Latest / The Dr Louise Newson Podcast / 284 - Migraines and menopause: what’s the connection?

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284 - Migraines and menopause: what’s the connection? · The Dr Louise Newson Podcast

1:02
So today on the podcast, I've got someone called Doctor
1:06
Rebecca Walker with me, who is AGP with a special interest in
1:11
migraines as well as hormones as well.
1:14
And as many of you know, the two are very closely linked.
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So I wanted to dedicate this podcast to really just talking a
1:20
lot about migraines. I have a big personal interest
1:24
being a migraine sufferer myself, and it's really
1:27
shocking. Menopause is neglected, but
1:30
migraines are really neglected actually.
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They're under recognise, they're under diagnosed, they're under
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treated. And actually the impact of
1:40
migraines is just still not recognised to the extent.
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So it causes a lot of personal suffering, a lot of professional
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sufferings, people are able to go to work and a lot of
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unnecessary costs to the NHS as well because people are not
1:54
given the right treatments or given inappropriate treatments.
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So hopefully we can unpick some of what migraines are, how best
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we can optimise them because us with migraines know will never,
2:07
not, will never be cured. It's not curable, but it's
2:10
manageable. And so we just want some really
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great tips from an expert. So thanks for coming today,
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Rebecca. That's my pleasure, Louise.
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Thank you for asking me and putting migraine on your agenda,
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because yes, it's important to me too, for all the reasons that
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you have said. Yeah, so it's very timely.
2:26
Actually. I'm just coming out of a
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migraine, so I still don't feel completely with it.
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But you know, yesterday ruling and I had one of these classic
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times where I was in a important meeting and I suddenly felt all
2:36
cold and shivery and I thought, oh, what's going on?
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And then the day progressed and I knew that I was developing a
2:43
migraine and my daughter, who's also a migraine sufferer, had
2:45
phoned me and she said, mummy, have you taken aspirin and
2:49
domperidone? I was like, no, I'm fine.
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She goes now. I can hear by your voice because
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you're slurring your words. It's something.
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But it's really weird when you have a migraine, you don't think
2:56
properly and you can't actually, you know what you should do, but
3:00
you can't do it sometimes and then it makes it worse and then
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it's sometimes too late because you have this window.
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And then I was taking Zoma trips in, but I knew it wasn't right.
3:09
But I also knew I had to drive and take my daughter to
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something else, another daughter.
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So I couldn't take the Zoma trip to and I hadn't eaten properly.
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And it's this viral of sort of, oh, it's awful.
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But I mean, you have just said so many things in that one.
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But it's one of those that I think a lot of people still
3:30
don't understand because when I say to people, I have a
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migraine, oh, do you just have a bad headache?
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I think that's the. Key and you feel like ripping
3:37
their head off, but actually they don't understand.
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So can we start record with Jess?
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What is migraine? So migraine is a complex
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neurological condition. It is not just a headache.
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We know that it has a strong basis in genetics.
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So most of the time there's a family history there.
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But the genetics are complex. So there is variable inheritance
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as some people will express migraine in one way and other
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family members might express migraine in another way.
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Like then that's part of the problem too.
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So it often goes unrecognised from family members to family
4:08
members. But we know that it's not just a
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headache. Headache is 1 symptom of
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migraine. Headache might not be a symptom
4:15
of migraine. So there are people out there
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who will be experiencing migraine where they don't get
4:19
headache at all, and that's because we know that migraine.
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So let's go back to sort of basics and some biology.
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Attack of migraine starts with an inherited tendency towards
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the condition, but we then know that there are environmental,
4:32
both internal and external environmental factors that push
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you over your migraine threshold.
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And once you hit that migraine threshold, you start to get
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activation in the hypothalamus part of the brain.
