E13: 7 Domains of Migraines

Okay. Check, check. We are going to get down right to it with headaches. Actually, guys, I am one-half hour after my very own incredibly beautiful aura today and we are going to be talking about the 7 Domains of Migraine.

So we're going to drill down, as I said, to migraine because the topic of headache is so big.

With us in the studio today is Dr. Kathleen Digre, who is professor and chief of the Division of Headache and Neuro-ophthalmology at the University of Utah. She is an internationally recognized expert in headache, and she's the former President of the American Headache Society. She's also a professor in the Department of Obstetrics and Gynecology, and the director of the Center of Excellence in Women's Health. And to me, she's the mother of the "7 Domains of Women's Health."

Dr. Jones: Thank you for joining us, Kathleen.

Dr. Digre: Oh, I'm thrilled to be here. Thanks so much, Kirtly.

Dr. Jones: Dr. Digre and I, Kathleen and I, came together and have known each other for 36 years. We raised our children together. We are in the same department in the sense that she's in my department, my husband is in her department, her husband is in my department. So we've spent our days and some of our times off together. She's seen me at my best, she's seen me at my worst, and she's taught me about resilience.

Dr. Digre: I can't believe it's been 36 years, but that's what it is.

Dr. Jones: It has been. So we're going to be talking about migraine and the seven domains. We're going to get started right away with my question for you. Why do women get migraines more than men? Can you tell me a little bit about migraine? And how come it's a woman's headache? It's not really . . . Men get migraine too, but why is it in women?

Dr. Digre: Migraine really is a disorder that affects men and women, preferentially women. And most people believe that is because there are hormones involved. The most active time of migraine is right after puberty, and the activity of migraine often increases over time, and then will decrease somewhat at menopause, although that isn't exactly the same for everybody. Almost 20% of all women get migraine and about 6% to 8% of men can get migraine. And we think it's an inherited disorder.

Medical Mystery: Diagnosing Migraines

A lot of women have headaches, but they're not ever quite sure about whether it's migraine. So we're going to bring in our producer and do a little medical mystery and talk a little bit about how you might diagnose migraine. So coming in with us is Chloé. She's our producer and she's got a headache or some headaches.

Dr. Jones: We're going to work this out together. Chloé?

Chloé: Yes.

Dr. Jones: So tell her about your headache.

Chloé: So they come really sudden. I'm sure something triggers them, but I don't pay enough attention to them to know what triggers them. But they come on kind of sudden and random, but it's intense. But the good thing about these headaches, I guess, is that they go away really fast too after I take ibuprofen. So I know what treats them, what makes them go away, so I never let it get too serious or hurts too much because I know what treats them.

Dr. Digre: Okay. So there are three crucial questions in trying to make the diagnosis of migraine. Does it interfere with your life?

Chloé: It does not.

Dr. Digre: When you get it, your thinking is perfect, you feel great, it's no big deal?

Chloé: I can feel it, and so, again, I take the medication and it'll go away. So I don't think it ever really interferes with my life. And in that sense, I'm sure if I don't treat it, I just let it dwell down forever, it'll make me anxious, but . . .

Dr. Digre: Do you ever get light-sensitive with your headache?

Chloé: I don't.

Dr. Digre: And do you ever get nauseated?

Chloé: I do not.

Dr. Digre: Okay. Does it get better with activity?

Chloé: What does that mean? Like if I exercise, it gets better? Is that what you're asking?

Dr. Digre: Yeah. If you are active and you exercise, does it get better?

Chloé: I don't think it gets better, but I think maybe it's a mental thing where I don't recognize it as much. It "goes in the back of my mind."

Dr. Digre: Okay. So I would say that the headache you're having is more like a tension-type headache. And it's really a misnomer between migraine and tension-type. Everybody thinks, "Oh, it's tension," or it's muscle or it's something like that, but it's really not.

We don't really understand tension-type headache as much as we do migraine, because migraine has specific phases and you diagnose migraine with key symptoms of a disabling headache with light sensitivity and nausea. And if you have two out of the three, studies have been done to show then you've got a really high chance of having migraine.

Chloé: So can you tell me what a tension headache is then? Is it just when I feel tension?

Dr. Digre: No. It's probably not tension and it's probably not muscle contraction. It's probably also a headache that comes out of your brain, but it doesn't seem to be as disabling as migraine. It's usually mild to moderate. It usually gets better with activity and there's never associated nausea. And if you have light or sound sensitivity with it, you'll only have one of those. But it is something that comes out of the brain, and it probably is related. It's probably a cousin to migraine, but it does not disable people as migraine does.

