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Welcome to Tales from the Cortex Stories from Inside the Brain, a story-driven neurology podcast that takes you inside the mysteries of the human brain.
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I'm neurologist Dr.
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Andrew Macelli, and this is episode 2 Between the Notes.
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Part 1 The Wrong Note Jasmine knew the piano piece well enough that she no longer needed the sheet music.
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Her fingers moved across the keys almost automatically, right hand dictating the melody and left hand quietly answering below it.
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She was seventeen years old, and the piano was the one place where she rarely felt uncertain.
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Tonight though, something was wrong.
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It began behind her right eye, not pain exactly, but pressure.
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She kept playing.
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She had learned to do that over the past year.
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The headaches had started occasionally, usually after a long day at school, sometimes after she stayed up late studying, sometimes around her period, but most of the time for no obvious reason at all.
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She struck the next chord, the pressure pulsed.
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Once, then again, she continued.
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The next note sounded strangely loud.
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She hesitated.
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She pressed another key.
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It seemed to explode through the room.
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She stopped playing.
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For a moment she sat perfectly still.
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The pressure behind her eye was changing.
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It was no longer pressure, it was a pounding pain, a deep rhythmic pounding.
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She could feel her heartbeat inside her temple.
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Thump, thump, thump.
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Her mother called from downstairs, Jasmine, it's dinner time.
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Even her mother's voice hurt.
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She closed the piano lid.
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I'm coming.
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She didn't.
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She stayed on the bench with her eyes closed.
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The light above the piano suddenly seemed impossibly bright.
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She switched it off.
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At dinner, Jasmine barely touched her food.
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Her father noticed first.
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Headache again?
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She nodded.
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You've been getting a lot of those.
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I know.
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Her mother looked over.
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Did you drink enough water today?
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I think so.
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How much sleep did you get?
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Jasmine shrugged.
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Her father smiled.
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You're seventeen and you're studying all the time, you're practicing piano, you're staring at screens.
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Then came the sentence Jasmine would hear again and again.
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It's just a headache.
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Just Jasmine hated that word.
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Because there was nothing just about lying in a dark room with a pillow over your head because the sound of someone closing a kitchen cupboard downstairs felt like it was happening inside your skull.
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The progressive nausea and then vomiting.
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She hated the vomiting most, but strangely felt better after it was over.
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There was nothing just about wondering whether accepting an invitation to a friend's birthday was worth the risk of being trapped somewhere where the pain started.
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And there was nothing just about the fear that came every time she felt that first familiar pressure behind her eye, because once it started, she knew where it would end.
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Eventually her parents took her to their family doctor.
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The appointment lasted about fifteen minutes.
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Jasmine described the headaches, throbbing, sometimes one sided, nausea, the light bothered her, but sound was worse, and they would last hours.
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The doctor quickly examined her.
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Everything was normal.
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Jasmine waited.
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She had been expecting something more after that, a test, a prescription, a plan.
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Instead, the doctor told her to take Advil or Talno when the headaches occurred and to get better sleep and would try to reduce her screen time.
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Jasmine almost felt embarrassed.
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Maybe her parents had been right.
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Maybe she was making too much of this, so she followed the advice.
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At first, it worked.
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Two Advil, a dark bedroom, an hour of sleep, and the headaches eventually faded.
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It was like discovering a secret exit.
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So the next time the pressure appeared behind her eye, she reached for the bottle immediately, then again the following week, and then twice the week after that.
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Soon Jasmine kept Advil in her backpack, Talnell in the bathroom, more in her piano bag.
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She began checking for medication before leaving the house the way
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other people checked for their phones.
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Keys, wallet, phone, Advil.
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Because the headaches were changing her, not just when they happened, between them.
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On headache free days, Jasmine would sometimes stop in the middle of class because she thought she felt something behind her eye.
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Is that it?
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She would wait.
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Nothing.
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Then twenty minutes later, was that a pulse?
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She started making calculations.
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I have piano practice tonight.
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I have an exam tomorrow.
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What if I get one of them?
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The migraines had found a way to occupy days when she didn't even have one.
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The anticipation was eating at her.
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Part two The Night It Changed It happened on a Thursday.
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Jasmine had an English presentation that morning and a chemistry test after lunch.
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Except she never ate lunch.
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At twelve forty she was still reviewing notes.
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At one hundred ten in the afternoon, the chemistry test began.
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Halfway through Jasmine noticed the familiar pressure behind her right eye.
