Dr Katy Munro: In the Victorian times I think it was, it was divided into men who got migraine were the clever ones, the cerebral ones, you know, the very intellectual types, and women who got migraine were the flaky ones who fainted and were pathetic. And I think that stigma has persisted and I think that's part of why we really struggle to get it taken notice of when you think that it's considered to be you're right up there in the in the top disabling conditions in the world.
Dr Rupy: Welcome to the Doctor's Kitchen podcast, the show about food, lifestyle, medicine and how to improve your health today. My name is Dr Rupy. I'm a medical doctor, I also study nutrition and I'm a firm believer in the power of food and lifestyle as medicine. Join me on this podcast where we explore multiple determinants of what allows you to live your best life. And remember, you can sign up to the doctorskitchen.com for the newsletter where we give weekly recipes plus tips and hacks on how to improve your lifestyle today. Dr Jessica Briscoe and Dr Katy Munro are my guests from the National Migraine Centre today, the only national charity that provides a clinic for migraine sufferers and cluster headache patients, although they do see a spectrum of different headache disorders. And they've been delivering expert and evidence-based support for over 40 years. And in addition, they're committed to advocating their cause and educating healthcare professionals in the conditions that they treat. They also have a podcast that we'll refer to during this episode called Heads Up, and I highly recommend you check them out for different topics on the subject matter of headaches. Migraine is something that I've wanted to talk about for a long time because it is the third most common chronic disease in the world and something that really does not get that much attention. An estimated one in seven people suffer from it as well, with more being female than male. In the UK alone, 25 million days are lost each year from work or school because of migraines. And in today's episode, we're going to define exactly what we mean by migraines against other headache disorders, as well as lifestyle and food measures that you can put into action today or share with your loved ones that might be suffering from migraine to help you in an effort to reduce the number of episodes and perhaps even get rid of them all together. Regular eating, migraine, diet myths, low carb diets, ketogenic diets, all these are on the subject matter today. We're going to be discussing a lot more than just things you should be eating versus things you shouldn't be eating and all the other lifestyle measures as well. I know that you're going to enjoy this podcast. It's a deep dive, it's a little bit longer than usual, but I think this is certainly going to be useful for lots of people. As always, check out the podcast show notes. We're going to put all the links down there as well as checking out the Heads Up podcast as well as the National Migraine Centre as well. It's a fantastic organisation and one that I hope to support going forward too. On to the podcast.
Dr Rupy: Why don't you tell me a bit more about the charity? Because I was really, really pleased to have come across it on a Google search. And then I read up about you guys and then I saw your podcast and stuff. So it was, it was great. So why don't you tell me a bit about the organisation?
Dr Jessica Briscoe: Okay, well, it's actually our 40th anniversary this year. We were planning to have a gala for it, but obviously due to social distancing, that's not possible. But yeah, it was set up by some neurologists. I think initially it was just to fill a gap where there wasn't very much headache, there wasn't, there weren't many NHS headache services. And the whole point was that it was meant to manage people who, so those who could afford it can pay and actually those who can't afford to pay for good expertise can have it for free. And there was a lot of research initially. And it's changed names and changed forms. We've had lots of different doctors coming and going over the years. And now it's a, so none of us work every day at the National Migraine Centre. We work, most of us work one or two or more, Katie sometimes works more days than that. But we do one or two days there and it's, it's the emphasis on seeing all headache types, not just migraine, trying to help people to sort of manage in, in more, I'd say more of a holistic approach of using medications, lifestyle management, and sometimes some other types of interventions and giving education to people too.
Dr Katy Munro: Yeah, the education is a really big part of it and that's not just, I mean, one of the beauties of working there is you have a much longer time with the patient so you can do a huge amount more education about what is migraine, what are we trying to achieve with the acute treatments, what are we trying to achieve with prevention, all of that. But it's also we roll out the education. So we do GP, GP training schemes, we do, I've spoken to pharmacists, we've done nurse training, we really want to kind of raise the profile of migraine and get better care and make more people who don't get migraine understand the really massive impact because I mean we see it week after week as people just so desperate and weighed down with the impact on them and their families and their work and everything. So I think as a charity, we really, that's a really important part of it. It's not just treating, it's all the education around it as well. And that's partly why we started our podcast because we felt there was a little gap in the, in the podcast market there for a good education. So we try and kind of put a different topic each, each episode and then spread the word. And we found lots of patients have said, oh my goodness, I learned such a lot. So we are actually wondering whether some of the simpler cases are not coming. We're seeing more and more complicated people now because they've sorted themselves out by listening to the podcast. But lots of GPs have said they liked it too.
Dr Rupy: Yeah, definitely. I mean, I was going to say, I mean, it's an incredible tool in the, in the sort of progress towards self-care, I guess, if people are listening to the podcast, actioning it, and then, you know, having benefits and not presenting eventually. What I was going to, I wasn't going to ask this actually, but it just popped into my head now, and I don't want to digress too much, but what do you think about the charitable status and how you're, you know, creating the service on a pay by what you can sort of method? And how that compares to NHS? Because it seems to me that you're providing such a good service that it should be NHS funded and people should have access to similar organisations up and down the country.
Dr Jessica Briscoe: Yeah, I mean, we very strongly believe that. And it is a, it's a very difficult thing to juggle. How much, I mean, as a charity, you're always fighting to survive essentially. And we don't, we have to, you have to juggle between being pushy and being sort of actually giving people the care they need. And there's also the difficulty that a lot of NHS people, GPs, consultants, they don't know who we are. So they sort of think, who, what is this strange private clinic that you've gone to? And we'll say, well, we're actually a charity. And they'll say, but you know, we don't understand. And then they'll read the letter and understand, but it, sometimes I feel like we're fighting that battle to sort of show that we are altruistic, we're giving good evidence-based advice as well.
Dr Katy Munro: We try, we've tried, yeah, we've tried quite hard to kind of liaise with the NHS services. And I think, you know, we, we know loads of the NHS headache specialist doctors and they're so overwhelmed with referrals, you know, that it makes sense for them to talk to us and commission our services, but we don't find that they're very interested. Commissioners don't kind of come knocking at our door saying, wow, could you do this for us? And it's a bit puzzling, but I think it's the nature of the sort of stigma attached to migraine, which is one of the things we're fighting is that people underestimate it all the time. They think, oh, migraine, yeah, everybody gets headaches, don't they? And of course, it's really much more than that. You know, so many people having the brain fog, having auras, having profound nausea and vomiting sometimes, neurological symptoms, it can go on and an attack can go on for five days, you know, and that if you're having that two or three times a month, your whole life is changed, but it doesn't get the air time and the, it doesn't get the recognition as a disabling condition, does it?
Dr Jessica Briscoe: Yeah, the invisibility of it really doesn't help. I mean, most people with a migraine look okay. You might, if you know them well, you might be able to say, oh, you don't look quite right or you're slightly pale, but because if people get them a lot, they're so good at hiding it, you know, they just keep going. And people say, well, you're fine now, whereas actually, if you've got another, actually as disabling condition, so stroke, paraplegia, something like that, it's, it's much more visible.
Dr Rupy: Yeah. I mean, it I was just looking at some of the stats on the website and in anticipation of the podcast and it's one of the most, what, it's the third most chronic, most common chronic disease in the world and affecting one in seven people. And then there's 25 million work days lost in the UK alone due to migraine. So this is a significant problem that's having a massive economic impact. You'd think that there would be more money directed towards services that are actually providing great clinical outcomes.
Dr Jessica Briscoe: Well, it does cost the UK economy 3.4 billion pounds a year, which is a lot of money. Wow. Wow, that's, that's incredible. Well, why don't we go and talk a bit about your backgrounds personally and how you got involved in the service and then we can dive into the whole subject matter and try and help some people if we can. But Jessica, do you want to start with a bit about your background and how you got involved?
