Noah Michelson (2:00)

And I'm Noah Michelson, head of HuffPost Personal.

Raj Panjabi Johnson (2:03)

Welcome to Am I Doing It Wrong? The show that explores the all too human anxieties we have about trying to get our lives right.

Noah Michelson (2:09)

Hi, Raj. Hi. All right, we have one that I'm excited about today.

Raj Panjabi Johnson (2:14)

Me too.

Noah Michelson (2:15)

Are you doing headaches wrong?

Raj Panjabi Johnson (2:18)

That's a good question. I recently just started getting them. It's like I'm chalking it up to the fun journey of aging. I've never really had them before and I don't really know what to do. I'll just pop an Advil or whatever and it helps most of the time, but I'm kind of like, should there be a lifestyle change? Should I be lying down? I have no idea. What about you?

Noah Michelson (2:38)

Yeah, I know nothing about them and that kind of freaks me out. And they seem so mysterious.

Raj Panjabi Johnson (2:42)

Do you get headaches?

Noah Michelson (2:43)

I do okay, but I don't know why, and I don't really know why they go away. I'm the kind of person who doesn't like to take medicine. So I kind of just like, tough it out.

BetterHelp Ad Voice (2:52)

Sure.

Noah Michelson (2:52)

Which also seems dumb.

Raj Panjabi Johnson (2:53)

Not dumb, but not compassionate to yourself.

Noah Michelson (2:55)

Yeah. And like, just take it and feel better. So, yeah, I am excited to learn. Like, why are these happening? What even is it? And how do we do it better?

Raj Panjabi Johnson (3:03)

Well, who do we have today?

Noah Michelson (3:05)

All right, so Today we have Dr. Christopher Gachok. He established the first headache medicine program at Yale, and he's also a professor and treats patients.

Raj Panjabi Johnson (3:14)

There's get our lives. Gottschalk.

Noah Michelson (3:19)

Dr. Gottschalk, thank you so much for being here. We have so many questions about headaches.

Dr. Christopher Gottschalk (3:24)

Glad to hear it. I love to talk about them.

Noah Michelson (3:26)

Let's start right at the beginning, because I feel like there's such a mystical, mysterious thing medically when we talk about headaches. How are you. How are we defining that? What is a headache?

Dr. Christopher Gottschalk (3:37)

Well, in the simplest terms, it is still true that the term headache, which is a. An everyday term, a colloquial term, means any form of pain in your head. So there are different things that can do that. You could have trigeminal neuralgia, you could have migraine, you could have cluster headache. You could have a terrible sinus infection that does cause pain in the head, although that's actually a very rare bird. But the general term headache, which is part of the official. The field of medicine called headache medicine, refers to the entire spectrum of things that can cause pain in your head. And although there are many, many different things that theoretically can cause pain or occasionally cause pain, it's also true that our main message is almost everything that people talk about when they're talking about a headache is migraine. That point is something that we're still working on, trying to get people to understand better.

Raj Panjabi Johnson (4:39)

So what's a migraine? How would you define a migraine?

Dr. Christopher Gottschalk (4:43)

So there are official criteria for that, but the simplest way to put it is if people have headaches that are getting in their way, if people have headaches that mean they have to stop what they're doing or slow down or do something different ever, that is almost certainly migraine.

Noah Michelson (5:00)

So it's more of a category rather than a cause. So I guess what you're saying is, and I've never thought of this seems so simple in a way, but a headache is really defining a pain, but it's a symptom of something else.

Dr. Christopher Gottschalk (5:15)

Well, that's an interesting point and really worth talking about. So yes and no. In our field, or the way we sort of divide this up is we talk about primary headaches and secondary headaches. Primary headache means the headache is the disease. You have episodes of head pain and everything that goes along with that. And that's the whole problem. It's not a symptom of a brain tumor, an aneurysm, an infection, whatever. Yes, it's true that any of those bad diseases will also give you a headache and other symptoms. But for reasons that are still not at all clear, most of the time, when that system gets set off and gives you that whole set of different symptoms that is the disease. It's simply that you have kind of a hair trigger, in technical terms. The stuff on the inside of your skull, the covering of your brain called the meninges, the blood vessels, the veins, et cetera, those are all innervated. The nerves that give you sensation to those structures are part of your trigeminal nerve, and they're there to tell you if there's a serious problem. If you suddenly get blood in your spinal fluid from an aneurysm, if you have an infection that caused meningitis, whatever, it will set those nerves off and you will have what, for all intents and purposes, looks like a terrible migraine, throbbing pain in your head, nausea, sensitivity to light, etc. So, yes, those are symptoms of an alarm that's gone off in your head. But amazingly and surprisingly to most people, including most doctors, almost all the time when those symptoms exist, it isn't because of one of those things. It's just somebody has that, that happens a lot or happens from time to time, but really bad.

Noah Michelson (7:14)

My mind is already like blown and we're three minutes.

Raj Panjabi Johnson (7:17)

I know, I know. I'm both terrified and comforted somehow. Okay, so let's start with what are the common causes, you see, of someone getting, you know, like a level three or four headache, like something that's annoying?

Dr. Christopher Gottschalk (7:33)

Well, so that depends a little on what you mean by that. So if you're saying people get bad headaches, and what we now know is that that's almost always a migraine, why does a bad migraine happen? Is that what you're saying?

Raj Panjabi Johnson (7:45)

Yeah.

Peloton Ad Voice / Podcast Sponsor Voice (7:46)

Yeah.

Dr. Christopher Gottschalk (7:47)

So that's another part of the, the demystification and the mythology of migraine, as I like to say, is the whole concept of triggers is just completely wrong. Oh, so we've, we've all grown up with this world telling us, oh, yeah, if you get headaches, it's probably because you are dehydrated, it's because you're stressed, it's because of weather changes. It's because of some food you eat. And all those things. We have studied all of those things, none of them is true.

