Dr Louise Newson: [00:00:01] So Elie, welcome to my podcast [00:00:03][1.6]

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Dr Elie Sader: [00:00:04] Thank you Louise. I'm honoured to be here.  [00:00:06][2.0]
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Dr Louise Newson: [00:00:06] Wow, it's great. I've been following you on Instagram and as many people listening know that I suffer with migraines. My daughter has migraine, my mother has migraine, my maternal grandmother had migraines. It is often an inherited condition and it's a long-term lifelong condition and it's really high up in the number of or the most frequent causes of disability, but it's been underrated, underspoken about. So Elie is with me today, who's a neurologist and a specialist in migraines, headaches, pain, and I'm just really keen to talk again about migraine, if that's okay with you?  [00:00:48][41.8]
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Dr Elie Sader: [00:00:49] Let's do it. No, I'm excited. I think there's a lot of misconceptions to correct and a lot education needed in the field.  [00:00:55][5.9]
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Dr Louise Newson: [00:00:56] Yeah, so as I was saying to you, I had a migraine recently for three days, and my husband who I love very dearly said to me, has your headache gone yet? And I nearly lamped him, but he knows it's not just a headache. But so many people think it is just a headache. And most headaches are a nuisance, but you can brush them off. Migraines, I just think differently. I'm a different person. And it's really hard to describe to people because also all migraine sufferers have different experiences and I've had so many different types of migraines and sometimes it's hard to know is it a migraine or is it something else? But let's just unpick it a bit like what is it? Some people say migraine or migraine and it's a bit US or UK but what is Elie, just tell us a bit more.  [00:01:47][51.3]
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Dr Elie Sader: [00:01:47] Yeah, great points. I personally like to define migraine as being a sensory processing disorder. I think that that potentially might be a better way to define it, obviously because the headache itself is not going to be the only thing that is involved in a migraine. And sometimes it's actually absent from the migraine in general. So the way to think about migraine is that basically the brain becomes hyper excitable. And I think that there is an element of sensory amplification where any kind of sensory stimulation, whether it's light or sound or smell or touch for some people, all of those essentially become amplified. And the threshold at the neurone level in the brain becomes lower for the person who's having the migraine to experience essentially pain from any of these stimuli, which is unusual in normal people. However, when you have migraine, unfortunately, any kind of stimulation, including light, can be perceived as being painful inside the brain of a migraineur. And as you mentioned, basically the headache part is only one of the four stages of a migraine, right? So unfortunately, migraineurs go through a prodrome, sometimes an aura phase for one third of patients, and then you have the postdrome phase. And for some of the patients, the actual headache is not even the worst part, right. Because they essentially get the prodrome where they feel tired or they have appetite changes. They become, you know, potentially hungry or they're eating more. And then you have changes in mood, changes in sleep that can happen. And all of that is even before the headache has started. And then, you have the aura, which is very disabling when it's a visual aura and people cannot see properly and then you obviously have the postdrome phase where people are tired and they just feel drained after the, the headache itself. And so the headache is only one of the 25%, so one fourth of the actual migraine. And just thinking and reducing a migraine to simply the headache part is just minimising it. And unfortunately people do that because you can't really see all the other parts of a migraine as easily, right? Usually pain is a little bit more perceptible and people can talk about it and quantify it and can rate it out of 10, as opposed to the other features. But that's a big part I think that people need to recognise and that's also why sometimes the duration of a migraine should not really be reduced to only the duration of the headache. So when people ask you how many migraine episodes have you had in a month or how many days of migraine have you have on a month, unfortunately a lot of people underestimate that number, right, so they might tell you that they've only had five migraines in a month when it's actually potentially 15 migraine days. Because if you take into account the prodrome and the postdrome, then it's significantly longer and then you're morphing into the domain of a chronic migraine, which is an entity in itself, where the pain essentially becomes nociplastic at the brain level and it is significantly more disabling and harder to treat for a lot of patients. So, going back to your question, I would say that migraine