Perimenopause and Migraine

0:05 we have Dr Candace Todd joining us some
0:08 of you may recall she presented last
0:10 year around this time as well uh Dr
0:13 Candace Todd is a general neurologist
0:15 and a heada medicine specialist at the
0:17 Scaro Health Network in Toronto Canada
0:20 she completed her residency at the
0:22 University of Toronto and completed her
0:24 Fellowship in headache medicine at the
0:26 University of
0:27 Toronto Dr Todd is interested in women’s
0:30 issues in neurology specifically
0:32 pregnancies and its impacts on headaches
0:35 as well as gender and racial disparities
0:37 in neurological
0:40 diseases and with that I’m going to turn
0:42 it over to Dr Todd
0:45 um I just want to thank Migra Canada for
0:49 asking me to do this again this year
0:52 update I’m also now at Women’s College
0:54 at the center for headache so if you
0:55 can’t find me at Scaro you can find me
0:57 at Women’s College um last year we
1:00 talked about kind of a lot of things we
1:02 talked about headache through a woman’s
1:05 life you know pregnancy per menopause
1:08 and the postmenopausal state but I think
1:11 that the param menopausal state is a
1:12 really interesting one and I and I think
1:15 from the interest it’s uh the state that
1:18 is more the most interesting to most of
1:21 my patients these days um so hopefully I
1:24 don’t spend too much time talking and
1:26 you guys can all ask me questions if you
1:29 want to after in terms of disclosures I
1:31 give talks um to you know family doctors
1:35 and other neurologists and they are
1:37 sponsored by uh pharmaceutical companies
1:40 but we’re not specifically talking about
1:42 any medications today so this should not
1:44 impact the talk
1:46 whatsoever the objectives I’m hoping
1:49 that we can touch on all eight of these
1:51 points and I think the most important
1:53 piece would be you know points eight and
1:56 seven because I really want it looks
1:59 like you are all from various places not
2:03 directly near me so I can’t see you all
2:06 um and so it’s important to kind of have
2:07 an idea of what you’re going to go back
2:09 and talk to your healthc care
2:10 practitioner about um should you be
2:12 concerned or should you want further
2:14 help with your
2:17 headaches so you know migraine in the
2:19 perimenopausal period is is quite
2:23 frequent and we know that migraine is
2:26 very common in individuals that have the
2:29 capacity for pregnancy or biological
2:31 women and that’s in comparison to
2:33 biological men the average age of uh a
2:38 young girl’s period is about 12 and a
2:40 half years old and that often coincides
2:43 with the beginning of migraine so I
2:45 don’t see a lot of pediatric or CH you
2:47 know children but when I do it’s often
2:50 you know in the eight or 10-year-old
2:52 young lady age um they start presenting
2:56 with headache and then shortly after
2:57 they do get their period and so it it’s
3:01 kind of the same in women that are
3:03 entering the per menopausal period and
3:06 often my patients will come to me and
3:07 say I have a history of high frequency
3:09 headache or lowf frequency migraine and
3:12 all of a sudden things are just out of
3:14 control and you know we do imaging and
3:16 we do blood work and we can’t really
3:18 find a clear reason and in the end it’s
3:20 not so dissimilar to the young girl
3:22 that’s getting worsening of her headache
3:24 before her first period there’s a
3:26 hormonal imbalance it’s throwing things
3:28 off and it’s especially in young in well
3:31 especially in women that have migraine
3:35 around their period or they get migraine
3:38 worsening with ovulation or migraine
3:41 with aura there’s clearly a hormonal
3:44 component or hormonal peace to their
3:46 headaches and that’s um and that’s
3:49 typically when we see worsening of
3:51 headaches is leading up to menopause and
3:54 we’ll talk about the perimenopausal
3:56 state but that can last anywhere from 10
3:59 to 15 years
4:00 so what I can what I can hopefully drive
4:03 home to you is that when you’re in the
4:05 perimenopausal State headache absolutely
4:07 can worsen for many people and it often
4:12 does the other thing I will say just as
4:15 an aside is there can you know in young
4:17 girls there can be you know more stomach
4:20 pain and abdominal pain um or abdominal
4:23 migraine they call it or worsening
4:25 motion sickness you can also get a
4:27 little bit of that or worsening of that
4:29 in the par menopausal State as
4:33 well so like I said in the previous
4:36 slide migraine affects close to a
4:38 quarter of per menopausal age women
4:40 that’s a huge amount and onset of
4:43 migraine can really happen at any age
4:46 there is some literature some data on
4:49 first presentation of migraine and
4:51 individual’s 60 60 plus which is not
4:56 common by any means but it is within the
4:58 realm of possibility
