For those who suffer from migraine headaches, the pain can be devastating. Intense throbbing and sensitivity to light or sound often keeps people from their normal lives for hours or even days on end. The World Health Organization ranks migraine as one of the most debilitating diseases, and more than 10 percent of the population suffers from it. Yet migraine is not widely understood and is often misdiagnosed. But patients can find relief with the right treatments. As scientists learn more about the cause of migraines, doctors and patients have their sights on better medication. Diane and her guests discuss living with migraines and the search for new treatments.

Guests

  • Dr. David Dodick neurologist at the Mayo Clinic and chair of the American Migraine Foundation.
  • Teri Robert author of "Living Well With Migraine Disease and Headache."
  • Dr. Perry Richardson neurologist at George Washington University Hospital.
  • Story Landis director of the National Institute of Neurological Disorders and Stroke at the National Institutes of Health.

Web Extra: Dr. David Dodick Answers Audience Questions

Is there a correlation between migraine and epilepsy? How are migraines diagnosed in children? Dr. David Dodick of the Mayo Clinic responded to these listener questions and more. Some questions have been edited for space and clarity.

Q: Is it common for children to experience migraines during puberty and then grow out of them? — From Twitter user @AFountain

A: Migraine tends to be begin during adolescence, peak in the 20’s-40’s, and diminish thereafter. While the clinical course is highly variable and migraine can go into remission at any time, it is not common for migraine to remit in adolescence. In addition, the predisposition to migraine is believed to be genetic and therefore, the predisposition is lifelong, though for a significant proportion of individuals, the attacks tend to diminish over time.

Q: What is the correlation between stroke, birth control and migraine? — From Twitter user @MigraineLand

A: The risk of stroke, particularly in women less than age 45, is increased two-fold in those who have migraine with aura. That risk is increased by up to 8-fold in women who have migraine with aura who also use an oral contraceptive pill. This risk is increased even further if the woman smokes. Therefore, all women with migraine with aura should be encouraged to quit smoking (if they smoke). In regards to the oral contraceptive pill, recommendations vary from never using the OCP in a woman with migraine with aura to using if aura is infrequent and limited to visual symptoms only. In general, for those young women with frequent migraine with aura, or aura that is prolonged (lasting longer than 60 minutes), or in those whose aura started or worsened after starting the OCP, it is recommended that alternative means of birth control be explored to minimize the risk of stroke.

Also, please keep in mind that while the relative risk of stroke is increased by a factor of 2 in those with migraine with aura, the baseline risk of stroke in young women without migraine with aura is very low (approximately 4 per 100,000 women). That means that while the risk is double, the risk of stroke is still very small (8 per 100,000 women) and even when the OCP is added, the risk is approximately 60 per 100,000. Those individuals with a family or personal history of blood clotting disorder (deep venous thrombosis, pulmonary embolus, should certainly avoid the OCP)

Q: Are there any studies that establish a correlation between fibromyalgia and migraines? — From Twitter user @araaajoooo

A: Yes, fibromyalgia and other chronic pain disorders are considered to be “comorbid” with migraine. That means that they are more often associated with migraine than one would expect to occur by change alone. This is likely due to abnormal function of the internal pain modulating networks in the brain in migraine, and this dysfunction leads migraine sufferers to be susceptible to other chronic pain conditions.

Q: I get cluster headaches which are often mistaken for migraines. Is it because I am female, or are they that similar? — From Twitter user @MJnTJ

A: Cluster headache does share some features with migraine. For example, cluster headaches are almost always unilateral (migraine is unilateral about 50% of the time), and cluster headaches may be associated with sensitivity to light (photophobia) and noise (phonophobia), and, less commonly, with nausea. However, cluster headache can usually be distinguished easily from migraine because cluster headache is almost always unilateral, side-locked (which means they occur on the same side), last a shorter period of time (30minutes to 3 hours; compared to the 4-72 hours of migraine), are associated with prominent tearing, reddening of the eye and nasal congestion, on the same side as the pain, and patients with cluster often need to pace during an attack while migraine sufferers generally like to be at rest and still. Cluster usually occurs once to three times per day for a period of months and then go into remission for months to years (hence the name cluster). Finally, in those with cluster, attacks that awaken individuals from sleep are very common. While cluster used to be considered a disorder that affected men 20-times more commonly than women, we now know what the ratio is much smaller and while cluster is still more common in men, the ratio is more like 3:1.

Q: Are most migraines onset due to triggers? What are common triggers? — From Twitter user @JoanneDavidhiza

A: The extent to which triggers are present varies considerably from one individual to another. It is certainly time well invested to keep a diary to determine which triggers may be relevant for you. Common triggers include stress, relief from stress, sleep deprivation, alcohol, certain medications (e.g. nitroglycerin), overuse of analgesics, triptans, narcotics, certain foods (processed meats, aged cheese, monosodium glutamate, aspartame, caffeine), menstruation, exercise, high altitude.

Q: Are the mental health issues mentioned by your guests also a concern for those who have aural migraines? — From Twitter user @TomGodell

A: Yes, the mental health issues are equally a concern for those who have migraine with aura. For those who have chronic migraine (headache more than 15 days per month), mental health issues are even more common. Rates of depression and anxiety for example are higher in chronic migraine sufferers than in those with episodic migraine (less than 15 headache days per month). This association is very likely due to similar underlying biology – in other words, the altered chemistry in the brain in depression and anxiety may be similar in some ways to migraine. This may explain in part why some antidepressants are effective for the prevention of migraine.

Q: Is there a comorbidity or other correlation between migraine and epilepsy? — From Twitter user @MmrghHmph

A: Yes, migraine sufferers are twice as likely to experience epilepsy and vice-versa. This is very likely due to a similar underlying biology. In other words, epilepsy and migraine are both due to abnormally excitable brain cells and networks in the brain. And, in fact, several of the most effective medications for the prevention of migraine are antiepileptic drugs.

Q: What research is being done regarding long term impact of migraine on the brain and long term (20+ years) exposure to daily meds? — From Twitter user @nikki_d

A: There have been a number of studies that have evaluated the long-term neurological effects of migraine, particularly with respect to cognitive function. A very recent and large study that evaluated over 6,300 women over the age of 65 at the time of the evaluation, and who had migraine with and without aura throughout their lives, found that cognitive decline was no more significant or rapid in those with migraine (with or without aura) compared to those without migraine. However, there is evidence that migraine sufferers are at an increased risk of stroke and brain lesions, particular those with migraine with aura. These individuals are at double the risk of stroke and up to 15-times more likely to develop brain lesions. It is not clear whether these lesions have an effect on these particular migraine sufferers over time compared to those without these lesions.

