Updated Headache Guidelines and Their Impact on Canadians

0:00 [Music]
0:14 so first of all um if you don’t know if
0:17 you aren’t already a member of our
0:19 community migraine Canada is a federally
0:22 registered charity supporting the
0:24 estimated 5 million Canadians who live
0:27 with migraine and other headache
0:28 disorders our mission is to improve the
0:31 lives of Canadians with migraine and
0:33 other headache disorders through our
0:34 five pillars which are advocacy
0:37 awareness education research and
0:41 support and this is our most exciting
0:43 time of the year because we’ve launched
0:45 our third annual move for migraine
0:48 campaign so June is migraine Awareness
0:52 Month uh June 21st coming up soon is
0:55 World migraine awareness day and at this
0:58 time of the year um we have our annual
1:01 uh awareness and fundraising campaign
1:04 we’ve dumped a lot of information on one
1:06 slide for everyone to check out you can
1:08 go on our website um you can also scan
1:11 this QR code I’m interested to see how
1:13 many people are interested in doing that
1:15 to get more information of what the
1:17 campaign is all about um you can check
1:21 out this year we have illuminations of
1:24 national landmarks across the country so
1:29 um at the bottom here here in the purple
1:30 section by province um we’ve let you
1:33 know which landmarks where um I don’t
1:38 think it’s included here but I do want
1:40 to point out um the missing Province es
1:42 skatan we have two or three confirmed
1:46 landmarks as well so we do this we have
1:49 the
1:51 landmarks lit in purple and we ask that
1:54 you guys go out check it out take a
1:56 picture of yourself share it on social
1:58 media help spread the word helps spread
2:00 awareness for the impact of migraine Dr
2:05 Elizabeth laru is a neurologist and
2:07 headache specialist she currently
2:09 practices at the Brunswick Medical
2:11 Center Glen neuro and is a faculty
2:13 lecturer for McGill’s neurology
2:15 department Dr laru completed her
2:18 neurology training at the University of
2:19 Montreal and her headache Fellowship in
2:22 Paris France she directed The University
2:24 of Montreal headache Clinic from 2010 to
2:27 2016 after which she directed The Champ
2:31 multi-disciplinary Program of the
2:32 University of Calgary from 2017 to
2:36 2019 Dr laru is past president of the
2:39 Canadian Headache Society the founder of
2:41 migraine Quebec and the founder and
2:44 chair of migraine
2:46 Canada a well-known speaker for all
2:48 audiences interested in learning about
2:50 headache medicine and science Dr laru is
2:52 passionate about education and advocacy
2:55 for headache disorders her particular
2:57 interests include multidisciplinary
3:00 holistic approaches impact of migraine
3:02 in the workplace vestibular migraine and
3:05 cluster
3:06 headache okay amazing great so good
3:09 evening tonight so it’s very it’s a it’s
3:13 a pleasure and an honor to present for
3:15 you uh tonight and um if I have one hope
3:19 is that during that presentation you
3:21 will learn something that will be
3:24 helpful or supportive so our title is
3:27 chronic migraine what is it can iove
3:29 improved you know how to revert from
3:31 chronic migraine back to episodic and I
3:34 chose this little red toolbx there
3:37 filled with tools because that’s what we
3:39 need tools all kinds of tools to
3:42 improve I do have uh disclosures
3:45 regarding my work with the
3:47 industry uh so that the those are the
3:50 pharmaceutical companies and some
3:52 companies here are actually uh selling
3:55 products that I will be mentioning
3:57 tonight so it’s important that you are
3:59 aware of this part of my work and I also
4:03 serve as the past president of the
4:05 Canadian Headache Society another group
4:07 of very dedicated um uh doctors who uh
4:11 work for
4:12 yall Kelly has already shown this so I
4:15 will not repeat all the statements but
4:18 uh it’s it’s very very important because
4:20 I am a specialist and I am a headache
4:21 neurologist but I’m not your healthare
4:24 provider the other thing is I want to
4:26 really emphasize that everybody’s
4:28 journey is different and I want to to be
4:31 super respectful uh to everybody if I
4:34 say anything that confuses you or shocks
4:37 you it’s not my intentions so I really
4:40 hope um that what I share uh will be
4:42 useful for you um and uh I will not if
4:46 there’s any confusion I really invite
4:48 you or um any questions that I’m not
4:51 answering please discuss with your
4:52 healthcare
4:54 provider so we base this webinar on the
4:58 questions from our community
5:00 um so what’s the difference between
5:02 chronic and episodic migraine and uh and
5:05 sub kind of subtitle how is high
5:07 frequency episodic migraine diagnosed so
5:09 I will cover that um are there risk
5:12 factors associated with migraine
5:14 becoming
5:15 chronic uh a few words about medication
5:18 overuse like when when is that happening
5:21 and is withdrawal mandatory so how can
5:24 we prevent this famous chronification
5:26 what is it uh and if you are in this
5:29 chronic category how can I improve and
5:33 and I think that’s a very important
5:35 question that uh some people share with
5:37 us is is there a stage where nothing can
5:39 be done that’s a question sometimes I
5:41 hear in my office so every day today I
5:44 saw patients and I discuss with them uh
5:47 the principles I will share with you
5:48 today I try to focus on what is the most
5:51 commonly discussed in my office with my
5:53 patients um and I I’m trying to make
5:56 this kind of clear uh and useful for you
6:00 so I thought I would start with just a
6:02 little preview of what I’m going to say
6:05 uh so that each person with migraine
6:07 needs a personalized plan and by the way
6:10 some of you tonight might not have
6:12 migraine maybe they have chronic tension
6:15 type headache post-traumatic headache so
6:17 a lot of the concepts I’m discussing
6:19 tonight actually might apply to you but
6:22 not all of them so be wary I focus on
6:25 migraine um but the concepts May apply
6:28 to you even if you have another headache
6:30 condition some of these Concepts
6:32 actually apply to any chronic pain
6:34 condition so migraine management is
6:36 complex it is influenced by a ton of
6:39 things each requires
6:42 consideration uh you will need allies
6:44 over uh your journey and medical
6:47 guidance my point is that migrant Canada
6:50 is all for people empowerment like
6:52 patient empowerment but I hear sometimes
6:54 from from patients that you know they
6:57 they like to be empowered but they also
6:59 need to be guided and supported like we
7:01 would not expect a patient with other
7:04 neurological diseases like Parkinson’s
7:06 or epilepsy or multiple sclerosis to
7:09 take the full lead of their whole
7:11 condition by being empowered and
7:13 knowledgeable um so you do need medical
7:16 guidance it is a chronic disease it is
7:18 often a lifelong journey migraine is not
7:21 something that is curable sometimes it
7:23 does improve tremendously sometimes it
7:26 doesn’t there’s no fairness in any of
7:29 this and and I think it’s very important
7:30 because with any chronic disease
7:32 especially pain can come a significant
7:35 amount of anger frustration
7:37 discouragement um so it’s a brain
7:39 disease and uh there’s no there’s no
7:41 fairness as to who responds to a
7:44 treatment and who doesn’t when we are
7:47 desperate and in a very dark place um in
7:50 the the
7:51 hell sometimes we are we look for
7:54 answers in everywhere anything and so I
7:58 also want to say that be aware of pseudo
8:00 science and fake claims of Miracles
8:02 because sometimes they can be harmful
8:04 and some situations are very tough but
8:06 we do have way more options now so there
8:09 is really really a lot of way more hope
8:11 than we had before so let’s dig in what
8:15 do we mean when we use the word chronic
8:19 migraine chronic usually has to do with
8:22 time from Kronos it’s the Greek U kind
8:25 of a god of time um and it means over
8:29 for a long period of time in migraine
8:32 it’s a bit particular because we use the
8:34 term chronic and I’ll tell you why in a
8:36 few seconds uh for a frequency of attack
8:39 per month so chronic migraine is a
8:41 definition where you need to have
8:44 migraine a diagnosis of migraine uh you
8:47 need to have 15 days or more per month
8:49 for more than three months of a headache
8:53 of which eight fill the criteria for
8:56 migraine that means that they are
8:58 accompanied by by nausea un vomiting
9:01 phonophobia photophobia not going to dig
9:04 into the whole details of migraine
9:06 diagnosis or um in a person with
9:09 migraine um they can also be the
9:11 headaches that you you might be treating
9:14 so for example if you say oh I think
9:15 that’s a migraine attack I take a trip
9:17 tan it goes away you never made it to
9:19 nausea photophobia and or light or Sound
