Myths and Facts of Migraine Diagnosis – Webinar

0:00 so hello everybody my name is dr
0:02 elizabeth larue and i’m a neurologist i
0:05 practice here in montreal quebec and it
0:08 is my
0:09 great great pleasure and honor to be
0:11 here for this webinar about myths and
0:14 facts about diagnosis
0:17 this is a special week it’s june the
0:19 month of migraine awareness
0:22 and i’m very glad for you to be here
0:25 i would like to thank our sponsors at
0:27 migraine canada and our work would not
0:29 be possible without them you can see the
0:31 list it’s a growing list if anybody has
0:34 a contact we aren’t now charitable if
0:37 anybody knows anybody who would like to
0:39 donate or support migraine canada a
0:42 company a corporation please do not
0:45 hesitate to get in touch with us and uh
0:47 we’ll get the the ball rolling
0:50 this is a special day this is actually a
0:53 day for illuminations uh so our team has
0:57 successfully arranged the illumination
1:00 of different uh places and different
1:03 monuments in canada across canada in
1:06 toronto niagara falls
1:08 beautiful falls will be illuminated in
1:11 purple purple is the color for migraine
1:14 awareness
1:15 vancouver calgary and my
1:18 charlotte town and montreal my hometown
1:21 so if you’re close to one of these
1:23 places take a pic and share it on our
1:26 social media
1:28 the other thing that uh we should be
1:30 doing is chase for migraine this is a
1:32 very nice initiative from a group in the
1:35 us uh and they have this campaign called
1:38 show you care wear repair so all you
1:41 have to do is take your coolest set of
1:43 sunglasses and a lot of people with
1:46 migraine have
1:47 sunglasses
1:49 put them on and take a pic and share it
1:51 on social media with hashtag shades for
1:54 migraine to raise awareness
1:58 before we start i am a neurologist and i
2:01 am a headache specialist uh but i am not
2:04 your neurologist and i’m not your
2:06 healthcare providers migraine canada
2:09 provides information not medical advice
2:11 so the discussion and information i’m
2:14 going to present tonight might not apply
2:16 to you
2:18 so whatever i’m saying first i don’t
2:20 want to go against your healthcare
2:22 provider my hope is that you learn stuff
2:25 that might raise questions or maybe
2:27 clarify things that have been told to
2:29 you already
2:30 and then you can go back to your
2:32 healthcare provider and
2:34 discuss and clarify what your diagnosis
2:38 is
2:40 so let’s get started so tonight is about
2:42 myths and facts about migraine diagnosis
2:45 and in med school we used to say you
2:48 know there are horses common things and
2:51 there’s zebras that are rare and then
2:54 you even have this thing here in the
2:55 middle which is a source a mix between a
2:58 horse and a zebra because sometimes
3:01 headache diagnosis is complicated
3:06 so once i was actually preparing a talk
3:08 for doctors and specialists and i i just
3:11 complete certain deputy on the big web i
3:13 found this website by dr smith this is a
3:16 real website you can have a look at it
3:19 and i found it was um interesting
3:21 because as a neurologist and headache
3:23 specialist this made me cringe because
3:25 those diagnoses are not correct
3:28 diagnosis but these are seen on social
3:31 media and i see a lot of them i think
3:33 the reason why it’s because
3:36 people very naturally will link the word
3:39 migraine with a lot of other things
3:42 and for example here we have aura
3:44 migraines chronic migraines ocular
3:47 migraines post-traumatic migraines
3:50 interestingly we try to use migraine
3:54 singular as a disease now
3:56 and migraines
3:58 plural we try to steer away from that
4:00 but you know just uh feel uh comfortable
4:03 using what you prefer but usually we try
4:05 to stay with the singer
4:07 so tonight we’ll go over dr smith’s uh
4:10 list and see you know if we can clarify
4:13 some of these terms and like i said some
4:16 of them are correct for example
4:17 intelligent migraine does exist but
4:20 others are very misleading
4:24 let’s start by by just a definition
4:26 about words tonight is a lot about words
4:29 correct words what what words we should
4:31 use
4:32 um the difference between a disease and
4:35 a syndrome
4:36 so the whole story of medicine is about
4:40 putting symptoms together right symptoms
4:42 are what people feel and perceive and
4:46 signs signs are what we doctors or any
4:49 healthcare provider will examine and
4:51 they will objectivize this they will see
4:53 this on clinical exam so we put a bucket
4:57 or a group of symptoms and science
4:59 together and it’s like well this looks
5:01 like it happens in the same person looks
5:03 like something that happens
5:05 and then we try to understand what is
5:07 going on with imaging blood tests
5:11 electrophysiology and so on
5:13 so if we can pair
5:15 an ensemble of symptoms uh and signs
5:18 with something that we can objectivize
5:21 and we that just tells us what the cause
5:24 is so biological evidence objective
5:27 evidence tests
5:29 then yes we’re talking about a disease
5:32 no then we may be talking about a
5:34 syndrome which is a set of symptoms and
5:37 maybe signs that are not yet explained
5:40 and for which we do not have yet tests
5:43 right so i’ll give you a few a few
5:45 examples
5:47 so some health issues are super easy to
5:50 uh to see right so here you have a ct of
5:53 the lung it’s a lung cancer there’s a
5:55 big mass there uh and it’s pretty
5:58 obvious on the other side you have a
6:00 bone fracture so let’s say this person
6:02 fell off a bike the bone is
6:05 visibly broken doesn’t take a diploma in
6:07 medicine to see this and you can
6:09 confidently diagnose a bone fracture
6:14 but then in the history of science um
6:16 what we could see with the naked eye was
6:19 not enough right there were things that
6:21 we could not understand
6:22 so then we started looking with better
6:25 tools an example was the eeg
6:28 electroencephalogram
6:30 because in the old days epilepsy right