With regard to the long-term effects of migraine medications that are taken daily, while there are adverse effects associated with all medications, and the type and severity of adverse effects vary between patients and depending on the particular medication, there is no definitive evidence that there are serious long-term effects of preventive migraine medications taken daily for migraine. All of the preventive drugs taken for migraine are used long-term for other disorders such as epilepsy, depression, high blood pressure, and other disorders, so there is extensive evidence that the long-term effects of these medications taken for other purposes appear to be relatively safe long-term.

Q: Biofeedback machines, watching my state of mind and breathing techniques changed my migraines substantially. I had been a serious sufferer from 12 until 21 years old and still get them, but not nearly as often. Please discuss application of meditation and breathing techniques. Was this my imagination? — From Facebook user Kathleen Galt

A: Biofeedback has been demonstrated to be effective and is recommended for the preventive treatment of migraine. By becoming aware of your body’s automatic responses to pain and stress, and learning to control those responses, some individuals are able to lessen your pain. Biofeedback monitors and measures your body’s involuntary physical responses to pain and stress, such as breathing patterns, heart rate, body temperature, and muscle tension. The monitors provide feedback to the patient during a session and with this information, individuals can better understand how their body reacts in certain situations and how they can modify these responses to reduce pain. These techniques are felt to exert control over the autonomic (‘involuntary’) nervous system and engage the internal pain modulation system in the brain and in these, and potentially other ways, have a positive impact on migraine.

Q: Is there any relationship between the brain disorder that causes migraines and trigeminal neuralgia? — From Facebook user Donna Mitchell MacKinney

A: No, trigeminal neuralgia and migraine are felt to be distinctly different disorders. They each have a unique biology and are treated differently.

Q: I was wondering if you can have migraines that do not manifest as headaches? I had ear pains that literally gave me vertigo so bad that I had to use my medical leave. We were never able to figure out what caused the ear pain. — From Facebook user Valerie Garza Estes

A: Migraine is a neurological disorder that can cause a wide variety of different symptoms, of which headache is one. However, other symptoms of migraine may appear without pain. In particular, the aura of migraine (e.g. visual disturbance may occur without pain), vertigo, and other symptoms may occur in the absence of headache. In children, abdominal pain, vomiting, and other symptoms may also occur in the absence of pain. The presence of ear (especially inner ear pain) with vertigo may be due to disorders other than migraine.

Q: I have suffered for over 30 years and now I am getting nocturnal migraines. Any idea why they are happening while I am sleeping? I have also suffered two episodes of cluster headaches in 1990 and 1996. Any input on what could have triggered my cluster headaches? — From Facebook user Chris DeBottis

A: It’s very common for cluster headache to occur during sleep and in fact, its also common for migraine to occur during sleep or upon awakening. While sleep sometimes provides relief of migraine, it can also sometimes trigger migraine. This may be due to inactivation of certain regions in the brain that may lead to activation of the pain pathways and other brain networks involved in generating a migraine attack. One should also beware that there may be sleep disordered breathing (sleep apnea), elevated blood pressure during sleep, and other disorders that can either trigger cluster headache or migraine during sleep. If patients whose attacks begin to occur during sleep, or occur exclusively or predominantly during sleep, a sleep evaluation, sometimes with overnight sleep studies (polysomnography) is recommended.

Q: My 5-year-old son has been suffering from weekly headaches for just over a year. They can be debilitating if we don’t treat them with Tylenol or Ibuprofen immediately. His pediatrician has prescribed Periactin nightly. How are migraines diagnosed in children, and is there more we could be doing? — From Marla via Website

A: Migraine is a clinical diagnosis, based on characteristics of the headache and associated symptoms. In other words, there is no blood test, x-ray, or brain scan that can make the diagnosis of migraine. These tests are used to exclude other disorders that can mimic migraine. While there may be some differences between migraine in children and adults (e.g headache may lasts shorter period of time), in general, the attacks are similar. Cyproheptadine (Periactin) is a commonly prescribed medication used in children to prevent attacks. There are a variety of treatment options, both pharmacological (drug) and non-drug treatments that can be used to effectively manage migraine in children. For those children who do are not responding to conventional treatment, and who are suffering from frequent and disabling headaches, one could consider a referral to a pediatric migraine specialist.

Q: I’ve heard that migraines are also associated with a higher incident of stroke. Does the latest research, which moves the disease from the vascular space to the neurological space, support that? — From acdames via Website

A: Yes, there is now considerable evidence that women who have migraine with aura are at an increased risk of stroke. Even though the migraine aura and the migraine headache is now not considered to be due to constriction and dilation o f blood vessels, migraine may be triggered in some patients by alterations within the brain blood vessels (e.g. reduced blood flow, particles in the blood). Also, during migraine attacks, there may be secondary changes in the blood vessels that affect blood flow and increase the risk of stroke. For example, during migraine with aura attacks, there may be a reduction in brain blood flow as a result of changes in brain activity. Also, individuals with migraine, especially with aura, are also at an increased risk for other disorders (patent foramen ovale, arterial dissection) that may increase the risk of stroke.

Q: Could there be a correlation between gastrointestinal diseases and migraine headaches? You discussed in detail on the show the numerous neurological conditions that have a strong relationship to migraines, but is there any research being done about possible relationships between Inflammatory Bowel Diseases and migraines? — From Schandra via Website

A: There is evidence of a relationship between migraine and irritable bowel syndrome. There is also evidence that gastric stasis (reduced movement or motility of the stomach) may be present during and in between migraine attacks. However, there is not yet convincing evidence that migraine is related to or more commonly associated with inflammatory bowel disorders that would occur by chance.

Q: What is the difference between migraine and Benign Paroxysmal Vertigo syndrome? If you have BPVS, will you become a migraine sufferer? — From Facebook user Deborah Couch

A: Benign Paroxysmal Positioning Vertigo (BPPV) is an inner ear disorder and unrelated to migraine. However, paroxysmal vertigo (episodes of vertigo) may occur in association with migraine attacks, whether or not the migraine attack is accompanied by the headache. This has been termed migraine associated vertigo or vestibular migraine. In fact, in young women, migraine is one of the most common causes of unexplained episodes of vertigo.

