Can you tell us how you became interested in this field of medicine?

Yeah, sure. I am a board-certified neurologist and I’ve done two fellowships. One was in stroke and the second one was in headache medicine. I had planned on doing just a headache fellowship and then I took a bit of a detour. I started getting migraines myself when I was in medical school and I learned sometime later that I do have a family history of migraines. It started around the time when migraines start in women which is their early 20s. This was really hard because it was during a time that was so stressful.

I was trying to get through medical school and I remember I would just have to come home and be in the dark. I felt like I was missing a whole day of being able to study. Normally I would go to the library and study for hours so the migraines were really frustrating. 

I didn’t really have a good sense of what they were at the time. I just thought, “Okay, I had a really stressful day and now I have a headache”. I didn’t realize it was an actual condition until I did a neurology residency. I was in a clinic and I would see these young women would come for their appointments and it would feel like none of the residents wanted to talk to them. I felt connected because that’s what used to happen to me in medical school. They were able to tell a story that I didn’t realize was happening to me back then. That’s when I realized that I wanted to get into this field. I completed my fellowship and then started my own practice. 

A lot of what we do in Western medicine is really just about giving medications and we don’t take this holistic view towards a chronic condition that involves pain that you can’t see from the outside. It’s really important to understand how it affects their life. It wasn’t until I started my own private practice that I started to shift to a more holistic form of practice.

I started looking into the importance of sleep, stress control, diet, and exercise. This is important in migraines because it really is a mix of your genetic predisposition, as well as your environmental factors, health, and well-being. It’s bad when your body is not in homeostasis and that’s what you really have to work towards.

A lot of people don’t understand the difference between headaches and migraines. Could you give us an overview of what headaches and migraines are and how they differ from each other?

The way that you differentiate between the two is a headache is a symptom of a disease and a migraine is an actual neurological disease itself. We typically talk about headaches and migraines as if they’re the same thing, but headaches are really just one symptom of migraines. For most people, it is the most disabling and prominent symptom, but there are some people where they are so many symptoms that they have along with migraines. People that have an aura with their migraines can have neurological symptoms like numbness or weakness on one side of their body.

They can have visual symptoms called the visual aura where you see a kaleidoscope or a field cut which is like a blind spot in the eye. Nausea is a huge part of migraines. They can have sensitivity to light and sound and sometimes people can have trouble thinking and talking.

When someone comes in with a headache and it’s the first time I’m seeing them, I don’t necessarily jump to migraine. I have to make that diagnosis from exclusion and make sure that I’m not missing something like a tumor, a stroke, or meningitis. There are so many diseases where headaches are a symptom, but migraine is a disease where headaches are most prominent.

What does your overall process look like when treating someone with migraines?

It’s really important to keep the whole patient in mind. Migraines are most prevalent during your reproductive years and it’s much more common in women from their 20s to 40s. My typical patient would be a 30-year-old woman who is working, married, and is having children. You have to keep all these other things going on in their life in mind when you decide how you’re going to treat their migraine.

I try to explain migraines to my patients as a genetic predisposition for environmental factors to trigger migraine attacks. It’s like their nervous system is at a lower threshold to go into a migraine than someone who doesn’t have that predisposition. Any person who has had a bad night of sleep and skipped their morning coffee and is having a stressful day can have a headache, but for someone with migraines, it doesn’t take that many triggers coming together.

What’s really important is understanding your own personal triggers and knowing what triggers tend to be universal for everyone.

Sleep is really important. Getting enough sleep is important, but also how you sleep matters. You have to think about the pillow you’re using and the position your head and neck are in. Sleep is supposed to be restorative. Sleep is supposed to be the time when your body is resting, but your brain is active. It’s consolidating your memories. If you’re not able to get good sleep then your brain is not restored.

 Stress is another big factor in migraines. It’s a trigger in about 80% of people. Learning how to deal with stress is really important. You can actively decrease the stress hormones that are released in your body. We release cortisol as part of the stress response. Yoga and mindfulness exercises have been found to actively decrease your cortisol levels.

Diet is important. There’s not a lot of data on which foods can trigger migraine attacks. Some people say that chocolate triggers migraines, but long term studies didn’t support that. Some people actually crave chocolate before they have a migraine attack. Some studies show that a ketogenic diet might be helpful. With dieting, it’s important to limit the amount of sugar in your diet and to avoid processed foods. Some studies show that Omega-3s can help prevent migraines. Magnesium has also been shown to help prevent migraines.

I also encourage patients to keep the amount of caffeine in their diet consistent. If they drink two cups of coffee a day normally and then one day they don’t have any coffee, they’re going to have a headache. The headache occurs because their body is withdrawing from the caffeine. I have some patients who drink coffee when they’re having a migraine because caffeine constricts your blood vessels which can decrease migraines.

Red wine is a common trigger for migraines. Sometimes I’ll have patients stay away from gluten to see if that helps. I’ll have patients keep a migraine diary.

It’s really about maintaining a lifestyle that can help with your migraines and decrease the chances that you’ll go into a migraine attack. 

 I also talk to patients all the time about medications because sometimes there are no ways around the symptoms other than to treat them. More recently we have discovered the pathophysiology of migraines and now we know that it starts in the nerve. We used to think it starts in the blood vessels, but now we know it’s the nerves. The trigeminal nerve is a huge part of migraine propagation and there are different molecules released by the brain and the body.

