Unknown Speaker 0:03 Hi, my name is Noreen Jamil and this is Unknown Speaker 0:05 Emily Kate Stevens. Unknown Speaker 0:07 Both of us have been diagnosed with long COVID. And we've Unknown Speaker 0:11 created this podcast dedicated to the condition. Welcome to the long papered sessions. So Norine How was your week? Unknown Speaker 0:24 This week has been Unknown Speaker 0:27 say good, say it's been good. That's been great. Unknown Speaker 0:30 What I do now is I try and ignore my symptoms. So I could say yes, it's been fantastic. Because you know, when my heart's racing, I'm like, shut up. Norine. You will find just carry on. Yeah. Because it's either that or give up. Right. Unknown Speaker 0:43 Yeah. I mean, I'm we had a conversation the other day, didn't we were I was really down about it. And I think that your attitude is possibly healthier mentally. Because we've got to keep going. We've got to keep positive. Unknown Speaker 0:54 Yeah, I mean, everybody has to, I understand like, you're almost twice as long into your long COVID session. As I am, I have, I do understand the difference. But, you know, there's so much else going on, like both my kids have birthdays this week and taking care of my elderly parents. I just, I can't sit around anymore. And just keep worrying about every tiny twinge that I have fair enough. Because, you know, we're trying everything we can to get healthy. We're seeking all the best medical help. We're trying to get. The people that we speak to, to speak to all our listeners, we're getting some good advice and some practical advice. Really just trying to give something back. And I think you can't ask more of us than that. Given that we're not well either. Think you're doing a phenomenal job. So you mean Emily, how was your week love? Unknown Speaker 1:45 Well, you saw me partway through it. It was really rubbish. And the days of feeling bad have been a lot but I am now on my second day of getting out of bed without feeling like I drank two liters of vodka last night. today. I feel good yesterday. I felt good. So I'm just going to take those two days as a small one. And fingers crossed tomorrow I'll be good two Unknown Speaker 2:09 fingers crossed. I'm sure you will be just stopped drinking vodka. Unknown Speaker 2:14 Obviously, I have not been drinking. Unknown Speaker 2:17 This week who we have on Unknown Speaker 2:19 Dr. Katie Monroe, who is a headache specialist at the National migraine center in London. This this week is going to really you know annoy people who say migraine or migraine because we repeat the word both ways. multiple times throughout throughout the interview. It's an episode about migraine. And Dr. Monroe is a she was just so lovely to talk to Wasn't she, I would love to be able to go and see a doctor who listened to me the way that she sounds like she listens to her patients. Unknown Speaker 3:00 I mean, that's why she has such good podcast as well, for her own specialty. But there was so much crossover between what she was saying about migraines. And what we are seeing generally about long COVID Unknown Speaker 3:14 Yeah. In the in the mechanisms in the symptom fluctuations. Yeah. Unknown Speaker 3:18 I think one of the most interesting things that she said would be about children, which I did not even have the foggiest clue about the way that migraines manifest in kids is not in their heads. And I think for the children with long COVID or parents of kids with long COVID This episode would really might open some doors for them. Can you explain to our listeners, what exactly is a migraine and the difference between a migraine and headache? Unknown Speaker 3:53 The first thing to say is I talk about migraine rather than a migraine. Because migraine is a primary headache disorder. It's a genetic, neurological condition. And the genes for migraine give you the vulnerability to have the symptoms of migraine and the symptoms include headaches. So headache is a symptom. Migraine is a diagnosis. And that's quite an important distinction. So when I'm talking to people about what's happening to them in their episodes of illness, I try and say to them, let's talk about migraine attacks, rather than migraine because migraine is the disorder that you're suffering from in the same way that we were talking about asthma and asthma attacks. Unknown Speaker 4:39 So if you just have a headache, Unknown Speaker 4:43 yeah. You're gonna say that awful phrase, just a normal headache. So now I'm going to bang my soapbox about that phrase. So there is no such thing as just a normal headache. A headache is a symptom of something you wouldn't say to May, if you had the normal rashes that everybody gets, because people know that rashes are not normal. And not everybody gets headaches. Some people never get headaches. And so just the normal headaches is the wrong sort of term. Or you need to be saying as why am