Raj Panjabi Johnson (8:21)

I mean, I knew that this was like constantly developing headache medicine. I knew that. Cause I read different things every day. And it's like it's in your head. It's hard to do testing on this, but this is wild.

Dr. Christopher Gottschalk (8:31)

Yeah, the in your head thing is a big part of the problem here. And it relates to the terribly stigmatized view of headaches that exists. So multiple strikes against you. Right. Headache is an invisible disease. Meaning? Meaning when you have those symptoms, there's no scan or blood test or biopsy that can say, oh, yes, this is migraine. So you have to take people on faith that their symptoms are real. And oh, there are many more women who have migraine than men. Which of course means they're exaggerating, they're making it up. Because women are hysterical and they lie, they exaggerate, and they're fragile. And all those ridiculous ideas that inform how we listen to women, as opposed to mental, when they say they're in pain. So all of that is happening when somebody said, my head is killing me and I feel like I want to puke.

Noah Michelson (9:28)

But I am also thinking of some things. Like, I was having really bad headaches when I was waking up in the morning and I didn't know why. And I went to the dentist and he was like, you're grinding your teeth, you need a mouth guard. And I got a mouth guard. It was $800. I wanted to jump out the window. But it has changed my life. It is literally my best friend now, and I freak out if I miss one night without it. So in a case like that, that is something that is causing it, right?

Dr. Christopher Gottschalk (9:55)

Yes. And part of that gets to. Yeah, there are a few specific conditions that can cause pain in your head or that can even make migraine worse. So either what you had is simply what we call bruxism grinding, sort of compulsive grinding of your teeth while you're asleep. And that'll make your head hurt by the time you wake up. So. So if one of a headache doctor had talked to you about that, like, what exactly were you having? Was it just achy pain in your temples and jaw? Or did you have throbbing pain? Did you have sensitivity light? So my guess is the headaches you were waking up, we wouldn't even call migraine. We'd say, that's something else. And sure enough, treating the grinding did it. But the next thing on the list, there would be or maybe you even had some degree of sleep apnea. Because no question, a person who has even a little migraine and then has sleep apnea, the migraine gets much, much worse. Because that repeated intense stress overnight of not breathing just drives the whole thing through the roof. So that's one of the things we look for most commonly. If someone comes to me with a lot of migraine, I'll say, you need a sleep study. Because half the time, that's half the problem.

Noah Michelson (11:15)

Wow.

Raj Panjabi Johnson (11:15)

Yeah. I feel like not good sleep is the root of so many symptoms. Conditions also true.

Dr. Christopher Gottschalk (11:21)

But let's talk about that. Right. So when people are asked, what do you think your triggers are for migraine? Stress is always number one. Lack of sleep is right up there. Weather. So other stuff. So we have studied this. So apparently if people don't sleep well, they get a headache. So you measure their sleep quality with a device for nights in a row and then you look at whether or not a headache happens and there's nothing there. There's no. We can't find any evidence that getting less sleep or bad sleep is actually causing it. However, people will say, well, yeah, I wake up and I'm tired, and then later that day I get a terrible headache. What does that mean? That's what we've come to understand is there are all kinds of symptoms of migraine that develop hours or even a day or two before the headach. So your brain is getting ready to have a migraine for a long time before the actual thing happens. And what are the symptoms of that? Being in what I call first year of migraine is feeling really tired or irritable or having trouble concentrating or, ooh, lights are bothering me and smells are nasty. And then you get a headache. What we've been taught to think is, well, there you go. Being tired gave me a headache, or bright lights gave me a headache. No, no, no. Your brain is on alert because migraine is about to happen. And so you experience the world differently for some number of hours or more. That is something you can learn to identify. And then you can jump in early, like, oh, yeah, when I feel like this, I'm going to get a migraine and there's medication you can take or there are techniques you can practice that might turn the corner in the better direction.

Raj Panjabi Johnson (13:14)

Before we get into the intervention, I have to really go back to dehydration. Are you saying that dehydration is not necessarily linked to headache? Because then what about hangover? Like, tell me what you know about this.

Dr. Christopher Gottschalk (13:26)

That's A good question. So, yes, I can say dehydration is not a cause of a migraine event. And on the other hand, the physical trauma of hangover is enough to, among other things, set off your headache system. So sugar. And yes, you're right that drinking a lot of ethanol means you've dehydrated cells all over your body, including in your brain and your nerves and all that. And so you wake up with something is really wrong and that system is running like crazy. But outside of that, many people who get a migraine say, oh, I feel really dehydrated. That must be what's wrong. When in fact, what that is, is migraine doesn't just cause pain. It causes the nerves that control the lining of your nasal passages to change. So symptoms of migraine are dry mouth or runny nose or puffy eyes or any of those things. Because migraine sets off lots of nerves, not just the nerves that control pain.

Noah Michelson (14:34)

I mean, I'm still trying to get my head around this.

Raj Panjabi Johnson (14:36)

I'm definitely not smart enough for this.

Noah Michelson (14:38)

So most of us are experiencing migraines, even though most of us would say, like, I would say I've never had a migraine. But you're saying we're thinking about it absolutely in the wrong way.

Dr. Christopher Gottschalk (14:49)

Correct. So here's an example. 20 years ago, somebody who was interested in this idea did a big study. They took 100 different primary care practices in 10 different countries, and they said all the people who walk in the door and say, I get headaches, for the next few months, we're just going to look carefully at them. So over a thousand people walk in and say, I get headaches. And the question is, what's the chance that that turns out to be migraine? And when I ask even other doctors that question, they say, oh, I don't know, 50% or something, because there's, you know, all these other things. Yeah. No, the answer is 95%.

Noah Michelson (15:29)

Wow.

