A National Migraine Centre Heads Up Podcast transcript
Heads Up is the award-winning podcast series on all things headache, brought to you by the National Migraine Centre. Produced by leading headache doctors, it’s the trusted source of information and support for all those affected by migraine and headache.
You can find our episode transcript below. Want to listen to the podcast? Just head over to our Heads Up section here for hours of episodes that can help you manage migraine and control your headaches.
Need personalised treatment and advice? We can help! Book a not-for-profit consultation today with a world class headache doctor through the National Migraine Centre, the leading UK migraine clinic.
Transcript
00:00:00 Welcome to the Heads Up podcast, brought to you by the National Migraine Centre, the only UK charity treating headache and migraine. Visit our website to book your appointment with a world-class headache doctor, wherever you are in the UK. There is no need for a referral. You can refer yourself. Our headache specialist doctors are looking forward to helping you soon.
00:00:35 Dr Katy Munro
So welcome to today’s episode of Heads Up podcast and today I’m talking about something which many, many people who I see in my clinic suffer from, and that is brain fog. And I’m delighted to share this episode with our lovely guest, Doctor Sabina Brennan.
Good morning, Sabina. Thank you for joining me today.
00:00:55 Dr Sabina Brennan
Good morning, Katy, thank you for having me.
00:00:57 Dr Katy Munro
So will you just tell us a little bit about your role and how you got interested in brain fog?
00:01:03 Dr Sabina Brennan
Yeah. So I suppose I’m a health psychologist and I’m a neuroscientist and basically a neuroscientist really is an umbrella term for people from lots of different disciplines who are interested in the brain, and I’m interested in the relationship between the brain and behaviour and the brain and our health and very much in terms of what we can do to improve the quality of our health and the quality of our lives.
So I’m really just interested in how the brain influences our behaviour and how our behaviour influences the brain. Really, my initial interest is fundamentally in brain health, I say on my website, I’m on a mission to get everybody looking after their brain health as routinely as they brush their teeth. And that gets people to set up, and I mean dental health is important ‘cause you need your teeth to eat, speak and smile, but you need your brain for everything, and we just rarely give it a second thought.
And it’s only when the brain begins to malfunction that you realise how much you rely on it. So my initial research area really was in in the area of dementia risk reduction and looking at modifiable lifestyle factors that we can adopt to reduce the risk of dementia, but also to minimise the symptoms, even if you have the pathology in your brain. So that’s my initial area and then I moved into brain fog, which is something that I’ve experienced myself as a consequence of various underlying causes, which we’ll talk about later, but I think one of the main reasons I wrote the book is that I don’t think that brain fog is given the – uh, how would I put it – the gravitas that it actually deserves? It’s sort of seen as a side thing. And I don’t think people realise how debilitating it can be and it can be very debilitating and I think that’s one of the positives that have come out of COVID actually is that — and it sounds awful to say it — because a lot of people are experiencing brain fog the spotlight has now been shone on it and it is being taken more seriously, so if ever I’m always one looking for silver linings. But for me that’s kind of a silver lining with COVID if it is to have one.
00:03:30 Dr Katy Munro
Yeah, yeah. I think seeing patients in a migraine clinic, as I do, I think sometimes they’ve gone to a doctor about their headache and the emphasis has been on “Oh well, I can reassure you that it’s not a brain tumour.” And if you go to a doctor about brain fog, I suspect that there’s a tendency to say, “Oh, I can reassure you that it’s not dementia”, but when you’re left still with those debilitating symptoms and can sometimes be the most bothersome symptom of people with migraine being even if it’s episodic, you know an episode of migraine that lasts 3 to 5 days with brain fog really impacts on people, doesn’t it?
00:04:11 Dr Sabina Brennan
Oh, you can’t function. And I mean, I just had – We were talking before we came on air. I am doubly vaccinated, and I want to say that because I’m very pro-vaccine, but I contracted COVID in October and whilst it was relatively minor, in terms of how terrible it can be, it really floored me. And ultimately, I actually ended up with a pulmonary embolism, so you know. But the reason I say that actually is because about two weeks ago I just got part of COVID. Got a headache from hell, you know, and people with migraine will know what I’m talking about when I say headache from hell.
00:04:49 Dr Katy Munro
Yeah.
00:04:50 Dr Sabina Brennan
And then I had four days, nearly five days of that headache again, which I was putting down, certainly myself, to migraine. But I haven’t had an attack like that in years because I have been prophylactic, I would have chronic daily migraine so I’m on a prophylactic medication and I still tend to have headaches most days, but they’re really — anyone who’s listening will know what I mean. They’re just ones you live with. Do you know what I mean? They’re not going to stop you in your tracks, but there a few weeks ago I completely stopped in my tracks.
