Headaches are just one component of migraines

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be "The Informed Patient," with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

How do you know if the severe headaches you get are migraine headaches? Today I'll talk about migraines with a specialist, Dr. Awss Zidan. He's an assistant professor of neurology at Upstate and the co-director of the headache and migraine Service at Upstate.

Welcome back to "The Informed Patient," Dr. Zidan.

Awss Zidan, MD: Good morning, Amber. Thank you for having me one more time. It's always a pleasure.

Host Amber Smith: What distinguishes a migraine headache from other types of headaches?

Awss Zidan, MD: Migraine headache at its core is not only a headache pain. I guess that's crucial for people to recognize, and it's something that I'm very passionate about advocating.

Migraine gets confused with headache, just a headache, all the time, while in reality migraine is a neurological syndrome complex and has many other symptoms aside from the headache. And the pain may not even be the most disabling one. At its very core, migraine is a syndrome of hypersensitivity, meaning that people would feel heightened sensitivity to the surrounding stimuli, like the lights, the noises, the gentle touch on the face, the pain sensation and headache, and pretty much every other stimuli. And I think that's the main thing that differentiates migraine from other kinds of headache.

Host Amber Smith: And the way you described it, I've never thought of it that way. But the headache is just one of the symptoms of migraine?

Awss Zidan, MD: Absolutely. Now we know that migraine starts well before the pain starts, and it ends well after the pain goes away. It involves multiple changes in the brain, hormones being secreted, neurotransmitters being secreted, and actual changes in the brain chemistry. And again, many of these symptoms sometimes are even stronger than the pain itself. They may not be. But they are always accompanying the pain, and they add to the disabling effect of it.

Host Amber Smith: What are the other symptoms besides a headache that a person might have that would tell them that they're suffering a migraine?

Awss Zidan, MD: Well, if we go to the same definition I just gave about migraine being a hypersensitivity syndrome, if somebody thinks about migraine this way, they will always be able to deduct and to extrapolate what other symptoms might be related to this. So light sensitivity, noise sensitivity are quite common ones. The smell sensitivity being just feeling every single smell is augmented is also one of the common ones in migraine. And actually that specific one might be the reason many people will have nausea, as it's nausea-inducing.

Another disabling one that frequently accompanies migraine is dizziness and vertigo. And if you think about it as hypersensitivity, it also follows the same paradigm. It's our inner ear and our brain being hypersensitive to the signal being sent from our balance centers, and hence that feeling of constant movement even if it's not happening. Now, all of these are part of the hypersensitivity feature.

Well, there is also another core feature of migraine, is that it's a brain dysfunction. It happens, as I said, even before the pain starts. And that brain dysfunction may manifest in many other ways. For example, the lack of concentration, the difficulty expressing words, the aura, which we will be talking about in a little bit. All of these might be other features that will accompany migraines.

Sometimes the brain dysfunction is so severe and so prominent that it mimics stroke, and that's when people start getting the numbness or the weakness that goes to one side of the body and hence makes them feel that they're having a stroke. I think these two features -- migraine being a hypersensitivity disorder, and migraine being a brain dysfunction -- these two features are the core characteristics of migraine.

Host Amber Smith: And when a person has a migraine attack, if you will, how long might that last?

Awss Zidan, MD: Migraine can last by definition anytime from four hours to 72 hours, if left untreated. Now, if somebody treats it, it may be much shorter than that. Like if, for example, somebody takes a medication and then the migraine goes away within one hour. That's still a migraine. But left untreated, migraine classically lasts four hours to 72 hours.

Every now and then, unfortunately, people will go into something we call status migrainosus, and they will go into a long migraine that won't break on its own. And this may last even way longer than three days.

Host Amber Smith: And how frequently might this happen?

Awss Zidan, MD: Frequency is all over the chart. It can range from once a month, once a year, to almost unremitting. Frequency in migraine is a very important attribute of it. And it should be thought of even more than just being a measure of how bad or how severe the migraine is. It actually affects so many things, including treatment decisions.