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Not now.
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She kept writing, the pressure pulsed.
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She reached into her backpack after class and swallowed two Advil with water.
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Usually that was enough.
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But this time it wasn't.
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By the time she arrived home the headache was pounding.
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She went directly upstairs, curtains closed, lights off, phone face down.
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At six o'clock her mother opened the bedroom door.
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Jasmine, please close it.
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Her mother stopped.
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Jasmine had one hand pressed against the side of her head.
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I took Advil.
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When?
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Hours ago.
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Tritalno.
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I did.
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Her mother stepped closer.
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Jasmine felt nauseated.
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She closed her eyes.
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Another wave of pain surged through her head.
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This one frightened her.
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Not because it was instantaneous, not because she collapsed, but because it kept getting worse.
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Seven o'clock, eight o'clock, nine, every hour
seemed to add another layer of pain, and eventually the thought Jasmine had been trying not to think became impossible to ignore.
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What if this isn't a migraine?
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She had never had a headache this bad before.
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Around ten fifteen in the evening, her father picked up the keys to the car.
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We're going to the hospital.
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The Emergency Department The Emergency Department waiting room was full.
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Jasmine sat between her parents beneath fluorescent lights that seemed specifically designed to make headaches worse.
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Someone was coughing, a child was crying, a stretcher rattled across the floor.
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Every sound amplified her pain.
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The monitors kept beeping.
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Jasmine closed her eyes.
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Thirty minutes passed, then an hour, then another, and as she waited her fear began to change.
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At home she had wanted the pain to stop.
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Here she wanted an explanation.
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She watched people being called ahead of her.
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She understood they were probably sicker, but that didn't make the waiting easier.
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Her mind filled the silence, a brain tumor, a bleed, an aneurysm.
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She knew almost nothing about any of them, that made them worse.
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She had tried to avoid Googling or using Chat GPT to get more answers.
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Finally, her name was called.
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The emergency physician asked questions, examined her eyes, tested her grip strength, and had her walk.
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Everything was normal.
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She was treated with the usual migraine cocktail of cotorlac, metaclopromide, fluids, and gravel.
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But because the headache was more severe than usual and the family was worried, a CT scan of the brain was arranged.
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Jasmine lay on the CT table staring upward.
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The machine began to move, so she shut her eyes and tried to breathe.
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For the first time that night she felt relieved.
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They were finally looking inside her head.
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Surely once they had a picture, they would know.
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The medications were starting to work.
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Slowly the pounding softened.
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Nine out of ten became seven.
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Seven became five.
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Eventually Jasmine opened her eyes without immediately wanting to close them again.
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She was exhausted and relieved.
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The emergency physician came back and explained that the CT was normal and that she could go home to follow up with her family doctor.
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At three forty in the morning, Jasmine climbed into her own bed.
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The headache wasn't gone, but it was quiet enough to try to sleep.
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Before she closed her eyes, one thought returned.
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If the CT was normal, why am I still getting these headaches?
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Part three The Scan At her follow up appointment, Jasmine's family doctor ordered an MRI of the brain.
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We're covering our basis since these headaches seem to be getting worse.
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The intention was reassuring, but to Jasmine, ordering an MRI meant something else.
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It meant there was something worth looking for.
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What exactly are you looking for?
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she asked.
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The doctor replied, Probably nothing, it's just to make sure.
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Make sure of what?
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she thought.
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She didn't ask.
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The MRI was booked for November, six months from now, and so began the waiting.
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At first Jasmine thought the hardest part would be waiting for the scan.
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It wasn't.
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The hardest part was having migraines while waiting for the scan because every headache now carried a question with it.
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During math class, what if there's something there?
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During piano practice?
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What if this is getting worse?
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At two o'clock in the morning after waking up with another headache, do brain tumors cause headaches at night?
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She couldn't stop the urge to search online, then regretted it instantly.
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She promised herself she wouldn't search again, then opened another tab five minutes later.
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Meanwhile, the migraines became more frequent.
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Her family doctor prescribed Suma Triptan twenty five milligrams.
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It seemed like the treatment she'd hoped for.
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Her stomach was sore from Advil, but it worked.
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Would this work better?
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Sometimes it helped, sometimes it didn't.
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She actually liked Advil better and sometimes added talent to the mix.
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Sometimes she took gravol, allowing her to sleep it off without having to throw up, but her day was shot.
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She stopped counting headache days, she counted headache free days instead.