00:05:20 Dr Katy Munro
Yeah.
00:05:26 Dr Sabina Brennan
In bed mode and if I wasn’t in bed, I was running to the bathroom to be sick and just nauseous. I’m trying to eat little bits of food to stem that. You know when the saliva or whatever kicks off at the corner of your mouth and it’s that the only way I can describe it and I think it’s probably nausea is that. You know when you get it, when you’re so hungry, you say, “oh, I’m going to be sick if I don’t eat” and I just have that constantly with the migraine. Now my GP was concerned that it could be something more sinister and it isn’t because it has sort of subsided, but my daily headaches now are much than they used to be. So I am going to see my neurologist next week. And I do believe that that COVID has switched it up or something. But this is a very long-winded way of me saying for those four days, I honestly think if you’d asked me any more than my name, I really couldn’t have responded.
00:06:06 Dr Katy Munro
Yes.
00:06:18 Dr Sabina Brennan
There was just nothing there in in my head to be able to function and as you said, even if someone is episodic, that’s losing a good few days a month that other people don’t have to lose. Yeah, do you know?
00:06:29 Dr Katy Munro
Yeah.
00:06:33 Dr Sabina Brennan
And yeah, it’s quite debilitating, and even if it’s not so, I’ve just recently made a documentary about migraine. It will air in the spring. I must share it.
00:06:41 Dr Katy Munro
Oh yes, do.
00:06:42 Dr Sabina Brennan
I made a radio documentary about migraine and it’s some lovely migraineurs who have never spoken about their migraine recorded for it so I’m very pleased with it, and actually that came up time and again about the inability to function cognitively, to think, to remember things, to just do what you normally do without thinking is actually probably the most debilitating. You know, because most of us eventually can get to a point where you can sort of manage the pain unless you have those terrible, terrible ones. But yeah, just not being able to function is very tough.
00:07:20 Dr Katy Munro
I said I woke up yesterday with a migraine and I don’t get attacks very often now, but I woke up with a bad one and took the normal painkillers that usually get rid of mine and they worked but they didn’t get rid of the brain fog. I think that’s one of the things I was interested to read in your book, which is called Beating Brain Fog, what can we do to try and help ourselves when we get an episode of brain fog and we’ll talk about that a bit more later in the podcast. But can you say, how would you describe, say, a definition of brain fog for somebody that’s never had it?
00:07:58 Dr Sabina Brennan
Yeah, yeah. And I think that’s a very important thing because it’s one of those words that’s bandied about. And people go “well, actually, what is it?” So, brain fog, I suppose I’ll start by saying it’s an umbrella term that describes a collection of symptoms, and you may have some of those symptoms if you’re unfortunate, you may have all of those symptoms.
But they generally involve problems with focusing, concentrating, paying attention, you might have difficulty with language, so trouble finding the right word or also just even that your language isn’t as fluid or as rich as it ordinarily would be. Problems with memory, forgetting things, problems with learning and this is very much a psychological phrase that we would refer to learning and memory, and we tend to think of learning as learning something by rote in school. But our days are constantly filled with learning. You know, it’s learning how to open the door to that room, learning how to make cakes, do you know what I mean? Everything. Anything. Anything you do that’s new that you have never done before is learning. So, I would say if you have brain fog and someone tries to show you how to use the new remote control for the new telly, you will not be able to take it in. You know that means you’re having problems with learning.
00:09:24 Dr Katy Munro
I can definitely recognise that one.
00:09:28 Dr Sabina Brennan
Yeah. I think that would. Also another one is a slowing of processing speed so it’s really that sense of, and I suppose some people will describe that as feeling slow or not as sharp as they ordinarily are. So it’s a case of it seems to take you a long time, and when I have it I almost feel like I’m in slow motion, someone says something to you and it’s almost like you have to have a pause and go hold on a sec, just stop for a second, what is it that you actually said? Yeah. And then you have to almost repeat it in your head. OK, got it. Now. Now, can we move on to the next bit? Just slowing. It’s the equivalent of if you’ve a sore ankle, you have to walk more slowly and more carefully in a way. What am I missing now? Yes, also like a mental fatigue. So actually we hear a lot with long COVID in the news about people saying they have fatigue.
And really I’m involved, as I’m sure you are, a number of international groups. I’m really interested in all neurological conditions and brain health if you don’t have a neurological condition as well but I’ve been putting forward the idea that we really need to distinguish between physical fatigue and mental fatigue. There are two very different things, and actually often mental fatigue is much more debilitating than physical fatigue, and I suspect that a lot of people with long COVID are having almost more mental fatigue. Yes, they may have lost stamina in that they can’t walk or do exercise as much as they could. I certainly lost it myself, and in fact, actually what the doctor said to me was because I was getting dizzy even if I just picked up the ball sitting down to throw it for my dog.
