The Effect of Weather and Migraine

0:00 topic and I just wanted to have to
0:03 disclose a few things
0:05 um just some commercial interests I’m
0:08 not going to be talking about anything
0:09 here that really I would favor any
0:13 particular company
0:15 um I do get some Consulting fees not
0:17 enough if you happen on a drug company
0:18 I’m going to give a talk it got kids to
0:20 put through school
0:22 um
0:23 I may occasionally use non-generic names
0:25 of medications I may discuss off-label
0:29 uses of medications I don’t think I will
0:31 in this talk but sometimes I ramble and
0:33 I might and I may use foul language and
0:36 for that I’m sorry or if you enjoy foul
0:38 language you’re welcome
0:42 um but thank you for Doc to Dr LaRue who
0:45 has done a lot of work for migraine
0:46 Canada and taught me a lot
0:49 um thank you Wendy for helping uh to I
0:53 don’t know maybe thank you and no thank
0:55 you for getting me to do this talk
0:57 um no actually I’m happy to be doing it
1:00 and uh thanks for getting me involved
1:02 and for Alexandria to help me set this
1:04 up and to migraine Canada
1:07 um I get migraines too full disclosure
1:10 so I appreciate everything that you do
1:11 to help people with migraines
1:15 so why am I giving this talk uh as I
1:18 understand it
1:20 um
1:20 I was the slowest runner I couldn’t
1:22 think of an excuse why not to I I work
1:25 in Calgary uh neurologist I do a lot of
1:28 migraine uh consults here and treat a
1:33 lot of people uh with migrants probably
1:35 in the thousands
1:37 uh so I see a lot of migraines we live
1:39 at high altitude which is a
1:40 predisposition to migraines we have
1:42 extremes of weather which is a trigger
1:45 for migraines and we have striking
1:46 weather fluctuations I.E the Chinook so
1:50 I see a lot of migraines and I see a lot
1:51 of weather involved in the generation of
1:54 migraines and uh finally I did make the
1:57 mistake of talking to Dr LaRue about uh
2:00 some observations in patients who have
2:03 migraines uh
2:04 uh subject to other fluctuations and uh
2:08 next thing I know I’m giving this talk
2:11 so the outline is I’m going to just kind
2:13 of review triggers uh as uh on hold and
2:18 then we’ll focus on weather specifically
2:20 and then what have we learned from the
2:22 research
2:23 uh what do the experts think is going on
2:27 um how do we treat migraines triggered
2:29 by weather and then we’ve got some q a
2:31 and Wendy sent me a bunch of questions
2:33 which I think were put on the website as
2:34 well uh so I’ll address those and any
2:37 other questions that might be thrown at
2:38 me
2:40 so as far as triggers go there are over
2:42 60 known triggers
2:44 average number of triggers per patient
2:47 is between 6.7 and 8 through 6 to 8.
2:51 sometimes patients don’t recognize any
2:54 triggers sometimes we’ll see a 20 30
2:58 different triggers
3:00 um
3:01 sometimes uh triggers aren’t 100 so uh
3:06 one day you might be set up to have a
3:09 migraine biotrigger another day you may
3:11 not be triggered by the same exposure so
3:13 say a food or a particular weather
3:15 pattern
3:17 um
3:19 generally speaking we see multiple
3:22 triggers acting together uh to trigger a
3:25 migraine headache and sometimes it’s a
3:27 particularly strong trigger so
3:28 particularly strong triggers would be
3:30 hormonal fluctuations like a menstrual
3:33 period or say something like I should
3:36 not be blowing through Calgary or
3:37 profound stress
3:41 so uh this slide is if you Google
3:45 migraine triggers Berkeley you’ll see uh
3:48 uh uh there’s a PDF which has ballooned
3:51 from two to about six pages now I
3:54 recommend this to all my patients I
3:55 looked on migraine Canada and it doesn’t
3:57 not quite the same layout there’s good
3:59 information there but I like this one
4:02 and it reviews the categories of
4:04 migraine triggers and then it’ll get
4:06 into specific
4:08 um food triggers
4:10 and of course big mistake that’s a bit
4:12 of a letdown you look at Food triggers
4:14 and the first one is chocolate so and
4:17 immediately say well these people don’t
4:19 know what they’re talking about because
4:20 you’re definitely not going to stop
4:21 chocolate and cheese is delicious so
4:23 that’s not going to be a trigger
4:24 hopefully
4:26 but uh if you do uh you know get
4:30 are you suspicious that you have uh
4:33 Foods as triggers what I typically would
4:35 recommend to people is go through this
4:37 list see if there’s a food that you eat
4:39 a lot and uh maybe try cutting it out
4:41 for a little while and see if your
4:43 migraines get better
4:45 so the top triggers
4:47 and this has been identified in not just
4:50 these studies but in many studies and
4:51 I’ll say right now that uh the the
4:53 studies that I’ve included as references
4:55 here are are not the extent of the
4:58 information available I there are so
5:00 many studies looking at triggers and
5:02 weather triggers uh it would take me
5:04 days to put all the the references in
5:06 here
5:08 um
5:08 but as far as the top triggers and
5:10 migraines go in adults and children
5:12 these are the top so sleep deprivation
5:15 and fatigue uh this is one of the
5:18 biggest stress or the stress let down
5:21 skip meals or fasting hormone
5:23 fluctuations as I mentioned for example
5:25 uh menstrual period weather fluctuations
5:28 prolonged screen time I got a tip for
5:32 you on that one Bright Lights loud
5:34 noises caffeine and caffeine withdrawal
5:36 alcohol and dehydration
5:39 and uh so to give you an example of how
5:42 this may work and how multiple triggers
5:44 are going to come together
5:46 um in preparation for this talk of
5:47 course I procrastinate so the stress is
5:49 on and I get migraines so the stress is
5:52 on to get the talk done and of course
5:54 I’m sitting at a screen in front of a
5:56 computer and I’m going to drink a bunch
5:57 of coffee just to get through the day
5:59 because I just got back from Disneyland
6:01 last night and the plane was late and
6:03 then stressed and uh yeah I’ll probably
6:05 have a migraine tomorrow but that’s all
6:07 right because we’ll be hanging out with
6:08 a bunch of other people who have
6:09 migraines well just I’ll just wine
6:10 though wine would be great
6:13 so let’s look at weather as a trigger
6:16 for migraine headaches
6:17 um in various studies and this is uh
6:20 reviewed in the first reference uh
