Search for tag: "chronic"

Interviewer: Severe, sudden, and sometimes debilitating face pain is a symptom of a disease called trigeminal neuralgia and some people suffer with the condition and don't even realize that's what they have. Or maybe it was misdiagnosed as something else so they can't get treatment.

Dr. Shervin Rahimpour is a neurosurgeon who specializes in the surgical treatment of trigeminal neuralgia, and he's going to help us understand how to come to that diagnosis. So first of all, you tell me it's a poorly diagnosed disease. What exactly do you mean by that?

Dr. Rahimpour: Often this pain is distributed around the cheek and jaw area. And so it's natural for patients to think that this is likely a result of their dental health. And so they often seek treatment through a dentist, usually, you know, undergo a tooth extraction or something like that, and that pain persists. So that's often why this is poorly diagnosed is because it overlaps with other common issues like having tooth pain.

Interviewer: Yeah. And I think a lot of us think well, the pain is here, this must be the source of the pain. It's in my mouth or my cheek, it must be the source. But that's not the case with this disease. Where does the pain originate from?

Dr. Rahimpour: The trigeminal nerve, which is one of the 12 cranial nerves that we have, supplies, amongst other things, the sensation that we feel over our face. So there are two nerves, one for each side. Each nerve supplies the sensation to that half of the face. And the nerve has three divisions associated with it. There's one that kind of overlays the forehead and around the eye. The other division is around the cheek area, and then a third division encompasses the jaw. And so most commonly, the pain is likely to affect those bottom two divisions, which is around the cheek and the jaw area, and that's where this overlap comes with potentially pain coming from your teeth.

Interviewer: And somebody goes to the dentist, they have an extraction done and that doesn't solve anything. Do they try to get a diagnosis beyond that, or do most people just give up or do you know?

Dr. Rahimpour: Yeah, I should add that sometimes it can be your teeth. So it is worth having that evaluation done by your dentist. But eventually, this pain syndrome is referred either to a pain specialist or even a neurologist. Those are the folks that typically end up diagnosing this as trigeminal neuralgia-type pain.

Interviewer: Explain some of the common symptoms that people might experience.

Dr. Rahimpour: Yeah, absolutely. So again, this pain used to be . . . this disease used to be known as suicide disease because it was such a horrible pain for patients to experience. And it's often a severe electric type jolt or stabbing pain involving one or more of the divisions of the trigeminal nerve of the face. It's often set off by very relatively innocuous stimuli. What I mean by that is anything as simple as just a gust of wind, or talking or brushing your teeth, or having water hit your face when you're taking a shower. These are kind of the very, very basic and innocuous things that can trigger that type of pain.

Interviewer: And what's going on with the nerves that is causing this pain?

Dr. Rahimpour: The vast majority of cases are thought to be caused by a vessel sitting on the nerve root as it enters into the brainstem. And so what this vessel causes is damage over a period of time that ends up injuring the insulation around the nerve known as myelin. And then this can result in sort of aberrant firing of the nerve.

Interviewer: So it's rubbing against there, damaging the insulation every time your heart beats.

Dr. Rahimpour: That's exactly right.

Interviewer: It's damaging the . . . Okay.

Dr. Rahimpour: So the thought is that if we can remove or transpose this vessel from the nerve root . . .

Interviewer: Yeah, get it away from there.

Dr. Rahimpour: Get it away from there, that could potentially allow the nerve to heal and prevent some of this aberrant firing.

Interviewer: And if a patient has this type of pain, they would go to their primary care physician first likely. What would that workup look like?

Dr. Rahimpour: Typically, the patient has these classic types of symptoms or the stabbing electric type pains of the facial region, again, involving either one or more divisions of the trigeminal nerve. And we often ask patients, you know, "How is this pain brought about?" If it's something, again, wind, chewing, talking, anything like that, that's pretty consistent with trigeminal neuralgia. The pain also again persists to seconds to potentially minutes, and so that's another signature or hallmark of the disease. And we often look for patients that, you know, typically we find that this disease occurs more often in the older population. So the incidence kind of climbs as age goes up. But this can also be a result of some other secondary processes. Certainly, it can range anything from facial trauma and include other secondary causes like multiple sclerosis.

