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- [00:01]
A
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B
So go ahead, show off a little.
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A
Buying shoes that get you at prices that get your budget. Head to your DSW store or dsw.com today.
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B
DSW. Let us surprise you, Cara. We're re releasing this episode on migraines, hormones and teens because the number of calls and emails and DMS we get on this topic from people who have kids struggling with frequent headaches is like, I, I've lost count at this point and I'm not even the doctor, so I can only imagine how many you get. And the reason people are in touch, it's varied, right? It's partially because it feels mysterious, like there's, is it hormonal? Is it something more serious? Is it stress related? Are they just like not drinking enough water on a consistent basis? So there's that source of the worry. It's also really stressful and scary for the caregivers when kids are consistently struggling with frequent headaches because it means they miss school, it means they can't participate in sports, it means they're kind of miserable. And so it makes the larger life really challenging as well. Which is why we're so excited to welcome headache medicine Specialist and neurologist, Dr. Daniel Noam Lax, who actually goes by Noam in this episode because he helps us make sense of these questions.
- [01:45]
A
Right. So if you haven't listened to this episode before, you will come to understand headaches in a way that, frankly, most people outside of the healthcare profession don't. And if you can understand the difference between different types of headaches, if you can understand why headaches impact different groups of kids, different genders differently, then you can begin to understand what you can do to support a kid who is living with them.
- [02:24]
B
Car Our listeners have been asking for a long time to cover the subject of teens and headaches, specifically people who menstruate and migraines. That question has come up over and over again. And we are so happy today to have Dr. Noam Lacks. So if you go Google him, it will say Daniel Noam Lacks, but he goes by Noam and he is like a font of knowledge and he gave us both a total education.
- [02:59]
A
I thought you were going to tee up this introduction with Cara you completely nerded out on this episode. And we're so into the fact that we got headaches 101.
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B
I mean, headaches 101. And Cara was actually. There was all sorts of stuff that she didn't know. And he.
- [03:18]
A
No, no, no, no. You're being so kind. That I had wrong. That I had wrong. And he was so kind. He was like, oh yeah, centuries ago. That's how they taught it in medical school. He's a wonderful font of information, a great communicator. You will love this episode if you've ever had a headache, if you've ever known a kid who's had a headache. I mean, he goes through it all.
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B
He goes through it all. And he does have like qualifications. He's board certified neurologist with a specialty in pediatric neurology at Einstein Montefiore Hospital where he primarily treats kids and teens with headache disorders and is doing research specifically in the area of pediatric headaches. And I learned something really important which the word migraine is a singular word, like fish. There are not migraines. There is migraine. So that was my schooling in addition to many other things.
- [04:23]
A
You know how I'm going to tee up this episode, Vanessa? I'm going to say what has to be said. Listening to it will not give you a headache.
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B
Badum. Boom.
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A
Enjoy.
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B
Hi, Dr. Lacks. Do you mind if we call you Noam for the rest of the episode?
- [04:39]
C
Not a problem. I pleasure.
- [04:41]
B
It's so great to have you here to talk about teens and headaches because we get so many questions from listeners about this very topic and we want to really inform people because it's a really stressful topic, as you well know. I'm sure you have families coming to you, worried, dealing with a really unhappy kid who may be in a lot of pain, who may not be able to go to school or participate in the activities they normally do. So you are here as our informational savior. You're going to give us a deep dive on teens and headaches. But we're going to start really, really basic and we're going to build up from there. So what causes headaches in human beings?
- [05:30]
C
Yeah, well, first, thanks for having me. What causes headaches? So as neurologists, we like putting people in boxes. And so I like to distinguish or separate out primary headache disorders from secondary headache disorders. So the first thing that a pediatrician or neurologist, whoever sees somebody with a headache is going to think is this a secondary disorder. Is something else bad or scary causing this headache or these headaches or is there nothing else really going on that's causing it? And it's purely a neurologic issue like migraine or tension type headache, which are what we call primary headache disorders, among some other much more rare type of headache disorders. And so what causes headaches? Well, if it's a secondary headache disorder, it could be anything from the big scary things like the big cancer, tumors, other things that can cause high pressure, which are extremely rare. But we have to keep in the back of our minds some systemic disorders and diseases that can cause headaches, rheumatologic diseases, or even run of the mill infections like a uri. I mean, tons of kids will get a headache with run of the mill cold or flu. Covid we all know. And so those are all secondary headache disorders which a pediatrician might encounter at the office or in the emergency room or urgent care. The patients who tend to see me have primary headache disorders, and so they've already been to the pediatrician for an urgent care and they ruled out those other scary or secondary causes, and now they're seeing me because they continue to have headaches, which we presume is a primary headache disorder. And I like to say disorder over and over because it's not just a headache, it is a whole thing. It is a disorder, it's a disease and should be treated like that. And the big problem occurs when we don't treat it like that. And then kids just continue to get their headaches because nobody bothers treating them.