6:23 um weather is reported as a trigger by
6:25 between 30 and 78 percent of people with
6:28 headaches and in fact one study that
6:29 we’re going to get into
6:31 pre-study it was reported as a trigger
6:33 by 88 of migrainers here in Calgary and
6:37 so there are many variables uh
6:39 meteorological variables AKA weather
6:42 patterns that have emerged from studies
6:44 over the years and this is as again I
6:47 stated not the extent of the studies
6:49 that have been done here these are just
6:50 the reviews look at these things and so
6:51 we’ve seen
6:53 high pressure
6:55 low pressure a significant change in
6:58 barometric pressure
6:59 and that change in barometric pressure
7:01 can be from uh the day of the headache
7:04 and looking back
7:05 from minus one day looking back at the
7:08 shift from three days ago to the current
7:11 date uh it can be uh dependent on wind
7:14 speed high wind speed or the average
7:17 daily wind speed high temperature low
7:19 temperature change in temperature high
7:21 humidity low humidity these have all
7:22 been identified in different studies as
7:24 carriers for migraines
7:27 um a new day-to-day change and
7:28 brightness and snow and rain Haze and
7:31 thunderstorms Etc
7:32 so if any of these are a trigger for you
7:36 um there’s a study that has also found
7:38 the same thing
7:42 the problem is that these studies don’t
7:44 agree leading to uh the situation where
7:48 um the studies don’t agree with the
7:49 patients the studies don’t agree with
7:51 other studies and the statement by this
7:54 group that the influence of whether a
7:55 migraine remains one of the most
7:57 controversial topics in the
7:59 pathophysiology of migraine
8:01 um
8:02 so part of the problem that I had for
8:04 this presentation is trying to put
8:07 together
8:08 um I because I’m a migrainer and I live
8:10 in a city with Chinooks and I see it all
8:12 day long I deal with migraines myself
8:14 professionally personally and then
8:16 there’s a literature and so
8:19 um I can see this from multiple
8:20 viewpoints
8:24 so what I thought I would do is I’m
8:26 going to focus on four interesting
8:27 studies out of the numerous studies
8:29 these four Studies have been referenced
8:32 in many reviews and I found them
8:34 particularly interesting and uh and
8:36 since no one else volunteered any
8:38 studies this is what you’re going to get
8:40 so this one the effect of whether on on
8:43 headache this goes back to 2004 by
8:45 Prince at all
8:48 the objectives were to assess the
8:50 headaches uh heading patients beliefs
8:52 about figures for the headaches and to
8:56 objectively investigate the influence of
8:58 weather patterns on headache
9:02 I’m just going to
9:08 the problem is that I have a bar across
9:11 top my screen so I can’t see the top of
9:13 my slides anyways
9:15 um the design of this study did they
9:19 gave every patient a questionnaire about
9:21 their beliefs if uh whether the weather
9:24 strong or not influenced their headaches
9:28 I mean what they had these patients do
9:30 is they collected daily Diaries from the
9:32 patients and compared those with the
9:34 weather collected from three separate
9:36 reporting stations with each station
9:39 being the most Central to the patient in
9:42 the study so they compared the patients
9:44 Diaries of their headaches with what the
9:47 weather station closer to them was
9:49 saying was going on with the weather
9:52 they collected 43 different variables
9:54 and of these variables they found that
9:56 some variables tended to fluctuate
9:58 together so they combined these into
10:00 what they called factors so three groups
10:03 of factors that fluctuated together
10:06 and then they looked at these three
10:08 factors compared those to what the
10:11 patients were experiencing and came up
10:14 with the results so the first Factor was
10:16 the absolute temperature and absolute
10:18 humidity second was a changing weather
10:20 pattern that could be barometric
10:22 temperature or humidity and that could
10:25 vary from day two to date one before day
10:29 Zero or the day-to-day actual headache
10:31 occurred on
10:33 and then they also looked at barometric
10:35 pressure and so that was two things in
10:36 barometric pressure was either a change
10:38 from two days ago to the day that you
10:40 had your headache or the absolute
10:42 barometric pressure
10:46 the results so before the study was
10:49 undertaken 62 percent of people felt
10:51 that their headaches were triggered by
10:53 my uh their headaches were triggered by
10:55 weather and 51 were found to be right uh
11:00 they were sensitive to whether in fact
11:03 39 were sensitive to one factor 12 to
11:08 two of these factors
11:11 um 14 were sensitive to a change and 13
11:14 were sensitive to absolutely pressure
11:16 absolute pressure so we’re flying from
11:18 this study that there are three
11:20 conditions uh in this large population
11:22 that could trigger uh uh migraine
11:26 headaches so AAA it supports that there
11:29 is this influence of weather on headache
11:33 turns out the patients are susceptible
11:35 to multiple variables and uh more
11:38 patients thought they were sensitive
11:40 than actually were
11:42 foreign
11:46 this one was done in Germany and there’s
11:48 a stereotype about Germans being very
11:51 rigid and and uh um
11:54 I’m not going to get into too many
11:56 stereotypes but the the dedication of
12:00 patients in this study the journaling
12:02 was astounding so this one was this was
12:07 a study that sat back and looked at a
12:10 lot of studies that had previously been
12:11 done
12:12 and one of the concerns with previous
12:15 studies many previous studies is that
12:18 they did pulled analysis so say you have
12:21 100 patients and of 100 patients 20 of
12:24 these patients had significant
12:26 fluctuations in headache or significant
12:29 headaches due to say fluctuations in the
12:31 water
12:32 but then you average that over 100
12:35 patients with ADP patients who aren’t
12:37 subject to other fluctuations and it all
12:41 averages out and you look at that
12:43 average and say well no one really is
12:45 sensitive to weather fluctuations and
12:48 that’s it’s an easy way of doing stats
12:50 so what this group did is they looked at
12:52 each individual and analyze their data
12:56 and they collected a ton of data
13:00 so 100 patients with migraines