I getting these headaches? What is the underlying reason, and usually, usually that is that you also have migraine or disorder. But it might be that you've got a headache because you've had a head injury, or you've had an infection, or you've may have something more serious going on. So there's a number of different conditions that can cause headaches. And some people with migraines, only get them very occasionally and get them quite mildly. So there's another myth, which is that migraine attacks have to be really, really severe, they have to put you in bed for three days. Otherwise, it doesn't count as a migraine headache. And I would say that's wrong. So this is why many people in the population have headaches, they think, just the normal headaches. But actually what they're getting is migraine attacks, and they just haven't had that diagnosis. So really, really common one in seven people get it. Unknown Speaker 6:11 Can you explain to us how you would diagnose migraine, Unknown Speaker 6:16 mainly, it's on the history as what people are telling me. So basically, if somebody comes to my clinic and says I'm getting recurrent episodes of headache, and I get sensitive to light, sound, movement, or smells, or touch, and I sometimes get nausea or vomiting, and it stops me doing what I want to do, or reduces my ability to do that, and I'm getting them but in between, I'm absolutely fine. That is very, very likely to be migraine. But not everybody with migraine gets headache. Some people get migraine attacks, which are dizziness, and some children get migraine attacks, which are mainly abdominal pain. So I think we need to be careful not to confuse a migraine attack with a headache. But headache is a common symptom that people do get with migraine attacks. So Unknown Speaker 7:09 have you seen a big uptick in migraine referrals to the national migraine center since long COVID or since COVID. But since long COVID became a phenomenon? Yes, we Unknown Speaker 7:21 absolutely have we have been inundated people can self refer to us, they don't need to go via their GP, they can just fill in the booking form on our website, or pick up the phone or leave a message on our info line. And we have seen a massive increase in the number of people asking for appointments. And there's a number of reasons that I think we know from some studies that people with migraine have found that the pandemic for lots of different reasons, has increased the frequency of their migraine attacks. Of course, it also decreased the availability of neurology appointments. And many neurologists were co opted onto COVID wards at the beginning, lots and lots of outpatient appointments are canceled. And there's also been some new treatments coming through which were approved on the NHS last year. And people have begun to know about those. And so they've come to ask the question, how do I get those? Would that be suitable for me? And and I think generally people know more about us at the National targeting center, because one of our missions is to raise awareness about migraine, and educate people. And we do that via our own podcast, which is called Heads Up podcasts, which is brilliant. Well, thank Unknown Speaker 8:36 you. And to be clear, self referral to the national migrant center is via the NHS, it's no Unknown Speaker 8:42 no, no. So the national migrant center was set up about 40 years ago as a charity. Okay, we're not linked to the NHS at all. We don't charge a fee at the moment, other than for the expensive treatments like Botox and the anti CGRP drugs, we have to charge for those. And we asked for a donation from patients who come the whole idea of the charity was to make good quality advice and treatment available to anybody who gets migraine attacks. And I think we really are trying to hold on to that. But it's been a very hard year for the charity and for most charities, because donations and fundraising have been really impacted by the pandemic. And the numbers are going up. Yes, we've got a lovely cohort of new doctors who are training up at the moment because we really, really want to reduce our waiting list and get to see people quickly. We also most of our doctors are GPS with a special interest and they've had extra training and they can really get into very expert levels of training about migraine and other headache disorders. But of course some of them are working also in the NHS as GPS and GPs are inundated at the moment and really working very, very hard. Trying to keep as I've had a huge amount of increase in patient contacts, and also a reduction in GP numbers. So yeah, it's been hard. Unknown Speaker 10:09 So how do you get the medicine? Is it via prescription? Or do you refer back to the GP if you're not part of the NHS. Unknown Speaker 10:17 So what we firstly do is we spend a lot of time talking about lifestyle, supplements, things that people can