is really defined by that hyper excitability at the brain level and the treatment for it will also have to take that into account, right. And so that's why a lot of the treatments will target that cortical spreading depression that usually accounts for the aura for a lot people. But then we have to keep in mind all the different triggers, right, because migraine, and that's actually the very interesting thing about migraine is that there's so many different things involved, right. So obviously you have a hormonal component. Stress has a huge impact on migraine, right. It's actually the number one trigger for most people who are surveyed. And then you have other factors that are beyond people's control. So weather changes, barometric pressure changes, certain, you know, fasting, food items, right, there's just so many different things that are involved that make it such a complex neurological disorder.  [00:05:52][245.3]
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Dr Louise Newson: [00:05:54] Yeah, and you're right, everyone is so different and it can make it, sometimes difficult to make the diagnosis if someone has the barn door aura and the flashing lights, then it can be very obvious, but certainly just personally and with my daughter, I don't have any, I've never had any flashing lights, before I have the head pain, I often feel very hungry, I feel very shivery, I feel cold, but my I sort of overthink and catastrophise and I sometimes feel very low in myself and I find it hard to recognise myself, whereas my husband can recognise this by the way I look, he'll go right, go and take a Zolmitriptan and you know, go, and I can make it and my daughter often will text me and say I'm no good at the trombone, I'm rubbish and I'm like hang on, I think and I kind of hear on her speech because she gets slowing on her speech as well. And sometimes she'll say, I don't think I've got a migraine, but I feel really not right. And I can hear her speech is fine and I can reassure her. So it's actually other people sometimes that need to understand. Because I think when you're suffering, you just don't think in the same way. It sounds really obvious, but it can be very hard. And I often don't know whether to take, because the earlier you take to prevent, you know, a medication often the better. And gosh, I'm 55 now, I should know better, but I often take it far too late and then it doesn't work as well.  [00:07:24][89.9]
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Dr Elie Sader: [00:07:25] It's very difficult to know when a given episode has started. So obviously if we're only thinking about the headache, that can be easier to define in terms of the onset. However, the problem is that you have all of that precursor that's happening and all of these changes are happening very gradually. So because the onset of the tiredness and the fatigue before the actual migraine and potentially also some of the changes in appetite and the hypothalamic activation and all of the different kind of sensory changes that are happening, they're just happening at a very gradual level, right. So nothing is really going to be suddenly turned on or off. And so that's why it can be difficult for people to know when a migraine has started. And like you said, if you take the medication early enough, especially for triptans, they are going to significantly more effective, right. So the success rate of aborting an actual migraine episode is going to much higher when the triptans are taken towards the very beginning, but defining that beginning can be difficult because most patients actually assume that the beginning is when the headache is essentially in its early stages. But the beginning, is probably 24 hours prior to that. And so even if you have full insight into the fact that migraine is not just a headache, unfortunately, it can still be difficult to delineate the onset, which makes it very tricky. And then it becomes a moving target. And like you said, there's a lot of different symptoms that people can tell maybe from the outside. Way more than the actual person, right. So for example, when you have the changes in speech, right, so the slurring in the speech and other stroke-like symptoms that can happen in certain migraine subtypes, right. And then when you the vision changes, when you some of the temperature dysregulation that can happened, right some people feel that there are chills or changes in temperature. So all of those can happen, but people can attribute them to other things, right so is it that you're maybe getting sick, Is it that, you know, there's something else going on and unfortunately, they're not consistently present across all migraine episodes for a given person, right. So that's why it can be difficult for the individual migraineur to tell if this is indeed a migraine or not, because not all episodes will obey the same rules. And that unfortunately can also become a way to blame oneself and to essentially, you know, have a lack of validation because people are not really confident about what is going on.  [00:09:50][145.4]
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Dr Louise Newson: [00:09:51] Yeah, it makes it very, very difficult. And what's actually going on in the brain? Like, why do they happen?  [00:09:57][6.5]