- [07:22]
A
Can I jump in and just walk through a little bit about what a pediatrician will do when a kid walks in with a headache? I would say when I was in practice, I don't know, 10% of my visits were headache. It's really, really, really common. And I loved how you just broke down secondary and primary. So pediatricians are going to take a history, which means ask what's going on. The more specific kids and their caretakers can be, the more helpful because about 80% of the diagnosis comes from that history. The physical exam is really important too, but it's the story, when did it start? When did it stop? What makes it worse? What makes it better? Is it positional? All of that kind of stuff that really takes us down the road. And when pediatricians check kids for headaches, they are looking for the big things. So they'll do a neurologic exam that will hopefully be able to rule out a big mass in the brain. Right. They'll look inside the mouth. Teething. Oh my gosh. Kids who are cutting teeth get headaches. And that includes kids between the ages of 4 and 6 who are cutting molars. Kids around the age of 12, sometimes it's as young as 9 or 10, sometimes it's as late as 13 or 14 getting their 12 year old molars, wisdom teeth. So one of the first things we always tell parents to do at home is look in the mouth and see if that's a possible source. You know, ear infection, sinus infection, all that kind of stuff is in the secondary basket. And that's why you want to start at a generalist. For those eager beaver parents who say, headache, I got to go straight to the specialist. It's not a great use of Noam's time to be saying, oh, you know what, they're cutting a molar and that's why they have a headache. So is it fair no to say, like, your brain is best used once someone has crossed off all of the more common reasons why people have headache?
- [09:21]
C
Oh, absolutely. And I'll say even more than that. You know, I did some pediatrics training, but I'm by no means an expert in general pediatrics anymore. And so I think a patient or, you know, a kid is better served seeing their general pediatrician to look for those specific secondary headache disorders.
- [09:39]
B
So that's a helpful sort of order of operations, right? Your kid has a headache, first place you go is to the pediatrician. You rule out some of the scary stuff and also some of the, like, day to day basic stuff. I noticed, Noam, you didn't ask the question, did you drink any water today when we were talking about talking to kids about headaches. But that is always my first question when my kids are like, I have a headache. And the other thing we didn't talk about, which is a common question I've had when I've taken my kids to the pediatrician, is have you had their eyes examined recently?
- [10:12]
A
Thank you.
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B
And do they have a prescription for glasses? And if not, maybe it's time to check that out. Or has it been updated recently? So those are two from a non physician. Those are two practical life lessons about Dr. Vanessa.
- [10:26]
A
That was excellent. Yes and yes.
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B
So now that we've officially cleared me of all knowledge I have on the topic. No. With Cara's assistance, we're going to go deeper on headaches and I would love it for you to talk a little bit more about what you described as primary headaches. What are they, what causes them, and how do you differentiate between the two?
- [10:50]
C
Yeah. So the most common primary headache disorder that I see is Migraine. And that's because migraine by definition is a chronic genetic debilitating disorder, meaning the attacks of migraine cause dysfunction. So, you know, kids get, besides for the severe headache pain, they're also getting hypersensitivities. So photophobia, which is hypersensitivity to lights, phonophobia, hypersensitivity to sounds, which is pretty miserable. In a typical classroom where you have these fluorescent lights and lots of noise. Some kids and adults get hypersensitivity to smell, which we sometimes call osmophobia. And then nausea, vomiting. I mean, this puts kids in, into bed for hours to days at a time, sometimes even longer than that. And so it's not just a disease of headache, it's a disease of hypersensitivity and really causing a lot of dysfunction. The other primary headache disorder, or I'd say the more common primary headache disorder which exists is tension type headache, which is usually less severe. So it should be mild to moderate. What you're thinking on like a 10 point scale, maybe 1 through 5, 6 doesn't really come with those hypersensitivities. Maybe a little bit of one of them. No severe nausea, no vomiting, doesn't stop you from doing your usual daily activities like staying in school or playing sports, going to the movies. And so kids are resilient. If something's not stopping them from living life, they don't need to see a doctor for it. And so I just tend to not see those kids. Migraine is the disease that I tend to see the most. There are other much, much, much less common primary headache disorders like cluster headache, which some people have heard of. Those are extremely rare in kids, although I do see it probably a few times a year. And it's important to know about, for us at least, and pediatricians, because those are reasons to send kids to us more urgently because those could be particularly terrible pain. And so we like to get them in a little bit sooner so we can treat them sooner.
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A
And those cluster headaches, they're named for the timing of the onset, right? They come in clusters?
- [13:01]
C
Yes. Which can be really confusing because migraine attacks can also come in clusters, but they're very different. So cluster headaches are usually much more sharp, localized, rapid onset, and they don't last more than a couple of hours, three hours max for each attack, but it could occur a couple times a day. Migraine headaches are usually more of a pounding or throbbing kind of pain. In adults we think of it as a one sided attack, but actually in kids it's more commonly right in the middle of the forehead, across the forehead, bi temporal, so on both sides of the head, and is associated with nausea or vomiting or light and sound sensitivity, and usually lasts more than a few hours. So actually the criteria, there's a headache bible. We like to call it the international classification of headache disorders, which is easily googleable. The criteria require that a headache last more than four hours to call a migraine in an adult, although in kids two hours is enough.
- [13:58]
A
And there's such a thing as an aura. Do you want to explain what an aura is?
