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For decades, migraine was explained as a blood vessel problem. Swelling, throbbing, treat it by shrinking things back down. Turns out that's mostly a myth. The real explanation is stranger and also a lot more hopeful than the older one ever was. In this conversation, you'll discover why migraine is neuroinflammatory, not vascular, and why some med schools still teach the old version. You learned how your brain can start treating chronic pain as normal, like a broken thermostat convinced a hot room is 72 degrees. We'll talk about why only a fraction of people with migraine ever get aura and how differently it can show up in so many different ways in so many different people. We'll explore what's happening while you sleep that either clears your brain out or leaves it inflamed, and why headache medicine may be entering its golden age. We'll talk a lot about cutting edge treatments as well. Our guide is one of the few physicians in the country trained in both internal medicine and headache medicine. Dr. Fred Cohn so excited to share this conversation with you. I'm Jonathan Fields and this is Good Life Project and we'll jump right in after the short break.
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Hi, it's Mark Bittman from the podcast
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Food with Mark Bittman. It's back to school time, which means many of us are going to be busier than ever.
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But from getting out the door in the morning to enjoying delicious meals together
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at the end of the day, Whole Foods Market can help with convenient options and delivery. Plus, because it's Whole Foods Market, you can feel good about the quality of the ingredients.
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Shop back to school must haves at
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Whole Foods Market in store or online. Goodbye Project is sponsored by Tonasi. So a few months back I started looking for something to add to my evening wind down. Something I could feel good about having in the house, not just one more bottle on the shelf. And a friend pointed me towards Tenasi and their unique CBD CBDA blend. What got my attention wasn't the marketing, it was the backstory. The founders put $2.5 million into university research before they ever launched a product. They they worked with scientists at Middle Tennessee State to study the hemp plant in detail. And what they found led to a patented formulation built around a specific 1:1 ratio of CBD and CBDA. That's the active ingredient in their softgels. Every batch is tested by an independent accredited lab for heavy metals pesticides. The full panel and they put the test results right on the label with a QR code so you can see exactly what's in what you're taking. For me, that's the bar. If a company's going to make something I'm putting in my body, I want to know they did the work. Tanasi did the work. If you want to try it, head to Tonasi.com and use the code GoodLife for 25% off your first order. That's T-A-N-A-S-I.com and use the code Good Life for 25% off your first order. Good Life project is sponsored by Nature Raised Farm. So if there's one thing I have learned after 14 years of deep conversations about living well, it's this. At some point you get tired of overthinking things that shouldn't require a decision tree. And somehow the chicken owl just never got that memo. Too many labels, too many claims, too many things to squint at before you can just make dinner. That's the problem Nature Raised Farms set out to fix. It's no antibiotics ever. Free from gluten, dairy and soy. No seed oils, nothing artificial. Good source of fiber. So whether it's a fast lunch between calls or a Sunday dinner with people you love, you're not trading taste for trust. Nature Raised Farms believes chicken should meet a higher standard. Chicken, that's just chicken. No trade offs, no second guessing. Look for Nature Raised Farms chicken in your freezer aisle and get back to simply enjoying dinner. What is the myth that we have been told or learned about migraines that was either never true to start with or is maybe no longer true today?
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Yeah, so that's a really great place because it's still, I would say, a problem, if you will, today. So first let me start with the myth and what migraine is still taught us. So migraine, you know, it's actually, there's documentation of migraine since like BC times and I, I, I think it was Aristotle actually has in a, like a log or a diary or whatever, him talking about having blood, blinding light in his eyes, then a splitting headache, which, that sounds like migraine with or. Yeah, so it's been around for as long as we've been keeping documentation of things. It's not like a, an occurrence of something new and arid. The first accepted theory was actually earlier in the 20th century by Dr. Harold Wolf is a very famous like forefather of headache medicine that it was a vascular issue, you know, migraines, that pulsating, pounding thing. But then later on towards the turn of the century, we know it's not primarily vascular. That's the myth, it's not a vascular thing. And they still teach that actually in like some parts of like med school and whatnot, that it's a vascular problem. It's a neuroinflammatory condition. That's what it is. And again, it's complex. I always tell someone, if you figure out a migraine 100%, you win the Nobel Prize in medicine. We understand a good bit what's going on, but there's still more to do. But it being a vascular blood pressure is a myth. The truth is it's more of a neuro inflammatory condition.
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A
I mean, that's interesting, right? Because I'm somebody who is a migraineura. I have lived with migraines for my entire life since my teens. And I remember hearing early in my doctor visits that this was exactly what you're describing, it's a vascular condition. And that a lot of the treatments were designed around that assumption. None of which ever worked for me or helped me in any meaningful way. So you're saying that that was the assumption until not too long ago, but now there's a deeper understanding that there's something different going on here and that's
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B
actually a big fight in, if you will, migraine education. I still have, I meet trainees, med students, etc. That they are still learning in their schooling in like the year 2026, that it's a vascular condition. And there's a concern of like, oh, you know, is it, you know, it's a blood pressure thing or something like that. And again, no, like there is a vascular component of it, like downstream. But the primary aspect thing that's going on migraine is this release, a soup, if you will, of these inflammatory neuropeptides that are released and then downstream. Yes, they can have vascular effects, obviously pain. You have the OR components like flashing lights, zigzags, weaknesses, all this other stuff. But it's the vascular parts, only one small component.
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A
So do we know at this point what causes that release that leads to all of this inflammation?
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B
Now that's the question. Because we know what the release is.
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Yeah.
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B
So the way it's growers, we know when a migraine starts, what's happening, or most of it, I should say. But the why, that is what we don't know. So there's something called the trigeminal vascular system and there is a switch. What turns that switch on? Is it all genetics? Is it environmental, is it dietary, is it. In my opinion, it's not just one thing, it's a multitude but anyway, you have migraine, you have something that predisposes you for the switch that turns on. And then there is a release of all these neuropeptides, calcitin G related peptide, cgrp, which there are now treatments that target that and amylin, vip, vip, pay cap, substance P. I go on and on and all these peptides come out. We also know there's a concept called cortical spreading depression. And what that is is this massive release of potassium. Think of if you have a bucket of water, start shaking it, the wave gets bigger and bigger. That's what sort of is happening. You see this ever so growing wave of potassium released and that's also happening again. We don't know the why per se, but we know that's happening and that is what and what that does is it. Now in your brain there's no pain receptors. If I was to melt in the middle of your brain, you wouldn't necessarily feel it. But what happens is the dura, which is the outside component of our head and brain that becomes super sensitized. And we believe it's a pulsating pain because the areas where the blood vessels are going through that is now sensitized. And that's why I can feel pulsating. The blood vessel is fine, but the area around it is sensitized. And I also going on myth, you know, you brought that up. Everyone commonly thinks a migraine has to be one sided behind the eye. No, it could be anywhere in the head. Now one sided behind the eye is the most common. But I have people who come thinking they have a neck issue or back in the head pain, I go, not if it's the migraine, you know, criteria. So it really could be anywhere in the head. It's not just focus behind the eye.