Dr. Christopher Gottschalk (15:30)

So if a person says to a doctor, I'm getting headaches enough that they need help, it is migraine until proven otherwise. And the chance that it's aneurysm or tumor or whatever is like 2 or 3%. And it's not hard to tell when that's the case. So for the most part, if headaches are getting in people's way, that's what's going on. Even in the emergency room, people coming in with, oh, my God, I'm in terrible shape. Same statistics. It is almost all migraine. So looking at the criteria, right, well, how do we Define migraine. It's the pain has to be two of severe throbbing, one side of your head worse with activity, and then it has to cause some sensitivity, light and noise or nausea, all, you know, some combination of those. So the problem is, everybody agrees if you have a terrible one sided throbbing headache that lie in the dark and throw up, that's a migraine. But the same criteria say that a moderate headache on both sides of your head that's not throbbing but is worse when you try to do stuff and makes you queasy, that's still a migraine. And that's where people get tripped up. We have this idea that muscles in your head can give you a headache. Yeah, not really. Maybe in something like chewing your, you know, grinding your teeth all night, that eventually hurts. But that's not the same as throbbing pain. That's worse with activity and nausea in the daytime.

Noah Michelson (17:07)

Right. Or if a feeling of pain in your head when you have a sinus infection or a cold, that would not be migraine either because that is being caused by a specific localized thing.

Peloton Ad Voice / Podcast Sponsor Voice (17:20)

Right.

Dr. Christopher Gottschalk (17:20)

So somebody who has bad allergies or a cold will say, yeah, my head feels stuffy and kind of achy. But the notion that sinus headache is a problem, Sorry, no such thing. Right. Even the idea of sinus headache, where does that come from? That came from advertisers on Madison avenue in the 1970s trying to sell cyanide and they came up with this term and it worked well, they sold a lot more cyanide. But then doctors were like, wait, what? Whose idea was this? What? And sure enough, if you take 100 people who say, I have sinus headaches, and you ask them careful headache questions, 90% of them have migraine.

Noah Michelson (18:04)

Hmm.

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Raj Panjabi Johnson (19:46)

Okay? I have a follow up. So why, why does allergy medication like Zyrtec work for me when I have a quote unquote allergy headache?

Dr. Christopher Gottschalk (19:55)

Well, so that says the type of pain you have is related to inflammation in your nose.

Raj Panjabi Johnson (20:02)

Got it.

Dr. Christopher Gottschalk (20:02)

But if we, if we talked to you when you had one of those headaches and ran down those different features of headache, I would guess that you would not.

Raj Panjabi Johnson (20:10)

Absolutely.

Dr. Christopher Gottschalk (20:11)

Right. It wouldn't sound like migraine. It's different kind of pain.

Raj Panjabi Johnson (20:15)

Yes. Accurate.

Noah Michelson (20:16)

All right, we have a question from a listener. Katie's saying, and again, I feel like all bets are off now. Now that we're in this weird new world that I didn't even know existed. She's asking if the location of a headache. So say it's in the front of your head versus the back of your head or the side of your head. Does that make a difference? Is there one that means like, oh, I should drink more water versus an I'm getting sick headache?

Dr. Christopher Gottschalk (20:39)

Excellent question. Surprisingly enough, for the most part, the answer is no. So the trigeminal nerve is the nerves that gives you sensation to the upper part of your face, the eyes and forehead, and the cheek and the jaw. And so that's where we think of headache pain being is right around your temples, front of your head, and sometimes in the back. But it turns out that the nerves in the back of your head are literally connected to, to the trigeminal nerve in your brain stem. So all kinds of evidence that shows if you do something that's going to make your trigeminal nerve irritated, the nerves in the back of the head will come along with it. So that fact that 75% of people with a migraine will say, oh yeah, my neck starts out feeling really stiff and sore. And people think that means somehow your neck is giving you a headache. On the contrary, headache gives you pain and other symptoms in your neck. So for the most part, that location thing doesn't matter. Sometimes it does. People who say, I always get pain in the back of my head and it seems like it happens when I get up and I'm upright, but if I lie down, it goes away. That's actually a Pretty common story for what we now know is more common than we thought. A spinal fluid leak. So a headache that is there when you're up and goes away when you're down, that definitely needs someone to look into it.

BetterHelp Ad Voice (22:11)

Wow.

Raj Panjabi Johnson (22:12)

Well, it sounds scary.

Noah Michelson (22:13)

I don't even like the phrase final.

Raj Panjabi Johnson (22:15)

Don't love it.

Noah Michelson (22:16)

Yeah. Fluid leak.

Raj Panjabi Johnson (22:17)

We have another listener question that I want to know too, from Angel. Are some people just more prone to getting headaches?

Dr. Christopher Gottschalk (22:24)

Sure. And that's the thing that we're trying to understand better. But we. It's. It's very clear that if you have people with migraine in your family, you are unfortunately more likely to have migraine as well. But then there are people who get migraine, you know, two or three times a year, and there are people who get a migraine two or three times a week. So what's going on there? Well, it's hard to tell, but some things are pretty clear. Like having had a head injury is. Means you're much more likely to have headache all the time. Having sleep apnea means you're much more likely to have headache all the time. And importantly, if the medicine that you take to treat a headache doesn't really work very well, then you will end up over time with headache all the time. Now, we used to call that medication overuse or rebound and basically blaming the victim. Right? You have headaches all the time. You take this medicine, apparently you've made yourself sick, and that's not really. Turns out, not really correct. What we're. What we should be saying is, gee, I guess that medicine doesn't really work.

Raj Panjabi Johnson (23:36)

That's right.

Dr. Christopher Gottschalk (23:36)

If it worked, you would have a headache, take it, it would stop, and you'd wait until the next one. But if you take something that just kind of kicks the pain down the field for a few hours, then you're going to need to take it again and again and again and again, and eventually you end up with some headache almost all the time. That is a problem of not the right medicine, not good enough medicine, but not that medicine makes you worse.

Noah Michelson (24:01)

We want to get into the medicine in a second, but I just want to know before we get there how often is too often to be getting a headache. When should someone come and see someone like you? Is there like three times a week, six times a week? Or is it just like when it starts to intrude into your life and makes your life not livable?