Q: While going through peri-menopause, I started suffering from the most painful headaches that often came in the middle of the night and often induced vomiting. Is there a link between migraine and menopause? I have a younger sister who is now going through the same symptoms I had at about the same time in her life. — From Facebook user Candy Allen-Smith

A: Yes, migraine is often affected by changes in hormonal cycles in women. For example, the onset of menstruation during adolescence, the menstrual cycle, pregnancy, hormone replacement therapy, oral contraceptive therapy, and menopause all may have a dramatic effect of migraine. However, there is considerable variation in the effect of each of these periods, including menopause, among individuals. Certainly, a significant number of women improve after menopause, but a substantial number of women worsen while going through menopause. The effect of fluctuating levels of female hormones during menopause appear to have an effect on the excitability of brain networks, including pain systems, that may adversely effect women with migraine and those genetically susceptible to migraine.

Q: Are ocular migraines related in any way to migraine headaches? Are they connected to any type of brain disorder, or something completely different? — From Facebook user Suzanne Rose

A: The formal or accurate term for “Ocular migraine” is migraine aura without headache. The visual symptoms experienced by these individuals is the same as those who experience the visual symptoms associated with the headache. One can think of the visual symptoms and the headache as two of many symptoms of the migraine attack. Sometimes they occur together, sometimes they occur in isolation.

Q: I have had dizzy spells for months, which some doctors think are related to migraine. I have tried physical therapy with mixed success to “retrain” the brain. Do you think this approach makes sense? — From Facebook user Barbara Carney-Coston

A: Yes, vestibular rehabilitation therapy is recommended for those with vesibular symtoms, whether related or unrelated to migraine. There are other potential approaches to treatment as well, and guidance from a neuro-otologist or migraine specialist may be useful if you do not make progress with physical/vestibular therapy.

Q: I still get the visual auras and as my migraines became less [severe], I began to have acute tinnitus. Is there a connection between tinnitus and migraines? I am 63. — From Facebook user Virginia Ann Ullrich-Serna

A: Yes, there appears to be a relationship between tinnitus and migraine. A number of migraine sufferers report tinnitus during migraine attacks. However, age-related tinnitus can have other causes as well, the most common of which is sensori-neural hearing loss.

Q: I think I have visual migraine when I exercise vigorously or I’m dehydrated. I have jagged lines in my field of vision, but no pain or sensitivity. It happens one or two times a year. Is that a migraine? — From Facebook user Janie Moretz

A: Yes, that is a migraine aura without headache. It has the same underlying biology as when these symptoms are associated with headache.

Q: My migraines seem to be triggered by hormones and seem to be getting worse as I approach menopause (I’m 45). Are there different approaches for hormonally-triggered migraines? Can I expect some relief after I go through menopause? — From Facebook user Lisa Tait

A: As noted above, migraine may worsen while individuals are progressing through menopause and may improve after menopause. This of course is not true for all. While treatment approaches may be the same as for migraine that is not associated with hormonal changes, there may be very specific strategies for treatment that include hormonal replacement therapy. It is highly advisable however that you enlist your doctor’s advice and guidance regarding the pros and cons of hormonal therapy.

Q: Has marijuana shown any promise as a treatment for migraines? — From Facebook user Lionel Hubbs

A: There is no evidence to support the use of marijuana for the treatment of migraine.

Q: If as much as 10% of the population suffers from migraines, why does the medical community lack basic knowledge of common symptoms and treatments? What will it take to put migraines on doctors’ radars? — From Erin via Website

A: That is an excellent question but complex to answer. A misunderstanding of the biological nature of migraine for centuries, an underestimation of the impact and suffering experienced by a substantial number of individuals with migraine, and the lack of education in undergraduate and post-graduate medical education of physicians and health care providers are certainly leading reasons. It’s also true that it takes approximately 15 years for advances in medical knowledge to make it into clinical practice. With the emergence of the internet and direct-to-consumer advertising, patients have and will continue to become more empowered and engaged in the management of their illness, and seek the most appropriate medical care for their condition. Also, as medicine moves toward reimbursement (“pay”) for performance rather than “pay-for-service”, physicians and health care providers will need to integrate evidence-based guidelines and best practices to ensure optimal patient outcomes.

Transcript

  • 11:06:52

    MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Thirty-six million people in the U.S. suffer from migraine, but doctors and patients say the disease is misunderstood and under-diagnosed. We'll talk about the search to better understand and treat migraine.

  • 11:07:16

    MS. DIANE REHMHere in studio is Dr. Perry Richardson, neurologist at George Washington University Hospital. Teri Robert is author of "Living Well with Migraine Disease and Headache," and joining us from KJZZ in Tempe, AZ, Dr. David Dodick, neurologist at the Mayo Clinic and chair of the American Migraine Foundation.

  • 11:07:42

    MS. DIANE REHMI invite you to join us with questions and comments, 800-433-8850. Send us your email to drshow@wamu.org. Follow us on Facebook or Twitter. We'll try to get to as many of your calls as possible. Good morning to all of you.

  • 11:08:09

    DR. PERRY RICHARDSONGood morning.

  • 11:08:09

    MS. TERI ROBERTGood morning.

  • 11:08:09

    DR. DAVID DODICKGood morning.

  • 11:08:12

    REHMGood to have you all here. Dr. Richardson, if I could start with you. A migraine is not just a headache. What's the difference between an ordinary headache and a migraine?

  • 11:08:27

    RICHARDSONWell, actually, ordinary headache is a difficult topic for me because I always get suspicious if somebody is telling me that they have headaches that are disabling that are different from their normal headaches. If somebody reports headaches that they interpret as normal, but they occur on a continuing basis or an episodic basis, I actually start asking questions about migraine predisposition.

  • 11:09:02

    RICHARDSONThe migraine also classed as a headache, as you said, is actually a brain disorder. It's not a blood vessel disorder. It has phases that have been recognized to occur before pain, although it is the most disabling type of benign headache syndrome.

  • 11:09:23

    RICHARDSONNot so benign because many people are put to bed with headache, disabled, cannot work, cannot enjoy their family functions, and cannot socialize. The diagnosis is lacking any kind of formal scientific test. You know, we use the term bio-marker so that when someone is diagnosed with migraine, it's based on a description of the event.

  • 11:09:49

    RICHARDSONThe headache pain may or may not be unilateral, one side of the head. That was the origin of the term. It comes from a Greek word for one side of the head. It is often associated with sensitivity symptoms and there's now good evidence that it is an excessively sensitized brain. Before pain occurs, there may be a warning sign that's often a visual change. That's called a visual aura, sometimes tingling.

