interpretation that there are a number
36:48 of differences between antidepressants
36:50 but the antidepressants that seem to be
36:52 most efficacious so work the best and
36:55 are most acceptable in terms of lowest
36:57 side effect profile are these two ones
36:59 here so uh escitalopram and sertraline
37:03 unfortunately these medications don’t
37:05 seem to have any effect on headaches but
37:08 can be taken in conjunction with the
37:10 number of other medications if need be
37:12 if you know Psychotherapy and other
37:15 types of treatments have been shown to
37:16 be ineffective
37:17 and so finally other non-medication uh
37:21 or other non-medication treatment
37:23 options for treatment of depressive
37:26 disorders in particular there’s
37:29 transcranial magnetic stimulation which
37:30 is a non-invasive neurostimulation
37:33 procedure where we kind of place a medic
37:35 or a magnetic coil over certain areas of
37:38 the brain to cause changes in terms of
37:40 how our brain functions in different
37:42 circuits electroconvulsive therapy for
37:44 more severe depression and then ketamine
37:46 infusions are starting to become more
37:47 frequent as well for that which does
37:50 have some efficacy for headaches though
37:52 it’s somewhat Limited at this point in
37:54 time foreign
37:57 also has some evidence for treatment of
37:59 Hague as well but uses a different
38:01 protocol
38:02 so that takes me to about the 45 minute
38:06 Mark so I do have a fair bit of time for
38:08 questions and answers or sorry questions
38:11 and I’ll try and answer them