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The Headache Diet: Part Two · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

• 0:32
  Much for being here today. I'm very happy to be here with you, Holly.
• 0:36
  So you've been doing this pediatric neurology for 41 years. That's amazing.
• 0:42
  That's correct. And I hope to continue doing it. I still have great fun when I see these patients.
• 0:48
  And you did your med school, residency, fellowship, everything here at the University
• 0:54
  of Texas Health Science Center, correct?
• 0:56
  In San Antonio. That's correct. I love the school. They had great training for
• 0:59
  me. I feel fortunate. in it.
• 1:00
  Dr. Gross, we're talking about headaches today. What child hasn't really had
• 1:05
  a headache? And they're so common.
• 1:08
  It's the most common problem that you see?
• 1:12
  That's correct, without any question. And there are things that parents can do on their own.
• 1:17
  But so often, foods we eat have chemicals in them, and those chemicals trigger migraine headaches.
• 1:25
  So one of the things that you can do is cut seven things out of your child's
• 1:30
  diet. You can eliminate chocolate.
• 1:33
  You can eliminate caffeine.
• 1:35
  If you go to the deli to buy meats, you can specify that you want meats that
• 1:40
  are nitrite free because nitrite is an additive in deli meats that triggers migraine.
• 1:47
  You can stay away from aged cheeses such as cheddar cheese or Swiss cheese or
• 1:53
  anything wrapped in wax that's aged for a long time.
• 1:56
  You can avoid peanuts or peanut butter. You can avoid artificial sweeteners
• 2:02
  like sweet and low and nutrisweet.
• 2:04
  And you can avoid the additive called MSG, monosodium glutamate,
• 2:09
  often found in Chinese food, sometimes found in some of the salty things that
• 2:15
  we buy at the grocery store.
• 2:17
  And I also tell people, make sure your child never misses breakfast or lunch
• 2:21
  and gets plenty of sleep, make sure that they exercise and even do maybe very
• 2:27
  mild weightlifting or strengthening exercises.
• 2:30
  Now, I have to tell you this one story. Exercise helps a lot of people,
• 2:34
  particularly strengthening exercises.
• 2:37
  And I can tell you that's a faculty member who's going to remain nameless,
• 2:41
  who had bad migraine headaches.
• 2:43
  She started lifting weights, her headaches are and she's a big time power lifter right now.
• 2:48
  Wow, so what is the science behind that? That's amazing.
• 2:52
  That's a great question. I have no idea how it is that strengthening works to
• 2:57
  help with migraine, but it's been documented numerous times,
• 3:01
  including one of my colleagues who's a fellow faculty member.
• 3:05
  So how much strength training would you? Well, that's something you would just
• 3:10
  individually go through with each patient.
• 3:12
  But I've spent a fair amount of time going through things that any primary care
• 3:17
  doctor could very easily do.
• 3:19
  That is all such great advice. And I should mention about a year ago,
• 3:25
  we were talking about this and I had migraines, suffered from migraines for about 20 years.
• 3:30
  And not all of those things you mentioned, but a lot of them that I put into
• 3:34
  practice and I have not had a migraine headache in a year. I mean, it's incredible.
• 3:38
  You're living proof. And what I would tell, the other thing,
• 3:41
  when sometimes I'll have young ladies start to cry about chocolate,
• 3:45
  that's usually the biggest thing that people object to the most.
• 3:49
  I still eat chocolate, but anyway.
• 3:51
  Well, what I'll say is, listen, if you have a wonderful response for the next
• 3:54
  four months, you can reintroduce things one by one.
• 3:57
  That's great. Because you may find out it's not the entire list I went through.
• 4:01
  It's just one or two things that you're sensitive to.
• 4:03
  So I tell people usually call me in three or four weeks. And what I found is
• 4:09
  so interesting, Holly, parents are tremendously grateful for that for one of two reasons.