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A
How do we distinguish between a quote everyday headache or attention headache and migwing, or we hear this other term sometimes cluster. Like what are the differences between those things and how do we actually tell?
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B
So there are three primary headaches and you name them all. So tension, which I call if you will, the regular headache, very broad, it's a mild to moderate pain. They also brought up cluster. Cluster is a very specific kind of headache. It's sudden, immediate, that one has to be behind the eye, one sided super severe pain for 15 minutes to three hours and then migraine. So the way we, we come to diagnosis is the sort of clinical picture of the pain. Some of the two most important things is duration and the quality a migraine must be. And I want to stress that this is not black and white. You know, pain is subjective. It's not like you, you know, so I have an internal medicine background before I went to headache medicine. You know, when you diagnose a heart attack, you see it, you know, you get a chest X ray. We can't do that with headache medicine. It's all by feel and pain is subjective. So to those listening, I want to stress this is not completely black and white. You know, this is a discussion with your provider. So the pain generally has to be at least four hours. So when someone says, oh, it's only last 30 minutes, I'm not as inclined. For a migraine, it needs to be moderate to severe. And usually the way to find it is it impedes. You have trouble focusing. You got to leave work. You can't keep going about your day. It's bothering you versus attention. Headache more mild. Yeah, it bothers, you know, but like, you could persevere. You know, you don't have to stop working. And lastly, that it also can be usually pulsating, throbby. But again, it doesn't have to be. But really, that duration and the quality is what hones me in. Now, again, we don't have a test to prove this, and it's actually a big popular area of research, but usually these are conditions of exclusion, which means we make sure it's not something else. You know, if you have certain concerning signs, we may get an mri, you know, make sure that's fine. Or if there's, you know, a reason to get a blood test, something like that. But again, there's no blood test to prove it. It's really by clinical picture.
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A
So it sounds like of those three that you just described, probably the most clearly discerned one is cluster comes on really fast and incredibly intense.
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B
Cluster is one that usually, like, yeah, there's no confusion about it because it's so specific and so unique than the others. I'll give an example. Like, it's a severe pain. So typically, you know, the way I. The way I bring the upper is like, if a patient tells me I think I'm in close, I'm like, how is it? Yeah, okay. I don't want to come off. Like, I don't believe the patient, but speak to someone cluster, they're like, they're on the ground. They can't talk. Like, so. And again, not like, not to sound dramatic, but it has, you know, this. Sometimes it could do this. It has a nickname of the suicide headache because people, if, you know, it's so severe that it has historically brought people to that when they haven't get adequate treatment. So it's a very different picture than tension and migraine, which could. Those have a lot more overlap?
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A
Yeah, I guess maybe there's a little confusion just in popular understanding because of the name, because the name itself, cluster, it kind of makes it sound like, well, if I have a headache four days in a row, that sounds like a cluster to me. Whereas like. So the common understanding of that word is very different than the medical understanding of the name.
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B
And yeah, it gets. I understand the, the nomenclature of the term. A lot of patients go beyond. But it's happening in clusters. Sure. Migraine can do that.
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Yeah.
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My people could. You know, it's very common. Women can have only migraine attacks around their menstrual cycle. That's. That is a very common thing. And I've had patients come, oh, I have cluster. Because they're happening in this grouping. And again, migraine attacks can happen in groupings. Cluster, again, it has to have that specific severe pain.
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A
Let's zoom the lens out just for a minute, because I'm curious too, about the prevalence of this just across large numbers of people. What are some of the general numbers, like the big picture numbers and stats for migraine? Yeah, for migraine, sure.
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So migraine, our epidemiology suggests it affects anywhere from 40, 60 million Americans. So that's one out of six Americans more common in women. So about 18% of the. Of American women, 6% American men. So about one out of five, almost American women. So very, very common. Now, chronic migraine, which for those who are having eight or more migraine attacks a month and 15 total headache days, we think that's around 1% of the population. So, you know, not as much as migraine, but that's still quite a bit. And think of having that many migraine attacks a month. That could be pretty, you know, disabling.
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Yeah. And you just described, and I've heard this, this mentioned also in the past, that there seems to be a much higher prevalence in women than in men.
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Yep.
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Do we know what that's about?
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B
So there's some suggestions. The most, well, the most common one believed is we know estrogen is related to migraine attacks and it's not the level, it's fluctuation. Because I've had patients ask, should I take a estrogen replacement? I go, hold on, no, that might not solve this. Most women notice their first migraine attack if they get one around their first menstrual cycle. We Notice that in the first trimester of pregnancy, there's increased frequency of migraine attacks. And for a lot of women, when they go through menopause, there's no more migraine. And that was the case with my mother and my grandmother, which my mom, when I complain about my migraine, just goes, oh, yeah, wait till you get older. I'm like, well, there's a phenomenon. I'm not going through menopause.
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A
The other fact that I've heard, which is more gender specific, is that. And I don't know how you measure this. I'm curious whether there's data on this is that not only is it more common in women, but that it can also be more painful, more intense. Is that. Is. Is that true or is there data around that?
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B
I don't know if there's data really behind it. Again, it's really hard to quantify pain. Yeah, because. So we have battles, if you will, for migraine in both sexes. You know, there's unfortunately a lot of women's health issues, you know, don't get as high a focus as they deserve and need to be. So there's always this fighting stigma around migraine and raising awareness of migraine. But the other side of the aisle, that migraine is a woman's disease. And again, where there are. I have. There are many men who. I've met patients of mine who just dealt with it thinking it's headache and didn't see treatment. Just, oh, I don't have migraine, I'm not a woman. And again, no, like, while, yes, it's more common in women, sure, men can still get it, and a good amount of men get it. So, you know, this. That's actually been a reason to shed light that, hey, if you're a male having, you know, severe headache attack, speak with your doctor. That could be migraine. As far as which gender has more pain, you know, I. There's no data behind that. And I never like to compare. I tell my patients, never compare your headache or pain to someone else. It's because pain is subjective. You know, how someone expresses pain differs by person, by culture, by. By so many factors. So that's why I never like comparing, oh, that's more painful than this, etc. But that's also why in my patient interactions, I don't just ask about pain. I think the best indicator for the impact of someone's migraine or headache is asking about their function. How many days have you missed work in the past month? How many days have you not been able to do, like, an activity, go out, spend time with friends or you. How many days could you not interact with your child? How many days are you taking medication, etc. Those could go, like, for someone who I've had patients, especially, you know, being in New York City, I have a good deal of immigrant patients. They come from areas that don't really have healthcare infrastructure, so they're not used to discussing or bringing these up with a doctor. And they come because their family member brings them, and they're like, yeah, I don't really have pain. But they start asking the questions. How many days have you not been as productive at work? Oh, yeah, like two or three times a week.