- [14:02]
C
Yeah, sure. So aura is sort of a warning sign before the migraine pain starts. But actually the physiology or the mechanism in the brain of what's setting off the entire cascade of events has already started. And actually some studies are telling us now that the cascade of events are starting hours or even a day or two before the pain of a migraine starts. And we call that a prodrome. And so there are different phases of a migraine attack. There's that prodrome, which is some people report frequent yawning. And that we assume is because you're tired and you're tired, therefore you get your headache. Some people get excessive thirst and we say, oh, well, you didn't drink enough and that's why you're getting the headache. Or some people get food cravings. And actually the area of the brain that controls hunger lights up on certain types of imaging hours before people experience their migraine attack. And so that's part of the mechanism. But then moving on to the next phase, which is aura, it's sort of a complex activation of different areas of the brain. And so you notice I said activation, so it's not a negative thing, it's more of a positive phenomenon, which means that there's something positive happening. The most common type of aura is a visual aura, where people will see flashing lights or a growing blob of gray in their visual field somewhere on one side, often with zigzaggy lines coming out of it with colors. And usually what I'll do is just Google image migraine aura in the office. And most kids who have a true migraine aura will point to the aura that they experience. There are other much, much less common types of aura, like sensory aura, aphasic aura, or motor aura, where you either can't speak or can't move properly. But those are extremely rare, and those require more of a workup to make sure we're not missing something else.
- [15:54]
A
We'll be right back. But first, a word from our sponsors. This Monday.com ad was created by a
- [16:01]
B
team of people and AI agents.
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A
The agents wrote the copy and managed the timelines, while our human creative director made sure it all made sense.
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C
Easy.
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A
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B
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- [16:30]
A
I mean, Purses aside, Quince's 100% European linen pieces are are the ones I'll be reaching for all summer long because they're lightweight, effortless to style, and Vanessa they start at just $32. Everything at Quint's is priced 50 to 80% less than similar brands because they work directly with factories. You're paying for quality, not brand markup,
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B
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A
They even have adventure packed attractions from Magi Quest, a live action game that kids can play throughout the lodge to the Northern Lights Arcade. And there's also a bunch of great dining options and complimentary daily events like nightly dance parties all under one roof. So bring your pack together at a lodge near you. Learn more@greatwolf.com that's G-R-E-A-T W O L F.com and strengthen the pack. This is not a podcast where we give medical advice at all by any means, but I am going to share that I get migraines with Aura and my son does too. And having been educated a little bit in this, we can both stop the progression of our migraines by drinking. The way we do it in our house is we drink three tall glasses of water in as quick succession as we can. We just get the fluids in and then we take an anti inflammatory medicine like ibuprofen and lay flat in a dark, quiet room. And if we do that, when the visual aura comes, we see what are called scotomas, these flashing lights. If we do that, as we start to see the flashing lights. Done, five minutes. Done. And I think the science of that, tell me if I've got this right, is that what's happening with those flashing lights is that the blood vessels are spasming and the blood is flowing intermittently. And if we hydrate really well and we lay flat and let gravity work, and we turn off the visual stimulus of light and the auditory stimulus of sound, and we just get a lot of good blood flow going, then we stop the spasm. Do I have that right?
- [19:31]
C
So, actually, that is a very common misconception that was taught for years and years and years. I'm really glad you brought that up, actually. And you're not alone. The vast majority of people I speak to, medical professionals included, still think migraine is a vascular disease or a disease of blood vessels, but it's really not. And we know this from studies actually. The blood vessel changes probably happen as a result of the neurologic issues that are occurring during the migraine attack. And so when you think about a migraine aura, there's this activation, and it spreads like a wave, and behind it is a wake of hypo activation. And so when you have less activation of the brain, you need less blood in those areas. And so the blood vessels can actually decrease in size slightly. And so it's more of a result of the neurologic problem and not a cause of the neurologic problem.
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B
So, Noam, can you describe what the neurologic problem is?
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C
Is I think the person who can really describe this perfectly would win a Nobel Prize, because I don't know that we know the true.
- [20:37]
B
Well, listen, this is a shot. I mean, come on. The puberty podcast might be your opportunity for a Nobel Prize.
- [20:45]
C
So, in the last 20 to 30 years, we've learned that there are multiple neurotransmitters involved in the propagation of a migraine attack. One of them, the most commonly known now, at least among neurologists, is called cgrp, is the calcitonin gene related peptide, which is fancy for a, you know, moderate sized molecule that gets secreted or gets, you know, pumped out of the trigeminal nerve, which is one of the nerves that gives sensation to your face and also to the coverings of your brain. And so what's happening is in the coverings of the brain, your meninges, for whatever reason, people have different Triggers, including weather changes. And so when those triggers occur, the gene turns on in those nerves and it secretes that hormone called cgrp. There are other hormones involved as well. Substance P, vasoactive intestinal peptide, which people can google to the arts delight. But when that hormone is secreted, it causes inflammation around the blood vessels. And actually those blood vessels dilate as opposed to constrict, so they get a little bit bigger as opposed to smaller. And then your nerves sense that stretching of those blood vessels and cause even more pain. And so it sort of propagates. So what you're doing when you use ibuprofen. Yeah, a good old nsaid, which is evidence based, first line therapy to break a migraine attack is you're cooling down that inflammation, what we call neurogenic inflammation, inflammation caused by nerves. And that helps to, to cool down the entire process.
