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- [00:02]
A
Welcome to Chasing Life around the world. More than 40% of people suffer from headaches. It's a real problem. We're talking 3.1 billion people around the world who miss work, they miss school, they miss some of life's biggest moments because of headaches. This throbbing pain that occurs in their head, behind their eyes, sometimes on one side, sometimes on the other. It can be really, really confusing for people. They can appear out of nowhere and they can be really, really disabling, tough to diagnose and then tough to treat. So today we're talking to Dr. Alexander Moscop. He's author of the book called the End of Migraines and he's the founder and director of the New York Headache Center. He's going to tell us why headaches hurt, what's really happening in your head and what you can do about it. Again, this affects a lot of people, but Dr. I'm Dr. Sanjay Gupta, CNN's chief medical correspondent, and this is Chasing Life.
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B
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C
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A
Well, thank you. Welcome to Chasing Life. Really appreciate it.
- [02:08]
D
Thank you. My pleasure.
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A
The numbers are pretty astounding. You know, 40% of the world's population, about 3.1 billion people suffering from headaches that are severe enough where they miss work, school, important activities in their life.
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D
Yes.
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A
How do you know something is a migraine?
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D
We have a very good strict definition which is very useful for clinical research. So we do research and you have to fulfill certain criteria. But in practice, there's a very simple way. If it's a severe headache, vast majority of These people will have migraine. If you have a little nausea, that's migraine. If the pain is throbbing, if you feel sensitive to light and noise, you don't have to have all of these symptoms. One or two is enough to make it a migraine.
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A
Usually on one side of the head or the other.
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D
But 60% of people get it on one side, 40% get on both sides.
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A
Interesting.
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D
So it doesn't have to be on one side.
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A
So you've identified now that someone has migraines, they have intense pain, it's throbbing, typically more likely than not going to be on one side. What is the first thing you sort of recommend then, in terms of lifestyle?
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D
So lifestyle begins with sleep. If you don't sleep, your brain becomes very irritable. And as you know, if someone doesn't sleep several nights in a row, you can have seizure from sleep deprivation. So sleep deprivation is number one. And people are busy not getting enough sleep. Sleep is one that's probably part of
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A
the reason headaches have gone up, just because we're getting less and less sleep.
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D
You're right. And the second one is diet is a very important factor as well. And people, for the most part, people realize when they get a headache from drinking wine or eating too much sugar. And there are many, many dietary triggers, but they don't apply to everyone. One patient told me that a glass of wine makes the headache go away, makes him relaxed. That's an exception to the rule.
- [04:01]
A
So as a general rule, getting enough sleep, wine does seem to be a trigger for a lot of people. And I'm sure there's lots of other triggers as well. Anxiety, things like that. Once you start to address all those lifestyle changes, at what point do you think, okay, now I need to try something else?
- [04:23]
D
Well, I do it on the first visit. I will not just tell the patient, get some sleep and exercise and diet and goodbye. Because they usually know that already. It's not something that they didn't think about.
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A
Well, I got to tell you, it's interesting for me is that I did know it. I mean, it makes sense, right? I mean, generally people know how to live as healthy a lifestyle as possible. But one thing I didn't realize about my migraines was how much a low carb diet could actually be helpful. That was one thing that my headache doctor ended up telling me. So, you know, not necessarily a keto diet, but kind of close to a keto diet. Why would that be helpful?
- [05:10]
D
Some people are not aware of that, that lowering your carbs can definitely help one Reason is that three out of four migraine sufferers suffer from reactive hypoglycemia, which means you eat something sweet or carbs, sugar goes up and then plummets. So three out of four, it's pretty high.
- [05:29]
A
Three out of four people who have migraines have this.
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D
Well, it's one study, but I see it in my practice and that's why one drug that I prescribe that's very unusual for neurologists to prescribe is Metformin.
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A
This is fascinating and I have to tell you just again, on a personal note, I think anybody who's listening this might feel personal to them because headaches are so common. But I wore a continuous glucose monitor for a while.
