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Migraine (transcript)
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(Clock ticking)

(Heart beat)

(Music)

(Dr. Peter Salgo) 
Welcome to Second Opinion where each week we solve a real medical mystery.  When we close this case file in a half an hour from now you'll not only know the outcome of this week's case, you'll be better able to take charge of your own health care.  I'm your host, Dr. Peter Salgo, and you've already met our special guests who are joining our cast of regulars, primary care physician Dr. Lisa Harris and communications expert, Kathy Cole-Kelly.  No one on this panel knows the case.  I've got it right here and we're going to get right to work.  Folks, I'm going to tell you a little bit about Mary Ann.  Mary Ann is forty-two years old.  It is 9 P.M. and do you know where Mary Ann is?  She's in the emergency room.  She had four days of a severe headache.  She had vomiting and what she calls - these are her words in quotes in the chart - "falling into walls."  She tells her ER doctor that the pain was so bad she just couldn't take it anymore.  Lisa, you're in the emergency room.  What is wrong with Mary Ann?

(Dr. Lisa Harris)  
Certainly, there are several things that pop up - that she's been falling into walls for four days is very concerning and having a headache of that sort.  Has she had headaches before?

(Peter)  
Oh, she sure has.  She's had what she calls migraines since the age of seven and she's been taking a lot of drugs for them over the years - Vicodin, Zofran, Compazin, Motrin, Tylenol.  Anything else you want to know?  I can give you some family history, if you'd like.

(Lisa)  
Sure.

(Peter) 
Mother, grandmother, aunts all had migraines.

(Lisa)
They all had headaches, let me guess.

(Peter)
She smokes, she's got a stressful job, she has two children age nine and eleven.  She drinks diet cola, occasionally she drinks red wine and she gets a migraine two to three times a month and when she does she has to lie in complete darkness.  She's had the same primary care doctor for the past fifteen years.  How would you define migraine?

(Dr. Deborah Friedman)  
It's a recurrent disorder that usually encompasses headache; sometimes there's other symptoms.  The headaches tend to be very severe in intensity.  They are often located on one side of the head.  They tend to be throbbing or pounding.  They're disabling.  People can't function during the migraine.  They often can't think straight and they get extremely sensitive to light, sensitive to noise, odors bother them, moving around bothers them, touching anything bothers them and they usually last many hours to days sometimes.

(Peter) 
We're talking about severe disabling disease here.  What's going on in the body that's causing these horrific symptoms?

(Deborah)  
What's going on in the brain?  Several things.  There are electrical changes in the brain that generally start in the back of the head and there's a wave of basically excitement in nerve cells that's followed by a wave of decreased activity of nerve cells and that phenomenon basically triggers a whole series of reactions in the brain so there end up being changes in blood vessels that dilate.  They release chemicals that tend to be very irritating and they provoke pain and there are various areas of the brain that are involved, so areas that control emotion are involved.  The areas clearly that sense pain are involved.  The areas in the back of the brain that make you nauseous are involved, so it's an entire brain process and it also extends down to the neck as well.

(Peter) 
Do they come in different flavors?  Are there different kinds of headaches, migraines and others?

(Deborah)  
There are lots of different kinds of headaches and there are lots of different kinds of migraines. 

(Dr. Mark Hyman)
Yes

(Deborah)
I think the thing that usually gets confused for a migraine most frequently is sinus headache.

(Peter) 
What's a cluster headache?  That's something I heard about in medical school and it always confused the heck out of me.

(Kathy Farmer)  
A cluster headache is found mainly in men.  It is excruciating and people go to the ER and they're considered psychiatric.

(Lisa)  
The interesting thing about clusters is it comes in spurts and you may have long periods where you don't have headaches, but we think the path of physiology is the same and cluster headaches do respond to tryptamine medications.

(Dr. Mark Hyman)  
The fact that migraine is just a name of a headache collection of symptoms and it may be that there are dozens of different types and dozens of different causes.  Unless you find out what the cause is for you then you're not going to solve the problem and you're going to be dependent on medications and dependent on treatments that you might not otherwise need.

