Tips and Tricks for Preventing Migraine

0:00 thank you very much uh to Alex and Wendy
0:03 and Mike are in Canada for inviting me
0:05 tonight and and thank you for enjoying
0:07 and um for joining me uh tonight we’re
0:10 going to talk about some tips and tricks
0:13 for uh preventing migraine and and
0:16 hopefully
0:17 um you’ll learn something that are going
0:19 to help with your migraines and if you
0:22 have any questions just say them to the
0:24 end and we can put them in the chat and
0:26 we’ll take a look at them then
0:29 these are my disclosures and as you can
0:31 see I do a lot of speaking and
0:33 educational events for all the different
0:37 pharmaceutical companies that are
0:39 involved in migraine but what we’re
0:42 going to do today we’re going to talk
0:43 about things that you can do to prevent
0:46 migraine when talk about when to ask for
0:50 for help from a migraine expert and what
0:53 to expect and what are those treatment
0:56 options a doctor can offer
0:59 so I better just start with a case this
1:02 is a sort of a typical patient that I
1:05 might see we could sort of talk about
1:06 her preventative uh Journey she’s a a 25
1:11 year old woman uh work full time for a
1:14 PR Company enjoys yoga but struggles
1:16 with insomnia and has had headaches
1:19 since the age of 13.
1:22 they occur mostly around the time of her
1:25 period but can but have increased in
1:28 frequency so they’re occurring at other
1:29 times so about four to six times a month
1:33 at other times other than her period
1:36 pain is bilateral it’s not that knock
1:40 them dead kind of pain it’s that
1:42 grinding six out of ten achy pain
1:46 it’s worse with physical activity not
1:49 associated with nausea or vomiting but
1:51 she prefers to avoid bright lights and
1:54 right now she’s been treating it by
1:56 lying down and she may or may not take
1:58 Tylenol
2:00 so the diagnosis here is migraine and
2:04 unfortunately patients like
2:06 um like Chelsea often get missed mostly
2:09 because she’s not describing a
2:12 unilateral headache that’s wiping her
2:14 off her feet and putting her to bed and
2:16 I think it’s important for people to
2:18 realize that they may also have migraine
2:20 that what they’ve been thinking is
2:21 tension that may be my brain so
2:24 what qualifies for migraine well a
2:27 patient must have had five episodes
2:30 if untreated they last four to 72 hours
2:34 and you have
2:35 to the following four things
2:37 so unilateral throbbing
2:40 moderate to severe
2:42 and worsened with physical activity and
2:45 then to or one of the following two
2:47 things
2:48 nausea or vomiting or light and Sound
2:51 Sensitivity
2:52 so if we go back to Chelsea who has more
2:56 moderate headaches but they’re
2:57 increasing in frequency she does qualify
3:00 there are sixes out of ten that’s
3:02 moderate it’s worse with activity and
3:05 she has light sensitivity
3:07 Chelsea is migraine and this is
3:09 important and it’s important to
3:11 recognize it because this opens up all
3:13 the treatments that are available for
3:15 migraine and they’re really increasing
3:19 I think you might hear the word chronic
3:21 migraine and and I think it’s a can be a
3:23 little misleading because chronically
3:25 always think oh that’s somebody who must
3:26 have had chronic migraines most their
3:28 life
3:29 but what it really refers to is somebody
3:31 who has a lot of migraine so 15 headache
3:35 days a month or more of which eight of
3:38 those days fulfill that criteria for
3:40 migraine and it’s been going on for
3:41 three months
3:43 it’s a special category because there’s
3:45 certain drugs that are applicable to
3:48 patients who have chronic migraine
3:50 rather than episodic migraine
3:54 so you know migraine is often
3:58 um misdiagnosed as sinus headache and
4:01 why is that well you know there’s a
4:03 certain amount of overhead
4:05 both conditions can have pain over the
4:08 sinuses
4:10 migraine is mediated by the trigeminal
4:14 nerve nc1 C2 and C3 so trigeminal nerve
4:18 have branches over the forehead over the
4:20 cheeks through the jaw and over the back
4:22 of the head and the shoulders and so
4:26 um when a patient has migraine they can
4:28 have my pain over the sinuses
4:31 um so both sinus headache and migraine
4:33 pain can be
4:35 pressure can be throbbing they can both
4:38 be associated with tearing and nasal
4:40 congestion
4:42 um they both can be triggered by changes
4:44 in weather
4:45 but true sinus headaches they have thick
4:48 discolored nasal discharge
4:51 their face pain can be pressure and but
4:54 there’s decreased smell or no smell
4:58 relax
5:00 so the real question is what can you do
5:04 to reduce your migraines now you know
5:08 you have migraines
5:11 so this is my Approach
5:14 um in the clinic and it’s you know
5:16 there’s lots of different things that
5:18 you as an individual can do
5:20 we’re going to talk about lifestyle
5:22 modification
5:24 I understand if somebody’s already
5:25 spoken to you about supplements so we’re
5:27 just going to touch on that lightly in
5:29 case you you weren’t able to attend that
5:31 talk and we’ll talk about uh
5:33 neurostimulation
5:35 we’ll talk a bit about expectations what
5:38 can you expect from from these these
5:41 preventative uh steps and importantly
5:44 when to ask for help
5:49 foreign
5:51 there we go lifestyle modification let’s
5:54 take a look at this
5:55 first of all
5:57 um you know micro nerves have this
5:59 lowered migraine threshold that other
6:02 people don’t have and it could be
6:04 genetic or it could be a result of say
6:07 trauma to the Head and then there’s
6:10 different things that bring the patient
6:13 closer to this lower threshold could be
6:16 menses
6:17 could be missed night’s sleep and either
6:20 of these things might not be sufficient
6:23 to trigger a migraine but hadn’t occur
6:26 on the same day boom away you go and so
6:30 it’s often very difficult for a patient
6:32 to identify a trigger because they’re
6:34 additives like this that on its own
6:37 chocolate might be fine or a glass of
6:39 red wine might be fine but have it on
6:42 the same day as the barometric pressure
6:44 is changing you might not be noticing
6:46 that one
6:47 and the two are additive and you get the
6:49 money the migrate so what I recommend to
6:52 patients is is
6:55 um
6:55 is uh you know taking so first of all
7:00 um leading a very moderate life we want
7:03 to try and eliminate these ups and downs
7:07 uh so that you want to bet the same time
7:10 every night and wake up the same time
7:12 every morning regardless if it’s a
7:14 weekday or a weekend you want that
7:18 routine of small frequent meals so your
7:21 blood sugar isn’t going go
7:24 um try and walk 30 minutes a day so
7:27 we’re trying to keep things very very
7:29 even and we’ll talk about some dietary
7:31 things in a moment
7:34 there are
7:36 um risk factors that lead to migraine
7:40 progression now there’s some things we
7:43 can’t modify so age you know increasing
7:46 age
7:48 female sex low education or
7:51 socioeconomic status and head injury are
7:55 do do lead to migraine or can lead to
7:58 migraine progression or identified as
8:01 risk factors not much we can do about
8:03 those things
8:05 there are other things we can modify
8:07 so
8:09 um you know looking at attack frequency
8:12 well what’s modifiable about that well
8:15 over to the right there in the next box
8:17 we could go on a preventative medication
8:21 to reduce the attack frequency one thing
8:24 we know is that migraine begets migraine
8:27 and it just sort of spirals and spirals
8:30 until suddenly you know somebody is
8:31 having attacks more often more days of
8:34 the month than not so we want to put
8:37 somebody on to prevent that that nasty
8:40 trajectory
8:42 obesity has been linked with progression
8:46 so weight loss
8:48 stressful life events and
8:51 um although we’d love to live
8:53 stress-free gosh I know I would
8:56 um it’s not realistic we all have to
8:58 work and you know manage kids and a
9:01 family and all those things that we
9:03 juggle and