One thing that the medical community has agreed upon some time ago is classifying migraine into episodic and chronic. And basically the difference being to how frequent the migraine is. So now we identify that headache that happens more than half the month, with half of these headaches appearing like a migraine, is classified as a chronic migraine. While anything less than that is classified as episodic migraine.

Where is the important in that classification? The importance comes from the fact that when migraine keeps happening, when it's really, really frequent, pain brings pain. And it allows the brain -- it does not only allow, it obliges the brain, actually -- to be more sensitive to pain and to process it differently.

And hence, when somebody goes into a chronic migraine stage, they are usually on their way of continuous progression until that migraine becomes disabling and even daily headache, which what the frequency at its worst might reach to -- daily unremitting migraine.

It's really important for any person who has a migraine to identify this and to understand that missing the window of treating a migraine before it becomes chronic is quite important. It will change everything. It's really, it's much easier to bring a migraine that's happening eight times a month to something very minimal, like one or two times a month. While it's extremely hard to bring, let's say 25 migraine days a month or 30 days a month, to such a good range. That latter is a very difficult goal to achieve. It's still achievable though, so don't lose hope if you're in that category. It's definitely still doable. However, if you have a headache, and the headache is frequent enough, you should start seeking medical attention. I would say you should seek a specialist's attention if the headache frequency is increasing without reduction and with the treatment you're taking.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Awss Zidan. He's an assistant professor of neurology at Upstate, where he's co-director of the headache and migraine service.

So let's talk about who is most prone to migraine.

Awss Zidan, MD: I have a strong opinion about this. Unfortunately, it's women. The reason for that is that, as I said, migraine is way more common in women. It happens about three times as much in women, three times more commonly in women compared to men. Unfortunately, because of that, many men do not relate to migraine headache. They don't feel what it means, actually, to be having such a severe and disabling syndrome. And they link it to equivalent is a very common one, which is tension headache, which is a completely different story.

Women usually tend to get migraine more. I think the prevalence is about 18% in the U.S. population of women have migraine, while 6% of men have migraines. By the way, not to say that men don't get it. Actually they do get it, and it can be quite disabling.

Migraine can start at any age. It's usually, the peak incidence happens in early teenager years. So between 10 to 18 is where most people start having their first migraine, whether women or men. However the prevalence becomes much more common once we're in the fourth decade, so between like in the 30s is where the maximum amount of people who would have migraine would actually have it manifest.

Host Amber Smith: Do hormones play a role in causing or making a person more prone? If more women have migraines, does it have something to do with hormones?

Awss Zidan, MD: Absolutely. Migraine, I have to say it again just to make it very clear, migraine is not a simple disease with one reason. So that doesn't mean every migraine will have a hormonal role. And again, it's not only a disease of women. Men can definitely have it. But hormones can play a role.

For the majority of women, the role of hormone changes in inducing migraines happens toward the reduction of estrogen. So if you think about it, most women, before they start their menstruation, there is a very small amount of estrogen that doesn't change. After the periods start, after menstruation starts, then you start having an uprise in the estrogen level with every single menstruation, as it goes higher, higher, higher, higher. And then suddenly after the ovulation, if there's no pregnancy, the estrogen would drop quickly, and the period would start. And this drop is exactly what triggers migraine in many people with hormonal migraine. Again, not always, but that's a common scenario.

And you can extrapolate this to actually every single other scenario in life when it comes to hormonal migraine. That will explain why many women will have a reduction in their migraine after pregnancy because estrogen keeps going up, and it doesn't come down until after delivery. That will also explain why once women deliver, they have a resurgence of that migraine, and it comes sometimes ferociously. And that will also explain why migraine tend to occur at increasing frequency around menopause. And then after menopause, for many women, it'll calm down and become less frequent.

And please, again, for the third time, it's really important, these are generalizations. They do not apply to every single case. I've had patients who had their first migraine after menopause. I've had patients who got worse in pregnancy. Actually, many of them. That's not uncommon. So that doesn't apply to every single case, but I think that's a good way to generalize the information about the role of hormones in migraine.