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Dr Elie Sader: [00:09:59] So, I mean, basically there's a lot of different things involved, but the main one is the involvement of the trigeminal vascular system. So the trigeminal nerve is one of the main cranial nerves. And the reason why it's a very important nerve when it comes to migraine is because of the way the enervation works. So I always have this model in my clinic that I borrow essentially all the time, but it makes life easier to show to patients. But basically with the trigeminal nerve, we're gonna pretend that what you see in yellow right here are actually the branches of the trigeminal nerve. And the important thing to keep in mind is that it has a lot of involvement in the face. So it's innervating the skin and a lot other parts of the face, you have the three different branches of that trigeminal nerve. So the sensation in the face is covered by that, but then also it's inervating the meninges. Which is basically the envelope around the brain. So this is the brain right here, and that's essentially, we're gonna pretend that's the envelope round it, which is called the meninges. Part of it is the dura, right. But the main thing to keep in mind here is that the trigeminal nerve is actually what innervates that envelope. And so that's why it receives pain and input from that envelope, whenever there's stretching, like in extreme cases when you have meningitis, right, but in migraine as well, obviously, and other conditions. You have all of that input that's coming through the trigeminal nerve and then going into the brain to tell the brain that there's a pain component going on. And then you end up with a vicious circle where you have essentially an amplification of the signals between the nerves, such as the trigeminal nerves, and then the brain itself. So it's an interaction between the peripheral nervous system and the central nervous system, and then they just keep hyping each other up. And then one thing that a lot of people unfortunately don't really pay attention to is the fact that you have a connection between the neck, right and the occipital nerve that is basically connecting the neck to the scalp and the actual face and the trigeminal nerve. Because the two have a landing synaptic connection that's happening inside the brainstem and the upper part of the cervical spine. And so what ends up happening is that people get neck pain during migraine attacks, and then also sometimes people will have referred pain in the face. I see this very commonly in my patients, but the pain might actually be coming from the neck. So that interplay between all those different systems is definitely a big component in migraine. The other one is actually the vessels, which you can see right here. So basically, the vessel diameter changes during migraines and also changes during different migraine stages. And that's something that some of the medications like triptans capitalise on, right. So they vasoconstrict the vessels and they have an effect on the serotonin receptors that leads to changes in that blood flow, right. And that is thought to be definitely an important factor when it comes to pathophysiology of migraine. But there's others too, right, and there's a lot of different things feeding into it, right, so for example, estrogen and hormones will have an impact on the trigeminovascular system. But also things like weather changes and barometric pressure change has been shown to actually activate that trigeminal nerve, right, both in animal models and in humans. So then you're, you know, kind of thinking about very different parameters that unfortunately all converge onto the same system, but that can have many faces, right, because to think about a disorder where you have impact coming from the weather change, which a lot of people think unfortunately is superstition. A lot of migraineurs don't believe themselves that the weather is leading to kind of pain and headaches and migraines, but it's very legitimate and there's a lot of research behind it and a lot different mechanisms, but a lot my patients tell me that they are walking barometers, but they don't really believe themselves until you validate and you tell them that yeah, this is actually true  [00:14:08][248.9]
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Dr Louise Newson: [00:14:09] Yeah and it's interesting because whenever I have a migraine I try and work out the trigger because anything to reduce my migraine frequencies I'll work really hard at because they're so debilitating and really just such a waste of time really because I can't function when I have them but often and the same as my daughter we're always like well what's triggered it and sometimes it's really obvious it might be that I've eaten a meal late or something has happened but when it's a weather change... When we both go, oh, yeah, but look, hang on, it's been raining and it stops or whatever, it's quite reassuring to know it's something that you haven't done as well because there's a lot of guilt that can go on. And when we look at sort of non-drug treatment, I think with migraine, you can never cure it, but you can try and reduce the severity and frequency of migraines, really. I hope you agree with that.  [00:15:06][57.1]