00:11:12 Dr Katy Munro
Uh-huh.
00:11:12 Dr Sabina Brennan
You know, shortly towards the end of COVID and I was having heart arrhythmias. Basically, he said to me that my heart had become deconditioned. Anyway, that’s sort of an aside. So that’s physical. When you’re physically fatigued, you should still be able to think. If you have trouble thinking, you’re mentally fatigued, you know it’ll happen.
And all of these things have happened to everybody on occasion, I mean, you’ll have a regular day, a really busy day. And at the end of the day, you come home and your husband says to you “do you know, we really need to sort out whether we’re going to change this mortgage”. And you’ll just say “I am too tired”. You know your brain has done enough. You know that’s normal. And there’s often reasons for that. The difference with brain fog is that these symptoms that I’m talking about recur and they’re consistent and they interfere with your ability to carry out your everyday activities, your work. They interfere with your quality of life and they interfere with your relationships because in a sense, and a lot of people I’ve talked about it in the book, a lot of people have told me that having brain fog felt like they lost themselves. They didn’t recognise who they are anymore, because even irritability or having a sense of humour requires sharpness in your brain and an ability to process information quickly, switch it up and come out with a funny retort. That’s a highly complex intellectual activity, and if you’ve got brain fog, you haven’t the capacity to do that. And if you’re a person who’s known for being funny and sharp in that way, that’s like a personality change. And then that kind of change can impact on relationships. And that’s another reason that I’m passionate about raising awareness about brain fog, that those living with people with brain fog can get a better understanding. Hey, look, it’s not to do with you and another thing that people have said to me is, information just not going in which is learning and memory together, but that that has caused them problems in their relationships because their partner might say to them, such and such and such and such and they say, oh, really, they say yes, I told you.
00:13:22 Dr Katy Munro
I told you.
00:13:36 Dr Sabina Brennan
I told you about that last week, I told you about that. Did you?
00:13:36 Dr Katy Munro
Yeah.
00:13:39 Dr Sabina Brennan
I don’t remember. See. You just don’t listen to me anymore. Don’t care anymore. You know, it can suddenly escalate into something, and I even find that myself like, you know, if I hear my husband as any normal human getting a little irritated over something. And I say I’m really sorry, David, you just have to bear with me. I’ve had migraine for two days and I just can’t think straight. Do you know? And I think probably we have to speak up a little more and just make people aware that it’s not just the pain.
00:14:08 Dr Katy Munro
Yeah, I sometimes say to my husband, I’m sorry. I forgot to listen.
00:14:14 Dr Sabina Brennan
That’s brave, but it is. It’s like a zoning out. That’s that attentional thing. And yeah, the attention. So, attention, if we talk about it from a perspective where you’re researching attention, we tend to talk about attention as just one single thing. But there’s multiple types of attention and a few of them are affected in brain fog, focused attention is very clear. You really struggle to focus on the thing. Another one is an inability to block out distractors.
00:14:49 Dr Katy Munro
Mm.
00:14:50 Dr Sabina Brennan
So, you’re trying to do something, but your attention has been drawn away by the noise of the radio and various different things.
And then another one is to sustain your attention, which is really what you’re talking about there. So, attention naturally wanes after about 30 seconds. And so, when you’re engaged in any activity that requires attention, it uses up a huge amount of brain resources. And it is actually a cognitively demanding activity and a tiring activity. So you do need to take breaks probably every 60 minutes anyway, but yes if you’re not actively focusing on paying attention, which can happen with brain fog. I love that I’m going to steal that one. Very good. Tell me it again. I forgot to–
00:15:33 Dr Katy Munro
Forgot to listen. I forgot to listen to ask a question and then he’ll reply and then I’ll say I forgot to listen and he has to tell me all over again.
00:15:42 Dr Sabina Brennan
That’s brilliant. At least it’s a polite way of saying. So, with regard to the main symptoms of brain fog, but I think it’s important also to say that brain fog is not a disease. It’s not a diagnosis. It’s not a disorder in and of itself. That doesn’t mean it doesn’t exist, it is very real and it has been researched, but it really is a warning, a signal that something is amiss. Essentially, your brain is malfunctioning and that’s why I think it’s hysterical when people go to the doctor with symptoms of what is a malfunctioning brain and the doctor, as you said, says “Don’t worry, it’s not dementia”. Yeah, but hold on. You know, if I came to you with a limp, you might send me to a physiotherapist. You’ll send me somewhere. You’ll give me something that I can work on. Or alternatively, they will say it’s stress or it’s the menopause. And they’re absolutely right.