9:05 um but having a way of managing stress
9:07 is important and there’s different ways
9:09 of doing it me I like to walk I like to
9:11 do yoga but there’s uh walking first of
9:16 all is is meditative Dalai Lama
9:18 considers it a form of meditation
9:20 there’s journaling
9:22 other forms of exercise
9:26 and so it’s about finding what
9:32 um what fits you
9:33 the other thing is caffeine now
9:37 um not everybody is caffeine sensitive
9:41 and some of you have probably found that
9:43 if you can have a coffee and all the
9:45 board of my brain
9:47 but some people are so sensitive that if
9:49 they have coffee every day it
9:51 predisposes them to more headache and
9:55 sometimes just eliminating that last
9:57 coffee can make all the difference and
10:00 especially in those patients who are
10:01 waking up every morning with a headache
10:03 mix that mix that caffeine you might be
10:06 one of these people who who have um who
10:09 are sensitive to it
10:11 snoring can uh lead to progression and
10:15 um often there’s a what’s called a
10:17 habitus of uh sort of a short neck often
10:21 often overweight not necessarily uh but
10:24 weight loss can help a CPAP machine can
10:27 help and reduce snoring
10:33 is when non-nauseous stimuli feel
10:36 painful so you know sometimes I don’t
10:39 know about you but sometimes my feels
10:41 like somebody’s punched me in the side
10:42 of the head not what I have headache but
10:45 after it’s it’s when I lightly touch my
10:47 head this feels like it’s Bruce but it’s
10:49 not and that’s called aladinia sometimes
10:52 things like a necklace will feel painful
10:55 and heavy that’s a form of validenia and
10:59 we find that if we can abort the
11:03 headache early it can help prevent
11:05 aladini or if we put people on
11:08 preventative medications they can
11:10 prevent paladinia
11:13 now many of you will probably have other
11:17 pain syndromes because you know my
11:19 patients who have the worst migraines
11:21 often have lots of other pain things
11:23 going on it’s part of this pain begets
11:26 pain and so it’s really important to
11:29 treat chronic pain because if there’s
11:31 pain going elsewhere pain in your
11:33 shoulder your neck or even chronic knee
11:36 pain it winds the system up the brain
11:38 becomes more sensitive and so we need to
11:41 try and settle all that pain down so
11:43 it’s important to treat those as their
11:45 conditions
11:47 lastly medication overuse and
11:51 um you know it’s easy to get caught up
11:53 in it right we’re told you know if you
11:56 want to abort a migraine you need to
11:57 take it right at the start of the
11:59 headache
12:00 because that is the way to abort a
12:01 migraine but if you have too many of
12:03 those then what happens is you’re taking
12:05 that medication more and more frequently
12:08 and if you’re taking your trip cans 10
12:11 days a month or more you may have
12:13 headaches secondary to the triptans or
12:16 if you’re taking your over-the-counter
12:17 medications 15 days a month or more
12:20 again you may have medication overviews
12:24 so so to keep in mind
12:27 now other lifestyle modifications
12:32 because they’re additive and it varies
12:36 from person to person
12:38 and it’s important to remember I know
12:40 people say I I live the healthiest life
12:42 and and I know so many of you do so much
12:46 uh really like do not have any sins left
12:52 in life because just trying to control
12:54 your migraines but what I for those of
12:56 you who haven’t done this done the
12:58 elimination but the thing to do is just
13:00 choose one thing initially right is it
13:02 sometimes they’re healthy foods like
13:04 citrus take Citrus out for three months
13:07 not with the expectation of being
13:10 headache free
13:11 uh but are they less frequent uh are
13:15 they less intense sorry or are you able
13:17 to treat them more easily if you are
13:19 then maybe that’s one of those additive
13:21 triggers keep them out if nothing’s
13:23 changed take them back in and enjoy it
13:26 so and and there’s a long list of
13:29 triggers and it varies some people it’s
13:31 cheese or chocolate red Wine’s a bad one
13:36 um but there’s
13:37 um you know we hear about monosodium
13:39 glutamate but it’s the glutamate in
13:42 monosodium glutamate that’s the problem
13:44 and then we’re going to glutamate and
13:46 seaweed hello tomato misu so if you like
13:50 your Japanese food you gotta watch for
13:51 that but glutamate occurs naturally in
13:54 tomatoes so there are some of these
13:56 triggers are are hidden in healthy foods
14:00 we talked about sleep being important
14:03 but not too much sleep not too little
14:05 sleep
14:07 changes in barometric pressure can be
14:10 real triggers and sadly there isn’t
14:12 anything we can do about that if you
14:14 want to move to Arizona where it’s
14:15 always a nice steady High
14:17 I talked about Stress Management and
14:21 um altitude can be a trigger so if
14:24 you’re a hiker a skier a mountain
14:26 climber you might notice it at altitude
14:28 but some of you may also notice it when
14:30 you’re in a plane because
14:32 um the pressure isn’t isn’t uh although
14:36 isn’t quite the same as it is as it is
14:39 at ground level and Air flight can also
14:42 trigger
14:44 um trigger migraines and really the best
14:45 thing to do is be prepared and have your
14:47 migraine medications with you on that
14:49 flight
14:51 foreign
14:52 okay so we talked about some lifestyle
14:55 modifications
14:56 how about
14:58 supplements and your and
15:00 neurostimulation
15:03 so uh there are some supplements that
15:06 have been demonstrated in a
15:08 meta-analysis
15:09 um and are supporting the guidelines the
15:11 Canadian Headache Society guidelines
15:14 these are my faiths
15:17 um and these are the ones supported in
15:18 the Canadian guidelines
15:21 so riboflengthen 400 milligrams a day
15:24 coenzyme Q10 100 milligrams three times
15:28 a day and Magnesium Citrate 200
15:31 milligrams three times a day
15:35 um I I used to have butterbur on there
15:38 um and there were some cases of hepatic
15:40 failure
15:42 um in patients who are taking bediber
15:43 none of that happened in Canada but uh
15:47 it happened here in Europe and we don’t
15:49 know where you get your source of butter
15:50 from so uh I just I I don’t recommend it
15:54 uh but there is evidence that that works
15:58 now the interesting thing is that
15:59 doesn’t work right away it takes four to
16:01 six weeks before it starts to kick in so
16:04 I recommend a good three-month trial
16:06 before you decide whether or not this
16:09 works for you
16:12 so what about neurostibulation you might
16:16 be familiar with the cephaly device
16:19 and uh here I think Wonder Woman must
16:22 have been a migrator because it looks
16:23 like she’s wearing it to the gentleman
16:25 in the picture there that’s that’s
16:26 what’s definitely advice really looks
16:28 like and you can get this actually
16:30 online through Costco without a
16:33 prescription
16:34 uh and there is some evidence for its
16:38 use so what it is uh you put it on and
16:43 there are um two protocols one to a
16:46 border migraine and it and it stimulates
16:49 the super trochlear superorbital nerves
16:51 the other protocol is to prevent
16:53 migraine where you wear it 20 minutes
16:56 every day
16:58 so I will tell you 20 minutes it turns
17:00 out is a long time every day and a lot
17:02 of my patients who’ve got this have told
17:03 me they find it difficult to find 20
17:05 minutes and you would think most of us
17:07 might be able to do a washing the dishes
17:09 or watching TV but that’s a tough habit
17:11 but
17:13 um so what was the data so when they
17:16 they had
17:18 um verum so that was the the treatment
17:20 group versus sham there was really no
17:23 significant difference in the reduction
17:24 of migraine days
17:26 but when they looked at something called
17:28 the 50 responder rate
17:30 so since you can understand this because
17:32 it’s sometimes hard to explain
17:34 50 responder rate refers to the
17:38 percentage of patients who had a 50
17:40 reduction in their migraines