5:00 migraine is typically the most active in
5:04 individuals less than
5:06 50 um and we do want to think that you
5:10 know per menopause has a lot of changes
5:13 overall in your body and you know with
5:17 param menopause you can get worsening
5:19 mood issues so anxiety and depression
5:21 you can get uh worsening of your sleep
5:24 and that can also contribute to
5:26 worsening of your migraine because
5:27 really migraine and headaches
5:30 um are very sensitive to changes in
5:33 lifestyle and balance and so that could
5:35 even be a Tipping Point in and of itself
5:37 for worsening of your headache I do
5:40 think if you have a history of lowf
5:43 frequency migraine you’re only having
5:45 migraine a couple times a year and all
5:47 of a sudden things you know start flying
5:49 out of control and the frequency really
5:51 ramps up you do still warrant
5:56 investigation plus minus Imaging of the
5:59 head and that’s really up to the
6:00 healthcare practitioner and based on the
6:02 history you provide and your examination
6:04 to determine whether you need further
6:06 Imaging but I often do some blood work
6:08 like checking your vitamin D level and
6:10 your iron level um just to make sure
6:13 that there isn’t something else that’s
6:14 driving the worsening of your
6:19 headache um the there was a study that
6:23 was done by the ampp or it’s a American
6:27 migraine prevalence and prevention study
6:29 and really what the literature shows is
6:31 that there’s often a worsening of
6:33 headache during the transition to
6:36 menopause
6:37 um and usually
6:40 postmenopause is associated with relief
6:43 of headache but that’s not always 100%
6:46 TR true all the time what I say to my
6:49 patients is how you enter per menopause
6:52 really dictates how you’re going to exit
6:54 it um and so it’s always good to be
6:56 prepared and to you know seek out a
6:59 healthare practitioner if you feel like
7:01 the headaches are starting to ramp up
7:02 and get a little bit of out of control
7:05 um because there is medications there
7:07 are treatments now for for migraine and
7:09 you really want to get a good handle on
7:11 on things before they get too crazy in
7:14 terms of frequency and
7:15 intensity um I will say the type of
7:18 menopause is an important consideration
7:21 so migraines were 40% less common after
7:25 what we call a natural menopause as
7:27 compared to premenopause frequent quency
7:30 so um you know the type of menopause has
7:34 an impact so you know early onset
7:37 menopause which is considered um in
7:40 women less than the age of 45 has been
7:43 linked to somewhat worsening of
7:46 headache especially surgical menopause
7:50 um if you have a hysterectomy and an
7:52 ectomy where they take out your ovaries
7:55 you have this really dramatic loss in
7:58 estrogen and that can
8:00 headaches um and you know if you don’t
8:04 have estrogen if they don’t add back
8:06 estrogen to you after the ectomy or
8:08 after the removal of your ovaries that
8:11 can often produce worsening and even
8:13 more disabling headaches um so it is you
8:16 know preventatives which are considered
8:19 medications that you would take on a
8:20 daily basis for a migraine were used
8:23 most in the late men par menopausal
8:25 stage and we’ll talk about why that is
8:29 but often um you know I think the the
8:33 gist of this slide is that headache can
8:36 definitely worsen during the par
8:38 menopausal period um and it really
8:41 depends on the type and the timing of
8:43 your of uh your
8:46 menopause so what is param menopause I
8:50 think most if not all of you know what
8:54 par menopause is or have heard of par
8:56 menopause I think there’s just some
8:58 verbage um that goes with it so really
9:01 menopause is one day and it’s really the
9:04 day that you stop having a period for
9:06 one year and then everything is either
9:09 before menopause or
9:11 postmenopausal um and you know menopause
9:14 per menopause can really start anywhere
9:16 but it’s typically after the age of 45
9:19 it can last 10 to 15 years and then
9:22 postmenopause is postmenopause forever
9:26 and that’s really where uh you stay for
9:28 the rest of your life
9:29 you don’t have a period anymore you
9:31 still have a little bit of estrogen
9:33 floating around but not really enough um
9:36 to be too bothersome but in the
9:38 postmenopause period you have enough
9:40 estrogen and enough adjustment uh to
9:43 your hormone system that you can have
9:46 persistent night uh night sweats and hot
9:48 flashes for a period of time even after
9:50 menopause has come and gone um and you
9:56 know the per menopausal period is really
9:59 what we’re going to talk about and the
10:01 hormonal soup so the red is depicts you
10:05 know uh the estrogen levels throughout
10:07 your life progesterone is less impactful
10:11 um and then the kind of fuchsia pink