Dr. Christopher Gottschalk (24:20)

It's the last one. If you ever have headaches that ruin your day or take you out of Commission for even a while, you deserve good treatment because you don't have to live with that. The point I make to other doctors all the time is years ago, something called the Global Burden of Disease Study was set up around the world to say what diseases cause the most trouble? Like, how do we decide what we should focus on? Policy issues. So they came up with the idea that the only way you can compare illnesses is to think about how much disability they cause. Either a disease cuts your life short, cancer, heart disease, or a disease means you spend a lot of time or some amount of time disabled, you can't do normal stuff. So when you measure disease that way, migraine is the most important cause of disability in the world.

Noah Michelson (25:16)

Wow. Yeah, that makes total sense though.

Dr. Christopher Gottschalk (25:18)

And absolutely. Because it happens over and over again. It might be two hours, it might be 12 hours, it might be three days, but it's. You're for decades. So in that same context, you can say a bad migraine, that's the same as quadriplegia. Right. You can't move, you can't talk to anybody, you can't get out of bed. It's the same as being paralyzed. And then suddenly people think about it differently. If you were quadriplegic twice a month, I think you'd probably go see a doctor. But somebody gets a migraine a couple times a month and like, oh, yeah, I just need to drink more water. Not really true. What you need is good treatment.

Raj Panjabi Johnson (25:59)

Yeah, it's scary. I mean, migraines are debilitating for a lot of people. And then if you don't figure out the medication, which we're just about to get into. My mom has trigeminal neuralgia and she found a medication that is for her. And before that it was headache. A lot of times, you know, this, like, people come to you because it's a mystery. You're like, what am I doing? Like, what am I missing here? And you're, you know, for two, three hours of the day even, like missing out on life. And it's.

Dr. Christopher Gottschalk (26:25)

Yes.

Raj Panjabi Johnson (26:25)

You gotta find out what's gonna make you feel better. And it's out there. Potentially.

Noah Michelson (26:30)

Yeah.

Raj Panjabi Johnson (26:30)

You know, let's start with the, the kind of over the counter stuff for people who just have headaches. They're not migraine, they're not sure what it is. Acetaminophen, which is Tylenol versus ibuprofen, Motrin, Advil, like, what works better? How do those work? Can you tell us a little bit about that?

Dr. Christopher Gottschalk (26:48)

A little bit. So in general, the so called nsaids, the non steroidal anti inflammatories, which is ibuprofen, naproxen, et cetera, but not Tylenol. Those are generally better than Tylenol, although there are people who say actually Tylenol works pretty well for me and that's okay. But those are just one part of a formula or a recipe for a good treatment for an attack of headache. And again, what really matters in the end is does it work? So what we want to be true is if you get a headache and you take whatever it is that should be totally gone within two hours and it doesn't come back. And that has been the definite, the FDA definition of a clinical trial of a drug for a migraine that works for 30 years. I meet people all day long, every day for decades with headaches and the first thing I say to them is, I would like to be sure that when you treat a headache it's gone in two hours and doesn't come back and their jaws drop. They're like, that would be amazing. Which makes me feel good. But it also says apparently nobody bothered to mention to you that this is the way it's supposed to be.

BetterHelp Ad Voice (28:04)

Right.

Dr. Christopher Gottschalk (28:04)

People don't believe that that's possible. And yet we have all kinds of tools that can do that. And what we see over time is that when somebody has the right tools and uses them to snuff out a headache fast every time it happens, they do great and they get better over time. But somebody who says, yeah, you know, it takes the edge off, get worse.

Raj Panjabi Johnson (28:26)

You know, I don't know what actual medication this is, but you know, what's my girl Aleve?

Dr. Christopher Gottschalk (28:32)

Oh, that's nap, that's Napoleon. And I agree. That's the drug I prescribe for people as an anti inflammatory for headache routinely. I agree with you.

Raj Panjabi Johnson (28:42)

Knocks it out and for me in 30 minutes. I don't mean to be advertising a.

Noah Michelson (28:45)

Drug like we're not getting paid.

Raj Panjabi Johnson (28:47)

No, we're not getting paid by a leave, send me some money. But truly headache is, it's terrible when you, when you have it. So you're, you want to find the thing that's going to make it go away quickly and then stay away.

Noah Michelson (28:58)

Well, I want to get your thoughts too on medicines that say they're specifically for headache. I think there's one called Excedrin. Tension headache relief. Is that just marketing or is that doing something?

Dr. Christopher Gottschalk (29:11)

Yeah, no, Excedrin migraine is the same as Excedrin. It's just labeled differently.

Raj Panjabi Johnson (29:18)

I love It.

Noah Michelson (29:20)

It's like when they had those pens for women, but they were just pink.

Raj Panjabi Johnson (29:24)

I cannot.

Noah Michelson (29:25)

And it's like, it's just a pen.

Raj Panjabi Johnson (29:28)

Okay, I. I have a question about the. The marketing on that. Does the placebo effect work, in your opinion? Do people buy this marketing enough so that their headache gets better or it's Excedrin, anyway. Yeah, both are true.

Dr. Christopher Gottschalk (29:40)

So, I mean, Excedrin can work pretty well for a headache and even for a migraine, if it's. If the migraine is not too severe, if it hasn't been there for too many hours, one or two Excedrin can work. And if it does, great, you're all set. But what I care about is most people who have headaches have them in different levels. Sometimes it's not a big deal. Sometimes, ooh, this took me by surprise. And sometimes I wake up and I can't move. And the point is, you should have a toolkit that is ready for any of those. If you wake up with a raging migraine, some Excedrin is not going to cut it. But there are things that can actually turn that off in an hour or two, or you start to feel that queasy, funky way that you do before a migraine, and you can tell this is going to be a problem in a few hours. There are things that you can take then that will keep it from getting there.