- [22:17]
A
Does the water and the laying down do anything?
- [22:21]
C
Absolutely it does, yes. So you might not be doing it for the right pathophysiologic reasons, but it's definitely working for a good reason. So those blood vessels do dilate and you're just. If it's plumbing, so you got bigger tubes, you have to fill them and so drinking. I usually recommend a sports drink. Something with like Gatorade, Powerade. G2 has less sugar, so less unhealthy. Something with electrolytes to help keep those fluids in the blood vessels and in your body instead of, you know, getting a little bit leaky or peeing it out.
- [22:53]
A
Do you have another one about migraine, Vanessa, or can I ask a quick one about tension headache?
- [22:58]
B
No, we're going to. After tension headaches, we're going to move specifically to, to tweens and teens. So get your tension headache question.
- [23:05]
A
Let's do it.
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B
So CAR is getting a free consultation on this.
- [23:09]
A
It's so fast, you know, My pleasure.
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C
I do this all the time with pediatricians.
- [23:13]
A
Neurologists are just brilliant and they're so interesting and they so much to offer and they're so hard to get into. So here we are on the puberty podcast, giving you like little inside look in a neurologist brain. Let's talk just for a minute about tension headaches because you described it as more. Is it more common to have a tension headache? And can you explain what it is and how? I mean, I always think of tension headaches as being involved with the musculature. So pop holes in that one. I want to hear like where I've got it right, where I've got it wrong. But can you walk us through just a quick top line description of them?
- [23:50]
C
Yeah. Well, tension type headache is probably less well understood, mainly because drug companies don't care to make medications for it. And so it's not worth studying very much. But it is thought at least to some degree to be involved in the muscle. And that's why, you know, we sort of call it attention headache. Although there's probably a lot more neurologic mechanism underneath it. And so I'll be totally honest, I don't know a whole lot about tension headache underlying mechanisms just because we don't tend to see it so much or even treat it so much any differently. What I will say is oftentimes kids or adults will have both. So they'll have headaches that meet the so called criteria for tension type headache and for migraine. And I'll usually just treat the more debilitating type, which could include an acute abortive therapy like ibuprofen or some other medications and sometimes a prevention medicine, a daily medicine to decrease the frequency of attacks and that should decrease the frequency of all the attacks. The migraine and attention type headache.
- [24:48]
A
And is there a particular spot that you feel them? I always think of it as jaw clenchers feel tension headaches on the side, but that may be an oversimplification.
- [24:58]
C
So TMJ disorders are temporomandibular joint disorders. Those like the jaw clenchers, they actually tend to get migraine more than tension diabetic. You mentioned something important, that it was on one side, which is classic for migraine and not tension. Tension diabetic is usually both sides. And so I suspect that the majority of kids who are diagnosed with tension type headache probably actually have migraine headache because otherwise they don't bother telling anyone that they're having a headache because it's
- [25:27]
A
just low grade and it's just there and they get on with their day.
- [25:30]
C
Yeah.
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A
Oh, this is so fascinating. Okay, Vanessa, take us to tweens and teens.
- [25:34]
B
You used a term in describing migraines, a series of terms, and included the word genetic. Can you talk about the genetic component to migraines?
- [25:45]
C
Yes. What we do know is 90% of kids with migraine have a family history of migraine, usually in a parent, although grandparents, aunts, uncles, siblings count as well. With rare exception, we don't know which one or two genes causes run of the mill migraine. The very rare types of migraine have some specific genes associated with it and we could test for those. But the typical migraine that we see is probably what we call Polygenic or multiple genes that affect different parts of the central nervous system. We don't quite know how they interact, but it's this genetic predisposition to getting these severe attacks of hypersensitivity and pain.
- [26:27]
B
So for those people listening, if you have suffered from migraines, if your spouse or the other parent of your child, if you have grandparents, keep this in mind. We actually have, in my family, there's, on my husband's side, all of the challenging aspects come from my husband's side. There's genetic. There's migraines all the way, like up many, many generations.
- [26:53]
A
Wait, can we do one, one more detail? Can you just draw the line between getting car sick and getting migraines that's always so interesting?
- [27:00]
C
Well, yeah, it's very common. So there are some, what we call periodic syndromes that are associated with migraine, including something called cyclic vomiting syndrome, which some kids get. And I'm sure many of your listeners have seen this before. Abdominal migraine and then car sickness or motion sickness is very common in kids with migraine. And so I'll usually ask them if they have a headache when that's occurring also, because if you have a headache, it might just be a migraine attack, but otherwise, for some reason, and we don't entirely understand it, kids with migraine or kids with a family history of migraine will be predisposed to getting those episodes of car sickness as well.
- [27:39]
A
Yeah.
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C
Miserable.
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A
So wild.
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C
Also for the siblings sitting next to those kids.