Chloé: Okay. So then my question would be is it normal? Because that's what we always ask on the "7 Domains." Is it normal, and should I be concerned?

Dr. Digre: Well, it depends on how frequent it is. If it's once in a while and it doesn't really interfere with your life and all of that, that's fine.

There are red flags in headache, making the headache diagnosis. If somebody has a systemic illness, let's say they have HIV or they have immune problem or they have some systemic problem, then I might look further to what is causing it.

Any neurologic findings, weakness, numbness, tingling, changes in vision, I would look further.

If the headache type came on sudden, sudden onset of the worst headache of your life, then I would look further.

In older people, let's say over 65, starting to have headaches, I am definitely going to evaluate those further.

Pregnancy, if you have a new headache in pregnancy, I think I'd do that earlier as well.

And a change in the pattern.

What I just spelled out for you was SNOOP. That's what doctors do when they are trying to figure out if there's a secondary cause to the headache that you should be concerned about. If you have none of those, then I would say that it's probably a tension-type headache.

There are things that we can treat it with if it became frequent. You could talk to your primary care about it, and they would do an examination and make sure that you didn't have any of those SNOOP factors.

Chloé: Got you. Okay. Sounds like I don't have anything too concerning then.

Dr. Jones: So I'm just going to come in as a migraineur, and it seems like everyone who's ever worked for me has had migraine. But if one in five women have migraine, then that wouldn't be uncommon.

The Physical Domain of Migraines

So I will give Dr. Digre my headache, and she can talk about that. My headache started when I was in my mid-teens, and it was always preceded by an arc, a very bizarre but very beautiful colored twinkly arc in one visual part of my vision. And then when I saw that, I knew that my headache would be coming.

Often, I had numbness of my face sometimes, and I had nausea, and I had to go out away from bright lights and everything was too bright. I couldn't tolerate bright light. And I had a pretty bad headache for a couple of hours.

And then after it went away, the rest of the day if I bent over, my head would hurt and I felt stupid the rest of the day. So that's my headache.

The good news for me is when I went through menopause, I still have aura, but I don't have headache.

Dr. Digre: And you just described textbook migraine with aura. And the key features . . . let's go back. The pain can be disabling. There's light sensitivity and brightness that follow the arc. The arc is this slowly, gradually enlarging aura and it comes out of the occipital lobe. So, frequently, it has twinkly lights. It may have a zigzag pattern. It frequently starts in the center and goes out, or it starts in the outside and goes in.

And then it's followed by this headache, and the headache is characterized by exactly those things I asked Chloe. Do you have nausea? Yes. Do you have photophobia or light sensitivity? Yes. Is it bad enough that you can't think? Yes. And the foggy brain is a very typical finding of people during the headache and in the postdrome period of time.

What's interesting is that when people have migraine with aura, frequently they lose the headache part and they keep the aura, just like you have.

Dr. Jones: I just had a beautiful aura as we were getting ready to talk today, and it was quite lovely, but I was very happy that I wasn't going to have the headache afterwards.

But can you describe what's happening in the brain? Because it seems like my whole brain gets involved with this. It's my visual, my auditory, my stomach, my thinking.

Dr. Digre: So let's go through the phases of migraine. First, there's a premonitory phase. Now, premonitory phases are not auras. They're just things like tired or yawning or poor concentration or changes in the mood or frequent urination, or maybe some light sensitivity. And during that period of time, we've done scans, fMRI, PET scans, etc., and we found that the hypothalamus, the brainstem, and the cortex are activated in some way during this premonitory, before any headache, before any aura, before anything happens.

Then the aura occurs. Now, only a third of people will get an aura. So not everybody gets an aura. Some people just get the headache. But the aura occurs, and if it's a visual aura, the occipital lobe, which is our seeing part of our brain, will light up and do this arc-y thing that you've had that's visual.

Now, some auras can be sensory, meaning numbness around the hand or the mouth. Some auras can even be language, like people get garbled speech. And then that aura usually lasts less than an hour, usually more than 15 minutes, but it's variable. Fifteen minutes to an hour. And then the headache can come on.

And during the headache phase, we know that the trigeminal vascular system, and that's the pain system in the brain, the brainstem, and the thalamus, all connected, will start to be activated. That's where you get the headache. The pain system gets activated. And that's somewhat complicated, because it links to blood vessels, but it also links to the pain centers in our brain.

