Dealing with crowded ERs; treating migraines; exercises for seniors: Upstate Medical University's HealthLink on Air for Sunday, March 19, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," an emergency physician explains why hospital ERs are so crowded lately.

Bill Paolo, MD: ... The emergency departments across the country are absolutely busy, busier than they've been, but it's important for everyone to note that we are still the place, the most effective place, the emergency department, to seek acute care for potential or actual life-threatening injuries, medical conditions or what have you. ...

Host Amber Smith: And a neurologist and pain specialist discusses migraine -- and it's not just a headache.

Awss Zidan, MD: ... 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. ...

Host Amber Smith: All that, some expert advice about the best exercise for seniors, and a visit from The Healing Muse, right after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, meet a doctor who is passionate about helping migraine patients find relief. Then, an exercise physiologist goes over exercises that are good for seniors. But first, an emergency physician explains why hospital ERs are so crowded and what you can do if you have a medical emergency.

From Upstate Medical University in Syracuse, New York. I'm Amber Smith. This is "HealthLink on Air."

Hospital emergency rooms across the nation are dealing with severe overcrowding. To understand why and what can be done about it, I'm talking with Dr. Bill Paolo. He's the chair of emergency medicine at Upstate.

Welcome back to "HealthLink on Air," Dr. Paolo.

Bill Paolo, MD: Thank you for having me.

Host Amber Smith: The Institute of Medicine did a study before the pandemic that showed more than 90% of emergency room directors in the U.S. reported overcrowding to be a problem, and 40% said it was something they dealt with daily.

What has happened over the last three years, during the pandemic?

Bill Paolo, MD: The pandemic dramatically shifted the health care landscape in many different ways. The biggest way by far has been the losing of staff because of the pandemic itself. So we've seen a turnover of around 10% of the health care workforce, and that comprises all of us, doctors, nurses, physician assistants, nurse practitioners, who have left medicine because of the stress of the pandemic, because of the personal health concerns of the pandemic or because of various personal reasons having to do with the pandemic.

So what we're doing, effectively, is going into the other end of the pandemic with a team that is much smaller than the team we had going into the pandemic to care for individuals who need our care.

Host Amber Smith: And it sounds like that's not a quick fix.

Bill Paolo, MD: No, unfortunately. At least as early as 2001, the Institute of Medicine had done a study looking at potential nursing staffing crises, by way of example, and predicted that by 2020 we were going to have a large nursing staff crisis in the country.

And certainly by 2030, was the most dire predictions. And I think what you're seeing is an acceleration of those predictions by almost a decade because of the pressures that the pandemic put upon us. So, the fix is slow, unfortunately, because this is a turnover of skilled individuals coming into the system that we need to recapture.

So we've lost a lot of intellect. We've lost a lot of people who've had a lot of time in the profession to care for individuals.

Host Amber Smith: Is that the only reason for the overcrowding?

Bill Paolo, MD: That's one of the biggest reasons for the overcrowding. But what you have to understand when I talk about that, too, is the emergency department is the end/common pathway of a lot of systems that happen all throughout the health care system.

So, by way of example, if there are less primary care providers for a patient to see, and you can't access primary care providers, you know an emergency department is open 24/7.

On the other end, thinking about it in a different way, if you get admitted to the hospital and, say, you broke your leg and you needed to go to a rehab facility. If there isn't a rehab facility bed to take you, you spend longer times in the hospital, therefore not allowing a patient who is new in the emergency department to move into that bed space.

So all of these create logjams in the system that creates crowding in the emergency department.

Host Amber Smith: Do you know what percent of emergency patients come there without having a primary care provider or without being able to get in to see their primary care provider?

Bill Paolo, MD: There are studies that look at this, and it's variable from geographic region to geographic region. In Central New York, the most recent study said that only around 40% to 50% of primary health care needs are met, and there are some barriers to access to care. When we've studied individuals, we find that there are multiple barriers to access care, even if you've obtained insurance and the ability to get care.

Maybe your doctor isn't open the hours you work, or the doctor's open the hours you work, and so you can't get to your doctor because you need to work. Maybe you have children, and you have to take care of them. Maybe your doctor requires a long bus ride away. So there's multiple access points that make it more difficult.