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Or.
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Well, you're having two to three headache attacks a week. So that's why I don't always focus on the pain number, but these other metrics as well.
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Yeah, it's such a good point. You know, and I have had, in my own experience over many, many, many years, there have been windows where the headaches are so frequent that you kind of forget what it's like to move through the day without them. And it almost becomes normalized where it actually really does become hard to understand. Like, if you were going to rate the pain, it's kind of hard to do that because you're comparing it to sometimes a window that is hard to almost relate back to. But if you said, how is this affecting you? Is it stopping you from doing X, Y or Z?
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A patient of mine who had headaches every day for years, and when I first met this individual, he told me that his headaches were a nine out of 10. We've done a lot of treatment. They're still daily, but they're down to a 5 out of 10. So I ask him, would you like to, you know, keep trying new therapies? He goes, listen, this pain came out for nine to a five. Five is nothing. I don't want new meds. I'm content. And I said, that's. That's up to you. That's fine. So, yeah, those are just. They're just numbers. And one of the biggest lessons in medicine is treat the patient, not the number. And again, like, yes, I always ask those things, but those numbers are not just specific, finite. All right. Like, that's all I'm going to work with. No, you know, one of the most important things is the history. Remember, you know, it's not just looking at, you know, tests and labs and whatnot, but how the patient is presenting it themselves.
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No, that makes a lot of sense. And we'll be right back after a word from our sponsors. Hey, so we'd love to share more midlife reinvention stories on the podcast, like the recent one from Sarai Bottin, who, after decades in her career, then being pushed out as she neared 60, launched Oldster magazine to an incredible reception that even led to a book deal. We love inspiring stories that show how change is not only possible, but often incredible at any age. And it's not just about work. It's about relationships, location, health and more. So if you've got a reinvention story you'd love to share, just tap on the link in the show notes and give us a quick summary. And who knows, you might just end up on the podcast excited to be inspired by your stories. Grow Live project is sponsored by BetterHelp. So you have heard me mention BetterHelp many times before, but there's something we haven't really talked about. How much people actually love this service once they're in it? I don't just want you to take my word for it. Go see for yourself. Head to betterhelp.com reviews and you'll find real feedback updated every day from people talking about what it's actually meant for them. And the numbers back it up. BetterHelp has an average live therapy session rating of 4.9 out of 5 based on over 1.7 million client session reviews. That's not marketing copy, that's people who actually sat down and done the work telling you what happened Next. More than 6 million people worldwide have used BetterHelp. Getting started is simple. You answer a few questions, get matched with a therapist suited to what you're working through. And if it's not a right fit, you can switch anytime. Because doing the real work on your life, the work we talk about on this show every week, sometimes means bringing in somebody trained to help you do it. See the reviews, see what stands out, see if BetterHelp is right for you. Visit BetterHelp.com GoodLifeProject that's BetterHelp.com GoodLifeProject
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A
You mentioned earlier in our conversation that you started out in internal medicine, switched over to headache. This is not just your practice, this is personal for you as well.
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Oh yeah. So I always say never trust a headache doctor who doesn't get headaches because you know, there's a lot of them. So my path was I always had a weekly severe headache. Since I can remember, there was never thought to be a thing, you know, and this is no complaint. I'm very close and love my parents very much. Although I do give a little bit of shtick to my mom, my aunt and my grandmother who have migraine and never thought that, oh, maybe Fred's having that. So I tell him that that's the only mistake he ever made raising me. But I just dealt with it all the way until residency, one day a week, pain out of commission. Now in residency you're not sleeping, you know, you're working 80, 90 hours a week. So now the migraine ramped up and you know, I take it as a blessing that I trained at Montefiore, a hospital system in the Bronx that has a very well known headache center. And I actually got a lecture from one of their providers and at the end I said, hey, I think I got that. And she, she was like, come on down. I went to see them, had a visit, life changing completely. Now these migraines that took a day, a week became non problematic. It's not common for me to lose a day now to the migraine. And I learned from them this is a field. And I said, this is what I want to do. This is the field of medicine I want to pursue. And then I learned that headache Medicine is a board certification. You don't have to be a neurologist for, you know, you could be an internist, family medicine, pediatrics, ob. Now, most headache medicine specialists are neurologists. The vast majority we. So I'm like sort of this uncommon one. But it's also what I love about our field, the collaborative nature. A couple days ago, I just came back from the annual scientific meeting of the American Headache Society and you meet people of. Not of just not from different areas, but different backgrounds, physical therapists, occupational therapists, psychologists, you know, of course, internists, family medicine, PEDs, etc. And, you know, it's such an interesting field that most fields of medicine are just in their own, you know, their area, whereas this. It's different specialties coming together.
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I mean, that makes a lot of sense to me. And also it sounds like. Tell me if this is accurate or not, as you described. You know, there is. There's neuroinflammation, there's inflammation in the brain. Part of the theory is that it somehow affects the dora, and that's where a lot of the actual receptors are, which we translate to, oh, this is painful. But I would imagine also like that it's systemic. This is not something which is reserved to what happens from the neck up. Like there's something going on that's more broadly systemic that also influences the entire experience.
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B
Does that mean it affects other systems? So, for instance, the GI tract is involved. We know during a migraine attack there is gastroparesis. Gastroparesis is, you know, going with the line and term, not per se, paralysis of the gastric system. So the stomach isn't moving as much. This is why we think there's nausea. There have been studies called a barium swallow. Patients drink a dye and we can see it on X ray and it is confirmed. In migraine attacks, there is a degree of gastroparesis, you know, and my, you know, we know this also. Migraine is not just a headache. There's multiple phases. The prodrome. So the beginning can have excessive hunger, fatigue, thirst, irritability. Then we have the headache with the aura phase and the headache phase. The prodrome, the postdrome, is nicknamed the migraine hangover because there's immense fatigue. But yes, it does affect other systems. Yes, neuro is the most affected systems. And it also is known for having very common comorbidities. Anxiety, depression. We know that asthma is a common comorbid condition. Obesity, there's so many things that are involved with it that it's not just neuro involved, it does affect other systems in more than one way.
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A
So now I'm curious about two things you just said there, too. One, the early part of it. What was the language you used for sort of like the very early part?
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Prodrome.
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A
Prodrome. Right. And you mentioned a couple of times this notion of an aura. And that, I think, is one of the things that in popular lore is associated with, like, oh, there's a migraine coming. And for some people, that's true, but that's not true for everyone. Right.
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Ready for me to dispel another myth?
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Yeah.
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B
What if I told you that most people with migraine don't get aura?