Then people get light sensitivity, sound sensitivity, nausea, maybe vomiting. They can get it so bad that even their hair hurts. They say they can feel their hair. They can feel their glasses on their face.

And then during this phase, the pain can last anywhere from a couple of hours to 24 to 48 hours. And during that time, all these systems can be activated.

Then once the headache goes away . . . and we don't understand where this is in the brain, but obviously, this is more brain stuff. There may be lingering fogginess. There may be lingering discomfort, but not really bad headache. There may be lingering light sensitivity, sound sensitivity, nausea, etc. Those are the brain changes during a migraine.

The Environmental Domain of Migraines

Most people with migraine -- and my patients, many have had migraine -- would say there were environmental triggers. Sometimes, of course, they were hungry, but sometimes it was bright lights or sometimes it was change in barometric pressure.

Dr. Jones: Can you talk a little bit about what might trigger these? Because sometimes they just seem like they come out of the blue, but for some people, they know what triggers them.

Dr. Digre: Right. And this is a little bit controversial because some people think they have a trigger, but if you really study it, there's not a one-to-one correlation. But I'll tell you what the common triggers are. Foods. MSG, monosodium glutamate, which is an enhancer in foods, often in some people can trigger headache. Overuse of caffeine, usually more than 12 ounces of a caffeine in a day.

Dr. Jones: Don't say that.

Dr. Digre: I know. A lot of people don't like that one. Overuse. I said overuse, not a little use, but overuse.

Dr. Jones: Oh. Okay.

Dr. Digre: Alcohol is a major trigger, especially wine and beers. Fermented things are triggers, dairy for some people, some of the aged cheeses, and then chocolate, unfortunately, is another trigger for some people. And then NutraSweet. So those are the kind of the food triggers. Not that everybody gets it. Everybody is individual.

Lights can trigger, so glare, strobe lights, stripes, computer screens, fluorescent lights, going to grocery stores or big supermarket type places. Sounds for some people can trigger it. Smells for some people can trigger it. So somebody is wearing perfume. And environmental pollution. A lot of people feel like pollution can trigger their migraine.

Weather changes like when we have fronts coming across the Wasatch Front. A lot of my patients say, "I can predict the weather because my migraine comes on." And even the winds, the Foehn winds, the westerly winds sometimes can be trigger. And then travel, altitude.

So there are lots of environmental triggers to migraine, but it's not the same for everybody. Everybody is a little different. And I can tell you some people have kept just exquisite diaries and they cannot find a single trigger that they can say reliably triggers their migraine. They just occur in the brain.

The Emotional Domain of Migraines

Well, I will tell you that I remember before I knew my trigger better, I remember thinking I had migraine because it was moral disease. This is the emotional domain for me. I thought if I had better control over my emotional life . . . I really work on having a very even emotional life, but if I were better, I wouldn't have migraine. So I was quite convinced that my migraine was moral disease.

Dr. Jones: There's this history of sick headaches. The women were neurotic. Women who had migraine were neurotic and they were self-absorbed. This is my fantasy about the way migraine was presented in women. The women who had migraine were emotionally unstable. So even after I went through medical school and I knew better, it was this sad sense that if I were a better person, I wouldn't get migraine.

Dr. Digre: Well, I'll tell you, since migraine is a brain disease that affects the limbic system, it's going to have an emotional component. We know that people with migraine have a higher incidence of depression than what's normal in the population. So maybe 10% of the population has depression. In migraine, almost 30%. There's about a 4.5 times chance of having depression, dysthymia. Anxiety can occur with migraine. OCD can occur with migraine. Bipolar disease is more frequent in migraine.

And this isn't a failure of your emotional system or a failure as a person. This is part of the disease. It is what we call a comorbidity. It comes with migraine. And the importance of recognizing it is we have great treatments for depression, dysthymia, panic, anxiety. So we have treatments for this. That can be treated and sometimes that can reduce the chance of having more migraines.

The Financial Domain of Migraines

Dr. Jones: I think that anybody who has chronic unpredictable pain would probably get a little bit depressed and a little bit anxious, and especially for women for whom their work is significantly interfered with. I mean, the economic aspects, the financial domain ends up being a big deal for some women who have regular migraine. It can keep them from being able to do their job.

Dr. Digre: Yes. This is a problem. And the financial aspect of migraine is really staggering, and these studies have been done. There is a direct and indirect cost of migraine in the United States of $27 billion.

Dr. Jones. Oh my god.