• 4:16
  Obviously, if it works, they're incredibly grateful.
• 4:19
  But even if it doesn't work, they're grateful that I did not just automatically
• 4:24
  pull out my prescription pad and instantly want to put their child on medicine,
• 4:28
  but I was willing to take time and explain a diet and let's try this first before
• 4:33
  we go to prescription medicines.
• 4:35
  People greatly appreciate that. Yes. And I was reading somewhere that some doctors
• 4:41
  may be hesitant to prescribe weightlifting because what if the patient gets
• 4:46
  injured at the gym or that...
• 4:49
  You have to go through things on it. You're not trying to get people to look like Schwarzenegger.
• 4:55
  You're trying to get people just to do even mild weightlifting.
• 5:01
  Can make a big difference.
• 5:02
  The person I gave you an example of became a power lifter. I'm not saying everybody
• 5:06
  has to be a power lifter, but doing light weights for 10 minutes a day may be very helpful.
• 5:12
  That's great. Getting something with maybe blood circulation to the brain?
• 5:16
  I don't know. That's a great thought.
• 5:18
  I'm going to have one of the medical students do a research project to see if
• 5:22
  he can figure out why it works.
• 5:23
  So much about migraine we still don't understand, but it's one of those things
• 5:28
  where you recognize it when you hear it.
• 5:31
  And again, the other fascinating thing about migraine, I can see 15 patients
• 5:37
  with migraine in a row who all have different complaints. planes.
• 5:40
  And just the power of taking it seriously and trying to work to help this person
• 5:46
  because it so often can be dismissed, right?
• 5:49
  Well, some people have recurring dizzy spells with no headaches at all.
• 5:54
  Some people have recurring abdominal pain that nobody can figure out.
• 5:58
  Some people have recurring visual changes that they just kind of ignore and
• 6:03
  don't pay much attention to.
• 6:04
  There's a whole list of things that migraine can do that does not involve headache.
• 6:08
  And oftentimes, I'm the fifth specialist to see somebody before they get the diagnosis.
• 6:15
  So when should a pediatric practitioner or the pediatricians,
• 6:20
  nurse practitioners, physician assistants, when is it time to refer to a neurologist for a headache?
• 6:27
  Well, there's several things I would tell people to look for.
• 6:30
  This is something that started very suddenly. A patient who never had headaches
• 6:35
  and then two or three weeks ago started having headaches and now they're getting
• 6:38
  worse and worse every day, that's a time that you would really want them to
• 6:43
  go to a neurologist right away.
• 6:45
  If you do a screening neurological exam and you find something abnormal on their exam,
• 6:50
  whether it's weakness, whether it's a loss of balance, whether it's looking
• 6:54
  in their eyes and seeing abnormalities of the nerve in the eye,
• 6:57
  if you see any type of abnormality on the neurological exam,
• 7:01
  I would say, send that patient right away to a neurologist.
• 7:06
  We often think that headaches that wake you up in the middle of the night can
• 7:11
  be migraine, but they can be other things more serious as well.
• 7:14
  So headaches that wake you up at night are headaches that occur first thing
• 7:17
  in the morning as soon as you wake up.
• 7:20
  And then I tell people, sometimes you have a bad sense about things and you can't verbalize it.
• 7:26
  Sometimes your gut feeling says something's not right, but if you ask me what is it, I can't say it.
• 7:32
  That's someone that you should send to a neurologist if you just don't feel
• 7:35
  comfortable with what you're hearing or what you're seeing.
• 7:39
  There was a patient you brought up where the mom was told, you know,
• 7:44
  everything is, it seems like everything's right, but then, can you tell me about
• 7:48
  that? But then it turned out not to be.
• 7:51
  Well, what can happen is family histories can play a major role.
• 7:57
  And I've often had patients who came in with headaches. It sounded very much like migraine.
• 8:01
  And the patient's exam was totally normal.