Dr Jessica Briscoe: Yeah, so I'm a GP by background. I've had migraine, as you'll hear most headache specialists do, since I think I worked out since I was about seven, actually. And I, yeah, and I hadn't, I'd always just thought it was a normal part of life because my mum got it, you know, other family members got it, you know, it's just a, you just cope with it and carry on. And it wasn't until I was at university and I was, I was had a placement in a GP with a special interest headache clinic in Exeter, David Kernick, who's one of, he's now the head of our special interest British Association for the study of headache group. So I, I tell him, I tell the story all the time and I embarrass him a lot. He was, he was, he was sort of teaching us and to, so we were fourth year, I think, medical students and he was teaching to GP trainees as well. And he said, right, there are four women in here, one of you must get migraine. So I put my hand up and he said, yeah, one in four women do. How do you manage it? And basically, I didn't do anything. And he said, right, and he, he completely revolutionized my migraine management. I suddenly could treat it and not and be able to do things for the rest of the day. And I sort of thought, oh, I really want to do that. I'd never really worked out how. And then when I was in my first year of GP, I just qualified fully, I saw an advert in my email inbox that said, do you, are you interested in headaches? Do you have a history of neurology? And I've done a bit of neurology during my training. Would you like to have 40 minutes consultation time with a new patient? I thought, yeah, that sounds really nice. So I applied and here I am today.
Dr Rupy: Amazing. That's great. And yourself, Katie?
Dr Katy Munro: Well, I interviewed Jessica, so I made a good decision that day. So I was a GP, I was a GP partner for 25 years in Potters Bar. And during the time that I was working, having never had headaches, I started getting these really horrible middle of the week headaches. And I took no notice. It took me ages for the penny to drop that I was getting migraine. And so I went to where it was in Charterhouse Square then the centre ran a couple of study days. So I thought, I'll go and see these study days. And it was so inspiring. I came away going, oh, I'd really like to work there. And my colleague who was also a partner said, don't be silly, you're still, you're far too busy. And I was. So when I decided to change my work life balance a little bit back in 2013, I thought, right, this is on my list of things to do is is explore working at the National Migraine Centre. And then an email came round and and the rest is history. So I've been working there since in fact it was 2014 I started. And it's been, it's great. It's just such an inspirational place and get such good job satisfaction from it. So, yeah, it's brilliant.
Dr Rupy: Brilliant. Yeah. And you work with like across like an incredible team as well from different backgrounds including neurologists and some researchers as well. Is that right?
Dr Katy Munro: Not so many researchers at the moment. We we're happy to do research, but at the moment, we aren't particularly actively involved, but we we liaise with people. So there's a group in Cambridge that are trying to raise the profile of migraine for children and they're doing an app for children to understand their migraine better. So we we work with them and you know, we do focus groups and things like that. But yes, we have consultant neurologists and and GPs working there.
Dr Jessica Briscoe: Yeah, and we've helped with chronic migraine studies. So there was a Warwick study looking at the impact of chronic migraine. Um, I think it wrapped up about six about a year ago maybe. Um, so we we do get involved with that, but we haven't done our own original research for a while, but our, I think our CEO is quite keen to do some research at some point.
Dr Katy Munro: We've also, we're also really keen to raise the profile of other headache types which are less well understood, which is why we do these Thursday tips. I don't know if you've noticed on social media, but basically one of us standing there for a minute or so just giving a tip. And my latest one was to say that we should rename the centre the National any kind of headache centre because we're, we're very happy to see patients with cluster headache. We, we Jessica and I've got quite an interest in Ehlers-Danlos and that is associated with CSF leaks and and various other types of headache resulting from that. Is it rare or was it rarely diagnosed is is the current discussion about these kind of connective tissue hereditary disorders. So, yeah, any kind of headache people can come and see us or if they have migraine that hasn't got headache, like vestibular migraine or you know, some of them have a lot of children have abdominal migraine and it's not picked up until they go, then often their parents go, oh, hang on a minute, I get migraine and my son or daughter is getting tummy aches, could it be linked? Often we point them in direction of the podcast episode about that. So, yeah. There's just too much to talk about, Rupy.
Dr Rupy: That's great. I know, I know. And there's probably listeners already listening to this like, I just need to book into the migraine centre. And I hasten to add all the links are going to be on the podcast website. So do check it out, the National Migraine Centre. But let's, let's talk about the different types of headaches actually, as you just alluded to there. There's loads of different types. I think they're used interchangeably, often incorrectly by not only patients, but also doctors as well. I'm sure I must have said something like a migraine cluster or something like that. I know, yeah, not on the podcast, don't worry, but perhaps during my training or, you know, when I was learning about headaches and I didn't, because unfortunately a lot of stuff, as a GP, as you both know, you know, we have to learn so many different things. And I think it's quite easy to fall into traps and bad behaviours and habits. So I hope this podcast is going to be good for GP trainees and doctors across different specialties too. But why don't we define exactly what we mean by the different spectrum of headaches and then we can dive into migraines specifically.
Dr Jessica Briscoe: So headaches are usually split into primary headaches and secondary headaches. Um, secondary headaches are where you, that basically something else is causing the headache. So that's the ones that everyone worries about. So every time there's always a theory that the patient is worried when they've had a headache that they've got a brain tumour. I personally think the doctor is worried that the patient is worried they have a brain tumour, but that's another story. Um, but it's things like brain tumours, other um, sort of meningitis, other types of conditions that will cause a headache. And then the primary headache disorders are the ones that we tend to deal with. But it's always important to try and rule out the secondary headaches. But they're such a small proportion of headache disorders that um, actually you can usually rule that out quite quickly once you get used to seeing, seeing people with headaches and knowing what to look out for. So the most common primary headache disorder is migraine. And that is split into umteen subtypes to be honest. I mean, I'm actually forever discovering a new one that I've never defined before. Um, but actually, to be honest, the important thing is to establish, do they have migraine? Do they not have migraine? And actually the subtype doesn't matter so much. It's nice to put a label on it, but we can talk about that in more detail. And then you've got the next big group of headaches are the trigeminal autonomic cephalgias or TACs. And cluster headache is the, is the big name from that group. And they are all essentially a problem arising from the trigeminal nerve, which is a nerve in which goes into the, into the face. Um, one of the branches can cause pain usually around the eye or forehead on one side. And um, that's the cluster headache is called the suicide headache. So it's meant to be the most painful condition known to humans. Um, although I hear that about a few conditions, but I do genuinely think it's true about cluster headache. And that one tends to be more, that one's very, that one has a very typical pattern. So it tends to be periodical. So people will get it once or twice a year or every two years or every 18 months, more so in spring or autumn. And then it will last for a few weeks, usually, usually at night. And you'll have a few patterns of it. And then there'll be other symptoms that people get with it like eye watering, eye redness, nasal obstruction, nasal running, sweating. Although those are not diagnostic of cluster headache, you can actually get those symptoms in all of the headache disorders. Um, and I think those are the, those are the sort of two main groups that we think of. When you were talking about migraine clusters, the only reason we get upset is because it really, when people say I've got cluster migraine, you sort of think, ah, do you have cluster headache or do you have migraine or both? Because you can have both.
Dr Katy Munro: The other, yeah, the other one I just like to flag up, which I think is hugely overdiagnosed is tension headache. So tension headache, very often people say, oh I, or the other phrase that presses our button is just the normal headaches. So there is no such thing as just a normal headache. You need to have a diagnosis. So there is no such thing as just a normal headache. But tension headache, lots of people have been told, oh it's probably stress or it's probably tension. And we, most of those are actually migraine that hasn't been properly diagnosed because tension headache by definition is a featureless headache. So if people have got any amount of nausea or vomiting or sensitivity to light or sound or movement or smells, then it's actually migraine. That is defining migraine, not tension headache. So tension headache is also quite more tricky to treat. So migraine, we've got a whole range of things that we can do now. I always say to patients at the end of a consultation, this is plan A, but there's always a plan B. So, and they come in and say, oh, I've tried everything. And I say, no, you don't, you haven't. I've got many things to suggest here. So, um, but yeah, I think,
Dr Jessica Briscoe: And also tension headache, I think tension headache is such a misnomer as well because everyone thinks it's caused by tension. So everyone said, oh, my neck's tense, it must be a tension headache. Actually, it's just a really bad name. It's not caused by muscle tension. I don't think we know what causes it, but it's not muscle, we know it's not muscle tension. That's a different type of headache, the cervicogenic headache, which is also overdiagnosed probably. Um, because um, it has to be diagnosed on scan. So it's a neck, that's a headache that's caused by structural problems in the neck. Um, if you scan most people, I think even over the age of 20, they will have some structural changes in their neck if you MRI people. Um, and do you say that their headaches due to to their that that neck damage? Do you say it's migraine? Is it, it's it can be very tricky. And that's not to say that manipulation therapies wouldn't necessarily help migraine, but it doesn't necessarily mean that it's cervicogenic headache. So it's, it's all a bit, I mean, I think most of it's migraine. I'm honest, but um, I'm biased.
