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The Dose Transcript for May 9, 2024

Host: Brian Goldman

BRIAN GOLDMAN: Hi, I'm Dr. Brian Goldman. Welcome to The Dose. 4.5 million Canadians have migraines. That statistic comes from Migraine Canada. I happen to be one of them. My headaches these days are mild, and I'm happy for that. What I do get is a blind spot in my vision and a bit of disorientation. For many others, though, the pain and nausea are dealbreakers. With a plethora of new treatments, we are asking, therefore, how should I treat migraine attacks? Dr. Elizabeth Leroux, welcome to The Dose.

ELIZABETH LEROUX: Hey. Hello, Brian. How are you?

BRIAN GOLDMAN: I'm fine today. I'm fine. You know, and, you know, there have been a number of weather changes, particularly in the last couple of months, where I've had my ups and downs with migraines. But before we begin our formal conversation, can you give us a hi, my name is? Tell us what you do and where you do it.

ELIZABETH LEROUX: Hi, my name is Dr. Elizabeth Leroux. I'm a neurologist and a headache specialist here in Montreal in Quebec. I'm also a past president of the Canadian Headache Society, the founder of Migraine Quebec, and the founder and current chair of Migraine Canada. I am a faculty lecturer at McGill Neurology Department and I love my job. I love what I do, and I'm happy to be here.

BRIAN GOLDMAN: It sounds like you love your job, which is why I'm really thrilled to be speaking with you today. Let's begin our conversation, Dr. Leroux, with a little bit of headache 101. There are tension headaches and there are migraines. What are some of the essential differences between the two?

ELIZABETH LEROUX: So that's relatively easy. A tension headache is a very common human experience, right? Close to 90% of human beings will have one. And it's just a headache. So it's bilateral, both sides, not severe usually and no other symptoms, and usually will go away with a bit of time or a bit of rest, and that's it. A migraine attack is a neurological event. So it is a headache that has some particularities, often on one side, but not always, sometimes pulsatile or throbbing. And then it comes with other symptoms. So those symptoms may be nausea, vomiting sometimes, a sensory hypersensitivity. So sensitivity to light, sound, smells, movement, and then other pains, neck pain, sinus pain, TMJ pain on the jaw, and finally, some cognitive issues, brain fog, irritability. And some patients with migraine also have what we call an aura, which is losing vision or seeing stars or weird things. So it's a bit of a mixed buffet that reflects the neurological storm that happens in the brain during such an attack.

BRIAN GOLDMAN: And, you know, I'll just say, you know, one of the best things about being the host of The Dose is I get to talk about my own stuff. I get the scotoma, the blind Spot with some flashing lights. And I have, you know, you called it brain fog. It's a bit of disorientation. It's more than just… because brain fog, for a lot of us, we think it means that, you know, we're kind of not firing on all cylinders, and it's deeper than that. Like I almost feel like I'm not part of my own body, like I'm an observer in the world, but I'm not part of the world. And it lasts for about 20 minutes, and then I get the headache after that. So that's in keeping with classic migraine, isn't it?

ELIZABETH LEROUX: Yes. Your description fits a visual aura with some cognitive elements. And some people with aura, it goes more than vision. Sometimes, people will actually lose their ability to speak or understand. Some people will have sensory symptoms, will become tingly on one side. And in extreme genetic cases, sometimes people will even paralyze. But that's exceptional. Don't think that paralyzing is a typical migraine symptom. If you have that, please seek medical advice. But visual aura is known to maybe a third of people with migraine will have a few of these.

BRIAN GOLDMAN: And there are some commonalities between what you and I have just described, what you've described so well as an aura and a TIA, a transient ischemic attack or a stroke.

ELIZABETH LEROUX: Oh yeah, absolutely. So when someone… I mean, if you have a new headache, please do not assume it's a migraine. That's a very important message. Because if you live with migraine and you have a headache that you never had before, that's not like your migraine, remember, there's 200 causes of headache. It can be a lot of things. It can be meningitis, sinusitis, a stroke, a tumour, who knows. So migraine is a disease that is chronic. It goes over time. Those are repeated attacks, and the person knows them. If there's anything new or unusual, please seek a proper diagnosis. Lesson one in headache.

BRIAN GOLDMAN: So what do we know about what happens inside the body to cause all of these phenomena, the aura and then the headache itself?