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D
So did I, for two weeks.
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C
Did you?
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A
Just to sort of see what was. And I have exactly what you described. I would have this. I would eat something that was sweet and I would have a spike and then I would have a dramatic drop in my blood sugar. And you're saying that can be associated with migraine?
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D
Absolutely.
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A
Don't eat sweet foods or try and avoid as much as possible.
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D
And that's what you said. The low carb diet helps you a lot.
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A
It tries to, but tough to stay on.
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D
I know, I'm sugar addict too, but if you stay away for two weeks, I can handle it better. If I start eating, it just keeps going.
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A
So in your own life, I'm sure, just like me, you tried the lifestyle changes. Did you have to go on medicines? And if so, how did you decide what to start with?
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D
Well, I tried the typical years ago. First of all, I should say that my headaches started when my kids were born. I used to get the visual aura without the headache in my 20s, which is occurs to people with migraines. About 20% of people with migraine get the visual warning before the headache starts. And then the kids, you know, lack less sleep and stress. So my migraine started and I would take over the counter. Stuff didn't work.
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A
Such as like non steroidals and things,
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D
Advil, Ibuprofen, that is, didn't work, not at all. But luckily Sumatriptan, that's the first migraine specific drug that we have, works like a charm. I take a pill as the earliest sign of a migraine and I don't skip a beat. So I would take that head, it goes away. But then I thought, why am I taking this? So my cure, magical cure. And you write about it in your book. And that's meditation. And not just meditation. When I was doing 10, 20 minutes a day did not work when I went up to 30. That was my cure for migraines. 30 minutes every day. Some is up to 45. And no more migraines? Literally none. Except when I drink wine or do something that I know will trigger.
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A
So am I to understand that probably one of the best known headache doctors in the country meditates for migraines and has essentially cured yourself of those headaches?
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D
Yeah, well, age may have something to do with that as well.
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A
As you get older, the headache frequency goes down.
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D
Correct.
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A
But that's quite an extraordinary thing, though, the meditation.
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D
I tell every single patient who walks into the door. I start with exercise. Exercise is number one. Number two is meditation.
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A
Sometimes it's so confusing because. And you write about this in your book, but for some people, exercise helps with the headaches. For other people, it induces the headaches. It can be tough to sort of parse that out, but meditation pretty universally seems to help.
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D
Yes.
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A
Why is that?
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D
We have good science, actually. And the science tells us that your brain structure changes with meditation. Not just connections between different parts of the brain, but MRI scan changes. I see enough to. You meditate for a long time. Meditators tend to have a slower rate of shrinkage of the brain with age. So we know that when you meditate, this is the only time when your brain gets a break. Because even in sleep, your brain constantly working and connecting and dreaming. Sort of a cleanup time.
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A
Can you just talk me through your routine? So when do you meditate? How do you meditate?
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D
So I recommend everyone to do it first thing in the morning, brush your teeth and sit down without checking your phone. And that's when I do it. I do what's called Theravada or just think about your breath. Buddhist meditation, in and out. And you get distracted. One important message to your viewers and listeners. You will never stop thinking. They've done studies, imaging studies of advanced meditators, people who meditate all the time for a long time. The longest they can go without a thought based on the scan is 10 to 20 seconds. You think that they sit for an hour and another thought crosses their mind. Not happening. So I tell people the only bad session is the one you didn't do. Even if you sit and your mind keeps running, just keep doing it. After years of doing it, you'll benefit tremendously.
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A
I tell you this story, not to brag in any way, but I did have a chance to meditate with the Dalai Lama.
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D
I read it in your book.
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A
Yeah, that was scary in a way. Because it's kind of like saying you're gonna go play baseball with Mickey Mantle or somebody, you know, but. And then he said to me that he still has trouble meditating. And he meditates for hours a day, but you're focused on your breath. 30 minutes sort of seems to be the dose, if you will.
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D
Yeah, some people may need less.
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A
10 to 20 minutes did not do it for you?