Interviewer: At what point should a person consider consulting with a physician who specializes in trigeminal neuralgia?

Dr. Rahimpour: I think early on it's best to have the medical therapy be optimized. So a lot of the medications we use for this type of pain are actually anticonvulsants used in epilepsy. The reason why is because, similar to epilepsy, the nerve can act on its own and fire. And so the idea is can we stabilize this nerve so that it prevents it from firing, the same way that we try for epilepsy. Those types of medications are started, they're increased to a therapeutic level and then the patient is evaluated to see if this treats their pain. Again, the vast majority of patients respond to these medications, something upwards of 90%, but half of those patients end up having unwanted drug side effects. And then, of course, there's a 10% that did not respond to the medication at all.

Interviewer: Yeah. And this medication, is it kind of a dialing-in process, you've kind of got to figure out the sweet spot for everybody?

Dr. Rahimpour: Yeah, I would say that most anticonvulsants are started at a low dose and gradually titrated up.

Interviewer: And for the individual that is not responding to medication, or the side effects are just so terrible that it's really impacting the quality of life, and that's where the microvascular decompression procedure comes in. That's what you're doing there.

Dr. Rahimpour: That's exactly right. So for patients that aren't responding to the medication, if they've had an MRI scan that shows that potentially there might be a vessel there pushing on the nerve, that's where microvascular decompression can play a role.

Interviewer: What about for patients where they have the condition, and it's not pressing against that nerve? That's possible, right?

Dr. Rahimpour: Patients where we don't necessarily see a blood vessel pushing on the nerve, or they might not necessarily be a good operative candidate, we can offer other minimally invasive approaches. Those approaches include percutaneous rhizotomies. The premise there is that we with a needle go to the base of this nerve, known as the trigeminal ganglion, and we try to damage that nerve to sort of disrupt the pain signal. The other option is using radiation in the same way that folks use it for tumors to try to focus the radiation and try to damage the nerve again, to stop this pain signaling.

Interviewer: Are these other last two procedures, are they an alternative to somebody getting a microvascular decompression?

Dr. Rahimpour: They are alternatives, but I should add that they're not as efficacious. So when we do find patients are good candidates for microvascular decompression, we try to advocate for that as it gives us the best chance for pain freedom.

Interviewer: After somebody has the microvascular decompression, what is the success rate that that actually takes care of the pain?

Dr. Rahimpour: We expect that patients often have immediate pain relief after surgery, especially if we do find a blood vessel that's compressing the nerve. Historically, 70% to 80% of patients are still pain-free at five years.

Interviewer: And the other 20%?

Dr. Rahimpour: Pain can reoccur. And if that's the case, we can always revisit other possible interventions, including some of the percutaneous and radiosurgery techniques that I mentioned.

Interviewer: For the patients who get the microvascular decompression, what's the satisfaction rate among those patients? I hear this could be life-changing for some people.

Dr. Rahimpour: Absolutely. So again, this is a very debilitating disease. I mean, you can imagine if it's affecting the way you eat, and the way you conduct yourself throughout your day-to-day in anticipation of a sudden pain strike, being pain-free means everything. And so when patients are pain-free again, where we expect that to be the case in the vast, vast majority of times after microvascular decompression, this is absolutely life-changing.

Interviewer: All right. Let's talk about chronic headaches. Dr. Bartel is an expert in headaches. He did a Fellowship in Headache Medicine, they call it. And for a chronic headache sufferer, man, it can really just impact your life in a lot of negative ways. How do you treat it? That's going to be the question we're going to answer today with Dr. Bartel. So first of all, what do you as a medical provider consider a chronic headache? What makes it chronic?

Dr. Bartel: So there are a lot of different types of chronic headaches. In a general sense, chronic headaches are headaches affecting somebody more than half of the month. So we tend to consider more than 15 headache days per month as a chronic headache.

Interviewer: And chronic headache sufferers, do the headaches last all day? Is it maybe just a half hour every day? What's that kind of look like?