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Those were becoming easier to count.
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The MRI report six months later, Jasmine finally lay inside the MRI scanner.
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The technologist placed the head coil around her.
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Try not to move.
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The table slid inward and the machine started.
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Bang, bang, bang.
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Jasmine stared at the plastic inches above her face.
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She tried to think about playing the piano.
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Instead, she thought about what she read online and the possibility of a brain tumor.
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Aneurysms.
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What if they find something?
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What if she's never able to play the piano again?
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Then another thought.
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Somehow worse.
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What if they don't?
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Because if the MRI was normal, what did that mean about the pain that had taken over her life?
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The scan ended.
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Jasmine sat up.
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Did you see anything?
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she asked the technologist.
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You'll have to discuss the results with your doctor.
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Of course, more waiting.
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The MRI report appeared electronically before Jasmine's next appointment.
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Her father found it first.
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There were several lines of ordinary medical language, then one sentence stopped him.
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Scattered supratentorial white matter T two, flare hyperintense foci.
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Differential considerations include changes associated with migraine, demyelination, inflammatory vasculitic processes, among other etiologies.
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Clinical correlation is recommended along with neurology consultation.
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Recommend repeat MRI brain in six to twelve months to ensure stability.
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He read it twice.
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Then called Jasmine's mother.
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Then Jasmine.
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What does demyelation mean?
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Nobody knew.
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Her father copied the report into Chat GBT and asked it to explain the findings.
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The response explained that white matter lesions could have many causes, including benign and incidental causes, migraine, inflammatory conditions, demyelating disease, and other possibilities, and that the findings had to be interpreted by the doctor based on her symptoms.
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Jasmine barely noticed the words benign or migraine.
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She noticed one possibility, demyelinating disease.
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She tried to sound out the word as she typed it into the search bar.
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Multiple sclerosis appeared, then vasculitis.
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Her eyes went wide.
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She spent the next four hours going down a rabbit hole of fear.
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That night, Jasmine didn't have a migraine.
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She couldn't sleep anyway.
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She lay in bed staring at the ceiling.
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There were spots in her brain.
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That is how she understood it.
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Spots.
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And nobody could tell her what they meant.
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The referral.
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At the family doctor's office they reviewed the MRI report.
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Her doctor tried to be careful.
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These findings can certainly occur with migraine, Jasmine nodded.
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But because the radiologist has mentioned other possibilities, I'd like a neurologist to review everything just to be sure.
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There it was again.
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Other possibilities.
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Something sinister.
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Like MS multiple sclerosis?
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Jasmine asked.
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It's probably not that.
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Probably.
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Jasmine had begun to hate that word almost as much as just.
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A neurology referral was sent.
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The appointment arrived several weeks later.
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Jasmine opened the letter.
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She stared at the date six months from now.
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Part four six months later.
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Six months is a long time when you're seventeen years old.
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Six months of calculus feels like a decade long penance.
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When you're waiting to hear back from the university of your choice, it feels like an impossibility.
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Every mailed letter, a torture device.
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None of that compared to waiting when you think there might be something seriously wrong with your brain.
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Jasmine's migraines continued, then worsened in both severity and frequency.
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She started waking each morning and assessing her head before she even opened her eyes.
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Is it there?
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Sometimes she couldn't tell.
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--> 00:14:33.600
The fear itself seemed to become a symptom.
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She took sumatriptan, then Advil, then Talanol, sometimes all three together.
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Sometimes she took medication early because she was terrified of what would happen if she waited.
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The medication that had once represented an escape now became part of the routine.
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Headache, medication, relief.
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Headache, medication, less relief.
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Another headache, more medication.
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By spring, Jasmine was missing school, her piano practice became inconsistent, she stopped committing to plans with friends.
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She hated saying I have a migraine.
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She could hear her father's old words every time she said it.
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It's just a headache.
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Except now her family wasn't dismissive, now they were worried too.
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Her mother watched her closely.
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Her father occasionally asked whether the neurology office had called with a cancellation.
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They hadn't.
00:15:26.879 --> 00:15:32.399
Jasmine's world slowly reorganized itself around a future appointment circled in the calendar.
00:15:32.639 --> 00:15:35.919
Maybe the neurologist would finally tell her what was wrong.
00:15:36.159 --> 00:15:39.679
Or maybe the neurologist would confirm exactly what she feared.
00:15:40.879 --> 00:15:41.759
Part five.