17:43 those who use the cephaly device
17:47 38 or 38.1 percent had
17:52 um a 50 reduction in their migraines
17:55 versus those who were on a placebo who
17:59 only had a 12 percent so it’s it’s not a
18:02 drug
18:04 um you can take it with your drugs and
18:06 it might help so I think it costs about
18:09 350 Costco online there you go
18:15 so what to expect from from treatment
18:19 options let’s take a look well first of
18:22 all
18:23 you’re not going to come headache free
18:24 and I uh yeah honestly we’d all love I’m
18:29 a migrator I would love to get rid of my
18:31 migraines
18:33 um uh and it but it’s not a realistic
18:36 expectation
18:38 um and so really what we’re aiming for
18:41 is an improvement in your quality of
18:43 life
18:44 okay usually these medications every
18:47 like we talked about the supplements
18:49 taking four to six weeks before they
18:51 start to kick in
18:54 um you’ll find that the oral medications
18:56 a doctor might prescribe also takes four
19:00 to six weeks before it kicks in so I
19:02 sometimes will see patients and go okay
19:04 so what have you tried oh well I tried
19:07 Propranolol for a week and I said well
19:09 why did you stop it what are the side
19:10 effects oh no no I as just a week later
19:12 I had a migraine well
19:15 weeks later you will have a migraine
19:17 because it will take four to six weeks
19:18 uh before to even start to work and
19:22 we’ll still get migraines a win in the
19:26 migraine world is a reduction in your
19:29 frequency by 50 and so when we’re
19:32 talking about prevention so if that drug
19:35 you’re on has cut your migraines in half
19:38 that’s a good one you might want to
19:39 consider staying on it and perhaps you
19:42 know
19:43 um talking using some of these other
19:44 things we looked at the cephaly device
19:46 adding in supplements doing those
19:48 Lifestyle Changes
19:53 the next thing here when to ask for help
19:58 well
20:00 first of all if your migraines are not
20:03 responding to over-the-counter
20:04 medications you should see
20:07 um a doctor because there are
20:09 prescription medications
20:10 [Music]
20:11 um that can help so the prescription
20:13 anti-inflammatories that are stronger
20:15 than the ones you can get over the
20:17 counter there are trip tens many of you
20:20 will have tried that and in the New Year
20:23 there will be the gpaps which are again
20:26 a migraine specific drug which has a
20:29 very different mechanism of action so if
20:33 you’re if you’re Tylenol and ethyl isn’t
20:35 working
20:36 seek some help there’s no point in
20:38 losing time at work time away from your
20:40 family and just and just suffering
20:45 cranes are starting to creep up so no
20:49 three you know if you take you have
20:50 three migraines and you can abort it
20:52 with Tylenol and I feel wonderful I
20:54 wouldn’t worry about it you know if
20:55 you’re getting up to around six
20:58 that’s when
20:59 you start thinking about
21:01 um preventing a migraine because
21:04 migraines we get migraines and they
21:06 start ramping up and they start getting
21:07 more and more
21:10 yeah
21:11 they’re impairing your quality of life
21:13 it doesn’t matter what the number is if
21:16 they’re wiping you out
21:18 um you’re fearing you’re you’re worried
21:21 about you’re not gonna be able to go to
21:22 your next event because you have you’re
21:24 going to get a migraine you know you
21:26 need to do something about that
21:29 and really any patient who has chronic
21:31 migraine 15 headache days a month or
21:33 more we need you really need to see a
21:37 physician because the chance of this
21:39 settling down
21:41 um on its own is a lot less likely and
21:45 likely will require some sort of
21:47 medication
21:50 foreign
21:54 so what can a doctor offer for migraine
21:57 prevention
22:00 but these are the um the Canadian
22:03 guidelines
22:05 um for uh first line therapy many of you
22:09 will be familiar with them
22:11 um so down in the bottom
22:14 um are the supplements the butterbur the
22:17 riboflavin coenzyme Q10 and magnesium
22:20 citrate as you can see the quality of
22:23 evidence for the moon’s law now that
22:26 doesn’t mean
22:27 um they don’t work what it means was the
22:30 studies were poorly designed and uh you
22:34 know they might have only lasted six
22:35 weeks when we would expect in the last
22:37 12 weeks uh there weren’t many people in
22:40 them all right but it’s a first line
22:43 recommendation because the side effects
22:46 side effect profile is really good
22:48 you’re unlikely to have side effects
22:49 from them and they may help
22:52 at the top we have drugs which have good
22:56 quality of evidence and and and a strong
22:59 recommendation
23:01 just mentioned
23:03 um briefly you know all drugs
23:06 potentially have side effects
23:08 and you know when we’re trying to decide
23:11 the right medication for you it’s about
23:13 weighing
23:15 um other other conditions you might have
23:17 so say you
23:19 um suffer from insomnia
23:21 and the trip plane fourth down on that
23:24 list might be a good option for you uh
23:27 yeah I recommend you take it a couple
23:28 hours before bed and can cause
23:30 drowsiness during the night
23:33 um and you might like that if you have
23:35 insomnia what we don’t want is you to
23:37 still have a drowsiness in the morning
23:38 some people are very sensitive to that
23:42 um generally at low doses there isn’t
23:46 any waking but that may be a risk to
23:49 pyramid at the top list however won’t
23:52 cause waking and may cause weight loss
23:55 but pretty much everyone can get
23:57 tingling in their fingers and toes they
23:59 can put up with that usually but there’s
24:02 um I don’t know there’s a low percentage
24:04 of patients who will not feel
24:07 cognitively sharp on it which is not a
24:10 nice sided it’s dose-dependent to me
24:13 start low gradually go up and often we
24:15 can overcome it
24:17 metoprolol propylol
24:20 metoprolol and Propranolol
24:23 um old drugs that we know well but it
24:27 decreases heart rate and can decrease
24:29 blood pressure and it can make you feel
24:32 draggy out so we might use it in an
24:35 older person who has good buoyant blood
24:37 pressure and we’ll be able to tolerate
24:39 that so we need to know bits more about
24:42 the individual when we make those
24:44 choices
24:46 then we had drugs with weak
24:48 recommendation but still good quality of
24:50 evidence
24:52 and the only reason it’s a weak
24:54 recommendation is that those drugs tend
24:56 to have a bit more side effects so you
24:58 really the doctor really needs to know
25:00 their patient
25:02 um to know if those are the right ones
25:04 for their patient
25:07 lastly at the bottom
25:09 uh are the are the migraine specific
25:12 drugs
25:13 and these are into the Canadian
25:15 guidelines yet because the Canadian
25:16 guidelines were back in 2012 and
25:21 um these uh these hadn’t come out yet so
25:26 on a bot
25:27 um actually it was 2011 it was approved
25:30 in Canada but just for chronic migraine
25:33 and we don’t have chronic migraine
25:35 guidelines specifically in Canada it’s
25:38 approved by Health Canada and and many
25:41 well all the headache doctors use at
25:44 many of the neurologists use it and it’s
25:46 very effective
25:47 we have the cgrp monoclonal antibodies
25:51 these are self-injectable drugs that are
25:54 very effective uh also and
25:57 um reducing migraine frequency and
26:00 intensity
26:01 in 2023 we’ll have a new new oral drug
26:06 called the g-pants this will be taken
26:09 daily or every other day depending on
26:11 the brand and can be used both for
26:14 migraine prevention and also to treat a
26:17 migraine so
26:19 um we are hoping to update the Canadian
26:22 guidelines we thought maybe this year
26:24 maybe the end of next year
26:26 um it’s a big big task
26:29 but these are some of the options that
26:31 may be out there for you
26:34 talk to Chelsea what happened with her
26:35 well remember young girl she did have
26:38 insomnia
26:40 um and depression onset of headache at
26:42 13.