Dr. Bartel: They can. It depends on the type of headache. So oftentimes, for instance, migraine headaches will last for many hours. There are certain types of headaches that do truly never go away, and some people have headaches every waking hour of their day.

Interviewer: So if you're having headaches 15 or more days a month, that is a chronic headache. Do you also look at the intensity of the headache when you're looking at a chronic headache? Is it kind of a balancing act, or is it really just purely how often are you having this headache?

Dr. Bartel: Yeah, certainly the degree of disability that is involved. Even if a headache isn't truly half of the month, we will often consider preventative medicine. If somebody has headaches at least four days out of the month, like once per week, and it's particularly debilitating or it really bothers them, we'll even sometimes try medication then. But oftentimes, we'll reserve at least some of the more involved therapies for people that have chronic migraine.

There's some evidence that there are a lot of medicines that help, a lot of different therapies that help for what we call an episodic headache, less than 15 days out of the month. They can work for both chronic or episodic. But we pay special attention to those that have headaches that are more severe or that are particularly debilitating.

Interviewer: So there's a difference between a chronic and an episodic headache insofar as what causes them and how you would treat them.

Dr. Bartel: Yeah, it's really a continuum. But between tension-type headaches, which are the most common type of headache, migraine headaches that tend to be the most common severe type of headache, there's cluster headache. There can be a chronic cluster headache or episodic cluster headache. In all of these, it really depends on how bad they are, how much this is affecting somebody's life. And we really use that information to help cater the treatment for everybody's different headache condition.

Interviewer: If somebody is genetically predisposed to a headache, are they just going to get them regardless of what kind of lifestyle decisions they're making? Or do those impact as well?

Dr. Bartel: Yeah, not necessarily. Certain things can reduce the likelihood of having chronic headaches. So things like effectively managing your stress. That's easier said than done, of course, but having certain various coping skills to help when you have a really stressful situation come up.

You can manage it by exercise. So for some people, exercise can make their headaches worse, but in general, exercise, when you do it fairly routinely, 5 days a week, 20 to 30 minutes a day, just enough to kind of get your blood flowing, your heart rate up a little bit, causing a little bit of sweating, that can all really help with reducing the likelihood of headaches.

Having good social support. Actually being married or in a committed relationship can actually be protective against headaches also.

Interviewer: Really? Wow.

Dr. Bartel: Yeah, as is it turns out. In general, just having a good social structure, social support system can be helpful for a lot of conditions, but headache is certainly one of them.

Interviewer: I like one problem, one solution. It doesn't sound like headaches are that at all.

Dr. Bartel: Unfortunately not. Yeah, it's not at all a one size fits all type of a condition. There are really so many different types of medicines, so many different types of alternative non-medication therapies that can be helpful. We try to really include the ones that we think are most likely to help each individual person, but we cater it to that person.

Interviewer: So for the person that has a chronic headache, if they wanted to try to treat it before going to a doctor, if they wanted to take a look at a few things to try to do it on their own, are there things that they could try before going to see the doctor? Dr. Bartel: Yeah. I think that trying to make sure that you're drinking plenty of water. You don't want to over-hydrate, but you want to make sure that you're drinking enough water. Getting enough sleep, regular sleep, every night is an important thing. Some people that have shift work jobs, that's difficult, but trying to get a good six to eight hours of sleep every night is really helpful.

Interviewer: Should somebody take a look at their diet? I mean, if they're eating a lot of sugar, for example, can that exacerbate a chronic headache? Dr. Bartel: Yeah, there are a lot of different food triggers for headaches, certainly. In general, there's no one diet that can help with headaches in a general sense, but trying to eat a little bit of protein when you have a headache can sometimes be helpful. Eating smaller meals throughout the day can also be helpful.

There are certain food triggers that can make headaches worse, things like MSG, monosodium glutamate. That's found in really every food these days practically, but also nitrates in certain cured meats, things like that.

Interviewer: So foods from our modern society.

Dr. Bartel: Pretty much, unfortunately. Yeah, there are really a lot of things. Simple carbohydrates can make headaches worse, just a lot of the sugars that we think about. But really, for everyone, it's a little bit different.