Raj Panjabi Johnson (30:32)

Just a slight digression because you've mentioned this. Why do headache and nausea go together? Because really, the only times I have a bad headache, I want to barf immediately. Is it just like a direction?

Dr. Christopher Gottschalk (30:43)

We had migraine, so that's technically because in the brain stem, the trigeminal nose nucleus, where all those fibers go first, is directly connected to the vagus nerve, the vagal nucleus, which controls your entire GI tract. So with an episode of something irritates your trigeminal nucleus, along with that comes nausea or even vomiting. And even if people only have a little bit of nausea, they also have what we call gastroparesis, meaning their stomach stops working. So fairly early in a migraine, your stomach is offline, which means you throw some pills in there, they may just sit there. So half of the thing that people say of like, yeah, if I get enough Excedrin in early, if I take this Motrin fast enough. Yeah, because if you do it fast enough, it actually gets into your body. But if you miss that boat, it just sits there. And that's why we commonly prescribe an injectable medicine for a migraine or A nasal spray that gets into your. That doesn't need your stomach because they get around that problem.

Raj Panjabi Johnson (31:52)

You know, Dr. Gottschalk, I just have to say that I feel so much better understanding the biology of this. Yeah, there's some guilt that comes along, especially as women or like, there's guilt that comes along with feeling shitty and feeling like it's your fault somehow or that you're exaggerating it or whatever. But understand, understanding that just that simple biology that he explained to me makes me like, no, my body is malfunctioning right now. Yeah, F you.

Noah Michelson (32:16)

It's not your fault.

Raj Panjabi Johnson (32:16)

Yeah.

Noah Michelson (32:17)

It also makes me think that our bodies are such wonderful and also terrible things. Like, I just.

Dr. Christopher Gottschalk (32:22)

You know, Roger, I just want to say I really appreciate you saying that. And that's a big part of what we try to do, right. Is if people understand better why all these things are happening, what they are telling us, and why it makes more sense to do this than that, then everybody is better off. And people don't get headaches because they're lazy or fragile or anxious or whatever. That. That embedded notion that it's a sign of some kind of moral weakness. Absolutely not. But it's out there every day.

Raj Panjabi Johnson (32:57)

No, I appreciate you because you're doing the psychological work alongside the headache. That's important.

Noah Michelson (33:02)

We got a question from Matt, and he has chronic headaches, and he said, is taking Excedrin or ibuprofen one to two times a week bad for my liver, kidneys, doing other damage to my body? Should I be worried that I'm taking pain meds too often for my headache?

Dr. Christopher Gottschalk (33:18)

Well, I think it's the right question to ask. Could I be. In general, I would say if it's really once or twice a week, probably not.

Noah Michelson (33:26)

Okay.

Dr. Christopher Gottschalk (33:27)

And if you compare Tylenol with any of those other things, Aspirin, ibuprofen, naproxen. Tylenol is the one that has a much higher risk of liver damage than. Than it should. If Tylenol were presented to the FDA today to be approved, it would absolutely be a prescription only drug, because every year there are a thousand or two people in the US who either die of liver failure or need a liver transplant. Transplant just because they've taken too much Tylenol. So it's a real thing. And that's not likely to happen with things like ibuprofen. But ibuprofen and its cousins can irritate your stomach, can cause bleeding. So once or twice a week, probably not a big deal. But next time you see your primary care doctor, you should talk about that. There's a couple of tests to do to make sure that things are okay.

Noah Michelson (34:21)

Okay.

Raj Panjabi Johnson (34:21)

You know, when I was living down in New Orleans where the drinking culture is even bigger than here, my friends taught me that you never drink while you've taken Tylenol. Like apparently it's very bad for your liver. And I love that. You know, it's just a widespread culture, but they know what, how to not screw yourself over long term. They're like, take an ibuprofen if you need to. Don't do the acetaminophen and alcohol. And I'm like, okay, Dr. Drunky, let's go. I love that.

Dr. Christopher Gottschalk (34:50)

Probably, probably a hard learned lesson, but definitely good advice.

Noah Michelson (34:54)

Beyond medication, there are some like old wives tales I've heard. One is if you stimulate a pressure point in your hand in between your thumb and your finger, that can help with headaches. Does that have any truth to it?

Dr. Christopher Gottschalk (35:08)

I think it's probably the kind of thing that has some use for people who have relatively mild headaches. So, yes, the whatever it is that acupuncture points and acupressure points are telling us that we don't really understand physiologically yet. Something about having headache makes that a sensitive spot. And pressing it either distracts your pain system a little bit or relaxes something that can give you a little relief. Sure. But there's no study that says you can stop a migraine by doing.

Noah Michelson (35:42)

Yeah.

Raj Panjabi Johnson (35:43)

Can we continue to ask about natural. Let's ask about like other quote unquote natural remedies that some people we know anecdotally have found relief from and ourselves. For me, this is so crazy. Peppermint oil on the temples or just smelling peppermint oil like it has really helped me. Is that psychological? Like, is that placebo? What's going on there?

Dr. Christopher Gottschalk (36:05)

No, I don't think so. And that's an example that again, what we wish we understood more deeply. But a migraine means a combination of the nerves on the outside of the head become sensitized, become more sensitive than normal to things. And also inside the head. So the part about, you know, I get a migraine and, oh, I got to take my glasses off, don't touch me. I can't take a shower, my head is on fire. Is literally sensitized nerves. And peppermint menthol, those are things that cool off those nerves. It's almost like novocaine. So yes, it'll actually cool or relax those nerves on the outside a bit. And that maybe helps nudge the whole process in the right direction of cooling down. If it works. Super.

Noah Michelson (36:58)

What about caffeine? And I also have friends who get, quote, unquote, I don't even know if I'm using this term right anymore. Headaches because they haven't had their morning cup of coffee.

Dr. Christopher Gottschalk (37:08)

Yep.