Dr. Digre: Now, direct costs . . .

Dr. Jones: That's a lot.

Dr. Digre: Direct costs mean going to the emergency room, being in inpatient, having frequent doctor visits, and having pharmacy costs. And then indirect costs or missing days at work and then having to go on disability for a period of time.

This is something that really can affect somebody financially, as well as emotionally. But it's important to understand that emotional component is probably related to the brain disease itself with migraine.

The Intellectual Domain of Migraines

So thinking about the intellectual domain, the cognitive domain of this particular disease, number one, certainly women can feel like their brain doesn't work as well when they are either having a migraine, of course, or after. But the business about learning more, how do people become more thoughtful?

Dr. Jones: Certainly, as I learned more about my own migraine, even before I went to medical school, it was very helpful for me to have smart people tell me that this was not moral disease. That was really helpful for me. Where do people go to get information that they can help to order their lives?

Dr. Digre: First, I would say you have to get the right diagnosis, of course. So I want to tell you a story about one of my patients. I had somebody sent to me who had migraine. She didn't know she had migraine. She just thought she had headaches, and she had not been treated with anything that would really treat her migraine. She had been given things like Valium or tranquilizer, etc. She also thought it was all in her head.

When I told her, "No, you have migraine. Migraine is a real disease and we can do something about it and we can get you on preventative medication and acute treatment when you get a migraine, and you can have your life back," she burst into tears and was really, really happy.

And you know what? That type of thing happens all the time. People just aren't diagnosed and they don't get the appropriate treatment. And so I'm really on a push right now to educate as many people, primary care providers, neurologists, everything, about migraines so that we can take care of people in this country.

But to get more information and to study it, there are several things that we can offer. Here at the University of Utah, for example, we have started a headache school. And if you just Google "headache school University of Utah," you will come to that website and you can actually attend headache school.

There, you find lectures that are about auras and about visual aspects of migraine, about emotional aspects of migraine, about migraine in general, about treatments. So learning as much as you can is great.

Then you can join the American Migraine Foundation. This is a foundation dedicated to patients, and they have free information on the internet that can be downloaded. They've even got a Facebook page. They've got a Move Against Migraine campaign. So there are lots and lots of great resources to learn more.

I think it's also important to realize that if you understand this disease better, there are other tricks that you can learn for treatment. For example, mindfulness has been used as a treatment for migraine, and it's shown in studies to be very helpful in helping to prevent migraine and control migraine when it happens.

Dr. Jones: Bright light is my number one trigger. So I don't go out in bright light without my sunglasses on. And even in my house if the sun is coming right in, I wear my sunglasses. I look silly, but it works pretty well actually.

Dr. Digre: That's a great thing. If you know that that's going to trigger it, it's great.

Dr. Jones: So there are famous people who have had migraine. You told me Elvis had migraine.

Dr. Digre: Yes. Elvis had migraine, Queen Elizabeth had migraine, Virginia Woolf had migraine, Einstein had migraine, Van Gogh had migraine, and even St. Paul is supposed to have had migraine. I know Cindy McCain has migraine.

Dr. Jones: Right. She started a big foundation. She started a big fundraising effort.

Dr. Digre: Right. And Jim Cramer of "Mad Money" is really an advocate for migraine and migraine research.

You don't have to feel alone if you have migraine. In fact, studies have been done that physicians have a higher incidence of migraine. Neurologists have migraine even more frequently, and a huge number of headache specialists can get migraine.

Dr. Jones: I was thinking about famous people who were artists who had migraine, and there's a whole field of migraine art. You could Google "migraine art" and you can see people who've drawn pictures of their auras. If you're not angry that you're going to have a headache, the aura sometimes can be quite beautiful.

Dr. Digre: Yes.

The Social Domain of Migraines

Well, I think in literature there are the stories of the mother who had a sick headache, and certainly, among privileged classes where women can actually go and lay down for a couple hours or a day, but it's a common theme in literature of women who have sick headaches or they have a spell where they have to go into the dark for a day. I always assume that the combination of some kind of pain and having to go into the dark for a day or two, these were young women, they were mothers, and it's a common theme in literature as well.

Dr. Digre: Well, you bring up some really important points. One is the stigma that's been associated with migraine. And what you bring up is really the stigma of women. "Oh, they're weak. They have to go in their room. They have to lie down. They have to disrupt their family." Women feel isolated, they are fearful of making plans. And that's been studied.

Dr. Jones: This is the social domain of what happens when a woman has migraine.