Interviewer: So it sounds like take a look at some of your lifestyle things. If some things have changed, like perhaps you're not sleeping as well or maybe you're hitting the candy bowl or the cookies a little bit harder than normal, could be some of those things that have all of a sudden brought on some headaches and a patient could definitely take a look at those and see if their headaches go away. Is there a time when a patient should not try to solve it on their own?

Dr. Bartel: Yeah, there are certain red flags that a doctor might think about to give us pause and want to recommend extra testing or at least more questions. So things like having stiff neck or fevers or just a change in your headache, generally, in the acute sense. So if you've had a certain type of headache for a long time and now all of a sudden there's something a little bit different about it, like you're just feeling kind of sick and you're just not feeling right, that can certainly be a red flag. It could just be worsening of your headache, but it could also be something else that's more threatening.

Having prolonged neurological symptoms with the headaches can be unusual. So it's one thing just to have a little bit of a visual aura before your headaches or numbness or tingling beforehand, but having prolonged symptoms like that isn't typical. It can be normal, but also it would be something to want to know more about from the provider's side.

Having weakness on one side is something that can happen with hemiplegic migraine, but it can also be a sign of other things happening in the brain.

Interviewer: Yeah, like a stroke.

Dr. Bartel: Exactly.

Interviewer: One of the signs of stroke is . . . yeah, wow. Okay.

Dr. Bartel: Having a new headache or kind of a changed headache in people that are a little bit older than age 50, for instance, can be a red flag also. There can be a lot of things that could be caused by, but that might indicate the need for imaging of the head.

Having a really sudden onset severe headache might be a reason to go into the ER for, which wouldn't be a bad idea because there can be bleeding in the brain. There can be a number of things that can cause that type of headache beyond just your standard tension headache or migraine headache.

Interviewer: Dr. Bartel, I don't know, after hearing those red flag headaches, I think I'm just going to go see a doctor and let one of you professionals work through it with me. It just sounds really complicated. It sounds like if I tried to get under the hood of my car and fix it is about the same thing as trying to diagnose a headache as well.

Dr. Bartel: It's difficult. I mean, it certainly can be. I think the main things to think about are if it's just a kind of a mild headache here and there that responds to ibuprofen, that's great. But you really want to be careful to not overuse your own research. If you're having headaches that are happening more often, certainly more than 15 days out of a month, it's probably a good idea to see a primary care provider to start with and then maybe see a neurologist or a headache expert otherwise just to kind of give you some tips and try to sort out what this headache is.

Announcer: Health hacks with Dr. Troy Madsen on The Scope.

Interviewer: What is today's health hack?

Dr. Madsen: Today's health hack is yoga for chronic low back pain. So here we're talking about people who have had lots of issues, who may have been prescribed even opioids for pain, who have looked into surgery. This was a study in "Annals of Internal Medicine," a few months ago, that looked at patients with this type of pain, chronic low back pain. They placed these patients in yoga classes. Other patients, they placed in physical therapy. Other patients, they just gave some education to, some information. Those who were in yoga did just as well as those in physical therapy. They used fewer pain medications, and even a year later, they saw these same results. They were still doing well.

So I think the big take-home for me from this was if yoga works for you, do yoga. If you're having issues accessing physical therapy, because of insurance issues potentially, consider yoga. Or if you're doing physical therapy, talk to your physical therapist potentially about even supplementing that with some yoga classes. It can make a big difference in the long run for a chronic issue that can cause all sorts of problems.

Announcer: For more health hacks, check out thescoperadio.com, produced by University of Utah Health.

I'm Carolyn Clancy, and I am a deputy undersecretary for health, leading efforts to improve quality, safety, and integrity in the veterans' health care system.

The real question is, how together do we create a new normal? And we need to do that. We need to do that because we haven't always met patient's needs because the nature of patient's needs is changing. It's much more about chronic illness now and because quite honestly health care costs too much in this country. So I see Dr. Lee at the University of Utah as being really visionary in bringing people from around the country together to say, let's put our foot on the gas pedal.