13:03 tracked their uh migraines in terms of
13:06 intensity location characteristic
13:08 Associated features every four hours
13:10 when we’re awake for 12 months
13:14 um I I would never ask a patient to do
13:17 this and and uh so uh this is just pure
13:20 dedication
13:21 and the weather was collected from a
13:25 reporting station that was within one
13:27 kilometer of the headache clinic and
13:29 that clinic was within 50 kilometers of
13:33 every patient who was enrolled in the
13:35 study
13:36 and so they collected uh um data on the
13:41 the weather in terms of three
13:43 meteorological factors one was
13:45 temperature humidity and barometric
13:47 pressure so looked at the absolute as
13:49 well as the fluctuations again for every
13:52 24 hours
13:54 um relative to each migraine so a
13:56 patient said uh today I had a migraine
14:00 the research was then would then go back
14:02 and collect the um
14:04 every four hours the information
14:06 preceding that headache by a day and uh
14:10 and collect that information relative to
14:13 the headache
14:14 as well as during the headache
14:17 so in the results what they got is in a
14:20 pooled analysis weather played an
14:22 insignificant role which was something
14:24 seen in previous studies before but when
14:26 they did an individual analysis they
14:28 found 13 patients who were clearly very
14:31 sensitive to the weather
14:33 but not to each uh not each to the same
14:36 variable
14:41 um
14:41 so the conclusions a subset of migraines
14:44 are very clearly sensitive to weather
14:48 um and this points out the problem of
14:51 previous studies where uh pooled
14:52 analysis didn’t clearly demonstrate this
14:55 um what they did find whoever was the
14:57 lack of the consistent trigger so for uh
14:59 some patients it was the temperature for
15:01 some patients it was the barometric
15:03 pressure
15:04 and they concluded then that there was
15:06 not a single weather pattern that you
15:08 could look at to say uh okay in the next
15:11 24 hours barometric pressure is going to
15:14 go up so everyone’s sensitive to
15:15 barometric pressure taking medication to
15:18 prevent your your migraine so for
15:20 example
15:21 um take a trip tan or take an Advil
15:24 Tylenol combination for example
15:27 the idea would be and this would be uh
15:30 their goal would be to know that
15:32 something’s about to happen and to get
15:34 your medication on board before you
15:36 actually get the headache itself
15:40 so this was a study uh done here in
15:42 Calgary by uh doctors cook and Becker
15:45 and I’m sure some of you in Calgary are
15:47 familiar with doctors cook and Becker
15:51 um just a shout out to Dr Becker I’m not
15:53 sure if he’s here uh but he taught me so
15:55 much about uh headaches and migraines I
15:57 always like to thank him for that
15:59 and he is happens to be a world expert
16:01 so we’ve been incredibly lucky to have
16:03 him here in Calgary
16:05 um so this study was looking at the
16:07 Chinook Winds and migraine headache for
16:08 those of you not familiar this is a
16:10 picture of a chinook Arch which is where
16:13 a ridge of warm air comes from over talk
16:16 to Rockies heading west to east
16:19 what happens with the Chinook is that
16:22 air Laden with moisture dumps a bunch of
16:25 snow and rain in the mountains and as it
16:29 comes down on the other side of the
16:31 mountains it heats up relatively quickly
16:33 because it no longer has to warm up
16:36 moisture and so you have dry air which
16:38 brings a lot of heat and can flip
16:42 Calgary from -20 Celsius to 10 degrees
16:46 Celsius in the span of 24 hours yeah
16:49 it’s vicious but it’s also awesome
16:56 so the goal here was to see if she looks
16:58 trigger migraines
17:01 75 patients were enrolled in so these
17:03 were patients who were already
17:05 journaling or taking their headache
17:07 diaries for the headache clinic and had
17:10 agreed to participate in any trials
17:11 these patients were already collecting
17:13 uh data and didn’t know that this data
17:17 or they knew retrospectively but didn’t
17:20 know that the data was going to be
17:21 analyzed for sensitivity to weather
17:25 fluctuations so in a way they were kind
17:27 of blinded
17:30 um and so the data was collected uh for
17:32 two stretches over the fall from
17:35 September to June which is when we tend
17:37 to get a lot of the Chinooks coming
17:39 through uh you know you get the cold
17:41 that comes with winter and then sudden
17:42 warming and it’s just profound shift in
17:44 barometric pressure and temperature and
17:46 days were classified as a chinook day
17:49 our appreciative day which was the day
17:51 before Chinook day and not a day
17:55 and the Chinook was defined by three
17:57 features which was the wind speed
17:58 greater than 15 kilometers an hour wind
18:00 direction had to be coming generally
18:02 from the the west southwest or Northwest
18:06 and we had to have an Abrupt change in
18:09 temperature of greater than three
18:11 degrees Celsius per hour for at least
18:13 one hour
18:17 the results
18:18 uh showed that
18:21 there was increased risk of migraines on
18:23 both apprecia day and the ship days
18:28 17 patients out of 75 were more likely
18:31 to have a migraine on a pre-snook day 15
18:34 more likely on Chinook day but on the
18:37 Chinook day this is a curious statement
18:39 that only days it had winds greater than
18:42 38 kilometers an hour
18:44 were sufficient to generate the Chinook
18:48 headache
18:49 uh most patients weren’t sensitive to
18:51 either of these
18:53 increased age made you more sensitive
18:55 and again before the study 88 of people
19:00 thought that the Chinook influenced
19:02 their headache and the study showed that
19:04 only 39 were actually affected
19:08 you’re shaking your head I know I know I
19:10 know I’m gonna get to it I’m going to
19:11 get to it
19:13 so the conclusion is because it can be
19:15 predicted if you reliably get headache
19:19 uh
19:20 uh due to Chinook that would be a good
19:23 time to take uh preventative treatment
19:25 or on a board of therapy
19:28 um
19:29 and we could discuss that we will
19:30 discuss that later I’m sure
19:34 um it also showed us two interesting
19:36 things so only two patients actually had
19:40 headaches due to Shooks and preciousness
19:43 otherwise people were sensitive to
19:46 either depreciative day whatever was