(Dr. Peter Salgo) 
It's funny you mention what causes it for you.  We happen to have a you here.  Melissa, that would be you.  Tell me a little bit about your headaches.

(Melissa Lipani)   
I actually started having blindness episodes when I was a teenager all the time on my right eye only and it would start like a sun spot and then it would encompass my entire eye and that was diagnosed as retina migraine syndrome and I suffered from that usually about three episodes a month lasting about ten to fifteen minutes of complete blindness in my right eye for nearly fifteen years and then in the last three years I've started developing the headaches.

(Peter) 
So it's changed from a visual thing to a pain thing.

(Melissa)   
Correct.

(Peter) 
Was there anything in your life, like your menstrual cycle, that would tend to trigger these things or what the timing would be?

(Melissa)   
With the visual aura, yes.  Those would be timed either with extreme physical activity or my menstrual cycle.  The headaches I'm still trying to pinpoint.  For me it seems like there's a lot of dietary triggers.

(Mark)  
Like what?

(Melissa)   
Red wine being a huge one.

(Mark)  
Sulfites maybe.

(Melissa Lipani)   
Nitrates, deli meats or processed foods seem to be a trigger.

(Peter) 
Let me tell you a little bit about Mary Ann.  She does not notice a difference in the frequency of her migraines around her period, but she recently has been getting more frequent migraines and her doctor told her to stop drinking anything with caffeine and to give up red wine altogether.  You were touching on this.  You want to start us off, why?

(Mark)  
In any person with a migraine there may be multiple causes, one of which are food substances that are chemicals, such as MSG or aspartame in diet sodas or sulphites which are in red wine or nitrates, as you mentioned, in deli processed foods, so if you really want to isolate those it's probably best to get rid of all the processed and junk food in your diet and all the alcohol and all the caffeine. 

(Peter) 
Why the caffeine?  Is it the sulphites in the wine that they're worried about?

(Dr. Mark Hyman)  
It's in the sulphites generally.

(Peter) 
But why the caffeine?  I always was taught that the constriction, squeezing the blood vessels and make the pain better.

(Deborah)   
Caffeine is a dual edged sword,

(Mark)
Right.

(Deborah)
so taken when the migraine comes on it tends to work very well, but for people that are drinking or eating a lot of caffeine it makes their underlying headaches worse and sometimes it turns an episodic migraine into a chronic daily headache that just never goes away.

(Lisa)  
And there's one thing that Mark said that I disagree with.  I think the foods are triggers but not the cause.  We don't really understand the cause.

(Kathy Cole-Kelly)  
I think stress can be a really important piece which would still be important to talk about in terms of treatment of helping people learn how to deal with stress.

(Dr. Peter Salgo) 
I don't think it would be complete at this point to talk about migraines without mentioning something that we just know is out there, which is a lot of people don't believe migraines exist.  They think people overuse the term; that it's a very convenient crutch - I don't want to go to work today.  Ah, I've got a migraine.  You must have heard this too.  Do you deal with that?

(Melissa)   
Yes, (laughs) but as my husband could tell you, when he sees me in that state it's very concerning for him.  I have difficulty speaking. I'm beyond nauseous.  Any movement at all just makes the back of my head feel like it's going to explode, but to see me in that state I think for him is very difficult and I'm sure in his mind solidifies the reality of that suffering.  From an outsider's perspective until you've experienced that kind of level of pain it's probably hard to imagine.

(Peter) 
How big a problem is migraine in the United States?

(Deborah)  
There are over thirty million Americans who have migraine. 

(Peter)
30 million.

(Deborah)
It affects eighteen percent of women, six percent of men, seven percent of children.  It's the most common neurologic disease by an order of magnitude.

(Peter) 
I get to pause for a minute and sum up where we are.  Migraine is a disease; it's not in your imagination.  Migraine headaches are real.  They can be disabling.  It is a severe, serious problem for the person who's got it and apparently millions and millions of people get this disease.  Let me tell you a little bit more about Mary Ann.  I'll tell you what she's taking.  She's taking Vicodin...