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So this is the thermostat if you like the the centre that
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controls our temperature regulation, our sleep wake
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cycle, our appetite cycle. So in that part of the brain is
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being activated, we start to get prodromal symptoms and they
4:56
might be feeling hungry, feeling thirsty, going to the loom
5:00
often, yawning uncontrollably, a dip in mood, slow thinking
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processes, neck stiffness. And that might be happening
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anywhere from a few hours to a few days before you start to get
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the more readily recognisable symptoms of migraine, which
5:14
would be the nausea, the light sensitivity, sound sensitivity,
5:18
the headache. And then as you are possibly
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right now in your post Rome where you're maybe, you know,
5:24
you're recovering, there's relief that the unpleasant
5:27
symptoms are passing, but you're still not back up to functioning
5:30
at your normal 100%, maybe 60 to 70%.
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Brain still feels thick and foggy.
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Energy levels are still a bit flat.
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So that's a typical attack of migraine without aura.
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There are to be in 10 people who experience migraine who get
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might have aura as part of their attack.
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But that just goes to illustrate, firstly that it can
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last anywhere from hours to days, but also the myriad of
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symptoms that a person with migraine can experience during
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an attack. And that's really difficult
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because I think that's why so many people, it can take a while
6:02
to be diagnosed. Especially we see lots of people
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in the clinic who have vestibular migraines.
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So they might have balance problems and they've never had a
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headache. And they've often been diagnosed
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as actually having a Tia, a transient ischemic attack.
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And people think that they've had a mini stroke.
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But when you take the history very clearly, it often isn't is.
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It there's a history of migraines.
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So vestibular migraine is a really interesting variant of
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migraine. I see it so commonly presenting
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in the perimenopause. It's typically characterised by
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episodes of Vertigo that last for maybe several hours or so,
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accompanied by other symptoms of migraine.
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So that light sensitivity, movement sensitivity, sound
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sensitivity, feeling nauseous, headache doesn't always have to
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be present. You know, it's usually been
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there at some point in the past within an attack, but it doesn't
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always have to be present. And what we often find with the
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stimulant migraine is that headache is there, but it's not
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the most bothersome symptom. So in migraine medicine, we're
7:00
really keen on finding out from people what is their most
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bothersome symptom. It might be ache, but it might
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not be. It might be balanced
7:07
disturbance. It might be fatigue.
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It might be brain fog. Yeah, a whole host of different
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bothersome symptoms. Yeah.
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And how do you define chronic migraine?
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Because that's a term that's used quite a lot as well.
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So what does chronic migraine mean?
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So I'm pleased that you asked about this because I think part
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of again, migraine awareness and helping people recognise that
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actually they might be experiencing migraine and not
7:30
just headaches. No one is born with chronic
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migraine. There is a point at which
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migraine which is episodic. So that means it comes and it
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goes and you feel well in between your attacks transforms
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to this chronic, more burdensome, more impactful and
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potentially life limiting condition.
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It comes down to essentially how impacting an individual feels by
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their migraine. But our classification systems
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use a cut off of 15 days. So if you have migraine days
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that number more than 15 per month, eight of which really
8:00
fall into typical migraine type attack days, then that
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constitutes chronic migraine. So as I said, that's when it
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becomes life impactful. But if you look at disabilities
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through WHO, it's really up there, isn't it as being one of
8:15
the commonest causes of disability because migraine is
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so common, yet there's so much we still don't know about it.
8:22
There's so little research that's done and there's very few
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specialist migraine clinics as well, isn't there?
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I think that probably comes back to it being a maybe a women's
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issue. It's predominantly condition of
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women, so it affects three times more women than it does men.
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It affects women disproportionately and men too,
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but it affects us disproportionately in our mid
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life, so during most productive years, working age, and that's
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largely in women due to the impact of hormonal influences.
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And I think it is stigmatised. It's usually stigmatised and it
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comes down to this lack of understanding.
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It comes down to thinking of it as just being a headache,
9:02
something that people should take a paracetamol for and get
9:04
over and get back into the office for.
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Which means that people are sometimes anxious or nervous
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about coming forward to volunteer, that they have an
9:13
issue that they need support and attention for.
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And equally perhaps as healthcare professionals, we
9:18
carry our own stigma related to migraine as well because of a
9:21
lack of training. I think you're absolutely right.
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There is a real lack of training and it's always difficult in
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medicine when you're dealing with a condition that there
9:28
isn't a diagnostic test for. So if I thought you had
9:32
diabetes, I could do a blood test and I could say yes or no.