• 8:05
  And under ordinary circumstances, I would have done all the things we just got
• 8:09
  finished talking about with diet and vitamins and lifestyle.
• 8:12
  And I've had numerous instances where the mother would say, I had an older brother
• 8:18
  who died from a brain tumor, and for the first three months,
• 8:22
  everybody told him he was fine, not to worry about it.
• 8:24
  He ended up with something horrible, and now he's gone.
• 8:27
  So when you hear that type of history, I really think it's impossible for people
• 8:33
  to be relaxed by you just telling them everything looks fine.
• 8:36
  And it's very easy to understand why they feel that way.
• 8:40
  That's the type of family that I would just go ahead and get an MRI scan or
• 8:45
  CAT scan done right off the bat, understanding that the odds are greater than
• 8:49
  98% that it's going to be normal.
• 8:52
  But doing it so the mother or father can get past the concern about,
• 8:58
  could this be another case like my brother who passed away from a brain tumor?
• 9:02
  So again, you really have to individualize every single family.
• 9:06
  And really tune in and listen to that gut feeling.
• 9:10
  That's right. And whenever I'm giving lectures to medical students,
• 9:14
  and I'm trying to tell them of the importance of listening to people,
• 9:18
  I always give practical examples of how I almost messed up because I wasn't listening to people.
• 9:27
  Do you want to share one of those with us?
• 9:29
  Well, the good news is I didn't mess up completely.
• 9:32
  Nice. And I did make the right diagnosis. Yes.
• 9:36
  What inevitably happens is everybody wants to take time.
• 9:40
  Sometimes you have an emergency come in that wasn't scheduled or someone shows
• 9:44
  up late and that puts you behind for the rest of the day.
• 9:47
  And you end up with five patients waiting to see you in the waiting room and
• 9:51
  they're all coming up to their front saying, I'm very upset.
• 9:54
  What's taking so long? I want to be seen. You told me to be here at three o'clock or what have you.
• 9:59
  And it's very difficult not to feel pressure to move quickly.
• 10:03
  And probably the best example I could give you, and this is one I tell the medical students about,
• 10:08
  is a mother who came in with a child who looked happy and was smiling and the
• 10:13
  mother says she has episodes, she loses control of half of her body,
• 10:17
  her left side or her right side.
• 10:20
  There is a condition called hemiplegic migraine where it's migraine related
• 10:25
  and you become weak on one side.
• 10:27
  So I almost right off the bat assumed that's what it was.
• 10:32
  And fortunately, the mother, who was a very sweet woman, raised her hand and
• 10:37
  quietly said, Doctor, I don't think you're getting a correct picture of what she's talking about.
• 10:44
  What was she really saying? She was really saying in a very sweet way,
• 10:48
  Doctor, you need to be quiet.
• 10:49
  You need to listen to my daughter because you're not listening to what she's saying.
• 10:54
  And then the light bulb went off and I realized the mistake I was making.
• 10:58
  And I said, please, please tell me in detail what these episodes are like.
• 11:03
  And she went on to explain, well, every time I make a sudden movement,
• 11:06
  my arm and my legs start to twist up and tense up and I can't control them.
• 11:11
  Sometimes it's my left side, sometimes it's both sides, but it's only when I make sudden movements.
• 11:17
  And I instantly knew what that was. It's got a long name, paroxysmal kinesiogenic chorioathetosis.
• 11:24
  It was not migraine. Giving her migraine medicine would have been exactly the wrong thing to do.
• 11:31
  And I made the right diagnosis and got her on the right medicine,
• 11:34
  and she did beautifully.
• 11:35
  That's wonderful. Now, had that mother not politely raised her hand and said
• 11:41
  in a very friendly way, you weren't taking time, you're not listening,
• 11:44
  I could have made the wrong diagnosis.
• 11:47
  And that's not what we like to do. So I try to give the students and the residents
• 11:52
  examples that prove a point I'm trying to make.