(Lisa)  
Oh God.

(Peter) 
I knew you were going to say that.  Zofran, Compazin, Motrin and Tylenol.  It doesn't sound as if you're surprised, are you?

(Dr. Lisa Harris)  
No, I'm not.  That's just a nasty mix.

(Mark)  
She's going to need a liver and kidney transplant soon.

(Lisa)  
Exactly.

(Deborah)  
How often is she taking these medications, particularly Motrin and Tylenol?

(Peter) 
Her prescription is already for 240 Vicodin per month.

(Mark)  
Wow.

(Dr. Deborah Friedman)  
That's a problem.

(Peter) 
I'll tell you that she's tried a drug called Triptan once.  It seemed to work.  How does that stop a migraine and why is that different from the drugs she's taking?

(Deborah)  
Triptans work very specifically for a migraine and they were designed to interact with specific receptors in the brain called serotonin receptors that help modulate pain in the brain.  They also have actions on blood vessels and so they were designed to not only eliminate migraine pain, but also to eliminate or diminish the other associated symptoms of migraine - the sensitivity to light and the nausea.

(Dr. Peter Salgo) 
It appears that Mary Ann gave up on the triptans not because they didn't work; they did, but she thought the other drugs were cheaper and she didn't want to pay for triptans.  What's the big deal?  If the Vicodin works why can't you just take the Vicodin?

(Lisa)  
The Vicodin doesn't work.  She now has a chronic daily headache from medication overuse.

(Peter) 
How can you get a headache from using a headache treatment?

(Mark)  
Rebound headache.

(Peter) 
What's that?

(Dr. Mark Hyman)  
Well, you rebound when you withdraw from the medication - rebounding another headache when you need more medication.

(Peter) 
Let me come back to the real situation here.  Mary Ann is in the emergency room.  She's in excruciating pain.  They did a CT scan of her head.  It was unremarkable. What does that mean?

(Lisa)  
That means that she didn't have an obvious bleed in her brain and other than that they can't make much of it.  If you're really looking for something in the brain you need to do an MR and not a CT scan.

(Peter) 
So, at this moment in the emergency room what they did is they plugged her into an IV.  They rehydrated her but she's told to follow-up with her primary care physician the next day and she does.  It sounds hopeless.

(Lisa)  
It's absolutely not hopeless.  The first thing we need to do is get a good handle on how frequently she's having headaches.  One of the things you would do is talk to her about migraines, what they really are, have her keep a headache diary so we can get a pattern of her headaches and the activities and the foods and things so you can get a better idea of what some of her triggers may be.

(Peter) 
You've had headaches a long, long time.  You've been in doctor's offices talking about this.  Have you ever felt hopeless?  Have you ever felt there's no light at the end of the tunnel here?

(Melissa)   
What I do think is that it's hard to always know exactly what to do for yourself and when to do it and a lot of these medications - well, they are expensive.  I can definitely agree with that even with health insurance, but also, they don't necessarily work once the headache has come on and so I think it's really frustrating when you are living with these kinds of headaches to try to figure out how to manage it.  You might think you're doing everything right and you're doing your headache diary and you're trying to watch what you eat and everything else and yet sometimes it is still hard to get a handle on it, so I think it can be pretty frustrating at times.

(Dr. Peter Salgo) 
Do you want to know what her primary care physician said?  Go to a headache clinic and she sends her to a headache clinic.  Now at first blush, simply grammatically this sounds like a bad place. It's a place that gives you a headache, but I'm sure that's not what a headache clinic is.

(Kathy)  
No.  About eighty percent of the people we see are like Mary Ann.  We have a one week program in which they see the physician daily, psychologist daily, physical   therapy daily.  It's much easier to prevent a case like Mary Ann than to treat it.

(Peter) 
Tell me what happens in a headache clinic.

(Kathy)  
Well, what happens is there's a protocol called DHE protocol in which it stops the headache.  We have to stop the headache for her to look at the other factors in her life.

(Deborah)  
DHE, it was developed in 1945.

(Lisa)  
What did you say?  It is a what?