19:49 happening there or the Chinook day
19:50 whatever was happening there but they
19:52 were not sensitive to both and most
19:54 patients with migraines didn’t respond
19:58 to the Chinooks in one way or another
20:03 and then another study and this one is
20:05 interesting because this group used uh
20:07 electronic device uh so instead of uh
20:11 and then children instead of children
20:13 having to to keep a headache diary
20:17 um and I have kids so I know how easy it
20:19 is for them to lose paper but there’s no
20:21 way in hell that ever leaves an
20:22 electronic device iPad is basically
20:24 stapled to their hands
20:26 um
20:27 so with the using advice uh to see if
20:30 weather fluctuations could be determined
20:33 by using electronic device so
20:36 um a similar similar study this is a
20:39 relatively small group but interesting
20:40 nonetheless
20:42 only five children who had recently been
20:44 diagnosed with a headache either chronic
20:46 migraine episodic migraine or a chronic
20:48 tension type headache three times per
20:50 day had to answer when they were
20:52 prompted uh features about their
20:55 headache so they had to say
20:57 um uh
20:58 duration and I can’t even see what the
21:02 damn slide says there because I’ve got
21:03 this uh this window blocking it
21:07 um but anyways features of the headache
21:10 intensity and duration
21:13 and then what other variables are
21:14 collected by the device as well so
21:16 interestingly instead of say for example
21:18 a reporting station 50 kilometers away
21:20 from where you were and weather can
21:22 change within 50 kilometers they looked
21:24 at the uh the weather variables right
21:28 there at the same uh location as the kid
21:32 and that was they were looking at
21:34 temperature humidity barometric pressure
21:35 precipitation presence of sunlight
21:41 oh okay I somehow managed to get rid of
21:44 this annoying little window I am now a
21:47 zoom God uh okay so results
21:51 turns out only humidity and the presence
21:54 of precipitation were predictive of a
21:56 new heading onset
21:58 and children who before the study said
22:01 that they thought they were sensitive to
22:03 uh whether we’re no more sensitive than
22:05 children who didn’t think they were
22:06 sensitive to weather it was stupid kids
22:09 so what are the conclusions uh fear
22:12 humidity and precipitation are confirmed
22:15 as triggers
22:16 um but triggers uh suspected by some
22:19 children just weren’t there and kids are
22:22 reliably reliable at uh playing with
22:26 electronic devices
22:28 um that is that I feel silly even
22:31 putting that conclusion in there because
22:33 this is something that we all know
22:36 so what’s going on with the weather
22:39 um this is one of my favorite bar sides
22:41 and I own I have bought so many Far Side
22:44 companions don’t anyone wrap me up but I
22:46 feel entitled to use a Gary Larson
22:47 cartoon even if I don’t have copyright
22:49 on it
22:50 so oh Ray and squalls are coming my
22:53 knees acting up and this guy is his
22:55 hands and then the other guy oh there
22:58 goes my head
23:00 I’m sure you’re all laughing at home but
23:02 that’s kind of a rather uncomfortable
23:03 laugh just listening to myself
23:06 so why are research studies not
23:10 confirming what so many migrainers are
23:12 experiencing and I include myself in
23:15 here the hell are these researchers up
23:17 to
23:18 so Dr Becker heady Guru here in Calgary
23:22 had the same question
23:24 can so many patients be wrong and this
23:27 has been asked by money expert many
23:30 experts
23:32 and we’re not crazy
23:35 so what is going on with the research
23:38 there is multiple explanations why
23:40 research doesn’t match what people with
23:43 migraines are experiencing one is that
23:46 there are likely multiple triggers
23:48 working in conjunction so we talked
23:50 about how most patients have between six
23:53 and eight triggers
23:55 and how typically it takes multiple
23:58 triggers at once so let’s say yes you
24:00 have a weather trigger but you get
24:02 enrolled in a trial at the time of the
24:04 trial you happen to be particularly
24:05 relaxed there’s no stress at work you
24:07 haven’t missed any sleep you don’t have
24:08 any caffeine with drug you’re not
24:10 worried about covid you’re not worried
24:12 about this you’re not worried about
24:13 a good list goes on so
24:16 you cannot control within the context of
24:19 a clinical trial up to six to eight
24:21 variables which all of which could be uh
24:24 triggers so each time some weather
24:26 pattern occurs you are not going to be
24:28 one of those people perhaps who has a
24:31 migraine in that day so studies can’t
24:33 look at multiple triggers
24:37 so many whether variables have been
24:39 identified but not consistently across
24:41 trials so
24:43 um some variables tend to go fluctuate
24:45 for example in the case of a chinook
24:47 pressure goes up or pressure goes down
24:49 temperature goes up uh uh so you’ve got
24:52 variables going in two different
24:53 directions
24:55 um humidity is down temperature goes
24:57 goes down humidity goes up temperature
24:59 goes up the variables can go
25:02 in different directions at different
25:04 times uh and not everyone has the same
25:07 trigger so until we can put everyone we
25:10 know as a sensitivity to a shift and
25:13 very much pressure into the same trial
25:15 this may not work or until we can put a
25:18 thousand patients in the same trial we
25:20 may not see this uh other problem is for
25:23 example you know the study with the kids
25:25 where they’ve got electronic device
25:26 that’s with them we know right there how
25:29 much what humidity it is what
25:30 temperature it is how much sunlight is
25:32 there
25:33 if you’re 50 kilometers away from a
25:35 reporting station you may not be getting
25:37 the same rain as the reporting station
25:39 so if rain is a trigger for you it’s
25:41 raining at the reporting station but
25:43 you’re not there so again it’s the other
25:46 variables go into this and then it’s the
25:48 fluctuations so the study where Chinooks
25:51 are very clearly linked to triggering
25:53 migraine headaches that’s a very extreme
25:55 example of a barometric pressure shift
25:57 barometric pressure sifts in some places
26:00 do not reach that extreme uh the
26:03 temperature swings in some places do not