Dr Katy Munro: Well, I think, I mean, we know that there was some studies and they showed that 95% of headaches that pitch up in a GP surgery are migraine. And if a GP says it's migraine, they'll be right. And if they say it's not migraine, they'll be wrong about 97% of the time. So it is much more common. And I think there's a lot of myths about migraine and and misunderstandings. And so going back to the neck thing, we know that migraine pain is referred down into the neck and shoulders and sometimes is predominantly in the neck and shoulders. So people think they've got to have something done to their neck. And we get the same with sinuses. Lots of people say, oh, I've got terrible sinus. And I get this knitting needle like pain in my sinus when I'm getting a migraine. So you can see why there's confusion and people go down the wrong pathway. Um, but I think, you know, migraine is incredibly common, but there's also a myth about, oh, it has to be one-sided and you have to have zigzag lights and you have to be vomiting. And of course, it's a massive spectrum of um, effects. So some people have really quite mild or infrequent migraine, right the way through to people who have relentless chronic migraine day by day. The other one we haven't really mentioned, which is linked to migraine is medication overuse headache.
Dr Jessica Briscoe: Oh, yes. I never think of it as its own headache. That's why. I always think of it as a, and you don't, and I mean, yeah, medication overuse headache is this very strange phenomenon. Um, it's most common in migraine. You can very occasionally get it in other primary headache types, but it's, it's rare. Um, it's where by, it's this headache that's called, it's usually quite a dull, featureless headache, um, generalized headache on a daily basis. Um, and it's caused by using too many medications. So any medication can cause medication overuse headache in people who are having migraines. So the very thing that people are doing to try and get rid of their symptoms is then causing the pain. And the amount of painkillers you take is different from different classes of painkillers. I tend to say on average, you want to not, you want to try and have painkiller, it's days of painkillers as well, not doses of painkillers. So you want to have less than roughly 10 painkiller days a month. Um, but it is dependent on different, on which types of painkillers you have. But if you do, if you have more than 10 painkiller days per month for three consecutive months or more, you're at high risk of developing medication overuse headache. And in the studies show that in migraine is something it was between 40 and 70% of migraine patients have medication overuse headache, which is quite a wide, a wide range, which shows you how difficult it's quite difficult to, and you can't diagnose it without trying to stop people from taking their medications. So people have to be on a detox for 12 weeks of no painkillers, which is horrible. Um, and they sort of think, well, I don't know if it's going to work. And you don't know if it's going to work until you stop the medication. And it can be, it's, it's, the key is to try not to get into that situation so that we don't have to try and get you out of it because it's, none of us like doing it to be honest.
Dr Katy Munro: I think, yeah.
Dr Rupy: Yeah, exactly. And I think I can imagine why that range is so wide because people would be quite reluctant to, and I think also the psychological stress of taking away a painkiller, your expectation of pain is going to go up and then that's going to have an erroneous result as well. I wanted to talk a little bit about the physiology behind and the mechanism behind migraines themselves. So what do we know in terms of, is there a genetic link? Is there, are there other mechanisms that perhaps people aren't aware of behind why some people have them in the first place?
Dr Katy Munro: There's definitely, definitely a genetic link, definitely. Um, not everybody can point to their family members that they've inherited it from, but there's, we know that there's at least 40 genes that are involved. And what how I explain it to people is that the genes set your brain to be always a little bit more sensitive to sensory changes in your and changes in your internal environment or your external environment all the time, whether or not you're having an attack. So your brain is doesn't deal with change. Um, but whether you get a migraine or not depends on environmental factors. So it's not all about the genes. Um, so if things are changing in your body or in your surroundings, and that could be things like hormones or blood sugar, sleep patterns, stress hormones going up or stress hormones coming down. So sometimes we have people saying, I get them at the weekend when I relax. Uh, or it can be things like stuffy rooms. I used to be really sensitive to candles burning and that sort of, I used to get one at the end of partners meetings where my colleague had put lovely candles to make a nice relaxing atmosphere and I'd come away going, oh my goodness, my head is banging now. Um, but also barometric pressure. So there's lots of different factors that can change and so that's why people are sort of hunting desperately saying to us, you know, I couldn't find the thing that caused it. And it's because it isn't the thing. It's the group of things and it can change, the group of things can change. Um, so for example, a peak time to get it is in teenage. I was speaking to some teenagers yesterday and one of them, um, was much better since the lockdown because he didn't have to get up in the morning, he had finished his huge growth spurt, he had been able to sleep a bit longer, he was eating more regularly. All those kind of things can make a massive difference. And I was speaking to an adult, um, who had the same thing. He'd, his work stress had changed. So the lockdown in some people has been helpful because it's reduced the amount of change, but in other people it's added a level of tension and sort of more screens and less exercise and maybe more, more cakes and biscuits to comfort eat. So, yeah, it, it's, it's about that. But we think what's happening in the brain is that, um, the irritations are triggering the production of neurochemicals. So there are lots of neurochemicals. One in particular has been studied recently called the calcitonin gene-related peptide. And that's, we can talk about medications directly targeted at that later on if you like. Um, once their level, once the level of the pain chemicals has reached a certain height, it triggers, uh, electrophysiological changes. So each cell has an electrical charge across the cell membrane and that changes and that rolls out over the brain. And so depending on where that rolls to, depends on what kind of symptoms that person gets. So some people will get visual aura because they get it in their occipital area of their brain, the vision part. Other people might get hemiplegic symptoms where they have weakness of one side because the changes are over that part of the brain, which is what makes it such a variable condition. And it can change for one person from attack to attack. Some people will get very dizzy sometimes, but then other times they'll get more of the headache part. Um, and it's, and it can change throughout a person's life. So we see people saying, oh, I used to get aura, but I never get it now, um, or vice versa. So it's, yeah, it's, it's basically your brain is reacting to changes.
Dr Jessica Briscoe: And I always think of it as a, because everyone always says, do I, do I need a scan? Do I need a scan? I always think of it as a, a problem with the wiring, not the computer itself. So the brain is actually usually fine, but the wires get, these neurochemical, these neurochemicals that are released get them over excited, I think is the best way to put it. And people with migraine are very sensitive to their surroundings when they have attacks. So again, according to which nerves are over excited. So that smell sensitivity, I don't know why I went with smell first, smell sensitivity, um, photosensitivity or um, sensitivity to light, motion sensitivity, the nausea is because your, you get your vagus nerve, which is that long wandering nerve gets stimulated and causes gastric stasis. So it's all because those nerves get, get over excited. And um, essentially what we try and do is find a way of calming them down. So we either do that with medication or by preventing those neurochemicals from being released in the first place.
Dr Katy Munro: We talk about the threshold, don't we, Jess? The, the things sort of adding together and pushing the brain to such an irritable state that it then hits a threshold for the migraine. And so what we're trying to do with the, with the preventative treatments is to push the threshold further away. And there are some things people can do themselves to make that threshold further away. And that's by taking control of their routine, which is a bit boring. But go to bed at the same time, wake at the same time.
Dr Rupy: No, I don't find that boring at all. I think it's brilliant.