00:15:42.000 --> 00:15:46.720
The Neurology Consultation Hi Jasmine, I'm the neurologist.
00:15:47.120 --> 00:15:52.080
He asked her specific questions that other physicians hadn't, like, are you on birth control?
00:15:52.320 --> 00:15:56.000
How long from when the headache starts does it reach maximum intensity?
00:15:56.240 --> 00:15:58.879
How it felt before and after the headache?
00:15:59.039 --> 00:16:01.919
How it was interfering with her school and piano.
00:16:02.080 --> 00:16:04.000
He really wanted to get a sense of the headaches.
00:16:04.240 --> 00:16:07.840
He wanted to know when they started and how they had changed over the year.
00:16:08.000 --> 00:16:11.759
He was detailed about her sleep, eating habits, and routine.
00:16:12.159 --> 00:16:15.120
How many days a month are you completely headache free?
00:16:15.360 --> 00:16:16.080
He asked.
00:16:16.399 --> 00:16:17.600
Jasmine paused.
00:16:17.840 --> 00:16:19.919
Maybe uh five.
00:16:20.720 --> 00:16:26.480
He wanted to clarify how much Talnal, Advil, and Sumatriptin she was taking per month.
00:16:26.960 --> 00:16:33.279
After about fifteen minutes of questions, he had a look on his face like he knew what was going on and what to do next.
00:16:33.519 --> 00:16:40.639
He took her blood pressure, completed a focus neurological examination, and looked at the back of her eye with a bright light.
00:16:40.879 --> 00:16:46.879
He reviewed the blood work with specific focus on vitamin B twelve, iron studies, and thyroid.
00:16:47.120 --> 00:16:49.600
Finally, he pulled up the MRI.
00:16:49.840 --> 00:16:53.200
He looked at the images himself, scrolling in silence.
00:16:53.519 --> 00:16:55.360
Jasmine's stomach tightened.
00:16:55.600 --> 00:16:56.480
This was it.
00:16:56.720 --> 00:17:01.120
All this waiting condensed into a few seconds while images appeared on the screen.
00:17:01.679 --> 00:17:03.600
The neurologist scrolled through them.
00:17:03.919 --> 00:17:04.720
He stopped.
00:17:05.200 --> 00:17:07.039
Jasmine watched his face.
00:17:07.359 --> 00:17:08.240
Nothing.
00:17:08.480 --> 00:17:09.599
Another image.
00:17:09.839 --> 00:17:10.480
Another.
00:17:10.720 --> 00:17:13.599
He leaned closer at the screen, then sat back.
00:17:14.160 --> 00:17:16.400
I'm not concerned about this MRI.
00:17:16.960 --> 00:17:19.279
Jasmine wasn't sure she had heard correctly.
00:17:19.519 --> 00:17:20.720
He continued on.
00:17:20.960 --> 00:17:23.359
These are tiny nonspecific changes.
00:17:23.599 --> 00:17:25.519
We see findings like this commonly.
00:17:25.680 --> 00:17:33.359
In someone with your history and no worrisome neurological symptoms, these brain changes are related to migraine or another nonspecific cause.
00:17:33.599 --> 00:17:40.400
You have no clinical symptoms of another neurological condition, and the way these look are not reflective of multiple sclerosis.
00:17:40.559 --> 00:17:43.200
Most importantly, they don't explain your headaches.
00:17:43.839 --> 00:17:48.799
He could tell how anxious she was about this report and tried his best to reassure her.
00:17:49.039 --> 00:17:56.559
Unfortunately, this was a common situation for the neurologist, and he reflected on how frequent he was having the same conversation.
00:17:57.519 --> 00:17:58.480
Silence.
00:17:59.039 --> 00:18:00.319
Her father leaned forward.
00:18:00.480 --> 00:18:02.480
So there's nothing wrong with her brain?
00:18:02.720 --> 00:18:06.799
There's nothing on this MRI that worries me, says the neurologist.
00:18:07.039 --> 00:18:09.839
Jasmine felt something loosen inside her chest.
00:18:10.160 --> 00:18:22.079
Six months six months of imagining something growing, spreading, or attacking her brain, six months of interpreting every strange sensation as evidence, six months of waiting for that sentence.
00:18:22.319 --> 00:18:24.000
The neurologist continued.
00:18:24.319 --> 00:18:26.480
But there is something we need to deal with.
00:18:26.799 --> 00:18:28.240
Jasmine looked up.