26:05 reach the same extremes that they reach
26:07 in other places
26:09 um
26:10 so you know to do a study in uh you know
26:13 some studies were done in the emergency
26:15 departments in North Carolina North
26:18 Carolina is not going to get the same
26:20 fluctuations in temperature that we get
26:22 here in Canada
26:24 lucky
26:26 um students haven’t studies haven’t
26:27 looked at medication Cycles I’m reminded
26:29 again today when I was doing Botox
26:31 injections and clinic so many of my
26:33 patients their Botox wore off and
26:36 they’ve got a 12-week cycle
26:38 Botox wears off at 10 to 11 weeks
26:42 our temperature here just went although
26:44 I was in Disneyland since I didn’t
26:46 experience it right away temperature
26:47 went from decent to shitty in the span
26:50 of a day now they already started
26:52 swearing again but that what do you call
26:53 this kind of garbage shoveling a foot of
26:55 snow in here today
26:56 um
26:58 of course the weather’s going to trigger
26:59 a migraine headache your Botox just wore
27:01 off so there are days when I inject
27:04 Botox I have 30 people who tell me 28 of
27:07 30 people will say they had a migraine
27:10 that was triggered by the weather
27:11 pattern that just swung through Calgary
27:14 three days ago so you’re predisposed
27:16 because but that’s not controlled in
27:18 clinical trials they’ve scoured the
27:19 result I’ve scoured the methods and uh
27:22 we don’t talk about whether your once a
27:25 month injection or whether you’re at
27:26 once every 12 week injection has
27:28 potentially worn off did you miss a dose
27:30 of your drug so that’s another thing
27:33 that we haven’t accounted for
27:35 at the end of the day we really don’t
27:37 know what’s going on with the brain we
27:39 have learned a lot but the brain
27:41 pathophysiology when it comes to
27:43 migraines
27:44 I have a review I can show you what’s in
27:46 a pile here right now 60 Pages going
27:49 through all the mechanisms through which
27:52 migraines occur neurotransmitters first
27:54 second order neurons this is just it’s
27:57 so complicated we’re unraveling it piece
28:00 by piece but the end of the day we just
28:02 don’t really understand it all that well
28:05 and at the end of the day uh finally uh
28:08 people with migraines are not the same
28:10 so you put 100 people in a trial
28:13 and this has come up in in several
28:15 reviews of the literature that you
28:18 cannot expect to see significant Trends
28:20 with a hundred different migrainers in a
28:24 study
28:25 um where everyone’s got a different
28:26 Trigger or a different constellation of
28:28 triggers so until we can roll like 2 000
28:31 people in a single trial which is never
28:34 going to happen we may not completely
28:36 elucidate the fact of weather on
28:38 migraines
28:41 so
28:43 um what else is going on with this uh
28:44 what if what if and and so this is
28:47 things are going to get interesting
28:49 folks so what if it’s not as simple as
28:52 weather triggers a migraine yes we’ve
28:54 talked about how there’s multiple
28:55 triggers but what if it doesn’t even
28:56 come down to triggers
28:58 so we’ve also looked at how multiple
29:00 studies people before the study think
29:03 they’re susceptible to whether as a
29:04 trigger but then it turns out that
29:06 they’re not
29:07 um
29:08 are we fooling ourselves into thinking
29:10 that that weather is causing a migraine
29:14 um are we all crazy well we have
29:17 migraines so maybe
29:21 no but okay so here it is drum roll
29:23 everyone at home drum roll unless you
29:25 have a migraine and you’re you’re
29:26 sensitive to loud noises
29:29 let’s look at the four stages of a
29:32 migraine
29:33 one stage in particular so I’m going to
29:35 use a figure from uh migraine buddy
29:39 I I looked at the my green candle
29:41 website doesn’t have an equivalent
29:42 figure obviously uh Wendy and Alex I
29:45 would like to incorporate that but um so
29:48 my green buddy fair enough
29:49 this is the migraine attack this is the
29:51 actual headache component that we’re all
29:53 familiar with it’s a throbbing headache
29:54 that varies in intensity uh all these
29:57 features burning nausea volume
30:01 we’re familiar uh most of us or many of
30:03 us with the aura which occurs lasting
30:05 about five to six minutes precedes the
30:07 headache itself
30:08 but what we’re not familiar with is the
30:11 prodrome in many cases and uh prior to
30:14 2017 2018 I had not learned much about
30:19 the migraine prodrome I blame Dr Becker
30:21 for that
30:23 um
30:24 so there are many features of the
30:26 migraine prodrome that we really need to
30:30 educate ourselves adult because this
30:32 part of the headache is intimately
30:34 involved in what uh I and many experts
30:39 see as potentially a confounding factor
30:42 in determining what triggers a migraine
30:45 headache
30:46 and then there’s a migraine post drill
30:48 so to get an idea of time here the
30:51 prodrome can occur for three days before
30:53 an actual migraine and the post drone
30:56 can occur for about 24 to 48 hours after
30:59 a migraine headache I’m going to get
31:00 into details on the migraine problem
31:01 here do a screen capture or just go
31:04 migraine body prodrome and you can see
31:08 this exact same slide
31:10 but let’s look at the migraine prodrome
31:12 so the prodrome itself
31:15 starts up to 72 hours before the actual
31:18 headache occurs
31:20 curiously a lot of Studies have looked
31:23 at wet weather patterns occur in the
31:26 previous 48 to 72 hours before the
31:29 headache
31:30 um about 30 to 40 percent of migrainers
31:33 will experience a proton as far as we
31:36 know but a lot of times the surveys you
31:38 may not tease out probably that figure
31:39 is higher
31:41 many people can sense that a migraine is
31:44 coming you you if you you can you know
31:47 what I’m talking about you just oh no
31:51 um it’s accompanied by numerous features
31:52 that I’m going to get into and even
31:54 Imaging studies so we’re looking at
31:56 detailed Imaging studies of the brain
31:58 show that up to 72 hours in advance of
32:00 the actual headache itself changes are
32:02 starting to occur in the brain
32:04 particularly in the part of the brain
32:05 that makes you more sensitive to
32:07 environmental and other triggers
32:11 so the most common symptoms include mood
32:14 swings fatigue difficulty sleeping