• 11:56
  That's the advantage I have of being out for 41 years. I've had time to have
• 12:01
  close calls where I almost messed up, and I try to learn from it,
• 12:04
  and I try to teach other people.
• 12:06
  And here at UT Health San Antonio, or the University of Texas Health Science
• 12:09
  Center, we've hired two new pediatric neurologists who are starting this summer.
• 12:15
  Dr. Azra Akbar recently started. The goal is to have enough pediatric neurologists
• 12:20
  to see the kids who need it in this city and the surrounding area.
• 12:24
  But you've also created a clinic where you can get patients in quickly.
• 12:29
  That's right. And I'm going to take a little credit. That was my suggestion.
• 12:32
  I read an example of this in one of the medical journals from one of the other medical centers.
• 12:38
  We keep one afternoon open with no patients scheduled.
• 12:43
  And whoever is the doctor on call has the option of making the determination
• 12:49
  that someone that is in the emergency room or someone that is calling from another
• 12:54
  doctor's office needs to be seen and they cannot wait the usual period of time.
• 12:59
  They're not sick enough to be in the hospital, but they can't wait three months
• 13:02
  either to be seen in clinic.
• 13:04
  So we keep this clinic called our FAST clinic open. open, say someone has a
• 13:09
  first-time seizure, but they look fine and they look great and they don't look
• 13:13
  like they're in any immediate trouble.
• 13:15
  That patient needs to be seen quickly, but not necessarily in the hospital.
• 13:20
  And Sheldon, you say anything other than a febrile seizure should be seen by a neurologist?
• 13:26
  Unless there's an obvious explanation.
• 13:29
  If someone is diabetic and they don't eat and their sugar drops down to zero
• 13:34
  and they have a seizure, I'm not sure that patient needs to see a neurologist.
• 13:38
  But unless you have an absolute rock-solid explanation for why a seizure occurred,
• 13:43
  yes, I think all seizure patients should be seen by a neurologist.
• 13:48
  They should have not only a careful history taken and a careful neurological
• 13:51
  exam, some of them need an electrical study called an EEG, some of them need
• 13:57
  blood tests, and some of them need imaging studies of the brain,
• 14:01
  Sometimes a CAT scan, sometimes an MRI scan.
• 14:04
  And your hope, Sheldon, is to create a clinic once a month that involves psychiatry and neurology?
• 14:13
  That's exactly correct. And this goes back to why I wanted to go into medical
• 14:16
  school in the first place.
• 14:18
  I've always had a real interest in psychiatry. And in fact, right now on Monday
• 14:23
  afternoon, the child psychiatry fellows come and see neurology patients with
• 14:27
  me because there's tremendous overlap.
• 14:30
  We see huge numbers of patients that have both epilepsy and depression.
• 14:34
  We see patients that have.
• 14:38
  Migraine headaches, and they're bipolar. And we see one person that has two
• 14:43
  different problems, one neurological, one psychiatric.
• 14:46
  But they go hand in hand. They can be seen in the same person frequently,
• 14:50
  and one can affect the other.
• 14:53
  So for instance, if you do have headaches, and then you become extremely anxious
• 14:58
  and can't sleep at night, I can guarantee you your headaches get worse.
• 15:02
  So it's not like those are two totally separate separate conditions.
• 15:06
  And the idea is, can we do a better job of caring for these patients if both
• 15:11
  the psychiatrist and a neurologist are at the same clinic at the same time,
• 15:16
  can see the same patient, and then communicate with each other,
• 15:19
  and of course with the patient?
• 15:21
  We're going to try it, and I'm very hopeful that we'll see it helpful in those patients.
• 15:27
  So more to come, hopefully, on that.
• 15:29
  Sheldon, is there anything else you want the pediatric practitioner to know about headaches?
• 15:34
  What I would tell you is listening is probably the most important.