What I think an ideal future health care system should look like is that it's all about the patients. Which may sound a little crazy or odd because after all, that's what the health system does – we take care of patients. But if we organize it, and we've started to do this, but we just have to keep pushing around patients' lives rather than around our routines.

So one of the questions one of my family members asked me is something like, "Why can't I have physical therapy on Friday nights? That's when I'm available." Now, I usually tell them something like, "I can't fix that for you from three states away today, so you're just going to have to deal."

But it is actually an important question. Why can't we organize ourselves in a way that makes it easier for patients? Because in the end, most people don't want to be patients. They want to get some help and then get back to real life. The nature of the business or in health care is very, very different. It used to be all about the hospital. That was the center of the universe and by the way, when a patient is in the hospital we're in charge.

Well, much, much more of it now is outpatient, which brings up the whole question of when do I have to come in face to face? When can’t I do it by telephone? When could a video visit be just as helpful? And that part is just wildly exciting.

I've learned at this summit about very exciting work going on in other health care systems, particularly work trying to figure out how do we get ahead of population health needs? How do we know ahead of time which patients are going to have problems if they are admitted to the hospital and then are discharged home? And frankly, how do we deal with that while they're in the hospital?

One system for example, actually sends people out to the patient’s home a day or two after discharge, which I think is just brilliant because that's when people get home and say, "Oh my gosh, I don't miss the noise of the hospital, but I actually don't know what to do now." And to have someone come into the house then it's wonderful.

One of the challenges with scaling up, and again, every system has this is, imagine in one clinic or one part of the hospital a dedicated doctor or other clinician is totally passionate about making change and making care better for patients. And they figure it out and they get everyone very excited and, by George, they do it. You know, they exceed all expectations, care for patients in that unit is just spectacular.

And then the question is, can other people do that or was that champion so vital that other people can't do it? Or, if it works in Boston, how is it going to work in Omaha, Nebraska or Salt Lake City, Utah or something like that? We can do this. I just don't think that we have focused enough on it. There's probably never been a more exciting time in health care.

We've known for decades if not centuries that health care is about science, but also the ability to customize and tailor that to the unique needs of individuals. That's what makes it wildly exciting. In the end, health care is about helping people get on with their lives so that they can go to work, be with their family, friends, whatever it is that gives them joy and pleasure in life.

Dr. Miller: You've tried physical therapy for back pain, and you're not ready for surgery. What other options are there? We're going to talk about that next on Scope Radio.

Announcer: Access to our experts with in depth information about the biggest health issues facing you today. The specialists with Dr. Tom Miller is on the Scope.

Dr. Miller: I'm here today with Dr. Richard Kendall. He's a professor of rehabilitative medicine, and he's also the Chair of the Department of Physical and Rehabilitative Medicine. Rich, tell us a little bit about what patients can do prior to surgery. I've heard about injections into the back for those patients who have sort of ongoing low back pain or pain in other parts of their back, but there are now injections that can be tried that might relieve their pain.

Dr. Kendall: So that's true. For people who have not done well with physical therapy program or medications like anti-inflammatories or Tylenol or even opiate medications, epidural injections are a tool for us to use to decrease pain. That's just what they are, they can decrease pain, they don't heal or cure a tissue, but getting rid or decreasing the pain is one option hopefully to let somebody go on, and further function before surgery.

Dr. Miller: So what exactly is an epidural injection? Where does that go on the back?

Dr. Kendall: The epidural space is the space around your spinal cord, and it's in the middle of the safe protection of the bones of the spine. It's a nice protected space that's filled with fat that we can put in some steroids and some Novocain in that can really help reduce inflammation as well as reduce pain.

Dr. Miller: Is this a difficult procedure or what does a patient expect when they come in to have this done?

Dr. Kendall: Honestly most of our patients expect the worst, but when we come in, we finish the procedure, and they say, "Wow, that's it? Are you kidding me? That's easier than the dentist." So . . .

Dr. Miller: That's pretty easy. If it's easier than the dentist, that's pretty easy.

Dr. Kendall: The thought of somebody poking a needle in your back is somewhat anxiety provoking but we do them with a lot of Lidocaine, and numbing under X-Ray guidance so most people really experience very little symptoms.