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A
Okay.
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B
And we think of migraine always OR no. Only 30% of those with migraine get aura. The majority don't. So that's why when someone's like, I don't get ora. I'm like, okay. Like, okay, you don't need to. And you don't even have or every attack. So aura can be any. I describe it as this. It's any neurological symptom that essentially collapses anywhere from 15 to 60 minutes. That timing is very important. Now, some auras can. But an aura should not last longer than 60 minutes. If it is, you have to speak to your provider. That has to be evaluated. The most common aura is the visual ones. Zigzag, flashing lights, blind spot that grows. Some people describe it as kaleidoscope vision. And generally, there's no pain during it. It happens, it goes, and then the pain begins. But aura could present in a lot of other ways. Or. Or it could present as numbness. It could present as weakness. There are some who have what's called hemiplegic migraine, where it mimics a stroke. Some who have vestibular migraine giving vertical, like, symptoms. There are those who have difficulty speaking. There's a famous video on YouTube of a news reporter who's, you know, on camera giving a report, and then she sort of starts saying nonsense like gibberish. And they thought she had a stroke. They took her to the hospital. Migraine, you know, now these have to be assessed to make sure it's not those things. But my point is, migraine aura is not just the visual symptoms. It really. Any neurological presentation.
- [28:35]
A
Yeah, I mean, that's so helpful because I had heard that, like, this is much more common than you're describing. But also understanding that aura is not just the classic, you know, spotty vision or. Or shift in what you see, but it can show up in so many different ways in your body.
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It really can.
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A
Yeah. I mean that those who, you know,
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lose sense of smell, those getting everyone that they get tingliness on their tongue for 30 minutes. It really, what I care about is the duration. That's the key thing.
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A
Yeah.
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B
That it's the last. It's because that is like the one, I would say absolute. When someone's like, it lasts an hour and a half. We need to get neurological testing to make sure that's not that it all comes back normal. Cool. We'll say it's that that's your aura. But it really could present in any way it wants.
- [29:18]
A
So my other question was about the sort of like the post phase and you mentioned that fatigue can be one of the things that we feel. That's certainly something that I have felt and I've always been curious about that because it's not just like my head is really tired and my eyes are tired, which often they are. But my whole body feels like I just went through this intense. Maybe it just did a 10 mile hike.
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B
That's why we call it the hangover. It's like when you had too much to drink.
- [29:46]
A
What's going on there? Why, why is there fatigue?
- [29:48]
B
Our thought, why? And you know, we don't have 100%, you know what this is, but we talked about a migraine. When it's happening, all these neuropeptides are firing, right. What happens if you, you're running for a while, you know, you push your body, you get tired. And I like to think of it like that you have all your brain. It's just neuropeptides are fuel and when you, you know, just like when you're running a lot, it makes, you know, the engine wear down and it's that sort of, that's how I sort of, you know, visualize in a way that your brain just spent so much fuel and it's like recovering.
- [30:35]
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Let's switch gears a little bit and talk about what we do. So somebody's joining us and they've had headaches, maybe they're new, maybe they've had them on and off for a long time. They weren't sure. Are these tension headaches, are these migraine? Are they cluster? Maybe now through this conversation they've got a lot more clarity and they're pretty convinced they have migraine. And as always we make clear like this is not medical advice. See your qualified healthcare provider. But I want to zoom the lens out and just explore options that probably a lot of people haven't known about. Let's start with this distinction between prevention and sort of like immediate treatment intervention and prevention. Because it seems like those are two different things, maybe with some overlap. So if you feel like something's coming on or you're in the middle of something, what are the common available main mechanisms that you look to now to try and stop it in its tracks? As much as we can.
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B
Sure. So I just want to make one point because this is sort of another myth.
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A
Yeah.
- [31:41]
B
If you're not, if you don't have a neurologist, start with your primary care. You'll be surprised because a lot of people wait to see a neurologist. You might need to see a neurologist. But if, you know, if someone's having tension of migraine, PCP is the place to start. So, you know, you said it correct. We have acute and preventive. So there's two different schools of thought of one, when starting a treatment, everyone needs acute when a migraine attack happens, but does everyone need prevention? And that's a bit of a gray area. So these are guidelines set forth by the American Headache society. There's no 100% like this is the where you start. It's sort of a, this like a scale, if you will, anywhere from at least four to six or more heading migraine attacks a month, but also how much the burden is. For instance, if someone tells me they have four attacks a month, but they're not that burdened from it, I might just do rescue medication. Someone has three attacks a month, but also they're really impactful. The day after the hangover is really bad. You know what? Okay, let me start preventative therapy. So that's generally how we pick it. So starting with acute therapy, there are two really common treatments, clinical classes, the Triptan family and the GPAN family. The Triptan family has been around since I believe. Yeah, the early 90s. You might have heard of these as sumatriptan, rhizan, etc. There are seven flavors of Triptan. They all have their differences, of course. They're available as oral, intranasal, even injection. And they work actually on a this 5ht serotonergic receptor and that actually causes vasoconstriction. But wait, Dr. Cohen, you said migraine's not a vascular problem. Oh no, we'll get. So yes, the drug itself does cause vasoconstriction, but that causes a decrease in release of cgrp, capsulin and gene related peptide, which is a neuropeptide, we know in the migraine cycle. That's how it achieves it Then there's the G band class. You might have heard of these as Remigipant, Nerdtech, Ubrogepant, Ubrelvi, Zavigipant, Zavspra. And those are antagonists of cgrp. So they're targeting directly. There's other therapies as well, but those are the two typically first line therapies I go to for acute treatment.
- [34:03]
A
How effective are these and are they universally effective for everyone? Is it completely different for everyone?
- [34:09]
B
I wouldn't call any migraine treatment universal if there was. Well, we cured it. But these are first line and they usually are quite effective. I would say, you know, more than often I don't need to go to a different class, that those two classes take care of the job. Now, I want to stress if you're someone who that those two classes are help, that doesn't mean there's anything wrong with you. Again, everyone's migraine is unique, but those generally are pretty effective.
- [34:35]
A
So let's talk about the triptans for a minute because I think that was sort of like the earlier class of drugs and then the things which use a different word. I've commonly heard of them described as anti CGRP meds.
- [34:47]
B
That's a newer class of GPANs or anti CGRP meds.
- [34:50]
A
Yes, yeah, GPENs, right. That's a newer class than the Tripans. Right.
- [34:55]
B
GPANs are released at the end of 2020.
- [34:57]
A
Okay, so fairly new. That's like six years old at this point, as we're having this conversation, and it sounds like what we know now, and tell me if this is right, is that the triptans work by a secondary effect in tamping down or limiting cgrp, whereas the newer class goes directly there, but at the end of the day it's sort of like a similar mechanism. Is that right?