26:44 mostly around her Menses but at other
26:46 times four to six other times so the
26:49 frequency was climbing bilateral achy
26:52 some more of a grinding pain which you
26:55 could probably get through a day worse
26:57 with exertion uh prefer to avoid the
27:00 bright lights last six to eight hours
27:03 and she was just using it with trading
27:05 it with Tylenol
27:07 so uh actually I prescribed her an
27:10 anti-inflammatory I chose cambia it’s um
27:13 a powder that you put in an ounce of
27:15 water very fast acting
27:18 um and uh this would work for most of
27:21 her migraines but not all and for ones
27:25 that it wasn’t com uh campir would
27:28 completely abort it I put her on a trip
27:30 called axer so it was a stepwise
27:33 approach to aborting her migraines
27:37 these sharpener migraines to two hours
27:42 um
27:43 she tried some supplements because that
27:45 was her first preference but there
27:48 wasn’t a benefit
27:50 so
27:52 um I started her on amitriptyline and
27:54 that really helped her sleep it actually
27:57 decreased her migraine so from six down
28:00 to two but she can’t wait
28:04 um and usually at 30 milligrams were
28:07 okay but she was sensitive to it so we
28:11 switched her over to to pyramid
28:14 um and this poor girl is very sensitive
28:17 she got cognitive slowing for this
28:20 um we tried increasing the dose we’re
28:22 trying to get up 100 milligrams couldn’t
28:24 get there
28:25 and she was having six migraines per
28:27 month at the lower dose and so we
28:29 thought okay that’s it you failed to
28:31 oral drugs
28:34 let’s try one of these migraine specific
28:37 drugs
28:38 so I put her on AIM of it this is a
28:42 self-injectable
28:44 um monoclonal antibody once a month
28:48 and her migraine frequency decreased to
28:51 two to three per month
28:53 she said the migraines were less intense
28:56 as well and they all responded to cancer
29:00 so instead of being on a daily oral with
29:03 side effects she was on the aim of a she
29:06 didn’t have the cognitive slowing she
29:08 was able to continue to work
29:10 she did have some constipation with the
29:12 aim of it she was just treating it with
29:15 an over-the-counter
29:17 medication with store Labs but after six
29:20 months she said the the constipation
29:23 result
29:26 so
29:28 um Now Chelsea also had we talked about
29:32 what we call comorbidities
29:34 um other conditions that we commonly see
29:37 in migraine it’s a bit circular we know
29:41 patients who have
29:43 migraine are more likely to develop
29:45 depression patients who have the than
29:48 the normal population patients who have
29:50 depression are two to three times more
29:51 likely to develop migraine than the
29:53 normal uh population then thank you
29:57 intertwined
30:00 um yet
30:01 Chelsea reported Improvement in both her
30:04 mood and her sleep
30:06 despite not being on any other
30:08 medications and and so
30:11 um what we find is that
30:14 um that some of these medications these
30:17 migraine specific medications also help
30:19 mood and sleep so if for example this
30:23 was a study they were just looking at
30:24 patients in Italy who were on aimovic
30:27 and
30:29 um what they did was they looked at
30:31 their Midas scores some of you may be
30:32 familiar with Midas so that certain for
30:35 your um
30:36 and it looks at migraine disability
30:39 migraine impact disability score and so
30:44 the patients who are on the EMA bag
30:45 there they had a significant reduction
30:48 in their migraine disability
30:51 um this is the Beck’s depression score
30:53 and there was also a significant
30:55 reduction in their um uh Beck’s
30:59 depression score and also the Gad 7
31:01 which monitors or is a measurement of
31:04 anxiety
31:07 uh on a bunch of line and toxin to gain
31:10 a migraine specific uh drug it also
31:13 works to reduce cgrp and in this uh they
31:18 looked at patients who had chronic
31:20 migraine and depression
31:22 and
31:24 they’re my the way they monitor
31:26 Depression was using a depression score
31:28 called the phq-9 and it just there’s a
31:32 question a depression questionnaire and
31:35 as we can see the longer the patients
31:39 were on the onabotage line in toxin the
31:43 the lower their score got this was
31:45 significantly different over time
31:48 and then the same thing when they uh
31:51 looked at anxiety
31:56 um and we also mentioned issues of sleep
31:59 that we commonly see in migraine and uh
32:02 this was a study
32:04 um by a colleague a friend of mine
32:07 Andrew palumenfeld who uh looked at
32:10 sleep as well and they looked at
32:14 um reductions in their sleep
32:18 um their their quality of sleep index
32:20 and so at Baseline it was 13.3 and
32:24 reducing down to 11 uh also with a
32:28 reduction in fatigue as well and these
32:30 were considered to be statistically
32:31 significant so it’s interesting this
32:34 close
32:36 um relationship between migraine
32:38 depression anxiety and sleep and that if
32:42 you help the migraines at least with
32:44 some of these newer drugs those other
32:46 things can also improve
32:48 foreign
32:50 so that’s the end of my talk we talked
32:52 about some of the things we could do to
32:54 prevent migraine we talked about
32:56 lifestyle modifications
32:59 supplements and and neurostimulators
33:02 which don’t require
33:05 um referrals or prescriptions
33:09 talked about when to ask help from a
33:11 medical expert when your quality of life
33:14 is impaired your acute medications are
33:16 not working you’re just getting too many
33:19 migraines
33:21 uh What treatments can doctors offer
33:23 well mostly after you’ve done all those
33:27 other preventative things then they will
33:29 go in and focus on medications the oral
33:33 medications and in Canada for the
33:35 insurance companies to cover you for
33:38 those migraine specific drugs one must
33:41 have failed too almost but those
33:42 migraine specific drugs can offer a lot
33:45 of0:00 thank you very much uh to Alex and Wendy
0:03 and Mike are in Canada for inviting me
0:05 tonight and and thank you for enjoying
0:07 and um for joining me uh tonight we’re
0:10 going to talk about some tips and tricks
0:13 for uh preventing migraine and and
0:16 hopefully
0:17 um you’ll learn something that are going
0:19 to help with your migraines and if you
0:22 have any questions just say them to the
0:24 end and we can put them in the chat and
0:26 we’ll take a look at them then
0:29 these are my disclosures and as you can
0:31 see I do a lot of speaking and
0:33 educational events for all the different
0:37 pharmaceutical companies that are
0:39 involved in migraine but what we’re
0:42 going to do today we’re going to talk
0:43 about things that you can do to prevent
0:46 migraine when talk about when to ask for
0:50 for help from a migraine expert and what
0:53 to expect and what are those treatment
0:56 options a doctor can offer
0:59 so I better just start with a case this
1:02 is a sort of a typical patient that I
1:05 might see we could sort of talk about
1:06 her preventative uh Journey she’s a a 25
1:11 year old woman uh work full time for a
1:14 PR Company enjoys yoga but struggles
1:16 with insomnia and has had headaches
1:19 since the age of 13.