(Deborah)  
Dihydroergotamine.  We often use it in the inpatient setting and I would admit this woman if she came to my office to try to break the cycle of headache.  It's given intravenously usually three or four times a day along with IV fluids and medication for nausea because it tends to be very  nauseating.

(Peter) 
When you talk to somebody with migraines, what specific information are you trying to get from them to help you work on a treatment plan?  What are you asking for?

(Kathy)  
Well, as a psychologist I want to know that there's psychological milestones.  There's something in Mary Ann's history which occurred at the same time the chronification occurred, so my job is to help her resolve those issues.

(Kathy)  
Kathy, as part of what you do at your center is relaxation training?

(Kathy Farmer)  
Yes, biofeedback.  Feedback in relaxation and that's a tool to turn off the fight of flight response.

(Peter) 
Is there anything else you want to know when you're talking to a migrainer?  What do you need to know?

(Deborah)  
I want to know exactly what she's taking.  We've heard about the Vicodin, but we really haven't heard about all the rest of it and so I want to know exactly what  she's taking and I usually tell people I'm not going to yell but I need to know really, truly what you're taking.

(Peter) 
I'll tell you what the clinic recommends.  They say to Mary Ann, look, first of all, you've got to get off the Vicodin so they want her to start a withdrawal program keeping in mind that the painkillers have worked for her for a while.  They also want to start her on Triptan again and they want her to go to smoking cessation classes and basically change her life and they say good-bye, please come back and talk with us again.  Is this going to work?

(Mark)
Probably not!)

(Deborah)  
I think they omitted one really important step other than the things that we've already talked about is preventative treatment.  There are a lot of good medications that we use to prevent migraines.  I also think it's important not to blame the patient for their condition and many of the things that we've talked about today it makes it sound like it's their fault.  You're eating this stuff so it's your fault.  Maybe fifty percent of people with migraine identify triggers.  The other fifty percent don't.  Or there are triggers that you can't control like changes in the weather.

(Peter) 
Do you want to know what happened with Mary Ann?  She got frustrated.  She didn't like the advice and she says, look, I've been dealing with migraines forever.  The pain that I have goes away most of the time.  Obviously, it didn't in the time  we've encountered her - if I take my pain med.  I want Vicodin.  I don't want to get off the Vicodin.  I don't want to go on this new stuff.  It might not work.  So she fires her doctor.  She does not go back to the clinic, at least so far in the chart and she finds one that will give her a prescription for Vicodin.  Does she have a right to do that?

(Dr. Lisa Harris)  
Well, patients have a right to do whatever they want to, but she needs to understand the consequences.

(Dr. Peter Salgo) 
What's going on here?

(Kathy)
Well that's talking about the quality of the doctor/patient relationship and how the patient is hearing the physician and what's being said to them.

(Peter) 
But what's going wrong?  She's had MRI's.  She's had CT scans.  She's been to the emergency room.  They referred her to a headache clinic.  What's fallen through the cracks?  It doesn't sound like she's getting the care she needs.

(Lisa)  
Communication. She's not getting the communication.

(Peter) 
What kind of communication is missing?  What should they be doing?  Could they have done more?

(Lisa)  
There hasn't been a basic connection at the level of the patient to find out where she is and what she's thinking to understand where she is in this process and how we need to address the problem.

(Kathy)  
What I always teach medical students is to ask the patient to restate to you what they understand is the problem and this would be a perfect example of why that's so important.

(Mark)  
And I always ask the patient what is your goal?  What do you want to have happen?  Where do you want to go with all this? And they'll tell you.

(Kathy)  
And many times when the patient reaches this stage they're really treating another problem; not just the pain.  Anxiety or -

(Peter) 
That's another thought.  I want to sum up what we were doing so far.  Dealing with migraines can be, as you can tell, very frustrating not only for the patient but frustrating for the doctor too.  Effective communication is critical to the treatment process, otherwise the patient isn't going to get treated appropriately and not going to get help.  What's the appropriate treatment right now?