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Rebecca, you've got diabetes or you haven't.
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With something like migraine, there isn't a test that we
9:41
sometimes do tests to make sure there isn't a brain tumour or
9:44
something else causing some symptoms.
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Not always. Most people don't need a scan,
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of course, so then you're going with a really good history and
9:51
story. But you have to be trained to
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ask the right questions, because if you don't ask the right
9:56
questions as a healthcare professional, you're not going
9:58
to get the whole story. And sometimes people don't think
10:01
something's relevant because like me at the beginning saying
10:04
I suddenly felt cold at a meeting.
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I know that my headaches and migraines are going to start at
10:10
summer stage, but I try and ignore it.
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But if I didn't know it was associated, why on earth would I
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tell a doctor that I feel cold sometimes?
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You know, So patients have to have more knowledge so they can
10:19
give the good history. But doctors and healthcare
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professionals need to be asking the right questions because so
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often in medicine when we don't know the answers, it's easy to
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say, oh, maybe it's because you're stressed.
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And the number of times that I have been told, but certainly my
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daughter has, oh, it's maybe because you're a bit anxious.
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Well, no. You might be stressed because
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you're in so much pain and disability and you're not being
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listened to and you don't know how to help and you're really
10:47
worried it's going to happen at a time when you are doing
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something public facing or you're doing something that you
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can't get out of. Of course that's going to make
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you worried. But the worry hasn't caused you
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to have migraine, if you see what I mean.
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And that's really hard for patients, isn't it?
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It's a real thing that the fear or the apprehension of
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experiencing migraine, it's a real thing.
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And I mean it is a vicious cycle.
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We know that the more migraine you experience, the more it does
11:14
impact on your mental health and your well-being and the more
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that makes you more predisposed or vulnerable to experience in
11:19
migraine. So it is a vicious cycle and our
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stress type hormones, adrenaline and cortisol definitely have a
11:24
role to play, but but they are never the only answer.
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And I hear it all the time that people that I wouldn't be
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feeling anxious if I didn't, if I wasn't worried about migraine
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or I wouldn't be feeling low if I didn't wake up with a headache
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every day of the month in all of these sorts of things that we
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hear so commonly in clinics. So yeah, I was.
11:42
Just going to say it's very interesting about mood because
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there's the anxiety that you can have thinking, oh gosh, I'm
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going to have a migraine at a bad situation, what am I going
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to do? But the other thing is, and it's
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taken me 53 years to realise that actually sometimes when
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people have migraine or just before it comes, you can get
12:01
very low in your mood. So I often have feelings of
12:05
really low self worth, really low self value.
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I really think that I'm no good as a person, I'm no good as a
12:12
doctor. And it's a downward spiral.
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And it's only been the last year that I realised that quite soon
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after I have these feelings, then the migraine occurs.
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And I've, I'd also learnt through my daughter because she
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has this as well. It's like, where's this come
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from? Why are you suddenly so
12:27
negative? And then, I mean, as I sit on
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the phone, I can hear this slurred speech and I, And so now
12:34
we can reassure each other. And I think that's really
12:37
important because I wonder how many people make the wrong
12:41
decisions because they're having migraines, if you see what I
12:45
mean, All. Because they say that they can't
12:48
acknowledge that they have an attack, that they need to take a
12:50
step back. Do you mean that they need to
12:52
take some time out, recover, give themselves space they need?
12:55
But I think, again, it comes down to validation, you know,
12:59
almost being given permission. I mean, it's not your fault that
13:01
you have migraine. It is the genetic lottery that
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we are, you know, living. It's no one's fault that they
13:07
experience migraine. And I think that's also really
13:10
important. Yeah.
13:12
It's not something you've. Caught.
13:13
No. And that is so important and for
13:15
others to understand. So recently for my daughter, I
13:19
actually helped her write a definition of what migraine is
13:24
and things that other people can do for her when she has a
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migraine. Because she's only young and a
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lot of people do think, oh, it's just a headache, just a bit of
13:32
stress or whatever. And then because her
13:34
coordination goes, because her speech goes, because her mind
13:37
doesn't work, it's very hard then to get the right help.