So when we study it, we find a good number of people are having trouble accessing primary care. And that's probably worsened recently as more people have been driven into the system and more people, in terms of the physician and health care end, have been driven out of the system.

Host Amber Smith: Can you explain what "boarding" is?

Bill Paolo, MD: Sure. So, if you come to an emergency department, and you are sick, and you need to be admitted to the hospital, the next step is to get you a bed within the hospital.

So, say you came into the hospital, and you had chest pain, and we found that we were concerned you were having a mild heart attack that didn't need any acute interventions or surgery, but you did need to be admitted to the hospital to be taken care of by doctors and to be medically optimized and to have rehab, by way of example. What we would then do is move you from the emergency department to an inpatient bed, so, somewhere within the hospital, outside of the emergency department.

What's happening is that the hospitals are so full that there are no available beds for that individual to leave the emergency department to take an inpatient bed.

So a boarder is somebody who needs care rendered by the hospital but can't leave the emergency department because there isn't a bed for them.

Host Amber Smith: And even if you had more beds, you don't have the staff to take care of people in those beds.

Bill Paolo, MD: Correct. One of the things that's always difficult to explain is that beds aren't just a physical bed.

They are staffed by somebody, because a bed is only an effective hospital bed if there's somebody there, a team, to render you care. So the bed in and of itself is defined as a bed that's available to be taken care of by a team. So it depends on how many nurses, doctors, custodians, food service workers you have in a hospital to make that bed into what a human being needs to render care.

So, effectively, we've had less of those because we've had less staff, and that contracts the amount of inpatient space that we would otherwise have.

Host Amber Smith: Well, let me ask you a little bit more about the staffing. In terms of emergency physicians, do you know how many complete residency each year and then will be looking for jobs?

Bill Paolo, MD: Sure. So, the turnover rate for emergency medicine is around 2,700 new physicians are produced every year. Interestingly, in 2020, the American College of Emergency Physicians put out a study that said, given some assumptions about where we were in the teens, we expect to be oversaturated with emergency medicine physicians by 2030.

Now, this was a study that was based upon the presumptions of a certain amount of turnover, a certain amount of medical students that are interested in going into the career, a certain amount of retirements at a basal rate. The problem has been that the past three years have completely blown up those assumptions, and we've lost a lot of physicians, so that data is very unclear what that will look like going forward.

And so what we're seeing now is less medical students, at least this past year, chose to go into emergency medicine than in any previous year. And we don't know whether or not that will be a trend, but it's certainly concerning to say potentially medical students are looking at what the emergency departments have been through in the past three years and saying, "Maybe that's not for me."

And so we don't know what this will look like for the future of the emergency medicine workforce because all of our presumptions are pre-pandemic.

Host Amber Smith: What about nurses? Do they still see the emergency department as an exciting place to work and learn?

Bill Paolo, MD: I think so, but I think the reality of the emergency department has become very difficult recently.

The emergency department generally attracts very altruistic, high-energy individuals who like to be there for people who are having their actual or perceived worst day of their life.

The problem for us recently has been that we do it with teams that are much smaller than we need. So, effectively, the demoralizing part of this is that we are good at our jobs, but we are having trouble doing them because we don't have enough people to do them, so I think that kind of stress also applies to the nursing staff, who have the same sort of predispositions that we all have, which is they want to do the best job they can but frequently feel like the system around them is falling apart so that extra stress gets put on them.

And that what you mentioned earlier, those characteristics, the exciting, interesting place to work and learn, becomes more of a "I'm going to deal with it for a couple of years, so I can go on to a more comfortable place."

And that is a drain of intellect away from a place where we need it, like the emergency department.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Bill Paolo. He's the chair of the department of emergency medicine at Upstate, and we're talking about overcrowding in the emergency room.

Now, despite the crowded situation, are people with serious illnesses and injuries still able to receive good medical care in a timely fashion in the emergency department?

Bill Paolo, MD: Yes. I think this is important for everybody to note: The emergency departments are absolutely in crisis, the emergency departments across the country are absolutely busy, busier than they've been, but it's important for everyone to note that we are still the place, the most effective place, the emergency department, to seek acute care for potential or actual life-threatening injuries, medical conditions or what have you.