10:13 squares are the menstrual periods and
10:16 over time they become irregular um and
10:19 you can go H you can start having longer
10:22 menstrual cycles shorter menstrual
10:24 cycles you could go months or weeks
10:26 without having a period and that’s
10:28 really what leads to the the worsening
10:31 of headache in many
10:32 women so I think of it like a soup um
10:37 and like I said in the previous slide
10:40 perimenopause or menopause is you know
10:44 one day where your period is you haven’t
10:46 had a period for a year um and like I
10:49 mentioned again in the other slide you
10:51 can have a menstrual cycle that you know
10:53 is starting to get longer more than 7
10:55 days your period goes you know anywhere
10:58 from you’re missing
10:59 two months at a time three months at a
11:01 time um or you’ve missed greater than
11:04 two periods in the last 12 months those
11:06 would be kind of clues that you’re maybe
11:08 slowly entering into the perimental
11:10 pausal state and the state and the
11:12 takeaway of this if you get nothing is
11:15 that it’s a soup it’s a hormone soup and
11:17 every week and every month is something
11:19 different um and as the estrogen levels
11:22 slowly die off that’s really well that
11:24 can often be a big trigger for uh women
11:28 and worsening headach
11:32 what is a
11:33 migraine I I think that we take for
11:36 granted you know I take for granted
11:38 sorry you know that everybody knows what
11:40 a migraine is and I think that the
11:43 labels do and don’t matter in in some
11:46 ways so for me in my clinic I obviously
11:49 want to diagnose you with a migraine and
11:51 that’s usually one half of your head uh
11:54 and it can be either side left or right
11:57 uh is typically in pain Al although in
12:00 individuals who have chronic migraine
12:01 it’s often their whole head sometimes
12:04 they feel like the hair on their head
12:06 the hair on their scalp is
12:08 tender it’s moderate to severe and that
12:11 really means you’re not showing up to
12:12 the emergency department for attenion
12:14 type headache right people don’t go to
12:16 the emergency room and wait 8 16 hours
12:19 for attenion type headache it’s really
12:21 for migraine so it’s that bad and you
12:24 tell me you’re going to the emergency
12:25 department I’m going to assume that it’s
12:27 likely to be migraine you don’t want to
12:29 do anything you’re missing events you’re
12:31 missing social functions you’re missing
12:33 work you’re missing school you’re making
12:35 an alteration or an adjustment to your
12:37 life because of the headaches the other
12:40 pieces you know nausea and or vomiting
12:43 you can have either or and then you
12:46 should have light or sound light and
12:49 sound should bother you so that’s the
12:50 photophobia which is light and
12:52 phonophobia which is sound um and it may
12:55 not be super striking to you you may
12:57 just think you know fluorescent lighting
12:59 is a little bit bothersome when you have
13:00 a bad headache you never may have
13:03 noticed that light bothers you but you
13:04 do prefer to rest in a dark quiet room
13:07 you don’t want to be at a party you
13:09 don’t want to be in your Subway or
13:10 transit or go to a concert because the
13:13 sound is bothersome that that would be
13:15 the clue that you have light and Sound
13:16 Sensitivity with your
13:18 headache um people that’s just migraine
13:22 and then there is this aura or this
13:24 visual or sensory disturbance that
13:26 people can often get with their
13:27 headaches and that that can really be a
13:30 bunch of stuff I think the classic is
13:32 you know the vision changes that people
13:34 can get um and that can be Bright Lights
13:38 some patients describe kind of
13:39 squigglies
13:40 Kaleidoscope um some people can even get
13:44 tingling of the arm sometimes they feel
13:46 like the speech is garbled that can all
13:49 be
13:50 Aura the the key piece with aura is that
13:53 there’s a time frame for it so it can’t
13:56 last seconds it’s got to be at least 5
13:58 minutes it’s got to last no more than an
14:01 hour so 5 to 60 minutes and you can have
14:04 multiple different symptoms with your
14:06 your headache or with your aura the aura
14:09 typically happens before the pain
14:12 starts but I know that many people you
14:15 know don’t pay attention and once the
14:17 pain starts and they’re like oh wait you
14:19 know I think I I can’t see perfectly
14:22 clear out of my left eye or my right eye
14:25 um you can have blurred vision you can
14:27 have vertigo or dizziness with your
14:29 headache and that’s not necessarily
14:31 always an
14:32 aura I think it’s important and we’ll
14:34 talk about why it’s important to be
14:38 clear and have make sure that your
14:40 health care practitioner is clear as to
14:42 whether you have aura or not Ora can
14:45 increase your risk of stroke and you