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But I've sort of read this list about things that are worth
13:45
thinking about for her friends who are with her.
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So if she starts to yawn, feel cold, is very hungry, then offer
13:52
her and make sure she has some aspirin domperidone.
13:55
So this treatment that could have brought an attack and also,
14:00
you know, tell her that it's likely that she's going to have
14:04
a migraine. Sometimes my husband can see it
14:06
in my eyes before anything else he can see.
14:08
You know what, I think you're absolutely right.
14:10
I'm very pleased you shared that because I think you're right.
14:12
I think as maybe as people, I experience migraine too, there
14:16
is this element of denial that happens and you do need somebody
14:19
objective who can say, I can see the changes, I can see fail.
14:25
I can hear it in your voice. This is what we do.
14:27
And I must admit again, I'm going to take that away for my
14:30
adult patients too do that I have for children.
14:33
So young people who are at school, I have a migraine action
14:35
plan that they can share with their school, they can share
14:38
with their educational environment.
14:39
That means that this is what I need to take when I have my
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attack on migraine. This is what helps me.
14:45
This is what you know helps me get through my migraine attack.
14:48
Yeah. And actually, that's important
14:49
for everyone who experiences. Migraine, it is really
14:52
important. My daughter always has
14:53
medication with her, but so often she'll phone me and I'll
14:57
say, right, have you taken a show?
14:59
And then she's clumsy so she can't open the purse and and
15:01
then she can't see the tablets and then she's, oh, no, I've run
15:04
out. So even just the other day she
15:07
got a tiny purse and it's just got one of everything she needs
15:10
in. And then she knows that she's
15:12
got enough for one attack. And it sounds really simplistic.
15:16
And we were both saying, when your mind's on it, you think
15:19
that's so obvious, but when you can't think, it's too much to
15:23
open a drawer. To look through the.
15:25
Tablets and it's really hard to describe to people, but again,
15:29
to make it easier because there are treatments that often they
15:33
don't always work but can reduce, even can stop sometimes
15:37
a migraine attack occurring, but they can reduce the severity as
15:40
well, can't they? They can.
15:42
So when I'm thinking about looking after people with
15:45
migraine, the first port of call is always migraine friendly
15:48
living. So that's good routines.
15:50
Migraine is inherently sensitive to change, so keeping good sleep
15:53
hours, hydration, regular healthy meals is important.
15:57
But a lot of people who've been living with migraine get to the
15:59
point where they say to me, if anyone else tells me to drink
16:02
more fluids, I'm going to, you know, solve them one because
16:05
don't they think that I've thought of that already?
16:07
Then when you move on from living your migraine friendly
16:10
life, it's important to have rescue treatment to hand so that
16:13
you can abort that attack soon as soon as possible.
16:16
And sometimes it can take trial and error to find the right
16:18
combination of treatments. But actually as you what you
16:21
say, a combination of treatments, it might be an
16:23
anti-inflammatory, it might be paracetamol if you can't take
16:26
anti inflammatories with a triptan.
16:28
It's shocking how many people with migraine haven't been
16:31
offered or haven't sought advice on migraine specific treatment.
16:34
Maybe one in four people with migraine have been offered a
16:37
triptan. So this is a migraine specific
16:39
medication to abort an attack. Having combination of those.
16:43
Sometimes taking these medicines with a small kind of colon can
16:47
be helpful. I have a kind of coke in the
16:49
fridge with my name on it that no one touches, just in case for
16:53
those times when. That's because of the caffeine.
16:56
Is that and the sugar or? How does that caffeine and sugar
16:59
boots? Yeah, absolutely.
17:01
I mean, I think from as you will, it's from your
17:03
description, I think going through migraine, these genes
17:07
that essentially mean that you perhaps are more vigilant or
17:12
more sensitive to the world around you.
17:14
Being in that condition demands a lot of energy.
17:17
And so when you're entering a migraine attack, actually that's
17:20
what your brain is craving, craving restoration, the good
17:23
energy levels. And so the caffeine and the
17:26
sugar boost with the migraine rescue treatment can be helpful.
17:30
Obviously we need to be mindful that it's not too much, too much
17:32
Coca-Cola is a bad thing, but it can be helpful.