9:22 Sensitivity it still counts because we
9:25 know these headaches you know you cannot
9:26 just ask people not to treat to double
9:28 check that they have migraine so those
9:30 are the cause and of course you don’t
9:33 want these this type of headache must
9:35 not be explained by another diagnosis
9:38 and that’s that’s also quite important
9:40 so where does that term come from just
9:42 for the from the for the History part of
9:45 it in the old days that’s 20 years ago
9:48 we did not use the term chronic migraine
9:50 we used something called transformed
9:52 migraine because the headache experts at
9:55 the time they were seeing people with
9:57 migraine deteriorating getting worse and
10:00 then getting in that kind of form where
10:03 you have you know mild headache days
10:05 moderate severe it’s mixed uh these
10:08 these patients were doing worse uh they
10:10 were more difficult to treat they more
10:14 they were more severely affected uh and
10:16 they had medication overuse and other
10:19 health issues so that was called at the
10:21 time transformed migraine at some point
10:24 and these patients were usually excluded
10:27 from research because they were so
10:29 called too sick and researchers thought
10:31 they would not improve with treatment
10:33 and so they were focusing on people who
10:36 have frequent episodic like eight or 10
10:38 migraine days per month but then all
10:41 along the process there was a time where
10:43 in the headache Community people were
10:45 discussing about this and talking about
10:48 this population of patients remember
10:50 chronic migraine is 1 to 2% of the
10:53 world’s population it’s a lot of people
10:56 and then along the way came Botox Botox
10:59 was tried like the other treatments for
11:02 episodic patients it did not work and
11:05 then the company said okay let’s let’s
11:07 try BOTOX for these patients who are
11:09 more severely affected and it worked and
11:12 that’s why now we have brotox approved
11:14 only for chronic migraine so that term
11:17 was then coined in the classification
11:20 the the Bible I use every day to
11:22 diagnose migraine exactly like I
11:25 presented to you and this is a
11:27 completely arbitrary limit this 15 days
11:30 per month limmit um it was decided you
11:33 know by experts around the table not
11:36 based on statistics or in research or
11:38 anything they just said okay let’s put
11:40 the bar at half of the day per month and
11:43 let’s say half of half that’s kind of
11:45 eight days with migraine symptoms since
11:48 three months because three months is in
11:50 medicine is usually a kind of a very
11:52 symbolic time where everything switched
11:55 to Chronic or or not so those are my
11:58 point here is that those those criteria
12:00 are not really based on science they’re
12:02 based on consensus and so what happened
12:05 is that we doctors those who know me I’m
12:08 a big fan of cats um and so we created
12:11 two distinct categories okay black and
12:14 white episodic chronic easy and then we
12:18 we started thinking all or nothing you
12:20 know am iodic am I chronic and then we
12:24 develop the concepts of chronification
12:26 or progression though progression
12:28 usually Improvement but sometimes in
12:30 medicine we use it for
12:33 deterioration um where you switch you go
12:36 from the bucket of episodic 14 less to
12:39 the bucket of chronic 15 plus so all the
12:43 research you know all the treat that the
12:45 trials for medications were switched in
12:47 episodic and chronic and then we studied
12:50 risk factors so research between the 9s
12:53 and 2000 and now actually still
12:56 distinguish those two categories
12:59 but that’s the reality the reality is
13:02 that there’s no two categories migraine
13:05 is a Continuum it is a spectrum and
13:08 people um will not stay in those two
13:11 buckets there’s no scientific reason to
13:13 keep it as
13:16 distinct so migraine is a spectrum you
13:18 might wonder what’s this little curve
13:20 there with little dots well those each
13:23 line is a person and the the uh purple
13:27 bar is the the famous 15 days per month
13:30 limit so below is you know zero and then
13:33 you have up to 28 days per month and so
13:36 you see that people come up and down
13:39 they have good months they have bad
13:40 months and that might depend on a lot of
13:43 different things from emotional
13:45 stressors to other health issues uh to
13:49 just pure Serendipity to hormonal
13:51 fluctuations and so patients do not stay
13:54 in these it’s not white or black so how
13:57 should we study m grade you know should
14:00 we qu create quartiles 0 7 8 14 15 22 23
14:05 30 because we know also in headache
14:08 medicine that the people who are at the
14:11 really the worst part of the spectrum
14:13 they have headache every day these
14:15 people are another subgroup they are
14:17 also more difficult to treat and they
14:19 suffer more so how should we study this
14:23 you know it’s not it’s not clear what’s
14:24 going to happen and then I’m going to
14:26 push F further based on a question from
14:29 a member of our community what is a
14:31 headache day um what is a migraine day
14:35 because when you think about it it can
14:37 be a migraine attack can be a lot of
14:39 different symptoms some symptoms are not
14:42 headache they’re not pain you can have a
14:44 pro Drome you know before the attack you
14:46 can have a post drum after the famous
14:49 migraine hangover so what was the
14:52 headache day you know was it mild
14:54 moderate severe did it last the whole
14:56 day did I take a medication did the
14:59 medication work um did the symptoms come
15:02 back uh we manag a Canadian migraine
15:05 tracker a lot of people ask us why they
15:07 cannot put two headaches in the same day
15:10 and that just reflects the reality that
15:13 sometimes you treat the the attack and
15:15 then the headache comes comeb back so if
15:18 we wanted to be super precise you can
15:20 imagine we could check at every five
15:22 minutes the state of the symptoms but it
15:24 would be just very very
15:27 cumbersome so the question is of
15:29 intensity is very important when I work
15:31 with my patients and this is a patient
15:34 before and after a preventive treatment
15:37 well if you uh you know the Canadian
15:39 migraine tracker it’s based on kind of
15:41 headache free mild which is green
15:44 moderate yellow severe red so on the six
15:48 months before the treatment you see this
15:50 person was suffering a lot as all most
15:54 of the days were moderator severe there
15:56 was just a little green a little mild
15:58 and no headache fre days after the
16:01 treatment I mean this person was still
16:03 severe chronic still every day but there
16:06 was way more severe mild green days so
16:11 that’s also a very important uh aspect
16:13 that we do not count so the conclusion
16:16 on this intro if you wish about the
16:19 definition of chronic and episodic
16:21 migraine is that this category uh does
16:24 not reflect reality it does not reflect
16:27 a scientific
16:29 truth and it was just a step forward in
16:32 our understanding of migraine to
16:35 recognize the diversity of frequencies
16:38 of intensity and to include everybody in
16:41 research because at the beginning in
16:43 migraine a lot of people were excluded
16:46 and those people were usually the more
16:48 severely affected it is still used it’s
16:51 still important to know about episodic
16:54 and chronic but I think in the new
16:56 classification it might be different and
16:59 uh but for now we still have to deal
17:01 with those definitions so what will be
17:03 the next step we’ll
17:05 see on one note so you might wonder you
17:08 know what migraine Canada does we offer
17:11 information webinars but we also try to
17:15 see how to improve care in Canada on a
17:18 more high level so I ideally migrain is
17:23 a disease that is uh not a not an
17:25 infection or a tumor you know it’s not
17:27 curable it’s something that uh we live
17:30 with all our lives or a long part of it
17:33 and so it should be listed as a chronic
17:35 disease if you look at chronic diseases
17:38 in America you know cancer diabetes
17:41 epilepsy is a chronic disease asthma is
17:43 a chronic disease so migraine should be
17:46 listed as a chronic disease at every
17:48 frequency and why is that important it’s
17:51 because if you are Aon if you if you
17:54 have this recognition of chronic disease
17:57 then it does come with Statistics
18:00 programs uh disability recognition um
18:04 and also money uh for research and other
18:07 policies uh on a federal and provincial
18:10 basis so we’re working on this but I
18:12 think uh it’s a it’s really an important
18:15 uh an important
18:17 aspect okay so we said that chronic and
18:20 episodic is a bit artificial but
18:22 nevertheless we all so we mean that
18:24 chronic is very more frequent more