Dr Jessica Briscoe: We're big fans, we're big fans at the centre of talking to people not just about medication because there's so much more they can do. So we, I always start by saying, right, one of the biggest things that irritates your brain is not having a constant supply of fuel and eating regularly, having regular snacks, having, we're quite keen, Jessica and I both very keen on talking about healthy diet and nutrition and and trying to, um, reduce the carbohydrates. So there's quite a lot of evidence that reducing carbohydrates in the diet can be very helpful for migraine and and even keto diets isn't it just,
Dr Katy Munro: It's quite restrictive though. It's quite restrictive. Some people have done it. I had, I've had a couple of patients who found it's really helpful because the theory is that it produces ketone bodies that are anti-inflammatory. Um, but if people can't manage to do that, even just changing the carb balance. I had a lady a few weeks ago and she really, really paid attention to reducing the carbs. She was a real fizzy drink guzzler and cakes and biscuits. And over three months, she reduced her migraine from 15 migraine days a month down to about one and dropped two dress sizes and she was simply so happy that that was the main thing she'd done, you know, and I think people underestimate that. And there's no time in neurological outpatients to go into it. And there's very little time in GP surgeries to go into those, they, they say to people, do you eat regularly? And everybody says yes, because we all eat regularly. But that might be, well, I never have breakfast or, you know, I go through,
Dr Jessica Briscoe: I learned from Katie. I learned from Katie that you have to ask about individual meal timings. So I always see her letters, she's written breakfast, 9 a.m. and I sort of think, oh, okay. So I, I used to just ask about the evening meal, but actually because that gap, how long are you having between meals? Are you having things in between? What are you having? And Katie's also a big fan of, she's not a big fan, she's a big fiend about caffeine as well. So, um, she's always asking people how much caffeine they're having.
Dr Katy Munro: Yeah. Quite a lot. Yeah, yeah.
Dr Rupy: What, what, let's, let's double click on the, the diet element there as well. So glucose regulation and glucose stability sounds like it's one of the most important things. And one of the sort of strategies, I guess, or tactics is to adopt a diet that is low in refined carbohydrates and maintains that sort of glucose level. Um, you mentioned regularity of meals. Um, what, what kind of foods are we talking about? Are things that people should be aware of not to eat too much or in an excess versus the ones that we should be getting more of in our diet? And I'd love to talk a bit more about the ketogenic diet.
Dr Katy Munro: Well, I, I don't get too bogged down because everybody's different with their dietary preferences. So if you're too restrictive, I think a lot of people have tried, um, the so-called migraine diets where you cut out every single thing that could possibly trigger your diet, your migraine. But of course, there are no convincing studies that have found that there is a particular food that you have to avoid to reduce your migraine. So people have cut out wheat, cut out dairy, cut out this, that, cut out bananas, cut out, goodness knows what. And we just say, no, no, no, no, no. Look at the balance of carbs and protein and fat. Protein and fat are your friends, carbs are not your friends. So I basically say to them, avoid white things that you eat in your diet, apart from cauliflower. So bread, white bread, potatoes, uh, pasta, pizza, cakes, biscuits, sugar, all of those kind of things, we'd cut them out completely, but reduce them so that you're cutting your portion in half. So you might have, I usually go to spag bol or curry and rice and say, if you're having spaghetti bolognese, half the spaghetti, twice as much of the sauce, put some extra cheese on the top. But then of course people go, oh, I'm vegan or I'm allergic, you know. Nuts and seeds are really, really good snacks, nuts and seeds, very healthy, good things to take. Um, avocados, um, dairy products as long as you're not vegan. Um, I think gluten is a, is a tricky one. Some people are definitely more sensitive to gluten and not necessarily celiac. So it's a bit of their taking them to a place where they feel they can find a diet that suits them that's along those kind of much broader guidelines, I think. Would you agree, Jess?
Dr Jessica Briscoe: I kind of want to also address the, yeah, I, I kind of wanted to address the cheese, chocolate, citrus, specific food trigger myths as well. Um, and I, yeah, I hate, well, not, I don't hate it. It's my pet hate actually, people coming in and saying, I've cut out cheese. I haven't eaten cheese for years. And I think, oh, that's really, I mean, I can't eat cheese because I'm, I am lactose intolerant, but that's different. It's not because of my migraines. Um, but I feel so bad for people that have cut out all of these, these specific things because the reasons that people think that they, that they, the reasons people that cheese, chocolate, citrus and other foods came up in the list is because, um, when people were initially writing their migraine diaries down, they, they'd look at about two hours before they'd have an attack and they'd say, oh, I'm always having cheese or chocolate or, I mean, chocolate digestive is the thing I always have two hours before my, my migraines actually. Um, and so say, well, that must be what's triggering my attack. But we now know that migraines actually start 12 to 24 hours before your pain phase starts. Um, so what's happening two hours before isn't your trigger. Actually, we also know that blood glucose levels drop around two hours before your migraine attack. So what happens is people crave things that will push up blood sugar levels, orange juice, chocolate, cheese, salty things as well. Some people will crave those. They will push your blood sugar up. So, um, and there are good reasons why cutting out, as Katie said, cutting out chocolate, you're probably stabilizing your blood sugar level a lot more. And similarly, possibly with cheese, if you're having a lot of it, people possibly are being a bit more careful about their blood sugar level. So cutting those out may have improved their migraines, but it's not the specific foods, it's more about the type of diet they're adopting and its effect on their blood sugar levels rather than the foods themselves.
Dr Rupy: Gotcha. That's super interesting. And I think that that definitely, I'm glad you said that because I think most people will think about their diet in very binary terms of like this ingredient versus that ingredient, but it, you're right, it's the orchestra of different foods and it's the holistic picture of what you eat over weeks and months rather than on a, on a day-to-day basis. Um, with regards to the ketogenic diet, so I had a colleague of mine who's a specialist dietitian and one of the only registered dietitians that prescribes the ketogenic diet for refractory epilepsy treatment in children. Um, they're also involved in a couple of studies looking at GBM of patients who have actually opted into trying a ketogenic diet of their own accord and just recording outcomes. Um, what I'd love to know about is the any evidence base around pain management, um, with ketogenic diets because like you alluded to Katie, there was a suggestion that ketone bodies are involved in improvement of of pain perception.
Dr Jessica Briscoe: There was a trial in Italy. Uh, it was a small trial. Um, it was a Noki Institute, um, in Italy did a trial which showed that I think people were either assigned to the very low ketogenic diet or the keto or the very low carbohydrate diet, sorry, or the ketogenic diet. And people on the keto diet had approximately a 30% improvement in their migraine, their number of migraine days. Um, so that is that they're now using that to do more research into it because as I said, it was a small study, it wasn't particularly, I don't think the methodology was brilliant, but actually I, I think that's, that's quite a good indication. But I do believe there are actually, there is actually evidence about epilepsy in children. So some forms of refractory epilepsy, the fact that ketone bodies can reduce inflammation. So I think that they're sort of, it's a difficult, I think it's quite a difficult thing to do to do studies on actually. It's not as easy as doing on medications where you've got sort of an X and a Y, you know, you've got placebo and X, you can't really placebo ketone diets and stuff. Um, so I think it's really hard to get good quality evidence on it. Um, and also some people don't get on with it at all. Um, you know, some people tolerate it really well. I've had, I've had friends who've done it from a fitness point of view and some of them have loved it and some of them have absolutely hated it and lasted about a week before they've gone off it. And so I suspect drop out rates are quite high for that kind of trial as well. Um, so I think to get good quality, as good quality evidence as we do for some of the medications, um, is going to be very difficult, I think. And and pain studies are notoriously difficult to get good quality evidence on anyway.
Dr Rupy: Yeah, I can imagine. I mean, like and the side effects from a ketogenic diet is huge. I mean, nausea and bad breath are just like some of the milder side effects compared to constipation and um, the restrictive nature of it as well. So it's um, yeah, it's an interesting topic, I think, um, that probably warrants a little bit more attention and research, but one that um is is quite unevidenced at the moment.