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D
No. I tell people, though, start with five, because they say, I'm busy, I don't have time. If you tell them, meditate, 30 minutes. No way, not happening. So just establish a habit of five minutes every morning and then you can extend it. Even five minutes brings great benefits.
- [10:58]
A
How does somebody know when they should see someone like you again? Headaches. 40% of the population, billions of people around the world, most of them are not going to require, you know, brain surgery or something invasive, but at the same time, it could be a warning sign. So how do they know when they should actually see you?
- [11:17]
D
Right. Well, whenever you have your first severe headache, you should see a doctor. And as a neurosurgeon and neurologist, we know the scary words. The worst headache of my life usually suggests there could be a bleeding into your brain, hemorrhage. So we always tell people immediately, go to the emergency room if it's the worst headache of your life. If the headaches recur and you've had them for years, the time to come to a doctor when they begin to interfere with your life or you're taking too many over the counter medications, because there are people who are living on over the counter drugs and they think it's fine because the headaches are controlled, but then they'll get an ulcer and get other complications, the kidney problems and liver problems from all the painkillers. So the other time is, even if the headache does not interfere with your life, but you're taking too much medicine, that's another time to come and see a doctor.
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A
So, I mean, it's probably hard to get in to see you though, right? I mean, should they go to the emergency room? Should they come, make an appointment?
- [12:18]
D
You know, I'm a subspecialist, meaning that there most people go to their primary care doctor and many good primary care doctors can take care of that. Prescribe the sumatriptan, the specific drug for migraines, and can make a dramatic difference. And most doctors will counsel them on lifestyle. And some people will even listen and start exercising and doing things. The next step is a general neurologist. And then if the General neurologist cannot help, then you go to a specialist like myself. So we tend to see people who have tried things and didn't work. So if you just started having headaches, you don't need to see me.
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A
Sumatriptan?
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D
Yes.
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A
Any sense of how likely that is to help people?
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D
We have good data. Oral sumatriptan, 60% injectable. It comes in the auto injector. You press the button, give yourself a shot. Up to 80% of people respond to that injection. And again, it's safer than over the counter medications. The petition that I submitted to the FDA lists all the studies showing that Sumatriptan and other triptans, we have seven of those on the market, are safer than Advil, Excedrin, Tylenol because those cause stomach bleeding, liver problems, kidney damage. Triptans are safe even for your heart because there is a contraindication for Sumatriptan. If you have heart disease, you shouldn't be taking it.
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A
That's why you petitioned to have this go over the counter. But also you talk about in the book these GLP drugs. These drugs like Ozempic and Mounjaro, same mechanism. How do they work?
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D
GLP1s I've written about on my blog. And GLP1s, you know, when the new drug comes out, they're too good to be true. As you probably know that they are being touted for the prevention of Alzheimer's and other things. They do have some anti inflammatory properties that could be one mechanism. But a very important mechanism is weight loss because we have multiple studies, hard data correlating the weight and the frequency of migraines. The heavier you are, the more migraines you get. And it doesn't matter how you lose weight. Even after bariatric surgery. They've done a study. Migraine incidence drops because the fat is pro inflammatory. So we know that losing weight helps migraines. We know that these drugs may be anti inflammatory. One study, small study, suggested that even without weight loss, these GLP1 drugs help migraines. That's a small study. I would like to see confirmation.
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A
But this wouldn't surprise you though. Not at all based on what you know of migraines? Yeah, it is really interesting how connected all these things are. You know, weight and blood sugar, diabetes and migraine headaches. I think people often think of migraines as sort of an isolated entity. But if you're heavier, if your blood sugars are out of control, not getting enough sleep, all those things can cause lots of different problems in the Body migraine's yet another one of them.
- [15:15]
D
Yes, that's correct.
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A
I feel like the, the. My. My threshold for wine causing a problem has gone way down. Like, I think in the past I could have a glass or two and really have no problem. And now just even a single glass. And I am, I am worried, you know, significantly that this is going to, you know, teeter over into a migraine.
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D
Right, Me too.
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A
But at the same time, as you get older, you have fewer headaches.