  • 11:10:16

    RICHARDSONAnd even before the aura, there's a premonitory phase that many people recall if you ask them about it, which consists of an odd malaise a day or two before, sometimes yawning, food craving, mood shifting. And some people actually are wrung out for a day or so after the headache. So I ask for panoply of these symptoms that help me recognize that this is migraine.

  • 11:10:46

    REHMDr. Perry Richardson, he's a neurologist at George Washington University Hospital here in Washington, D.C. Dr. Dodick, I heard Dr. Richardson use the words brain disorder. I had certainly previously thought that migraines were thought to be vascular disorders. Has the entire outlook regarding migraines changed over the last decade?

  • 11:11:28

    DODICKAbsolutely, Ms. Rehm. I mean, for three centuries...

  • 11:11:32

    REHMPlease call me, Diane.

  • 11:11:32

    DODICK...Diane, okay, Diane.

  • 11:11:33

    REHMThank you.

  • 11:11:34

    DODICKI mean, over the past three centuries, migraine has been considered to be a vascular disorder, a problem with dilation of blood vessels. But we now understand over the past decade or two that migraine is a neurological disorder and that has tremendous implications for drug discovery for new treatments, if you will, because now instead of targeting the blood vessel, that new pipeline of medications that are becoming hopefully available in the near future will target the brain and nerves themselves.

  • 11:12:03

    DODICKSo, yes, this is, as Dr. Richardson said, a genetically-inherited disorder due to sensitization in the brain or hyper-excitability of certain brain networks.

  • 11:12:15

    REHMAnd what does that mean, this shift? What does it mean to the patient to begin to understand that he or she has a brain disorder and not simply an expansion or compression of some vein in the brain?

  • 11:12:40

    DODICKWell, what it means to the patient and any patient will tell you that, you know, headache, I often say we should take the headache out of migraine because migraine has been defined by the headache for millennia. But there are so many neurological symptoms that accompany the headache and disable patients almost equally as badly as the headache itself.

  • 11:13:01

    DODICKSo what it means for patients is that when we say that a patient has a disease, not only does it mean necessarily that they have abnormal structure of that organ but abnormal function. So normally, when we do an MRI scan or scan of the brain of someone with migraine, generally speaking, it's normal.

  • 11:13:18

    DODICKThe problem is that if we did a functional scan of the brain, we see how abnormally the brain is behaving. So it's a disorder of function, if you will, rather than structure. Patients shouldn't get alarmed that they have a brain disease, but by the same token, when any patient who sits in my office and tells me that they can't concentrate, they can't remember, they have trouble speaking, they have trouble understanding, they have dizziness and so on and so forth, one recognizes very clearly that this is so much more than a bad headache.

  • 11:13:50

    REHMDr. David Dodick, he's a neurologist at the Mayo Clinic in Arizona. He's chair of the American Migraine Foundation. I can see that we've already got a great many callers and I know that we won't be able to respond to each and every listener's question on the air ,but Dr. Dodick has agreed to answer some questions about migraines after the show if you will submit your questions on our website, drshow.org

  • 11:14:35

    REHMYou can email or send us a tweet or leave a Facebook comment and Dr. Dodick will try to get to your question. Now, turning to you, Teri Robert, you are a patient educator and advocate. You're the author of "Living Well with Migraine Disease and Headache." Tell me about your own experience with migraine.

  • 11:15:06

    ROBERTI had my first migraine that I remember when I was six. My father used to say he would come home from work and find me in my closet with my blanket and pillow because it was dark and quiet there. Through most of my school years, they were infrequent, they were episodic and they weren't a big deal.

  • 11:15:26

    ROBERTBut as I got into my mid-30s, they became more frequent. Then when I got to my early 40s, they were almost daily, five and six days a week and I was flat on my back in bed all day and nothing worked. And unfortunately, no doctor within 100 miles or so of my house seemed to be able to help me.

  • 11:15:47

    ROBERTSo after nearly two years of this, realizing I had no life, I decided to hit the internet looking for information and I couldn't find anything, any real consistency. One website would say this, one website would say that. It became really aggravating beyond belief.

  • 11:16:08

    ROBERTI went to about.com because I'd used their diabetes site to great success, but they had no migraine site. So I finally was looking at things like the American Headache Society and the National Headache Foundation and was finding finally some good information and decided, well, you know, if I'm having this much trouble, there have to be other people.

  • 11:16:34

    ROBERTAnd about.com was looking for someone to start writing a migraine site for them so the old English teacher in me decided, well, this is interesting so I'm going to apply for the job and I got it. Not something that I could do a lot of, but it was the kind of job that maybe I could do at home on my own when I -- those few hours a week that I was up and felt like work.

  • 11:16:56

    ROBERTSo once I started that, I discovered neurologists are not necessarily migraine specialists, but there are migraine specialists out there. Well, that was news to me. So as we worked on this site, I met someone who had gone to the Jefferson Headache Center in Philadelphia and seen Dr. William Young. That's eight hours from my house. I decided I didn't care. I wanted to cut to the chase.

  • 11:17:24

    ROBERTI waited nine months for my first appointment because he was that booked. But working with him, I got my life back and I'll never forget the first day in his office, sitting there in tears after he said to me, if you don't give up on me, I won't give up on you. You do not have to live this way.

  • 11:17:42

    REHMTeri Robert, she's patient educator and advocate, author of "Living Well with Migraine Disease and Headache." Dr. Richardson, why is it that there's so few migraine specialists out there?

  • 11:18:00

    RICHARDSONWell, this is a condition that has flipped over in so many ways, was thought to be stress-related, even by my colleagues in neurology. And now if you look at the International Headache Society classification, there's no such headache that is defined as stress headache. Instead, things like that can be a trigger for underlying migraine and also there are people who do not...

  • 11:18:31

    REHMYou've lost your train of thought.

  • 11:18:32

    RICHARDSONLost my train of thought.

  • 11:18:34

    REHMThat's all right. We'll come back to it after a short break, Dr. Perry Richardson of GW, here in Washington.

  • 11:20:05

    REHMAnd welcome back. Just before the break, Dr. Richardson, you were about to make a point about why there are so few physicians to treat migraines out there and I also want to understand what a migraine looks like in the brain.