Noah Michelson (37:09)

What's going on there?

Dr. Christopher Gottschalk (37:10)

So no question that caffeine withdrawal will cause a headache in most people. And the more you drink, the worse it'll be if you try to stop suddenly. And interestingly, if you are somebody that has had migraines from time to time and you suddenly stop drinking coffee, you're more likely to get a bad headache, something that feels like a migraine. So whatever the exact biology of caffeine is an adenosine antagonist. And it changes something about the way nerves are functioning. You get your, your body gets used to a certain level of that you suddenly pull the rug out and the system flips out a little bit. However, you go through that withdrawal for a couple of days, you're done. And then the system has reset and you can, you don't care anymore. But on a short term basis, it feels like caffeine withdrawal is a problem. Yes. So you either gently taper down over time or you just keep doing what you were doing. But over time, people in the headache field, there was a time when people thought that was the main thing. Like anybody with headaches can't drink coffee ever. That's definitely an overstatement.

Raj Panjabi Johnson (38:23)

Okay, one more that works for me. 95% of the time is a small dose of cannabis, a little edible. I know there's like limited research, but what do you know about weed for headaches?

Dr. Christopher Gottschalk (38:38)

So it's still a very mixed bag. Right. There have been a few small studies that try to look directly at either ingesting THC during a headache or people who have a lot of headaches. If they start having a daily dose, does, does that reduce it? And it's basically some of the times it helps and a lot of the times it doesn't. And it's not clear why is it about getting the ratio right and the dose right? There's, we know for sure that there are cannabis receptors in the, in the brain. So they, they serve a purpose, they have a function in your body. But how exactly to take advantage of that. And headache is not at all cost clear for the most part. What we have so far says it does not appear to be one of the better tools that we have. But then for some people, it seems to Be a pretty good thing.

Raj Panjabi Johnson (39:29)

Well, when you're ready to work on your next clinical trial, I volunteer as tribute.

Dr. Christopher Gottschalk (39:33)

Well, let me tell you that the one that has us really excited in this area is psilocybin, right?

Noah Michelson (39:39)

Oh, wow.

Raj Panjabi Johnson (39:40)

Oh, I, I know, I know. I've been reading a lot about that too. That's so cool. Can you say, are you, do you, are you a believer? Like, do you think?

Dr. Christopher Gottschalk (39:48)

It's not even a believer. There's no question that psilocybin and other serotonin agonist drugs that happen to be psychedelic are phenomenally effective headache drugs. So how do we know this? 25 years ago, some Irishman posted on an Internet chat board, I think LSD cured my cluster headaches. Oh my God. Turns out he was wrong. He was actually talking about psilocybin. Doesn't matter. But just having said that set off a worldwide in investigation of bi headache by cluster headache patients. If this is true, we got to know more about it. And they now have an international group called Cluster Busters has a scientific meeting every year where they talk about having refined a protocol of tiny doses of psilocybin five or so days apart. Two or three doses can shut off cluster headaches for months. And at Yale, one of my colleagues is studying this. In doing controlled trials, Dr. Schindler has studied psilocybin for, for migraine and cluster headache. And so far the data says yep, absolutely. And it's no surprise at all to us because the first approved drug in US history to prevent migraine, a drug called methysergide, was basically a derivative of lsd. It was produced by the same chemist, Albert Hoffman, who created LSD out of ergotine. And this is a non hallucinogenic cousin of lsd, works fantastically well to prevent migraine. Unfortunately, that particular drug was turned out to cause very rare serious side effects. So they pulled it off the market. But there's many lines of evidence that show these drugs that have a strong, certain type of serotonin activity are fabulously effective. And also are telling us something about the biology here. Right? Cluster headache means I go into a period of time where I get attacks of the most severe pain known to human beings multiple times a day. It might only last 15 or 30 minutes, but I would rather shoot myself than have another one of these. And then that lasts for weeks or months and then it suddenly stops. No one has any idea what turns that on or off. But what psilocybin will do is you start into one of these periods, you take a Few small doses and it stops.

Raj Panjabi Johnson (42:29)

Wow, that is so cool.

Dr. Christopher Gottschalk (42:31)

So that says there's a switch, that this drug can flip that switch. No one knows what that switch is or where it is. We just need people to get funding to study that and figure it out.

Noah Michelson (42:43)

That's really cool.

Raj Panjabi Johnson (42:44)

I mean, I've been reading so much about psilocybin and treating mental illness, the potential for that. This is newer to me. I'm really enjoying the destigmatization.

Noah Michelson (42:54)

It's the plant medicine. Yeah, I love it. Yeah. Okay, I have a question for you and I almost regret asking this. Can a cluster headache be a migraine? Is a migraine a cluster headache?

Raj Panjabi Johnson (43:07)

This is just math at this point.

Noah Michelson (43:08)

I know they're not.

Dr. Christopher Gottschalk (43:09)

No, no, but it's. But it's a great question. So on the one hand there are people who are so unlucky that they have both. That's a different problem. But if you know how to ask the questions the right way. A cluster headache is easily distinguished from migraine. Cluster headaches only ever happen on one side of the head. They are very brief, 30 minutes on average. And they always have so called autonomic features that go with an attack. So you have intense pain and a race, runny nose or a red eye or tears. Those autonomic things often make people think it's a quote unquote sinus problem and they contribute for sinus whatever until somebody says, yeah, that's apparently not right. But the fact that they're so brief, so intense and have those autonomic features makes it pretty easy to distinguish from my neck.

Noah Michelson (44:03)

Okay, got it. If we feel a headache coming on, what can we do to prevent it from becoming worse? Are there things we can throw at it? Is that when we take the medication right away? What have you learned in your research about that?