18:27 severe so what is chronification is
18:30 going from less severe to more
18:33 severe and what are the risk factors
18:36 it’s important to distinguish a cause of
18:38 a disease that for example if you have a
18:40 bacteria you you remove the bacteria you
18:43 have a cure a risk factor is something
18:46 that is a cause partially so it
18:48 increases the risk of a disease but if
18:50 removed the disease eventually still
18:53 exists so for for example vascular
18:56 health so stroke or heart problems we
18:59 know the risk factors and there’s a lot
19:02 of risk factors for migraine because
19:04 migraine is really a disease of the
19:07 interaction between the brain and the
19:09 body and you will see and like where is
19:11 she going is she supposed to tell us how
19:13 to improve well it’s very important
19:15 before I discuss how to improve um where
19:18 where what is the theory being behind
19:21 all this so the idea is yes the the
19:24 migraine is the brain disorder it
19:26 impacts the brain and how it interacts
19:28 with the periphery with other things so
19:31 the the state of the body the state of
19:33 the spirit the state of the environment
19:36 and so if to treat migraine you can
19:39 improve your load so decrease your
19:41 triggers decrease what is pushing on the
19:43 brain and triggering the migraine
19:45 situation or you can also stabilize your
19:48 brain um and uh and modify your brain
19:52 chemistry to make it more
19:54 resistant chronification usually happens
19:57 over time uh sometimes we see people who
20:00 are chronic even in ch childhood or
20:02 teenage but usually the people who are
20:05 chronic are more in their 30s and
20:06 especially 40s and this comes you know
20:09 over the life though this is a multi you
20:11 know kind of multi-year multi- deade
20:14 process um and I think it’s very
20:16 important that we talk about this
20:18 because the the community the scientific
20:21 Community we hope that if we treat
20:23 migraine better earlier maybe even if we
20:27 we we start educating child children
20:30 with migraine teenagers with migraine
20:33 young adults with migraine that maybe
20:35 they will not chrony they will not
20:37 transform they will not get to this
20:39 severe stage so we should probably be
20:42 more proactive in education about
20:45 migraine so now we get into those risk
20:48 factors and from the risk factors you
20:50 will see come part of the treatments so
20:53 I I did separate this some of these
20:55 tables they put into you know what you
20:57 can change and what you cannot change uh
21:00 of course you cannot change your age so
21:01 the demographic aspect uh the
21:04 socioeconomic status so might be here
21:06 you know how the income and the uh in
21:09 which type of um uh environment you uh
21:12 you grow or you live and hardship you
21:15 know is is definitely one of the of the
21:18 factors um and then you have all the
21:20 other health issues okay so having had
21:22 if you have migraine and you’ve had
21:24 whiplash trauma concussion uh it’s
21:27 usually then it becomes sometimes a new
21:30 headache post-traumatic headache but it
21:32 definitely is worse in people who had
21:34 migraine before and it can lead to
21:37 deterioration of migraine one thing
21:39 that’s very important mental health
21:41 issues all of them in my clinic I see
21:44 depression anxiety of course but I also
21:47 see ADHD autism or the spectrum of
21:50 autism uh I do see patients who’ve had
21:53 difficult childhoods and some of them
21:55 might have complex PTSD post-traumatic
21:57 stress disorder
21:59 uh some people have disorders from other
22:01 events uh traumatic events on the body
22:05 side and you know I the body and the
22:07 mind for me are with the ears closer and
22:10 closer but obesity is really uh
22:13 something that has a great impact on
22:15 Health in general but in migraine also
22:18 we know that more weight more overweight
22:20 you are the more obese you you uh you
22:23 are you are um you have higher risk of
22:26 having chronic migraine and there’s many
22:28 reasons for that stressful events of
22:31 Life uh caffeine intake is an
22:33 interesting one I mean it’s uh we all
22:35 wish that if we stop caffeine just
22:37 migraine could go away it’s not
22:39 necessarily true but people who do drink
22:41 a lot of caffeine uh are more at risk of
22:45 having uh of becoming chronic snoring
22:48 and Sleep Disorders sleep apnea for
22:50 example and sleep apnea is also linked
22:52 with overweight and obesity and people
22:55 who have other pain syndromes
22:57 fibromyalgia end metriosis and so on and
23:00 then it turns you know fibromyalgia is
23:02 also associated with adversity in
23:04 childhood and other pain so some of
23:07 these are kind of
23:08 related and then migraine characteristic
23:11 you know people who start having a
23:13 higher frequency are a higher risk of
23:15 becoming chronic that’s kind of natural
23:18 but um you know in when I trained in
23:20 neurology we said epilepsy gets seizure
23:23 gets seizure more seizure more seizure
23:26 and that’s true for migraine more
23:27 migraine more migraine the system
23:29 becomes a more and more unstable and
23:31 more and more sensitive sensitize we
23:34 call it and with no surprise and we’ll
23:37 discuss this question of overuse but
23:39 sometimes it’s a cause sometimes it’s a
23:41 consequence um so it’s very difficult to
23:44 know which is which but people who have
23:46 a lot of migraine attack treat a lot and
23:49 that’s usually not a good sign uh is it
23:51 a cause or consequence it’s difficult to
23:53 know and people also who do not respond
23:56 to acute treatment and we’ll talk about
23:58 this a bit more detail
23:59 later a few words about trauma so a neck
24:03 trauma or head trauma um it is very
24:06 difficult in the classification at
24:08 present time for doctors in general to
24:10 to make diagnosis that make sense
24:13 because if you think about it um the
24:16 life is long and some people have you
24:18 know a little concussion here that did
24:20 not cause trouble and then they have
24:22 another Whiplash that maybe the person
24:25 started having more neck pain and then
24:27 the migraine got worse and then there
24:29 was another accident so often this kind
24:32 of mix between migraine cervical genenic
24:35 headache the neck is a big thing we’ll
24:38 talk about the neck later but the neck
24:40 is really a big thing and the neck and
24:42 troma and Whiplash are related so
24:45 sometimes it be it becomes just this big
24:47 mixed bag of diagnosis and it becomes
24:51 difficult to treat if you try to
24:53 separate you know all of this so it is a
24:56 challenge and just so you know it’s Poss
24:58 if you see different healthare providers
25:01 some of them will say you have occipital
25:03 neuralgia others will say you have
25:05 cervical genic headache others might say
25:07 you have migraine other might say you
25:09 have post-traumatic headache or a big
25:11 mix of
25:12 everything migraine does not come alone
25:15 so migraine is associated it doesn’t
25:18 mean that those this is the cause it’s
25:21 an association with a lot of stuff so on
25:24 the top you see insomnia depression
25:27 anxiety my migraine is a brain disorder
25:30 these are also brain disorders but then
25:32 you have other things for example asthma
25:35 psoriasis Osteo arthritis um and
25:38 Vascular risk factors so when I meet a
25:41 patient it’s and if you know if you want
25:44 to look at your own situation probably
25:46 you’ve done it already your Global
25:48 medical history is very important for
25:51 two reasons well first because there are
25:53 some drugs that you cannot take if you
25:56 have one of these conditions and on on
25:58 the other side there are some drugs that
26:00 might actually kill two birds with one
26:02 stone so sometimes we will favor drugs
26:05 that might for example treat epilepsy
26:08 and migraine at the same time like to
26:11 Pyramid or valpro or if you have
26:14 hypertension then you might take
26:15 something for blood pressure that’s also
26:17 good for
26:19 migraine this being said sometimes well
26:21 we want to give a blood pressure
26:23 medication and then the person has very
26:25 low blood pressure to start with so that
26:27 becomes a problem so when I see people
26:30 with chronic migraine who are difficult
26:33 you know they they are struggling very
26:35 often there is a list of comorbidities
26:37 of other diseases that sometimes play a
26:40 role they might play a role on the
26:42 inflammatory aspect on the metabolic or
26:46 energetic aspect of the body they might
26:48 play a role on the pain system if there
26:51 are other pains feeding in the brain
26:53 they might play a role on the brain
26:55 itself if we talk about anxiety or
26:57 depression
26:59 um and then they might play a role also
27:01 on the vestibular for example system m i
27:05 see a lot of patients with vestibular