17:35
Now and again you can get painkillers that contain
17:38
caffeine as well, can't you? That sometimes people find and
17:41
taking an anti sickness can sometimes help to contact with
17:45
the medication, yeah. Absolutely.
17:48
The stomach goes into a state of paralysis in migraines, So
17:50
taking medicine into your stomach, sometimes it just sits
17:53
there and actually a lot of people feel that and describe
17:56
that. Then I feel like my system just
17:57
stops. Some people who do vomit feel
18:00
like actually the action of vomiting in some ways goes to
18:03
relieve or bring respite from their migraine attack.
18:06
But taking an anti sickness tablet that also works to move
18:09
medicine into the intestine can also be very helpful too.
18:13
It's all about getting that medication into the system as
18:15
quickly as you can. We use an analogy at the
18:19
National Migraine Centre likening an attack to a fire
18:22
starting in the waste paper bin in your office room.
18:25
You know you don't want to go with it with a plant sprit, so
18:27
you want to go with it with great bucket of water, put it
18:30
out quickly so that it doesn't take holes and burn everything
18:33
down. Yeah, it's a really good
18:35
analogy, isn't it? And there's also the some of the
18:38
triptans you can have as a nasal spray or they can melt in the
18:41
mouth, which again is really good if people find that they're
18:45
feeling sick or they're not absorbing properly.
18:47
And there are different triptans as well.
18:48
So what suits 1 isn't going to suit someone else.
18:50
Sometimes people have side effects with one and not with
18:53
others. And it's like anything in
18:54
medicine, isn't it record, you just try something else.
18:57
So it's really important if people are suffering, not to
19:01
feel bad, know that you can go back and ask for an alternative
19:04
treatment. So it doesn't agree with me.
19:07
This isn't the right thing for me.
19:09
We are listening to a professor of neurology talking about how
19:12
we define triptans intolerance. And, and he said, well, you
19:16
know, perhaps we shouldn't be defining it.
19:18
Our patients should be defining it for us.
19:20
You know, that's how it's the people coming back to us saying
19:23
this isn't working for me. Is there anything else I can
19:25
try? Yeah, I think knowing that we're
19:27
all individuals because you know how I manage or try and reduce
19:32
my migraine frequency, I have a very routinely life because I
19:37
know my brain likes homeostasis. So if I skip a meal, I'm
19:40
guaranteed to have a migraine. If I eat processed foods, I'm
19:44
guaranteed to have a migraine. So if I had a can of Coke and a
19:48
Mars bar, I know I'd get migraine.
19:50
So I don't have it. And I don't have caffeine at
19:52
all. I don't have alcohol.
19:54
I'm really regimented the way I exercise.
19:56
If I know if I do more than 20 minutes of yoga in the morning
19:59
before I've had breakfast, I'll get a migraine. 20 minutes is
20:02
enough, but that's fine. 20 minutes most mornings is good
20:05
enough for me. But if I go for a long cycle
20:08
ride, I'll get a migraine. I'm really, it's really
20:11
restrictive to the way that I live, but it's actually quite
20:14
good because it means I have to be healthier because I.
20:17
I otherwise would eat probably far worse.
20:20
I probably would drink alcohol, I probably would go to bed far
20:23
too late and try and have a lion at the weekends.
20:25
But I can't because the last thing I want is migraines
20:28
because they affect me so badly. Some people makes no difference.
20:31
So if it doesn't make a difference, what you don't want
20:34
to do is restrict your lifestyle.
20:36
But I do know also, and I hopefully you'll agree, that any
20:40
changes in lifestyle, you have to wait a good sort of three to
20:42
six months to see if it's made a difference.
20:45
So giving up drinking for one day and then getting a migraine
20:48
2 days later doesn't mean that alcohol is something that you
20:52
can continue drinking. So you've got to try changing
20:54
things and waiting. Yeah.
20:57
Absolutely. I think you're totally right.
20:59
And it's the same with medical interventions too.
21:01
So the treatments that we use, it seems to take that amount of
21:04
time for the brain to recalibrate and to adjust to a
21:07
new way of being, as it were. So yes, give any intervention
21:10
long enough and that usually it's about 3 months.