do themselves to try and manage their migraine better. Often, it's about knowing how to use the medications they've already been given, but may not have been given accurate information about the best way to use them. So often find that people have been told all you can have this trip time, but it's really, really strongly shouldn't take it unless you're really really unwell. And that is really the wrong advice. So the best time to treat your migraine attack is when it starts as soon as you can, because it's a bit like a snowball, it gathers, momentum gets bigger and bigger. And if you delay treating it, then you're very likely to not manage to get rid of it. And there's so much medication that is can be really, really helpful. But if they need a further prescription, we can do private prescriptions, and then people would have to pay for those. Or we can ask their GP and we send a really long an explanatory report to GPS, I hope GPs have time to read it, we try and put the bullet points at the top and say to GPS, please could you prescribe X Files that and normally GPs are very happy to do that, and helpful and supportive. So there are certain treatments which aren't available through GPS. And that would be things like Botox injections, or the new anti CGRP drugs. And those are available on the NHS. And we can do those in our clinic. But they there may be very long waiting lists for the neurology clinics, and there are very few headache specialist clinics. Sadly, there should be more because with such a common condition, we really need more headache specialists in both primary care and secondary care, I think Unknown Speaker 12:06 affecting one in seven people. Absolutely. Before we get too deep into the treatment, can you set up for us? Because I think there are a lot of similarities between the migraine process and the long COVID process. Now I don't necessarily know that I can discern my symptoms between being one and the other because they're so so interlinked, and they sort of roller coaster at the same time. Can you explain for our listeners, that process of migraine when it actually starts because it doesn't start with the head piercing pain, that's not the beginning of the migraine. So you take it back to the point at which that migraine is already in process. Unknown Speaker 12:47 So if you think of the genes giving your brain the vulnerability to have attacks, what the genes do is they mean that your brain is always going to be more sensitive to change. And I say to patients, this is a change in your internal environment or your accent environment. And changing things adding together, start to irritate the brain and push it towards the threshold of having a migraine attack. So it might be changing blood sugar, changing sleep patterns, hormones is a huge one. It might be changing weather conditions. And we know that falling barometric pressure can often trigger migraine, and it's usually combination of those changes, irritating the brain. And those changes can be occurring up to 48 hours before you know anything about the attack. Some people do get prodromal symptoms like yawning, or intense fatigue, or irritability. And some people tell me, it's my spouse that knows what I'm getting at me. And they say my a bit crabby today. Maybe watch out take your medication. But so that kind of one or two days builds up is the prodromal phase. And then we have the in 25% of people we have the aura phase, which just lasts an hour. So not everybody gets that by any means. And that is where the neuro chemicals trigger electrical changes in the cells of the brain in aura that causes visual disturbances very often, like zig zags or flashing lights. But if you don't get aura, then that's when the headache starts. Assuming you're having headache is one of your major symptoms. I talk sometimes about the most bothersome symptom because sometimes people say to me, Well, I get headache, but actually I get really dizzy, and that bothers me more than the headache. So it's important that we don't get fixated about headaches. But that impact stage then can roll on for about three days, often rolls on for three days. That's all in one migraine attack. And then after that's finished, there's this period which is sometimes called the hangover phase or the post Dromore phase. So it's a complex process. And it's all down to the buildup of those neuro chemicals, causing electrical disturbances that roll out over the surface of the brain. Unknown Speaker 15:08 Okay? How long would you say the process can be from from start to finish. Unknown Speaker 15:13 So in children, it's often shorter. And children, they often have a much shorter migraine attacks that may last only a number of hours and resolved quite quickly. But in adults, it can be anything between a day and five days, I would say. And of course, if you're getting migraine attacks quite frequently, but