14:48 have to take in other risk factors with
14:50 it but if you’re someone in the
14:52 perimental pausal state that has a lot
14:54 of hot flashes and night sweats and
14:56 you’re considering hormone replacement
14:58 therapy that plus Aura could potentially
15:01 increase your risk of stroke so that’s
15:03 why when I see patients and they
15:05 describe you know visual or sensory
15:08 symptoms I’m very clear and try and get
15:10 as detailed of a history as I can
15:12 because once you’re labeled with having
15:14 an aura it really changes your
15:16 management and it changes your ability
15:18 or rather it changes the therapies that
15:21 are available to you so whenever you see
15:24 your Healthcare practitioner just be
15:25 very clear as best as you can with the
15:28 symptoms that are having um and I find a
15:31 headache diary which Myra Canada has
15:33 lots of or just writing on a calendar or
15:35 piece of paper trying to be very clear
15:37 about your symptoms and when they’re
15:39 happening just so your health care
15:40 provider can can be as
15:43 detailed um and as clear as to what
15:45 you’re
15:47 experiencing as
15:50 possible
15:52 um I the other the reason why I added
15:55 this slide is because often when I see
15:59 people in the office they really want to
16:01 know like what is wrong with me what is
16:04 the per like what is the cause is there
16:06 something wrong with me and the answer
16:09 is there’s nothing wrong with you but
16:11 migraine is an inflammatory or an
16:13 inflammation disease just like rator
16:15 arthritis um it’s not similar to
16:18 diabetes but it’s it’s a disease like
16:20 any other and I think that there’s a lot
16:23 of stigma associated with migraine uh
16:26 amongst Healthcare Providers amongst
16:28 friends and family that don’t really
16:30 understand it because it’s not like we
16:32 can do a CT scan and diagnose you with
16:35 migraine it’s not like we can do blood
16:36 work that we can follow and say yep they
16:39 have migraine and it really is and can
16:41 be an invisible disease we know that
16:44 there’s a genetic component to it we
16:46 have genes for certain types of migraine
16:49 and we know that there’s what we call an
16:51 inherited or heritable component meaning
16:54 that you know I always ask you know does
16:57 your mom your aunts or grandparents have
17:00 migraine do your kids have migraine
17:02 because it often runs through the family
17:05 and so we know that there is an
17:06 inherited component to it as well um and
17:10 really what is a migraine it’s just it’s
17:12 connectivity dysfunction and that can
17:15 increase your risk or your increase your
17:17 sensitivity to lots of stimuli so um
17:21 many of my patients say you know the the
17:24 sun is too bright that can you know
17:26 trigger my migraine you’re just
17:29 sensitive to environmental factors that
17:31 are present at all times um the you know
17:35 a normal brain is able to block out
17:39 signals uh that do not benefit them but
17:41 in a person who has migraine you’re
17:44 always hyperaware
17:46 um Dr Lei who’s the head of the center
17:49 for headache at Women’s College I was
17:51 her fellow I did a fellowship in in
17:53 headache medicine she always said that
17:55 migraine is people with migraine are
17:59 evolutionarily more advanced meaning you
18:01 know migrain people are able to perceive
18:04 danger faster than someone like myself
18:07 who doesn’t so you’re able to perceive
18:08 light and sound better than someone like
18:11 myself and evolutionarily you are more
18:14 advanced and although you may not feel
18:16 like it um it makes you hyper aware you
18:20 are always in survival mode um and that
18:23 can be really disruptive to someone on a
18:26 day-to-day basis um
18:29 you know there is a link and we’re not
18:32 going to get into it too much today but
18:33 there is a link between what we call
18:36 adverse childhood events or trauma uh
18:40 and these Aces happen before the age of
18:43 18 um and that can be anything from you
18:46 know what you didn’t get get enough of
18:49 as a child or what you got too much of
18:52 um whether you were sick whether you had
18:54 you
18:55 know verbal physical abuse whether you
18:59 traveled and fled a country um your it
19:03 kind of causes certain parts of your
19:05 brain as you’re developing to become in
19:07 this overdrive situation and that’s why
19:09 many individuals with migraine have what
19:13 we call comorbid or they have anxiety or
19:15 depression or they have other mood
19:17 symptoms because that’s all the same
19:19 pathway and your brain is just in this
19:21 hyperdrive or overdrive State there’s a
19:24 really good book if you’re interested in
19:27 understanding a little bit more about ad
19:28 first childhood experiences or Ace or
19:30 trauma it’s called the body keep score I
19:33 have no affiliation with them um but