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Dr Elie Sader: [00:15:07] Yes, absolutely.  [00:15:08][0.5]
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Dr Louise Newson: [00:15:08] And it's really important to work with, with patients to understand that it's multifactorial as well. So it's not like if you cut your finger, it's very easy. You then have a stitch in it or your plaster on it and it will repair. There's so many different things. Some you can control and some you can't and everyone's different. And so, I've spoken about it before, you know, I don't eat processed foods because I know they trigger migraines. I wouldn't be able to drink a glass of orange juice because it would trigger a migraine, whereas my mother has migraine. She drinks orange juice every morning. I can't understand why I can't. And we're different and you have to work it out, but it can sometimes take quite a long time to make changes and you don't want to make too many changes because then you can't work out what it is that's either made it worse or better.  [00:15:57][49.3]
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Dr Elie Sader: [00:15:58] Great point, great point. And I think that what's important to mention here and the way I like to think about migraine and the whole kind of trigger thing is basically that you have essentially like a jar or a glass of water that you're filling, right with different triggers. And then you reach a certain stage or a threshold where basically that's going to trigger a migraine.  [00:16:18][20.0]
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Dr Louise Newson: [00:16:19] Yeah.  [00:16:19][0.0]
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Dr Elie Sader: [00:16:19] And really every one of those factors are going to contribute, but to a different extent. So it's almost like each factor is going to have its own coefficient, right. So you have the weather changes for some people, you're going to the hormonal changes at certain times, you are going have maybe if somebody had chocolate or if somebody had caffeine or if they did not sleep properly the night before, right, or if there's too much stress going on in their life, each and every one is going be its own trigger. And then potentially, up until that stage, even with all of those, they're still compensating and you still don't really have a migraine. But then all of a sudden, if you add on top of it, some blue light or bright light or something of that sort, and now you have crossed that threshold and you're gonna get your migraine. But each individual factor on its own may not be sufficient, right. Combine them all together and then you end up with the magic concoction to actually have that excitability in the brain and potentially end up a with a migraine. And that's why it's so difficult for patients to keep track of all the different triggers, right, because they might think that one day the weather may have had an impact, but then the next week, even with the same weather, you know, they didn't really have a migraine. So then is it really that weather has an impact on them or not. But they're not keeping track of all the other factors, what they ate, whether or not they had some red wine, potentially, some nitrates, smoked meats, all of the common triggers, which are different between different people, right. But even for the same person, I think that one trigger on its own is not gonna be sufficient to trigger the migraine. It's really the combo, right, and that's essentially how I like to think about it and why it's so important to keep a headache diary, right. And to, or these days, more of an app, right. So there are apps that can keep track of your triggers. But that's so important because I think humans usually overestimate their abilities at remembering things. So we think that we're going to, you know, remember if, you know, a coffee has an impact on our headaches or the chocolate or something, right. But then you actually need to have a probably like a month or two of tracking the data to be able to tell.  [00:18:26][127.3]
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Dr Louise Newson: [00:18:28] At least, absolutely. I mean, it's a bit funny in some ways, but about 20 years ago I was getting palpitations, really awful palpitaitons and I'd often get them at night. They'd often wake me up and sometimes I got chest pain and shortness of breath with them and a few times I thought I'm going to have to call an ambulance. I went and saw a cardiologist. I had various tests, everything was fine and they said, well, I think you should probably give up caffeine and alcohol. Now I've never drunk much alcohol. Caffeine. I really liked my 10 o'clock in the morning cup of coffee, but I thought, well, I don't want these palpitations because they're scary. You've only got one heart, right? And it's really quite unnerving. So I gave up alcohol and caffeine. And then after about, it was probably about three to six months, quite a long time, I realised I wasn't