00:18:28.559 --> 00:18:30.400
How to treat your migraines?
00:18:31.920 --> 00:18:33.279
The treatment plan.
00:18:33.839 --> 00:18:36.640
The neurologist pulled a piece of paper toward him.
00:18:36.880 --> 00:18:43.759
You have chronic migraine without aura, and on top of that you have likely developed what we call medication overuse headache.
00:18:44.000 --> 00:18:45.200
Jasmine frowned.
00:18:45.359 --> 00:18:47.279
From the migraine medication?
00:18:47.519 --> 00:18:51.759
From needing acute medication too frequently, it's a very common trap.
00:18:52.000 --> 00:18:54.720
You get more headaches, so you take more medication.
00:18:54.880 --> 00:19:00.880
But once certain acute treatments are being used too frequently, they can actually help perpetuate the headache cycle.
00:19:01.200 --> 00:19:02.720
He added more directly.
00:19:02.960 --> 00:19:04.880
It's certainly not your fault.
00:19:05.200 --> 00:19:06.799
Jasmine stared at him.
00:19:07.119 --> 00:19:09.359
So the medication is causing my headaches?
00:19:09.839 --> 00:19:10.880
Not exactly.
00:19:11.119 --> 00:19:17.839
You have migraine, that's the underlying disorder, but the frequent use of medications can potentially make things worse.
00:19:18.160 --> 00:19:23.440
For the first time someone drew the whole picture for her in simple terms she could understand.
00:19:23.759 --> 00:19:27.759
And then the neurologist had a plan that nobody had said during the previous year.
00:19:28.079 --> 00:19:29.519
Here's your treatment plan.
00:19:29.680 --> 00:19:38.319
We're going to optimize your lifestyle, add in migraine specific vitamins, alter your acute rescue plan, and start a prevention strategy.
00:19:39.039 --> 00:19:43.839
Not another scan, hopefully not another emergency department visit.
00:19:44.160 --> 00:19:45.119
Prevention.
00:19:47.119 --> 00:19:48.079
Part six.
00:19:48.319 --> 00:19:49.519
Taking back control.
00:19:50.319 --> 00:19:57.759
They discussed regular meals, especially breakfast with the addition of protein, sleep, exercise, and hydration.
00:19:58.000 --> 00:20:02.400
The neurologist explains that none of these meant jasmine had caused her migraines.
00:20:02.559 --> 00:20:07.279
They were ways of making a migraine prone brain less vulnerable to attacks.
00:20:07.519 --> 00:20:17.839
They discussed evidence-based supplements, sometimes used for migraine prevention, such as magnesium, vitamin B2, also known as riboflavin, and coenzyme Q10.
00:20:18.000 --> 00:20:20.480
He also recommended vitamin D daily.
00:20:20.720 --> 00:20:27.920
For your acute rescue medication, I want you to take Sumatry 10 100 milligrams at the onset of more significant headaches.
00:20:28.079 --> 00:20:31.599
This was a higher dose than her family physician prescribed initially.
00:20:31.839 --> 00:20:38.000
The earlier you treat, the more likely you are to be successful, but I want you to keep track of how often you're using it.
00:20:38.240 --> 00:20:41.599
I would like you to use it less than nine days of the month.
00:20:41.920 --> 00:20:44.480
Then they discussed prescription prevention.
00:20:44.799 --> 00:20:51.200
Because you're having headaches this frequently, he explained, I don't want us relying only on medication when the headache starts.
00:20:51.440 --> 00:20:54.960
I want to reduce how often the headaches are
happening in the first place.
00:20:55.200 --> 00:20:58.079
This requires a daily prevention medication.
00:20:58.319 --> 00:20:59.839
They discussed options.
00:21:00.240 --> 00:21:05.680
Beta blocker, candisartin, or amitriptyline were the preferred options to discuss.
00:21:05.920 --> 00:21:14.319
For Jasmine, they decided together to start a beta blocker called Natalol at a low dose with appropriate monitoring and gradual titration.
00:21:14.480 --> 00:21:20.799
She had no contraindications such as asthma, low blood pressure or heart rate, and no history of heart block.
00:21:21.119 --> 00:21:28.720
Jasmine left the office carrying something she hadn't received from the CT scan or the MRI, a clear, tangible plan.
00:21:28.960 --> 00:21:33.200
He booked a follow-up in three months to give time for the treatment plan to work.
00:21:34.720 --> 00:21:35.680
Part seven.