6:32 seizures were
6:34 thought to be demonic possessions right
6:37 so people thought that some kind of
6:39 spirit because you couldn’t see anything
6:41 right so people thought that it was all
6:43 about a spirit taking hold of you it’s
6:46 what it’s called a seizure actually it’s
6:48 because you’re being seized by some
6:49 external thing
6:51 now with eeg we know what epilepsy is
6:54 and we’ve come to understand it
6:56 on the other side we have the examples
6:58 of infection something we’ve talked a
7:01 lot about in the recent years remember
7:03 that in the old days we could not see
7:05 viruses and bacterias and prions so it
7:09 was just like some things in the air it
7:12 was impossible to see them and and to
7:14 treat them so something like
7:16 tuberculosis for example that we know
7:18 very well now um we couldn’t see before
7:21 the later in the night in the 1900s
7:24 so we have examples of bacteria and
7:26 thank to the microscope now we can see
7:29 bacteria and viruses and prions and
7:32 understand them
7:34 other diseases we can measure easily as
7:36 well and reliably so for example the
7:39 thyroid disorder well you can do a tsh
7:41 right you can just take a blood test and
7:43 then the doctor says oh your tsh is high
7:46 your tsh is low because the symptoms of
7:49 thyroid disorders are not super typical
7:52 they are actually very common symptoms
7:54 fatigue weight gain right very
7:56 unspecific on the other side we have
7:59 another disease hypertension which has
8:02 no symptoms most of the time the problem
8:05 is when it leads to a stroke or heart
8:08 disease so we we know now that we should
8:11 keep blood pressure low and luckily for
8:13 us we can measure blood pressure very
8:16 easily so you can see just a whole array
8:19 of symptoms and how
8:21 disease is diagnosed
8:23 so can we measure migraine can we see
8:26 its cause that’s the question
8:30 so here are the official diagnostic
8:33 criteria of the international
8:35 classification of headache disorders i’m
8:38 sorry this is a bit dry this is kind of
8:40 medical lingo but i think it’s important
8:43 that you guys
8:44 understand
8:46 understand why we have a classification
8:48 of criteria is because since we didn’t
8:51 have any evidence for the cause of these
8:54 things well we needed to have at least a
8:57 fair definition and description of what
8:59 we were talking about
9:01 so experts
9:03 sat together in the 90s and said okay
9:06 this we’re going to call migraine based
9:08 on observations of the previous
9:10 centuries right
9:12 and then
9:13 criterias were formed and it was an
9:15 agreement so in science we need rules to
9:18 say okay this is what we’re talking
9:20 about let’s look at it and let’s try to
9:22 see if we can make some sense and find
9:25 some causes for this set of symptoms
9:30 so the key symptoms for migraine as i’m
9:32 sure you have experienced are attacks of
9:36 head pain with other symptoms nausea
9:39 sometimes vomiting sensory
9:41 hypersensitivity this is an old drawing
9:44 from the 18th century and this lady here
9:47 is holding her head
9:49 she she probably will go to the bed
9:51 because her um her supporting lady here
9:55 is maybe the nanny is preparing the bed
9:58 the other nanny is taking care of the
10:00 kids saying that maybe now is not a time
10:03 to play the drums
10:04 and the boyfriend here is um said maybe
10:07 i was going to do a little show but i’m
10:09 going to
10:10 forget about that because obviously i
10:11 need to be very quiet now
10:13 and she isn’t she even has a butler who
10:16 is kind of hiding the fire because she
10:18 has sensitivity to light
10:21 um in the modern days a lot of us ladies
10:24 do not have two nannies and one butler
10:27 to take care of us
10:29 but still we do live with migraine and
10:32 the men as well
10:33 we live with migraine and we have to
10:36 deal with it
10:38 so up to this day migraine does not have
10:41 a biomarker that we can use in practice
10:44 so when we talk about a diagnosis
10:46 we cannot measure migraine with a blood
10:49 test or imaging that we doctors can
10:52 prescribe reliably right so if you had a
10:56 big brain tumor it would be very visible
10:58 on an mri or ct scan it’s like if you
11:01 take a laptop and it’s completely
11:03 visibly destroyed this is very obvious
11:06 migraine is seen on
11:08 other techniques so for example if you
11:10 do an mri of the brain with migraine you
11:12 will it will seem normal in appearance
11:15 but it’s not normal
11:17 how do we know that migraine is not just
11:20 a syndrome and a set of symptoms how can
11:22 we
11:23 say that migraine is different that
11:25 there is a cause there is a biological
11:27 cause for migraine
11:29 in the 70s people thought that migraine
11:31 was a psychosomatic disease that it was
11:34 all a matter of emotions and that maybe
11:36 it was even imaginary but now thanks to
11:39 different techniques gene analysis
11:42 microscopes
11:43 fmri which is functional mri
11:46 chemistry analysis we know more
11:49 so we can actually now see migraine and
11:52 research and we can actually have models
11:54 human models this is a model from the
11:56 denmark center where we can inject
12:00 substances to someone with migraine and
12:02 see if it triggers attacks and so we
12:04 understand that those substances can
12:06 actually be targets for treatment
12:09 you might be wondering now why is she
12:11 doing dr larue because she she told us
12:13 she was going to talk about diagnosis
12:15 but it’s very important to understand
12:17 that that diagnosis is linking symptoms
12:20 with a cause and with what we call
12:22 pathophysiology so that’s why i’m
12:24 showing you this
12:25 um so it that’s another evidence on the
12:28 right side
12:29 a functional mri study done in germany
12:32 showing the zones of the brain that are
12:34 active during migraine my point is we
12:37 know the causes some of the causes of
12:40 migraine now what we know is that it’s
12:42 something genetic that there are some