  • 11:20:28

    RICHARDSONSorry about that. I thought almost a migraine might have been coming on to me. But the point I was going to make is it does not have a traditional nook around on the body or even on a standard MRI scan. And many neurologists go into the field because they're interested in documenting where is there a problem in the circuitry. But it's changing. It's turning upside down. There's now evidence that there is an anatomy and there is a chemistry of migraine.

  • 11:20:55

    RICHARDSONIt's picked up on functional MRI, which is not a standard procedure in most radiologist's office and it's often used for research. Inside the brain, though, there is a cascade of neurotransmitter changes that are activating the pain nerves in the body. One of the biggest advances is an animal model of a headache is now available. And that's leading to understanding more.

  • 11:21:20

    REHMWhat kind of animal?

  • 11:21:22

    RICHARDSONRats that are subjected to inflammatory chemicals can be recorded to have pain experience by microelectrodes that are implanted in the nerve cells. And medications can be developed to reduce and correct this activation.

  • 11:21:41

    REHMOf course, pity the poor rats. But one hope that for the sake of scientific research, we can move forward here. Dr. Dodick, what does that brain look like under a PET scan when someone is having a migraine?

  • 11:22:06

    DODICKWell, Diane, when one does a functional scan, like Dr. Richardson just talked about, whether it's a PET or a functional MRI, we see activation of certain regions in the brain and certain networks in the brain, particularly those networks that process sensory information, like light and noise and pain and emotion. So we see activation of all of these networks during migraine. And indeed what we've come to recognize now is that not just during a migraine attack.

  • 11:22:37

    DODICKBut even in between attacks the brain is processing all of that sensory information in an abnormally excitable way. So, migraine was thought to be just a disorder that comes and goes and you're perfectly normal in between. But we now recognize the fact that it's an abnormal processing -- abnormal network processing in the brain that continues even between attacks.

  • 11:23:02

    REHMAnd here's an email follow up on that comment, Dr. Dodick. It's from John in Cleveland who said, what is the possibility that people suffering from migraines are also predisposed to other mental health issues?

  • 11:23:24

    DODICKThat's an excellent question. And that's one of the reasons why we, as a medical community, absolutely must take this to sort of more seriously. Migraine sufferers are three times more likely to have psychiatric disorder such as depression, anxiety, bipolar illness. They're twice as likely to have epilepsy. They're twice as likely to suffer an ischemic stroke. They're six to 15 times more likely to develop brain lesions.

  • 11:23:51

    DODICKThey're four and a half times more likely to have attempted suicide in the past year. So, you know, it's not just migraine, but it's all of the company in the (word?) disorders that migraine keeps.

  • 11:24:03

    REHMHere's another email. It's from Zanad (sp?) who says, "My daughter is five years old, suffers from migraines about once or twice a month. Her triggers are exhaustion and dehydration. How often do you see migraines in children? What are the treatment options for young children and especially interested in natural remedies." That five-year-old child must resonate with you, Teri.

  • 11:24:40

    ROBERTWell, she does and especially since I now have four grandchildren with migraine. The first thing I'd say to this parent is you know the triggers. Right there is a very first major step in migraine management is managing the triggers. If you know the triggers, avoid them when possible. With dehydration and exhaustion, regular sleep patterns are extremely important to migraine horrors, and avoiding that exhaustion and avoiding the dehydration.

  • 11:25:08

    REHMDr. Perry, are the treatments for children different from those for adults?

  • 11:25:16

    RICHARDSONWell, there's not a lot of evidence about medication use in children. So we would try to emphasize non-medication treatment until we get more data that shows that drugs can help. Now, in adolescents, some of the triptans, which you'll hear about, had been found to be useful if the headache is bad enough to warrant it. In adolescents and I think in children also, headaches tend to be shorter than in adults.

  • 11:25:46

    REHMAnd Dr. Dodick, Teri mentioned something else that her grandchildren now have migraines. Are migraines hereditary?

  • 11:26:00

    DODICKAbsolutely, Diane. You know, there are now five genetic mutations and over a dozen genetic variants that have been identified with migraines in various subtypes of migraine. So it's unquestionable that is an inherent disorder that's modulated or modified by the environment. And that's an important point. Some people think that stress is causing the headache or changes in barometric pressure are causing the headache.

  • 11:26:24

    DODICKThey are simply triggers. And anything that upsets the internal homeostasis or balance in the body, be it sleep deprivation or eating certain foods or taking certain medications can trigger a genetically susceptible brain to activate these networks in the brain and cause the symptoms of migraine. I'll also say that children, 17 percent...

  • 11:26:48

    REHMSorry.

  • 11:26:48

    DODICKSeventeen percent of children are affected by severe and recurrent headaches in this country, 17 percent. And while there's a broad spectrum of suffering, some may experience one attack a month, other may experience pain and other symptoms of migraine continuously, 24/7, and they're terribly disabled.

  • 11:27:07

    REHMAnd women are more susceptible than men?

  • 11:27:13

    DODICKYes, women are three times more likely to experience migraine. This past year in the United States, 22 percent or basically 1 in 5 women will experience and suffer from recurrent migraine, which is an amazing statistic. Over the lifetime of a women, over a third will experience migraine. So it's three times more likely. But in children, the prevalence or how common it is seems to be equal between boys and girls.

  • 11:27:39

    DODICKAnd it isn't until sort of adolescence and teenage years that it seems to become more prevalent in girls and women.

  • 11:27:45

    REHMTeri, do you think that doctors are now taking migraine much more seriously?

  • 11:27:52

    ROBERTOh, absolutely. I see a world of difference just in the 12 years that I've been working in this field. They're taking it far more seriously and, you know, it's a privilege for me to sometimes meet with and work with doctors such as Dr. Dodick and Perry here and Dr. Young who first treated me who have so much knowledge, but also so much compassions for the patients. If 12 years ago someone had told me that kind of doctor was out there, I'd have laughed myself silly.

  • 11:28:26

    ROBERTBut, yes, I think things are being taken more seriously. We just need more doctors like these fellas.

  • 11:28:33

    REHMAll right. And here's an email, "Five years ago," this individual says, "I suffered from a series of debilitating rebound migraines that left me incapacitated. Dr. Richardson figured out I was having an allergic reaction and put me on a series of Botox shots, which were experimental at the time, and the only thing that made me better. First, I want to thank Dr. Richardson for figuring out what was wrong with me. And second, please comment on where the Botox studies are now."