• 15:40
  Listening to what people tell you, because there are certain things that help
• 15:44
  you right off the bat know what you're dealing with.
• 15:47
  Someone who has a headache and they say, yes, and I see purple and yellow spots
• 15:51
  in my vision during a headache, that's very specific for migraine.
• 15:57
  Someone who has a headache that says, the listening is so hugely important because
• 16:03
  the scariest thing you can hear is someone saying, I just had the sudden onset
• 16:08
  of the worst headache of my life.
• 16:11
  And we always tell doctors, if you hear that, that could be an intracranial
• 16:15
  hemorrhage. That's how they present.
• 16:17
  So that patient is someone you wouldn't even send to a neurologist.
• 16:21
  You would send them to the emergency room at a hospital because they might need
• 16:25
  an emergency and see CAT scan or something of that nature.
• 16:28
  Listen to people is probably the best advice I would give.
• 16:32
  You don't have to automatically, instantly send them to a neurologist.
• 16:35
  A lot of the things we spoke about will probably help between 30% and 40% of
• 16:40
  your headache patients.
• 16:41
  For the other ones, watch them. And if you don't see them making progress,
• 16:44
  then get them in to see a neurologist.
• 16:46
  And if someone has dizzy spells, that also could be migraines?
• 16:51
  Dizzy spells, recurring abdominal pain, recurring numbness with no headache,
• 16:57
  but just numbness that affects half of your body.
• 17:00
  It comes and goes in episodes, recurring changes in your vision.
• 17:04
  There's a fascinating type of migraine called the Alice in Wonderland syndrome.
• 17:09
  Where during the episode, everything around you looks very, very small.
• 17:14
  Or on the other hand, it could look very, very large. That sounds terrible.
• 17:18
  Well, it can be frightening and people may think they're going nuts,
• 17:21
  but it turns out that's another type of a migraine. Wow.
• 17:25
  And it's still a mystery what causes one versus the other?
• 17:29
  I would say it's a mystery. We know a lot more than we used to,
• 17:31
  but if you ask me to give you the fundamental reason why some people have migraine,
• 17:36
  why in some patients it presents this way, in other patients it presents another
• 17:40
  way, I don't think we're there yet. it.
• 17:42
  How do you know when it comes to abdominal pain that this child would need to see a neurologist?
• 17:50
  Well, I have one rule for anyone that you're considering abdominal pain or abdominal migraine.
• 17:57
  You don't see them first. You let a gastroenterologist see them first so they
• 18:03
  can do all the testing that they think is necessary, whether it's endoscopy
• 18:07
  or colonoscopy or whatever.
• 18:09
  And it's only when they say, we've done everything we can think of,
• 18:13
  and we can't come up with anything, that's when it's time to go to a neurologist
• 18:18
  to see if it might be abdominal migraine.
• 18:21
  Now, there are some things that can be helpful.
• 18:24
  You ask about a family history, and if they say two of my siblings have migraine
• 18:28
  and my mother and father both have migraine, that obviously makes you more suspicious.
• 18:33
  If they say, I have abdominal pain and sometimes my head hurts at the same time,
• 18:37
  that makes you suspicious?
• 18:41
  Again, it comes back to listening and understanding that you don't automatically
• 18:46
  make the diagnosis of migraine.
• 18:48
  It's largely a diagnosis of exclusion, and especially abdominal migraine.
• 18:53
  You never make that until a stomach doctor or gastroenterologist has told you
• 18:57
  they can't find anything.
• 18:59
  And there's new things being done for migraines. I understand Botox can be helpful.
• 19:05
  Botox has been used for a long time. It's actually, I'm not even sure I'd call
• 19:09
  that new anymore. Oh, really? But there are new medicines that have been out
• 19:12
  for the last few years that are having a dramatic impact.
• 19:16
  Those are called the CGRP antagonists, and some of them are given by mouth,
• 19:21
  some subcutaneously, some IV, drips once every three to four months.