Host Amber Smith: Are migraines hereditary? Do you see them in families?

Awss Zidan, MD: Migraine is mainly a genetic disorder, even if we don't have a single gene for it. So when we say genetic disorders, many people think about hereditary disorders, like the ones that have a single gene that will pass on to your children. And not all diseases are like that.

Most diseases, actually they have some genetic component, but it's not that it's a single gene that you either pass it or no. Think, for example, of hypertension. A family history definitely plays a role, but that doesn't mean every single one is doomed to either have hypertension or no, based on genetics. The same thing applies for migraine. Family history is extremely common. Most people who have migraine do have family history of migraine. And the reason for that, as I said, it's complex. There are multiple genes at play. These genetic changes probably have to do with the hypersensitivity situation I was talking about.

Another analogy I give to my patients all the time is that we all should have a gate to stop excessive sensory stimuli from coming to our brain. If we don't have these brake systems, then we will be considerably, all the time, overwhelmed by sensory stimuli. I mean, just think about it. We have nerves everywhere. And these nerves, even when we don't feel them, it's not like they're not doing anything. They're constantly sending signals, but our brain has grown to actually suppress that signal and put a brake on it. This is what happens in the majority of people. Migraine patients have a deficiency in that brake system. It allows this stimuli to come in more aggressively, and sometimes it's episodic. The gates open and close, and if you leave the gate open too long it dysfunctions, and then it becomes open longer and longer and longer until it's really hard to close it again. I think this analogy really helps with understanding migraine and how it progresses, and that main feature of the gate and the way it works has to do with genetics.

Host Amber Smith: So are there anatomical differences between people who suffer from migraines and people who do not? Like, is there some way, could you examine them in some way and tell that this person is likely to have migraines and this person is likely not to?

Awss Zidan, MD: This is a very difficult question with common diseases, Amber. Whenever you have such a common condition and you run studies to look specifically for things, you can find some statistical significance here and there. However, how relevant it is to the practice is really not that much. I wouldn't say there's any anatomical differences.

I would say, though, that many patients with migraine have evidence of that hypersensitivity, even in between the attacks, even when they're not having the attacks. Many of them suffer from car sickness, for example, because the stimuli that comes from the inner ear, the balance system is not working properly. Many of them express artistic behavior because they can feel lights and colors better. But I wouldn't say there is anatomical differences, per se.

There is one thing that comes to mind, which I don't know if it's really relevant. But some congenital conditions come with an opening in the heart. And this has been linked to increase in a migraine frequency. However, this is of very limited use in medical practice, in the way we currently practice. And it's a very rare thing.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast, with your host, Amber Smith. My guest is Dr. Awss Zidan. He's an assistant professor of neurology at Upstate and the co-director of the headache and migraine service.

Well, let's talk about how you go about diagnosing migraine. What can a person expect if their primary care provider sets up an appointment for them with you or a colleague? What can they expect at that appointment?

Awss Zidan, MD: Migraines, just like many headache disorders, are mainly clinical diagnoses, which is fantastic. It means all we need is a really good history, where you listen to the patient and you feel exactly what they're experiencing, and you see if it fits with that diagnosis or no, and how to best address it with treatment.

So the majority of the first time I meet with my patients will be basically just listening to their history, listening to how they had headaches, what symptoms they feel with their headaches, how much they're disabled by the headaches they're getting, what kind of effect it has on their functionality and social life, what treatments they've tried before, what has worked, what hasn't worked, what kind of treatment they're interested in at the moment, and then doing a physical examination to make sure that we don't find anything specifically that will alert us toward another condition. And if it's all done, and if it all fits within migraine, then many times it stops there, and we don't need to do anything further when it comes to workup.