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B
Yeah. And the adult responsible for cleaning the car afterwards. So, Noam, our listeners know that when a person starts puberty, the sex hormones in the body don't just circulate in the body, they also circulate in the brain and affect all sorts of aspects of kids experience. Can you talk about the impact or the interplay of sex hormones and migraines, headaches and help us understand what is connected and what may or may not be connected.
- [28:20]
C
Yeah. Just like most things in neurology, we've only just scratched the surface of it. But what we do know is that, you know, we've seen this for decades and decades, and it's probably centuries that women experience migraine so much more than men. Like, you don't have to be a doctor to know this. And so there must be some relationship. We just assume maybe it's a genetic relationship or truly a hormonal relationship. There are such things. There are specific disorders called menstrually related migraine, which is. So there's menstrually related migraine, where individuals experience severe or worse or a migraine attack with more associated features around the time of their period. And then there are other disorders or other individuals who experience migraine attacks exclusively around their periods that could even be from day negative one or negative two, meaning a day or two before the first day of their period through day three, four, or five, even. About 7 or 8% of women experience that menstrually related migraine, or they have migraine attacks on other times of the month as well. About 2% experience migraine attacks only around their period. And it's actually the estrogen withdrawal, but it triggers the migraine attack in a genetically predisposed individual. What happens when that estrogen drops is serotonin also drops and cgrp, that molecule I mentioned earlier, increases, and that sets off the cascade of events that happens during a migraine attack. There are some medications called triptans or specific triptans that we will sometimes prescribe specifically around people's periods, and that can be really effective at treating those migraine attacks. Most of the girls that I see also have other migraine attacks, and so I just treat them all sort of the same. But for people who want a medication only around that time of the month, they can use those triptans specifically during that time. There are also hormonal treatments which might be more relevant to some of your listeners. And you can prevent that estrogen withdrawal by giving estrogen. And so we used to see a lot more, and I speak more for my adult colleagues because I tend to not see this as much as men, but women who are on estrogen supplementation and back when they were using higher doses of estrogen, they really felt that estrogen withdrawal, and so they get really terrible attacks. Nowadays we tend to use lower doses of estrogen, and so it tends to maybe not be quite as bad, but if you continue. So when you're treating somebody with birth control, whether to prevent pregnancy or for period regulation, you usually have a placebo week, which is a fake medicine week, essentially. And so instead of giving a placebo week, some people will prescribe a lower dose of estrogen during that week. So they don't completely withdraw, but it's enough to stimulate the period. And so that could be one option for menstrually related migraine as well.
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A
So one thing our listeners are very familiar with is that in the first few years of puberty, because puberty starts right much earlier than it used to, and it drags on much longer than it used to for the first few years, there's this up and down and up and down, surging and falling of the sex hormones. And it's on an hourly basis rather than a weekly or a monthly basis. Right. You get surges and then few hours later drops. And we see the mood swings that kids experience, kids of all genders, we think, based on the science, estrogen impacts, moods in some directions. Testosterone. There's so little data on this because all they talk about is rage and not any of the other moods that you might see from testosterone withdrawal. But it's that delta, right? It's the difference between the high highs and the low lows that causes some of these. Hate to use the word symptoms of puberty, but I'm going to say symptoms of puberty. Let's talk about it in terms of headache. So if hormone withdrawal causes headache, help us understand, should we be seeing or anticipating seeing more headaches among these kids who have peaks and troughs and peaks and troughs of these hormones, or is it happening so quickly that as the trough sets in, they're already starting to see some hormone rise and they're. It's not like a period where your hormones sit at a low level for several days. The resurgence of another round of hormone is quick enough that we're not going to see headache. Does that make sense, that question?
- [32:53]
C
It makes sense, but I think that's such a difficult thing to even study or measure just because of that crazy fluctuation that teenagers experience. You know, there are some studies looking at people who show up to the emergency room, you know, what time of the month they're tending to come to the emergency room. But daily fluctuations are so complex in every individual. Trying to do that across, you know, hundreds of women is just so hard to study. So I don't think we quite understand what an individual peak or trough of hormonal levels really does to somebody. And then on top of all that, kids have wacky lives. I mean, you know, there are social stressors. School, I mean, high school is tough and, you know, and then with social media these days, kids are really stressed out and constantly have other things on their minds. I think there's so much more at play that it's so hard to pin down. Any one specific cause for kids. Headaches?
- [33:50]
A
No.
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B
I'd be remiss if I didn't ask whether there's been any research about testosterone and migraines. I mean, it's clear there's a lot of work around estrogen and migraines. But do we have any information about, like, females, more likely than males, get headaches Is it possible testosterone is like protective in some way? I just would be curious.
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C
It's possible and I bet there are some more studies out there. I just tend to not see it because I don't see the teen boys for the most part. You don't And I, and I definitely. Well, yeah, I. Yes. I mean the vast majority of my, my practice are adolescent girls but we do get younger, younger kids, both boys and girls because that actually that split of women more commonly experiencing migraine than men usually happens around the time of puberty. But younger kids tend to experience migraine about equally between boys and girls. But yeah, I haven't seen. There are really aren't a ton of studies on testosterone.
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A
We'll be right back but first a word from our sponsors.
- [34:54]
B
Hey friends.