Dr. Christopher Gottschalk (44:18)

Well, so the thing we can say for sure is that yes, the sooner you take a good effective migraine treatment, the better it will work. So if you take for example the triptans, things like Imitrex, Maxal rail packs, the ones that have been around the longest, we've careful research has shown they work really well in the first hour or two, maybe three of a migraine. But once you get past a certain point in migraine and the head becomes sensitive, they don't work anymore because the migraine has literally, literally moved from the outside of your head to the inside into the brain. And those drugs don't get in there. So that's when you need an injection of something or some IV treatment. Or whatever. But the, the practical take home there is if you intervene early, you're much, much more likely to be successful. And then a more recent study with one of these fancy new drugs, right, we have NuRtech and Uber LV. We've had all these ads. They are totally different in terms of their biology from something like Imitrex or Maxal. But those are perfectly decent medicines to take for a migraine attack, especially if it's not too severe. But they last in your system quite a while. So some smart person said, well, let's just try this. Take a bunch of people who recognize their prodrome. I know that if I feel sensitive to light and queasy or I'm really irritable and foggy, whatever that is, that I'm going to get a migraine brain in the next six or eight hours. Take the medicine then before you have a headache. They were half as likely to get a headache. So at least we can say there's an example of if you are mindful and you know where you are in the process, you can intervene and completely turn it off. Amazing. So could that be true about meditation, about deep breathing, about some kind of exercise?

Progressive Insurance Ad Voice / Euromonitor Ad Voice / MeUndies Ad Voice (46:16)

Probably.

Dr. Christopher Gottschalk (46:18)

We just need to look.

Raj Panjabi Johnson (46:20)

That's cool. That's very open minded. Mine's kind of related to that. I was telling Noah that the worst headache I've ever gotten in my life was when I was landing in a small plane in the Caribbean. And the plane was like flying really low. It was kind of lingering before it landed. I still don't understand what happened. It was such a bad headache. And then as soon as the plane landed, it ended. It was the pressure thing. And what should I like the intervention, like, what should I have done? What should I take with me on the plane?

Dr. Christopher Gottschalk (46:49)

That's a tough one. But there's a good chance that that really was related to the sudden shifts in extra outside pressure, barometric pressure, that go along with you're up high, you drop down, the pressure shoots up. It's in a small plane, they don't regulate that pressure as well as in a big plane. And you may very well have had one of the little airways in your sinuses got stuck and you suddenly had a high pressure in one of those that just felt like the end of the world. And then once that opened up, you were fine. So that's an example of, you know, an off brand of what can cause bad pain in your head.

Raj Panjabi Johnson (47:28)

And is there anything I could have done or could do to prevent that from happening again?

Dr. Christopher Gottschalk (47:32)

Like a medicine Maybe in a situation like that, you know, equalizing the pressure, you know, holding your nose and blowing hard, or maybe if you'd had some nasal spray that would open up your passages, that could have helped. So those are possibly things that would fix it.

Raj Panjabi Johnson (47:49)

Free medical advice.

Noah Michelson (47:50)

Exactly. Send us the bill, I guess, for the last question. This is one that I think is really interesting. It comes from Caroline, a listener. She said, I became terrified of brain aneurysms after a friend's mom died after complaining of a headache one day. When should we be worried about a headache? Are there any symptoms or situations that would make you say, go see a doctor asap?

Raj Panjabi Johnson (48:12)

Good question.

Dr. Christopher Gottschalk (48:13)

Super question. And yes. So the, the most, the main rule there is if you suddenly get the worst headache of your life, especially if it's something that went from zero to 60 in a minute or two, okay, yeah, you should call an ambulance because there's a chance that that's something like an aneurysm. Even in that situation, the chance is maybe 30%, but that's much, much, much higher than somebody who says, yeah, I get bad headaches here and there. So a sudden, severe, explosive headache that makes you miserable and sensitive to light noise, that probably deserves a workup pretty fast. Other than that, it's, you know, we're mostly talking here about people who are in middle age, right. 20, 30, 30, 40, 50 year olds who get headaches. It's almost certainly migraine. A person who starts to get headaches for the first time in their life when they're 60 and they're having trouble walking. Yeah, that's probably not migraine. That deserves some evaluation. But for the vast majority of people walking around the street who get headaches, it's just a matter of getting access to the right treatment.

Raj Panjabi Johnson (49:25)

I actually wanted to close with one more again, related. Is there anything we can do preventatively to try, try and like, alleviate or lessen the headaches in our lives? Like just lifestyle choices, you know, like lots of physicians that come in here and talk to us at the end of the day, they're like, try to, try to eat your veggies and be active, you know, get sleep.

Noah Michelson (49:47)

Yeah.

Raj Panjabi Johnson (49:47)

Super important. Is there anything you would say that, you know, you would implement in your own life to avoid headaches?

Dr. Christopher Gottschalk (49:54)

Well, it's not so much, I think, about avoiding headaches as those that kind of advice is true for just general health. That, yes, it's true. If you eat healthy and you have good exercise and you get regular sleep and you practice any form of mindfulness to De Stress yourself. All of those make your quality of life better and are at least going to prevent you from making a disease that you have worse. Whether that's high blood pressure or seizures or, you name it, a healthy lifestyle is only going to help you. But the flip side of that is what we're trying to get away from, which is it is not true that people get headaches because they're not taking care of themselves. Right? That's just blaming the victim and figuring out how to say that in a way that says, sure, take good care of yourself. It's good for anything that ails you. But it's. But you don't have this problem because you aren't living right. That needs to know.

Raj Panjabi Johnson (50:55)

That feels great.

Noah Michelson (50:55)

What a beautiful message.

Raj Panjabi Johnson (50:56)

Yeah, that's beautiful.

Noah Michelson (50:57)

That feels like so permissive.

Raj Panjabi Johnson (50:59)

Because I'm definitely not living right, but I'm trying every day. I'm trying every day.