32:17 muscle stiffness tenderness neck pain
32:21 food cravings nausea so you don’t you
32:24 want to eat certain foods and other
32:26 times you don’t want to eat at all you
32:28 have unquenchable thirst you have
32:30 difficulty concentrating difficulty
32:32 talking difficulty reading increased
32:34 urinary frequency
32:36 um and a heightened perception
32:37 sensitivity to light and sounds and the
32:41 theory goes weather as well
32:44 so this gives rise to is a symptom uh
32:48 are we looking at a symptom of a
32:50 prodrome or are we looking at a trigger
32:53 for migraine so for example
32:55 let’s say you have a pro German your
32:58 prodrome is you have no appetite you
33:01 just don’t feel like eating so you skip
33:02 a meal but one of the biggest triggers
33:05 for migraines is skipping a meal so what
33:09 is missing that meal part of your
33:10 children prodrome or was it actually
33:13 what triggered your migraine headache
33:15 yeah
33:18 a lot of us get neck pain I’m lucky I
33:21 don’t but a lot of people uh that I see
33:23 have neck pain that precedes the
33:26 migraine headache
33:27 that’s actually a symptom of project but
33:30 in other people it may be the trigger of
33:33 a headache you get tension in the neck
33:35 and that leads to I explain some
33:37 mechanisms it’s not really the point of
33:39 this talk but that will lead to the
33:41 headache
33:42 uh
33:44 part of your program you have difficulty
33:46 concentrating you get stressed because
33:48 of that you know that you’ve got a
33:49 report that’s due you can’t focus on
33:50 report you have to give a presentation
33:52 and uh that leads to stress
33:56 then you get a headache and the headache
33:59 was going to happen within two to three
34:01 days anyways but was it triggered by the
34:05 stress or was the prodrome causing the
34:08 stress in the first place
34:09 so it’s impossible to tease these out
34:11 and it’s particularly difficult in the
34:13 case of weather so let’s look at this a
34:16 different way
34:17 so
34:18 uh let’s look at uh identification
34:21 program and identity how it confounds
34:23 the identification of triggers so this
34:25 is fairly simple if you miss sleep or
34:28 have stress or skip a meal
34:30 you’re going to get a headache put all
34:31 these three together almost guaranteed
34:33 you know what I’m talking about
34:36 what if you have a pro drone so your
34:38 prodrome is difficulty sleeping
34:41 which results in mislead you have
34:43 causative impairment which leads to
34:44 stress and you have nausea or lack of
34:48 loss of appetite which leads you to skip
34:50 a meal that’s your prodrome
34:54 that’s also going to lead to headache so
34:56 so was it the prodrome that eventually
34:58 led to the headache because you were
35:00 predetermined to have that headache
35:02 anyways
35:03 or were those actually triggers well now
35:06 I’m in your head I’m in my head too I’ve
35:08 been trying to think of I’ve been
35:09 thinking about this for months folks
35:11 driving me crazy
35:13 so
35:14 um
35:15 there’s a problem was the headache going
35:17 to come because the program or the
35:19 program was there was the headache going
35:21 to happen anyways in which case their
35:22 fate was sealed or was actually
35:25 triggered by something that you know is
35:27 a trigger and this is where we get
35:28 ourselves it’s all kinds of problems
35:31 so how about this scenario then
35:34 so that’s hard to tease out um
35:40 I’m just going to check the time okay
35:42 we’re good
35:43 what if we’re predisposed
35:47 to uh weather as a trigger because we’re
35:49 set up so let’s look at the stages
35:51 migraine that we’re in if say you get
35:54 migraines
35:56 the migraine headache eight days in a
35:59 month
36:00 and the prodrome May precede that
36:02 headache for uh say two days that 16
36:07 days a month where you may be in a
36:10 prodromal stage where you are more
36:13 sensitive to triggers you’re going to
36:16 have that headache potentially anyways
36:17 but then you stacked up a couple of
36:19 triggers
36:20 so
36:21 you have an increased risk of being
36:23 susceptible and uh maybe through the
36:26 presence of other triggers were you
36:28 anticipating and migraine and then more
36:30 likely to see the triggers and this is
36:31 something where uh there’s some uh
36:34 there’s some controversy about this as
36:36 well
36:37 so let’s just I’m just going to throw
36:39 out a couple of scenarios here so let’s
36:41 look at
36:43 situation where you’re in a project
36:46 and uh
36:48 if you’re sensitive to weather
36:51 and you’re in a prodrome the likelihood
36:53 of you getting a migraine or sensing a
36:56 migraine coming on when the weather
36:58 trigger is present is very high because
37:00 you’re already in that state if you have
37:03 a headache it’s possible that the
37:05 weather May exacerbate that headache if
37:08 you’re going to post room if you already
37:10 had the headache you’re kind of in that
37:11 refractory stage whether it’s unlikely
37:13 to be as big a trigger for you so that’s
37:16 just two variables the stage of the
37:19 migraine that you’re in
37:20 and then whether your weather trigger is
37:22 present yes or no let’s add in not just
37:26 eight variables or eight potential
37:28 triggers but just one more trigger
37:31 so let’s look at
37:34 um sleep deprivation so
37:37 um it’s a 3D graph now and it’s already
37:39 blowing my brain just to think about it
37:40 but on the y-axis there’s a headache
37:43 trigger there yes or no if it’s there
37:46 you’re more likely to have a headache
37:48 but if the stress is low you’re less
37:50 likely if the stress is high you’re more
37:53 likely and then you’re in the program so
37:55 if you have if you look at the very top
37:57 of the graph here if you have you’re in
38:00 the prodromal phase the weather trigger
38:02 is present and your sleep deprived
38:05 looking at say 100 chance of getting a
38:08 migraine headache
38:10 if you’re well rested
38:13 and you’re in a pro drone you might have
38:16 a slightly higher chance of having a
38:17 migraine but maybe you can ride this one
38:20 out maybe you’ll make it through
38:22 um that weather fluctuation or that
38:24 barometric pressure because you’re
38:27 really well rested and you just got your
38:29 Botox say three weeks ago
38:31 so so many variables
38:35 okay this slide is left blank just to