1:22 they occur mostly around the time of her
1:25 period but can but have increased in
1:28 frequency so they’re occurring at other
1:29 times so about four to six times a month
1:33 at other times other than her period
1:36 pain is bilateral it’s not that knock
1:40 them dead kind of pain it’s that
1:42 grinding six out of ten achy pain
1:46 it’s worse with physical activity not
1:49 associated with nausea or vomiting but
1:51 she prefers to avoid bright lights and
1:54 right now she’s been treating it by
1:56 lying down and she may or may not take
1:58 Tylenol
2:00 so the diagnosis here is migraine and
2:04 unfortunately patients like
2:06 um like Chelsea often get missed mostly
2:09 because she’s not describing a
2:12 unilateral headache that’s wiping her
2:14 off her feet and putting her to bed and
2:16 I think it’s important for people to
2:18 realize that they may also have migraine
2:20 that what they’ve been thinking is
2:21 tension that may be my brain so
2:24 what qualifies for migraine well a
2:27 patient must have had five episodes
2:30 if untreated they last four to 72 hours
2:34 and you have
2:35 to the following four things
2:37 so unilateral throbbing
2:40 moderate to severe
2:42 and worsened with physical activity and
2:45 then to or one of the following two
2:47 things
2:48 nausea or vomiting or light and Sound
2:51 Sensitivity
2:52 so if we go back to Chelsea who has more
2:56 moderate headaches but they’re
2:57 increasing in frequency she does qualify
3:00 there are sixes out of ten that’s
3:02 moderate it’s worse with activity and
3:05 she has light sensitivity
3:07 Chelsea is migraine and this is
3:09 important and it’s important to
3:11 recognize it because this opens up all
3:13 the treatments that are available for
3:15 migraine and they’re really increasing
3:19 I think you might hear the word chronic
3:21 migraine and and I think it’s a can be a
3:23 little misleading because chronically
3:25 always think oh that’s somebody who must
3:26 have had chronic migraines most their
3:28 life
3:29 but what it really refers to is somebody
3:31 who has a lot of migraine so 15 headache
3:35 days a month or more of which eight of
3:38 those days fulfill that criteria for
3:40 migraine and it’s been going on for
3:41 three months
3:43 it’s a special category because there’s
3:45 certain drugs that are applicable to
3:48 patients who have chronic migraine
3:50 rather than episodic migraine
3:54 so you know migraine is often
3:58 um misdiagnosed as sinus headache and
4:01 why is that well you know there’s a
4:03 certain amount of overhead
4:05 both conditions can have pain over the
4:08 sinuses
4:10 migraine is mediated by the trigeminal
4:14 nerve nc1 C2 and C3 so trigeminal nerve
4:18 have branches over the forehead over the
4:20 cheeks through the jaw and over the back
4:22 of the head and the shoulders and so
4:26 um when a patient has migraine they can
4:28 have my pain over the sinuses
4:31 um so both sinus headache and migraine
4:33 pain can be
4:35 pressure can be throbbing they can both
4:38 be associated with tearing and nasal
4:40 congestion
4:42 um they both can be triggered by changes
4:44 in weather
4:45 but true sinus headaches they have thick
4:48 discolored nasal discharge
4:51 their face pain can be pressure and but
4:54 there’s decreased smell or no smell
4:58 relax
5:00 so the real question is what can you do
5:04 to reduce your migraines now you know
5:08 you have migraines
5:11 so this is my Approach
5:14 um in the clinic and it’s you know
5:16 there’s lots of different things that
5:18 you as an individual can do
5:20 we’re going to talk about lifestyle
5:22 modification
5:24 I understand if somebody’s already
5:25 spoken to you about supplements so we’re
5:27 just going to touch on that lightly in
5:29 case you you weren’t able to attend that
5:31 talk and we’ll talk about uh
5:33 neurostimulation
5:35 we’ll talk a bit about expectations what
5:38 can you expect from from these these
5:41 preventative uh steps and importantly
5:44 when to ask for help
5:49 foreign
5:51 there we go lifestyle modification let’s
5:54 take a look at this
5:55 first of all
5:57 um you know micro nerves have this
5:59 lowered migraine threshold that other
6:02 people don’t have and it could be
6:04 genetic or it could be a result of say
6:07 trauma to the Head and then there’s
6:10 different things that bring the patient
6:13 closer to this lower threshold could be
6:16 menses
6:17 could be missed night’s sleep and either
6:20 of these things might not be sufficient
6:23 to trigger a migraine but hadn’t occur
6:26 on the same day boom away you go and so
6:30 it’s often very difficult for a patient
6:32 to identify a trigger because they’re
6:34 additives like this that on its own
6:37 chocolate might be fine or a glass of
6:39 red wine might be fine but have it on
6:42 the same day as the barometric pressure
6:44 is changing you might not be noticing
6:46 that one
6:47 and the two are additive and you get the
6:49 money the migrate so what I recommend to
6:52 patients is is
6:55 um
6:55 is uh you know taking so first of all
7:00 um leading a very moderate life we want
7:03 to try and eliminate these ups and downs
7:07 uh so that you want to bet the same time
7:10 every night and wake up the same time
7:12 every morning regardless if it’s a
7:14 weekday or a weekend you want that
7:18 routine of small frequent meals so your
7:21 blood sugar isn’t going go
7:24 um try and walk 30 minutes a day so
7:27 we’re trying to keep things very very
7:29 even and we’ll talk about some dietary
7:31 things in a moment
7:34 there are
7:36 um risk factors that lead to migraine
7:40 progression now there’s some things we
7:43 can’t modify so age you know increasing
7:46 age
7:48 female sex low education or
7:51 socioeconomic status and head injury are
7:55 do do lead to migraine or can lead to
7:58 migraine progression or identified as
8:01 risk factors not much we can do about
8:03 those things
8:05 there are other things we can modify
8:07 so
8:09 um you know looking at attack frequency
8:12 well what’s modifiable about that well
8:15 over to the right there in the next box
8:17 we could go on a preventative medication
8:21 to reduce the attack frequency one thing
8:24 we know is that migraine begets migraine
8:27 and it just sort of spirals and spirals
8:30 until suddenly you know somebody is
8:31 having attacks more often more days of
8:34 the month than not so we want to put
8:37 somebody on to prevent that that nasty
8:40 trajectory
8:42 obesity has been linked with progression
8:46 so weight loss
8:48 stressful life events and
8:51 um although we’d love to live
8:53 stress-free gosh I know I would
8:56 um it’s not realistic we all have to
8:58 work and you know manage kids and a
9:01 family and all those things that we
9:03 juggle and
9:05 um but having a way of managing stress
9:07 is important and there’s different ways
9:09 of doing it me I like to walk I like to
9:11 do yoga but there’s uh walking first of
9:16 all is is meditative Dalai Lama
9:18 considers it a form of meditation
9:20 there’s journaling
9:22 other forms of exercise
9:26 and so it’s about finding what
9:32 um what fits you
9:33 the other thing is caffeine now
9:37 um not everybody is caffeine sensitive
9:41 and some of you have probably found that
9:43 if you can have a coffee and all the
9:45 board of my brain
9:47 but some people are so sensitive that if
9:49 they have coffee every day it
9:51 predisposes them to more headache and
9:55 sometimes just eliminating that last
9:57 coffee can make all the difference and
10:00 especially in those patients who are
10:01 waking up every morning with a headache
10:03 mix that mix that caffeine you might be