Dr Katy Munro: I actually, I actually tried it myself because I like to try things if I'm recommending them, you know, within reason. Um, so I tried it, but it was the week or two before we were going to the Dublin headache conference. And so I was being scrupulous and weighing out everything and making sure the fat percentages were all right. And I felt really awful. Um, because I think I was in that keto flu bit, you know, that first couple of weeks. And then of course you go to a conference and you're at the mercy of whatever's put in front of you. Yeah, you just, you just can't do it. It was very hard. So, and yeah, so I, I, so I'm very aware that we can say things to patients, but it has to be something that's realistic for them to try that they feel some belief in or some motivation to do it. And the other thing I say to people is, if you genuinely are sensitive to a particular food and every single time you have it, you feel bad, don't eat that food. But there's no studies to prove which one of those foods it's likely to be. So, but I, I think it is, um, something that a lot of our patients have looked into. And then of course there are these other diets which are very popular now, which are like the 5-2 diet or the 16-hour fast diet. And people say, oh, I'm trying that. And you think, well, actually, if you're fasting, so I, you know, some people may get away with those kind of diets if they're in a phase where their threshold is high. But if they're in a phase where their brain is very irritable, then I would really guard against that because you will get big, the whole point of it is to get swings in your blood sugar so that your body goes into repair mode. Uh, and I think when your brain is very irritable, then that's not the time to try those kind of diets.
Dr Rupy: Yeah, I I I was um interviewing Walter Longo who's the uh proponent of the FMD, the fasting mimicking diet, more so from type two diabetes and um longevity, a longevity perspective. But I I I imagine if your goal with a diet that is um useful for those who have migraines is to maintain glucose uh balance, then having those vast swings, particularly if you're coming from a diet that isn't perfect and then you automatically go into a fasting mimicking regime or a 5-2 diet or intermittent fasting, then those swings are going to potentially exacerbate migraines. Is that what I'm right in saying that?
Dr Katy Munro: I think so.
Dr Jessica Briscoe: I've had a couple of patients who've tried intermittent fasting for other reasons and their migraines got worse. And I've said, please avoid it because I, I, I like, I'm not, I'm not against intermittent fasting at all. I think it's, but it's that whole, it's that whole one size fits all, fits all mentality just doesn't work because there is just no, particularly with nutrition, there's not one thing that works for every condition. So I always advise, I advise people with migraine to avoid it where they can.
Dr Rupy: Yeah. Are there any other elements of the diet with regard to specific additives that might be irritant? Um, one's, I know that, you know, there are certain migraine diets that remove like citrus and cocoa, cacao and all the rest of it. But are there particular additives perhaps MSG or aspartame or nitrates and cured meats that are shown to be irritant?
Dr Katy Munro: We're both pulling faces because we wouldn't want to, we wouldn't want to eat that stuff. I'm a great, I'm a big fan of buying ingredients and know what's in your food, you know, don't, don't buy processed foods, don't, you know, it's start reading the labels, know what you're putting in your mouth because if you're eating a lot of diet things, you know, with a lot of sweetness in it, I mean, that's not, to me, that's not a great idea. And your body, I think fizzy drinks that people say, well, I only have the diet version. Your body can still give an insulin surge, uh, as a result of a sweetener. Um, so, yeah, I, I keep it a bit, I'm a bit more purist in ingredients really.
Dr Rupy: Yeah, yeah. What, what, I wanted to ask a general question about inflammation. Um, there's a few things that I think I've come across from patients asking about omega-3 versus omega-6 imbalances. Um, and whether you think there's any evidence about the preponderance of arachidonic acid, which is the long chain O6, which can cause inflammation in a systemic manner. But I'm wondering if there's any relationship with with migraines or other types of headaches for that matter.
Dr Katy Munro: I don't know. I don't know of any studies on it. Um, I don't, I think there's a lot of interest in omega-3 and omega-6. Certainly, I've been interested in chronic pain even before I was a headache specialist and there's certainly a lot of interest in improving the omega-3 levels. And the problem is that you, if you go into Boots or one of the pharmacists, you can pick up any kind of combination of omega-3, omega-3 and 6, omega-3, 6 and 9, and people are like, well, which, oh, it's got more things, it must be better. So I'm quite a purist in saying, well, if you're going to take omega-3, you need to just take omega-3. And you can do that through dietary methods, you can do it through supplements if you wish. But I don't think there's any studies that I'm aware of that say that there is a significant impact on migraine headaches. But we do know of three supplements that do have some study evidence, although we'd like there to be more studies on these things because I think people really prefer not to have medication. Um, so the three are magnesium, uh, vitamin B2 or riboflavin, and coenzyme Q10. And all of those have been studied, uh, a while ago to see and and some improvement in some people. We always have to say that nothing works for everybody. Some, some improvement in some people. Um, but they're safe. You have to take them for at least three months in quite high doses to to see if they're effective. And we haven't got studies to know whether it's better to take one or two or three. So it's, it's a kind of personal choice, I think really then and it comes down to funding as much as anything. Some of these supplements you can spend a lot of money on.
Dr Jessica Briscoe: Yeah. And there's also some small evidence actually on probiotics as well. So they're doing lots of studies on probiotics and migraines. So I'm sure you've spoken about probiotics before. Um, but um, there's the whole point about the fact that the the different bacteria in your gut um can release different neurotransmitters. Um, there's this whole brain around the gut and we've already established that there's clearly a big link between migraine brain symptoms and gut symptoms. Children get abdominal migraine, people get abdominal symptoms too. So that I suspect that um, I think we all suspect that that brain around the gut has a that neurological system has a big part to play. And they believe that changing that there's some evidence that changing the makeup of of the um gut bacteria can actually improve migraines. Um, it's very low level evidence and it was the actual, it was the company that produced the probiotic that did the study. Um, I think we're hope that but they are there is a lot of interest in doing wider studies. Um, I it's one of those ones that I do if if people have tried lots of things, may have IBS type symptoms too, I will probably say try this one type of um probiotic and because it's not going to give you side effects, so there's no sort of harmful effects from it. Um, for three months, which seems to be the magic number for trying any type of migraine preventative. Um, and then you won't have lost, I mean, apart from the fact that it can be expensive, you won't have lost too much from trying it and actually some people have found there's been a benefit from it.
Dr Katy Munro: That's brilliant. I think the jury's out on that actually as well because I think there's so many different probiotics. And then I was uh, I was at a conference recently about depression and the the gut and microbiome and things. And I think there's a lot of interest in the overlap between depression and and migraine and pain and all these kind of things. Uh, and they were talking a lot more about prebiotic foods feeding the variety of your gut bugs. So the message was more that it's important to eat a wide variety of vegetables, as many different, we had a chat to somebody who'd been to another microbiome conference and he was saying you have to eat 30 different vegetable types in a week. And so my daughter misheard and thought he'd said 30 a day and she was like, oh my goodness. But no, 30, so the old adage of eat a rainbow, you know, many different colours and and types of vegetables. Um, I think that's probably the most healthy way to encourage your gut flora. And I think there'll be more and more um, discoveries about that in the next few years, I suspect, because it's a real hot topic at the moment.
Dr Rupy: I agree. Yeah, I I I imagine like a migraine diet if you if you like, just being one that is incredibly colourful and incredibly diverse. So like you said, you've got those pre, prebiotics, which are the um, fermentable fibres and and specialized fibres that nurture your gut microbes, um, with the potential of maybe some probiotics. I know John Cryan is doing some incredible research with him and his team in, I think it's Cork in Ireland. I've read some of the papers looking at psychobiotics, which is this new term about the use of potential um, symbiotics, so pro and prebiotics in a formula that nurtures certain microbes that might be beneficial in um, uh, types of mental health issues. Um, but the jury, like you said, the jury is very much out on these things and it's interesting to talk about. Um, but I think there's so much you can do with diet alone, which is, which is fabulous. Um, though those supplements are fantastic. With regards to magnesium, I know there's different types of magnesium. Um, is there a particular type of magnesium that is better or is it just based on the bioavailability?
Dr Jessica Briscoe: We are always, we are always debating this. So, um, I think I always suggest, and I probably because I've tried, again, like Katie, I try and try things if I where feasible. Um, I found magnesium citrate tablets. They were like horse tablets essentially, they were huge. Um, so but they are slightly better absorbed. And I'm not, I'm such a bad patient. I'm terrible at taking tablets. I'm, I am a bad, doctors make terrible patients. So I'm a living proof to be honest. Um, so I tend to say, or if you can get magnesium malate, they're available in capsules. And but actually any magnesium that's well tolerated. So the ones that have a better bioavailability, the ones that are going to give you fewer um, gut symptoms, so less loose stools, bloating, pain, which can be the symptom of taking magnesium. And you want high dose. So I say between 400 and 600 milligrams. It's all about how much you tolerate, um, because a lot of the side effects are dose dependent. Um, and I don't really like people getting too het up on, oh, I must take my two tablets, you know, if you can get one that's got roughly, you know, if it's got 500 milligrams, great, if it's got 400, that's fine too. Um, but there's no specific sort of compound type of magnesium that um, I'd particularly suggest.