21:14
Yeah, I agree with you. It can feel very restrictive.
21:17
But I think as you've experienced, for most people,
21:19
the benefits outweigh the restrictions that are posted
21:22
online. Often people find that once
21:25
you've got good migraine control, it affords you a little
21:28
bit more flexibility. So you can push the boat a
21:30
little bit. You can't go out, enjoy that
21:32
concert or that meal out. It just might mean that you pay
21:37
a bit to catch up the next day. Or I think another thing about
21:41
migraine is, I don't know how you feel about the word trigger,
21:44
but the more I do migraine medicine, the more I'm becoming
21:47
less keen on using the word trigger.
21:49
I think trigger sort of invokes avoidance behaviour.
21:53
And actually what we find with migraine is that people retreat
21:55
from their lives and stop living the lives that they want to lead
21:58
because they're avoiding triggers.
22:00
I think it's perhaps kinder to ourselves to think of these
22:03
things as conditions that make us more vulnerable to migraine,
22:06
and we can prepare conditions. We need to sort of create some
22:10
more proactive approach. We have some autonomy over
22:15
migraine rather than dictating how we live our lives.
22:18
I think that's really important. Yeah.
22:21
And you do have to be prepared and you do have to, I think
22:24
you're right, think about alternatives.
22:26
So even some of the tube lines, my daughter can't go on because
22:30
the noise of the tube, some of them are really noisy and
22:32
trigger, whereas some of the other, like the Elizabeth lines,
22:34
she said it's beautiful because it's really quiet.
22:36
But she's got and it's, it's really interesting, but once
22:41
you're aware of it, you think, well, OK, so she plans her
22:43
journey differently and you know, and looking at what noise
22:46
protection you can wear and but you've got to be one step ahead
22:51
all the time, but. You can only get that step
22:53
ahead. You've recognised it to start
22:55
with. And I think again, that's why,
22:57
well, it's so lovely to be here to say, you know, please, if
23:00
you're having recurrent headaches and your, you know,
23:02
headache is a symptom, it's not a diagnosis.
23:05
Do seek advice. It's really important.
23:08
I totally agree. And I think that's where using
23:10
other people to recognise. What did you do differently?
23:12
Was there anything that sort of brought it on?
23:15
But it sometimes it can just happen.
23:17
And so like you say, these triggers, sometimes you do feel
23:20
like, oh, I shouldn't have gone to that concert or I shouldn't
23:23
have done whatever, but actually it could have happened anyway.
23:26
And so we really need to be careful that we're not just
23:31
blaming everything that we do on because they will happen
23:33
regardless and sometimes we don't know why.
23:36
I think you're right. And different things at
23:38
different times. So often people come in to see
23:40
me and they're really frustrated that they haven't found that one
23:43
single trigger that flips their migraine switch.
23:46
And that's because migraine is complex and it's rarely one
23:50
thing. It's usually a combination of
23:52
things. And that combination of things
23:54
might be hormones and a missed meal one month and it might be a
23:57
late night and a work deadline the next month.
24:00
It's just really one of those kind of conditions.
24:03
And so, well, obviously you can't come on to podcast about
24:07
menopause and not talk about hormones.
24:09
So we said at the beginning, it's more common in women.
24:11
And there are people who it definitely, we know it can be
24:15
triggered by changing hormones. There are some people that have
24:18
migraines just before their periods, which is when their
24:20
hormone levels are lower. But especially in the
24:23
perimenopause, when hormone levels really fluctuate, that
24:27
can be quite a difficult time for some people who suffer with
24:30
migraines because again, the brain is exposed to changing
24:33
levels of hormones, isn't it? So I think the combination of
24:37
perimenopause, migraine and midlife is just a recipe for,
24:41
you know, turmoil for some women.
24:43
I mean, it's a really, really awfully challenging time due to
24:46
the reasons that you're many of your listeners will be familiar
24:49
with already. So we have menstrual migraine,
24:52
which is essentially our thinking is that it's driven to
24:55
a large extent and it's complex. This is unlikely to be the only
24:58
thing, but to a large extent by the drop in estrogen levels
25:02
coming up to the period after a period of relatively sustained
25:05
levels of estrogen. So it's the brain again
25:07
adjusting to a changing environment predisposes to
25:10
migraine. But then we see these biological
25:13
changes happening to the cycle, to the menstrual cycle.