38:38 build up anticipation
38:40 so let’s look at three scenarios
38:43 relative to weather weather is a
38:46 significant trigger
38:47 whether when combined with other
38:49 triggers can be enough to push someone
38:51 over the edge or whether it’s not a
38:53 trigger
38:54 but
38:55 it occurs during the prodromal stage in
38:58 someone who’s going to have a migraine
38:59 anyways in the third scenario you might
39:01 say the weather triggered my migraine
39:03 but in fact you were going to have the
39:04 headache anyway so it looks like the
39:06 weather’s a trigger but it just happened
39:08 to occur during the prodrome and so
39:10 we’re dealing with three scenarios that
39:12 definitely occur
39:15 and it’s near impossible to tell the
39:17 difference
39:19 so what do we do well
39:22 um you do as much as you can to control
39:25 the triggers that are within your
39:27 control you can’t change the weather
39:30 but you can uh adjust some other
39:33 triggers and one of them is identifying
39:35 and knowing what triggers are relative
39:36 to you so you’ve got a list you’ve
39:39 thought about this a lot so look at
39:41 those triggers
39:43 um some of the simple ones I recommend
39:45 when it comes to sleep
39:46 I tell my patients just Google this or
39:49 uh or um any other search engine I’m not
39:54 paid by Google uh just a 37 tips sleep
39:57 this is everything that you can do for
39:59 your sleep without using a medication
40:03 um on certain phones you’ve got the
40:05 night shift some of the uh um there’s a
40:09 program called f dot Lux as in flux but
40:12 with a DOT between F and L you can load
40:15 that onto any platform
40:17 and shift your screen from a Bluetooth
40:20 Spectrum to an orange Spectrum which is
40:21 much less likely to trigger a migraine
40:23 headache
40:24 a lot of screens a lot of uh software um
40:28 operating systems now you can actually
40:29 go into controls and display and adjust
40:32 the orange shoe on your screen and I
40:35 shift mine all the way to Orange when
40:37 I’m uh up all night putting together
40:40 presentations
40:42 um
40:42 get in for your Botox uh every 12 weeks
40:46 make sure you take your prophylactic
40:48 medications
40:49 and if you do identify that you’re
40:52 sensitive to particular shift in the
40:54 weather you can take in a board of
40:56 medication so discuss with your doctor
40:58 of course as Alex already mentioned but
41:01 have your cocktail ready to go when the
41:03 weather shifts if you know you’re
41:05 sensitive to it take it
41:10 so learn about your program if you have
41:12 one maybe you didn’t even know about
41:13 projo now you do so uh there’s your
41:17 homework I’ve done my homework and I’ve
41:19 I’ve empowered you
41:23 um are you avoiding food because you
41:25 feel nauseated is that part of your
41:28 program
41:29 so uh try not to miss a meal even if you
41:31 feel crappy maybe take an anti-nausea
41:34 and then uh and then eat something
41:36 delicious but not a food that could be a
41:39 trigger
41:40 uh keep your aborted medications with
41:43 you at all times the second you feel
41:44 this is a key and I’m going to give you
41:46 one other tip that just came to me now I
41:48 meant to put a picture of this
41:51 um this is this is audience
41:52 participation one and I’m going to stand
41:53 up and hopefully you can all see me here
41:56 um your stomach
41:58 uh and Wendy can you can you hear me can
42:00 you talk right now
42:03 I can yes I can can you see me okay when
42:06 I’m standing here like this I see the
42:09 big flaming calorie flame go Flames go
42:12 okay so what I’m doing right now I’m
42:15 gonna demonstrate because this should be
42:16 your Embassy my stomach all of our
42:19 stomach’s empty from the left to the
42:21 right
42:22 so stomach is sitting here but drugs get
42:25 absorbed in the small intestine here so
42:28 you want to get your drugs through your
42:29 stomach to a small intestine as fast as
42:31 possible so when you take your board of
42:34 medication lean to the right this is
42:36 this is not even made up this is just
42:38 this is actually research that’s been
42:41 demonstrated and known to be true a
42:43 medication could be can be absorbed
42:46 within 10 minutes if you lean to the
42:47 right because the the drug is going
42:50 through your stomach into the gut where
42:53 it gets absorbed if you lean to the left
42:55 like this
42:57 your medication gets stuck in the
42:59 stomach it doesn’t go uphill and get
43:02 into the spot in the gut where it’s
43:03 absorbed can take two hours for the
43:06 medication to be observed over here so
43:07 you can take it in the board of cocktail
43:08 lean to the right if you go home take
43:11 your pills go to bed okay you go you lie
43:14 down
43:15 close the doors
43:17 turn off the lights everyone go away
43:19 pick your pill and lie down and you lie
43:22 on your right your medications are going
43:24 to be absorbed right away if you lie
43:25 down on your left it’s going to take you
43:27 two hours for your pills to be absorbed
43:29 so even if you can just lie down on your
43:32 right for the first five or ten minutes
43:34 you’re going to make your border with
43:36 medications much more effective
43:39 I’ve never heard of that thank you for
43:41 sharing I know just you you can Google
43:44 this I I’m sorry I meant to put some
43:46 pictures in there to demonstrate this
43:47 but the research has been done it turns
43:49 out the studies uh they are uh data
43:51 going back over 20 years and it it just
43:52 makes sense you don’t need me to tell
43:54 you about a study for what just makes
43:55 sense
43:57 um I had four patients during uh uh and
44:00 I don’t think it was personal
44:03 um during covet who who realized it wait
44:05 a minute I could work remotely from
44:07 anywhere it just moved out to Victoria
44:09 from Calgary where they don’t get any
44:11 migraines anymore so you can’t change
44:13 your weather but you can change your
44:14 address
44:15 before
44:17 uh so these are questions from Wendy but
44:20 um
44:21 I can I can tackle some of these or uh
44:24 we can I can just kind of give you quick
44:26 answers to some of these right now and
44:28 uh we can move on to q a from the
44:30 audience uh Wendy uh leave that up to
44:31 you what do you think we should do here
44:34 I am I’ll I’ll actually turn it over to
44:36 Alexandra
44:38 um and let her manage this