12:44 chemistry things some electricity things
12:47 for example people with migraine have a
12:49 low serotonin they have also difficulty
12:52 habituating the stimuli
12:55 and all of this leads to the symptoms
12:57 that people have
13:00 i won’t go into detail here this is the
13:02 slide the more advanced slides that i do
13:04 show
13:05 healthcare providers and neurologists
13:07 when i teach
13:08 this is all the pieces of the puzzles
13:11 the migraine puzzles that we know up to
13:14 this day okay so this and if you want to
13:16 dig just for fun let’s dig a bit deeper
13:19 this is a sensory neuron this is a
13:22 cell that we all have in our bodies that
13:24 takes care of carrying sensory
13:26 information and pain those are all
13:29 things that we know about little
13:30 proteins and so on that we can study so
13:33 you can see the degree of complexity
13:35 that we have reached in understanding
13:38 migraine
13:39 this is another thing i’m going to skip
13:41 very very quickly on but this is
13:43 actually a diagram just explaining the
13:46 metabolic aspect of migraine i show you
13:48 this just to tell you that we have
13:51 understanding of some of these things
13:53 that causes migraine
13:55 all right
13:56 let’s go back to dr smith now that we
13:59 have said that migraine is a disease and
14:01 not only a syndrome though it is still
14:04 difficult to measure
14:05 so dr smith here treats things like
14:08 cluster migraines
14:10 hypertension migraine tension migraines
14:12 and post-traumatic migraines
14:15 so this is actually not a good way to
14:18 make a diagnostic diagnosis
14:21 let’s go back to our international
14:24 classification
14:25 here i have to make the distinction
14:27 between something called
14:29 primary headaches which is migraine is
14:31 the the most common not the most common
14:33 but a very common cause
14:35 and secondary headaches so there’s
14:37 actually 210 plus diagnosis in this
14:41 classification with just which justifies
14:44 why as a neurologist i’m never bored
14:47 so here we have primary headaches
14:49 migraine tension type headache
14:51 trigeminal autonomics of algias and
14:53 others and secondary headaches are
14:56 headaches that are caused by
14:58 something like
15:00 an infection a vascular problem a trauma
15:04 a concussion
15:05 a drug
15:07 an intoxication and so on right
15:10 so migraine is not a secondary problem
15:13 migraine is something that comes
15:14 directly from the pain system in the
15:16 brain that’s why we call it primary
15:20 so the first thing i want to do is
15:22 separate migraine from tension type
15:23 headache this is the one question that
15:26 the media asks me all the time and i’ve
15:28 shown here this tree which is the black
15:30 and white picture in the reverse to see
15:32 that migraine and tension type it’s are
15:35 mostly mutually exclusive in a sense so
15:38 migraine usually will be associated with
15:41 other symptoms like nausea sensory
15:43 hypersensitivity
15:45 tension type is mostly a headache
15:47 usually both sides of the head that’s
15:49 mild to moderate and there’s no other
15:52 symptoms for some reason like
15:54 phonophobia is there but usually i i
15:56 don’t mention phonophobia so tension
15:58 type is just a headache and migraine
16:00 comes with other symptoms this is how it
16:03 has been defined
16:05 of course humans can have both tension
16:08 type and migraine because both are
16:10 extremely common and many people will
16:13 make the difference between a tension
16:15 type and a migraine and if you have
16:17 chronic migraine you might definitely
16:19 have both
16:21 headache um i want to make a few
16:23 comments on cluster headache this is a
16:25 topic that i’m it’s very dear to my
16:27 heart i i follow a lot of these patients
16:29 i saw one today
16:31 cluster headache is different from
16:33 migraine it is a diagnosis i will go
16:36 actually on the differences so cluster
16:38 headache is usually something that is
16:40 only on one side migraine usually will
16:42 not be only on one side it’s less long
16:45 it’s shorter the attacks are shorter
16:47 than a typical migraine so usually less
16:49 than three hours
16:50 the intensity is usually more severe
16:53 than a migraine
16:55 and then people with cluster will be
16:57 restless they will rock they will move
16:59 they will be agitated people with
17:02 migraine usually are quiet they want to
17:04 stay calm
17:05 in the dark room
17:07 uh cluster headache also works by bouts
17:10 and remission so sometimes the attacks
17:12 are there and sometimes there’s no
17:14 attacks at all as migraine usually goes
17:17 over and over with a kind of a regular
17:19 frequency
17:20 so i i’m not going to do to go into
17:23 great depth about this because this is
17:25 something that even neurologists
17:27 sometimes struggle with but just to tell
17:29 you that migraine cluster have some
17:31 things in common right but also have a
17:34 lot of differences
17:36 now this being said i want to go now to
17:38 the cluster the dr smith cluster
17:40 migraine and i see this diagnosis a lot
17:43 on social media
17:45 so cluster migraine is not an official
17:47 medical diagnosis diagnosis it can mean
17:50 two things usually when people say they
17:52 have clustered migraine it can mean that
17:55 they have both migraine and cluster
17:57 headache so they have both things but
17:59 they do differentiate
18:01 or it can mean that they have attacks
18:03 with traits of both disorders and it’s
18:05 difficult to kind of tear them apart
18:08 which is which right
18:09 so this is something we see sometimes um
18:13 you know not everybody is exactly like
18:15 the international classification says it
18:18 should be right so some people are
18:20 sitting somewhere in between and then
18:22 it’s the decision of the patient and the
18:24 doctor which treatments should be tried
18:27 so cluster migraine is not an official
18:29 diagnosis but it exists for a reason
18:32 that sometimes things are not clear
18:35 another thing i see a lot on social