  • 11:29:20

    RICHARDSONSo, FDA has approved one type of Botulinum toxin called OnabotulinumtoxinA for very specific subtype of headache that's called chronic migraine. It's defined by 15 or more days per month of headache and four hours per day of migraine. Now, there are a lot of patients who develop this kind of transformation from episodic headache to a chronic migraine, probably about 14 percent of people who have episodic migraine can fall into that pattern, like Teri.

  • 11:29:55

    RICHARDSONSometimes it's because there is overuse of the analgesic. So we have a long way to go to educate physicians and patients not to just rely on overused medications, like analgesics. Some drugs, for example, barbiturate-containing drugs like butabarbital with caffeine can subject somebody to chronic headache as a rebound effect and with as little as five days per month of use of that drug.

  • 11:30:25

    RICHARDSONMore often, about two to three days maximum per week is recommended lest we put somebody over into chronic migraine. Botulinum toxin has been a bridging drug to help us wean patients off of analgesics that are overused.

  • 11:30:43

    REHMAnd how are those injections given?

  • 11:30:47

    RICHARDSONSo after a lot of early phase studies, a consensus for distributing the Botulinum toxin in the scalp muscles, in the forehead over the eyebrows, in the temples and in the back of the head and then the neck muscles. This has now been standardized and patients will often get a reduction in the frequency of the headache that last about three months.

  • 11:31:13

    REHMAnd what that does is to paralyze the muscles?

  • 11:31:20

    RICHARDSONWell, it's not -- the mechanism is not precisely known. It may be that it is having to do more with the sensory nerve endings in the muscles, even though it's injected into muscle because the trigeminal nerve, which is the nerve of pain -- and I said there is anatomy now of migraine -- is bathed in the Botox also. And so, there may be -- a theory goes that the sensitization of the sensory nerves is affected by Botulim toxin.

  • 11:31:49

    REHMDr. Dodick, the migraine drugs available today are called triptans. Tell us what they are and how effective they are.

  • 11:32:03

    DODICKSo, Diane, the triptans represent the only class of medication that were specifically designed to treat migraine in the past 60 years. That's it, one single class. The first one was approved in 1991. There are now available triptans on the market, available from pills to injections to nasal sprays. When the triptans were developed, they were developed on the premise that they were to constrict blood vessels.

  • 11:32:30

    DODICKBecause 20 years ago, as we discussed, migraine was thought to be a blood vessel disorder. What we didn't realize is that these drugs actually bind to the nerve endings and also get into the brain and bind to centers in the brain that shut pain off. So the triptans are very effective. They really revolutionized the acute treatment of migraine, but we still have a long way to go. There are a lot of patients who can't take these medications if they have heart disease or high blood pressure or had stroke.

  • 11:32:58

    DODICKThere are certain medications that they can't be taken with. And, really, while I say they were revolutionary, 60 percent of patients will have some response to them. But most patients when they take a medication they want to be pain free, symptom free very quickly and not have to take another tablet within the next 24 hours. If we consider that as an endpoint, only about one-fifth of patients will actually respond in that way consistently to the triptan. So we have a long way to go.

  • 11:33:27

    REHMDr. David Dodick of the Mayo Clinic and you're listening to "The Diane Rehm Show." And joining us now from the studio of the National Institutes of Health in Bethesda, Dr. Story Landis. Good morning to you, Dr. Landis.

  • 11:33:49

    DR. STORY LANDISGood morning. I'm glad to be able to join you and sorry that I missed the first half of the show.

  • 11:33:53

    REHMAll right. And Dr. Landis is director at the Institute of Neurological Disorders and Stroke at the NIH. Dr. Landis, part of the problem with migraines apparently is that NIH has not been able to adequately fund migraine. Is that correct?

  • 11:34:27

    LANDISI would have to agree that it is correct. I think both headache and migraine warrant greater investment than we've made in the past. In fact, I have migraines as does my son. I'm fortunate among migraine sufferers that Verapamil, a calcium channel blocker that may have been discussed earlier has actually stopped them.

  • 11:34:49

    REHMSo, why is it that more resources have not gone to a problem that apparently affects a great many people in this country?

  • 11:35:02

    LANDISSo, one of the important aspects of having a well-funded research area is that there be a reasonably large group of investigators, dedicated scientists with novel ideas. And for a variety of reasons, that may or may not have been discussed earlier. The headache research community is actually rather small. Fortunately, this has been changing. NIDS in particular has focused on supporting career development awards for junior investigators with an interest in migraine and headache.

  • 11:35:43

    LANDISIn fact, in the past six years, we funded 12 such junior investigators to grow the community. NIH staff will have to watch carefully to make sure that their careers develop well and that they, as their careers progress, actually submit grants to the NIH which fall within a fundable range.

  • 11:36:05

    REHMDo you think that NIH has been primarily interested in disorders or diseases that actually kill people and that that's why there has been less interest, less funding?

  • 11:36:28

    LANDISThat's an interesting question. Maybe I could say a little bit about how decisions are made about what grants will get funded and what areas?

  • 11:36:38

    REHMSure.

  • 11:36:40

    LANDISSo, NIH -- most of what NIH funds depends upon selection of applications for funding that individual investigators have submitted.

  • 11:36:50

    REHMSure.

  • 11:36:51

    LANDISInvestigator-initiated research. Researchers write applications. They send them into NIH. They're reviewed by study sections made up of scientific peers and they're given a priority score that ranges from 10 to 90. We then take that score and turn it into a percentile for each grant. And the institutes fund as many of the grants as their budget allows. Now, given constraints in our budget, that's been fewer grants than we would like to be funding or have in the past.

  • 11:37:19

    LANDISAt NIDS, if the grant has a 15 percentile or better for a particular year, this last year, then we fund it. So, it's obvious that the more investigators work in a particular area, who have good proposals, it's more shots on goal and more likely that additional dollars will be invested.

  • 11:37:37

    REHMDr. Story Landis, she joins us from NIH in Bethesda, MD. Short break. We'll be right back.

  • 11:40:05

    REHMWe've been talking about migraines. In this hour we're going to finally open the phones to take your calls, 800-433-8850. Let's go first to Fort Lauderdale, Fla. Good morning, Denise, you're on the air.

  • 11:40:27

    DENISEGood morning Diane. Thank you very much for taking my call.

  • 11:40:29

    REHMSure.