44:41 but this has been amazing I think a lot
44:45 of very valuable information so I’ll
44:47 turn it over to Alexandra okay
44:51 hi yes thank you so much I think if you
44:54 can answer those questions that would
44:57 probably hit the majority of the ones
44:59 that we are getting okay and then we can
45:03 go through the Q a
45:05 um yeah no this is great okay can you
45:08 see my screen now yeah
45:12 all right so um
45:15 there are multiple forecasts oh I got a
45:18 good one I gotta go in here hold on oh
45:20 wait oh this is good okay first question
45:23 barometric pressure dot app
45:26 this is Calgary’s barometric pressure
45:29 shift in the last 72 hours so you can
45:32 look back 72 hours or 120 hours or look
45:35 forward 72 to 120 hours
45:38 so the last uh 72 hours and uh so one
45:42 study uh at least one study shows that
45:45 migraines are more likely to occur above
45:47 a barometric pressure of 760 millimeters
45:51 Mercury so um
45:54 you can see uh Calgary kind of muscled
45:57 up over 760. then we went back down then
45:59 we went back up this is Honolulu in the
46:02 bottom
46:04 um
46:04 yeah so uh the scale is Honolulu
46:08 fluctuated over about two and a half
46:11 millimeters of mercury Calgary
46:13 fluctuated over about
46:15 um 20. but this get this this is so um
46:19 the snowfall just started and uh the
46:22 temperature is going to plummet now this
46:23 is a barometric pressure shift in
46:25 Calgary over the next 72 hours so
46:28 um pressure over 760 is sufficient to
46:31 trigger migraine headache we’re gonna
46:32 hit 780 within the next 72 hours here
46:37 um
46:39 but I really want to swear right now but
46:41 I’m I’m holding it in I obviously
46:43 haven’t had enough coffee yet so um so
46:47 we’ll go back to questions from Monday
46:49 uh variables uh in the index Factor uh
46:52 in predicting a migraine
46:54 there are several apps out there that do
46:56 this
46:57 um
46:58 I I don’t know what individual uh which
47:01 uh variables individual websites or
47:04 applications are using
47:06 um
47:07 I think uh people are as good at
47:10 predicting these as the Ops I’ve looked
47:13 at some of the apps sometimes uh there’s
47:14 one uh in particular that I haven’t
47:18 actually is found to be that reliable
47:20 for my own migraines or my patients
47:23 migraine so I I think you know some of
47:26 them may be pretty accurate but
47:28 barometric pressure one is pretty
47:29 interesting that I just demonstrated to
47:31 you though
47:32 um but I suspect they’re using a
47:33 combination of barometric pressure and
47:35 and temperature and humidity most likely
47:39 um so what do we know about the impacted
47:40 parametric pressure we know that
47:42 absolute barometric pressure high or low
47:44 can be a trigger for some people we know
47:47 the shift going up or down can be a
47:49 trigger for some people so I’ve got some
47:51 patients who uh uh when the barometric
47:53 depression goes up others will not very
47:55 much pressure go down
47:57 um so that’s all over the place so we
47:59 know
48:00 um that barometric pressure plays the
48:03 role but we don’t know it’s all
48:05 individual
48:07 what seasons are worse uh than others
48:09 around Calgary it’s the spring of the
48:12 fall this is where we get the greatest
48:14 shifts in temperature and pressure
48:18 um so that those variables have emerged
48:20 in clinical trials as well as
48:23 significant
48:24 um weather patterns for uh um triggering
48:27 migraines
48:29 um yeah so how does the environment do
48:31 where you live still I haven’t even
48:33 touched on uh altitude how that plays a
48:36 role uh definitely a role here in
48:38 Calgary there’s something called
48:40 spherics
48:41 um these are uh their
48:44 electromagnetic radiation that’s
48:47 produced by weather patterns uh so uh
48:50 positive ions we know that positive ions
48:53 uh for example from Schnucks in the air
48:55 could trigger migraine headaches there
48:58 are probably triggers that exist that we
49:00 don’t even know about yet
49:02 so your environment plays absolutely a
49:05 significant role
49:07 um in combination again with all the
49:09 other triggers that we know about
49:11 how does a weather influence migraine uh
49:14 in so many ways we um we know that
49:17 whether it does but the uh the actual
49:20 mechanisms
49:21 involve multiple neurons multiple neural
49:24 transmitters
49:26 and so how do you manage the weather
49:28 related triggers if you clearly identify
49:30 your triggers one one thing that that
49:33 can be done is look at the weather but
49:35 say you may be in a prodromal stage
49:39 what if you’re also uh if you other have
49:43 you have other triggers going on or if
49:46 you have other features if you
49:47 consistently can identify features of
49:50 your prodrome then ask yourself am I
49:53 missing a meal because I’m not hungry or
49:56 am I missing a meal because my prodrome
49:58 has told me that I’m not hungry so
50:01 um you you you have to identify whether
50:06 you’re in a pro drone or not and uh if
50:09 the weather is coming and you’re not in
50:11 a prodrome then uh
50:14 you know then then take your medication
50:17 um at the same time
50:19 and I know this gets that all chicken
50:21 and egg kind of stuff now but
50:24 um some Studies have shown that you can
50:27 take in a board of medication if you are
50:29 in a prodrome and taking uh your board
50:32 of medication you can stop the migraine
50:34 even if you were in the prodrome 24
50:37 hours 48 hours out from the actual onset
50:39 of headache you’re born with medications
50:41 like Advil and Tylenol kryptons two may
50:45 be as effective during the prodrome as
50:47 they are at the time of the headache
50:49 onset uh the down the only problem with
50:51 this is we can’t study in detail because
50:53 no drug company is going to give us
50:55 enough money to study 100 people with
50:56 prodromes
50:58 um
50:59 I saw what medications can be used to
51:01 treat weather related migraines
51:03 um a board of cocktails uh make sure
51:05 you’ve got your preventative medications
51:08 on board
51:09 um and uh and finally is it possible to
51:12 prevent a migraine it definitely
51:15 um and the key here is to know your
51:17 other triggers get them under control
51:20 and if you can tell you’re in a
51:22 programal stage take your medication
51:24 then and uh and
51:27 I always keep your medications on hand