ELIZABETH LEROUX: So one thing I try to promote is to never tell a person with migraine that we don't know what the cause is, because it's not true anymore. Maybe a century ago, we didn't know anything. But now, we have many pieces of this puzzle. And the one piece that we understand better and better is the nature of the pain and what I call the migraine cascade. So the migraine is brain has a particular software. It is kind of engineered to be sensitive to different triggers, different changes in the bodily environment or in the worldly environment. And once a certain threshold is reached, the brain will do something very strange. It will trigger a reaction where the sensory nerves that are supposed to kind of carry pain to the brain will kind of sprinkle themselves with inflammatory proteins, and that will actually cause the pulsatile pain of migraine. So a migraine attack is a very complex brain event. It is something that we understand. We know a lot about the chemistry of it, the electricity of it, the genetics of it, and that's why it's a bit difficult to summarize. But we know what happens during a migraine attack in the brain.

BRIAN GOLDMAN: Do we know why women experience migraines more frequently than men?

ELIZABETH LEROUX: In part. So if I were to tell you it's them hormones, it's a bit not specific enough. If I want to dig deeper, I would say that after puberty, that's where we see little boys and little girls separating and women starting having more migraine than men. The menstrual cycle is a cause for menstrual attacks. They’re very common in females with migraine when oestrogen and progesterone drops. It's probably more the oestrogen, but the brain of the female human being is different. There are a lot of other things that different hormones, including progesterone and oxytocin, will do to the female brain that will make it more prone to chronic pain diseases in general, and also migraine.

BRIAN GOLDMAN: How does ageing affect migraine headaches?

ELIZABETH LEROUX: Well, that's another very interesting and actually encouraging question, because it's true that for females, after menopause, a percentage of women will improve, and some of them really significantly. Well, so that's part of the diversity of migraine. You know, migraine is a brain disorder, but it is influenced by a lot of different factors. And for a subgroup of ladies, one of these factors is hormones. So for some women, I call them hormonal dependent or hormonal sensible, they will have menstrual migraine. They will get much better with pregnancy. They might be influenced by oral contraceptives. And then when they reach menopause, sometimes it will almost disappear. And if you ask those women, sometimes in their family, the women, the females in the family also reported a similar evolution. But that's a subgroup of migraine. I have patients, women where hormones play no role. So a lot of diversity there.

BRIAN GOLDMAN: Got it. Now, you mentioned genetics. And, you know, my late mother had migraines, and so I had migraines. So how strong is the genetic effect?

ELIZABETH LEROUX: The genetic effect is definitely present. There's more than 140 genes that have been linked to migraines. So it's not like, you know, one gene and then blue eye or brown eye thing. So it's not like one pendant around your neck. It's like a string of pearls, you know? So that probably explains the symptomatology and the diversity of it. So there are some genes, for example, that are linked to something called hemiplegic migraine. So those big auras where people paralyze. But that's extremely rare. Actually, I have patients where the whole family has migraine, and I have patients where they are the chosen one, you know, nobody else. So it's a bit puzzling, but that's probably because of all those combinations of genes that can lead to different types of migraine.

BRIAN GOLDMAN: And this leads perfectly into what I was going to ask you next, which is triggers. And, you know, different people have different triggers. I mean, there are… I remember classically they used to list about a half a dozen triggers, food triggers. But obviously, it is more complicated, which is why we're asking you. Let's start with how alkaloids like alcohol, caffeine and nicotine can affect migraines.

ELIZABETH LEROUX: If you look at the triggers, there's a long list of them. And most triggers cannot, are not powerful enough in themselves. So usually, they will come in combination. Alcohol is a well-known one, but one thing I always tell my patients is it’s very useful to know about your triggers, the ones you can control. If you cannot control them, then it's better to focus on what I call protective habits and treatments. And I assume we'll talk about that later. But if we look at triggers, so alcohol is one. Everything sleep related. Too much sleep, not enough sleep, skipping meals, emotional variation. So not only stress, sometimes it can be excitement or anger. Fuels, toxins, smokes, perfumes. A lot of patients are very sensitive to those kind of smells. And then of course, we mentioned already the hormonal fluctuations, and whether changes for some patients can impact neck pain, inflammation, other things going on in the body. You know, the list is really virtually endless. But all of those triggers coalesce into what we call oxidative stress, which is kind of a mental load, the energy load on the brain. So we think that's why they coalesce and they accumulate and build up to the migraine attack.

BRIAN GOLDMAN: Oxidative stress?

ELIZABETH LEROUX: Yeah.