Dr. Christopher Gottschalk (51:05)

So, Raj, let me just riff on something you said a few minutes ago about feeling relieved that this was not something you're doing wrong. So about two years ago, a friend of mine, a colleague, Bob Shapiro, and other colleagues published a study that, that said, well, let's take a look at stigma and how that impacts people with migraine. So you look at some measure of quality of life with migraine. How often is it true that migraine means you can't be a good partner, a good husband, a good father, a good worker? And no surprise, the more days of migraine you have in a month, the worse your quality of life is. Then they ask, how much of the time do you feel stigmatized? How much of the time do you feel like people are saying to you, come on, you have a headache, so do I, but it doesn't get in my way. So what's the matter with you? Why are you exaggerating or worse? Yeah, sure, you have a headache, right? You have a hangover or you forgot that your kid's recital is today and you just want to say that you have a headache. I mean, you know, headache is not really a thing. So when you ask people about that and you look at if somebody experiences stigma all the time about headache, their quality of life is much worse than somebody who never has that reaction for people to the point that you could have 30 days of headache a month. But if you live in a compassionate environment, your quality of life is much better than somebody who has two days of migraine a month, but who feels like everyone thinks they're full of crap.

Raj Panjabi Johnson (52:39)

Wow, that's mind blowing.

Dr. Christopher Gottschalk (52:41)

Yeah. So how the world sees you and your disease has a direct impact on whether or not you can function. I'm sure that's true of many illnesses. Absolutely. But here with migraine, it's saying if people are giving you a hard time about this, somebody needs to do something to educate them because that's just crazy.

Raj Panjabi Johnson (53:02)

Wow, that's a beautiful takeaway.

Noah Michelson (53:05)

Yeah, for sure. Dr. Gottschalk, thank you for this.

Raj Panjabi Johnson (53:08)

I feel like I my iq.

Noah Michelson (53:10)

I feel like I need to go lay down.

Raj Panjabi Johnson (53:12)

Yeah. No, truly, thank you for imparting your wisdom about this because I think there are a lot of misconceptions.

Noah Michelson (53:18)

Yeah, it's great.

Dr. Christopher Gottschalk (53:19)

Well, I appreciate the opportunity to talk to you both very much. This has been a blast.

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Noah Michelson (56:02)

Okay, it's time for better in five. These are our top five takeaways from this episode.

Raj Panjabi Johnson (56:06)

Number one, okay, it's gonna blow your mind, but most of what we refer to as a headache is actually a migraine.

Noah Michelson (56:12)

I still can't believe that.

Progressive Insurance Ad Voice / Euromonitor Ad Voice / MeUndies Ad Voice (56:13)

I know.

Noah Michelson (56:13)

Number two, headache pain can be caused by specific things like grinding your teeth, but that's a different phenomenon.

Raj Panjabi Johnson (56:20)

Okay. Number three, this is one that I can attest to. Advil, Motrin, and Aleve tends to work better for headaches than Tylenol does for most people.

Noah Michelson (56:30)

Yep. And the earlier you take it, the better. Number four, if you're experiencing sudden severe pain, you should go see a doctor immediately. That might mean something dangerous is actually happening.

Raj Panjabi Johnson (56:41)

Right. And number five, having headaches is not a moral failing. And the stigma that comes with them can be super damaging to our health.

Noah Michelson (56:49)

So we want to remind you that if you have a question or something you want us to investigate, you can email us. It's Am I doing it wrong? Huffpost.com we love to get emails. We love to get ideas. Some of our best episodes come from your ideas. So hit us up.

Raj Panjabi Johnson (57:03)

That being said, all right, Noah, were you doing headaches wrong?

Noah Michelson (57:09)

Absolutely. This is one of those episodes where, like I said, I didn't seem to understand anything.

Raj Panjabi Johnson (57:14)

Do you have a headache now?

Noah Michelson (57:15)

I have a headache right now. But what I learned is that that's not my fault, actually, and we shouldn't be so hard on ourselves. I like this whole thing about the compassion and the stigma. The idea that, like, if you have you're in a community where people are supporting you and you have bad headaches a whole month, that's better than having really bad headaches two days a month. But having no support that really, I thought was kind of a beautiful thing for him to tell us.

Raj Panjabi Johnson (57:39)

Melted my cold, cold heart truly.

Noah Michelson (57:41)

Have you been doing it wrong?

Raj Panjabi Johnson (57:42)

I've definitely been doing it wrong. I think there's again, this societal idea, especially for you. And I don't love running to the drugs unless it's weed that you like, wait until it gets really bad or whatever. And I love that he reiterated, like, if you start to go down this road, do what you need to do to feel better. You know, don't be a soldier. And I'm gonna react quicker.

Noah Michelson (58:04)

I will say, though, this is one of those episodes where I'm not exactly sure we figured out how to do do them better. Yeah, like, other than being more compassionate, taking drugs earlier, that kind of thing, I'm still a little bit cloudy about, like, what should I be doing?

Raj Panjabi Johnson (58:15)

I argue that nobody knows how to do them better. We're just trying to understand headaches right now.

Noah Michelson (58:19)

Okay. That makes me feel good.

Raj Panjabi Johnson (58:20)

Yeah.

Noah Michelson (58:21)

Yeah. Anyways, as long as there are things to get wrong, we're going to be right here to help you doing better.

Raj Panjabi Johnson (58:27)

I love you guys. Am I Doing it Wrong? Is a co production between HuffPost and Acast.

Noah Michelson (58:35)

Our producers are Eve Bishop, Carmen Borca Carillo and Malia Agadello.

Raj Panjabi Johnson (58:40)

Our executive producers are Jenny Kaplan and Emily Rutter.

Noah Michelson (58:43)

Special thanks to HuffPost's head of audience.

Raj Panjabi Johnson (58:45)

Abby Williams, Head of Video Will Took.

Noah Michelson (58:48)

As well as Kate Palmer, Marta Rodriguez and Terry d'. Angelo.

Raj Panjabi Johnson (58:51)

And we're your hosts Raj Panjabi Johnson and Noah Michaelson.

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