18:37 media when i reach i read the groups is
18:40 something like this you know um so my my
18:43 migraine attacks are very difficult to
18:45 treat um according to my neurosurgeon uh
18:49 and since i had the brain tumor um it’s
18:51 been very difficult
18:53 or you know my migraine started after an
18:55 accident
18:57 so this is where it gets a bit
18:58 complicated because
19:01 migra any headache okay any headache
19:03 will
19:04 be head pain
19:06 and then either you have the migraine
19:08 symptoms like nausea and sensitivity to
19:10 light and sound and so on either you
19:12 don’t have them so either you are
19:14 tension type or either your migraine
19:17 type but the hard truth is that most
19:20 secondary headaches tumors strokes
19:23 infections sinusitis thrombosis
19:26 um a headache related to an inflammatory
19:30 condition
19:31 they will come with nausea and
19:33 phonophobia and photophobia or
19:35 sensitivity to lighter sound so when the
19:38 residents that i trained in the old days
19:40 when i was at the gym
19:42 i told them stop calling those migrants
19:45 symptoms because those are symptoms that
19:48 are also associated with secondary
19:50 headaches
19:51 so the key to a primary headache like
19:53 migraine is that there’s no other cause
19:56 and that usually it comes
19:58 as a recurrent form over years and years
20:01 so the other thing is that of course if
20:03 you do have migraine like you know 15
20:06 percent of the planet
20:08 you are absolutely entitled to also have
20:11 another headache somewhere in your life
20:13 so someone with migraine might have a
20:15 tumor might have a stroke might have a
20:18 bleed might have a sinusitis and then
20:21 develop a headache that may look like
20:23 migraine but maybe slightly different
20:27 so the point here
20:28 is that um if you have a cause to your
20:31 headaches that’s really clear and it’s
20:33 been diagnosed that way
20:35 well it’s better not to call it a
20:37 migraine it’s called it headache caused
20:39 by or secondary tear
20:41 but you might have migraine and
20:44 a secondary headache
20:47 so this is interesting because this is
20:48 the classification of epilepsy and
20:51 epilepsy actually made that very clear
20:55 so they said okay we have different
20:57 types of seizures we have the big
20:59 seizures like people shake you know and
21:01 they of all limbs like we see in the
21:03 movies
21:04 and their arm seizures are more subtle
21:07 okay where people just stop you know
21:09 look in the air and so on so different
21:11 types of seizures but then there are
21:13 different types of causes so epilepsy as
21:16 well can be caused by an infection a
21:20 stroke a tumor and it can also be
21:23 genetic just like migraine can be
21:26 genetic without any other cause than
21:29 software issues in the brain so i wanted
21:32 to show this just to say that in
21:34 epilepsy i think the classification
21:36 reflects a bit better reality than what
21:39 we’re trying to do with this secondary
21:41 primary
21:42 headache all right so now we thought
21:45 about how migraine is different from
21:47 tension headache cluster and secondary
21:50 headaches uh let’s go back to dr smith
21:53 and i want to say a word about post
21:55 traumatic headache because it’s super
21:57 common so post-traumatic migraines
22:01 post-traumatic headache is not the same
22:04 as migraine with no history of trauma
22:07 and here’s a bunch of recent references
22:09 um that just proved the point so first
22:12 they are different on the functional mri
22:14 so we have imaging proof that they are
22:16 different they have different symptoms
22:19 of course some symptoms can be similar
22:21 because just what i said you know any
22:23 headache will be either like a migraine
22:26 or like tension type but they are
22:28 different in other characteristics
22:30 they have a different prognosis it is
22:32 more difficult to treat post-traumatic
22:35 headache than treat pure migraine with
22:37 no trauma
22:39 and if those of you who know about cgrp
22:41 antibodies like emma vega jovi and
22:44 galileo and so on um
22:46 those work very well for migraine they
22:48 do not seem to work very well for
22:50 post-traumatic headache so it looks like
22:53 those things are different right if
22:55 you’re if you develop migraine as a teen
22:58 or young adult with no headache trauma
23:00 or nothing no head trauma and you have
23:02 pure migraine it’s one thing but if your
23:05 headaches started clearly after a trauma
23:08 it’s a different thing
23:10 the problem is that of course it can be
23:12 more complicated because here you have
23:15 all the different scenarios that can
23:17 happen after an accident so you can have
23:19 someone that had no headache before has
23:22 a headache and then it gets better
23:25 but you can have someone who had no
23:27 headache before
23:28 has a headache doesn’t get better
23:30 or you can have someone that had
23:33 migraine or tension type headache before
23:35 as a primary headache then had an
23:38 accident
23:39 and then either the migraines get the
23:41 migraine gets worse
23:43 or there’s a new type of headache that
23:45 is added to the pre-existing thing
23:48 and that is where the insurance
23:50 companies are so complicated because
23:53 they will tell you that’s always because
23:55 you had migraines before right
23:57 so there there are a lot of different
23:59 scenarios that require a careful history
24:03 and sometimes just last week i saw a
24:05 woman she’s had five different head
24:08 traumas in her life and all of these
24:10 contributed to her current state of
24:12 things
24:13 so lots of scenarios and in our practice
24:16 we know that when someone has a history
24:19 of migraine there’s more risk of
24:21 developing post-traumatic headache and
24:23 sometimes it’s just not one trauma it
24:25 can be a whiplash 10 years ago it can be
24:28 a ski accident five years ago and then
24:30 it can be another accident just last
24:32 week and then you have a mix and match