27:06 migraine and sometimes it’s complicated
27:09 these patients can have you know bppv or
27:12 which is a benign postol paroxysmal
27:15 vertigo um and then there’s subset of
27:17 patients who have respiratory problems
27:20 uh inflammatory or allergic problems so
27:23 that’s very
27:25 important I’m kind of a social doctor
27:27 you know I I I like to think in terms of
27:29 systems and networks and if I look at
27:33 you know Health the determinance of
27:35 Health there is Recent research
27:38 suggesting that pollution is actually
27:40 now the number one driver of vascular
27:43 Health in the world maybe not if you
27:45 live in a nice forest with a lot of nice
27:48 air though now you know there’s a lot of
27:50 fires but um it’s it’s very difficult to
27:53 kind of dis intricate all of these
27:56 drivers those deter
27:58 where you live you know in what type of
28:00 envir environment climate change your
28:03 workplace um and and all of those Basics
28:06 where of the the system where you grow
28:08 in and then the risk factors here it’s
28:11 it’s a graph about vascular health so
28:14 you know your diet your diet is not only
28:16 what you decide it’s also what Society
28:18 puts in front of you right um
28:21 sedentarity lack of activity well it’s
28:24 easy to see someone is not training but
28:26 we know our society is very s
28:29 so all of those risk factors play a role
28:31 in all of those other chronic diseases
28:34 and I think they also play a role in
28:36 migraine and some people have all of
28:38 this together and so we have to see this
28:41 in a more Global aspect so to sum it up
28:44 before we actually move toward ideas of
28:48 improvement um those are what I call the
28:50 The Vicious Circles of chronic migraine
28:53 someone is born with migraine genes or a
28:56 migraine software a migraine is brain
28:58 um might have occasional attacks and
29:01 then sometimes something happens can be
29:04 a lot of things an accident and hormonal
29:06 change I put perim in a pause but it
29:09 could be a pregnancy uh stressor another
29:12 disease comes in a surgery whatever and
29:16 then and then attacks increase and then
29:18 the Cycles the brain is destabilized the
29:21 person starts having insomnia anxiety
29:24 depression difficulty struggling and
29:27 sometimes you know it’s stuff at work
29:29 it’s stuff in the family and then people
29:31 tense up you know today I saw I don’t
29:34 know how many patients who had this kind
29:35 of jaw and neck tension related to
29:37 chronic pain and anxiety uh and then you
29:41 start kind of you cannot cook anymore
29:42 you cannot train anymore everything
29:45 becomes more struggling uh and then you
29:47 start drinking caffeine and taking more
29:49 pills because you need them and then and
29:52 then you get into this vicious circle so
29:56 this is kind of the bad Circle but the
29:57 good good news is all of those things
30:00 are things we can act on to reverse The
30:02 Chronic status it’s just trying to find
30:05 which button or which lever to pull
30:08 first or in what order this is a slide
30:11 for doctors it’s not it’s not something
30:13 I usually present to the public but um I
30:16 think we should consider as we close
30:18 this chapter of definition and Concepts
30:22 um could we use a predictive score you
30:24 know beyond this this kind of a bit
30:27 stupid stupid
30:28 thing of chronic episodic could we just
30:31 look as they do in the Psychiatry world
30:33 and say okay what’s your diagnosis what
30:35 are your what is your map you know what
30:37 is your medical comorbidities what is
30:39 your mental health aspect where do you
30:42 you know what are your social factors
30:44 what is the impact on you and then we
30:46 build a plan for example here I have a
30:49 30 42 year old lady she has Migraine
30:52 with and without Aura she has status
30:54 like long attack status migros she has
30:57 asthma allergies obesity a bit of
31:00 anxiety panic attacks but not anymore
31:03 she works full-time she has private
31:05 coverage to access drugs something very
31:07 important too we know uh and this is a
31:10 score for function and from this we go
31:12 forward we build the
31:15 plan okay so now this was kind of the
31:19 you know setting up the stage so we
31:22 understand why I’m going to make the
31:24 recommendations or the chapters each of
31:27 those those kind of green things
31:29 sections is a full chapter in a book um
31:33 the time does not allow me to go and go
31:35 into a great depth you know about which
31:38 drug you should take or how you should
31:40 take it but I want to just present the
31:42 chapters to you and those chapters are
31:45 things that I see in my office today I
31:47 saw them in my patients the first here
31:50 and also I’ll I’ll just give you a hint
31:52 about how migrant Canada is trying to
31:54 improve things for you so the first
31:57 thing is um you know get a competent
32:00 healthcare provider I have to say this I
32:02 mean I think it’s a um it’s a bit uh
32:05 it’s a bit unfair to people to ask that
32:07 they treat themselves I mean it’s very
32:09 important to be involved and to take
32:12 care of yourself as much as you can um
32:16 but I think having an ally is important
32:18 so what is a good health care provider
32:21 this person can be a primary care
32:22 provider a neurologist um can be another
32:26 specialist can be uh and then you have
32:29 also other allies so this person should
32:31 take a good history of you uh be
32:34 organized a little bit uh listens to you
32:38 uh recommends a headache diary if
32:40 someone does not mention a headache
32:41 diary in this field it’s I would say
32:43 it’s a bit particular uh includes you in
32:46 the decision you know does not make the
32:48 decision for you proposes things and
32:50 then listens to what you you want to say
32:52 or what you think answers your question
32:55 I hear there’s a lot we’re all dead B
32:57 busy in our offices but if you have
33:00 questions and and there’s never time to
33:02 answer your question uh in management of
33:04 chronic disease it’s not good and does
33:07 not blame you you know for for for
33:09 things now of course if if there are
33:12 recommendations and you commit to
33:14 something and it’s not done well there
33:16 might be a discussion on why and how but
33:18 you should not feel shamed or guilty or
33:21 blamed I see a lot of my patients they
33:23 tell me they’ve seen doctors and they
33:24 left in tears um because they were were
33:28 told like why are you doing anything and
33:30 it’s your fault and bl BL so that’s not
33:33 that’s not good right you would want
33:35 someone who’s your partner who’s your
33:37 your uh your your your supporter not
33:40 someone who makes you feel
33:42 guilty you should get the the right
33:45 diagnosis uh so obviously you know is it
33:48 migraine is it post-traumatic headache
33:50 do you have other things and then you
33:52 should start the headache diary to make
33:54 this more precise than episodic or
33:56 chronic um
33:58 I want to pitch for our Canadian
34:00 migraine tracker this is an app that we
34:02 created with the Canadian Headache
34:04 Society um because we we were told by
34:07 people that migraine body was too
34:09 complicated and too heavy on the long
34:11 term so we decided to create something
34:13 super simple and I invite you to try it
34:17 or we can you can check on our YouTube
34:19 there’s a YouTube channel to explain to
34:21 you a few things about how to make the
34:23 best um with my gracious person so you
34:26 can go and uh and learn how to use the
34:29 app and you can see I mean it gives you
34:32 it uses this kind of tree level you know
34:34 it’s not perfect it might not fit for
34:36 you you might always use another type
34:38 paper app whatever works um but it’s
34:42 very important to get a diary because
34:43 especially when you have a high
34:45 frequency and there’s a lot of different
34:48 intensities a lot of different
34:49 treatments uh without a diary I’m I’m
34:52 not too sure how sometimes we take a
34:54 break today I had two patients they were
34:55 going through a lot of hardship and they
34:57 took a break from their diary perfect uh
35:00 but usually I it’s very
35:02 useful and then what I presented to you
35:05 what we Healthcare Providers do I think
35:07 it’s probably a good idea that that you
35:10 have your own map and you you are aware
35:13 of the different factors that you could
35:15 work
35:16 on um to be aware of you know what your
35:18 attacks are is this clear or not um what
35:22 is your health you know what and it
35:23 might seem really easy but I sometimes I
35:26 build those stories with my patient and
35:28 I we make we make links when as we build
35:30 a story about what happened um in the
35:34 body and the mind uh in the environment
35:38 um be aware of your triggers uh I’m
35:40 usually not a good a great proponent of