00:21:35.920 --> 00:21:40.559
Back at the piano Several months later, Jasmine sat at the piano again.
00:21:40.640 --> 00:21:42.559
She placed her fingers on the keys.
00:21:42.720 --> 00:21:54.720
Her migraines weren't gone, that wasn't the ending, there were still difficult days, still attacks, still moments when she felt the first pulse behind her eye and wondered how bad this one would become.
00:21:54.880 --> 00:21:58.480
But they were less frequent now, and something else had changed.
00:21:58.720 --> 00:21:59.759
She understood what was happening.
00:22:00.240 --> 00:22:00.640
Happening.
00:22:00.720 --> 00:22:02.000
She knew what to do.
00:22:02.160 --> 00:22:06.720
The migraine no longer felt like a mysterious warning from somewhere inside her brain.
00:22:06.960 --> 00:22:08.720
She pressed the first key.
00:22:08.960 --> 00:22:09.920
Then the next.
00:22:10.160 --> 00:22:11.759
The melody filled the room.
00:22:11.920 --> 00:22:14.079
Halfway through Jasmine noticed something.
00:22:14.240 --> 00:22:19.680
She wasn't thinking about her head, she was thinking about the music, and she kept playing.
00:22:21.440 --> 00:22:25.839
Jasmine's story illustrates something that's easy to underestimate about migraine.
00:22:26.079 --> 00:22:28.480
Migraine isn't simply a bad headache.
00:22:28.640 --> 00:22:46.640
It's a neurological disorder that can cause substantial disability, and inadequate treatment, especially early in its course, can contribute to a cycle of increasingly frequent headaches, escalating acute medication use, emergency department visits, unnecessary investigations, and tremendous anxiety.
00:22:46.880 --> 00:22:51.279
So let's go back through Jasmine's story and ask what could have been done differently.
00:22:52.559 --> 00:22:54.880
Did Jasmine need brain imaging?
00:22:55.359 --> 00:23:04.000
In a patient with typical migraine history, a normal neurological exam, and no concerning red flags, neuroimaging is often unnecessary.
00:23:04.240 --> 00:23:21.039
Among patients with migraine and a normal neurological exam, the prevalence of significant intracranial
abnormalities on neuroimaging can range anywhere from 0 to 3.1%, and combining this data in a meta-analysis resulted in a prevalence of only 0.18%.
00:23:22.480 --> 00:23:25.519
The diagnosis of migraine is primarily clinical.
00:23:25.680 --> 00:23:29.119
That's important because ordering a test isn't always reassuring.
00:23:29.279 --> 00:23:37.680
In fact, it can lead to incidental findings, with increased anxiety and potentially more unnecessary and sometimes invasive investigations.
00:23:37.920 --> 00:23:42.559
Jasmine's MRI identify tiny, nonspecific white matter hyperintensities.
00:23:42.720 --> 00:23:47.599
Findings like these can be seen in people with migraine and often have no clinical significance.
00:23:47.920 --> 00:23:53.519
But an MRI report has to describe what is visible and may provide a differential diagnosis.
00:23:53.680 --> 00:23:59.680
Words such as demyelination and vasculitis can be terrifying when read without neurological context.
00:24:00.000 --> 00:24:01.680
This is an important distinction.
00:24:01.839 --> 00:24:04.480
An MRI report is not a diagnosis.
00:24:04.720 --> 00:24:12.640
The imaging has to be interpreted alongside the patient's symptoms, examination, and the actual pattern of abnormalities on the scan.
00:24:14.160 --> 00:24:17.359
What went wrong with Jasmine's migraine treatment?
00:24:17.680 --> 00:24:20.640
Early on, Jasmine's treatment plan was actually reasonable.
00:24:20.880 --> 00:24:30.559
Her migraines were infrequent, and for an occasional migraine, an over-the-counter medication such as Advil with Tylenol taken early in the migraine can be perfectly appropriate.
00:24:30.799 --> 00:24:38.960
The problem wasn't necessarily how her migraines were treated at the beginning, the problem was that her treatment never evolved as her migraines did.
00:24:39.279 --> 00:24:49.359
As the attacks became more frequent, more severe, and began interfering with school, piano, and her daily life, she needed a more effective acute or abortive treatment.
00:24:49.519 --> 00:24:52.240
This is where medications like tryptents come in.
00:24:52.400 --> 00:24:55.440
And this is something we see far too often in migraine care.