24:34 of migraine tension type neck pain post
24:38 traumatic headache this is not an easy
24:40 situation and it does require once again
24:44 a careful analysis by a healthcare
24:46 provider just to try to see which way is
24:49 the right way to go
24:52 okay so now i i’ve gone over you know
24:54 what is not migraine um let’s say it is
24:57 migraine you’ve diagnosed you’ve made
24:59 the diagnosis it’s pretty clear there
25:01 are attacks and so on what type of
25:04 migraine is it right because there’s so
25:07 many different declinations of migraine
25:09 migraine is very diverse it can come
25:12 with different triggers with different
25:14 patterns with different symptoms with
25:17 different severities
25:19 and with different uh problems like
25:21 medication overuse for example
25:24 so
25:25 because migraines in the end it’s more
25:27 than just a headache so we have taught
25:29 about the criteria
25:31 but in addition to the criteria it’s
25:33 like you know you have the basics and
25:35 then you sprinkle your toppings you know
25:37 a bit like on a pizza right so you have
25:39 basic pizzas dough with tomato sauce and
25:42 then you can put top toppings on it so
25:44 you know i have migraine with um in my
25:46 case i have that like in someone’s case
25:48 you have diarrhea someone else might
25:50 have vertigo and dizziness and then we
25:53 call this vestibular migraine someone
25:55 might have aura and we’ll talk about
25:57 that
25:58 so there’s a lot of different things
25:59 that can be added to just a basic
26:02 migraine criteria to
26:04 build a more a precise picture of your
26:07 situation
26:09 so if we look at migraine classification
26:11 over time um well this has been very
26:15 fascinating because in the 19th century
26:18 when nobody you know there was no ct
26:20 scan no mri no like i’m not sure eeg eeg
26:24 existed then
26:26 um we had really nothing to look at the
26:28 brain and so well people classified
26:31 migraine based on the color of the face
26:33 of the person so there were white
26:35 migraine when you turn pale and there
26:38 were red migraines where you were all
26:40 red right
26:41 so this was an interesting theory based
26:43 on what people could see
26:45 after that it went to migraine with aura
26:48 which we will talk about in a few
26:49 minutes
26:50 and then there were other things by
26:52 symptoms vestibular migraine um
26:54 exploding imploding was another thing
26:56 that we talked about
26:58 then there’s the world of triggers and
27:01 this i see a lot on social media so for
27:03 example i know a lot of people who would
27:06 love to find a treatment for weather
27:08 migraine or sinus migraine or neck
27:11 migraine so those are popular things
27:13 those are not in the classification
27:16 because we lump all migraine together
27:18 but in practicality this is what happens
27:21 right this is migraine that’s linked to
27:23 a particular trigger the one that we put
27:26 in the classification is menstrual
27:28 migraine because this
27:30 is has been actually studied and there
27:32 are particular treatments for it
27:35 and then the current way to diagnose
27:37 migraine is according to frequency right
27:40 so when we go back to the uh to the dr
27:43 smith thing and i’m gonna go back here
27:46 oh my god this okay here
27:48 um you see so there where you see you
27:50 can see transformed migraine right
27:53 so all of these things sorry i’m moving
27:55 here um oh there we are so
27:59 so if we go back to dr smith here he put
28:02 chronic migraine complex migraine daily
28:05 migraine and transformed migraine all of
28:08 this refers to migraine and headache
28:11 frequency
28:12 so migraine is actually a continuum some
28:15 of you might have a lower frequency and
28:18 others in some cases you have no
28:20 headache free days like your life is
28:22 having a headache to some degree
28:25 so migraine is this continuum
28:27 and over a lifetime you might actually
28:29 go from one a better state to a worse
28:32 state and maybe hopefully you go back to
28:35 what we call episodic where you have
28:37 less frequent attacks
28:40 the majority of people on earth have low
28:43 frequency episodic migraine so people
28:46 who have one to six or seven days per
28:48 month of headache
28:50 um and and that’s that’s very good
28:52 because of course the impact is less it
28:54 doesn’t mean there’s no impact
28:56 but the majority of people have this but
28:58 still if you put together chronic
29:00 migraine and high frequency episodic
29:02 migraine it is a lot of people
29:07 okay so here is one of the things i say
29:10 a lot to the insurance companies
29:13 migraine is invisible on an mri right
29:17 but very visible on a headache diary so
29:19 i’ve put the headache diary of one of my
29:22 patients
29:23 this is a paper diary
29:25 where patient just said you know one is
29:27 mild two is moderate tree is severe this
29:29 is kind of a tree tier tree level
29:31 approach uh and you can see this poor
29:33 person here doesn’t have a lot of
29:35 headache free days has a lot of triggers
29:37 like stress and fatigue and he’s using
29:40 the peroxide and almo trypton to treat
29:42 the attacks
29:44 so this is another actually a diary from
29:46 another patient i saw recently
29:49 this person this is kind of a bit of a
29:51 more compact version
29:53 and you can see this person has a free
29:55 episodic so it’s not chronic there’s not
29:58 15 plus days and if you look carefully
30:01 you’ll see that p is the beginning of
30:03 her period
30:05 and there’s always something linked with
30:07 her period so that would be she also has
30:10 other attacks but there’s something
30:11 around the period where she always had a
30:14 bad cluster if she looked at the bottom
30:16 in june there’s a p there and you have
30:18 this block of attacks so she has
30:21 episodic migraine with menstrual
30:23 migraine so that’s one example of a
30:26 diary that says the diagnosis
30:29 if you’d like to try our canadian app
30:31 for migraine monitoring um the canadian