19:36 I’ve had a lot of patients that have
19:37 read the book and found that it’s been
19:39 very
19:41 informative in the this bottom point I
19:43 just talked about where I highlighted
19:46 interal burden which is just a fancy way
19:49 of saying that in between the migraine
19:52 people the actual migraine pain people
19:55 are disabled and still have difficulty
19:59 participating in their activities of
20:01 daily living going to work saying yes to
20:04 social functions and that’s because you
20:06 know they uh are just not able to
20:09 function in between a migraine during a
20:11 migraine and so I think what we do need
20:14 to you know places like migraine Canada
20:17 and just through further advocacy we
20:19 really just need to get out through the
20:20 or get the point out that migraine is
20:23 incredibly disabling um and that we
20:25 really need to start focusing on
20:27 patients you know better and you know
20:29 screening for migraine and treating uh
20:32 migraine patients uh better overall
20:35 across
20:37 Canada so hormonal changes in migraines
20:41 so again it is a soup of hormones and
20:45 estrogen is not all good and estrogen is
20:48 not all bad so estrogen is as I’m sure
20:51 you’re all aware very vital hormone it
20:54 can impact how we feel pain it can
20:57 impact um obviously headache it can
21:00 cause dizziness nausea the we have an
21:03 internal
21:04 thermometer that gets adjusted during
21:07 the par menopausal State and that’s what
21:09 causes the hot flashes our body is just
21:11 trying to offload all the heat our
21:13 thermometer is higher than what it
21:15 should be it naturally is going to
21:17 impact mood and estrogen truly is a game
21:20 of balance you have a positive and
21:22 negative effect on the brain and
21:24 perimenopause skews that completely and
21:26 you start becoming more negative and
21:29 that’s really what contributes to the
21:31 hormonal changes and the worsening of
21:33 the of the migraine um and you know
21:38 estrogen is not necessarily a huge
21:40 factor for everybody and like I said
21:43 estrogen can be a big factor for
21:46 individuals who have Migraine with the
21:48 the aura symptoms if you had a history
21:51 of worsening headaches around your
21:53 period that could be you know a big
21:55 trigger for you men per menopause could
21:57 be a big trigger for you um women who
22:00 had a lot of what we call Prem menstrual
22:03 symptoms may be more sensitive to the
22:06 fluctuations that you get during during
22:08 param
22:09 menopause um and you know you just have
22:14 to kind of be able I think half the
22:15 battle is just being able to identify
22:17 what’s going on and kind of tracking
22:19 your symptoms in order to kind of be
22:22 able
22:23 to describe them and ask for help from
22:27 your Healthcare practice
22:30 practitioner um hormonal so per
22:33 menopause and migraine exacerbations
22:35 appear most pronounced in women like I
22:37 said with the history of men menstral
22:38 migraine which we just talked about um
22:41 the the interesting piece is that like I
22:43 said before many women will come to me
22:46 and say once I go through menopause I
22:48 will hopefully not have any more
22:51 migraines and I really do I do hope that
22:53 for everybody that’s not always the case
22:56 what I will say is those individuals
22:58 that have low frequency headache are the
23:01 most likely to lose their migraine
23:03 features and no longer we say diagnostic
23:07 criteria they no longer fit that
23:09 criteria for migraine as they transition
23:11 into menopause the diagnostic criteria
23:13 is that moderate to severe intensity
23:16 light and Sound Sensitivity nausea Andor
23:19 vomiting uh throbbing pulsating headache
23:22 they they may lose those
23:25 characteristics um some women can have
23:27 higher frequency of with a decrease in
23:29 migraine um so they can you know have
23:34 more M they could typically be you know
23:37 have a lot of migraine all their life
23:39 and then uh have higher frequency
23:43 headaches during the param menopausal
23:44 period or vice versa um it really I
23:48 think the point of this slide is that
23:50 there’s no guarantee and there’s no
23:53 rules you could
23:55 basically be anything during the per
23:57 menopausal state
23:59 um and so the the belief that things go
24:01 away right after U menopause is not
24:05 necessarily true but again I I believe
24:07 that how you enter into per menopause
24:09 and how you manage your headaches during
24:11 per menopause can really dictate um how
24:15 you leave per
24:19 menopause so I think the important piece
24:21 is how do you manage migraines during
24:24 per menopause
24:26 so since being a fellow at women’s
24:30 college now three years ago the
24:33 medications that I had available to me
24:36 and during my fellowship have exploded
24:39 and have tripled so we have a lot of