And we always encourage everyone, if you think you are having one, and you don't know because you're not trained, come to the emergency department, so we can tell you whether or not you're actually having one of these emergencies.

People, if you are considering that this is disconcerting enough to seek care, then come seek care with us.

What we are finding on the flip end, however, to your question, is that when you do come to the emergency department, you are waiting longer than you ever have before. So we are rendering care, and we are getting you back, and our queue is defined by the sickest.

So it doesn't matter when you arrive. It matters what you're arriving with that determines when you get back. So we take care of everyone. It's just that it's taking us longer to take care of people than it had in the past.

Host Amber Smith: Can you give any guidance for a person who's trying to decide between the hospital emergency room versus an urgent care center or something like a specialty orthopedic service?

Bill Paolo, MD: Sure. For urgent-care-type stuff, I think of this as low-acuity episodic care needs. And what do I mean by that? I mean, it's something that you are otherwise well, but have some sort of condition that is minor to you that needs treatment today. So what would things like that be? If you have a small laceration or a cut, if you have a small infection or a bug bite, if you think you have a cold, or you wanted a COVID test, and you're not very sick.

All of those things are great to go to an urgent care center for. They're good at taking care of these low-acuity episodic needs. What I mean by episodic is, it's something that you can't wait for your primary care doctor in a couple weeks. You need it taken care of today. But it's not so bad that you need to go be taken care of at a tertiary-care trauma center (such as Upstate University Hospital), by way of example, so your lacerations, your cuts, your bug bites and what have you.

For things like the orthopedics, like (the) Fly Road (facility), who has a walk-in Ortho Now clinic, things like sprains, strains, I think are perfect for that. Athletes who are young, who may have potential fractures. Minor trauma goes well there.

Anything that's bigger than that, you fall, you hit your head, you think your arm is broken, your femur (thigh bone), that's the emergency department. That's what we do. That's what we do well. So I think if you know you have a condition that needs care today, but you aren't so sick that you feel that you don't know whether or not you have a life- or limb-threatening condition, you can go to an urgent care.

And the final thing I'll say on that, too, is that urgent cares are generally pretty good at: then, if you go there, and they say, "Oh no, this is worse than what we expected," pretty good about sending you to the emergency department once they've identified a condition that may be above and beyond their capabilities.

Host Amber Smith: Well, even though it's crowded and the wait may be a long time at the hospital emergency department, some people can't really avoid coming there. Do you have some tips for making things go a little more smoothly?

Bill Paolo, MD: Sure. It is a busy, crowded place right now, and whatever you can do when you come to our emergency department to kind of get yourself through it, whether you're bringing a book or your iPhone or a charger, anything that will provide you some of your creature comforts that you need to deal with a potential wait. So, whatever it is that you need to deal with that wait I think will help you in the emergency department.

We try to supply food and snacks to patients who can have food and snacks. Not everybody can. If you're coming in with abdominal pain, and we're worried you might have appendicitis and need surgery, we're not going to give you food. But if you're coming in because your elbow hurts, and we don't think you need surgery, we're going to feed you. So anything that gives you comfort while you're waiting.

The other thing I would say is, if you are concerned about your wait, you can always talk to the individuals that are there. We have charge nurses, we have triage nurses, the doctors are there. And we're re-evaluating you in a certain periodicity, usually every one or two hours, to see where you are and looking at our emergency department.

But the anticipation, unfortunately, is that the wait is longer than it ever had been in the past.

Host Amber Smith: So when you come in and you're triaged, you see someone pretty quickly when you come in, then they sort of categorize how urgent you are, right?

Bill Paolo, MD: That's correct. So based upon a number of different items, historical data, what you're complaining of, your vital signs, you get assigned a certain triage level, essentially one through five, with five being the least acute -- you know, "I'm here because I need a COVID vaccination," by way of example -- to one being the most acute: "I'm here because I'm in full cardiac arrest."

So you get graded with that, and your gradations may change depending upon how conditions change as it goes. But generally, you get into these categories, and we're moving you in and out of the emergency department based upon those categories and where you are and how sick you are in a triage system.

Host Amber Smith: All right, so that's mostly for adults. What is the situation for children who need emergency care?