- [34:54]
A
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B
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and for full details visit the upsstore.com packing if estrogen withdrawal is what we think causes the onset of the migraine, Right? Is that a fair way of describing it?
- [36:34]
C
No.
- [36:34]
B
Okay.
- [36:35]
C
Yeah.
- [36:35]
B
Okay, so if you have a kid who is in puberty but not yet menstruating, right? Maybe she has breast buds. Maybe she has. Or breast development. Maybe her hips are widening. Maybe she's gaining more weight. Like there's clearly estrogen circulating in her body. Would we expect to see the onset of migraines before she starts menstruating? Or is it your experience or your research that it's really once she starts menstruating that the migraines begin to set in?
- [37:06]
C
So one thing I'll correct real quick is that one of my mentors will always tell me migraine is a disease and headaches are the symptoms. So migraine is singular without headaches. Although a lot of people disagree with me.
- [37:19]
B
Um, it's like Brussels sprout. It's not Brussels sprouts, It's Brussels sprout. I just learned that. I'm sorry. Okay, so migraine is the disease. The headaches are the symptoms. So the right.
- [37:33]
C
Or migraine attacks. Right. So you can have asthma. Not asthmas. You can have asthma and asthma attacks.
- [37:38]
B
Oh, great. Okay.
- [37:39]
C
So kids will experience migraine as early as, you know, six, five, five, Seen a couple of them, you know, four, even three year olds with migraine. But you brought up an interesting point that those hormonal fluctuations are occurring even before kids have their first period. And so. Well, we have seen that. And actually where I trained on their questionnaire, it specifically asks about if there's one week out of the month that's particularly bad that people have noticed. And we do know that kids can experience menstrually related migraine before they even have menses. So that's definitely something that happens.
- [38:15]
A
That's fascinating. I would love to just do a quick sidebar because you're talking about testosterone earlier and not seeing as many boy patients as girl patients. Just a quick sidebar on concussion related headaches, which are not gendered, but I think tend to happen a little bit more, especially in the teen years in boys because of sports that involve tackling and heading. But just wondering in that group about. I mean, I think my real question is how as a neurologist do you convince kids to disclose their headache when they've had a head injury causing a headache? Because they would think that connected to. One of the reasons you don't see boys as much as kids get older is they're socialized to under report.
- [39:03]
B
Right.
- [39:03]
A
And shake it off. And it's no big deal. And if we do that with a post concussion headache, there can be some pretty serious consequences.
- [39:11]
C
Yeah, I think one of the things to remind these young men, young boys or old boys, young men, is that one concussion you could sit out of the game. You could maybe sit out for a week or two, but if you have a second one before those symptoms go away from the first one, you're going to be out for the rest of the season or for multiple years even. So, we know the highest risk of having prolonged post concussive syndrome is repeated head injuries before the symptoms of the first one are gone. And so that's really the majority of the counseling I give is you must avoid a second hit. And sometimes coaches can preemptively warn kids, hey, you know, if you hit your head and you have a headache, it's better to sit out the rest of this game and then when you're feeling better, go right back to it without any restrictions, even if you're feeling totally normal. But if you go back to you soon, you might be out for the rest of the season and then you're really gone.
- [40:04]
B
And by the way, this messaging is not just for the kids. This is messaging is for the parents who are eager for their kids to get out there and perform and maybe they're being recruited for a sport and they're worried about ruining their chances. So much better for your kid to miss two weeks than an entire season or destroy their athletic career by not waiting it out. So I'd love to do a little role play with you because I can tell Noam that you are comfortable talking about stuff on the fly. I am a 13 year old girl and I am miserable. I'm miserable because I have terrible headaches and it feels like no one is taking them seriously. So I'm the kid, you're my parent, and we're going to do a little role play and I want you to roleplay for the people listening how they can respond to their kid in a way that is supportive and can get them some help. Right? Because then car could role play exactly what the other parent would sound like.
- [41:13]
A
Every time you say the word role play, my blood pressure goes up ever so slightly.
- [41:17]
B
So I just, I'm here to make you both think you're feeling that way.
- [41:21]
A
It's okay.
- [41:22]
B
I'm going to go teach the class in medical school called role play.
- [41:26]
A
It's going to be attended by no one.
- [41:30]
B
But you know what? American medicine would be so much better if it was attended by everyone. Okay, so no, I'm. You're the parent, I'm the kid. And I'm just like, I feel so sick I couldn't stay in school today. Like, I need you to come pick me up. No, I can't do my work. Like, I don't know what's wrong with me. I'm so miserable. I don't want to play sports. I can't even read. Like everybody talking is making me crazy. Like I just have to get out of here. What does the parental response sound like to that?
- [42:05]
C
First of all, validation. I almost never see kids make up headaches and these symptoms to get out of banks. I mean, you know, we've had tons of nurses and parents, like school nurses and parents or teachers who will say they're faking it to get out of class. Kids are almost never faking their migraine attacks and sometimes you can just see it in their eyes. So validate, right? I'm so sorry that you're feeling this way. Let's get you something. And I think the first thing to do is after speaking to a doctor about which treatment is best, is to give that medication and a big sports drink and lay down for a little while in a quiet and dark place. Or if you're one of those people who has already seen the doctor or the neurologist or a headache specialist and has given you great meds that you could take right at the onset, you take your medicine, you drink your sports drink and go right back to class. Because while you're suffering, we want to treat you right away at the beginning and get right back to what you, what you need to do right back to life.