Dr. Miller: What are you injecting into that space that actually reduces the pain?

Dr. Kendall: We put in two medicines. One is corticosteroid or cortisone, and that gets rid of the inflammation. It'll sit in the fat cells for about two weeks around your spine and get rid of inflammation. The second is just a Novocain or a Lidocaine which is an anesthetic, and it'll numb those nerves and areas for several hours.

Dr. Miller: That lets you know that you're probably making a difference. I mean if the Novocain is working in the area where the back pain is emanating from, you'll know you're at the right place I guess, right?

Dr. Kendall: Yes, many people will be pain free when they leave. Some people that's only for four, five hours. However the Lidocaine does sometimes essentially stung the nerve if you will, and people's pain does disappear for much longer afterwards depending on the diagnosis.

Dr. Miller: How effective is this in reducing pain? Is it 80% effective, 50%, 30%? What's the story on that for patients that might be considering an epidural injection?

Dr. Kendall: Well in certain conditions, it can be very effective with disc herniations and people with radiculopathy or pain down the leg from that disc herniation. If you take all patients who could be surgical candidates and you do the injection, 60% of them choose not to have surgery because their pain improves significantly with the injection, and they choose to just not have the surgery because they're doing better.

Dr. Miller: So a great option to may be postpone or prevent surgery.

Dr. Kendall: So a great option for more than half the people . . .

Dr. Miller: That's great.

Dr. Kendall: . . . to really decrease pain, get them on, and avoid a surgery that lays you up for a few weeks or more.

Dr. Miller: Now can you have repeated injections if necessary or is there a limit on the number of injections one can have?

Dr. Kendall: There's not an actual limit, however we usually say three or so a year would be the most we would consider. Some people, it does take one or two injections to really get rid of that leg pain that they have and avoid the surgery. However if we do two injections and your pain comes back within a week, then actually surgery is probably a much better choice.

Dr. Miller: So you do these under imaging, and that helps direct the shot into the area that needs to be infused I guess.

Dr. Kendall: We do these all under X-Ray guidance, so we know exactly where we're going, we know exactly where the needle tip is. We inject a little bit of contrast die to make sure we're not in a nerve or a blood vessel. So overall these are very, very safe injections.

Dr. Miller: Now how would a patient find a physician that would be qualified to do these kinds of treatments? I don't think they necessarily need to go to a surgeon per se, do they?

Dr. Kendall: No, in fact most surgeons don't do these epidural injections. Most are non-operative either anesthesiology or physical medicine rehabilitation physicians. Most people who are pain board certified have done significant amounts of injections, and finding a physician who specializes in back pain and pain will certainly have enough training to do these.

Dr. Miller: Now last question is, if the injection is effective, how long could someone expect to have the effect last?

Dr. Kendall: Most of the time, I tell people until they do something that irritates their back again, it's really not easy for us to say a time frame. It's mostly until you bend funny again or slip or shovel too much snow or do something again that may irritate that disc again.

Dr. Miller: I'm assuming you'd also have them follow up with exercise therapy and physical therapy as another modality to continue to strengthen the back and prevent further injury.

Dr. Kendall: Yes, we always have our patients continues with their exercise program throughout this even before and afterwards just because that's going to decrease the likelihood of you flaring it up again.

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Recording: Medical news and research from University of Utah physicians and specialists you can use for a happier and healthier life. You're listening to The Scope.

Interviewer: Chronic migraines are a mysterious and debilitating illness that affects an estimated 36 million people in the United States. That's a large number of patients who have a chronic illness for which there is no known treatment or cure.
Dr. K.C. Brennan is an assistant professor of neurology at the University of Utah School of Medicine. He's an expert in treating and researching migraines and he's here today to talk to us about migraines. Dr. Brennan, welcome.

Dr. K.C. Brennan: Thank you for having me.

Interviewer: Would you just quickly explain what a migraine is.

Dr. K.C. Brennan: Imagine a pounding headache, throbbing pain, then imagine that normal light hurts your eyes, sound hurts your ears, normal smells and tastes make you feel nauseous, you're completely incapacitated, that's what a migraine is.