Dr Katy Munro: I think I'd agree. The studies were on magnesium citrate and they were on 600 milligrams. But if you go straight in at 600 milligrams, then the patients will spend a lot of their day cursing you as they are in the toilet because it really is, it can have some quite dramatic. Now, if they need that kind of effect, it can be very helpful. So it's again, it's about personal choice. And there's a bisglycinate format. A lot of um, so I speak to quite a number of patients with um, chronic pain and and the malate forms and the bisglycinate forms seem to be quite easily bioavailable and less laxative. Um, but it's, yeah, trial and error really. I had spoke to somebody yesterday who was taking a liquid ionic form and she found that suited her much better. But uh, there are no studies about which particular, nobody wants to invest money in spending, you know, doing studies on supplements really.
Dr Rupy: I think the motto from for all of those is just to keep going at the dose that you tolerate, just keep going because people want a quick fix and with all of the things we're talking about in terms of changes, um, in lifestyle or supplements or medications, it's going to take at least three months before you can judge if it's working. So a lot of times people are coming and saying, well, I tried this for two weeks, it didn't work, so I stopped. And you have to be a little bit patient.
Dr Katy Munro: Yeah.
Dr Rupy: Just go, keep going. Yeah, I think, I think doctors and patients alike are lack a lot of patience. I from my own experience, like we try something, didn't work after a week. We live in this world of instant gratification. If it's not working after a week, I'm going to quit it. I'm going to, you know, I'm not going to bother. But people just need to be reminded, ourselves included that everything takes time.
Dr Jessica Briscoe: I always think if you're thinking about it as actually raising that threshold, that's not going to happen quickly. Like you can't, you can't push it up quickly. And it feels like the migraines happen very quickly, but actually it's probably been gradually building for ages. So I think I always think of it that can be a bit more helpful in in the patience building.
Dr Rupy: Definitely. Um, you described this as the boring stuff, but I actually find this stuff fascinating, which is lifestyle in general. Yeah. So exercise, sleep, uh, stress reduction techniques. Why don't we dive in with sleep? Because I think sleep is something that we all uh, suffer with. I personally average around six and a half hours a night, which is not enough for me because I know how I feel after seven or eight consecutively. I feel amazing. So I really try my hardest to try and improve my sleep quality. But what do we know about sleep in relation to migraine management?
Dr Jessica Briscoe: Again, it's the boring stuff. So the amount of sleep you get is important, but actually having too much or too little is a problem with migraine. You need to be consistent. So it's the routine. So going to bed and waking up at the same time is really important. And shifts of an hour either way, going to bed time or waking up time, um, can trigger migraine attacks. So times that tend to be bad are um, around the clock changes. I remember we did a Thursday tip actually around the October clock change. Um, where we were saying, oh, you might all find that your migraines get worse. And lots of people replied and said, yeah, actually every time the clocks change, they get worse. And you think, yeah, it's because you can't do anything about the fact that your body clock shifts an hour. And it's similar, one of the reasons why traveling causes a problem because if you're shifting your sleep routine, um, that that can, people can find on the, on the second day of of traveling somewhere if they're going, if they've been traveling to a different time zone, they might be more likely to get attacks.
Dr Katy Munro: I think that there was a study that showed that people with migraine generally need a little bit more sleep probably than than other people. And I often emphasize the, the bit that Jessica mentioned, which is that extended sleep is really not your friend because, so the teenagers don't like that really, but it's having a regular set amount of sleep is much better for your brain. And if you, so I spoke to somebody yesterday and he said the one, one of the things that jumped out from my first consultation was that you told me that I shouldn't have extended periods of sleep. And he said, I've, I would always assume that if I felt really tired, I should just sleep for as long as I can, but then I'd have another migraine the day or the day after that. We quite often find that kids will have a migraine on a Monday because they've had a long lie in at the weekend and it takes their brain a day or two before the migraine reveals itself. So just by putting in that sort of routine. The other thing I was, um, I always say to people is I don't know how anybody travels with that, anybody who's got migraine, how they ever travel because when you think of the changes, you're excited or stressed, you then have to get up in the middle of the night to go to some airport which is loud and bright and glaring and more noise. And then you're in a stuffy aeroplane and then you land in a different time zone. I mean, mind you with the, with the way the world is now, we may not be doing that so much. So maybe that will make a difference. But yeah, all these.
Dr Jessica Briscoe: I have to say that's something with lockdown that's made a difference. People's sleep has been, there's been loads of reports of sleep disturbances during um, during the pandemic lockdown. And I've definitely seen that with people with migraine. They'll say, I just can't sleep. And there is this thing about the brain being active more during the day. You have less of that commute, that dead time, that commuting time where your brain's not really doing very much or um, or doing things in between tasks. If you're just sitting in one place all the time, um, you're not exercising as much generally if you're not even walking around, as Katie said earlier. Um, people are finding it much more difficult to sleep. Um, so they're getting shorter amounts of sleep, the sleep quality is probably not as good. And some people's routines are off because they're lying in bed for ages trying to get to sleep, not managing it. Did that age old, oh, I've only got half an hour, I've only got a few hours until I wake up. Oh, now I've only got three hours, now I've only got two. Um, and I think that's affected people a lot during um, during lockdown too from a migraine point of view.
Dr Katy Munro: There's also something about, um, we had a very interesting, uh, study day which was from some of the sleep doctors at Guys and St Thomas's the other day who were amazing, inspirational. And they were talking to us about, uh, not training your brain to think that your bed is the place that you play games on your computer or check your emails or do watch videos or whatever because a bit like the Pavlovian reflex with the dogs salivating at the sound of the bell, if you get into bed and your brain is trained to think, oh, here's where I watch the telly and, you know, catch up with the latest episode of Killing Eve or whatever it is, you're not going to be in the right frame of mind. So they suggested that you take all of those activities to a little comfy nest somewhere. So if you're living in one room, you know, let's face it, a lot of people trapped in the lockdown in very small environments with not much choice of where they do things, um, to try and make a little nest somewhere with pillows and a blanket. And then when you feel drowsy, you go to your bed. So your brain goes, oh, this is where I sleep. Um, and this is all part of a technique called CBT for insomnia. So cognitive behavioral therapy for insomnia seems to be the really good way of retraining the behaviors and looking at what you're doing that's giving your body the signals to stay awake rather than to go to sleep. So I think there's a lot that that can be done. But fixing the waking up time seemed to be also very key. So we sometimes think, well, I've got to go to bed at the same time, but actually making yourself get up in the morning and getting out into the daylight and getting some uh signals to your brain that it is now daytime because of course, if you stay in a dark place the whole day, your brain is very confused whether it's day or night. Um, and then um, spending some time winding down for that hour before you are going to try and sleep. So you're not doing rushing around and getting, you don't do your exercise just before you're going to get into bed, for example. So lots of little tricks that can make your sleep quality a lot better. And that always helps with migraine, I think. It's it's a but not just about the quantity of the sleep, it's about the restorative nature of the sleep because we know there's a system in the brain called the glymphatic system. You have to be asleep for that to clear out the toxins from your thinking and activities that your brain's been doing through the night. So you do need to look after that as well, I think. It's very important. Yeah.
Dr Rupy: I'm getting the impression that with a lot of these things, it's um, routine and consistency. So, you know, if you're getting up at a certain amount, a certain time a day, you're exposing yourself to natural light, you're resetting your circadian rhythm every day and you're getting into that sort of pattern. Um, that's brilliant. And I'm glad you picked, you made a point about the glymphatic system and the quality of your sleep. I've uh, been using an Oura ring um, for a couple of years now just because I'm fascinated by tracking. Um, and just to see what impact certain activities have on my sleep. And I know that if I exercise or if I have more than a glass of wine before I go to bed, my sleep quality massively disrupted. Um, and even though sleep tracking devices aren't fantastically accurate at all, it can give you a picture of trends. And so just that insight for me personally, that's been quite um, quite good for my behavior change actually. Uh, and and definitely improve my sleep quality. Um, you mentioned CBT, which is a beautiful segue into, it's almost like this is scripted. It's a beautiful segue into stress management, um, and CBT obviously has multiple uses, but uh, I I was interested to to learn about its impact on on migraine sufferers.