35:43 watching everything all the time but at
35:45 some point it’s good to make this work
35:47 and have an idea of what influences you
35:50 and then build your own map of what
35:52 you’ve tried I see a lot of people they
35:54 come for the the consultation and this
35:57 is you Universal for us headache
35:59 specialist and patients will come to us
36:02 and they will say oh I’ve tried
36:03 everything and usually it’s not true
36:07 usually they haven’t tried everything so
36:10 it’s so helpful to have a list of the
36:12 drugs you tried the preventive the acute
36:16 and also you know the other things that
36:18 you’ve tried you know have you tried
36:20 physiotherapy massage hypnosis whatever
36:23 else so to have this some somewhere uh
36:26 is tremendously helpful
36:28 to also see you know what you haven’t
36:30 tried and do you want to try
36:32 it so the one of the first thing when we
36:35 build a plan once the diagnosis is clear
36:38 the DI then the diary is there is to
36:40 adjust Li lifestyle and as you see I see
36:45 adjust you cannot modify the whole thing
36:48 right and there’s usually two levels I
36:51 could give a full talk only on this line
36:54 for each line and I will not do that
36:58 but this table I present to Primary Care
37:00 Providers to explain to them that some
37:03 people are beginners they they are
37:05 starting you know they haven’t tried a
37:07 lot of things and they can definitely
37:09 benefit from basic advice and others and
37:12 I suspect a lot of you listeners are in
37:15 this category um they have done a lot
37:18 already they have read a lot they have
37:20 tried a lot sometimes they have been
37:23 disappointed a lot um and then you go
37:26 into the world of of you know other
37:28 Allied healthc carees nutritionists
37:31 physiotherapists kinesiologists for
37:34 exercise um different types of
37:36 therapists and I’ll I’ll go a bit deeper
37:38 on that
37:40 aspect and occupational therapy as as
37:43 sometimes recommend as well so you know
37:46 what is your personal list of things
37:48 that are realistic feasible accessible
37:53 affordable and I can tell you I see
37:56 patients for now 50 years it’s a path
37:59 and it’s a journey and sometimes you
38:01 know you need a village and you need
38:03 allies and you cannot do it all at a
38:05 precise time or at the same time so
38:09 that’s also just that’s just a a useful
38:12 thing a few words on therapy because
38:15 this first of all remember I mean I
38:17 didn’t get one second of training about
38:20 therapy when I was in neurology training
38:24 it’s it’s very weird but that’s what it
38:26 is and I’m not Too Short it’s different
38:28 now um because usually when we talk
38:31 about CBT cognitive behavioral therapy
38:35 there are many different types of this
38:37 usually it’s to address your thoughts
38:39 and to look at them and then to work you
38:42 know to behave differently to reflect
38:46 and to try to move away from the
38:48 negative to the positive because our
38:50 brains are just geared to be very
38:53 negative that’s a survival thing that
38:55 dates back million years ago we cannot
38:57 do anything anything about it and so
38:59 there’s a lot of of of things that can
39:01 be done in
39:02 CBT but CBT is not the only type of
39:05 therapy that can be done okay one word
39:08 about talk therapy sometimes my patients
39:11 they go to see a therapist and uh and no
39:14 offense to any therapist but they will I
39:17 say okay what do you do with the
39:19 therapist and they say well I talk to
39:21 them about my week and you know they
39:23 asked they asked me about my childhood
39:25 and all of this okay but after a few
39:28 years it becomes a place sometimes you
39:31 need to vent to get support that’s
39:33 perfect but it doesn’t lead to change
39:35 does it lead to Improvement and
39:38 sometimes what I’ve seen is some of my
39:39 patients they they go to therapy they
39:41 just reinforce their patterns because
39:44 they repeat the same things over and
39:45 over again but there’s no attempt at
39:48 changing for the better so it just a
39:51 little word sometimes therapy can be
39:53 good sometimes it’s just keeping you in
39:55 your patterns not necessarily
39:58 ideal there’s so much stuff in therapy
40:00 okay I’ve seen people they have seen one
40:02 or two therapist they hated it and they
40:05 said no more therapy for me well it’s
40:09 difficult it’s tough to find therapists
40:11 they’re expensive it’s a big investment
40:13 of time effort and money but it can pay
40:17 off for example sleep CBT for insomnia
40:21 is something that extremely powerful but
40:24 it’s difficult to find and it is
40:26 expensive
40:27 um dialectic behavioral therapy is
40:30 usually more for people with borderline
40:32 personality but that’s something that
40:33 exists there are all kinds of approaches
40:36 for post-traumatic stress disorder
40:39 acceptance commitment therapy or act is
40:41 something tremendously important in
40:44 chronic pain I discuss about this with
40:47 my patients I have a few books I
40:49 recommend um and it is really something
40:52 that can help you do not need to do it
40:54 for years usually in a few months you
40:56 can already be trained and basic
40:59 principles pain reprocessing therapy is
41:01 a bit different than act it’s actually
41:03 something that’s shown a lot of Promise
41:05 in low back pain um and it’s something
41:08 that that is growing now art therapy
41:11 I’ve sent patient to Art therapy and
41:13 sometimes it’s just the key dealing with
41:15 chronic pain and uh it’s it’s actually
41:19 sometimes if you revive something that
41:20 goes in that very soft very joyful part
41:23 of you it’s not going to take the pain
41:26 away but it will support you through it
41:28 hypnosis I’ve sent some patients to
41:30 hypnosis to great success not all of
41:33 them um but it’s something interesting
41:36 EMDR or eye movement desensitization and
41:39 reprocessing is something for
41:40 post-traumatic stress disorder and then
41:43 there’s a a new thing a new kit on the
41:45 Block if you wish that’s called fnd
41:48 functional neurological disease it’s
41:50 usually more molder like people who have
41:52 Tremors and stuff um but it might apply
41:55 to some people with pain and with for
41:57 for example chronic climb or chronic
41:59 fatigue syndrome fascinating area very
42:03 complicated what sometimes makes makes
42:05 me a little bit sad as people tell me
42:07 Well if I didn’t have migraine I would
42:09 not be depressed and it’s maybe true but
42:13 this D it’s bidirectional so sometimes
42:16 people also live with depression and
42:19 anxiety disorders and and migraine is
42:22 not the only key so I would say just
42:26 Target everything
42:27 right uh it’s usually not a good idea to
42:30 say well if when I never have migraine
42:32 when migraine is gone then I will be
42:35 perfect it will be okay that’s extreme
42:37 um but don’t underestimate the
42:39 importance of taking care of mental
42:42 health meditation I could give a once
42:45 again a full webinar on meditation I
42:48 practice meditation I play with it I’m
42:50 still very beginner but there’s so many
42:53 different ways cardiac coherence is a
42:56 good way to start
42:57 uh you can find tons of YouTube videos
42:59 on it uh breathing practices there are
43:02 tons of them uh it’s all about doing it
43:04 if you’re like me you can look a lot of
43:06 YouTube videos
43:08 but looking at the video is not enough
43:10 you actually have to do it um just basic
43:13 meditation Buddhist Meditation
43:15 mindfulness base stress reduction is a
43:18 usually an eight-week program that can
43:20 be extremely good today I recommended
43:23 the progressive muscle relaxation of
43:25 Jacobson that’s a very interesting
43:26 German thing where you clench and declen
43:29 your muscle very good for people who
43:31 have this kind of tension and anxiety uh
43:34 Circle uh practicing self-compassion
43:36 gratitude expressive journaling so this
43:39 is really a path of many years many
43:41 books and if any of these words you
43:43 don’t know or you haven’t explored maybe
43:45 there’s something for you
43:47 there um in my clinic I have my multi-
43:51 disciplinary team of books um because I
43:54 I don’t have the privilege of having you
43:56 know a occupational therapist or
43:58 psychologist or working in the clinic so
44:01 I built my little list of books there
44:03 are many those are I would say some that
44:06 I really recommend uh body keeps the
44:09 score is about the trauma another about
44:12 trauma is speed Walker surviving and
44:14 driving uh the way out is the companion
44:17 book to the app curable which sometimes
44:19 is actually quite effective it’s based
44:21 on the acceptance commitment therapy um
44:24 um there are some masters of meditation
44:27 Pon is someone who’s amazing for just
44:29 kind of more philosophical Buddhist
44:31 approach is this going to cure your