BRIAN GOLDMAN: Can you say more about that? Because, you know, this resonates with me because for a long time, we've talked about holiday headaches, you know, that people are under stress. I think people tend to think of it as emotional stress. But for me, it's always been cognitive stress, having too many things to do at once, too much, too much, too much. And then it ends, and then I get the migraine.

ELIZABETH LEROUX: Yeah, we call that the release migraines. They’re terrible because they happen when you thought you would have that, you know, wonderful weekend. And we think that's also another change that happens after a stress release, which is a sudden drop in cortisol. And that might actually be a trigger, but there's all kinds of things that happen during a stress release on neurotransmitters. So when I talk about oxidative stress, it's really our brain is like a computer. You know, you have a certain amount of fuel and power, and you have a certain amount of demands and sensory demands, integration demands, cognitive demands, emotional demands. And we believe that that's when there's a mismatch between too that the migraine starts. So it's where, you know, behavioural lifestyle changes can help the person with migraine by modulating the triggers and the environment. But also importantly, never forget that the migraine brain has a particular genetic software, and that also can be treated with medications.

BRIAN GOLDMAN: Now, people are saying, experts are saying that alcohol can trigger migraines. I remember that it was red wine, that it contained tyramine. So red wine, pickled herring, processed meats, that kind of thing. But that's not necessarily the case, is it?

ELIZABETH LEROUX: No, it's not. And people focus on diet because they can control it. So sometimes, they will come to my office, they eat virtually nothing anymore. And sometimes, those triggers actually are not relevant for them. I mean, a famous example is chocolate. And there's been a study interestingly showing that chocolate is not a trigger for migraine for 90% of the people with migraine. So a lot of people deprive themselves of food because they're trying to do everything right to get rid of the migraine. So I would say like probably skipping meals, maybe alcohol, and then the occasional other food trigger. But those histamine, tyramine hypotheses, I'm not saying that they do not affect a subgroup of people with migraine, but please do not deprive yourself of food and seek medical help, because sometimes, it's not about avoiding your life. It's about actually raising your brain tolerance to treat the disease.

BRIAN GOLDMAN: But for individuals, once they know their triggers, that those tend to be repetitive triggers for them.

ELIZABETH LEROUX: Yes, if that's clear. When people arrive to me, right, it’s often after years and years or decades of migraine, and they have kind of figured this out. So if you have figured out triggers, then avoid them. But some of them are more difficult to manage. For example, you know, neck tension, emotional thing, mental load. So that's a forest of triggers that you have to avoid. And that's where we're trying to say, well, managing migraine is not only about avoiding triggers, because sometimes, your threshold is so low that just living and going to work and doing things with your family is unbearable. And that's where I think medical care comes in.

BRIAN GOLDMAN: Okay. We could spend the next two hours just talking about triggers. They're obviously important, but we have to move on. What are the most effective ways to stop or abort a migraine headache in its earliest stages?

ELIZABETH LEROUX: So acute treatment, which is something you take as needed, you know, when the attack starts. There are many different categories and classes of treatments you can use. Usually, acetaminophen or good old Tylenol is not really powerful. Like it's very common that it doesn't work for migraine. Then you have anti-inflammatories, you know, aspirin, ibuprofen, naproxen, diclofenac and all those. Those can be over-the-counter or on prescription. And then the big revolution that happened in the 90s were the triptans. So triptans can be life changing. They have things like Zomig, Imitrex, Maxalt, you know, Relpax. There are seven of them. And triptans can be extremely helpful for some people with migraine, though sometimes, there are two bad sides. One is that sometimes, they're not super well tolerated. So people say, my attack goes away, but I feel somnolent. I cannot go back to work. So that's not good. And the other thing is if you have to use a lot of triptans, you might have what we call rebound headaches or medication overuse headache. And the last class that just arrived in Canada this very, this very month or a few months are the gepants. So gepants are drugs that act on a little protein. So it's kind of a designer drug for migraine. And interestingly, gepants can be used for acute treatment and prevention. And then you can add and sprinkle things like neuromodulation things, meditation, acupuncture, massage oils and any other, you know, kind of a remedy that can help you and drugs for nausea. So we have a very big cookbook to treat the migraine attack, and that's usually, you will need the help of a doctor to navigate that.

BRIAN GOLDMAN: And, you know, there are people who are going to be listening to this conversation because they're intensely interested in the subject of migraine headaches and others who are just interested in health. You know, I want to point out we are talking a lot about medications, prescription medications. And, you know, it's not that we're pushing medications.

ELIZABETH LEROUX: oh no, we're not.