Interviewer: What are the common migraine treatments right now and how well do they work?

Dr. K.C. Brennan: The best medications we have are called the triptan drugs, Imitrex, Maxalt, those are the names of these drugs and you see them advertised. There's been no single medication developed to prevent migraine.

Interviewer: How much do we know about these migraines right now, in terms of what causes them?

Dr. K.C. Brennan: We know that migraine is a pain disorder; it's a disorder where your pain system is activated when it shouldn't be activated. But we also know that migraine is an excitable disorder of the brain, it's the brain firing when it shouldn't be firing.
Migraine is also a disorder of plasticity, plasticity is the ability of the brain to change itself and it's what the brain does when it learns. When you see a chronic migraine patient you realize that their brain has learned to produce pain when it's not supposed to. I think that's a very important way of framing the question of migraine.

Interviewer: At the moment though we really don't know why the brain is doing this.

Dr. K.C. Brennan: We know that your genetics contribute a lot, there is your environment, you know, light and sound can trigger migraines, they sort of set the process off. Stress is a huge trigger of migraines, and release from stress, so not just a kid going into exams but that kid after they're done with exams suddenly stress releases and that's when they get their migraines.
Hormones are a very big part of it so two-thirds of people with migraine are women, only one-third are men, why is that? Well we think it's because of female sex hormones. So there's a lot of factors that can trigger or modulate, they can turn the volume knob up or down or start things off. We do not know the ultimate cause and that's probably because there are many ultimate causes.

Interviewer: Do migraines tend to run in families?

Dr. K.C. Brennan: They do tend to run in families.

Interviewer: What's the current state of research in migraines? How much are we learning and what are the big questions that people are looking at?

Dr. K.C. Brennan: I think there's been a real infusion of strength into the migraine field from two fronts, one is that we're now doing imaging in humans with migraine, so we're able to actually look at the brains of people with migraine. The other area where we've really had an infusion of strength is we're looking at migraine as a pain disorder, how pain works in the brain in general and then what makes migraine unique.

Interviewer: Can you just give us a little bit more in depth detail about what you've discovered and what you're hoping eventually to accomplish.

Dr. K.C. Brennan: What we've done recently is try and look at what this event, cortical spreading depression, which is the event that underlies the aura, what it does to the brain that might contribute to the migraine attack because the aura is something painless.

Interviewer: Yeah, and to be clear, when you talk about a spreading depression, the cortical spreading depression, define that if you would, that's a massive firing of?

Dr. K.C. Brennan: Right, it's got an unfortunate name, spreading depression is a massive wave of activity, it's like a tidal wave in the brain and it spreads out and it doesn't respect boundaries in the brain, it just moves out like a ripple in a pond.

Interviewer: And this itself, the aura itself is not, is it the migraine or is it what pre-stages the migraine?

Dr. K.C. Brennan: It's considered part of a migraine attack for people who have migraine with aura. Now there are people who have migraine without aura and there's fertile debate in our field about whether these are different kinds of migraine or whether they're all the same thing.

Interviewer: Where do you see research going and how much more do you think we will know about migraines 10 years from now?

Dr. K.C. Brennan: I'm optimistic we're going to know a huge amount more and I'm optimistic for a number of reasons. We've got tools to study migraine, in the lab and in the clinic that are just wondrous.

Interviewer: Is there some evolutionary reason that this volume knob might have been turned up?

Dr. K.C. Brennan: One line of thought goes, what goes on in migraine is essentially the sickness response. A person with migraine is very much like a person with a bad flu. When you have a bad flu or when you have meningitis or something like that, you know, all the senses hurt. And this is known as the sickness response that there's an inflammatory everything hurts reaction that goes on that incentivizes the person to get somewhere where they can get better, go to a dark room, lie down, heal up.
It seems like that sickness response gets switched on, that sickness volume knob gets turned up in migraine for reasons that don't make sense. The circuitry that creates migraine exists for a reason but it gets overused in migraine and then it entrains itself it becomes this daily miserable thing.

Recording: We're your daily dose of science, conversation, medicine. This is The Scope, University of Utah Health Sciences Radio.