Dr Jessica Briscoe: Yeah, I mean, um, stress, I always think stress gets a very bad name in migraine because I think a lot of people blame migraine on stress and it's just one of the many factors. Actually any emotion can do it. And actually if you've got high levels of stress all the time, you're less likely to, when your stress levels are high, you're less likely to be having lots of migraines. It's when they're dipping up and down that the problem occurs and that's largely a hormonal response of a cortisol um, sort of response. Um, there is, there is actually very good evidence for CBT in in all types of pain, but it really can be helpful in in um, in migraine management, particularly where people have um, coexisting anxiety or depression. And if people have, people have chronic, any kind of chronic pain condition, the the likelihood of having coexisting anxiety and depression is high because it's, it's awful having, having migraines all the time, um, and not being able to do your usual things. And CBT can be really, really useful for that. So it can be useful in actually how to manage the pain itself, but also how to to deal with the stress levels you're having, manage your anxiety, manage your um, anxiety symptoms and sort of retrain the brain so that you're, you're less likely to to go that way. Um, so I'm, I'm a big fan of CBT for most things, I have to say. I sort of, I sort of feel like everybody should have CBT at one point in their life whether or not they have any kind of problems. I just think it would be quite useful for life management. Um, but actually I, I'm often um, advising people to um, to to self-refer or try CBT for their for their migraines.
Dr Katy Munro: I think the other one that we often recommend is mindfulness as well and meditation and uh, you know, or yoga breathing or simple relaxation breathing techniques. Any of those kind of places where you can learn how to or practice, because I do think you have to practice some of these things to get good at them. And it's practice just to focus on now, what's happening now and uh, and that calming effect of noticing, you know, what's around you, what's within you, what your body's feeling like, uh, seems to, I mean, they've done some studies on people having scans while they're doing mindfulness and it does seem that that quiets down those activated pain areas in the brain. And so, but people, people will sometimes say, well, I can't do it because my brain starts chattering at me and, and of course that's what everybody's brain does because as soon as you're sitting quietly, your brain starts throwing up all sorts of little thoughts and and things which you can either fix on and go, oh yes, what shall I have to dinner tonight? Or you can, or you can go, oh no, hang on, I'm meant to be looking and thinking about my breathing and concentrating. So it does take practice, but I think it, it's part of the solution. I think why stress gets a bad name is because people feel dismissed. Um, and when they go and they talk to their doctors about, I'm having these terrible headaches or I'm having, you know, I think it might be migraine, they say, well, it's probably stress, which means go away and and, you know, deal with it, cope better. And it's very judge, it can feel very judgmental. It's probably not meant that way, but I think people feel like they've been told, well, you're not a strong enough person, go away and and pull yourself together. And that's really harmful, I think.
Dr Jessica Briscoe: I think that harks back to the, so the, we've done a lot of reading on history of migraines as well. And um, there, I mean, in the, in before, I think 1989, it was in the um, DSM-4, which is the psychiatric, um, for for listeners who don't know, it's the psychiatric, um, uh, list of um, of of medical problems, so of psychiatric problems, not a medical problem. So migraine was always thought of as the housewives disease. And I actually had a patient, um, who sadly still gets migraines even though she's in her 80s, and I saw her a few months ago and she said, I was told, um, when I, I had to, I had to ask my neighbor to look after my, to pick my children up from school one day. And she said, and that stuck with me. And then my doctor told me it was the housewives ailment. And I thought, oh, you know, and I think there is still a lot of that that's carried forward. And I think that's why when people say, oh, it's stress, it, it's, it's that sort of, oh, yeah, I mean, if you just calmed down or if you just, you know, just bucked up your ideas, then you'd be fine. And it's, it's far more complicated than that.
Dr Katy Munro: In the Victorian times, I think it was, it was divided into, um, men who got migraine were the clever ones, the cerebral ones, you know, the very intellectual types, and women who got migraine were the flaky ones who fainted and were pathetic. And I think that stigma has persisted and I think that's part of why we really struggle to get it taken notice of when you think that it's considered to be, you're right up there in the, in the top disabling conditions in the world. Um, and the years lived with disability, you know, it's the second most common cause of years lived with disability in, in all the gradings, the WHO gradings. But yet it's not recognized properly and people, you know, get dismissed and get this kind of, this feeling of shame or guilt that they've got migraine. And so they, going back to what we were talking about earlier about, you know, going to work and not letting on, people pitch up at work and there's this thing called presenteeism where they, they go to work but they've got a migraine so they're not working to their full potential when they should actually be at home caring for their migraine, getting rid of it and then going back into work at 100%. And that, and there are so many migraine sufferers push through. I've done it myself. I've sat through doing GP surgeries, sitting very, very still. And as soon as the patients have finished, I stand and go, oh gosh, you know, I don't tend to do that now. I've learned better, but.
Dr Rupy: Yeah. That's terrible. I was just going to say, like, the word stress itself is just this huge umbrella term that has so many nuances to it. It's kind of, um, it's very vague, I think. And I think it deserves a lot more sort of, um, refinement in the way we use it as well, because like you said, it's kind of like a, a flagrant use of the term, oh, it's, it's just stress or it's probably stress. So, you know, I can't help with that. You need to go sort it out yourself. And I think all the things that you've just talked about here are ways in which we can, you know, improve people's resilience and tolerance to the different emotional stresses that we all suffer on a, on a daily basis. Um, one thing I, I learned about from the podcast, a couple of podcasts I listened to was this notion of expressive writing. I haven't come across this before, to be honest. Could you tell me a bit about expressive writing?
Dr Jessica Briscoe: So we both have different ideas about how long and how often you're supposed to do it for. Um, but essentially it's, I don't know where I, I for some reason had it in my head that you have to do three consecutive days for 30 minutes. I don't think the amount of time, I think you just have to write down whatever comes into your head for a certain amount of time with pen and paper, cannot be typed. Um, whatever comes into your head and then you throw it away. You don't then reabsorb it and reflect on it and sort of navel gaze essentially at it. It's, it's trying to get that emotional pain out of your head. And it does take time. So again, it's not that you'll do this one week and you'll suddenly think, oh, I'm better. It, they say it actually takes at least nine months of, of persistently doing this. And I think the key is doing it, um, I don't think it probably has to be three consecutive days. I think it has to just be a regular, a period and at least 20 minute period of time of writing whatever comes into your head down and getting rid of it just because the the idea that this emotional pain and physical pain are are linked and actually hopefully getting rid of some of the emotional pain will help with the, the chronic pain to relieve that.
Dr Katy Munro: I came across it when I went on a conference about chronic pain and it was run by the SERPA organization, which is S I R P A. And um, Georgie Oldfield, who's a physio who organized that, had had got these speakers and one of them was talking about that he was a back surgeon and an orthopedic surgeon in the states and he has taken his patients who need back surgery and insisted that each of them write for 20 minutes a day for four days before they're allowed to have back surgery. And he had really decimated his surgical practice because their pain actually eased. And the idea behind it was that they were unlocking uh childhood traumas and experiences that were locking them into that pain cycle. And I think it's again, it's something I think is fascinating, you know, that that the brain is all joined up. There's no section that's pain and a section that's depression and a section that's, you know, it's, it's all joined up. And so it's makes sense that emotions can affect pain. It doesn't mean you're inventing it, it means that the neurochemicals all overlap. And by, I sat and tried to do this expressive writing and sitting and writing everything that you can think of for 20, it's quite hard to do. But if you persist at, because you stop and you think, what am I going to write next? And that's when the magic happens because then things begin to unlock and then you start to write things you didn't even know were deep and inside and um, so I think it's a very interesting technique, but getting people to do it is quite tricky, I've found.