getting as many migraines. And so then I thought I'll do anything to help my migraine. So I haven't drunk alcohol or eaten chocolate since then. But It was probably my hormones that was causing my palpitations. That's the funny part about it. So if I'd seen a cardiologist who understood hormones, I'd probably still be eating chocolate and drinking alcohol. And I probably would say to you, well, I don't have much, so therefore it's not really a trigger, but because I've stopped it completely. You know what I mean? And so I think that's the thing. Sometimes people reduce something and say, well it's not really the alcohol or it's not really in the chocolate or it was not really whatever. But you have to really remove it, I think, for a length of time before you can decide whether it does make a difference or not. [00:19:56][88.6]
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Dr Elie Sader: [00:19:57] It's a process of elimination and I think that it has to be done in a very controlled and measured way by taking out one factor at a time, right. Because there's so much interplay between these factors, right. Let's take caffeine as an example. Caffeine itself has more than one mechanism in terms of how it affects the brain, right, so you have the nitric oxide mechanism where it's going to lead to vasodilation of the vessels, right but then you also have the adenosine pathway, right and the problem is that all of that is gonna happen in different ways during the day. So depending on how tired you are, depending on you slept the day before, that's gonna influence how caffeine will affect someone. Not to mention the dose in itself. So caffeine, let's say less than 200 milligrammes in a day versus more than 400 milligrammes is gonna have a very different effect. And that's why sometimes we use caffeine as treatment for certain headaches, including migraine. We have it in a lot of different medications like Fioricet and Excedrin and things of that sort, right. But then also for other people caffeine can definitely be a trigger.  [00:20:59][61.6]
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Dr Louise Newson: [00:20:59] Yeah.  [00:20:59][0.0]
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Dr Elie Sader: [00:21:00] And then for other people, caffeine withdrawal is a huge issue, right. So if you drink a lot of coffee and then you stop drinking, right, so there's just so many factors that unfortunately, we generally like to make things simple, right, as humans, we like to simplify and make everything binary. It's like, okay, caffeine is good, caffeine's bad. Right, but it's not that simple. With a lot these triggers, it's really not that simply in terms of whether or not they're going to be good or bad when it comes to migraine.  [00:21:26][26.6]
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Dr Louise Newson: [00:21:28] Yeah. It's also interesting the sex difference, isn't it? Because it is more common in women.  [00:21:33][5.2]
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Dr Elie Sader: [00:21:34] Yes.  [00:21:34][0.0]
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Dr Louise Newson: [00:21:35] And a lot of people, there's a hormonal change like you've already said, but there's different hormones that we need to think about and people respond quite differently. And certainly I've got a huge amount of clinical experience because we see thousands of women every month in our clinic. So, we really noticed that having the right dose and type of hormones can really help. And I know myself, if I'm not on the right dose, it will trigger a migraine it, because I get muscle and joint pains, which it's not a migraine thing. It's related to having no hormones. And I use patches of estradiol, which is, is the only way I can get the estrogen through my skin. The gel floats off my skin, so the patches is the only way I could use it, but every so often you might see if you follow me on Instagram. I put a picture of one of my patches that's literally flapping in the wind. And a few days ago I was doing some yoga and I could hear this crinkling. I'm like, what's going on? And then I realised it was my patch. It was just making a noise. And actually before that time I was getting some migraine and I thought, oh, it's probably because I'm getting an intermittent absorption of the estradiol. It's like being perimenopausal again. It's not constant and I've went through another three patches before I've like found one. It's every so often, I think the glue changes, but it's really important because anything small that changes, the brain likes homeostasis, especially if it's a migraineur's brain, isn't it. And, you know, when hormone levels are fluctuating, whether it's estradial, whether its progesterone or low testosterone, all of those hormones can really have an important role and I see a lot of people who are told by various specialists, it can't be your hormones because you're still having periods. And I'm like, no, you still can have hormonal changes. And it's worse actually when the hormones are fluctuating.  [00:23:32][117.4]