10:06 one of these people who who have um who
10:09 are sensitive to it
10:11 snoring can uh lead to progression and
10:15 um often there’s a what’s called a
10:17 habitus of uh sort of a short neck often
10:21 often overweight not necessarily uh but
10:24 weight loss can help a CPAP machine can
10:27 help and reduce snoring
10:33 is when non-nauseous stimuli feel
10:36 painful so you know sometimes I don’t
10:39 know about you but sometimes my feels
10:41 like somebody’s punched me in the side
10:42 of the head not what I have headache but
10:45 after it’s it’s when I lightly touch my
10:47 head this feels like it’s Bruce but it’s
10:49 not and that’s called aladinia sometimes
10:52 things like a necklace will feel painful
10:55 and heavy that’s a form of validenia and
10:59 we find that if we can abort the
11:03 headache early it can help prevent
11:05 aladini or if we put people on
11:08 preventative medications they can
11:10 prevent paladinia
11:13 now many of you will probably have other
11:17 pain syndromes because you know my
11:19 patients who have the worst migraines
11:21 often have lots of other pain things
11:23 going on it’s part of this pain begets
11:26 pain and so it’s really important to
11:29 treat chronic pain because if there’s
11:31 pain going elsewhere pain in your
11:33 shoulder your neck or even chronic knee
11:36 pain it winds the system up the brain
11:38 becomes more sensitive and so we need to
11:41 try and settle all that pain down so
11:43 it’s important to treat those as their
11:45 conditions
11:47 lastly medication overuse and
11:51 um you know it’s easy to get caught up
11:53 in it right we’re told you know if you
11:56 want to abort a migraine you need to
11:57 take it right at the start of the
11:59 headache
12:00 because that is the way to abort a
12:01 migraine but if you have too many of
12:03 those then what happens is you’re taking
12:05 that medication more and more frequently
12:08 and if you’re taking your trip cans 10
12:11 days a month or more you may have
12:13 headaches secondary to the triptans or
12:16 if you’re taking your over-the-counter
12:17 medications 15 days a month or more
12:20 again you may have medication overviews
12:24 so so to keep in mind
12:27 now other lifestyle modifications
12:32 because they’re additive and it varies
12:36 from person to person
12:38 and it’s important to remember I know
12:40 people say I I live the healthiest life
12:42 and and I know so many of you do so much
12:46 uh really like do not have any sins left
12:52 in life because just trying to control
12:54 your migraines but what I for those of
12:56 you who haven’t done this done the
12:58 elimination but the thing to do is just
13:00 choose one thing initially right is it
13:02 sometimes they’re healthy foods like
13:04 citrus take Citrus out for three months
13:07 not with the expectation of being
13:10 headache free
13:11 uh but are they less frequent uh are
13:15 they less intense sorry or are you able
13:17 to treat them more easily if you are
13:19 then maybe that’s one of those additive
13:21 triggers keep them out if nothing’s
13:23 changed take them back in and enjoy it
13:26 so and and there’s a long list of
13:29 triggers and it varies some people it’s
13:31 cheese or chocolate red Wine’s a bad one
13:36 um but there’s
13:37 um you know we hear about monosodium
13:39 glutamate but it’s the glutamate in
13:42 monosodium glutamate that’s the problem
13:44 and then we’re going to glutamate and
13:46 seaweed hello tomato misu so if you like
13:50 your Japanese food you gotta watch for
13:51 that but glutamate occurs naturally in
13:54 tomatoes so there are some of these
13:56 triggers are are hidden in healthy foods
14:00 we talked about sleep being important
14:03 but not too much sleep not too little
14:05 sleep
14:07 changes in barometric pressure can be
14:10 real triggers and sadly there isn’t
14:12 anything we can do about that if you
14:14 want to move to Arizona where it’s
14:15 always a nice steady High
14:17 I talked about Stress Management and
14:21 um altitude can be a trigger so if
14:24 you’re a hiker a skier a mountain
14:26 climber you might notice it at altitude
14:28 but some of you may also notice it when
14:30 you’re in a plane because
14:32 um the pressure isn’t isn’t uh although
14:36 isn’t quite the same as it is as it is
14:39 at ground level and Air flight can also
14:42 trigger
14:44 um trigger migraines and really the best
14:45 thing to do is be prepared and have your
14:47 migraine medications with you on that
14:49 flight
14:51 foreign
14:52 okay so we talked about some lifestyle
14:55 modifications
14:56 how about
14:58 supplements and your and
15:00 neurostimulation
15:03 so uh there are some supplements that
15:06 have been demonstrated in a
15:08 meta-analysis
15:09 um and are supporting the guidelines the
15:11 Canadian Headache Society guidelines
15:14 these are my faiths
15:17 um and these are the ones supported in
15:18 the Canadian guidelines
15:21 so riboflengthen 400 milligrams a day
15:24 coenzyme Q10 100 milligrams three times
15:28 a day and Magnesium Citrate 200
15:31 milligrams three times a day
15:35 um I I used to have butterbur on there
15:38 um and there were some cases of hepatic
15:40 failure
15:42 um in patients who are taking bediber
15:43 none of that happened in Canada but uh
15:47 it happened here in Europe and we don’t
15:49 know where you get your source of butter
15:50 from so uh I just I I don’t recommend it
15:54 uh but there is evidence that that works
15:58 now the interesting thing is that
15:59 doesn’t work right away it takes four to
16:01 six weeks before it starts to kick in so
16:04 I recommend a good three-month trial
16:06 before you decide whether or not this
16:09 works for you
16:12 so what about neurostibulation you might
16:16 be familiar with the cephaly device
16:19 and uh here I think Wonder Woman must
16:22 have been a migrator because it looks
16:23 like she’s wearing it to the gentleman
16:25 in the picture there that’s that’s
16:26 what’s definitely advice really looks
16:28 like and you can get this actually
16:30 online through Costco without a
16:33 prescription
16:34 uh and there is some evidence for its
16:38 use so what it is uh you put it on and
16:43 there are um two protocols one to a
16:46 border migraine and it and it stimulates
16:49 the super trochlear superorbital nerves
16:51 the other protocol is to prevent
16:53 migraine where you wear it 20 minutes
16:56 every day
16:58 so I will tell you 20 minutes it turns
17:00 out is a long time every day and a lot
17:02 of my patients who’ve got this have told
17:03 me they find it difficult to find 20
17:05 minutes and you would think most of us
17:07 might be able to do a washing the dishes
17:09 or watching TV but that’s a tough habit
17:11 but
17:13 um so what was the data so when they
17:16 they had
17:18 um verum so that was the the treatment
17:20 group versus sham there was really no
17:23 significant difference in the reduction
17:24 of migraine days
17:26 but when they looked at something called
17:28 the 50 responder rate
17:30 so since you can understand this because
17:32 it’s sometimes hard to explain
17:34 50 responder rate refers to the
17:38 percentage of patients who had a 50
17:40 reduction in their migraines
17:43 those who use the cephaly device
17:47 38 or 38.1 percent had
17:52 um a 50 reduction in their migraines
17:55 versus those who were on a placebo who
17:59 only had a 12 percent so it’s it’s not a
18:02 drug
18:04 um you can take it with your drugs and
18:06 it might help so I think it costs about
18:09 350 Costco online there you go
18:15 so what to expect from from treatment
18:19 options let’s take a look well first of