BRIAN GOLDMAN: How many people, what percentage of people with migraine headaches actually need medications to be able to function?

ELIZABETH LEROUX: To be honest, if we talk about acute treatment, I would say probably a good three quarters of them would need. But then, I mean, the problem with migraine is that a lot of people endure a lot and are not treated properly. Now, my motto is like migraine is not treated with water. Because if you talk to people with migraine, they will tell you that they're sick and tired of being told, you know, oh my God, did you think about Advil? Or oh my God, did you drink enough water today?

BRIAN GOLDMAN: Yeah. Yeah. Yeah.

ELIZABETH LEROUX: And everybody goes at them with their remedies and things that ultimately have not worked. And do not forget that migraine starts sometimes in childhood and teenage. And we're talking about decades of disabling attacks going on and on and on. If you have three per year, that's one thing. But if you have eight, 10, 20 per month, that becomes extremely disabling. So I think people perceive migraine as this minor ailment, you know, that maybe if you're stressed, you're getting one. But for some people, it is a neurological disease that affects their lives. And that's where medical care comes in, right, because migraine is not treated with just essential oils and water.

BRIAN GOLDMAN: What about non medicinal treatments for migraine?

ELIZABETH LEROUX: So it depends how you… what you include in, I call those behavioural or non-pharmacological. And there's a wide array of things. So trigger management is one. And then sometimes, people will think about things like chiropractic treatments, osteopathic treatments. Those can work well if you do have like neck issues. Acupuncture has been shown to be effective for migraine, but most of the effect is probably a placebo response to the needling. But, you know, that's okay because placebo is good. You know, it works. And then you have all the world of lifestyle and what I call neuro health. So that would be taking care of your sleep, taking care of a healthy diet. Exercise is key. More and more I practice medicine, more and more I'm a strong advocate for exercise. And then the world of brain management. So that includes managing your mental load, your emotional reactions, trying to navigate your life and, you know, meditation, for example, cognitive behavioural therapy. And for some patients, there's also an important thing that if they have gone through abuse or different things, you know, they do suffer from post-traumatic stress disorder or anxiety or mood disorders, then they might need a specific mental health care. So there's a wide array of things that can be done that are not drugs.

BRIAN GOLDMAN: Got it. Now, we talked about how to treat the acute migraine. What are some of the most effective preventive options for addressing migraine attacks before they happen?

ELIZABETH LEROUX: So prevention in the world of migraine relates to like decreasing the frequency and intensity of the attack, and also that helping the person not, you know, being afraid of having an attack all the time. So there are different drugs that can be used to decrease. So the older drugs, there's a lot of pills that can be used, but those were found a bit by serendipity. So they were used to treat, for example, hypertension, depression or epilepsy. So there are brain modulators. But the problem with these drugs is that, well, they were not effective for every person with migraine. That's fine. But they also came with a load of side effects, including, you know, weight gain or somnolence or difficulty exercising or tremors and so on. And so we didn't have really designer drugs for migraine. Botox came in in 2011 in Canada, and Botox can be used on indication for chronic migraine. That's a very interesting approach. I do use it, and some patients respond very well to it. But the recent revolution in our world is what we call the CGRP blockade. So CGRP is this little peptide or protein I mentioned earlier for acute treatment. It does play a role in migraine. We have abundant scientific evidence of that in humans and in animal models. So blocking CGRP is an interesting approach, and we can do that two ways, with pills or with antibodies. So antibodies are things we inject like a bit like EpiPen or I.V. infusions. And those have proven to be extremely effective for a subgroup of people with migraine, but also better tolerated than oral mints. So I've seen, I have to tell you this. I mean, I'm not… I don't want to push any medication or anything, but I've been doing this for 15 years, and now I see super responders to this approach. They come to me after decades of migraine. Their life has changed. They don't have to watch everything anymore. They don't fear the next attack. Their frequency has drastically decreased by half, by 75%. The family is happy. The employer is happy. So I think this has been a really big step forward for migraine, because then people understand that it was not the water, the weather, the period, you know, the food. It was something in the brain that was overreactive. And once controlled, then people live much better. I mean, over the past six years, every year, we've seen a new treatment for migraine arriving in Canada. That's really great. I really hope that these will be made more accessible and covered in Canada for patients.

BRIAN GOLDMAN: You've started to mention accessibility, which I think is a subject we need to say a little bit more about. When you say accessibility, you're talking about expense and coverage, aren't you?