24:43 migraine specific medications on the
24:47 market um and you know if you were
24:50 someone that did not have a good
24:52 response to uh medication in the past
24:55 know that there still is Hope and
24:57 there’s a l Cape of medications now
25:00 available to us
25:02 now hormone replacement therapy that was
25:05 a question that I got a lot of last year
25:08 and I think that HRT or hormone
25:11 replacement therapy has a really great
25:13 purpose for many
25:15 individuals um the only thing I would
25:18 say is that we want to be mindful if you
25:21 are someone that’s going to start HRT
25:24 that you are aware of the potential
25:27 impact that it can have on migraine
25:29 frequency and severity so in if you are
25:33 an individual that has uh migraines that
25:36 are triggered by hormone fluctuation so
25:40 your your period when you
25:43 ovulate um HRT could in theory stabilize
25:47 things because it’s providing a steady
25:50 amount of estrogen to you and that could
25:52 actually make things better but um if
25:55 you have migraine with aura or menstrual
25:59 M migraines HRT could potentially worsen
26:02 things so it’s really a mixed bag and
26:05 it’s really dependent on the type of
26:07 migraine again that you have um the type
26:11 of HRT is important to understand so um
26:17 you know estrogen only therapy can be
26:20 more suitable for women who’ve had
26:22 undergone a
26:23 hysterctomy um combined tablets so
26:26 estrogen and progesterone um is often
26:30 prescribed for people for women who have
26:34 a uterus still um progesterone is a nice
26:37 I like progesterone only options because
26:39 it’s a nice kind of
26:42 safe hormone to provide and that can
26:45 kind of level the estrogen fluctuations
26:49 that you can get um for in some
26:52 individuals um the root of
26:54 administration and what I mean by that
26:57 is uh we’ve got lots of different ways
26:59 to to get estrogen so a tablet um a
27:03 tablet
27:05 usually
27:07 um is a little less stable and you can
27:10 have more fluctuations in in your level
27:13 um you know the patch is a little bit
27:18 more preferred obviously I’m a big fan
27:23 of you know local Administration so if
27:26 you’re someone who has a lot of V vagal
27:28 dryness and and sexual dysfunction you
27:31 know local estrogen topical gels are um
27:35 never never a bad idea and has less
27:37 impact on uh migraines as a whole um and
27:43 you really want something that’s going
27:44 to provide a sta as stable as you can
27:47 level of estrogen in the system because
27:50 again it’s that fluctuation that’s
27:51 really triggering migraine for many
27:54 people um individual risk factors I bold
27:57 that because that’s really the space
27:59 that I live in as a neurologist I don’t
28:01 prescribe HRT I don’t manage HRT no
28:04 neurologist really should um but what we
28:08 do talk what I often get asked is you
28:10 know what is the risk of stroke and that
28:12 really is what it all comes down to um
28:16 so you know the things that I take into
28:18 account is obviously age medical history
28:21 meaning do you have a history of high
28:23 blood pressure cardiovascular disease
28:26 the type again the type type of migraine
28:28 that you have are you someone that has
28:30 migraine with aura um because that
28:33 increases your risk overall of stroke um
28:37 do you smoke um have you ever had a clot
28:41 frequent miscarriages these are things
28:43 that I’m always asking um because you
28:47 know estrogen therapy may increase your
28:49 risk of a heart attack or stroke overall
28:53 and so we just really want to be the
28:55 safest that we possibly can be as well
28:58 make you as happy as you can and
29:01 I uh understand that you know the night
29:04 sweats and the hot flashes and all that
29:06 are awful and we want to make sure that
29:09 you know you’re able to function and be
29:11 happy for those 10 15 years it’s not a
29:14 short period of time but we also need to
29:16 mitigate or reduce the risks um of
29:19 serious medical
29:20 complications and then the most
29:22 important thing is if you are going to
29:24 go the HRT through HRT route you really
29:28 have to have someone that is going to
29:30 monitor you closely um and you really
29:32 have to find someone that you’re able to
29:34 follow up with um that’s going to check
29:38 your hormone levels um are going to be
29:41 knowledgeable enough and and assess your
29:43 your migraine or your headache symptoms
29:46 to make sure that you’re not having any
29:47 worsening Aura while on the HRT therapy
29:51 or you haven’t developed a new
29:52 neurological symptom while being on the
29:55 HRT um medication so you really want to
29:58 just find someone that uh is is able and
30:03 and willing to follow you a little bit
30:05 closely you do not need to be in your
30:09 family doctor’s office on a weekly basis