18:22 all
18:23 you’re not going to come headache free
18:24 and I uh yeah honestly we’d all love I’m
18:29 a migrator I would love to get rid of my
18:31 migraines
18:33 um uh and it but it’s not a realistic
18:36 expectation
18:38 um and so really what we’re aiming for
18:41 is an improvement in your quality of
18:43 life
18:44 okay usually these medications every
18:47 like we talked about the supplements
18:49 taking four to six weeks before they
18:51 start to kick in
18:54 um you’ll find that the oral medications
18:56 a doctor might prescribe also takes four
19:00 to six weeks before it kicks in so I
19:02 sometimes will see patients and go okay
19:04 so what have you tried oh well I tried
19:07 Propranolol for a week and I said well
19:09 why did you stop it what are the side
19:10 effects oh no no I as just a week later
19:12 I had a migraine well
19:15 weeks later you will have a migraine
19:17 because it will take four to six weeks
19:18 uh before to even start to work and
19:22 we’ll still get migraines a win in the
19:26 migraine world is a reduction in your
19:29 frequency by 50 and so when we’re
19:32 talking about prevention so if that drug
19:35 you’re on has cut your migraines in half
19:38 that’s a good one you might want to
19:39 consider staying on it and perhaps you
19:42 know
19:43 um talking using some of these other
19:44 things we looked at the cephaly device
19:46 adding in supplements doing those
19:48 Lifestyle Changes
19:53 the next thing here when to ask for help
19:58 well
20:00 first of all if your migraines are not
20:03 responding to over-the-counter
20:04 medications you should see
20:07 um a doctor because there are
20:09 prescription medications
20:10 [Music]
20:11 um that can help so the prescription
20:13 anti-inflammatories that are stronger
20:15 than the ones you can get over the
20:17 counter there are trip tens many of you
20:20 will have tried that and in the New Year
20:23 there will be the gpaps which are again
20:26 a migraine specific drug which has a
20:29 very different mechanism of action so if
20:33 you’re if you’re Tylenol and ethyl isn’t
20:35 working
20:36 seek some help there’s no point in
20:38 losing time at work time away from your
20:40 family and just and just suffering
20:45 cranes are starting to creep up so no
20:49 three you know if you take you have
20:50 three migraines and you can abort it
20:52 with Tylenol and I feel wonderful I
20:54 wouldn’t worry about it you know if
20:55 you’re getting up to around six
20:58 that’s when
20:59 you start thinking about
21:01 um preventing a migraine because
21:04 migraines we get migraines and they
21:06 start ramping up and they start getting
21:07 more and more
21:10 yeah
21:11 they’re impairing your quality of life
21:13 it doesn’t matter what the number is if
21:16 they’re wiping you out
21:18 um you’re fearing you’re you’re worried
21:21 about you’re not gonna be able to go to
21:22 your next event because you have you’re
21:24 going to get a migraine you know you
21:26 need to do something about that
21:29 and really any patient who has chronic
21:31 migraine 15 headache days a month or
21:33 more we need you really need to see a
21:37 physician because the chance of this
21:39 settling down
21:41 um on its own is a lot less likely and
21:45 likely will require some sort of
21:47 medication
21:50 foreign
21:54 so what can a doctor offer for migraine
21:57 prevention
22:00 but these are the um the Canadian
22:03 guidelines
22:05 um for uh first line therapy many of you
22:09 will be familiar with them
22:11 um so down in the bottom
22:14 um are the supplements the butterbur the
22:17 riboflavin coenzyme Q10 and magnesium
22:20 citrate as you can see the quality of
22:23 evidence for the moon’s law now that
22:26 doesn’t mean
22:27 um they don’t work what it means was the
22:30 studies were poorly designed and uh you
22:34 know they might have only lasted six
22:35 weeks when we would expect in the last
22:37 12 weeks uh there weren’t many people in
22:40 them all right but it’s a first line
22:43 recommendation because the side effects
22:46 side effect profile is really good
22:48 you’re unlikely to have side effects
22:49 from them and they may help
22:52 at the top we have drugs which have good
22:56 quality of evidence and and and a strong
22:59 recommendation
23:01 just mentioned
23:03 um briefly you know all drugs
23:06 potentially have side effects
23:08 and you know when we’re trying to decide
23:11 the right medication for you it’s about
23:13 weighing
23:15 um other other conditions you might have
23:17 so say you
23:19 um suffer from insomnia
23:21 and the trip plane fourth down on that
23:24 list might be a good option for you uh
23:27 yeah I recommend you take it a couple
23:28 hours before bed and can cause
23:30 drowsiness during the night
23:33 um and you might like that if you have
23:35 insomnia what we don’t want is you to
23:37 still have a drowsiness in the morning
23:38 some people are very sensitive to that
23:42 um generally at low doses there isn’t
23:46 any waking but that may be a risk to
23:49 pyramid at the top list however won’t
23:52 cause waking and may cause weight loss
23:55 but pretty much everyone can get
23:57 tingling in their fingers and toes they
23:59 can put up with that usually but there’s
24:02 um I don’t know there’s a low percentage
24:04 of patients who will not feel
24:07 cognitively sharp on it which is not a
24:10 nice sided it’s dose-dependent to me
24:13 start low gradually go up and often we
24:15 can overcome it
24:17 metoprolol propylol
24:20 metoprolol and Propranolol
24:23 um old drugs that we know well but it
24:27 decreases heart rate and can decrease
24:29 blood pressure and it can make you feel
24:32 draggy out so we might use it in an
24:35 older person who has good buoyant blood
24:37 pressure and we’ll be able to tolerate
24:39 that so we need to know bits more about
24:42 the individual when we make those
24:44 choices
24:46 then we had drugs with weak
24:48 recommendation but still good quality of
24:50 evidence
24:52 and the only reason it’s a weak
24:54 recommendation is that those drugs tend
24:56 to have a bit more side effects so you
24:58 really the doctor really needs to know
25:00 their patient
25:02 um to know if those are the right ones
25:04 for their patient
25:07 lastly at the bottom
25:09 uh are the are the migraine specific
25:12 drugs
25:13 and these are into the Canadian
25:15 guidelines yet because the Canadian
25:16 guidelines were back in 2012 and
25:21 um these uh these hadn’t come out yet so
25:26 on a bot
25:27 um actually it was 2011 it was approved
25:30 in Canada but just for chronic migraine
25:33 and we don’t have chronic migraine
25:35 guidelines specifically in Canada it’s
25:38 approved by Health Canada and and many
25:41 well all the headache doctors use at
25:44 many of the neurologists use it and it’s
25:46 very effective
25:47 we have the cgrp monoclonal antibodies
25:51 these are self-injectable drugs that are
25:54 very effective uh also and
25:57 um reducing migraine frequency and
26:00 intensity
26:01 in 2023 we’ll have a new new oral drug
26:06 called the g-pants this will be taken
26:09 daily or every other day depending on
26:11 the brand and can be used both for
26:14 migraine prevention and also to treat a
26:17 migraine so
26:19 um we are hoping to update the Canadian
26:22 guidelines we thought maybe this year
26:24 maybe the end of next year
26:26 um it’s a big big task
26:29 but these are some of the options that
26:31 may be out there for you
26:34 talk to Chelsea what happened with her
26:35 well remember young girl she did have
26:38 insomnia
26:40 um and depression onset of headache at
26:42 13.