25:16
Cycles in the early perimenopols start to get shorter.
25:19
So you have these long lasting attacks.
25:21
Menstrual attacks of migraine tend to be these longer lasting,
25:24
more intense, more disabling, more painful, more nausea, less
25:28
treatment responsive attacks. And because the cycle length is
25:31
changing, they're coming thick and fast and the recovery phase
25:34
in between attacks is getting less and that drives medication
25:39
use up. So lots and lots of things are
25:40
happening to lead to migraine becoming a really big issue
25:45
during the perimenopause, on top of which you have all the other
25:48
symptoms of menopause to deal with potentially.
25:51
Low mood. Sleeplessness, hot flushes,
25:54
anxiety. Which can then make migraines
25:56
worse as well, of course. Aren't they so?
25:59
So it is important that yes, that we're helping women spot
26:02
these things so that we can put together really comprehensive,
26:05
holistic, individualised care plan that supports them with all
26:09
of these symptoms. Yeah, and I still, most days I
26:11
have somebody who messages me through my social media to say I
26:15
have migraine. I've been told I cannot have
26:17
HRT. What can I do so we can still
26:21
have HRT when we have migraines, can't we?
26:23
Or some types of HRT. Yes, we can.
26:26
That's a big myth, Buster. So yes, of course women with
26:29
crigrain and women with migraine with aura can also have hormone
26:32
replacement therapy. I think making the distinction
26:35
about whether women have migraine with or without aura is
26:38
important. Women with migraine with aura
26:40
have an elevated background risk of stroke.
26:43
It's still very small, but it's higher than women who don't
26:45
experience migraine, who don't experience migraine with aura.
26:49
For those those women, then estrogen is still OK to give.
26:53
It's just it should be given through the skin because that
26:55
means that it doesn't lead to the risk of stroke or blood
26:58
clots. Women without migraine with aura
27:01
potentially have more options in terms of their hormone therapy
27:04
or the regimens of hormone therapy they could use.
27:06
But again, that's going to be something that's decided on an
27:08
individual basis with the clinician who's looking after
27:11
you, looking at your wider lifestyle factors.
27:14
So body mass index, smoking, water stuff.
27:16
Yeah, and it's really important with hormones because as I've
27:18
said many times before, there's the three main.
27:20
Hormones that we. Consider estrogen, which is in
27:23
estradiol, they're body identical estrogen that's
27:25
anti-inflammatory progesterone and testosterone.
27:29
And actually we work really hard often to individualize dosage
27:34
and types because some people even if they're on a cyclical
27:37
regime, so they're having periods, they have two weeks of
27:40
progesterone and two weeks without that can sometimes
27:43
trigger their migraines. So then we give progesterone all
27:46
the time because again, it's about the brain having the same
27:49
and that that can be a lot better.
27:50
Or sometimes we change oral progesterone to vaginal if it
27:54
gets absorbed differently and they feel better.
27:57
And testosterone, again, with some people find when they're on
28:00
testosterone, they have less migraines as well.
28:02
And there's some small data to show that probably has an
28:05
effect. But certainly clinically we see
28:08
that it does for some women. Some women if they're not on the
28:11
right dose of estrogen, it's too high or too low, depending on
28:14
whereabouts they are that can even.
28:17
So some people say, well, I can't take HD because I felt so
28:20
awful when I was on it. And then you see what they were
28:23
on and maybe it was a synthetic progesterone or maybe it was a
28:26
really low dose of estrogen and they needed slightly more or
28:31
different progesterone. So again, it's, and in the
28:33
perimenopause we often have to change it as well because their
28:36
own hormones are changing, aren't they?
28:37
So. I think when we're thinking
28:39
about hormones and the perimenopause, there will be
28:42
plenty of women out there who have migraine, but it isn't
28:45
hugely impactful and they will may fare perfectly well with
28:48
standard regimens of replacement therapy, making a diagnosis of
28:53
menstrually related migraines. So you're having really good
28:55
diary evidence that shows that there is a real link between
28:58
periods and attacks of migraine can be really a really helpful
29:02
tool in terms of working out who's going to benefit from what
29:05
type of hormone replacement therapy.