the time one is settling down, the other one may be starting to roll. And when this is happening very frequently, people are getting more than 15 days, impacted by migraine in the month, then we would say that's chronic migraine. But if you say to me, Well, I just get one, maybe once a month, or sometimes even less than that. That's called episodic migraine. Unknown Speaker 15:55 I will get maybe two smaller headaches, and then a gap of maybe two days and then I will get the huge migraine where I can't get out of bed and do anything and then I get the massive hangover after it those smaller blips, are they migraines in themselves because I thought that they were kind of preludes to the bigger event, Unknown Speaker 16:18 I think they probably are. And I think sometimes what happens with people as they, they feel their headache starting, they take some medication, and it suppresses the process enough to make the headache go away. But the migrainous process in the background is still going and so they say to me, Well, I took it went away, but it came back the next day, or we see a pattern if we're looking at diaries, where on the Monday they had the the migraine attack starting they got rid of it Tuesday was fine, but then they got it back again on Wednesday. And I think it's just at their threshold is relatively low. And that impact of the symptoms can come and go a little bit. But it's all part of the same process really. Okay, in between attacks, if you're having really true episodic migraine, people should be absolutely completely fine in between attacks. So if you're not I say to people, I don't just want to know about the bad ones, I want to know about any level of symptoms that you're having. So if you're keeping a diary of your migraine, think about writing down every day, the impact out of 10. So some days, yes, it might be an eight, nine or 10. But some days, it might be a one or a two where you're just a bit brain foggy, or you're a bit tired, or you've got a little bit of a headache, but you can push on through, I want to know about those as well, because that means you've got quite a low threshold for going into another migraine attack. If you say to me, Well, 25 days of the month, I have a crystal clear head, I have no symptoms at all, then you're very much into episodic migraine. And that is a slightly a difference in how we manage those in terms of the preventative options, Unknown Speaker 18:00 be noticed anything particular about the long COVID patients that are coming through your clinic. Unknown Speaker 18:07 So knowing that I was going to speak to the two of you, I did a little search about what sort of studies have been out there. And I was really interested to read some case studies from Barcelona. But there's a really good headache specialist team. And they describe some different presentations of people who've had COVID infection. So one of the patients they describe had previous migraine got COVID and then fairly quickly changed from episodic to chronic migraine. So it really did affect migraine attacks and make her have more trouble with them. And they had to end up treating her with Botox injections. And they did manage to reduce the impact quite considerably, but not back to previous levels. So that was one. The other two patients they described were people who'd never had headaches at all. One of them got a headache as part of the COVID infection. And it is a common symptom. It's about the fifth most common symptom when you get COVID. Sometimes it can be a prodromal symptom that shows that you're becoming positive for COVID. But sometimes it occurs during the act of infection. And that's what happened to the second patient. And she then went on to develop a quite troublesome headache having never had those before. And then the third one was a man who had COVID infection didn't particularly have much headache until about two months later. And then he developed a daily persistent headache. So think when we're talking about headaches and long COVID We need to understand what the potential mechanisms can be. And those can be variable. So I think it can be a worsening of pre existing headache condition or at they hypothesized that it may be that there is infection of the nerve cells with the COVID virus. And that that activates the system, which is the trigeminal vascular system, which is that system in the brain that we know is implicated in migraine. And although people haven't had migraine before, they've now got migrainous type symptoms, because those areas have been infected with virus. So it's a, it's a complicated thing, I think. And most of the treatments will be the same kind of treatment that we use for chronic migraine, because the underlying goal is the same to try and settle the brain down and reduce the threshold for getting pain and the other symptoms that go with that. Unknown Speaker 20:47 