30:11 that would be crazy but I think some
30:13 being being able to have access and
30:15 having a practitioner that’s willing to
30:17 kind of follow you along closely is is
30:20 important especially if you’re someone
30:22 who has migraine and other risk
30:24 factors alternative therapies I’m going
30:26 to talk about on the next slide so I’m
30:29 just going to get to
30:33 that okay so I love living in the space
30:37 of alternative therapies um and what
30:40 does that mean it really means lifestyle
30:42 and for anyone who sees me in my office
30:44 I usually give you a headache Tip Sheet
30:46 and on that Tip Sheet has various
30:48 lifestyle strategies that seem simple in
30:51 theory but are not always simple so you
30:55 know getting regular sleep screening for
30:57 sleep apnea especially if you’re someone
30:59 who has morning headaches making sure
31:01 you’re getting enough water protein is
31:04 key um and I always say a gram of
31:06 protein for every kilo some people that
31:08 are very into fitness will say a gram of
31:11 protein per pound that could seem a
31:13 little crazy so I say a gram of protein
31:16 per kilo but you want to make sure that
31:17 you’re always getting a good source of
31:19 protein within an hour of waking um you
31:23 know reducing screen time um trying to
31:26 manage stress you know meditation prayer
31:29 yoga whatever you can do um that can fit
31:32 into your into your lifestyle
31:35 neutraceuticals I think I think no I
31:39 don’t think I know that uh many patients
31:43 have had huge gains in terms of control
31:46 of their headaches with neutraceuticals
31:48 and what does that mean we have kind of
31:52 five five vitamins that have goodish
31:56 research evidence behind them so that’s
31:59 magnesium B2 coenzyme Q10 um there’s a
32:03 small body of evidence for butter bur
32:06 melatonin believe it or not has some
32:08 evidence in headache and so there’s
32:10 various neutraceuticals that have been
32:12 proven to be helpful if you’re a little
32:14 bit on the older scale and you can’t use
32:20 you know Advil for whatever reason or
32:22 another anti-inflammatory or you have a
32:25 lot of Aura Mel um magnesium is really
32:29 wonderful for for many patients and I
32:32 find that that’s probably if you’re
32:33 going to start one vitamin that would
32:35 probably be the vitamin to consider I
32:38 also have patients that do really well
32:40 with acupuncture and cupping and fascial
32:43 stretch and you know whatever whatever
32:47 you find that works for you and we can
32:51 reduce the amount of medications that
32:52 you’re using I’m always very much um for
32:56 I like to think of Alterna ative
32:58 therapies and pharmacological therapies
33:00 or medications it’s all kind of working
33:02 in Synergy you really can’t have
33:05 one I mean I like to think that you
33:08 really need to use medications and you
33:11 know lifestyle neutrals acupuncture kind
33:14 of treating a patient holistically and
33:16 that you really shouldn’t just be doing
33:18 one
33:21 thing um I’m getting to the end of my
33:24 slides which I think is pretty good
33:28 um so the importance of seeking medical
33:31 advice I think the first step is seeing
33:36 someone and getting a diagnosis of
33:38 migraine if you haven’t already had one
33:41 it’s interesting because
33:43 um I have quite a few patients that have
33:47 come to me in the param menopausal State
33:50 and they have had my grain since they
33:53 were 12 and they were just told that
33:56 that was something that you just needed
33:58 to live with and deal with and that is
34:01 by far the furthest thing from the truth
34:04 especially the landscape at the moment
34:06 there’s just never been a I wouldn’t say
34:08 a better time to have migraine but it’s
34:11 never been um a more exciting time
34:15 especially as a headache uh physician to
34:18 be practicing in this space because
34:20 there’s just so many options available
34:23 for me to provide to my patients which
34:25 is is great um I think patients come to
34:29 me often with labels that they’ve been
34:32 given or labels that they think they
34:34 have and I think it’s just better for
34:37 everyone to have a good assessment agree
34:40 on the labels that you’ve been provided
34:42 so that when you you know as you go
34:44 through per menopause as you enter into
34:46 the per menopausal State and then leave
34:48 it into the postmenopausal state
34:50 everybody’s on the same wavelength
34:52 everybody has the same game plan and you
34:54 yourself are able to identify your
34:56 triggers and um be able to talk about
35:00 your your symptoms and be able to manage
35:02 them as best as you know as you possibly
35:05 can uh like we said in the beginning of
35:09 this presentation really migraine is
35:14 individualized I you know I’m sure you
35:16 know if you if you have migraine and
35:18 your daughter has migraine or your son