(Mark)  
Preventatively I think is where I would focus first and the things that I would do immediately are put her on a regimen that I found very success in my practice which is put her on an elimination diet.  Get rid of the common food allergens or sensitivities.  That's gluten, dairy, eggs, yeast and corn and doing that often alone can have a dramatic impact.  I would put her on a number of nutrients.  Based on her history I would need more information, but things that often are effective are magnesium, Riboflavin which is B2 and often CoQ10  and I would look at her hormonal balance, whether she's having premenstrual migraines and work with that if I needed to.  There's a series of things that can be very effective and be very powerful interventions that I've seen work over and over again.

(Peter) 
What would be a textbook answer, not that your answer's wrong, but what would be a textbook answer?

(Dr. Deborah Friedman)  
That's not opposed to the textbook at all.  I have a slightly different approach to the diet.  I like to eat, personally, I enjoy food.  So if somebody told me that I had to go on a diet I would probably die.

(Mark)  
Not permanently; just as a test.  This is a test.  I maybe didn't make myself clear; just as a test for two weeks or for enough time to give yourself a sense of whether or not it's going to be effective and then you reintroduce the foods and see if they trigger the migraines.

(Deborah)  
That's one approach.  My approach is the other way around.  I have people keep a diet and symptom journal and write down everything they eat, everything they drink.  Be as specific as they can.  Do it for a couple of weeks and take a look at it and see what seems to connect with their diet and their headaches, but either approach is valid.

(Dr. Mark Hyman)  
You may not find out because there might be more than one thing so if you take one away it doesn't make you better.

(Deborah)  
I know what most of them are so I can usually look at the list and say cut out this, this, this and this.

(Peter) 
She's telling me she'd rather not die.

(Deborah)  
Both approaches have worked.

(Dr. Peter Salgo) 
Let me talk a little bit about the medications now.  I haven't heard anybody say that you want to keep giving her Vicodin.

(Lisa)  
No.

(Deborah)  
No, no way.

(Peter) 
So, if you're not going to give her Vicodin, what do you want to give her for her pain?  What are the other drugs that are out there?  What can stop the pain?

(Lisa)  
She needs to be on preventive medications and there's a laundry list.  Diane can tell it better than I can, but one of which would be something like Topiramate.  You can use calcium channel blockers.  You can use beta blockers.

(Peter) 
These are all medications that if you know that you're a person who suffers from migraines you can take chronically to try to decrease them.  Are these medications you take when you have an aura?

(Deborah)  
No.  You take them every day.

(Peter) 
Every day, chronic medications.  Come back to the pain meds.

(Dr. Deborah Friedman)  
In her case the key to her successful treatment, or one of them, is you have to stop her pain cycle and as long as she's in pain she's not going to want to stop using analgesics and she's not going to believe what you say about analgesic overuse.  I would hospitalize her and I would give her probably dihydroergotamine and maybe other medications by vein to try to break her pain cycle so that we can introduce a slightly healthier way of managing her headaches.

(Dr. Lisa Harris)  
And I have to throw in here - this is the worst case scenario.  We have to remember there are thirty million migraines - we have to make sure that we impress upon our audience that many, many, many migraines, the vast majority, are not as severe as this case that we're seeing and can be adequately treated and certainly you need to get to the dietary stuff -

(Peter) 
Let me run down some of the options out there for the pain.  NSAIDs, Motrin, aspirin, for example.

(Lisa)  
Stop it.  Stop it.

(Peter) 
Did it work?

(Deborah)  
They work on a short term basis, but most of them cause medication overuse headache in the long term basis.

(Dr. Peter Salgo) 
So they give you rebound if you use them a lot.  Things like acupuncture.  Does it work?

(Kathy)  
Yes, it does work.

(Peter) 
How well?

(Kathy)  
There have been studies to show it works.

(Mark)  
Nothing works for everybody because migraine is not one disease.  It may be twenty-nine different diseases, so in one person acupuncture may help.  Another person magnesium might help.  Another person getting rid of gluten or eggs might help.  Another person CoQ10 might help.  It's very individualized.