44:34 chronic migraine absolutely not but it
44:37 might actually help you manage the
44:41 ordeal okay so this was for Behavioral
44:43 and lifestyle Now we move to drugs
44:47 medications uh we have a lot of
44:49 information about drugs and medications
44:51 and those can be prescribed here I just
44:54 have one slide about acute treatments
44:56 because because we have other resources
44:59 for this but just to say that optimizing
45:02 acute treatment is key um so that means
45:06 that ideally you know uh you would have
45:09 ways to treat your attacks properly and
45:12 there’s a lot to be tried um we still
45:15 advocate in headache medicine to avoid
45:18 at all cost and I know this is a heated
45:21 debate on patients for rums uh opioids
45:24 and barbiturates for example fural
45:27 because of the high risk of
45:28 chronification and deterioration and
45:31 side effects and addiction now there are
45:34 people who Fair well with opioids and
45:36 bitrates they are a minimal minimal
45:39 minimal
45:41 subgroup and uh and if you want to
45:43 discuss this with your provider I think
45:45 it’s a good idea but don’t be my point
45:48 is don’t be surprised if your provider
45:52 um just says I don’t prescribe aids for
45:54 migraine because that’s what we teach
45:57 day in day out uh that should be a very
45:59 very a very large Last Resort and I have
46:01 to say even the best clinics in the
46:04 States now they they do not prescribe
46:06 opioids for migraine um so that’s that’s
46:09 something we could discuss more but it’s
46:11 still a rule gpants uh so that would be
46:14 nertec and ueli for acute are really a
46:18 welcome addition because they have no
46:20 risk of medication overuse so if you do
46:23 need to treat often um you might want to
46:26 try these new
46:28 options switching now to the world of
46:31 prevention okay so I don’t know here
46:35 there’s more than 100 people out there
46:36 so I’m so glad um I don’t know your
46:40 story I don’t know what you’ve tried I
46:41 have no idea if the people on the line
46:44 you know have tried one two three four
46:47 five 10 15 preventives uh I bet most of
46:51 you have tried a few but here are the
46:54 new guidelines uh for prevention that
46:57 will be soon out this is not the final
47:00 publication it’s kind of a preview um
47:03 but overall what’s going to happen is
47:05 there will be 10 medications that will
47:07 be strongly recommended for migraine
47:10 prevention episodic and one for chronic
47:13 which is
47:14 Botox uh so episodic and chronic so the
47:17 big the big thing is that the pyramid
47:19 topax is downgraded to a weak
47:23 recommendation Candis Artin which is a
47:25 drug for blood pressure is upgraded so
47:28 and all of them are on the same equal
47:30 foot right so the message here is if you
47:34 haven’t tried cgrp medications or toxin
47:38 keep hope my friends because those can
47:40 really change the life of a person with
47:42 chronic migraine um these and there we
47:45 have webinars and PDFs on all of these
47:47 uh so if you haven’t tried the kind of
47:49 second second uh uh generation
47:53 treatments uh you should definitely try
47:55 them now if you have tried all of that
47:57 uh there’s definitely other options what
48:00 we call weak
48:02 recommendations uh in case of you know
48:04 because either they are poorly tolerated
48:06 or they have more risk of side effects
48:09 um and then what we will need for
48:10 research is what will happen you know do
48:14 these drug are these drug useful for
48:16 someone who has not responded to a cgrp
48:20 antibody a gpan the toxin
48:23 combinations um and so those drugs some
48:26 of them are older drugs like for example
48:27 epival theal proex pizotifen very rarely
48:31 prescribed uh some are newer like
48:33 memantine for example uh is something we
48:36 give for Alzheimer’s you can see the
48:38 pyramid will be in that list V the
48:40 vaccine so there’s a lot of drugs I mean
48:43 there’s 10 on the previous page and then
48:45 11 there so that’s 20 drugs that are on
48:48 guideline by the Canadian Headache
48:50 Society to prevent migraine and all of
48:53 these can be you know increased or
48:55 combined there’s a lot that can be tried
48:58 but now this being said there are the
49:01 first 10 ones are the ones that have the
49:03 strongest evidence and those ones are
49:06 those with less evidence or more risk of
49:08 side
49:09 effects if you haven’t tried a cgp drug
49:13 I have to say uh this is changing our
49:16 world this is changing my world this is
49:19 an example two Diaries uh of um of
49:24 patients um and I’m sorry I just
49:26 realized that didn’t remove the name of
49:27 the patient but um so here uh this
49:32 patient is happy with three migraine
49:35 days per month or one instead of like I
49:39 don’t I think she had 15 or 16 uh per
49:42 month so great response to a cgrp
49:45 antibody here HOV can be any they’re all
49:49 good and then on the other side you have
49:51 the Canadian migraine tracker data for
49:53 patient who had a partial response went
49:55 from 14 to uh 14 12 to you know 5 9 6 7
50:01 3 and going so if you haven’t trying one
50:05 of these uh or many of these actually I
50:07 mean it’s worth trying many or try them
50:10 all I mean I try everything in my clinic
50:12 uh it’s worth trying definitely you can
50:15 also respond partially I mean it’s
50:17 sometimes I this is the patient I’ve
50:18 shown you before who is also on a CG
50:21 antibody uh it could be also a Gant like
50:24 U lipta for prevention um
50:27 sometimes people respond and they are
50:29 very happy to have at least a partial
50:31 response right because instead of being
50:33 moderate or severe all the time they
50:35 move to this kind of mild category and
50:38 that’s already a little relief and
50:41 sometimes after years of trying it’s
50:43 okay you know at least we have this
50:46 response um it’s important to make that
50:49 understood to insurance companies though
50:52 so the partial response sometimes you
50:54 know we all wish we could have a super
50:56 response resp but sometimes we have a
50:57 partial response it’s not only frequency
51:00 it’s a you know how you can tolerate
51:02 triggers uh how can you plan your
51:04 activities uh do you have better mood
51:07 better sleep um a better response to
51:09 acute meds um a lot of people tell me
51:12 when they respond partially they say
51:14 well maybe I still have a lot of
51:16 migraine days but my tripon work or my
51:19 gent work or my nid work I can control
51:23 most of my attacks as before I was you
51:26 know I had to go to the imerge or I was
51:27 missing my work or I was just lying in
51:30 bed miserable all day so that’s very
51:33 important so we should not kind of you
51:35 know hope for the the superb Miracle of
51:39 of super response um and sometimes a
51:42 partial response is already something
51:45 good on the other side super response
51:48 has also you know made us reflect
51:52 because a lot of my patients um who have
51:54 tried years of stuff years of you know
51:59 meditation drinking tons of water doing
52:02 yoga cutting everything from their diets
52:06 well after all I give them an antibody
52:09 or a Jeep an and wow
52:12 Miracle so it makes us think there’s
52:15 probably subgroups of people with
52:17 migraine there are people that if you
52:19 block their cgrp it goes Super well and
52:22 that’s great and there are people where
52:24 you block their cgrp it does nothing and
52:27 maybe the key is
52:28 elsewhere so I think we we should really
52:31 reflect about you know how long and how
52:33 much we should push on people to change
52:35 their whole lifestyle because they have
52:37 migraine um when maybe you can treat
52:40 them and some of them you know that’s
52:42 that’s all they need uh we cannot guess
52:45 who’s going to Super respond or respond
52:47 to any drug for migraine but that’s
52:49 definitely something that you know like
52:52 oh you know you can do it or yes you can
52:54 be empowered and and manage stress so
52:57 that’s a fine line when we deal with
52:59 migraine you know how much you can
53:01 really control and how much you should
53:03 be doing to deal and cope uh if you
53:07 don’t find a treatment is there a new
53:09 treatment that could help
53:11 you so the other thing I want to share
53:14 with you guys is something we I I try to
53:16 share you know things that are
53:17 relatively consensual in our world of
53:19 headache specialist most of my
53:22 colleagues will agree that if you have
53:25 severe refractory chronic migraine you
53:28 want to improve the combination of the
53:31 toxin Botox with a cgrp blocker an
53:35 antibody or a Gant might be the future
53:39 because they actually combin they have
53:41 different mechanisms of action this is a
53:44 Tango you know this is a Tango with the
53:46 insurance company usually because you
53:49 have to prove to them I showed you a