- [35:26]
B
So, yes, it's not as concise as that because while yes, triptans in my view are this sort of secondary effect, they also work quicker. You know, the mechanism of GP hands, what we see is they, they on average take a bit longer to get their effect than the tripped hands do. So I don't like, like I get a salt time which one's better there. Unless until we do a superiority test, there aren't. You know, I never like to put a claim on which one's better there. They have their uses, you know, they're, you know, there are some, you know, it's the individual patient, if I pick if they're getting a gpan, a triptan first. Yes. In theory, triptan is having a secondary effect, but that's a common thing in medicine. In a lot of conditions, we don't always get something that goes right to the area of concern that it takes a bit of other things to get there. So I never like to sort of diminish that of its thing. But, yeah, triptans on average actually have a quicker onset.
- [36:24]
A
So about how long is the difference between those two classes?
- [36:27]
B
Now, I want to stress this is averages and.
- [36:29]
A
Yeah, yeah, yeah.
- [36:30]
B
Anecdotally. This is anecdotally.
- [36:31]
A
Right.
- [36:32]
B
You know, meaning I like. I don't want, you know, this is not, you know, clinical trial, whatever. What I see is triptans are anywhere from 30 minutes to an hour, per se. G pants are an hour to two hours. But that is my anecdotal answer. I've had patients that the G pants work very quickly. It all depends on the individual. There's a lot of things going on in the body that sort of dictates that.
- [36:55]
A
Yeah. Does it also depend to a certain extent on the delivery mechanism? You mentioned oral, nasal and injection.
- [37:01]
B
Yeah, definitely. So we have oral, intranasal and injections. Generally, injection is the fastest. So sumatriptan injectable. We also have sumatriptan and zolmotriptan. Intranasal and intranasal Zavagapan, zavsprain. And yes, there's. That one is a quicker onset than the oral G pants.
- [37:22]
A
Got it.
- [37:23]
B
Now, nasal, again, there's. There's no right or wrong for each individual person. I'll give you an example. I personally love intranasal. That's what, you know, I use myself. They got a nasty taste. It's not fun getting something, you know, spray nose. But again, to each their own. They're all useful things.
- [37:40]
A
Yeah.
- [37:41]
B
So there's not like. I don't just, you know, sumatriptan injectable is the highest. The fastest onset. I don't prescribe it to everyone. It doesn't mean. That's the. That that's it. That's the one for you. There's different reasons why one would get a certain route.
- [37:56]
A
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- [40:04]
C
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- [40:37]
A
So what about this idea also of medication rebounds? I've heard that with certain types of medication, let's say you have a migraine for one day and you take it migraine for second day. And then I've heard, well, don't take it for the third day because then you have a likelihood of having a rebound. What's true and what's not true with this?
- [40:58]
B
So medication adapted headache or medication overuse headache, they're interchangeable terms. There's actually I just gave a talk at the American Head exciting meeting last week on this specifically. So yes, what I guess let me first define what is a medication overuse headache? It is using a rescue, certain rescue medication, in this case triptans, opiates or combination drugs that you're Excedrin, more than 10 times a month or over the counter Advil, Tylenol, et cetera, more than 15 times a month over three months. Meaning if you have one week of taking Advil every day, that's not necessarily going to give you a rebound headache. This takes time and it's averages. For example, I have patients, oh, I use the triptan three times in a, like for three days in a row. Am I screwed? And I go, well, how I'm using it before that, oh, once a week. Okay. You know, that short span is not going to do it. It takes time. It takes, it's a repeating pattern. That's why like when I meet with a patient, let's say every three months, I'm looking at their overall use, not one week. It's not like if you take a triptan three or four times in just one week, that's it, you're, it's all over. No, it's, you know, it takes time for this because what's happening in a medication overuse headache is your body is, you know, we have a couple of theories that it's going through the sensitization, if you will, and the brain doesn't go through that so quickly. It takes time. But that's why whenever I prescribe these things and when I have follow ups, I always ask about its use because we want to prevent that from happening.
- [42:30]
A
Let's move on to prevention. What are the main things that we look at here and actually what is prevention? Let's define that a little bit more.
- [42:37]
B
So great. Think about, we were talking about medication overuse headache, right? Well, if you're having 8, 10, 12, 15, et cetera, headache days a month, you can't use a rescue med every day. Right? So that's where prevention comes in. Reduces the frequency. I never like setting the goal as curative. I think that's misleading. Migraine typically isn't per se curative. Breakthrough attacks will happen. I think it's a Very important distinction to not be misleading to someone. That's why I always prescribe acute medications to my patients, because it'll still happen. So prevention is to do that, prevent the migraine attack from happening. And there's now a lot of medications, so I'll do it, I guess in a chronological order we have what we call the legacy drugs, which have been around for decades. The three legacy drugs are anti seizure drugs such as topiramate, beta blockers such as propranolol and tricyclic antidepressants such as amitriptyline and nortriptyline. Their evidence is great, but they are work. You know, their original design was for something else and also found to be effective for treating migraine. Then in the late 2000 and tens, we had the first use, first FDA approved use, I should say. I've CGRP based medications, the CGRP monoclonal antibodies, which is oringumab, daconizumab, feminizumab and eptinezumab. These are monoclonal antibodies which are once a month injections. You know, think of it like, you know, a lot of you are familiar with like Ozempic or Zempam, like that kind of applicator, but for your migraine or once every three months infusions. And there's also Atogepant Culipta, which is, take it back to that Nertek Ubrovi. Right, the gpan. You could take it every day. And that's for prevention instead of acute. We also have Botox. Botox, believe it or not, is FDA approved for chronic migraine. Meaning this isn't for everyone. This is for someone who's having 15 headache days a month, eight of which are migraine attacks. And it's 155 to 200 units of Botox injected over the entire head once every three months. So, and those are, you know, first lines, then there's a lot of other possible treatments. Again, what goes to me, choosing what a patient gets is not only their headache frequency, their comorbidities and what else is going on in their life.
- [45:06]
A
Yeah, how does, I mean, you sort of describe the mechanism for some of the earlier ones. How does Botox actually work in this particular context?
- [45:16]
B
So Botox. And you know what, I'll give a good demonstration here. Botox is given 31 to 40 injections are on the head, so both by the brow, the forehead, the side of the head, the occipitalis, back of the head, upper part of the neck and trapezius. And that is how it's given every three months. And the mechanism is onobotulinum toxinate, which is what Botox is. When it's injected, it gets into the neuromuscular junction. And what that's doing is preventing the release of neuropeptides at. At that level. So for cosmetic purposes because of that muscles don't move as much. But for pain, for migraine, it interferes with the release of neuropeptides related to migraine like cgrp, which is why I'm actually and I'm biased, but I'm a big fan for those who have refractory migraine of one of the CGRP drugs, either the monoclonal antibodies or a cheap hand with Botox. That's one of the first migraine projects I was I ever did. Back when I was at Montefiore, we had the first paper showing that together it has a synergistic effect than just by itself are reducing monthly migraine days. Now, again, I want to stress that there's. I never like coming off as oh, there's one great treatment or that's the best treatment. There's many treatments. You know, everyone said it is unique because I've had people come to my office saying I want A, I want B. And I'm like, let's talk. And then I'm like, hey, I think C is actually a better fit. So, you know, there's no one true treatment for them all.