That's interesting. Unknown Speaker 20:48 All of the triggers that you mentioned for migraine are basically the same triggers that we have been told to avoid for triggering long COVID relapses, but also separative. The mechanisms behind me grain, the one that you've just mentioned, and others in your book are also in line with long COVID. What you were just saying one of the triggers is the energy metabolism in cells sort of is that is that mitochondrial? That's right. Yes. So can you talk to us a little more about that in migraine because it's also one of the theories behind long COVID. So Unknown Speaker 21:25 there's some evidence that people at migraine have some sort of deficiency in the energy production within cells. And some of the supplements that we give patients who may find these helpful for migraine prevention are very much trying to replace things intracellularly that people have found to be deficient and have been doing studies. So that would be magnesium riboflavin, or vitamin b two, and coenzyme, q 10. And all of those have quite good evidence that they can be useful in some people with migraine always say that in some people, because not anything works for everybody. And I think you know, we're trying to find out more about long COVID. And why causes these things. And there is a big overlap between Long COVID and patients with chronic fatigue syndrome, and fibromyalgia. And also in our clinic, we are aware of a lot of patients who have migraine attacks, who also have problems with histamine and mast cell activation syndrome. And I think it's a fascinating area. I'm I'm hoping to do a podcast episode fairly soon. With the mast cell activation. Marcel action people. Fantastic. Yeah, because we do feel that histamine is implicated in some people with migraine attacks. And I'm hearing that there's a lot of similarities between muscle activation syndrome, and long COVID. And so fragility of the mast cells, which are defenders of our body in all sorts of surfaces around the body. So they may be in skin, in lungs, in gut, and in the nervous system. And if those have become more fragile, we don't fully understand this whole process yet, then that can cause an aggravation of migraine headaches, as well as some of these other symptoms. Unknown Speaker 23:25 You do talk a lot about food as being a trigger for migraine. So I guess that that kind of histamine response is, is food driven in migraine? Unknown Speaker 23:33 Yes, it can be. Although sometimes people try excluding histamine from their diet completely. And that's actually really hard to do. And it doesn't make a difference for everybody. But what we find in our clinic is that not only are we asking more specific questions about do you get asthma? Do you get acid? In your gut? Do you get sudden bouts of diarrhea? Do you get rashes, sometimes I get people to draw with their fingernail on their forearm very lightly, don't damage yourself. And if they are getting a really red flare line, over a minute or two. After you've done that, if just firmly pressed with your fingernail on your inside of your forum, I usually do it at the same time, just to prove to myself that I don't get that. But it's surprising how many of my patients on Zoom will go, Oh, I've got a really big red line. And that is histamine release in the forum. It can be it's a thing called dermatographia. Unknown Speaker 24:31 So you're saying for brown people? Unknown Speaker 24:35 I think it can be yes, you would see a reaction because a bit like a nettle rash. So yeah, I've Unknown Speaker 24:42 got a red line. Yeah. I've got a big red line. Yeah, I Unknown Speaker 24:46 haven't. Well, we know you're terrible Unknown Speaker 24:48 with your skin. Having done it at the same time. I have no, I have no so you've probably got an element of histamine as part of your symptoms. We also find that linked with hypermobility. And so we asking specifically about hypermobility? Do you think that you're flexible? Were you able to do the splits when you were younger? Can you push your thumb down onto your forearm? Those kinds of things? Have you got very bendy elbows? Or is your neck very kind of loose and new? Sometimes people have had dislocations. And the other condition this is linked with his pots, which is Postural Orthostatic Tachycardia Syndrome. Unknown Speaker 25:31 One big links up thing, so many, Unknown Speaker 25:35 so many links, and you start to join the dots and you think I actually need I need a lot longer with this patient. Once you've had patients saying yes, I get this, this and this. And then we need a much longer time to discuss all the implications of that. Unknown Speaker 25:51 So you're saying that the pots is linked to the mast cell activation and the histamine driven things it is Potts part of the migrainous process in any way. I think Unknown Speaker 26:01 the whole thing doesn't overlap. And