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D
Y. Yes, but your tolerance. And the same with stress. People tell me I've always had stress. I have the same job for 20 years. Well, you're getting 20 years old and you may not tolerate as much stress, just like with alcohol. But an interesting tidbit. When you go to Europe, do you get a headache from wine there? Have you? Do you remember? Probably not, because many people don't even cheap table wine in Europe, nobody knows for sure why. It could be they, the barrels, the different oak, different tannins and different things. Or maybe you're just on vacation and relax. But people often tell me that when I go to Europe, have wine in Italy or in France, no headache, I come here, a good bottle of wine, still get a headache.
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A
If I drink Italian wine, would that be better? I can get Italian wine.
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D
Well, it's not the same, actually. You. On the label on the back of each bottle, as you know, there's a warning added sulfites for preservatives. As a preservative, every bottle has a warning label on the back. So maybe it's less of those preservatives that are required for export.
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A
So three important things that I've learned. First of all, the low carb diet that can have an impact, obviously the meditation. And for you, this has been pretty, pretty significant, almost a cure for your migraines. And then look for the sulfites on the wine. Look for that label if you are going to be drinking any wine. Those things can make a difference. Okay, stick with us. We're going to learn much more about headaches with Dr. Moscop right after the short break.
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E
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- [18:15]
A
You have 60% of people who get benefit from the from the triptan sumatriptan type drugs. At what point do things like Botox become a good option?
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D
So we divide treatment into acute and preventive. So if you use a lot of acute therapies, like taking Sumatriptone constantly like I did, you may want to think about preventive measures. And Botox is the top of my list because it's probably the safest treatment there is. I give it to pregnant women off label, not cleared, not approved for pregnant women. But we know from research that very, very little of it gets out into the bloodstream and none of it crosses the placenta. The molecule is too big, 150 kilodaltons. And that's a big molecule to go through the placenta. So there's no problem at all.
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A
Seems like it would always be better to prevent the headache than try and, you know, take something to stop it. Why, why, why doesn't Botox used earlier in the chain of potential options then?
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D
Well, it depends on the frequency of the headaches. If you have a headache once every other week, you don't need Botox or other preventive measures as long as the acute treatment works. There are people who have two migraines. Some women have menstrual and ovulation migraine that lasts for several days and acute treatments don't work for them. That would be appropriate to try preventive measures. But there are people who have twice, three times a week. But they say Osamatiruan is like magic. I don't want to take preventive drugs because some preventive drugs, the old ones, epilepsy drugs and antidepressants, can cause more side effects.
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A
All these treatments that you're talking about, are these FDA approved and covered by insurance?
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D
Those are two different things. FDA approved.
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A
Okay, let's start with FDA approved.
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D
So we have about a dozen preventive treatments that FDA approved, starting with, I mentioned beta blockers like propranolol and another one Timolol. And then there are a couple of epilepsy drugs develop sodium Depakote and Topiramate, Topamax. And then we have Botox and we have now gpens and we also have monoclonal antibodies, very advanced treatment for migraines that again addresses the CGRP chemical calcitonin gene related peptide. Three of those are self injected once a month for prevention and one of them infused intravenously every three months. And they can be extremely effective. About 50% of people have very good response to that. So those are FDA approved. And Botox is also FDA approved for chronic migraines.
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A
FDA approved Botox for chronic migraines. Does insurance cover it?
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D
Well, that's the second part of your question. Most of them do, but they have certain prerequisites. For example, you have to fail to all preventive drugs like a blood pressure medication or antidepressant or epilepsy drug. And most of them will cover eventually Botox.
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A
It's fascinating. And again, this is just working on the. What we call the periphery. Yes, these are the peripheral nerves. This isn't working, obviously inside the brain. You're just injecting it in the periphery. What about all those chemical signals that are still going on in the brain though? Do those still need to be addressed even if someone's getting Botox?