- [46:53]
A
So what I'm hearing really is that even on the prevention side there are a range of different treatments. It's really important that you work with somebody who is skilled at understanding what is the best approach for you. And also what I'm hearing you say is that sometimes it's not a matter of just working with one, but sometimes you may weave different things together for the optimal effect is a lot.
- [47:18]
B
There's. I could keep going. There are certain antidepressants, the snris, the loxatine and effects have evidence blood pressure, blood pressure medications like candaceartin or Lisinopril have evidence you have neuromodulation, which is becoming a popular thing. Which are these devices you wear like cephaly goes on your forehead. Gamma core is on the neck nerve use on the shoulder sav these, you know, back and they're. They, they work by sort of. It feels like if I vibration but they're altering your pain pathways and therefore you're not taking, you know, you're not, you're not taking a med. There's so many different treatments. Is of course, off label uses, like for patients who are really, really refractory, believe it or not, Ketamine, now that's very uncommon, but there are some people who warrant that level of therapy and have done very well.
- [48:09]
A
Yeah, the define refractory for mate. Just like. What's the common term?
- [48:13]
B
Sure, refractory. I use the same definition that the European Headache Federation uses, which is a headache that has become not responsive to at least three or more treatments on average in the span of three months.
- [48:27]
A
Class of drugs that you mentioned earlier that I'm curious whether they play any role in this. GLP1 agonists.
- [48:36]
B
Sure. This is actually a really popular thing that was actually discussed also at this past American Head exciting meeting. So the GLB1 agonist, these are your Ozempics, these are your, you know, wegovy, Zeppelin, Mangerno, etc. It was seen in those trials that those who had headaches or migraines started reporting less. And anecdotally, a lot of providers saw it too. So the question is, how is it? And it goes to is it direct or is it indirect? Because for instance, we know with migraine or chronic migraine, obesity is a very important risk factor in worsening things. And we, and the reason why we, that we think the GOP one's working, that is of course it's reducing weight. So is it that it's making headaches better because we're reducing weight or is it having a neuroprotective capability? There's a proposed mechanism that GOP1s actually get help reduce cerebral, cerebral spinal fluid pressure. So our brains are like a goldfish in a tank. This cerebral spinal fluid, you know, increased pressure, intracranial hyper. Intracranial hypertension, IAH is too much, you know, pressure in the head and that could lead to headache, et cetera. So it's a question of is the GLV one actually reducing it directly? Is that the mechanism? Is it suppressing CGRP in some mediated pathway down the road? Or is it just as simple as you reduce obesity? And therefore we know. So obesity is an auto, is an inflammatory state. Adipose tissue, we know when there's excess adipose tissue that releases inflammatory markers. So is it just as simple as, hey, there's less weight, there's less adipose tissue, therefore there's less of an inflamed state. So then what's my take on it? What do I use? Have I prescribed GP1s? Absolutely. But I view it as do you warrant weight loss? Because I don't prescribe it specifically for only migraine in mind because again it will, you know, gov1s will have an effect on weight. That's what they're designed to do. If someone comes to me who has a BMI of you know, they're not obese, they're 20 or 27 or less, then I don't really recommend it because it might have other consequences. You know, I wouldn't call this as a wonder pill is had a. They're very popular and have a tremendous effect on bringing weight down and helping resolve obesity. But that doesn't mean that non obese people should be taking it, you know, like, because they, there, there are known side effects. There's a talk about are they causing hair loss, you know, affecting endocrine issues. There's a lot of safety data like I'm always reading about. So I don't directly prescribe it to treat migraine. I prescribe it to those who have those risk factors, diabetes, obesity, etc. With the thought in my hey, this will also hopefully help you migraine.
- [51:28]
A
And that kind of brings us to lifestyle also, you know, because. Yes. So here are a whole bunch of medical interventions of you know, pharmaceutical interventions to a certain extent or you brought up, you know, this growing field of tech and devices which work in a variety of different ways. Interrupting pain pathways, stimulating the vagus nerve. And I think we're really early days from what I've seen seen in that. But when we bring it just down to basic lifestyle modification, do the basics work like nutrition, you know, like exercise, sleep, hydration, do they make a meaningful difference?
- [52:04]
B
Because I don't want to ever come up like oh yeah, well the biggest stigma in migraine. If I had a nickel for every time someone said have you tried drinking more water? Like it's not, you know, it is a neurological condition that, you know, it's not just a lifestyle issue but it goes, there's definitely a component of it. Because what I was saying before, migraine is an inflammatory condition. Treatments involve reducing inflammation. So proper hydration, proper meals, you know, maybe the food's having an effect. So everyone's body reacts differently to different foods. So you know, when I meet with a patient the most important. So headache diaries are paramount because that allows me to track data. I tell patients don't worry what's in a headache diary. That's my job, to be worried about it. And that's when I can start finding things that may be interfering on a lifestyle level. I have found patients with certain foods affecting it. I had a patient or eggs could trigger migraines and other spicy foods. It's not common. Why does happen to them? I don't know. But that's how their body is responding to that inflammation. There's no one true migraine diet. But I've had patients who have, you know, improved headache frequency, gluten free ketogenic. And again it's not because. Oh yeah, that's it. And I won't ever say that's gonna work for you, but from themselves they found that that's effective. Sleep is probably the most important thing. I can't stress that enough. When we sleep, when we hit REM stage four, what happens is our brain activates what's, what's called the glymphatic system. Don't ask me why it's called that. We have lymphatic. Okay. When we sleep, add the G. I don't know. So we have the glymphatic system and, and remember I told before with like that migraine hangover and because all those neuropeptides. Well the glymphatic system cleans up the waste from neuropeptides. That's why when you don't sleep well, you what's groggy? That's what groggy is. Your brain didn't get to clean itself so it's inflamed, it's in this tired state. So if you don't achieve proper stage four sleep, your brain is not cleansing itself and it's in a pro inflammatory state of mind. And that's why it's every single new patient visit. I do, I do a sleep a assessment. For those who I think there's obstructive sleep apnea. I'm getting them a sleep test. I diagnosed delayed sleep rhythm insomnia. But sleep is so important. Caffeine gets asked all the time. Caffeine is a double edged sword. For most people it helps, for some it makes it worse. I drink coffee myself. Caffeine is fine in moderation. Don't exceed three or four cups a day. You know, sort of a no brainer with tobacco. Tobacco is known to cause migraine attacks. We do know that some of the big, the one of the biggest risk factors for cluster headache is tobacco. Alcohol is a really common treatment for migraine and cluster headaches. Some people makes it better for me. Like I abstain from alcohol. It will give me no matter what. You know, that's actually my trigger. But speaking of triggers, you don't necessarily have to have triggers because people get sort of and rightfully so sensitive about it. Because then when you start talking about triggers, it means you, you did this, you triggered it. Well, some things in life are unavoidable, like weather. Weather is a very common trigger in people. I have patients who feel like their doctors, call them crazy for thinking that. You talked about lightning before. Yes, we, like that's actually a working group I'm part of, where we looked at clinical trial data that at the same time weather metrics were taken, where we have spoken at headache conferences, that we found that if there's a 10 degree Fahrenheit change within 20, 24 hours, you have an increased risk of headache. Same thing if there's a 0.24 barometric change in 24 hours. You have increases of headache. Headache changes are real. No, you're not crazy. So some triggers are just unavoidable. What do you do then? That's where acute medication comes in.