• 19:26
  And it's been tremendously helpful for a large number of patients.
• 19:30
  I'm upset because it's only approved for patients that are 18 and older.
• 19:34
  So in pediatrics, we're not yet able to easily use that. I'm hopeful in the future we will.
• 19:40
  But our ability to help migraine patients is just getting better and better and better.
• 19:44
  Are there any medications out there in particular that have nothing to do with
• 19:50
  migraines, but that could be causing the migraines?
• 19:53
  Well, probably the most common one to do that are stimulant medicines used for
• 19:58
  attention deficit disorder.
• 20:00
  The most common one being Ritalin. And it's a well-known fact that the stimulants
• 20:06
  can, in some patients, cause headaches. You remember earlier I said get off of caffeine.
• 20:12
  That is a stimulant. But there are also other medicines that can cause a condition
• 20:18
  where the pressure in your head is elevated, and that can cause headaches.
• 20:22
  So for instance, I've had several patients where I'm getting a history and I
• 20:27
  ask them, what other problems do they have and what medicines are they taking?
• 20:33
  Often they'll say, well, I've got acne,
• 20:34
  and my dermatologist is giving me menocycline, which is an antibiotic.
• 20:40
  Menocycline is a derivative of another antibiotic called tetracycline,
• 20:44
  which is classically famous for causing this condition.
• 20:49
  It's called pseudotumor cerebri, where there's no tumor, but the pressure in
• 20:53
  your head becomes very elevated, and that causes headaches.
• 20:56
  So part of listening and part of talking to people is asking them not only about
• 21:01
  the description of the headache.
• 21:03
  But what are their other medical problems? What other medicines are they taking?
• 21:07
  What is their family history? All that's very important.
• 21:09
  The doctor we had on last week, immediate past president of the AAP,
• 21:14
  she said, and I love this quote, children are about 20 to 25% of the population,
• 21:21
  but they're 100% of the future.
• 21:24
  And Dr. Gross, you're doing so much to help the future and help our children.
• 21:29
  It's just such an honor to talk to you today. Do you have time for one more
• 21:33
  story? Let's hear it. Because this just happened yesterday.
• 21:36
  And I get these types of experiences maybe twice a year, if I'm lucky.
• 21:41
  I had a patient who had gone eight years without a seizure.
• 21:46
  I was the second neurologist. The first neurologist gave a very bad dismal prognosis.
• 21:52
  I gave a more hopeful prognosis. The child is now developmentally normal.
• 21:56
  And for the first time in eight years, the EEG was normal.
• 22:01
  And I said to the mother, it's time for us to taper off of medicine because
• 22:06
  I think your child has outgrown this.
• 22:08
  And she was very quiet. Her eyes were turning red. You could see tears coming out.
• 22:14
  And she asked if it was okay if she hugged me. I said, yes, you can hug me.
• 22:18
  She was so incredibly grateful that That not only had I given them hope when
• 22:22
  someone else had basically taken that away,
• 22:25
  but I had continued to work with her long enough to see her child grow up normally
• 22:30
  and hopefully do beautifully off of seizure medicine.
• 22:35
  That type of experience is so incredibly gratifying.
• 22:39
  And again, that doesn't happen every day. That happens occasionally.
• 22:43
  Or they're probably thinking it and not actually say it, but that's such a beautiful story.
• 22:49
  Well, it's a wonderful story. It makes me glad I'm a doctor.
• 22:52
  It specifically makes me glad I'm a child neurologist. And it makes me want to keep doing this.
• 22:57
  So I'm 71, almost 72, and I really don't have any plans to retire.
• 23:02
  As long as I can do this and do a good job of it, I'm going to keep at it. We're glad about that.
• 23:09
  Thank you so much, Dr. Sheldon Gross, with the University of Texas Health Science
• 23:13
  Center at San Antonio and University Hospital.
• 23:58
  Music.