ELIZABETH LEROUX: Well, I'm talking about two things. First, being able to see a doctor that will prescribe this.

BRIAN GOLDMAN: Okay.

ELIZABETH LEROUX: Because just seeing a doctor sometimes is complicated for migraine, and seeing a neurologist and a headache specialist in certain provinces. I mean, I'm not even able to take new patients, by the way, because my clinic is packed. And a lot of people will claim that they wait one year, two years, three years to see a migraine specialist. So that's the first barrier. Then there's the coverage. But the greatest barrier now is maybe not the coverage. It’s actually access to a doctor willing to treat migraine and fill the forms for all those new medications.

BRIAN GOLDMAN: I'm a physician, and I didn't know 90% of what you've been talking about. I can imagine that there are patients, there are people who are listening to this who have been suffering with migraine headaches for years, maybe even decades. Where do they begin their search for better relief? What do you recommend?

ELIZABETH LEROUX: Well, I mean, as the chair of Migraine Canada, I will strongly encourage your listeners to have a visit at our website. It's going to be actually updated and improved very shortly. June is the migraine month, by the way. So we have an awareness campaign, and we want to break the stigma and bring access to care to most Canadians. So Migraine Canada is a good place to start. I'm tipping my hat to the American Migraine Foundation. They're also excellent. Migraine Again is another excellent website. And for those who really want a higher level, you know, more scientific approach, the Migraine World Summit is another excellent website where you can see conferences with experts. So information is out there. The problem is that we cannot ask a person to be their own physician. So they still will need, you know, a healthcare provider to guide them and help them. And I see, by the way, I see a lot of patients who know more than their doctors sometimes. And so I think we need to kind of replace how doctors are trained in Canada to take care of migraine.

BRIAN GOLDMAN: Dr. Elizabeth Leroux, you have been a fund of knowledge. You've taught me a lot, and I'm sure our many subscribers will appreciate what you've had to say. Thank you so much for coming on to The Dose.

ELIZABETH LEROUX: My pleasure.

BRIAN GOLDMAN: Dr. Elizabeth Leroux is a neurologist and the founder and board chair at Migraine Canada. Here's your dose of smart advice. Migraine is different from the more common tension headaches that lots of people get. Migraine causes throbbing headaches, usually on one side of the head. They can last for several hours and are often associated with nausea, vomiting and sensitivity to light and sound. Classic migraines are preceded by an aura lasting 20 to 30 minutes. Common aura symptoms include squiggly lines or a blind spot in your vision, flashing lights, nausea, yawning, numbness, tingling or weakness on one side of the body. Migraine is more common in women, but does occur frequently in men. For some women, migraines tend to occur in the two days leading up to or during the first three days of a menstrual period. Migraine has many possible triggers. These include alcohol, lack of sleep or too much sleep, and skipped meals. Some people have food triggers. Some are sensitive to bright sunlight and other changes in the weather. Migraine triggers tend to be individual. For instance, chocolate triggers headaches in some people, but not others. There are several kinds of treatment. Acute treatment, also known as rescue or abortive treatments, stop a headache in progress. The most effective established abortive medications are triptans, ergot and anti-nausea medications. A new type of acute medication blocks calcitonin gene related peptide or CGRP, which is believed to cause pain and inflammation. Medications in this group include ubrogepant or ubrelvy, and atogepant or qulipta. Another group of medications prevent migraines or reduce their frequency. These include topiramate, valproic acid, amitriptyline, olanzapine, propranolol, and the aforementioned CGRP blockers. Injectable medications that can help prevent migraines include Botox and CGRP monoclonal antibodies that are self-administered via automatic pen injectors. There are lots of non-medicinal treatments. Lifestyle changes, stress management, eating and sleeping at regular times and exercise can make a big difference. For many women, headaches tend to decrease dramatically or disappear completely with menopause. Men may also have fewer migraines as they reach their 50s and 60s. Go to an emergency department if you experience a headache that is unusually severe or of sudden onset, or a headache associated with fever or unusual neurological symptoms like weakness on one side of the body, double vision and speech problems. If you have topics you'd like discussed or questions answered, our email address is thedose@cbc.ca. If you liked this episode, please give us a rating and review wherever you listen. This edition of The Dose was produced by Isabelle Gallant and Sameer Chhabra. Our senior producer is Colleen Ross. The Dose wants you to be better informed about your health. If you're looking for medical advice, see your health care provider. I'm Dr. Brian Goldman. Until your next dose.

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How should I treat migraine attacks? - Transcript

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