26:44 mostly around her Menses but at other
26:46 times four to six other times so the
26:49 frequency was climbing bilateral achy
26:52 some more of a grinding pain which you
26:55 could probably get through a day worse
26:57 with exertion uh prefer to avoid the
27:00 bright lights last six to eight hours
27:03 and she was just using it with trading
27:05 it with Tylenol
27:07 so uh actually I prescribed her an
27:10 anti-inflammatory I chose cambia it’s um
27:13 a powder that you put in an ounce of
27:15 water very fast acting
27:18 um and uh this would work for most of
27:21 her migraines but not all and for ones
27:25 that it wasn’t com uh campir would
27:28 completely abort it I put her on a trip
27:30 called axer so it was a stepwise
27:33 approach to aborting her migraines
27:37 these sharpener migraines to two hours
27:42 um
27:43 she tried some supplements because that
27:45 was her first preference but there
27:48 wasn’t a benefit
27:50 so
27:52 um I started her on amitriptyline and
27:54 that really helped her sleep it actually
27:57 decreased her migraine so from six down
28:00 to two but she can’t wait
28:04 um and usually at 30 milligrams were
28:07 okay but she was sensitive to it so we
28:11 switched her over to to pyramid
28:14 um and this poor girl is very sensitive
28:17 she got cognitive slowing for this
28:20 um we tried increasing the dose we’re
28:22 trying to get up 100 milligrams couldn’t
28:24 get there
28:25 and she was having six migraines per
28:27 month at the lower dose and so we
28:29 thought okay that’s it you failed to
28:31 oral drugs
28:34 let’s try one of these migraine specific
28:37 drugs
28:38 so I put her on AIM of it this is a
28:42 self-injectable
28:44 um monoclonal antibody once a month
28:48 and her migraine frequency decreased to
28:51 two to three per month
28:53 she said the migraines were less intense
28:56 as well and they all responded to cancer
29:00 so instead of being on a daily oral with
29:03 side effects she was on the aim of a she
29:06 didn’t have the cognitive slowing she
29:08 was able to continue to work
29:10 she did have some constipation with the
29:12 aim of it she was just treating it with
29:15 an over-the-counter
29:17 medication with store Labs but after six
29:20 months she said the the constipation
29:23 result
29:26 so
29:28 um Now Chelsea also had we talked about
29:32 what we call comorbidities
29:34 um other conditions that we commonly see
29:37 in migraine it’s a bit circular we know
29:41 patients who have
29:43 migraine are more likely to develop
29:45 depression patients who have the than
29:48 the normal population patients who have
29:50 depression are two to three times more
29:51 likely to develop migraine than the
29:53 normal uh population then thank you
29:57 intertwined
30:00 um yet
30:01 Chelsea reported Improvement in both her
30:04 mood and her sleep
30:06 despite not being on any other
30:08 medications and and so
30:11 um what we find is that
30:14 um that some of these medications these
30:17 migraine specific medications also help
30:19 mood and sleep so if for example this
30:23 was a study they were just looking at
30:24 patients in Italy who were on aimovic
30:27 and
30:29 um what they did was they looked at
30:31 their Midas scores some of you may be
30:32 familiar with Midas so that certain for
30:35 your um
30:36 and it looks at migraine disability
30:39 migraine impact disability score and so
30:44 the patients who are on the EMA bag
30:45 there they had a significant reduction
30:48 in their migraine disability
30:51 um this is the Beck’s depression score
30:53 and there was also a significant
30:55 reduction in their um uh Beck’s
30:59 depression score and also the Gad 7
31:01 which monitors or is a measurement of
31:04 anxiety
31:07 uh on a bunch of line and toxin to gain
31:10 a migraine specific uh drug it also
31:13 works to reduce cgrp and in this uh they
31:18 looked at patients who had chronic
31:20 migraine and depression
31:22 and
31:24 they’re my the way they monitor
31:26 Depression was using a depression score
31:28 called the phq-9 and it just there’s a
31:32 question a depression questionnaire and
31:35 as we can see the longer the patients
31:39 were on the onabotage line in toxin the
31:43 the lower their score got this was
31:45 significantly different over time
31:48 and then the same thing when they uh
31:51 looked at anxiety
31:56 um and we also mentioned issues of sleep
31:59 that we commonly see in migraine and uh
32:02 this was a study
32:04 um by a colleague a friend of mine
32:07 Andrew palumenfeld who uh looked at
32:10 sleep as well and they looked at
32:14 um reductions in their sleep
32:18 um their their quality of sleep index
32:20 and so at Baseline it was 13.3 and
32:24 reducing down to 11 uh also with a
32:28 reduction in fatigue as well and these
32:30 were considered to be statistically
32:31 significant so it’s interesting this
32:34 close
32:36 um relationship between migraine
32:38 depression anxiety and sleep and that if
32:42 you help the migraines at least with
32:44 some of these newer drugs those other
32:46 things can also improve
32:48 foreign
32:50 so that’s the end of my talk we talked
32:52 about some of the things we could do to
32:54 prevent migraine we talked about
32:56 lifestyle modifications
32:59 supplements and and neurostimulators
33:02 which don’t require
33:05 um referrals or prescriptions
33:09 talked about when to ask help from a
33:11 medical expert when your quality of life
33:14 is impaired your acute medications are
33:16 not working you’re just getting too many
33:19 migraines
33:21 uh What treatments can doctors offer
33:23 well mostly after you’ve done all those
33:27 other preventative things then they will
33:29 go in and focus on medications the oral
33:33 medications and in Canada for the
33:35 insurance companies to cover you for
33:38 those migraine specific drugs one must
33:41 have failed too almost but those
33:42 migraine specific drugs can offer a lot
33:45 of