Dr. Digre: Correct. This negatively impacts relationships and family life. But what's sad is that if you don't understand that this is something coming out of your brain. So if you had diabetes, everybody would go, "Oh, my goodness. Let's have you eat right and everything else." When you have migraine and somebody goes into the dark room, they go, "Oh, there she goes again. She's got a migraine." But this is the problem with this disease. It has been stigmatized, and it has real pathology, it has real anatomy. It's a disease just like any other disease, and we can do things about it.

But we know from lots of studies that it affects relationships between partners. There are more arguments, less time spent together. In family life, there's reduced ability to do the housework, the chores.

Frequently, women and men -- let's remember men can get migraine too -- will miss social activities and then it has an effect on children. Well, the children may have a 50% chance of getting migraine if one of their parents has it. If both parents have it, probably they'll all get it. But these children have noticed that their parent doesn't have as much time to take care of them, and there's a negative impact on that relationship with the parent.

This is a problem. It's a social problem that can affect relationships, whether you're married or not, friendships. And it's been stigmatized, I think, to the point where people are embarrassed to bring up that they have migraine.

The Spiritual Domain of Migraines

But that's part of it. If a woman in a family has a headache and all of a sudden other people have to pick up the pieces for her, that can make people not very understanding about the reality.

Dr. Jones: Well, for people who are migraineurs, and there are so many of them, how does this become involved in one's spiritual life? For many people, this can make them angry. They can be depressed. They can feel like they're being punished. But how does one frame this in a way of something that's bigger and more spiritual? Dr. Digre, Kathleen, do you have any ideas about that?

Dr. Digre: I always say think of migraine as a yin and a yang, a blessing and a curse at the same time. The blessing comes in that the people who get migraine tend to have these beautifully sensitive brains that see things other people don't see, hear things other people don't hear, smell things other people don't smell. And there may have been an evolutionary advantage to having migraine.

People who have migraine, their brains are really creative. They can multitask. They've got all kinds of balls in the air. They're usually really sensitive people that pick up on stuff. That makes them special.

There's a reason that these famous people have had migraine, because that's the way their brain works. So you have to embrace the good part of migraine, which is you've got a special brain.

And it is true that the malfunction is very disruptive, but now we know if we get the right diagnosis, we can get some treatments. And we've got great treatments now that we've never had before. We have migraine-specific therapies to treat it, both acutely and preventatively. But I do think that it's important to understand the specialness of your brain.

Then the other thing I think that's important if you have migraine is to realize that downtime for your brain is good. Meditation, being out in the wilderness, taking a walk, being mindful, all of these types of things are extremely important.

Even studies have shown people who are spiritual, not necessarily regular churchgoers, but spiritual people who have a connection to their environment, to their surroundings, are less likely to have chronic pain, less likely to have fatigue.

And what I thought was interesting is they tried to correlate it with going to church, and it didn't really correlate with church-going. So that underscores the importance of your spiritual life, the connection that you feel. You can have it to God, to nature. It could be to your church, etc. But I think it tells us that having that sense that your brain is special, that you're special, that you can make contributions even if you have this disorder, I think that is really important for both understanding yourself, making your migraine better, and for helping other people in your family that may have the same problem.

Dr. Jones: It builds resilience. It helps you get through the hard times. And it's a power, I think it's a superpower, that can be grown. Everyone can make it bigger. And it helps them get through the hard times. That's really important for people who have this unpredictable signal from somewhere, your brain, to say, "Ah, this is coming. I know what this is. I have some good therapies for it because I've sought out for help. And this is my signal that I need a little downtime and connect to something bigger than I am."

That's, I think, an important thing for anyone who has any chronic disease. We have so much research that shows that people who have an active spiritual life can bring this connection to something bigger to help them heal. Even though they may not be cured, they are healed in a way that helps them carry on.

Dr. Digre: Yes. It really is remarkable. Resilience and understanding really are keys to getting better, because that means that the person is in control of the migraine, not the migraine being in control of the person.

Well, with that, I think we will wrap up the 7 Domains of Migraine. It bridges the paradigm for the concept of "7 Domains" because it affects all parts of women's lives.

I want to thank everybody for joining us. Join us wherever you get your podcasts. And you can join us here.

Remember that men can get migraine too, and we have a podcast on men's health called "Who Cares About Men's Health."

So thank you for joining us, and I'm going to leave you with a little Haiku.

Sharp, small, fairy lights
On the windows to the world
Not Christmas. Migraine

Thanks. Talk to you later.