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Dr Elie Sader: [00:23:34] It is, it is 100%. And that's, I think one of the biggest misconceptions about migraine. And I think we have so much evidence when it comes to estrogen, right. At different stages in a woman's life. So whether we're talking about puberty or whether we talking about pregnancy and the postpartum phase, but especially for perimenopause and menopause, I think that's where we have a lot of the evidence about the impact that estrogen fluctuations will have on migraine, right. So with pregnancy, for example, usually about 70% of women will actually have an improvement in their migraines, right. And that's because of the fact that you have more steady levels, but then as soon as they drop in the postpartum phase, that's when things can happen again, unfortunately, right. And same with the perimenopause period, right, so you have a lot of irregularities that happen. And that in itself usually brings about a couple of years of a lot trouble for many patients. Because they are suddenly having that resurgence of their migraines, which they were sort of, you know, somewhat managing over the past 10, 20 years, but then they come back with full force, right during perimenopause and unfortunately, because of the stigma around hormones and HRT and some of the misconceptions that were, you know, that still exists, unfortunately, right, in terms of the stroke risk and the other risks of hormones, a lot of women have that fear. In terms of being on hormones, and sometimes even their doctors are telling them that they shouldn't be, but not for the valid reasons, right. So I think it's important to educate ourselves and educate our patients.  [00:25:14][100.1]
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Dr Louise Newson: [00:25:15] Absolutely.  [00:25:15][0.0]
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Dr Elie Sader: [00:25:15] So that they know what is safe, what is not, and also what for. So what you mentioned earlier was actually a great point because with the transdermal estrogen, the idea is that you're having less fluctuations as opposed to taking an oral estrogen every day where you're gonna have the ups and downs. And so that's why usually that's what I recommend to a lot of my premenopausal women who have migraines. And I tell them that the transdermal is gonna be the best option from a headache standpoint, right. because that's gonna minimise the fluctuations. Transdermal HRT is safer than oral when it comes to stroke risk. And so I think a lot of people need to change the way they think about the risk and benefit ratio when it comes to that.  [00:25:59][44.3]
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Dr Louise Newson: [00:26:00] Absolutely, and also the progesterone, making sure it's the natural body identical progesterone because the synthetic progestogens have a clot risk, a stroke risk, but they can also worsen migraines too.  [00:26:11][11.4]
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Dr Elie Sader: [00:26:12] Yeah. Yeah. 100%.  [00:26:13][1.0]
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Dr Louise Newson: [00:26:14] And there's increasing evidence that testosterone can have a role as well. It's very anti-inflammatory, but all these hormones can have effects on other neurotransmitters in the brain and they can also modulate the pain receptors. So, which is important because they are natural analgesics as well, and so anything that's going to help our brain function, reduce pain as well it's got to be a good thing. But it's working with the right practitioner. Some of you who are listening might have listened to the podcast I did with my daughter Jess and you know it's a long journey often to get the right treatment and you know making those lifestyle changes can be a lot harder often than taking a tablet but with migraine we have to be looking at lots of different adjustments as well to really get the most out of our health but It's such a big disability. And I'm always very sad to read how little funding there is for research and for even clinics. It's a nightmare over here. You know, the clinics oversubscribed. My daughter has Botox regularly as well, and it's really difficult to have that on the NHS. And when I ever take her to an appointment, the nurses are really stretched. There's a long waiting list. And for my mind, like, I don't understand because Botox isn't a systemic treatment and if it works, then that's really good, isn't it?  [00:27:48][94.4]
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Dr Elie Sader: [00:27:50] It is. And I think that's important to keep in mind that you need to have a multimodal approach to migraine, right. So I think hormones play a really big role, right, but unfortunately they're not sufficient for a lot of patients. So we have to always think about whether or not a given patient needs preventative therapy, right with a prophylactic migraine such as the Botox that you mentioned, right which can help a lot patients or some the newer CGRP medications, whether we're talking about the injectables or the gepants. But essentially a lot of those will be needed in addition to the lifestyle modifications, right. Sometimes supplements can help, but usually none of those factors on their own is gonna be sufficient. You need all of them at the same time to be able to have a profound change in the disability coming from migraine.  [00:28:38][47.7]