00:24:55.680 --> 00:24:57.839
Triptens are not prescribed when they should be.
00:24:58.000 --> 00:25:03.599
Sometimes they're prescribed only after months or years of an inadequate over-the-counter treatment.
00:25:03.839 --> 00:25:10.319
And even when they are prescribed, the dose may be too low or patients may wait until the headache is severe before taking them.
00:25:10.640 --> 00:25:13.279
For many patients, timing matters.
00:25:13.440 --> 00:25:25.759
Acute migraine treatment generally works best when taken early in the attack, ideally within 30 minutes, while the pain is still mild, rather than waiting until the migraine has fully established itself.
00:25:26.160 --> 00:25:33.200
Jasmine needed an appropriate acute migraine plan, one that she could reach for confidently when she felt an attack beginning.
00:25:33.359 --> 00:25:35.599
But there was another important change happening.
00:25:35.839 --> 00:25:40.400
Her migraines weren't just becoming harder to treat, they were becoming more frequent.
00:25:40.640 --> 00:25:50.400
Once Jasmine was experiencing roughly four to six headache days per month, particularly given how disabling her attacks were, it was time to have a different conversation.
00:25:50.720 --> 00:25:58.400
Not just what do we do when the next migraine happens, but how do we stop so many of these migraines from happening in the first place?
00:25:58.640 --> 00:26:01.680
That's where preventive migraine treatment enters the picture.
00:26:01.920 --> 00:26:09.279
Preventive treatment can include daily medications, and depending on the patient and migraine burden, other options are available as well.
00:26:09.519 --> 00:26:13.119
The decision isn't based on a single magic number of headache days.
00:26:13.279 --> 00:26:21.680
It also depends on severity, disability, response to acute treatment, patient preference, and how the migraine is disrupting someone's life.
00:26:21.839 --> 00:26:25.200
And for Jasmine, migraine was beginning to take too much.
00:26:25.440 --> 00:26:31.920
The goal was no longer simply to survive the next attack, it was to give her fewer attacks to survive.
00:26:33.440 --> 00:26:36.000
What is medication overuse headache?
00:26:36.240 --> 00:26:44.240
Medication overuse headache can develop in a person with an underlying headache disorder who uses acute headache medications too frequently over many months.
00:26:44.400 --> 00:26:47.200
The exact threshold depends on the medication.
00:26:47.440 --> 00:26:54.640
For example, for tryptans, use on nine or more days per month for months at a time can meet the overuse threshold.
00:26:54.880 --> 00:27:01.839
For simple analgesics such as acinamidophilin or NSAIDs, the threshold is generally 15 or more days per month.
00:27:02.000 --> 00:27:06.640
And notice that we're talking about days of use, not simply the number of tablets.
00:27:06.880 --> 00:27:12.799
This is one reason I like asking patients, how many days each month do you take something for your headache?
00:27:13.759 --> 00:27:16.720
What should acute migraine treatment look like?
00:27:17.039 --> 00:27:18.160
Treat early.
00:27:18.400 --> 00:27:28.240
Once a patient recognizes that a migraine attack is beginning, effective acute therapy should generally be taken early in the headache phase rather than waiting until the pain becomes severe.
00:27:28.480 --> 00:27:35.519
Depending on the patient, this might include an NSAID, a tryptan, a GPAT, or another appropriate acute treatment.
00:27:35.759 --> 00:27:43.039
But every patient should leave with boundaries around frequency of use and a plan for what happens if their first-line therapy fails.
00:27:43.920 --> 00:27:46.240
When should we think about prevention?
00:27:46.480 --> 00:27:50.400
When migraine is becoming frequent,
prevention should be discussed.
00:27:50.640 --> 00:27:56.720
Options with high-level evidence include select beta blockers, candisartin, or amitriptyline.
00:27:56.960 --> 00:28:01.680
In select cases, topiramate, venlofaxine, or gabapentin can be used.
00:28:01.920 --> 00:28:12.559
Newer migraine-specific treatments often require inadequate response or intolerance to the above treatments for insurance coverage, as these treatments can often be cost prohibitive otherwise.
00:28:12.799 --> 00:28:16.000
Realistic expectations are also important for treatment.
00:28:16.240 --> 00:28:19.119
The goal isn't necessarily zero migraines.
00:28:19.279 --> 00:28:28.160
The goal is fewer attacks, less severe attacks, better response when they do occur, and ultimately giving patients back control over their lives.