However, sometimes, things come that are not very clear or that raise some question, and then it's reasonable to do some studies to exclude other conditions that can mimic migraine, like for example, such as MRI (of the) brain, or even getting some fluid from the lumbar puncture to look at the CSF (cerebrospinal fluid), the fluid surrounding our back. But again, that's not the common scenario. The vast majority of patients who come to the clinic with headache, they have migraine, and it's typically classical, and all it requires is a good history and good physical examination.

Host Amber Smith: Now you mentioned earlier the word "aura," and I wanted to ask you more about that. Because when you say classically migraine, isn't the aura -- the symptoms that someone might get before the headache comes on -- isn't that part of a classical migraine?

Awss Zidan, MD: No, it's not. Although the reason people have aura is very complex and might be present even in people who don't have aura. And I know this is confusing, so give me a second to explain it.

So, aura happens when a part of the brain start dysfunctioning. And here we're talking about the higher cognitive levels. We're talking about usually the visual cortex, the area where we process our vision, or the sensory cortex, the area where we process our sensation. Now typically, aura is visual. And it usually happens as seeing some kind of visual alteration that shimmers and then starts expanding little by little, by little, by little. It lasts anytime from five minutes to one hour, and then it stops. It goes away. And then usually the migraine headache would follow.

Migraine with aura is only 30%, so the majority of migraines are actually without aura, not all of them. And now whether that actually happens because the migraine with aura starts without the dysfunction that happens with aura, or whether that happens because the dysfunction happens in an area of the brain that just -- it's not easy to feel, like if it's not vision, if it's not sensation, how would somebody know? So that's still actually controversial and not very well settled. But the aura is one of the reasons why migraine is not just a headache.

It's a classical presentation of a symptom that involves the higher level of brain functioning that's getting disrupted during a migraine.

Host Amber Smith: I see. Let me ask you, for someone who headaches are becoming an issue with, do you advocate that that person keep a diary of their headaches, even before they come to see you, perhaps?

Awss Zidan, MD: I think academically and classically, the answer should be yes. Practically, I would say that if the person is a very good historian and they can keep track of their headache even in their head and they can tell like how commonly they have it and how long it lasts and what usually prevents it or what usually triggers it, then many times that would be sufficient.

Obtaining a headache diary is helpful in many aspects. Sometimes it's helpful for the person, for the involved person, to figure out if they actually have a trigger or no. Triggering with migraine is a very complex issue. It's not really easily settled. For example, most people will report that eating some food or having weather changes, smelling some smells, being subjected to bright lights, being deprived of sleeping, all of these can trigger the headaches, and these are usually, these are very common triggers that people report on their visits.

There are other triggers that people are not always aware of. Sometimes they may link specific food only. Sometimes they may link it to a certain time in their hormonal cycle. Sometimes they link it to certain exercises. And so sometimes it helps the patients suffering from migraine actually to just basically write down their migraines and write down what happened before, and then looking at it a few months later to find if they get a trigger that they can modulate or no.

That's one of the useful uses of headache diary. Another useful use is, making sure that they're responding to treatment well and that the headache frequency is actually coming down. If somebody, for example, let's say they're having 10 migraines a month, and then we give them treatment and it becomes two. I mean, it's a clear-cut improvement. Nobody would be, nobody will be, blind to this improvement.

However, it becomes much more complicated if, let's say, somebody has a daily headache that almost never goes away, and then 15 days of the month, the headache is really bad, and then when we treat, they still have daily headache, but it becomes 10 days a month. Now this difference might be missed. Sometimes, although it's important, it tells us the treatment is working, and we may need to up it or we may need to add to it. We shouldn't just dismiss it. So sometimes like that, it's helpful to keep a headache diary just to figure out the real effect of the medication.

In my experience, these are probably the most two common scenarios of why one would need a headache diary. And the best headache diary used to be very cumbersome, very annoying. It's like sheets of paper, and who would fill them out? I mean, it's really difficult. However, right now we have many apps -- I don't endorse any -- that people can use, and they can record their headaches, and with one look at their phone, it will give them all the frequency, all the triggers, all the characteristics of migraine. And that can be quite helpful for both the patient and their treating physician.

Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast with your host, Amber Smith. My guest is Dr. Awss Zidan. He's an assistant professor of neurology at Upstate and the co-director of the headache and migraine service.

In terms of treatment, what are the medication options, and how do you decide which is best for each patient?

Awss Zidan, MD: First thing that we typically educate patients on is the difference between preventative medication and rescue medication. So what that is, Amber, is that medications can either prevent migraine, making it less frequent, and that typically happens by routine use of the medication. And rescue medications, which aim to stop the migraine after it happens. And these two should not be mixed together.

For example, if somebody takes over-the-counter medication like Tylenol or ibuprofen, and it makes their headache go away, it's a rescue medication. Taking this medication on daily basis will not be helpful and most likely will be harmful. On the other end, somebody who's taking a preventative medication, and they used to have eight migraines a month, and now they're having two, but the two are still miserable, they are still terrible and very debilitating. Well, that's not the fault of the preventative medication. It did what it's supposed to do. But now we need to focus on a rescue medication that can get us out of that severe headache.

So, these two treatment lines need to be separated in the mind of the patient, and they need to know that they're attacking different parts of their migraine.

So, when it comes to preventative medication, we have many, many, many options. Unfortunately, most of the migraine treatments that are preventative, they were not originally made for migraine. They were made for other reasons, and then they were found to be effective in migraine. Many of these medications are antidepressant or seizure medications, anti-neuropathic pain medications, blood pressure medications and sometimes supplements.

Sometimes that really scares people off these medications, like they don't feel like they want to take one of these. I mean, the names, rightly so, may feel intimidating -- that I'm taking now a medication for depression, or for epilepsy, for seizures. However, in reality, if you have a conversation with your physician, you should be made aware of all the side effects that may happen. And the majority of these medications, when they're used in the right way, in the right circumstances, they're quite benign, and they can be quite helpful.

Recently, in 2018 specifically, a group of preventative medication was developed, and that's called CGRP medications. So CGRP is a hormone or a neurotransmitter, basically meaning a chemical in the brain, that's secreted heavily in migraine. And opposing that neurotransmitter, or blocking the effect of that chemical, has been found to be extremely helpful in migraine. And this was one of the first classes of preventative medication that aimed specifically to target migraine. And it has represented a very good option so far. We have had many medications in this family, and new medications are coming out every year. So the list is expanding. So I have to say, in the last few years, migraine treatments have changed drastically.

Host Amber Smith: Are the over-the-counter pain relievers, like aspirin and ibuprofen, are those just ineffective in migraine?

Awss Zidan, MD: These are rescue, Amber. So they are, they can be, quite effective. Many times I don't even change them if the patient feels good on them and if they are using them appropriately.

So these are rescue medications, and rescue -- as long as it's not being overused, as long as it's being used rationally and in the right circumstances and with the known expectation of what it might do -- then all of these can be very helpful medications. So over-the-counter, Tylenol, aspirin, many of the combination medications for the migraine, all of these are reasonable rescue medications.

We also have a family called triptan, and this was also a family that got developed many years ago. And it helps with the rescue of migraine headaches. People need to take it as soon as possible when they get the headache because of that gate effect that I was talking about. Again, imagine we have a gate open, and we want to force it closed as soon as possible. The longer we leave it open, the more things that have gone through, and the changes in the brain have already started, so it might be too late to fix that. Triptans is also a very good option for rescue.

And recently, some of the CGRP medications that I was talking about have gone from being purely preventative to being rescue medication as well. So that's another line that was added to our arsenal and been very helpful.

Host Amber Smith: So what happens without treatment? Will the migraine eventually resolve on its own, or does it do lasting damage if it's not treated?

Awss Zidan, MD: Anything can happen. I don't know if lasting damage would happen just from migraine.