30:34 migraine tracker i certainly encourage
30:36 you to do it because you can actually i
30:39 record the intensity what you took uh
30:42 triggers auras periods etc and all of
30:46 this is really helpful to help your
30:48 healthcare provider um
30:51 to uh to help your healthcare provider
30:53 to guide you and choose the right
30:56 treatment so if you haven’t tried it it
30:58 is way more simple than migraine buddy
31:00 that’s why it was designed and i hope
31:02 that you will find it helpful you can
31:05 actually send your diary to your doctor
31:07 by email or even fax
31:11 so let’s go back to chronic and episodic
31:14 okay i want to make just one political
31:16 comment uh as migrant canada chair i
31:19 mean my goal is to have migraine
31:21 recognized treated and so people have
31:24 access to therapy
31:26 chronic migraine is actually using
31:28 chronic migraine just for people who
31:31 have more than 15 days per month is a
31:33 very unfortunate use of this term why
31:37 because in chronic diseases you know
31:40 monitoring if if you have this kind of
31:44 tag of being a chronic disease you get a
31:47 lot of good stuff for example
31:50 money for monitoring research public
31:53 health programs therapeutic education
31:56 for people disability recognition
31:59 so what are chronic diseases things you
32:02 know diabetes cancer chronic lung
32:05 disease
32:07 kidney disease so migraine in general is
32:11 a chronic disease it goes over years and
32:13 years starts very young often and then
32:16 goes over your life and then has a
32:19 severe impact on you it’s a one of the
32:21 top causes of disability
32:24 so my point is how should we classify
32:26 quantify slash diagnose migraine
32:30 personally i think we should let go of
32:32 this stupid episodic and chronic
32:34 dichotomy uh there’s just like two
32:36 buckets we know it’s not true we know
32:38 it’s way more complicated than that and
32:41 we know we can quantify migraine with a
32:43 headache diary
32:45 and we know the frequency will actually
32:47 go up and down right depending on people
32:50 so
32:51 usually the way that i diagnose i treat
32:53 my patient is i look at what they are
32:56 now and i say well you know are you at
32:58 four to six per month are you at 20 plus
33:01 per month are you are you at 12 15 per
33:04 month right because to me as a physician
33:07 it’s way more useful to have exact
33:10 statement of facts instead of just
33:12 episodic or chronic so in my perfect
33:15 world we would just take migraine as a
33:17 chronic disease and then we would have
33:20 an exact quantification of what the
33:23 current state of things is
33:26 okay so let’s move now to migraine
33:28 associated with other pains right
33:32 a lot and dr smith actually did not put
33:35 that there but i’m talking about the
33:37 neck migraine the sinus migraine and tmj
33:40 pain
33:41 so this is something called the
33:42 trigeminal cervical system
33:45 sorry my cat is getting dangerously
33:47 close here hello hello now she leaves
33:51 she’s getting close to my keyboard
33:53 um
33:54 okay so
33:55 so the trigeminal cervical system is
33:58 something that we have as human beings
34:01 and it is actually a link between the
34:03 nerves of the face and the nerves of the
34:06 back of the head and the neck right
34:09 and all those nerves just kind of have
34:11 connections together
34:13 leading to
34:14 a link between the back of the head and
34:16 the front and the jaw and the ear and
34:20 the sinuses
34:21 all this is one pain system right
34:25 so here you can see that the different
34:27 pains i’m sure some of you have had
34:29 pains like this
34:30 so this leads to a lot of problems in
34:34 diagnosis
34:35 because quite a bit right people are
34:38 falsely diagnosed with something like
34:41 sinus headaches there’s been a study in
34:43 male clinic showing that sinus headaches
34:46 80 percent of the time are actually
34:49 misdiagnosed migraines
34:51 or migraine um that has symptoms in the
34:55 sinuses or triggers in the sinuses right
34:58 so we have to understand that the this
35:01 is kind of a two-way road between uh our
35:04 painful parts like the eyes the tmj the
35:07 neck and the sinuses
35:09 and the migranus brain so sometimes it’s
35:12 very difficult to differentiate
35:14 between your triggers and your symptoms
35:17 and sometimes both can be true so i’ll
35:20 give you an example
35:22 patient of mine has allergies so every
35:25 season of allergies triggers tons of
35:27 migraine because then the sinuses are
35:29 all irritated and then this triggers
35:32 attacks but sometimes this person may
35:34 have a migraine that cause pain in the
35:37 sinuses
35:38 so every time that you think about pain
35:40 somewhere and a migraine is brain you
35:42 can think kind of a ping-pong game both
35:45 sides
35:46 so this is true for the sinuses this is
35:49 true for tmj
35:50 80 of people with chronic migraine
35:53 frequent migraine have tmj pain this is
35:57 something that is seen very often
35:59 and then the cervicogenic headache i’ll
36:01 make a bit more comment about that
36:05 so when you think about the brain with
36:06 migraine that has this particular
36:08 chemistry and electrophysiology that i
36:11 mentioned um well it is since it is
36:14 sensitive to the environment and then to
36:17 you can you have to see this as really
36:19 as a ping-pong between the brain and the
36:22 environment
36:24 so migraine is frequently mistaken for
36:27 sinus headaches for the reasons that i
36:28 just told you so migraine can be
36:31 triggered by different things like
36:32 weather changes tearing and nasal
36:35 congestion are common during migraine
36:37 attacks sinus medication can help
36:39 migraine sometimes so people think it’s
36:41 a sinus problem
36:43 uh so the sinus i spoke about but i want
36:45 to say a few words about cervical genic
36:47 headache
36:48 um this is something that is very
36:50 controversial even for us doctors i’m
36:53 just back from a conference and i had