- [43:05]
B
What doesn't it sound like, Cara?
- [43:07]
A
Oh, gosh, it doesn't sound like so many things. I mean, it doesn't sound like you're fine, it's no big deal. It doesn't sound like focusing on all the zillions of other things going on in this 13 year old girl's life, which inevitably are contributors to stress, right? The friend drama, the this, the that, whatever's happening for her. When she says she has a symptom, you're just addressing the symptom head on and validating, which is a really wonderful thing. I wonder for the parent who immediately goes to the terrified place. Let's say you don't just believe your kid, you believe your kid and you think your kid 100% for sure has a gigantic tumor causing the symptoms. And I am not actually mocking in any way catastrophizers. I am one. I went to medical school. And that is one thing that happens in medical school is you go through this crazy four years of either there but for the grace of God go I, or oh my gosh, this could happen to me. So then when you raise children, having gone to medical school, you Remember all the scary things that happened to people. And so you can go from fine to freaking out in two seconds because you're so sure it's going to be. In medical school and in, in medicine in general, we always say, you know, when you hear hoofbeats, think of horses, not zebras.
- [44:33]
B
Right?
- [44:33]
A
You should be thinking about the common things, but you often think about the not common things. So let's change the scenario. The parent is a catastrophizer and is terrified.
- [44:42]
C
Doctors will always do an extensive history. Hopefully they have time for it. I get the time for it, so I can take a really good history. That is the number one thing that we all have to do to help differentiate between those secondary and primary headache disorders. And then the neurologic exam, full neurologic exam, especially if headaches have been going on for more than a few months without any red flags, like, you know, signs of high pressure, headaches consistently happening in the middle of the night or terrible in the morning, no other neurologic symptoms. And then having a normal neurologic exam after having headache, the same types of headaches for about six months. The likelihood of having a tumor in there is pretty much nil. I mean, I don't. The guidelines actually recommend against getting imaging because you're, you'll have a higher likelihood of finding something that's completely irrelevant and then going down this, you know, crazy rabbit hole.
- [45:32]
A
I want to put a highlighter on that. That is such an important. Can you amplify that comment just a little bit for parents who think taking pictures of everything is the solution?
- [45:42]
C
Oh, gosh, yeah. I mean, I, I get nervous when I do imaging, usually more because I'm worried I'll find something that I don't know what to do with because it's probably nothing, but I can't ignore it. And then you do more pictures and more pictures and. And then sometimes people even get procedures. And when you're talking about procedures in the brain, those are not mild nothing procedures. And so I really try to avoid imaging. Unless, of course, there are red flags or anything weird on the neurologic exam. And what I tell parents is the history isn't telling me anything scary is neurologic, or his or her neurologic exam is completely normal. If there was something growing in there, we'd know by now. I mean, and it's just not worth chasing something that's not going to be there.
- [46:29]
B
We talked a little bit about hydration. Can we talk about diet and sleep as related to migraines? Because as Parents, there is a little bit of the I told you so syndrome. Or why didn't you listen to me? Like you didn't get enough sleep or you ate all that junk or all that sugar or whatever. Do diet and sleep enough or not enough impact cause headaches?
- [46:55]
C
Absolutely. But we have to be really careful to balance that against blaming kids because some things are really out of their control. I mean, the teenage brain isn't wired to fall asleep until around midnight and wake up at 9:00am I mean, these crazy schools make kids get up at 6 in the morning to start at 7:30 or 8 o'. Clock. And actually in California there are laws based on this type of research that require middle schools to start no earlier than, I think eight and high schools that start no earlier than 8:30.
- [47:25]
A
8:30. Yep.
- [47:26]
B
Yeah.
- [47:27]
C
And they're moving to enact similar laws in the tri state area here in the New York area as well. And so I'll tell them you do need more sleep, you do need more lilies, but it's not your fault that you're not doing a lot of these things. Kids have pretty busy schedules. Well, I'll give you the spiel I normally give when I'm talking about treatment for kids with migraine and kids and teenagers with migraine. Treatment is usually divided into four categories. An acute or abortive medication, something you take right at the onset, which is usually ibuprofen or an nsaid, sometimes one or two other medications. A prevention medicine, which we usually recommend discussing when kids are having headaches at least a couple times a week, with the goal of preventing them because we don't want you using NSAIDs too often. And the third and most important treatment are healthy habits. So drinking, eating, sleep and exercise. I recommend eight to ten glasses of fluids a day, non caffeinated fluids, because caffeine just makes you pee it right out so you don't get hydrated eating three good meals a day. So if a kid is running out to catch the school bus, grab a little something on the way out, you need something in a tank, a breakfast bar, a yogurt. The younger kids tend to skip school lunch, so bring something with you or at least have a snack. Most people eat dinner though.
- [48:38]
A
And can I just ask about the medication? In the olden days, there used to be a recommendation for taking caffeine or consuming caffeine when a headache came on.