Migraine is linked to some changes in the brain that we can see on the MRI, specifically in something called the white matter. However, we are still not sure what these changes mean. We don't know if they actually affect anything. We do not believe so. We don't believe that they significantly affect the overall outcome. So yes, there are some changes that happen with long untreated migraine, but, again, I'm not sure what that means in terms of health and overall outcome.

However, one thing that gets affected for sure is the work status and overall quality of life and the socioeconomic status and the social life. Multiple studies have shown that people with migraine feel that they are not good parents. They don't feel that they get the support of their spouses. They feel that they are sidelined in social ceremonies. They feel that they can't work to their best potential because of headache. And all of that is severe and devastating and requires attention and requires treatment.

So I always encourage people to really think about, to consider their options and think about initiating treatment when migraine comes to an extent where it's affecting their function. We have many treatments now. Needless to say, there is no treatment that's absolutely devoid of side effects. The possibility of side effects may happen. However, that doesn't mean they will always happen. That means they may happen. And we have so many treatments that no one needs to settle for anything. We can just keep trying until we find something that works really well and has no adverse events on the patient taking it.

I think that's one big message for people listening to us today.

Host Amber Smith: Well, I'd like to ask you what people can do on their own, to sort of help manage their migraines, and I guess one thing is they need to learn what their triggers are, and you can help them with that?

Awss Zidan, MD: Correct. I, for one, believe really in the importance of patients owning their disease and advocating for themselves. More than anything else, I think that's what helps them the most, is just recognizing how debilitating their migraine can be, how many aspects it can affect in their life, and being aware of that effect rather than just getting the self-blame of this being just a headache and that they're not tough enough to actually be able to function with it -- because that's really not the case.

I tend to underestimate the role of trigger avoidance in managing migraine. And I think because the overstress on this factor has played into the victim-blaming for migraine patients. It has played into that, "Oh, it's your fault. Like you just, you need to stop that diet. And don't do that. And don't do this. And then sleep well, and stay hydrated."

And no, no. Like, I mean, yes, it can play a role, but no, it's like many times that's totally not enough, and something should be done to help more than avoiding triggers.

So people can avoid triggers, and it may help. It may not have a significant effect. Actually, the majority of people are interested in alternative pathways, and this includes supplements and diets, which are OK. There are a few supplements that are believed to be helpful in migraine. Most of these supplements work for the mild frequency of migraines. You shouldn't expect too much out of it. You should expect some reduction, but nothing life-changing for the majority of the patients.

Obviously, needless to say, there are always exceptions. There are always patients who did one thing different, and then things changed completely for them. There is the patient who took one supplement, and then it changed the nature of their migraine. There is the one patient who avoided one trigger, or followed one diet, and then it changed their whole migraine. But please be aware, migraine is not the same disease in every single patient. It's quite different. And because that happened -- and believe me, it's quite rare, it's extremely rare for that to happen -- because that happened, that doesn't mean what they did is the right thing for you.

So by all means, I always encourage my patients to try supplements, reasonably, at least the ones that we know that are safe and don't have toxic effects. I do not discourage them from trying any diet at all. I just ... I try to keep the expectation as to what that means for their overall management.

Host Amber Smith: Have you seen patients who have been helped by acupuncture?

Awss Zidan, MD: Acupuncture is very controversial. In general, when people attend to their migraine, attend to their disease, they do feel some improvement just by the fact that they become on top of it. We call that the placebo effect. So in general, most migraine patients have really high placebo effect in clinical trials. And basically what that means is that, let's say there is a treatment, a whatever it is, and then there is the placebo (a useless treatment or medication). And by the end of the trial, we find that patients with treatment A had some reduction of their migraine, 30%, and even the placebo had significant reduction in their migraine. And that effect is very common in migraine patients, and part of it is because care is better than no care, even if that's placebo.

Patients who feel cared for, and people who come to clinical visits, or they do something about their migraine, they're changing something in their life. And that usually make things do feel better a little bit. So acupuncture is one of these very controversial things. It's harmless, which is the reason I don't discourage people from trying it. I don't think it's life-changing for any patient, to be honest, when it comes to reduction in headache frequency. But if you do it, and you feel your headaches are getting better, go ahead. I'm with you.