Dr Jessica Briscoe: And keep doing it. And keep doing it. Yeah. I had, I did have a patient that was very, I saw her another lady, I think she was 78 last week. She was a lovely lady. And she's very, and she's learned how to paint in the last two years and she's learned how to play the piano. And she was very excited about expressive writing because she writes her own poetry and she's found that helpful. So I think it's also sometimes about actually not everybody's going to get on with it. So choosing the people who who you think will benefit from it or if um, because otherwise it's that age old, oh, you're you're trying to make someone to do something that they're just not going to benefit from or enjoy and it's possibly going to make things harder. So, yeah, it's it's fascinating.
Dr Rupy: Well, I'm definitely going to try that. I I I mean, that sounds fascinating. And I can imagine, you know, putting a 20 minute timer on and just writing whatever. And and just for clarification, do you write shorthand? Do you write whatever you like? It doesn't matter. Just just write freely. And then but then some people say, oh, and then what do I do with it? And I said, then you get rid of it. You don't re, the idea is not to ruminate on it. The idea is to detox onto paper. Um, and then get rid of it. So, yeah.
Dr Katy Munro: I mean, we often suggest a range of things. So some people find yoga is really helpful. Some people find that the tai chi and that sort of smooth pattern of moving is really helpful. Um, other people will do Pilates because that can be quite helpful for any sort of neck and postural issues. Um, and some people have tried osteopathy or acupuncture. So we're, we're very happy for people to find the thing that works for them. Uh, but it's kind of nudging them towards those options that they can use for their own self-management, I think is what we try and do at the center really.
Dr Rupy: Brilliant. And and again, a lovely, lovely segue into one of the other things I wanted to talk about, which is exercise. And I I imagine from a glucose disposal point of view, like thinking about it mechanically here, you know, skeletal muscle is one of the biggest glucose disposal mechanisms. So it sort of stands to reason that if you have good long lean muscles that are able to stabilize your sugar, um, that can be beneficial potentially in migraine management. But of course, it really depends on the individual and the types of exercise that they want to engage in. Um, are there any particular types of exercise that you guys recommend? And also the hurdle of suggesting to someone who has chronic migraines, you know what, you need to go out and exercise now. I mean, that can be a huge obstacle in itself.
Dr Jessica Briscoe: So this is one of my favorite subjects. I love talking about exercise and migraine. Um, so, um, essentially there are a few things to think about. So some people can find that their migraines are triggered by exercise and we talk about it a lot with children as well when they're doing sports and things like that. Um, and that as you said, I mean, again, it's to do with the glucose levels. people, I think if people are doing high intensity forms of exercise, they can get um a cortisol, they can get a a boost in cortisol levels, um so that's another variation which can trigger a migraine. And then dehydration as well. So, um, I think it's I always say to people, just be mindful that you've been hydrated and you're you're fueled before, during and after exercise. So that's the first thing to consider. So I'm very, I'm very pro exercise generally, but for migraine, I do think it's quite helpful. Then you have to think about what forms of exercise you're doing. So I have some patients who can't run because that pounding on the street, they find that it it shakes their head and they will get irritation or especially with chronic migraines and that motion sensitivity is too much. I had one patient who found rock climbing really useful because he could just keep his head in one position and it was less sort of moving around. Vestibular migraine patients often hate yoga because inversions will make them feel, um, feel, uh, give them vertigo. Um, and then there's this other, um, my other favorite topic, which is cold water swimming. So this is the thing that I tend to advise people who are really struggling. So there is evidence that, um, open water swimming can actually relieve symptoms, particularly when you're in the water. And that's for two reasons. Um, it's the cold, so that biofeedback from actually having cold taking pain away. So, um, it's I suppose I always think of it like a distraction technique for the nerves. So it's taking redirecting the nerve fibers. So cold immersion, the swimming itself, the actual exercise seems to also relieve symptoms. Um, so I do have one or two patients that try and go out to the sea every day, rain or shine. If they've got chronic migraine, they say that the only thing that will get rid of their pain at the time. Um, so I that's I swimming, I think is possibly another thing that can be quite helpful, but it seems to be particularly open water swimming that's the thing.
Dr Rupy: I find that fascinating because I've I've I've read some and and obviously I haven't read as much as you guys, but I've read some uh um papers stating that some of the utility of supplements is based on um defective mitochondrial energy production. And cold water swimming is a really good way of boosting mitochondrial biogenesis. Um, so I wonder if there's a sort of like a a parallel with that and perhaps that's one of the mechanisms of action behind cold water swimming. That's fascinating.
Dr Katy Munro: I'm quite a fan. I took a dip in the sea in Cornwall on Christmas day and had a bit of a migraine beforehand and I came out and I was so buzzing and tingling. It was amazing. But sadly the migraine came back later on as I was cooking the Christmas dinner. You can't stay in the, you can't stay in the sea all day sadly. The other thing I was going to say about exercise types is I find if people have got a lot of, if they're posturally very head forward and round shouldered, they tend to have a lot of tension in the muscles of the the trapezius muscles and and then even the deltoid muscles. And so if they're doing a lot of weightlifting in the gym, that can actually aggravate or if they're doing breaststroke swimming with their head up out of the water. So I think look, we do need to look a little bit at posture and and because of the bidirectional influence of neck, the neck and shoulders send messages to the brain that can trigger migraine, but also the other way around. So migraine can trigger neck and shoulder pain. And I do sometimes turn people sideways and look at them and get them to put their head in the correct anatomical position and and roll their shoulders back and they they sort of, um, but you need somebody to help you with guidance on uh the right muscle exercises to do with that. So physios or osteopaths can be really quite helpful with that. But yeah, I agree with Jess about the eating and drinking around exercise, especially kids. We I had a little boy who we'd largely managed his migraine and he'd much, much better. His mom came back and said, it's always this particular day he gets it. And it was always the day after he had football training the night before after school. And he always got a migraine the next day. And so we put in more snacks. I haven't seen him since. So I'm assuming he's better. Good sign.
Dr Rupy: Yeah. Just a word about menopause. Uh, so menopause, there are lots of different products as you know, which are used for HRT. But because for migraine, we're trying to keep the even blood hormone levels, the best form of HRT for people suffering from migraine in their perimenopause, that's the time around the change or in the menopause is the transdermal through the skin methods. So patches are ideal. You just put one on and you change it usually twice a week. And uh, if you have still having periods, you obviously need to have the estrogen and the progesterone in a combined patch. And that can just nicely smooth the level out. It seems to be the falling level of estrogen that triggers the migraine aggravation. And so when people are going through the menopause, of course, their estrogen levels will vary and fluctuate quite a lot. They don't just smoothly decline. Um, so they can go down a bit, up a bit. And so by putting some HRT in there and just leaving, raising that estrogen level so that it's more consistent throughout the month, um, some people find that's really, really helpful. I mean, I think we, we would both be big fans of HRT. I think we think it's underused in general and people shouldn't be scared of it. They need to get good advice and that may be from their GP if their GP has a special interest in menopause or it may be from a specialist menopause clinic. Uh, and there are quite a number of those available, but there's a British menopause society has a leaflet on their website about menopause and migraine that we often, I often direct people to that because it gives them a good range of choices. So, yeah, there's lots to talk about with hormones.
Dr Rupy: Yeah, I'll make sure to link that in the show notes for sure. And we we've actually done a podcast all about the menopause and the menopause treatments as well with a friend of mine who's a GP and a specialist um in uh female hormones as well. So that's, that's, that's brilliant. Um, this has been great. I feel like I've learned so much about migraines and I really think this is going to be empowering for a lot of people suffering from them. Um, your podcast goes into a lot more depth across a range of different headache types, like you you guys talked about at the start, as well as specific instances. And I noticed that you've done one recently that I haven't listened to about COVID and uh, and migraines as well. So I'll definitely direct people to to that podcast too in particular. Um, but I just want to say thank you um for the incredible work you guys are doing, the attention you're bringing to this highly, um, highly important subject that affects so many people. And that's why I was super keen to speak to you guys about it. And I and I promise you I will cook with you too. Yeah. Well, we're witnesses for each other now, so we're going to hold you to that. Yeah. Exactly. That's great.