- [55:43]
A
Right.
- [55:44]
B
There's going to be a storm happening. You have your trip to your GM it or whatever on you. So if it happens, you take that. And that's sort of why I don't like getting too lost in reads the triggers. Because some is just, that's the world, some is just the environment that, you know, of course you can move and whatnot, but some things that you're unable to adjust. But that's where other treatments come in.
- [56:05]
A
Yeah. So lifestyle matters for some people, matters more than for others. There are things that are probably fairly universal, like sleep, where it really makes sense to focus on that. And for others could be a wide range of things that do or do not trigger a migraine, completely dependent on the individual. You brought up ketamine before also, which I think is really interesting because psychedelics in all sorts of forms, the volume of research that's going into them for a variety of different conditions is kind of incredible. Over the last ten years or so. Talk to me about ketamine or just the general class of psychedelics. And I know some people debate whether ketamine actually should even be in the class of psychedelics, but I don't think
- [56:49]
B
ketamine is classified psychedelics. Ketamine is a nmda. And again, I want to stress this is not a first line treatment. Yeah, you know, this is where others. This is for those who are very refractory headaches. But we believe that ketamine functions to help reverse this concept of central sensitization. So central sensitization is, you know, sort of the, you can think of it in a very simple way of how like the brain is adapting to migrate and more susceptible to migraine attacks. We know it works a variety of different receptors in the brain. One being gaba. GABA is brain injury. GABA glutamate. Like we view these as brain energy. So the brain doing a lot of signals. So you know, then therefore bringing those down reduces how many transmissions are going and reducing the headache. We're not fully sure of course what it is. This is, you know, there's no test to prove it, but that's the general understanding. Psychedelics, you know, I want there to be more research in psychedelics for migraine. There's been evidence in other countries of psychedelics for the treatment like LSD for the treatment of cluster. You know, I know some groups are beginning to underway with looking at it at migraine and cluster in this country. I believe the federal administration recently did an executive order to sort of, you know, know, speed that up. I because of its effect with cluster, it makes it hopefully a promising treatment. But I guess on the topic of illicit, you know, treatments, marijuana does have a lot of evidence. There's been many, there's been two or three major trials done. So it does have a medical, medicinal purpose. But it has been shown that marijuana can be an effective migraine abortive medication.
- [58:42]
A
These are things that are kind of, we're on the edge of knowing they're kind of like. And some, you could call them fringe but maybe further research is really going to prune them out. When you look five, 10 years out, what are you seeing in the research pipeline now that really makes you excited. That's not yet available.
- [59:01]
B
The impact and success of the seizure B drugs have flung the doors wide open, which is great because again those were the first treatments that were specifically involved for treating migraine. And the fact that they were so successful that now there's a lot of attention. For instance, right now we have this ongoing trials for a neuropeptide called acap pcap. So it's another neuropeptide related to migraine. There are ongoing trials right now. So I hope within the next two years we have a whole new treatment class. There is. I also saw a presentation at the American Society about one that targets histamine because you know, histamine is involved. There's a lot of different potential neuropeptide and other and enzyme targets that I think if we did this video 10 years from now there'll be a lot more treatments to talk about and a lot more success because the content gets brought up for. There are people who have migraine that the CGRP drugs didn't help at all. What does that mean? I thought CGRP was involved in migraine. I believe it's again, migraine is complex and that if we know there's a bunch of neuropeptides involved. I think there are individuals who have migraine attacks that aren't super CGP driven. Maybe they're driven by a different neuropeptide. So by what I really hope to see is when in a couple years we hopefully have a pay cap drug that's out for those people whose seizure PS didn't help, this can hopefully be an effective measure. And then that brings the question, what do you combine stuff, what do we target both PACAP and cgrp, what does that do? Now this is why we need clinical trials like, you know, to make sure we're not scrambling brains. But I will say the CGP drugs, the monoclonals have been out since 2018 and there's not really been a vast increased signal seen concerns. Does the FDA release post marketing warnings that they may lead to increased blood pressure? Anecdotally, I've really not seen it that much but there's been no contraindications, nothing's been pulled, you know, so they're relatively pretty safe drugs. And we're at the eight year mark. And again it's only one peptide class we targeted. What do we reach a world? We have three or four. So it's very exciting stuff happening.
- [61:19]
A
Yeah, I mean it sounds like you just described. If we have this conversation again in 10 years, we could have a whole new suite of opportunities of offerings to draw upon and maybe even bring together.
- [61:31]
B
I can't tell you how many patients who said they last saw a provider about the headache, let's say in the 90s. And they're like, I was reluctant to come back because what am I going to do? I'm like, let me tell you, it is a different. We are in the golden age. Like, you know, there's a lot of things we could do. I can't say it enough. If you're suffering from really any kind of headache, speak with your provider. There's a lot that can be done.
- [61:52]
A
Last question about maybe less conventional approaches. I have read and I'm sure a lot of people have read like years ago, guys like Dr. John Sarno came out with his theory around TMS. And then more recently Howard Schubiner with MBS mind body syndrome. And it's this notion of. I recently spoke with a researcher from Stanford, who used the phrase biopsychosocial in reference to just generalized pain or chronic pain. Is there something potentially bigger going on that can lead to migraine? Whether it's relational or social or psychological, that manifests in pain in migraine.