- [48:46]
B
Can you just speak to that with Tylenol? That was the first.
- [48:50]
C
Yeah, there are medications that, that come. I mean, Excedrin is caffeine Aspirin, Excedrin, Migraine is caffeine, aspirin and Tylenol. So yes, some people do respond to caffeine because I mentioned earlier those blood vessels dilate a little bit. Caffeine is a vasoconstrictor, so it, it actually shrinks the blood vessels back down to size. I find that anybody that I ask whose headache gets better after they drink caffeine, they're caffeine drinkers in general, for teenagers at least. And so they're probably addicted to caffeine and they're treating withdrawal because caffeine is a drug. And just like any other drug, you can become addicted to it and withdraw even after drinking caffeine consistently for three days or so. So I usually warn kids about that too.
- [49:33]
B
And what about sleep? What do you say to kids about sleep?
- [49:36]
C
8 to 9 hours of sleep is the goal, and then I say it's a goal. We don't all reach our goals right away. If your school schedule is crazy and not normal for you, compensate as best you can. I really, really, really recommend against napping after school, even though that's sort of a normal thing for people to want to do because they're so tired, because our sleep schedule is so terrible. But then you get into this really bad habit of napping and then you can't sleep at night and then your schedule is flipped and so eight to nine straight hours of sleep at night.
- [50:06]
B
This is so fantastic. We are so grateful for you. I like, feel like I just got a full education in.
- [50:13]
A
I know Vanessa said I was getting the free consult, but she's over here like a sponge just sopping it up.
- [50:20]
B
Well, I'm getting, I'm getting a free class. I'm like getting. I didn't even have to sign up for master class or anything. No, I'm. I was just like, it was just, you know, a tutorial.
- [50:30]
A
Well, because it. Headaches are scary. I mean, that's the reality is they're painful, they hurt. We've heard about scary bad things that can happen with headache. I think bear stating that if anyone of any age ever says it's the worst headache of my life, that is an emergency room visit. Right? I mean, that's just an important statement to land on. But go ahead, Vanessa, take us home.
- [50:52]
B
No, I just was going to say I think the most important thing is that we should validate kids who are feeling these symptoms. So for kids who are not seemingly having migraine level headaches, but are clearly having menstrually related headaches, is that someone who should come see a neurologist or like, what's your advice on that? Where it's not debilitating, it's just clearly related to a menstrual cycle.
- [51:22]
C
Well, start with a pediatrician or even an adolescent medicine doctor. I just listened to one of your earlier podcasts with one of my colleagues. Speak to them. They have some tricks up their sleeves, including hormonal treatments or even over the counter or some stronger NSAIDs that aren't quite over the counter.
- [51:39]
B
Oh, can you tell people what NSAIDs are? I meant to ask you to define that.
- [51:43]
C
Non steroidal anti inflammatory drugs, things like ibuprofen, naproxen, diclofenac is another one. Those are medicines that treat inflammation and pain.
- [51:54]
B
Right.
- [51:54]
C
There's one plug I have to put in for mental health treatment because anxiety and depression are so common in kids with migraine. And one of the main parts of treatment for migraine includes biobehavioral therapies, even for kids who don't have anxiety or depression. And some of the best evidence based therapies for migraine include cognitive behavioral therapy for chronic pain. And these are accessible by seeing a psychologist or some websites even have some tutorials on this and some apps as well.
- [52:27]
B
Do you find that the anxiety and depression are brought on by the struggle of dealing with the pain and debilitation of migraine?
- [52:37]
C
Usually not. We know that treating one doesn't necessarily cure the other. Uh, and so you really have to tackle both individually.
- [52:44]
B
That is such an important point and I'm really, really glad you brought it up. So for those of you who have kids suffering from this, don't forget about the mental health component of migraine and headache suffering. That is a critical point. And Noam, thank you for bringing that up. I'm so glad you did. So we are going to wrap. I'm now feeling incredible, readily knowledgeable. I hope all of our listeners are too. There's going to be a flood of new patients into your office. Just prepare yourself. They're going to be armed with the puberty podcast on their phones in one hand. But we will link to your website at monure and so people in the New York area can access that. And are there any websites that you recommend for people around the topic of migraine and in particular pediatric migraine?
- [53:38]
C
Yeah, the American Headache society, which is Americanheadachesociety.org has an incredible website with tons of resources. There's a patient page and there's also a linked organization called the American Migraine foundation, which also has tons and tons of resources for people suffering from migraine, and there are some pages specifically for pediatrics kids suffering from migraine, and also women's health and migraine, including overlapping issues like menstrually related migraine and teenagers. So it's a huge, amazing resource and I work with them a lot on some of these resources as well.
- [54:14]
B
Fantastic. Noam, thank you so much for coming on. We really appreciate it.
- [54:18]
C
My pleasure. Thanks so much for having me.
- [54:23]
B
Thank you so much for listening. You can email us with questions, feedback, feedback or episode requests@podcastawkward.com if you want
- [54:33]
A
to learn more about what we do to make this whole stage of life less awkward for everyone involved. Our parent membership, our school health ed curriculum, our keynote talks, and more are
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