  • 11:40:31

    DENISEI wanted to express that I was a migraine sufferer for many years and I started keeping a log of everything I ate, drank, what did I do and I made a chart after a few years and I have found that my migraines were related to food. Mainly, the sulfites in wine, I haven't had wine for 18 years. MSG, monosodium glutamate which is in soups, salad dressings, barbeque potato chips, everything. Nitrates, which you find in bacon and sausage, which is easy to get without at health food stores.

  • 11:41:11

    DENISEFluorescent lights, flickering fluorescent lights are a terrible trigger and also, oddly, the sunglasses that are tinted a pale green or yellow such as the maker Varna or that type. Those were instant triggers, the few times I'd put those sunglasses on. And also coffee, oddly enough, is a terrible trigger for me.

  • 11:41:34

    REHMSo I gather in terms of food, you know, it may be one thing for one person, another thing for another person. Dr. Dodick, there is generality or are there generalities?

  • 11:41:52

    DODICKNo, there really aren't any generalities, Diane. I mean, the caller describes triggers that are notorious for triggering migraine but for every individual sufferer may report different dietary triggers and then many sufferers can't find any dietary triggers and they go through these dramatic elimination diets where they're eating very little actually, rice and water, and still they suffer. So the triggers for migraine are ubiquitous, they're all over the place both internal and external triggers. Dietary happens to be one of them but as you say, it varies between individuals but I'm very glad to hear that the patient found her triggers.

  • 11:42:30

    REHMNow, what about for you, Teri, were there food triggers?

  • 11:42:35

    ROBERTNot a one and I did the kind of elimination diet Dr. Dodick is talking about, twice over. Not a single dietary trigger.

  • 11:42:43

    REHMDr. Landis, is anyone at NIH looking at dietary factors?

  • 11:42:53

    LANDISNot to my knowledge. I checked through the roster of grants that were funded and I don't recall any that were looking specifically at dietary triggers.

  • 11:43:03

    REHMAll right. To East Brook, Me. Good morning, Gary, you're on the air.

  • 11:43:08

    GARYGood morning, Diane. A question that I have is that are we inadvertently impacting the population by developing and continuing to develop wind turbines all over the United States. 10 to 15 percent of the population all over the world reports that they have migraine type illnesses that they relate to wind turbines.

  • 11:43:35

    REHMAnd we heard some of that in our last hour. Dr. Dodick?

  • 11:43:42

    DODICKYes, well, you know, environmental factors are a trigger for some patients. While the caller's right, 10 percent of the population suffer from migraine, a percentage of them will report changes in barometric pressure and weather fronts as being a trigger for migraine, not necessarily just wind per se. We're still trying to struggle to find out the mechanism by which, and the consistency with which environmental factors trigger migraine. But we're a ways off from understanding that relationship.

  • 11:44:12

    REHMAll right. To Cleveland, Ohio. Good morning Ken.

  • 11:44:18

    KENHi, Diane and thank you for taking my call this morning.

  • 11:44:20

    REHMSurely.

  • 11:44:21

    KENI have two questions for your panel. I've been a migrainer for the past 34 years having common migraine or migraine without aura. My two questions are, number one, what, speak further about prophylaxes for migraine. Verapamil was mentioned and I've been through a number of drugs. I've actually found roughly equivalent protection taking over the counter supplements, specifically massive amounts of magnesium and B2.

  • 11:44:47

    KENAnd secondly, if you could elaborate a little bit more on the association that was mentioned between migraine and stroke, specifically stroke in the young. I had a massive ischemic stroke at age 34 and while I have no deficits from it, I also have no more left hemispherical migraine as a result. And I'll take my answers off the air. Thank you Diane.

  • 11:45:09

    REHMAll right, thanks for calling. Dr. Richardson, do you want to take prophylaxis?

  • 11:45:16

    RICHARDSONYes, I think that's an underutilized treatment for migraine and it, especially in this day and age, when we know that people who take too many acute pain medications can actually invite more chronic migraine. Physicians and patients need to know that there are four drugs FDA approved for prevention of migraine, reduce of the frequency and several others that have fairly good evidence that they work.

  • 11:45:44

    RICHARDSONIt's hard to detect which medicine would appropriate for each person so we do what this caller has done. We go through a trial and error process often but we can choose medications that might attack two things at once. One of the medications, topiramate can cause weight loss and someone with obesity or diabetes may benefit from that in terms of weight loss and migraine and other medicines, beta blockers, and Verapamil, hypertension, can be treated by those things. so I individualize that question and supplements are just beginning to get some evidence of their efficacy but it's, they often take longer to work than the standard prophylaxis, pharmacologic agents.

  • 11:46:29

    REHMAnd what about strokes in the young, Dr. Dodick?

  • 11:46:34

    DODICKWell, in actual fact the increased risk of stroke that I referred to earlier in patients with migraine, it appears that those who have migraine with aura are more likely to experience an ischemic stroke. They're twice as likely compared to people who don't have migraine and those who have migraine without aura. In fact, in point of fact, it tends to be more common in women and it tends to be more common in younger women less than the age of 45. So it's interesting to hear the caller say that he suffered an ischemic stroke at such an early age, at the age of 34, and it begs the question as to whether or not his migraine disorder was related or causal in some way to the stroke that he had.

  • 11:47:16

    REHMAnd from our website, someone sends this. "I've been a migraine sufferer since I was in high school, I'm now 47. In the past four years, I have experienced two complex migraines which mimic having a stroke. They are terrifying to go through. What are your recommendations for these specific migraines?" Can you speak to that, Dr. Dodick?

  • 11:47:50

    DODICKSure. People and some physicians use the term complex migraine, the technical term for that is migraine with aura. What that means is that there are reversible neurological symptoms that can either be visual, where you lose vision. They could be sensory where one side of the body goes numb. It can involve language where you lose the ability to speak or understand speech or you can actually become paralyzed on one side of the body. So very closely mimics stroke, although there are some features when a patient presents that allow us to distinguish between those. What to do for them, it depends on the frequency with which they occur, but there are preventative medications that we specifically use to try to prevent them from occurring in the first place.

  • 11:48:36

    REHMSuch as?

  • 11:48:37

    DODICKWell, such as Dr. Landis mentioned, Verapamil as being one of them, but there are others that used as well. I will make the point that the American Headache Society and the American Academy of Neurology just published and released their new updated guidelines for migraine prevention and I would encourage listeners to go to the American Academy of Neurology or American Headache Society website, to look up those medications which are recommended for the prevention of migraine.