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Dr Louise Newson: [00:28:39] Yeah, absolutely. And we are all different, but it's great to have this discussion so people can just think differently, hopefully, and not just for themselves, but for others, whether it's at home or at work or wherever. So before we end, I always ask for three take-home tips. So three things, if someone's listening here and they are either a migraine sufferer or they know someone, what are the three things that you would say initially to someone who has migraines that might help?  [00:29:08][29.1]
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Dr Elie Sader: [00:29:08] So one thing I would definitely say is basically not to take their doctor's opinion for granted. So I see this a lot, unfortunately, patients sometimes think that their doctors have that 100% certainty rate in terms of whatever they say. But we make mistakes, as I'm sure you know, so we're not always right. And especially when it comes to complex disorders, we don't really have all the answers. So assuming that we do, can often do more harm to patients. And so usually what I tell patients is that they have every right to second guess their doctors and to basically seek a second or a third or even a tenth opinion if needed, right, if they feel that they're not getting the proper treatment. So if they are, let's say with a physician who is telling them that hormones have no impact on their migraine and that they should maybe stay away from HRT, right, for the wrong reasons. Then in that case, they should probably go and, you know, talk to somebody else, right. And I think that can be life changing for some patients, but they need to have that change in mentality and that mindset shift because otherwise they're going to have the guilt and blame themselves, right. And unfortunately, that can do a lot of harm for disorders like migraine. So that definitely would be the number one thing is to get a second and a third opinion. And then a second recommendation that I have is to pay very close attention to the triggers and the lifestyle changes and to be very patient with them too. So when a given change is made, whether that's stopping coffee or stopping cheese or whatever it is, I think that you need to give yourself at least a month, I would say to know whether or not this is having a meaningful impact, right. Because you have to keep in mind all the other factors that are also having some kind of effect. And so doing it over a month by a process of elimination is probably a more scientific way to test it out. And then the third recommendation that I would have for migraine patients is to basically remember that migraine is way more than just the headache phase. And so, because of the impact that the prodrome and the postdrome can have, especially on disability, because when you're having all of those sensory changes, whether they are before or after the headache, that's unfortunately affecting your way to be able to think, to be be able work. You're gonna have some brain fog. There's gonna be changes in the temperature in your body. You're going to feel fatigued. Sometimes you feel like you need to be in a dark room and sleep. So a lot of those unfortunately affect somebody's ability to function even at the basic mode. We're not talking about competing in the Olympics. We're just talking about being able to survive on a day-to-day and do your usual job, which two days prior would have been very doable. But then now all of a sudden, because of the migraine and the other, you know, the different stages, is becoming insurmountable. So I think it's important to keep in mind that there's way more to migraine than the headache and to also try to appreciate the fact that the onset itself is often several hours before the actual onset of the headache, right. And because of that, the timing of when to take the rescue medication should potentially be earlier. So at the very first stage, whether it's the visual aura or the prodrome or whatever it is before the actual headache, that's gonna be the highest impact in terms of taking the rescue meditation. And potentially for a lot of patients, if they're having more than five headache days or migraine days in a month, I would say that being on a preventative option, whether that's, you know, a CGRP or whether it's a Botox injections or occipital nerve blocks, there's a lot of different prevention options. But then that becomes essentially paramount, because otherwise you'd run into medication overuse headache, right, which is a real thing in itself with all the rebound you can get from taking too many rescue medications.  [00:33:16][247.4]
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Dr Louise Newson: [00:33:18] Great advice from such a wonderful expert, so thank you so much for your time today, it's been brilliant.  [00:33:23][5.0]
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Dr Elie Sader: [00:33:23] Thank you for having me.  [00:33:23][0.0]

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