Host Amber Smith: Does migraine affect other health conditions that a person might have?

Awss Zidan, MD: There is a specific connection between migraine and heart diseases and stroke. That came from a few studies that looked at a very large population of migraine patients. And they found that migraine, especially the one with aura, carries a little bit increased risk of having stroke and heart attacks. Now, before you get freaked out, this increase in incidence is quite rare. Statistically, it has a very little significance.

Now, one condition where this becomes a prominent issue is the combination of migraine with aura, smoking and using of contraceptive pills, so hormonal therapy. Now these three conditions together can increase the risk of strokes and blood clots by a significant amount. We don't know the contribution of every single one of them, but we know that these three conditions together, they have an added effect on each other. So I try to avoid being one of these three conditions at the same time. So typically, for example, our patients with migraine with aura, we highly encourage them not to be smokers. We highly encourage them to use contraception methods that are void of estrogen, not to increase their risk of blood-clotting.

Host Amber Smith: Is there a connection between neck pain and migraine?

Awss Zidan, MD: This is probably the topic that I'm most passionate about, as being a pain management physician and a headache specialist at the same time. I think I love that link between musculoskeletal and migraine, which is a brain disorder.

The link between neck pain and migraine is absolutely there, and it's very common, and it needs to be addressed individually. So what does that mean? So the way we should look at this is that the same nerves that trigger the headache, which is mainly in our head, is the trigeminal nerve. The trigeminal nerve is the sensory nerve in the head, is the major sensory nerve. Now this nerve has very tight connections with the nerves that come from the neck and from up our upper cervical spine. So these two have really tight connections together. They cross multiple times in multiple areas. Because of that, and because of what I talked about, migraine being a condition of hypersensitivity, one might lead to the other.

So migraine patients may feel that their neck is getting stiff and they're getting neck pain and that their headache is transferring from the back of their head to their neck all the time because of that connection. The opposite is true. People with neck pain, that neck pain may trigger the nerve and may trigger a migraine that may become very resistant to treatment unless you treat underlying disease, which is neck pain.

So neck health is extremely common in migraine. This absolutely stands true for people who, for example, noticed increase in the severity of their migraine after a whiplash injury or after long screen hours by the end of the day when they're sitting in an un-ergonomical position, and in general in people who think that they have a chronic neck pain and then on top of it, headache, rather than headache with some neck pain.

Host Amber Smith: So they might be totally connected?

Awss Zidan, MD: They are absolutely connected.

Host Amber Smith: Do you have patients, migraine patients, who you see become cured of migraine, where they just, they stop having migraines and they stop needing their medication? Do people kind of outgrow this, ever?

Awss Zidan, MD: I mean, just like the analogy of high blood pressure -- I don't think anyone gets really cured of hypertension -- the same thing: Migraine is mainly a genetic contribution with some environmental factors. It's modulated by many triggers in the surrounding area, in the vicinity. So I don't think anyone truly gets cured from a migraine. If you have a migraine, you're always going to be at risk of having an attack one time in your life.

Now frequency, though, does change a lot with life, as I said. Usually the 30s are the bad times for migraine, when it's most prevalent. However, it can happen at any age. The natural course of migraine is that a significant portion of migraine patients would describe that their migraine settled with age and became less and less frequent. If this were always true, it would've been very easy; my patient population would stop at certain age. But unfortunately it's not. However, it's something that's frequently noticed and conveyed to us by migraine patients.

Host Amber Smith: Dr. Zidan, thank you so much for making time to tell us about migraine.

Awss Zidan, MD: You are more than welcome, Amber. Thank you for giving me the platform to talk about this topic.

Host Amber Smith: My guest has been Dr. Awss Zidan, who co-directs the headache and migraine service at Upstate, where he's also an assistant professor of neurology.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe.

Find our archive of previous episodes at upstate.edu/informed.

This is your host, Amber Smith, thanking you for listening.