  • 11:49:04

    REHMDr. Dodick, you heard Story Landis say that, you know, there hadn't been that many applications for research or from research investigators for migraine and I wonder how you see that. Why do you think there has not been that interest? Do you see that increasing in medical specialists around the world?

  • 11:49:38

    DODICKYes, I totally agree with Dr. Landis. Part of the problem, Diane, is that in medical school, for example, I had zero hours of education in migraine and other headache disorders and in my residency, when I was training to become a neurologist I had two hours. So it's hard to get inspired to chase a career in a disease or a disorder for which I've had no education. That's part of the problem. That's changing fortunately and now headache medicine is an accredited specialty of neurology in the United States right now and we're board certifying headache specialists.

  • 11:50:11

    DODICKSo we've come a long way, but when you don't have qualified scientists or clinician scientists in the field to competitively, you know, submit grants for research that are competitive with other disease states, then it becomes very difficult for Dr. Landis and her colleagues at the NIH to actually support that. But that's changing and I'm already starting to see now more scientists in the field, much more aggressive research agenda and more money coming from NIH to fund these research projects.

  • 11:50:41

    REHMDr. Landis, do you want to speak to that?

  • 11:50:45

    LANDISWell, we work very hard to create a cadre of investigators. I know one of the concerns that they headache research community has had for some time is that perhaps their applications are not viewed as well as applications from people working on other disease states. We actually were concerned about that as well and did an analysis and the success rates are very similar. So I don't think it's a question of people being disinterested or thinking that the quality of, reviewers being disinterested or thinking of the quality of the applications is poor because those applications do just well.

  • 11:51:21

    LANDISAnd we work with all the headache scientific organizations presenting workshops on how to write a good grant and encourage them to apply and the particular program director who has this portfolio has, I think, been very aggressive in working with the community to encourage applications and to help people make sure that it's the best possible application it can be when it comes in.

  • 11:51:45

    REHMI'm glad to hear that. Let's now go to Farmington Hills, MI. Good morning, Roberta.

  • 11:51:54

    ROBERTAHi, Diane, thank you and thank your panel. And Diane, I love your show.

  • 11:51:58

    REHMThank you.

  • 11:52:00

    ROBERTAI have a quick question and a quick comment. I almost came to tears listening to this program because I suffered from being a very little girl and I just hear the things that I went through and I'm calling because my daughter, who now suffers with migraines, she's in the Minneapolis area, and she can't seem to find anyone who knows what to do about this. She suffered with them as a child.

  • 11:52:30

    ROBERTAWe've been to doctors throughout Michigan. Medication after medication after medication, I've kept all the medication. I kept them in a bag over the years just because I became so overwhelmed. And she's been calling me for the last week, Mom, I just -- I go to this clinic and they just give me this particular medicine. And, I go this clinic and -- where can she go in the Minneapolis area to get help?

  • 11:52:57

    REHMThat's just heartbreaking. Teri, and kind of the same problems you went through.

  • 11:53:04

    ROBERTHi darling. Yes, I have gone through this and there are a lot of people going through and quite honestly I don't have the information at my fingertips right now but are you online? Do you, you have internet access, right?

  • 11:53:19

    ROBERTAI do have internet access, yes I do.

  • 11:53:20

    ROBERTFind me on Facebook. We'll find you someone in that area, we'll find you someone who can help you and we'll get you some support in the meantime, okay?

  • 11:53:28

    REHMSo, give me the website.

  • 11:53:30

    ROBERTI'm Teri Robert on Facebook and so just find me there and we'll get you some help.

  • 11:53:37

    REHMAnd you're listening to "The Diane Rehm Show." Dr. Dodick, any recommendations for physicians out in Minneapolis?

  • 11:53:48

    DODICKSure. well, I hesitate to use their name on this show but I have, there are a number of qualified specialists in the Minneapolis area and full disclosure here and obviously I have a conflict of interest but the Mayo Clinic is just up the road 90 miles in Rochester, MN, and I have many highly qualified and expert colleagues up there at the Mayo Clinic. So I would highly encourage the caller to help her daughter seek care perhaps at Mayo Clinic.

  • 11:54:16

    REHMDr. Richardson, is there a migraine gene?

  • 11:54:22

    RICHARDSONSince it's certainly hereditary there's probably a combination of genes that will be discovered ultimately that render somebody susceptible to migraine.

  • 11:54:33

    REHMDr. Dodick?

  • 11:54:35

    DODICKYes, Diane, there are four genes now that have been identified where mutations in those genes will render people susceptible to what we call hemiplegic migraine, where they become paralyzed on one side. And as I alluded to earlier, there are now more than a dozen genes, including a couple on the X chromosome which may in part explain why migraine is more common in women.

  • 11:54:57

    DODICKBut there are over a dozen genes now where variants or abnormalities within the gene seem to occur more commonly than migraine than in those who don't have migraine. So there are many investigators on the hunt for migraine genes but we're unlikely to find a single gene. We're likely to find a multitude of genes where abnormalities within those genes lead one to be susceptible to migraine.

  • 11:55:21

    REHMWe have had so many emails, so many callers, here's one last email. "I have been diagnosed with silent or optic migraines. Other than having no pain, how else do these migraines differ clinically from the more common ones?" Dr. Richardson?

  • 11:55:46

    RICHARDSONSo that's very interesting and it shows that there's a brain disorder underlying migraine and pain does not necessarily have to be linked. Migraine often evolves over the lifetime of an individual, sometimes goes away for good but sometimes after menopause in women or middle age in men, the disorder changes into migraine without pain. And one of the most common things is the visual aura which is not followed by pain. If it's very frequent it can respond to the preventive medicines as migraine with headache can.

  • 11:56:20

    REHMAnd is brain surgery ever an option for migraines?

  • 11:56:27

    RICHARDSONWell, there are some severe headaches variants like cluster headaches, that's not the same as migraine, where deep brain stimulation surgery has been tried with some success. But there are less invasive ways to try to modulate the excitability of the nervous system and this is the new era in migraine.

  • 11:56:49

    REHMDr. Perry Richardson at GW Hospital here in Washington. Teri Robert, she's the author of "Living Well With Migraine Disease and Headache." Dr. David Dodick, he's a neurologist at the Mayo Clinic and Dr. Story Landis of NIH. Dr. Dodick has said he'd be willing to answer more of your questions from Facebook, from Twitter and at our website. Thank you all so much and thanks for listening. I'm Diane Rehm.

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