- [21:28]
D
That's a great question because yes, it's not. I tell patients it's not a magical cure because they come in and tell me, Botox was great, but why did I get headache? Well, if you get enough triggers, you'll still get. It's not 100% proof. None of these therapies. If you deprive yourself of sleep or drink alcohol, Botox is not a guarantee that you will not get a headache.
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A
Have you ever had a migraine patient that you have not been able to help?
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D
Of course, if someone tells you that they have 100% success rate, I wouldn't believe that the doctor, no matter what the condition is. So I definitely cannot claim that I have.
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A
With all that we have, the generations of triptans and Botox and all these meds, there are still patients.
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D
Well, the important thing I tell my patients, and they often come in already having been to three neurologists before me, and they say I've tried everything. So my message always is, I've never seen a person who've tried everything. So the title of my book is the end of migraines 150 ways to stop your pain. My second edition has 160 listed items and the next one will have more. So the point of the book is give patients hope because people come and tell me, my last doctor said, I have nothing to offer you. And that's devastating. And people become hopeless and really have no reason to live because the pain is so severe. And I always give them hope and we often find a solution for them. You mentioned in your book pain reprocessing therapy, it really can be very dramatically effective besides the cognitive behavioral therapy approaches. So I can help most of my patients not cure them. I tell them we have to set realistic expectations. I may not be able to eliminate all of your headaches, but the goal is improve your functioning and enjoyment of your life. And then we keep trying and trying and trying. And one other interesting fact, that depending on the study, 40 to 60% of people who have chronic pain or headaches have a history of traumatic event in their life, whether it's childhood abuse or bad accident or serious illness. And that traumatic experience makes your brain hypersensitive. And that's a predisposing factor to chronification of pain of any kind, back pain or.
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A
It's really interesting that I'm sure you, you know, Bessel van der Kolk work, the body keeps a score. You buy into that?
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D
Well, patients often ask me. They buy into it. Proof is in the pudding. That means if you feel better from thromotherapy, and many people do, and you know, drugs like beta block help traumatic experience as well, they slow your heart rate down. PTSD beta blocks can be helpful. Antidepressants, therapy, psychedelics are coming hopefully soon through the FDA approval process. All these things reset your brain. So there's no question about the fact that when you have a traumatic experience, I actually have a two question screening questionnaire in my intake form. Have you had a traumatic experience like an accident, illness, childhood abuse, and if yes, do you try not to think about it? And the second question is, when you think about it, does it upset you? So if you answer yes to those two means you're always living in this state of alertness, hypervigilance we call it, or state of fight or flight. So clearly your brain is susceptible to all kinds of things. So I don't think we need definitive proof. I think for most people it's pretty obvious.
- [25:02]
A
That's really interesting. Have you had this and do you try not to think about it? I hadn't thought about the second part of that question.
- [25:09]
D
That's a validated screener. It doesn't, it's not 100% of course, but it gives us an idea. Somebody has. Sometimes people will not admit that they have it. And you ask them about their childhood because people who've gone to a doctor doctor Nothing works. First thing I have to think about is what was your childhood like? Oh, my father beat me all the time.
- [25:29]
A
I am sort of blown away by the number of options that people have for headaches because even as a neurosurgeon myself, I think people tend to get pretty reductionist about having a few things in their tool belt. But 150 things, and we've talked about many of them. Are you really writing another book called 160 Ways to.
- [25:48]
D
Dr. No, it is just an update, a new edition of the same book, 10 more ways 150 because I don't want to change the, the title changes all the kinds of legal things.
- [25:59]
A
Well, I really appreciate your time. I appreciate the conversation. As you said, I hope this will provide some hope for people. This is a significant problem and I think for a lot of people, they don't have that hope because they've been suffering for a long time.
- [26:14]
D
Yeah. Well, I appreciate you having me here.
- [26:16]
A
Thank you, sir.
- [26:17]
D
Thank you. My pleasure.
- [26:19]
A
That was my conversation with Dr. Alexander Moscop, the author of the End of Migraines. 150 Ways to Stop your pain. Thanks so much for listening.
- [26:35]
C
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E
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D
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