(Peter) 
What about biofeedback?  That's been in the literature.  You open the magazines every day - biofeedback cures everything - even halitosis.  What does it do against migraines?  Helpful?  Not helpful?

(Kathy Farmer)  
I think it's the tool for almost any pain management.  It's the tool because it turns down the volume of the pain and it helps them calm their nervous system.

(Kathy Cole-Kelly)  
And it gives the patient a sense of their own control which I think is so important.

(Melissa)   
Can you guys explain what biofeedback is because I don't even know what that means.

(Kathy)  
Thermo biofeedback is you warm your finger temperature to ninety-six degrees.  The average finger temperature is eighty-five degrees.

(Peter) 
But you don't your finger in a pot of warm water, right?

(Kathy)  
No, it's internal.

(Peter)
You say to yourself I'm going to warm my fingers by focusing on what my fingers are telling me.

(Mark)  
It's the power of the mind, engaging the power of the mind to change your biology and your physiology by having feedback about what's happening.

(Lisa)  
If you don't buy into that it's not going to work, so the patient has to believe that they're able to do that.

(Peter) 
But I've seen biofeedback machines.  You put a temperature sensor on the finger and you focus on trying to make that warmer and some people can do that.

(Mark)  
Stress is one of the major triggers of migraines and it affects or makes worse or causes ninety-five percent of all disease, so in migraines it particularly is a major factor in exacerbating or worsening a symptom, but it may not be the only factor.

(Dr. Peter Salgo) 
What about massage therapy?  Does that work?

(Lisa)  
I think massage could be useful for stress reduction if you're going to use it in a preventive mode, but if you're in the midst of having a migraine and someone tries to massage you you might end up decking them.

(Peter) 
I did want to point out that one person's going to be decked and one person's going to be dead if you do some therapies for migraines.  Help me out here.

(Deborah)  
There are certainly preventative treatments that have been shown in studies to be effective including magnesium, Riboflavin, Coenzyme 10 and butterbur  but we also have a whole host of prescription drugs, if you will, that are extremely effective and one size does not fit all and sometimes you have to try a few of them before you get it right, but it's important to really emphasize the concept of holistic as well as medicinal prevention.

(Peter) 
Is this poor woman - is Mary Ann ever going to be cured of her migraines?

(Deborah) 
Well, cure really means - if you look at the dictionary definition - restoring someone to good health.  It doesn't mean eradicating the underlying problem.

(Peter) 
Let me just say that if you're treating something by avoidance or by giving some medication and the symptoms don't recur, that's not necessarily the same as being cured, but it sure feels better than having symptoms.  We're going to stop right here for a moment and sum up what we've been talking about, which has been quite a bit.  I can boil it down.  While there is no cure for migraine, effective management of migraine is possible through lifestyle changes and pharmacologic interventions.  It's a mixed individualized for each patient.  Everybody agree on that?  Is it fair?

(Everyone)  
Yes.

(Peter) 
All right.  I can tell you a little bit more about our patient.  What she finally wound up doing was going to the hospital and getting admitted.  Mary Ann was taken off of the medications that she had been using in copious quantities prior to that.  Started on lifestyle changes.  Given other medications to take if she needed them, but I think she's been convinced that she doesn't need to take powerful painkilling drugs just to deal with this disease, so not a bad outcome.  How are you doing?

(Melissa Lipani)  
Doing well right now, thank you.  I've learned a lot just by talking on the panel today.  I think there's some options out there that I hadn't even been aware of, so I definitely would like to explore some of that.

(Peter) 
I want to thank al of you for being here.  Another tremendous discussion.  Before we leave let's sum a lot of things up.  We did cover a lot of ground today, a lot to remember.   Migraine is a disease.  Migraine headaches are real.  Migraine headaches can be disabling.  Dealing with migraines can be very frustrating for the patient and for the doctor.  Effective communication is critical to the treatment process and while there is no cure for migraine effective management of migraine is possible through lifestyle changes and pharmacologic interventions.  Our final message is this - taking charge of your health means being informed and having quality communications with your doctor.  I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.

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