53:51 little table of you know what I usually
53:53 build up with my patients so at Baseline
53:56 you know what what’s the Frequency
53:57 mother is severe the hit scores the
54:00 function and then we have to prove
54:03 treatment one works enough but not
54:05 enough and then treatment two works and
54:08 the combination it’s complicated but
54:11 tonight is about you know what can be
54:13 tried this can be tried and definitely
54:16 it’s an interesting approach for the
54:18 future oh I put here the the Canadian
54:21 Headache Society has written a letter a
54:24 four-page letter that you can use news
54:26 to appeal of your insurance companies we
54:29 do have access to this at migraine
54:30 Canada and if you need you know your
54:33 doctor to be supported in writing appeal
54:36 letters and discussing with your
54:37 insurance that’s definitely a document
54:40 you uh probably
54:42 need okay so now we have our steps we’ve
54:45 discussed already a lot of things
54:47 lifestyle acute prevention what about
54:51 overuse just this today we had a lunch
54:54 and learn with our team of headach where
54:56 I work we discussed cases of medication
55:00 overuse so that means person with
55:02 chronic migraine who’s using frequently
55:05 I don’t like the term overuse because
55:07 it’s like a bit judgmental but anyway
55:10 overuse or frequently uh different drugs
55:13 tripon Tylenol Advil opioids uh fural a
55:19 mix of all these things and the key here
55:22 the key con concept it’s a key concept I
55:25 try to to teach teach to Primary Care
55:27 Providers pharmacists
55:30 neurologists it’s impossible it’s very
55:33 difficult to predict in a given person
55:35 with migraine if the overuse is a cause
55:39 of the chronification or a
55:42 consequence I mean by that that some
55:45 patients you treat them with toxin gend
55:48 the pyramid Botox whatever antibody and
55:51 then they don’t overuse anymore because
55:53 they don’t need these drugs anymore and
55:55 then you don’t need to withdraw people
55:58 just improve on the reverse some people
56:02 who overuse you give them your best you
56:04 know you try drugs and drugs and
56:06 prevention it doesn’t work and what you
56:09 need to do is to stop the overuse and
56:11 organize a
56:13 withdrawal so the point is here um do
56:16 you does everybody who uses a lot of
56:19 acute treatment need to withdraw to
56:21 improve the answer to that is no but
56:24 some people definitely do need I just
56:27 recently saw a lady of 75 years old she
56:31 was on fural every day for the past 40
56:33 years she had tried to withdraw it had
56:37 it it she withdrew it didn’t work but
56:39 then I gave her an antibody VIP te and
56:42 she did withdraw I mean so the first
56:44 shot of VI didn’t help that much and so
56:46 we planned the second shot the second IV
56:49 and then she did the creaser Fel one
56:52 little quarter at a time over a month
56:55 and now is she cured no she’s not but
56:58 she has eight days per month treated
57:00 with Almo trip 10 and she’s a happy
57:03 camper and when she goes back to Florida
57:05 she’s going to have way more fun than
57:07 when she had her daily Migraine with
57:09 every like the fural every day so
57:12 overuse is a problem uh it’s
57:15 complicated and uh definitely uh it’s a
57:18 it’s a something that you need to
57:19 discuss so that’s actually this lady
57:22 here we are 40 Years of daily techno
57:24 very I mean diary very clear so you look
57:27 here in August uh you can see she’s
57:30 taking her Tech Nile every day Almo
57:32 tripan occasionally and then she has her
57:35 first dose of Viet te and then she
57:37 decreases her fural technal uh and then
57:40 y y y y it all improves and here you are
57:43 with very nice diaries with um a very
57:46 way less
57:48 headaches all right so now we switch to
57:50 another chapter uh I have to say in my
57:54 clinic when I see a person with chronic
57:56 migraine often I talk about the neck and
57:58 the TMJ and the mental health those are
58:01 the two kind of big zones that I usually
58:04 discuss so I’ve learned a lot on this
58:07 over time with the help of my patients
58:09 and I want to thank them because they
58:11 they teach me everything um over nobody
58:15 tell told me any of this in neurology
58:17 training just so you know it’s something
58:19 that we do not learn in
58:21 neurology uh and so you will find some
58:24 doctors who are really interested in
58:26 neck pain and others who do not want to
58:29 get involved in neck pain management um
58:32 and that’s okay so if you’re neurologist
58:34 is not really interested in neck pain or
58:37 doesn’t know what to do you might need
58:39 other healthc care providers who can
58:41 help you so here’s a few things IM and I
58:44 I’ll just it’s just kind of a mixed
58:46 bouquet of things I’m not going to
58:48 discuss any of this in at length but
58:51 it’s just a few
58:52 Concepts Imaging is rarely useful a lot
58:55 of my P Pati they you know they say oh
58:57 what about MRI CT
58:59 scans MRIs we do them we see something a
59:03 bit you know a bit of arthrosis a bit of
59:05 crunchy facet joints here and there very
59:08 rarely useful to manage the only time
59:10 where it’s useful is if you need to call
59:12 the surgeon because the spinal cord is
59:14 compressed that’s extremely rare so I
59:17 would say it’s okay to get Imaging just
59:19 don’t expect too much from it the
59:21 osteopaths and chiropractors okay they
59:24 help a lot of my Pat patient but often
59:27 they will focus on an idea that there’s
59:29 a misalignment that needs a
59:33 correction that’s not really based in
59:35 actual science um despite all they will
59:38 say and the only way to actually change
59:42 this the balance of the spine is to
59:44 reinforce muscles passive manipulations
59:47 are not a key long term um and so nerve
59:51 compression is also rarely the issue um
59:54 and so it’s very difficult to evaluate
59:56 the neck properly okay we don’t have
59:59 perfect testing for this um we can
01:00:01 palpate we can massage we can you know
01:00:04 feel tenseness we can do an MRI but at
01:00:07 the end of the day God it’s difficult
01:00:10 and I I cannot claim you know that I I
01:00:14 know exactly what to do so we try but
01:00:17 the missing piece is often muscle
01:00:21 strengthening because painful muscles
01:00:23 usually need strengthening not only
01:00:26 stretching or man passive manipulations
01:00:28 and the only way to strengthen the
01:00:30 muscle is to activate it and only you
01:00:33 can do that it takes time it takes help
01:00:36 now you’re going to tell me if I do
01:00:38 exercises I have terrible pain that’s
01:00:41 possible that means you need to go on
01:00:44 milder exercises very Progressive it’s a
01:00:47 lifelong process of coping but um
01:00:50 there’s definitely something there that
01:00:52 often my patients haven’t tried uh for
01:00:55 all kinds of very good
01:00:57 reasons so cervical genenic headache
01:00:59 this is something I use a lot when I
01:01:01 present to doctors um there’s not only
01:01:04 you know there’s the muscles the the
01:01:06 bones the roots and then the the brain
01:01:09 that puts all this pain together and all
01:01:11 those Sensations together and all of
01:01:14 this can be managed you know with
01:01:16 massage manipulations exercises trigger
01:01:19 point injections acupuncture Botox facet
01:01:23 blocks you know tall kinds of blocks
01:01:25 injection
01:01:26 and then medications and pain
01:01:29 reprocessing therapy so it’s very
01:01:32 complex and I have to say in my clinic
01:01:34 just today I would say half of my
01:01:36 patients had neck issues and we had to
01:01:38 find a way to try to move forward on
01:01:41 that
01:01:42 front the the another Point here and
01:01:45 this is kind of the modern you know this
01:01:47 is me probably on a daily basis
01:01:49 approximately um it’s very I mean this
01:01:52 is just how humans are now and it’s not
01:01:54 only the neck this is the whole thing um
01:01:57 so usually I’m a big fan of trying you
01:01:59 know to keep a better body it’s very
01:02:02 tough um I’m all for walking in
01:02:05 stationary bike by the way but it’s not
01:02:08 going to build your arm and neck muscle
01:02:10 it’s it’s great to walk I’m not saying
01:02:12 don’t walk just saying it’s not enough
01:02:14 so what I often recommend Kinesiology so
01:02:18 working with a trainer to find a right
01:02:20 exercises a lot of kinesiologists now
01:02:22 actually are trained in chronic pain
01:02:24 management um
01:02:26 Ecentric is great look it up chi gong
01:02:29 Tai Chi Pilates dancing if you like it
01:02:31 can be great stretching any movement uh
01:02:35 to address all this kind of spinal
01:02:37 problem that we a lot of us have and
01:02:40 that will not be corrected by any
01:02:43 passive
01:02:45 manipulation we’re getting close to the
01:02:46 end now um that’s a very important thing