00:28:29.279 --> 00:28:33.759
Before we finish, here are five things I want you to remember from Jasmine's story.
00:28:33.920 --> 00:28:38.559
Number one, migraine is a neurological disease, not just a headache.
00:28:38.799 --> 00:28:45.759
Migraine is a primary headache disorder, meaning it's not caused by an underlying structural lesion or secondary medical condition.
00:28:46.000 --> 00:29:01.519
Migraine is thought to involve abnormal neuronal excitability, dysregulation of pain pathways within the trigeminovascular system, and the release of neuropeptides, such as calcitonin gene-related peptide, which contribute to headache pain and associated symptoms.
00:29:01.759 --> 00:29:09.920
Management is largely supportive and focused on lifestyle modification, acute symptom control, and prevention strategies when indicated.
00:29:10.880 --> 00:29:11.359
2.
00:29:11.599 --> 00:29:17.440
Generally speaking, a typical migraine with no red flags does not require neuroimaging.
00:29:19.279 --> 00:29:24.640
Acute abortive treatments require an adequate dose of a tryptan or GPANT.
00:29:24.960 --> 00:29:33.359
For significant intensity migraines, an NSAD such as advil or leave can be combined with the tryptan taken at the onset of the migraine.
00:29:33.519 --> 00:29:37.440
It's important to treat the headaches early for maximum effectiveness.
00:29:39.200 --> 00:29:42.319
Provide a diagnosis for the patient at the first encounter.
00:29:42.480 --> 00:29:45.599
This can be done for the majority of patients at the first encounter.
00:29:45.759 --> 00:29:50.160
Too often physicians know that it's a migraine, but don't explicitly tell patients.
00:29:50.400 --> 00:29:52.880
This can reduce patient uncertainty.
00:29:54.160 --> 00:29:59.440
And number five, the burden of migraine isn't limited to the hours when the patient's head hurts.
00:29:59.599 --> 00:30:03.680
There can be disabling parts that happen just before or after the migraine.
00:30:03.920 --> 00:30:15.759
The food cravings, sensitivity to light and sound, difficulty reading, yawning, increased need to urinate, irritability, depression, inability to concentrate, and or fatigue.
00:30:16.000 --> 00:30:19.839
There can also be disabling parts that happen just between attacks.
00:30:20.079 --> 00:30:22.880
It's canceling the dinner because you might get a migraine.
00:30:23.039 --> 00:30:25.200
It's carrying medication everywhere you go.
00:30:25.359 --> 00:30:29.119
It's waking up and checking whether your head hurts before you even get out of bed.
00:30:29.279 --> 00:30:36.799
It's waiting months for an MRI, reading a report you don't understand, then waiting six more months for somebody to tell you what it means.
00:30:37.119 --> 00:30:41.279
Jasmine spent nearly a year afraid of what might be happening inside her brain.
00:30:41.440 --> 00:30:45.200
In the end, the most important thing she needed wasn't another scan.
00:30:45.359 --> 00:30:50.799
It was someone who understood her migraine, a diagnosis, a treatment strategy, and a plan.
00:30:50.960 --> 00:30:56.400
Because sometimes the scariest part of a neurological illness isn't knowing the diagnosis.
00:30:56.640 --> 00:30:58.240
It's waiting for one.
00:31:00.799 --> 00:31:02.880
This is Tales from the Cortex.
00:31:03.119 --> 00:31:05.680
Stories from inside the brain.
00:31:07.680 --> 00:31:12.400
Disclaimer, this podcast is for general educational and informational purposes only.
00:31:12.559 --> 00:31:19.359
It isn't intended to provide medical advice, diagnosis, or treatment, and it doesn't establish efficient physician-patient relationship.
00:31:19.519 --> 00:31:23.039
If you have concerns about your health, please speak with your own healthcare professional.
00:31:23.200 --> 00:31:28.240
Cases discussed on this podcast may be fictionalized or based on composites of clinical experiences.
00:31:28.480 --> 00:31:32.000
Details have been changed to protect patient confidentiality.
00:31:32.640 --> 00:31:33.920
Story written by Dr.
00:31:34.079 --> 00:31:35.440
Andrew Michelli and Dr.
00:31:35.519 --> 00:31:36.559
Michelle Yeeggy.
00:31:36.799 --> 00:31:38.559
Original piano music performed by Dr.
00:31:38.640 --> 00:31:39.920
Andrew Michelli.
00:31:42.240 --> 00:31:43.599
Until next time.