I think we have to think of all of these things as a spectrum. So there will be some people with migraine that have it mildly. Some people that have it moderately some people that have it really badly. And it's the same with hypermobility. And with pots, I'm with Marcel issues, some people get mild effects from these things, and other people have everything. And I have some patients who have chronic migraine, you have severe pots and bad Marcelle issues and are diagnosed with Ehlers Danlos Syndrome. And it's all overlapping and all linked, but they often have to go to lots of different specialists for each of those individual things that they're suffering from, which is a real shame. And it's a real area where I think we could improve our team working in healthcare systems, you know, if we, we need to have an overview when when the whole body is affected by something, it's the same with low long COVID. You know, if if the whole body is affected by something, and you only go to a dermatologist, or you only go to a cardiologist or you only go to a neurologist or a rheumatologist, then you're having to run around to all over the place to get good help. Unknown Speaker 27:12 Yeah, it's that holistic overview that basically everyone's asking for in terms of the multidisciplinary teams for the long COVID clinics that aren't necessarily being followed yet. Unknown Speaker 27:22 So as I suffer from long COVID, does that mean I can when I suddenly become hypermobile? I would love to be able to do this. Unknown Speaker 27:33 Oh, I wish that was the case. No, the hypermobility is genetic. So if you're not born with the genes of hypermobility, then you don't get them later in your life. Unknown Speaker 27:43 And it's very much connected to IBS and leaky gut syndrome and things, isn't it? Unknown Speaker 27:48 Yeah, I think that's true. I mean, that's the other thing that I am constantly talking to people about is the importance of diet and the importance of gut health, and the microbiome. And, and that can be nurtured by simple things by not having too much of the high GI foods, so the sugary foods, the carbs, white things. So white things like white flour, white sugar, white, processed, bread, pasta, etc. An exception is cauliflower, feel free to eat lots of. So a low GI diet is what we recommended. I know I've been recommending that for my patients when I was in NHS GP who had fibromyalgia or chronic fatigue. So it seems as if the processing of carbohydrates can be quite difficult in people with these kind of chronic conditions. So having a slightly more protein and fat in the diet gives them more slow release energy and seems to suit people better. And that certainly applies to people with migraine. And the other thing is to have a wide range of plant based foods. So as a rule of thumb, try and have 30 different plant based foods in your diet every week. Basically, a meat and two veg diet is not going to be rich enough in plant based things. We know that plant based diets are very helpful. But that doesn't mean you have to just eat lots of traditional veg. You can count garlic, chili, herbes all of those things count as plant based foods so it's Chanda Unknown Speaker 29:23 pulses and legumes absolutely don't necessarily Yeah, pulses. I mean, this is the problem is trying to marry any of these various things and because in your book I was reading possibly low histamine and then you say low GI is possibly the one that you've had the best results with. There has been a lot of criticism in the press of the low histamine diet for long COVID One of the things with it is that I think I basically ended up being slightly malnourished because I was trying to cut out these things that you must not eat this you must not eat that The way that he's framed the low GI diet, it's a little more flexible, it can enable people to not stop eating. Unknown Speaker 30:10 I don't think there's very strong evidence that doing a strict, low histamine diet is useful for most people with migraine. But it may be something that people want to try. I think it's very much about finding what works for you. And I think also, if it's a diet, which is really hard to follow, then it's probably not going to be something you're going to be able to sustain anyway, I say to people that, you know, you have to live with this condition, be it migraine, or long COVID, or chronic fatigue, or whatever. So you need to make it something that you can practically do that does seem to help you, but you can continue doing it. And I think with any Jaci change, you also need to be aware that you're gonna have to probably do it for at least a month, if not to, and if at the end of that time, it hasn't really made much difference, then I probably wouldn't bother anymore to be quite honest. Unknown Speaker 31:05 That's really sound advice. Unknown Speaker 31:07 Some of the time when especially when