01:02:50 dear to my heart um a lot of my patients
01:02:53 are living with hardship a lot of
01:02:56 hardship can be a difficult relationship
01:02:59 sometimes an abusive relationship it can
01:03:02 be a loved one with chronic illness it
01:03:05 can be a kid with autism a loved one
01:03:08 with addiction or mental health issues
01:03:11 it can be uh an elder an elder person
01:03:14 having their loved one sick or even
01:03:16 dying today one of my patients lost her
01:03:18 husband last week and the other one is
01:03:20 dealing with the Alzheimer’s of her
01:03:22 husband uh another is dealing with um a
01:03:25 sever early ADHD an autistic kid uh
01:03:28 sometimes it’s the workplace that’s
01:03:30 horrible uh it can be I have a few
01:03:32 Ukrainian patients there enduring you
01:03:34 know having their family in Ukraine
01:03:36 that’s something they have no anyway so
01:03:39 hardship true struggle that contributes
01:03:42 to mental load and chronic stress and
01:03:45 that adds up and sometimes it just is
01:03:48 too much and for the migrainous brain
01:03:50 and that’s why I put this person here
01:03:52 just carrying this heavy load um and in
01:03:56 these people sometimes when I deal with
01:03:58 patients like this I just try to support
01:04:00 them it’s very difficult but I just want
01:04:02 to analge this and please if you are
01:04:05 abused or threatened uh try to get
01:04:07 support and safety and I I address
01:04:09 especially to women or men but usually
01:04:12 it’s women who might be in difficult
01:04:15 situations and so then the question is
01:04:18 you know are there people who cannot
01:04:20 improve all right where there’s nothing
01:04:22 else to do this is one example and and I
01:04:25 think it’s important to recognize that
01:04:28 sometimes things have been done this is
01:04:31 a lady of 54 years old She has chronic
01:04:34 migraine refractory to everything and in
01:04:36 her case I can say everything um
01:04:39 interestingly she doesn’t have any neck
01:04:41 issues no accident she has some insomnia
01:04:45 depression that really seems to be
01:04:46 caused by the migraine she’s seen seven
01:04:49 neurologists best Doctors Two
01:04:51 neurosurgeons four pain clinics three
01:04:54 psychiatrists she’s tried the whole
01:04:57 gamut Shaman raiki hypnotist naturopath
01:05:00 psychologist she’s done every diet
01:05:03 possible um she’s tried all of this and
01:05:06 you know that’s roughly the whole
01:05:08 cookbook of migraine medicine she’s even
01:05:11 had implanted oipal neuromodulation
01:05:14 something I that’s not recommended for
01:05:16 migraine by the way usually 2013 and
01:05:20 2017 she has trans cral magnetic
01:05:23 stimulation very rarely used for
01:05:25 migraine ver difficult to access IV
01:05:27 ketamine very rarely used I do not
01:05:30 recommend she’s had all this and nothing
01:05:33 worked and so um at this stage I have to
01:05:36 say for this person I I think like she
01:05:40 will have to live with whatever is there
01:05:42 I think there’s nowhere in the planet
01:05:43 where there might be a treatment that
01:05:46 science is endorsing that can help her
01:05:49 relieve her headaches why is it the case
01:05:52 I don’t know um so why is are are some
01:05:56 people very refractory to treatment um
01:05:59 it can be you know we talked about cgrp
01:06:02 could be other peptides could be
01:06:04 metabolic pathways you know there are
01:06:06 all kinds of of of chemistry things in
01:06:08 the body we don’t yet know about um
01:06:11 other medical problems uh other mental
01:06:14 health problems we talked about the
01:06:16 hardships um uncontrollable neck issues
01:06:19 uh some maybe the brain just
01:06:21 chronification
01:06:25 and some pain control mechanisms you
01:06:28 know there’s a lot of
01:06:29 possibilities but what’s really nice is
01:06:32 that like it’s less and less now that we
01:06:35 have more approaches and of all kinds
01:06:37 you know blockers and Di bodies toxin
01:06:40 behavioral modulation a better
01:06:43 understanding of
01:06:45 migraine if you are in the dark pit of
01:06:47 Hell and uh some of you are probably and
01:06:51 you’re trying to find relief uh so first
01:06:55 of all you know you’re end you’re
01:06:57 absolutely welcome it’s normal that
01:06:59 you’re trying to find relief everybody
01:07:01 in your situation would do everything to
01:07:03 find relief right but as a doctor it is
01:07:07 my responsibility to keep you safe from
01:07:10 harm and uh so usually there are a lot
01:07:13 of things believe me there are people
01:07:15 out there who know that you are
01:07:18 desperate and they will try to sell you
01:07:21 stuff okay so it can be surgeries like
01:07:24 migraine surgery iies usually not
01:07:27 endorsed um there’s a few exceptions but
01:07:29 not endorsed for migraine by most
01:07:32 headache experts um all kinds of funky
01:07:35 devices that promise you hear this and
01:07:38 that I have patients who paid hundreds
01:07:41 and hundreds of dollars in naturopathic
01:07:43 treatments Miracle diets manipulations
01:07:46 like I
01:07:47 said um and then also the testing world
01:07:50 you know Imaging Imaging Imaging trying
01:07:52 to do lots of blood tests with no no
01:07:56 real reason you know fishing for um
01:07:58 heavy metal intoxication or chronic clme
01:08:01 disease or um neck Imaging I told you
01:08:04 very limited importance or relevance um
01:08:08 and then of course if some of you here
01:08:09 have had diagnosis with proper testing
01:08:12 and found something it’s great but I’m
01:08:14 it’s just a little warning there um so
01:08:18 if you find something of Interest right
01:08:21 um does it make sense to use it is it
01:08:24 safe and how much does it cost can you
01:08:27 afford it and who recommends it so I
01:08:30 think that’s the idea so when my
01:08:32 patients want to try stuff that is you
01:08:34 know off the Box um I look at that with
01:08:38 them and I try to say okay does it make
01:08:40 sense or could you be harmed by this is
01:08:42 it completely insanely expensive um and
01:08:46 sometimes they will try and if it works
01:08:49 that’s great but just be
01:08:51 careful but there are many options to
01:08:53 treat I think there’s this is kind of a
01:08:55 list list uh we have guides on our
01:08:56 website about this uh there are many
01:08:58 different sources you can use um so
01:09:01 there’s a lot and so there’s more hope
01:09:04 you know I put I finish with you know
01:09:06 the extreme situation of something of
01:09:08 somebody who could not be helped um but
01:09:11 I would say the vast majority of my
01:09:13 patients we find something um to help to
01:09:16 relieve partially or at least to cope um
01:09:19 and that’s uh I think that’s very
01:09:21 important so back to our Concepts as we
01:09:23 close uh so each person does need a
01:09:26 personalized plan and you need a medical
01:09:29 guidance to do that usually it’s
01:09:32 complicated uh it’s influenced by a ton
01:09:34 of things which each requires
01:09:37 consideration and as you’ve seen mental
01:09:39 health and neck pain or TMJ pain and
01:09:42 sinus pain I didn’t talk a lot a lot
01:09:44 about those but they are also sometimes
01:09:46 key um you need allies um it is chronic
01:09:50 it’s a lifelong Jour it’s not fair it is
01:09:54 a brain disease
01:09:56 um be aware of pseudo science and fake
01:09:58 claims and sometimes it’s very tough but
01:10:01 we definitely have more options now and
01:10:03 there are uh there’s also research going
01:10:06 on all right so we’re here to help um
01:10:09 you know what we do at migr Canada is to
01:10:12 make this accessible to you guys so the
01:10:16 app was created to help you monitor your
01:10:18 headaches uh the list of headache
01:10:20 clinics is there to help you find you a
01:10:22 specialist it’s growing uh we have all
01:10:25 our PDFs podcast webinars we try to make
01:10:28 it clear for you uh the our website will
01:10:31 be fully updated and renewed in the next
01:10:34 two or three months so look it up
01:10:36 because we’ve had some comments saying
01:10:38 that information was tough to find uh so
01:10:41 we heard that loud and clear we do
01:10:43 advocate for access to care coverage but
01:10:46 also access to better trained healthc
01:10:48 Care Professionals in partnership with
01:10:50 the Canadian Headache Society and we
01:10:52 also work on uh workplace awareness to
01:10:54 try to improve understanding of migraine
01:10:57 in the workplace uh and uh putting in
01:11:00 place policies to support people with
01:11:02 migraines so this is our amazing board U
01:11:05 missing from this picture is also uh uh
01:11:07 Malak our social media uh responsible
01:11:11 person and uh and Kaye who you’ve seen
01:11:13 tonight and also all of our volunteers
01:11:16 our summer students um and people who uh
01:11:20 app manager website master all our team
01:11:24 [Music]