36:56 heated debates with my colleagues about
36:58 what is cervicogenic headache and what
37:01 should we do about it right because as
37:03 i’ve shown you the neck and the head are
37:06 one and only pain system it’s the same
37:09 pain system
37:10 so sometimes it is very common for
37:13 people with migraine to have neck pain
37:16 and it is very common for people who
37:18 have neck issues to trigger headaches so
37:20 once again you have this kind of two-way
37:22 road
37:23 um and more complicated
37:25 uh in the neck the neck is is a very
37:28 complex structure right it has
37:31 muscles bones facets
37:34 nerves and then all of this just talks
37:37 to the pain matrix to the brain
37:39 so it’s not easy to make sense or rhyme
37:41 or reason of this um and usually it’s
37:44 actually best to just
37:46 look at the whole picture and try to
37:48 figure out treatments that could be
37:50 helpful
37:52 okay last part with dr smith
37:54 so dr smith treats also aura migraines
37:58 hemiplegic migraines silent migraines
38:01 and
38:02 two times silent migraines i’m not too
38:04 sure why it’s there twice
38:07 so what is an aura right some of you
38:10 might have it um the aura is something
38:13 that’s been described since quite a bit
38:15 of time this is one of the first
38:16 description in the 1870s
38:19 it is usually usually a visual symptom
38:23 so and here i’ve shown you here
38:25 um some drawings made in brazil by
38:28 people who had auras and you can see how
38:31 diverse
38:33 and how even artistic those auras are
38:35 they can be in color they can be in
38:37 black and white they can be little dots
38:40 flashes they can be one side they can be
38:43 both sides they can be uh they can be um
38:46 progressive usually
38:48 and so the vast majority of auras are
38:51 visual
38:52 this being said this is a study from uh
38:55 uh scandinavia in 1996 um some people
38:59 who have auras i saw one today in my
39:01 office has
39:03 have visual symptoms but some have also
39:06 sensory stuff tingling numbness on one
39:09 side of the body
39:10 and some of them have speech
39:12 difficulties so what is the cause of the
39:15 aura
39:16 well the cause of the aura and here you
39:18 see a guy from brazil this is dr liao so
39:21 this guy was studying epilepsy so he was
39:24 looking at abnormal electrical activity
39:27 of the brain and he was hoping to find
39:30 some epilepsy stuff on the rabbit brain
39:34 but what he found was a different type
39:36 of electric abnormalities called he
39:39 called cortical spreading depression
39:41 because he saw on the brain it was kind
39:43 of a wave of what we call in neurology
39:46 depolarization so it’s like the neurons
39:49 fire and then they stay very quiet all
39:52 right
39:53 and this is thought to be the cause of
39:55 the aura so this wave goes on the brain
39:58 depending where it goes it causes
40:01 symptoms usually
40:03 visual
40:04 um there’s been a lot of other research
40:06 made on this with fmri um and then also
40:09 uh other experiments just showing that
40:12 cortical spreading depression can
40:13 trigger a migraine i don’t want to go
40:15 too deep in there i know it’s a a bit of
40:18 a advanced science but just to tell you
40:21 that the aura we know where it comes
40:23 from when it’s typical and it’s
40:26 different from just a migraine attack
40:28 where you know it’s usually an
40:30 inflammation with peptides released in
40:32 the brain and so on
40:34 so when we see a migraine aura the aura
40:36 is one thing and migraine is another the
40:39 headache the headache phase and they are
40:41 related
40:43 the other problem we have is that
40:45 there’s a lot of other symptoms that
40:47 come with a migraine attack and it’s not
40:49 clear if they are typical right so a lot
40:52 of disorientation brain fog weird tastes
40:56 um
40:57 somatic sensation tightness of the neck
41:00 dizziness
41:01 vertigo vestibular migraine
41:04 for all of this it is not clear at all
41:07 if these symptoms are caused by cortical
41:10 spreading depression so it’s not clear
41:12 if we should call these aura so usually
41:15 we keep aura for
41:17 a set of symptoms that ideally a
41:19 neurologist will clarify with you
41:22 it doesn’t mean that those symptoms do
41:24 not exist it just means that we don’t
41:27 know yet where to come from
41:30 and here is the usual way that a
41:32 migraine attack will evolve over time
41:35 and interestingly there’s something a
41:37 bit weird here is that i know a lot of
41:40 patients who have premonitory symptoms
41:42 like prodrome and i know a lot of
41:44 patients who have auras but a lot of
41:46 patients have no prodrome and no aura so
41:49 i think the point i want to make here is
41:51 that everybody’s different and some
41:53 people might have a prodrome or a
41:56 postdrome or none of these um some
41:59 people might have aura some people might
42:01 have symptoms that we do we do not yet
42:05 understand
42:07 so i want to go now to this term silent
42:11 migraine i’ve seen it a lot on the
42:13 social media
42:14 and actually even contacted the american
42:17 headache society so they remove it from
42:20 their their um terminations because
42:22 silent migraine first is not an accepted
42:26 diagnostic term
42:27 why do people use this word there’s
42:30 always a reason i mean usually when we
42:32 use words it’s because they serve they
42:34 describe something that exists
42:36 so this is usually used either to talk
42:39 about the face without headache prodrome
42:42 or post drum right so this should be
42:44 called prodrome and postro not silent
42:47 migraine
42:48 the other thing is sometimes it’s called
42:50 to describe an aura without headache
42:53 so this is an aura without headache so
42:55 not silent migraine
42:57 and then sometimes we use silent
43:00 migraine to describe any other symptom
43:03 usually dizziness that is not explained
43:06 by uh that is not associated with
43:08 migraine diagnosed right
43:11 um
43:12 and that it’s that that we don’t know