Bill Paolo, MD: We have a separate pediatric emergency department in the Golisano Children's Hospital. Obviously, the same conditions that we're dealing with in the adult emergency department, we're dealing with the pediatric emergency department.

So, we're still dealing with crowding and staffing issues, but what we try to do is from the age of zero all the way up to 18, take individuals out of the adult emergency department and provide a very separate space, different needs, different type of nursing needs, different sort of support.

We have child life specialists who are there to help individuals and help kids and parents through, potentially, procedures dealing with the emergency department and dealing with the discomfort of needing emergency department care, the scariness of getting an IV, potentially.

So we have specialists that are there to help with all of that. So we very much take kids into a separate emergency department to ensure that they have a much more comfortable place to be seen that is specifically for children.

Host Amber Smith: Thank you for making time for this interview, Dr. Paolo.

Bill Paolo, MD: Thank you. I appreciate your time, and I appreciate the chance to get to talk to the community again.

Host Amber Smith: My guest has been Dr. Bill Paolo, the chair of emergency medicine at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

A description of the various migraine treatments -- next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

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 "HealthLink on Air," 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 kind 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 follow 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 importance 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 "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Awss Zidan. He's an assistant professor of neurology at Upstate, where he is co-director of the headache and migraine service.

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 there is some congenital conditions, comes 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: 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: Migraine, 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 in 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 raises 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 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.

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 starts 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 start 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: Upstate's "HealthLink on Air" has to take a short break, but we'll be back shortly with more about migraine with Dr. Awss Zidan.

Welcome back to Upstate's "HealthLink on Air." I'm your host, Amber Smith. My guest is headache specialist Dr. Awss Zidan. He's an assistant professor of neurology and co-director of the headache and migraine service at Upstate.

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 happenss. 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 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 close 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 be 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 void 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 need 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. 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 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 for it. 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 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 in 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 the 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. I wish 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. I'm Amber Smith for Upstate's "HealthLink on Air."

Here's some expert advice from exercise physiologist Carol Sames from Upstate Medical University. What exercises do you recommend for seniors?

Carol Sames, PhD: So generally, I usually, when I talk to seniors, I say what do you enjoy doing? Because this is a lifestyle change. So you don't want to have people engaged in an activity they're not interested in. Not surprisingly, most seniors engage in walking. It doesn't require any types of equipment. It's fairly straightforward. Of course, you need to have a place to walk. But here in Central New York, we do have a lot of wonderful places that we can go. Winter's a little bit more challenging, but a couple of the malls will have indoor facilities that you can walk in early in the morning, before they get busy.

But if somebody says something like, I really enjoy yoga, or I really enjoy my water aerobics class, wonderful. If somebody says I have a stationary bike that I've been using to hang my clothes on, but I'm going to use it now, wonderful. The whole idea is that I want to be consistent, that I want to try to achieve the activity guidelines. And so whatever that activity is, great. If you want to mix it up, wonderful.

Host Amber Smith: You've been listening to exercise physiologist Carol Sames from Upstate Medical University.

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Bryana Barreto worked in EMS (emergency medical services) for seven years before starting medical school in 2022. Her poem "Thank You for Your Service" asks us to think more deeply than just giving a quick shout-out to health care workers who are as exhausted by this pandemic as we are.

Thank you for your service

For everything you do

Thank you for fighting the fight

We would have never made it through

Thank you for your service

That's what they say

We smile, nod

As they go on another day

But the looming weight remains

Bottling everything inside

Move on and keep going

An inner contract we abide

No time to stop

No time to pause

Another goes home to their family

We line up, give an applause

But the looming weight remains

It never gets lighter

Can't put this burden on my family

My chest fills, gets tighter

Seeing friends, colleagues, slowly splinter

Burning out, quitting

Never thought it would get this bad

Our hearts keep splitting

But the looming weight remains

I'll just push on through

Keep reminding myself, I love this profession

Or at least, I think I still do

Hold on to the wins

Remember those lost

I will persevere

Until I exhaust

Two years and counting

When will this fight end

Don't know how long I can continue smiling

Don't know how much longer I can pretend

Thank you for your service

That is what they say

We smile, nod

As they go on another day

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York.

Next week on "HealthLink on Air," a scientist describes his work in protein and DNA engineering. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel.

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