I'm in a meeting, it's but I am so nauseous that the only thing I can eat is dry white flatbread. That's not allowed in any of these diets. They got no nutritional value, but at least it put something in my stomach. So my, Unknown Speaker 31:21 my tip for you would be why haven't you got a good anti nausea treatment? Because I so often hear people saying, well, I get these migraine attacks, and I'm really, really nauseated. Well, have you had something from your GP to help with the nausea? No, no, well, why not? Why not? It's a basic thing. But look at the guidelines for treating migraine attacks. An antiemetic anti nausea tablet is right up there. Because we know that the migraine attack affects the vagus nerve that goes wandering down to your stomach and stops your stomach emptying. And if your stomach isn't emptying efficiently, two things happen. One is people feel nauseated or possibly vomit, some people really sensitive to that. And the other is of the take painkillers for their migraine. And they don't go and they're not absorbed in the stomach. So they don't go in very quickly. And so the migraine attack may have rolled and gathered momentum and been much harder. And people say well, the those tablets didn't work. Well, it didn't work because they weren't absorbed because they were stuck in your stomach. So an anti nausea treatment is really a key part for some people of getting effective management, their migraine attacks. And then there's some other tips like ginger, some people find ginger really, really helpful. Unknown Speaker 32:39 I was just drinking ginger in hot water yesterday because it really does help. Unknown Speaker 32:43 Yeah, acupressure bands can be helpful for some people. I had a child who was getting trouble sickness, travel sickness is linked with migraine. So a lot of kids who get travel sickness that Unknown Speaker 32:54 is so interesting. I always had travel sickness as a child. And I've been praying to me again as an adult. Yeah, I had no idea until today that they were linked, strongly Unknown Speaker 33:02 linked. And she had acupressure bands just for the journey to school. And that made a big difference to her travel sickness. Yeah, talk to Unknown Speaker 33:11 us a little about the abdominal migraine that you mentioned in children is actually something that I saw someone posting about today, because we know that a lot of children with long COVID have GI symptoms rather than necessarily some of the other symptoms that adults are getting. Unknown Speaker 33:29 So abdominal migraine is quite a common feature of migraine in children, and they may not get headache. And so if you have a child who is getting recurrent bouts of abdominal pain, and sometimes they look rather pale, it can be quite severe the pain, they may want to go lie down, they might become a little light sensitive or smell sensitive. So they like or don't like the smell of the cooking or whatever. And if they're getting that and especially if there's a family history of migraines their mom or dad or grandparents have got migraine attacks, then I would have a high level of suspicion that they are getting migraine. And many, many children with migraine don't have a diagnosis, about 50% of children never get diagnosis until they grow into adulthood and start getting more typical headaches. It often changes in teenage and they begin to get more teenagers as a peak time of getting migraine developing. Because of all the changes if you think of the changes of teenagers going through first of all, they're changing to secondary school. They're changing they're they may be growing they may be having the changes of puberty. menstrual cycle cycle starts, their need for sleep changes and teenage have we no need longer periods of sleep, their brain development, but we don't as a society. Let them have a lion every day we say no, no, you've got to get up at 730 in rush off to school. So they then have erratic sleep because they catch up with on the weekend. And we know that changes in sleep pattern is a big trigger for migraine. And then they may have stresses of exams, learning schools, relationships with friends, romances, alcohol may come into the picture, you know, lots of things for teenagers. So we see a peak instance of migraine around 14 and 15. Boys and girls get it to same amount before that age. After that, because of the menstrual cycle, girls tend to get it more frequently than boys. How is it treated in children. So it can be treated as if it is a headache migraine in just the same way. Simple anti nausea treatments, simple painkillers often work quite well for children, getting them to eat something in case they've had a long gap in between meals, because sometimes they've had their dinner at five o'clock in the evening. And then they haven't eaten anything till quite late the following morning. So trying to correct those routine