35:20 has migraine and you use similar
35:23 medications there is some there that is
35:26 real like one family member May respond
35:29 really well to the same medication but
35:31 the thing that I like so much about my
35:33 job being a migraine specialist is that
35:35 it really is tailored and it’s
35:37 individual to the person the combination
35:39 of medications when to try one versus
35:42 versus another is really 100% unique uh
35:46 for every patient that I have and so you
35:49 really want to find someone that looks
35:51 at you as a whole and says what is the
35:54 best game plan for you in the time of
35:58 your life um and so you really just want
36:01 to find someone that’s willing to listen
36:03 to you and and provide you a diagnosis
36:06 in a treatment
36:08 plan the second last slide um so what
36:13 type of practitioner is most suitable
36:15 for you I think the simplest because
36:17 everybody comes from different places in
36:19 the countries you just want to find
36:21 someone that’ll listen to you and I
36:23 think that’s I don’t think I know that’s
36:25 it’s a lot harder than what it sounds so
36:27 so you know you just want um you know
36:30 your family doctor or a nurse
36:32 practitioner to just listen to you and
36:34 maybe sometimes you have to make a
36:36 special appointment and carve out time
36:38 just to talk about your headaches I do a
36:42 lot of talks for um family doctors and
36:46 neurologists and family doctors from
36:49 what I’ve gotten as feedback is it’s not
36:51 something necessarily that they are
36:53 screening for some absolutely do but
36:56 many don’t
36:58 um and they’re really waiting for you to
37:00 come to them and say listen these
37:01 headaches are getting out of control I I
37:04 want help and so you just need to find
37:06 someone or carve out time to kind of
37:09 have that conversation with your healthc
37:10 care
37:11 provider um the training for a headache
37:15 is CH Ever Changing in neurology and as
37:19 a resident you know I was lucky because
37:21 I was I was at University of Toronto we
37:24 have um you know we have headache
37:26 clinics we have headache fellowship and
37:28 so I had a lot of exposure and my
37:31 colleagues who are not headache Medicine
37:33 Specialists also had exposure to uh
37:36 headache so many neurologists do have
37:40 maybe don’t have a sub specialty in
37:41 headache but they have an interest in it
37:43 um and so you you can definitely ask to
37:46 be referred to a neurologist and at
37:48 least they would have some kind of uh
37:51 path for you to follow can can at least
37:54 provide you a diagnosis with with or
37:56 without migraine and hopefully start
37:58 medications um migraine specialist
38:01 someone like myself we are not very
38:04 common in Canada there’s not too too
38:07 many of us but we’re in every is
38:11 province I want to say there’s one of us
38:13 around somewhere um obviously I think
38:16 we’re more densely populated in Ontario
38:18 so anybody that is in the GTA or
38:21 surrounding area there’s at least five
38:23 of us kind of kicking around outside of
38:25 Ontario is a little bit more challenging
38:28 um and then if you want to find someone
38:29 that has a special interest in women’s
38:31 issues and headaches that’s also
38:32 exceedingly uncommon in not many of us
38:35 um but I think your best bet would just
38:37 be starting with a you know your health
38:39 care provider and just starting to have
38:41 the conversation there’s more resources
38:43 out now um in terms of diagnosis and
38:46 management and if they get you know if
38:48 they get out of their comfort zone there
38:50 should be a neurologist um in your
38:52 nearby area that hopefully you can can
38:55 be referred to
38:58 um advocacy I always like adding this
39:01 slide because again there’s still so
39:03 much stigma and I think you know
39:06 migraine Canada has been such a great
39:09 resource for many patients to kind of
39:12 seek out help these webinars hopefully
39:14 are helpful for people um and just you
39:17 know getting the word out in terms of
39:20 you know what is migraine and how do we
39:22 treat it it’s still incredibly
39:24 underreported like I said most patients
39:26 don’t bring up to their primary care
39:29 physician you know even Physicians don’t
39:32 necessarily find headache the you know
39:35 the most attractive disease and many
39:37 practitioners shy away from it because
39:39 they’re not interested in it you know I
39:42 think the best thing for migraine as a
39:45 whole is we just need more headache
39:48 Specialists we need more research we
39:50 need to continue to advance the field
39:52 but for you all I just hope that you
39:56 continue to just try
39:57 and get help and if you get roadblocks
39:59 keep pushing um and eventually you will
40:03 find someone that will listen to you and
40:04 and and help you