29:07
So women with that type of menstrual migraine sometimes
29:11
benefit from measures that essentially switch off
29:13
background ovulation. And so you get rid of all those
29:15
crazy hormonal fluctuations. You have nice constant levels of
29:19
hormones that can be really helpful.
29:21
Looking at Diaries, again, if you've got a woman with really
29:25
disabling chronic migraine, she may well be having attacks of
29:28
migraine around her periods too. But actually when migraine is
29:31
that burdensome, sometimes hormones aren't the answer.
29:35
And we really do need to be thinking about adding in
29:38
additional migraine care. And I think that, again, it's
29:40
about managing expectations and knowing when we need to step
29:43
things up. Totally.
29:45
And like we said, it's often a combination of treatments.
29:48
There's not going to be usually one single treatment, whether
29:52
it's a hormone or non hormonal, that's going to do it for you.
29:55
And you might just think great, I've got the right balance and
29:58
then something happens. And sometimes people find that
30:02
having a good quality magnesium supplement can help other people
30:06
find it makes no difference. Some people find having there
30:10
are other treatments that are available, some on the NHS and
30:12
some not, or in certain areas or by certain specialists that can
30:17
help reduce frequency of migraines.
30:20
So it's really important that everything is explored if
30:23
someone's struggling. Yeah, and that people feel that
30:26
they can come back and that I think Diaries can feel like just
30:30
an additional admin task, but actually they're really helpful.
30:33
They are a really key tool for helping guide treatment
30:36
response, but also working out what the right treatment is
30:39
worthwhile to give a go. So I would strongly recommend
30:42
Diaries too. I often, I said to a patient
30:46
recently that I think living with migraine, and perhaps it's
30:48
the same with living with menopause as well.
30:50
Managing migraine in the perimenopause.
30:51
It's like raising a baby or raising a toddler.
30:54
You know, once you think you've got it cracked, they change or
30:57
there is change and it's because this is a constantly.
31:00
Changing environment, absolutely and there's still so much that
31:03
we don't know we certainly need to do more research and have
31:08
more evidence and really look so that it is a condition that is
31:12
managed more appropriately with less suffering yeah.
31:15
So there's lots more we. I think I'm going to have to
31:17
invite you back for another podcast, Rebecca, because we've
31:20
still so much more that we can talk about about other
31:22
treatments, but we will share some resources with the podcast
31:25
notes. So I'm very grateful for your
31:28
time. But before we finish, I always
31:30
ask for three take home tips. So three things that you think
31:34
people could do if they are migraine sufferers and just want
31:40
to be more empowered about treatment choices, What are the
31:42
three things that they could do? I think so.
31:46
Recognition is the first thing. So I'm going to take it back
31:49
just a step in saying, because I think there are so many women
31:51
out there who are living with headaches who haven't had a
31:54
diagnosis of migraine and who actually could do with
31:57
recognising they have migraines. That would be the first thing.
32:00
Think get a diagnosis. Headache is a symptom.
32:03
It's not a diagnosis. What's driving those headaches?
32:06
I think keeping a diary is key because I think again, that
32:10
shows us what's going on. Recognising that headache is a
32:13
symptom that warrants or is worthwhile the time and
32:16
attention of your healthcare professional and then getting
32:18
advice from reliable resources. So my top resources, obviously
32:23
I'm going to say the National Migraine Centre is a good
32:26
resource. Katie Monroe's book Managing
32:28
your Migraine is fantastic. These are all resources for
32:33
empowering yourself to know more about your condition and what
32:35
treatment options are available. Great advice, so thank you so
32:40
much for your time and sharing so much of your fantastic
32:42
knowledge. So thank you.
32:44
Pleasure. Thank you.
32:45
For asking me, you can. Find out more about Newson
32:52
Health Group by visiting www.newsonhealth.co.uk and you
32:58
can download the free Balance app on the App Store or Google
33:02
Play.