things to prevent them getting a tax can be really important. And putting in a bedtime snack or making the sleep routine a little bit more routine. And regular regular can be helpful. And then the trip towns that we use for migraine headaches work for abdominal migraine and children as well. And they're licensed for children as well. They're not licensed for children, but they're widely used globally. So a lot of headache specialists are using pretty much all of them. sumatriptan is the most commonly used, but zolmitriptan is a good second option. I use that one quite a lot in in young people. Yeah, works well. But there are seven different triptans. And that's something that a lot of adults don't know. I have patients coming and saying, Well, I tried one trips and didn't help. I'm like, well, there are six others you could try. One of them may suit you very well. So do they all behave differently? They're slightly different. And everybody's different in their pharmacogenetic processing of drugs. So it's a question of working through. And we find this with people with Marcelle issues as well. Somebody may be suited very well by one type of anti histamine. And another person will say, well, it didn't work for me, or I felt sensitive to to try different ones keep trying. Looking at the different options. That's interesting. Unknown Speaker 37:11 We will put on h1 and h2 blockers. The Unknown Speaker 37:15 availability of the h2 blockers has been really tricky lately, because it we used to use Ranitidine and then that got withdrawn globally. And sigh metody. And so now the only one that I'm managing patients to get is the fermata D Yeah. But h one blockers, there's quite a number of those that are available. And then there are other things like Montelukast, which can be a histamine blocker that some people have been put on. Unknown Speaker 37:38 I was put on that for my asthma. Yeah, Unknown Speaker 37:41 yeah. Long time ago. Yeah. So it can be really helpful. If histamine as part of the issue of your respiratory symptoms, Monty Lucas 10 milligrams at night can be quite useful. So interesting. Unknown Speaker 37:51 These overlaps they the overlaps between the potential for lung COVID and asthma or allergies and pre existing conditions, then you put the migraine and it looks like it looks like we're looking at the same mechanism behind these things, or Unknown Speaker 38:07 I think it's, it's a little bit more complicated. If only we could find the one key to these things. It would be so much simpler, wouldn't it? Yeah. And but I think because it is a complex interaction of all sorts and the expression of things in different people is very variable as well. I think it's it's really about just knowing that there are options and keep looking for the right recipe for you. Unknown Speaker 38:34 One question on that because the the diet recommendation of try it for a month with your patients with migraine, how long do you give any, say you give them a certain trip down? How long would you allow that to work before potentially changing it or deciding that it is not working. Unknown Speaker 38:50 So if I'm giving them an acute treatment recipe, then I would say to them, try this for at least three attacks. So that's for episodic migraine. So give it give it three goes and see how you get on with it. If I'm talking about preventative medications, then it's important to get to the maximum tolerated dose and keep on that maximum tolerated dose for at least three months. And the same goes for the supplements. So the magnesium the b two and Coenzyme Q 10. You need to get to a good dose and stay on it for at least three months because it doesn't seem to help quite in the brain down. Unknown Speaker 39:34 So what's a good dose, Unknown Speaker 39:35 so a good dose of berries. There there are guidelines for target doses for all of the different medications to prevent migraine, but some people get benefit at lower doses. And some people get side effects at lower doses. So why say to people start low, increase slowly? When you start if you start to get side effects, go back one step. Don't just go Oh, it doesn't work. I'll abandon the whole thing. creep gently up, creep back down one step, and that's your maximum tolerated dose for whichever thing you're taking. So often I have patients who say, Oh, I was given amitriptyline 10 milligrams, I took it for a fortnight and it didn't work. So that's not the high enough dose, and not for long enough. So I say to them, Go back, try again, often side effects will settle. If you have side effects in the first couple of weeks, they often do settle with those kinds of medications. And if you can push on through that first fortnight, you may well find that you do get some benefit gradually as the dose increases and as the length of time increases, but you have to be patient, I think. Transcribed by https://otter.ai