43:14 exactly where it comes from so now that
43:16 we understand migraine better
43:19 the natural thing to do is say well
43:22 you know maybe this could be caused by
43:24 the migraine chemistry and
43:26 electrophysiology and we just don’t know
43:28 it yet and there’s no headache phase so
43:30 we’ll call it silent migraine
43:33 remember that all we know about migraine
43:35 has been found in people who had the
43:38 typical headache according to criteria
43:41 so if there are other symptoms that are
43:44 completely separate from migraine i
43:46 think we should be very careful about
43:48 calling them migraine
43:50 i know this might be a bit shocking to
43:52 some of you but i just want to be
43:55 wary of using the right words so we
43:57 actually can do good science and develop
44:00 proper treatments
44:02 a last word on migraine and triggers
44:05 so migraine and triggers there’s a lot
44:07 of this i see as well on discussions my
44:09 patients talk to me about about this all
44:11 the time um you know can i adapt my
44:14 treatment to my triggers so if i have
44:17 menstrual migraine weather migraine
44:19 emotion migraine food migraine neck
44:21 migraine sinus migraine
44:23 so obviously if you think about this
44:25 kind of brain and periphery thing
44:28 sometimes there are triggers that you
44:30 can manage right you can
44:32 take different types of contraception
44:34 for menstrual migraine
44:36 you can
44:38 manage your food your diet you can adapt
44:41 your exercise you cannot do a lot about
44:43 the weather sadly
44:45 and then usually improving prevention is
44:48 best right so you actually increase the
44:50 threshold of your brain to the triggers
44:53 instead of just controlling the triggers
44:55 um and so far in our practice
44:58 it is still trying at trial and error
45:01 there is no predictor saying that this
45:03 drug is going to work better for
45:06 any trigger apart from menstrual there’s
45:08 a bit of an exception there but the
45:10 other triggers usually will just use our
45:14 treatments that we have
45:16 and we’re lucky because there’s actually
45:18 a ton of different treatments and i
45:20 invite you to look at our webinars or
45:22 podcasts or pdfs um there’s a lot of
45:25 options to treat migraine these days
45:27 right so basics are just kind of
45:29 lifestyle then all the natural and
45:31 alternative worlds
45:33 then the acute meds the preventive meds
45:36 and now we have things that do both so
45:38 it’s even uh cooler neuromodulation
45:41 devices
45:42 cgrp antibodies botox g-pans
45:46 and then things that are controversial
45:48 like cannabinoids and things we should
45:50 not be using like opioids so this is a
45:53 bit of a map of what people usually try
45:56 and
45:57 whatever the diagnosis is right and so
46:00 for those of you who have maybe
46:02 a tumor maybe you had a stroke maybe you
46:05 have other diseases and migraine you
46:07 have a secondary headache or you have a
46:09 mix of different things or maybe your
46:11 doctor doesn’t know what you have
46:13 because it’s a big complex thing well
46:16 very often we will use migraine
46:19 treatments anyway because you know
46:21 migraine treatments act on this
46:23 chemistry of the brain on the
46:25 electricity of the brain
46:27 we have evidence for them we have data
46:29 for them so why not use them the most
46:32 typical example is post traumatic
46:34 headache usually what we do is if it
46:36 looks like migraine we treat it like
46:38 migraine right but we do need more
46:40 research to treat secondary disorders
46:43 and secondary headache
46:45 so because we don’t have something
46:47 specific that’s developed for those
46:49 headaches we use migraine therapies but
46:51 it doesn’t mean that it should remain
46:54 that way
46:56 so in conclusions um i want to encourage
46:59 you to use precise terms as much as
47:02 possible right clarify your diagnosis
47:05 with your health care provider
47:07 usually the key is in the history of
47:09 what happened your symptoms uh what
47:12 you’ve tried
47:13 you can have many diagnosis a lot of my
47:16 patients have two three four five
47:19 different diagnoses and then we tackle
47:21 them one after the other
47:25 there are still gray and blurry zones i
47:26 mean there are patients i i saw one
47:29 today i’m not even sure what the
47:30 diagnosis is and i’m just trying things
47:33 to help my patient
47:34 um based on her symptoms and her
47:37 symptoms are right in between neck
47:39 problems nerve problems and a migraine
47:41 problem so
47:42 you know even in the best of hands uh
47:45 there might be some uncertainty and then
47:47 try available treatments with the
47:49 guidance of a healthcare provider
47:52 looking at your symptoms and finding
47:53 your way
47:55 so i want to thank you for attention
47:57 i’ll take questions but before that
47:59 i would like to
48:01 share with you that this is our first
48:04 ever fundraiser for migraine
48:06 canada
48:07 it’s move for migraine canada so you can
48:09 still sign up and as a team or as an
48:12 individual i did it it took me like
48:16 virtually 10 minutes to do it
48:18 and you can do anything uh you can do a
48:20 little stretching session you can walk
48:22 around your block uh if you’re an
48:25 athlete you can do more
48:26 um and whatever you want to do the key
48:29 is to raise awareness right so uh sign
48:32 up uh talk to your networks uh talk
48:35 about it uh and then maybe you can even
48:38 raise a bit of money i think we’re
48:40 already over our goal but um more money
48:42 is more projects for people with
48:44 headaches
48:46 i want also to uh call you and invite
48:49 you to join our community uh by joining
48:51 us by supporting us watching our
48:53 webinars uh looking at our advocacy page
48:57 uh looking at our library where there’s
48:59 a lot of pdfs that can actually help you
49:01 listen to our podcasts and
49:04 write to us if you have suggestions
49:06 questions or if you’d like to volunteer
49:09 so on that i’ll close and
49:12 take
49:13 questions