- [62:42]
B
Pain is a concept, if you will, a creation of the brain. Your body doesn't feel pain. Pain is a warning that something is wrong in this area. If I cut your foot, it's pain to make you look at your foot. Oh, there's injury. I need to do something about it. Pain in my stomach, I eat something bad. I'll give an example. Ibs. If you do a colonoscopy, endoscopy of someone, ibs, it usually comes out clean. But then why is their stomach acting like this? The brain controls all. With that said, it's not just going as, oh, it's in your head. The symptom is real. Symptom is very real. We're going to treat the symptom. Just saying it's in your head. Every pain is in your head. If I cut your foot off, the pain is in your head. You know, it's a manifestation of the brain, if you will. So, yes, that's what goes back to this concept of chronic sensitization. When the migraine goes untreated for a while, your brain enters this sort of, you know, new environment. This is where things like, let's say you have a thermostat at home, but it's broken. Well, room temperature, 72. It thinks it's room temperature, but it's really 82. Okay, the house is hot, but the thermostat says we're good. Think of it like that. When you've had untreated migraine so long, your brain thinks this is normal. This is the normal way to feel. I'm supposed to feel this way. And that's where things like biofeedback therapy and other psychological therapies come in. And it's, again, not saying that, oh, it's in your mind. Your brain is thinking of pain wrong. And it doesn't mean that everyone needs that kind of thing. But yes, those get involved. You brought up tms. And TMS can also have its purpose as well. There's ones that are given in an office setting and some that are going to be giving in a home setting. And that could work on numerous different pathways. But the point being is that it's not as simple as migraine is. Brain has pain. It's more complex than that. And again, it comes to your brain how your Brain handles certain stimuli. Another example or thing to bring up is so depression is the most common comorbidity for migraine. Why, why is your mood, if you will? I'm not down, I'm saying this simplistically. I'm not downplaying anyone with depression. But why would that cause pain? Well, depression, anxiety, that's stimulus. It's also noxious stimulus. Then it's not good stimulus. The brain starts seeing that as bad stimulus. Again, what do we say pain is? So there's bad and therefore the brain takes in a state of danger. And now we're having a painful syndrome. And this is a big over simplification, you know, very oversimplification. And while we don't fully understand, we don't. If we knew exactly causes whatnot, we would cure migraine. But this is what we theoretically like have a theory of how it's sort of interacting.
- [65:39]
A
Yeah. So for someone who's been joining us, this conversation you just went through just incredible depth in what migraine is, is and how we start to distinguish these from different types of headaches and the different ways that you think about acute versus preventative and also lifestyle and, and beyond and what's coming down the pipeline. So somebody's joining us, kind of nodding along, fascinated by this. And maybe they're somebody who's been dealing with, with migraine. Maybe they've just realized for the first time in this conversation, oh wait, this actually I think may be migraine. And maybe there's actually something that I can do about this. But they don't know where to start. What would you tell them? Like where do they step into this?
- [66:20]
B
Your primary care doctor is always your first place. And you know, I always say patients of their own best advocate. If your primary doctor, you know, make sure you're making the case that how it's affecting you and if they're shrugging you off, sounds like you need a new primary care doctor. You know headache medicine specialists exist. You can always go to general neurologist. There's people like me who are board certified in headache medicine. You could use resources online like at the National Headache foundation and the American Migraine Foundation. They resources to connect you with a board certified headache specialist. I run a headache like education blog on my website headache123.com so I would summarize it again as you know, be your best advocate, bring them to your primary care doctor and then just seeing if there's a headache specialist in your area, it could take a while to see when they typically have long wait lists then that's why starting with your primary care doctor. But you feel this is affecting you. You're not alone. You know, up to 60 million Americans are thought to have migraine. Who in many more untreated or unknown that they have it. It's super common and there's things we could do.
- [67:24]
A
I love that it makes the person who maybe has felt a little bit hopeless realize even if maybe they'd seen somebody a long time ago, times have changed and there's probably a lot more that can be done to help you out.
- [67:38]
B
I can't say it enough. I feel I'm very fortunate. I love my job. There's so much we could do in headache medicine.
- [67:45]
A
Love that feels like a good place for us to come full circle as well. So I always wrap these conversations with the same question question in this container of a Good Life project, if I offer up the phrase to live a good life, what comes up to live
- [67:57]
B
a good life is finding ways to not let chronic conditions beat you down. And that's harder. That's easier said than done. But your patient medical journey never ends. And always finding the best care you can get.
- [68:15]
A
Thank you. So the thing I'm sitting with from this conversation is how long that the blood vessel story stuck around and how many treatments, including some that I've tried myself over decades, were built on it. A few things I don't want you to lose. Also the broken thermostat idea, this notion that untreated pain can quietly convince your brain that this is just normal now. Or the migraine hangover, that whole body exhaustion after an attack, that's actually your brain running out of fuel. And the golden age, Dr. Cohn's phrase, not mine, for where headache medicine actually is and is going right now. So here's the concrete thing for you this week to think about. If you or somebody you love has been living with head pain with migraine or headache, and assuming there's nothing left to try, or hasn't seen anyone about it since it felt hopeless years ago, that assumption is probably out of date. Start with your primary care physician or your closest qualified healthcare provider. That's it. The whole first step. And hey, before you leave next week, we're sitting down with Marissa Renee Lee to talk about why the tidy stories we tell ourselves about grief and resilience, they tend to fall apart and what it actually looks like to build a life around pain instead of just waiting to get past it. So be sure to follow Good Life Project wherever you get your podcasts so you don't miss that or any upcoming episodes. And do me a quick favor while we're here, share this episode. Especially anyone who is either personally suffering with or knows people has people around them that deal with these things called headaches or migraines. This can be incredibly helpful and eye opening for them. And while you're at it, if you have three extra seconds, go ahead and leave us a quick review wherever you get your podcasts. This episode of Good Life Project was produced by executive producers Lindsay Fox and me. Jonathan Fields editing helped by Troy Young. Chris Carter crafted our theme music. And of course, if you haven't already done so, go ahead and follow us wherever you get your podcasts so you never miss a conversation. Until next time, I'm Jonathan Fields signing off for Good Life Project. Good Life Project is sponsored by Tonasi so a few months back I started looking for something to add to my evening wind down, something I could feel good about having in the house. Not just one more bottle on the shelf and a friend pointed me towards Tenasi and their unique CBD CBDA blend. What got my attention wasn't the marketing, it was the backstory. The founders put $2.5 million into university research before they ever launched a product. The they worked with scientists at Middle Tennessee State to study the hemp plant in detail, and what they found led to a patented formulation built around a specific 1:1 ratio of CBD and CBDA. That's the active ingredient in their softgels. Every batch is tested by an independent accredited lab for heavy metals pesticides. The full panel and they put the test results right on the label with a QR code so you can see exactly what's in what you're taking. For me, that's the bar. If a company's going to make something I'm putting in my body, I want to know they did the work. Tanasi did the work. If you want to try it, head to toe.com and use the code good life for 25% off your first order. That's T A N A S I dot com and use the code good life for25% off your first order.
- [71:44]
C
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- [72:44]
A
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- [72:56]
B
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A
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