There are specific medications now made to alter those molecules that are released. It’s a very important part of treating migraines. It’s kind of like asthma where you have asthma every day, but whether or not it’s going to be bad that day depends on the pollen count. If you’re going to exercise, it’s really important to take your environment into consideration when you’re deciding how to best treat your migraines and to know your toolbox of things that you can do to lower your risk of having a migraine attack.

This approach is meant to tackle it from every aspect. Is your sleep not good? Are you finding effective ways to treat your stress? Are you working out enough? Are you sitting at the computer with correct posture? Your neck and shoulders can become stiff and irritate the nerves that are in the head and neck. You tackle each problem one at a time. Before you know it, you’re doing mindfulness once a day, you’re sleeping better, you’re eating better, and you have improved. It’s important to let patients know that this is not something that’s going to get better overnight. This is a process, especially if patients have been having chronic migraines for years and years. It’s going to take time to improve. It could be six to eight months before you start to see an improvement.

When you have a patient who is brand new to migraines and another patient who has been having migraines for 15 years, are they treated differently or the same?

The duration typically does not matter. Patients who have had migraines for years have tried a lot of different treatments already so you’re kind of limited to what you’re going to treat them with because you know they’re going to say to you, “I already tried that”. You have less treatment options. If they have had migraines for a long time, they have a better indicator of what their triggers are and they have more experience with it.

Women tend to have variations throughout their life and how bad the migraines are. They might say to you, “In my 20s they weren’t bad and then they got worse in my 30s and now in menopause they are getting worse”. It’s unfortunate because a lot of these women have been dealing with them on their own for so many years before they seek care. 

If someone is new to migraine, you want to make sure that you’re not missing something else as the cause of it. If someone has been having the same type of headache for 10-15 years, you can be more sure that these are migraines and not anything else.

Are there any specific treatments that you believe are the most effective for treating migraines?

There are a lot of different ways to treat migraines now. There are oral medications called abortives that you can take when you’re getting a migraine. There’s preventive therapy which is taking something more consistently or to decrease how often they’re happening. There are oral medications and injections.

There is neuromodulation which sends electrical or magnetic signals to the nerves right under your head. This can be done on the forehead or the back of the head. There is Botox which paralyzes the muscle and talks to the neuromuscular junction. There are complementary ways to treat migraine. There’s evidence that yoga decreases migraine frequency and severity. There’s evidence that acupuncture can be beneficial. Now there is evidence for physical therapy as well. Treatment for each patient is individualzed.

A lot of it has to do with patient preference and motivation. It’s easier for someone to take a pill everyday than going to acupuncture once or twice a week. Other people are motivated to try things where they’re not taking pills because they’re thinking about getting pregnant or they are pregnant. We go over side effects and pills versus injections. It’s very individualized. 

 Typically what works best is trying a medication, but also making some lifestyle changes. It does end up being trial and error. It’s like we have this toolbox of different treatments and there’s like 30 things in there. It’s a process and it can be really frustrating because you can work with a doctor for three to four months and see no improvement.

How often do you find that these treatments work?

Somewhere between 60-70% of patients end up finding some kind of relief and improvement. I think it also really helps that they have more information and that they understand their disease. The most frustrating part for a patient is just not knowing what’s going on.

New medications have come out within the last six to seven years and they specifically target a molecule that plays a big role in migraines. They’re called CGRP inhibitors and they work specifically on the molecule that’s involved in migraines. Before CGRP inhibitors, we used to use non-specific medications that were made for seizures. With CGRP inhibitors, 50% of patients notice an improvement and our numbers in real life have actually been higher than 50%.

You mentioned mindfulness earlier. Can you explain how mindfulness can be used to treat migraines?

I don’t know enough about mindfulness to speak to that, but I do recommend apps to my patients. They’re called Headspace and Calm.

Is there any current research or trials going on right now that you think are going to bring forth any new forms of treatment for migraines?

The CGRP inhibitors are the biggest, newest thing for migraines. Initially, they were injections, and then they also made oral pills. Now they are working towards nasal sprays.

There are also more neuromodulation devices coming out so that injections or pills don’t have to be taken. Neuromodulation is becoming very big.

Cefaly was the first neuromodulation device that came out. Since then a few others have been released as well. There’s another one that stimulates the supraorbital nerves. Then there is Gamma Core which stimulates the vagus nerve. Patients find that one very helpful. 

Overall, they’re not necessarily the first line of medications that we go towards, but if patients can’t tolerate oral pills or they’re someone who is pregnant, this could be a really good potential option for them.

Is there anything you would like anyone struggling with headaches and migraines to know or anything you want healthcare people to be more aware of?

I think the most important thing if you are struggling with headaches is to speak to your physician about it. A lot of people just deal with it on their own and they think that it’s just a stressful day. Stress might be a contributing factor but it is a real neurological disease. It’s important to help patients understand that they have a condition and there’s an underlying reason for it and there are ways to treat it.

If these patients have to take a day off work or tell their boss that they have a headache, people who don’t get migraines and can’t see them might say, “You have a headache. Take a Tylenol. What’s the big deal?” It can be really stigmatizing. So then they just stop complaining about the migraines. It’s important to just feel like there are people that understand that the pain is real and find someone who is able to help you along the way.

Takeaways:

• Headaches are a symptom of a disease. Migraines are a disease.

• People with migraines often have a genetic predisposition for environmental factors to trigger a migraine attack.

• Sleep, stress levels, exercise, and diet need to be taken into consideration when treating migraines.

• There are a lot of treatment options for migraines, but it will take time to notice a difference.

Thank you so much to Dr. Huma Sheikh for doing this interview. She is absolutely brilliant and an amazing resource to those of you struggling with migraines. Keep learning and hang onto hope!