Those are factors that contribute to brain fog. But they really need to start giving people support and advice and tips on what to do and that’s part of what I did very early in the book. You’ll know, Katy, from having read the book, very early in the book. I mean, I treat the book as sort of arming people with the information that they can take to their doctor, so, at the very start, all those things that I’ve spoken about, like focused attention, et cetera. I have little questionnaires that can help you isolate which part of your brain function is not working correctly. And then also I have a whole load of strategies that you can use to deal with those until you actually make the lifestyle changes that will ultimately affect it, but they help out, but they’re good. They’re just little tips. Like if you’re having trouble with attention turning off all distractors, decluttering your desk will actually allow you to be able to focus on the thing, because your brain doesn’t have to deal with all those competing sensory signals coming in. So you can go to your doctor with specifics and then also the book really goes into the various underlying factors that can influence brain fog. And I think it would be good to go through those.
00:17:57 Dr Katy Munro
Yeah. So, I’d like to talk about those. One of the things I was going to say from a point of view of people with migraine is that of course brain fog can occur at any of the four stages of migraine, can’t it? So, it can be in the prodromal phase in that sort of feeling that you’re getting a migraine, which people may or may not notice, they may just sort of think, oh, I don’t, can’t, it’s harder work to think today and then the headache phase starts, but it can also go through all of the phases.
00:18:25 Dr Sabina Brennan
Yeah, and afterwards, I mean, I’ve spoken to people who say that they’re useless the day after, that they’re almost worse cognitively, the day after it. And then that makes sense to me, they’re just so drained from whatever they’ve been through. And I think it’s funny how we are. I just think we’re funny human beings, particularly those of us who live with migraine on a regular basis. I will feel off is the best way I can put it. And actually, I get, oh, that’s something I didn’t say. Another symptom of brain fog is clumsiness, and people often have clumsiness. “That’s a physical thing.” No, it’s not. Your brain is constantly assessing the distance between where you are and everything in your environment so that you don’t bump into things. It’s constantly making these judgments. And so, when you have brain fog and it falls off, that definitely affects me. I am not a clumsy individual, but I will bump into things or drop things or break things when I have brain fog and I used to have it pre-menstrually a lot and definitely with migraine also, but probably just to say and I think it’s really important to say to people: just because you have migraine doesn’t mean you will have brain fog. And also, I think sometimes a typical tipping point can be reached in a sense that if you have multiple factors, yes, something then adds into that like additional stress or something or disrupted sleep that then triggers the brain fog and I think for most people brain fog has multiple causes and that is really where the solution lies in a sense. So, while you might have an underlying neurological condition like migraine, there are probably multiple lifestyle factors that are also contributing to that brain fog that if you deal with those you may find then that your brain fog won’t actually be as bad, or may be gone altogether. I suspect – I’ve been selling my house for the last year, and anyone who knows, not for the last – and since April I’ve gained weight. Do you know, all these terrible things? You know, with all the stress of it. And so that would be likely to make my brain fog worse. In addition to having migraine. Anyway, yes. So, the underlying condition is basically a warning that something is amiss and a signal to take action and the main causes of brain fog are well recognised as an underlying health condition and I’ll very briefly touch on those because a lot of people with migraine often have another condition.
00:21:19 Dr Katy Munro
That’s commonly found, isn’t it, we see that a lot in the clinic.
00:21:21 Dr Sabina Brennan
It is. So basically, and I would have a cluster of things that contribute to, to brain fog. And a lot of them disproportionately affect women. So we’re talking autoimmune diseases. So they are often associated with brain fog. So things like lupus, Sjogren’s disease, rheumatoid arthritis, any chronic health conditions tend to be associated with brain fog. Crohn’s disease, you will also find some cancers. Then you will have Type 2 diabetes, depression, anxiety, migraine obviously, as we’ve said, but also neurological conditions like multiple sclerosis. So there’s a whole cluster of conditions and then migraine can be a side effect of a medication that you’re taking, and unfortunately, a lot of the medications for those conditions that I’ve mentioned actually can bring about brain fog and a lot of medications that we take operate on the central nervous system. So they’re operating on your brain and so they have a capacity to impact on how your brain is functioning. So I’m sure a lot of your listeners will have heard of chemo fog. So that would be associated with chemotherapy. Fibromyalgia actually is another chronic condition with what people would prefer to call fibro fog. A lot of people have their own little names depending on what the condition is associated with. So brain fog is really just the umbrella term for that. But medications that you might be unaware of, regular painkillers, antihistamines, anti-nausea medications, they all operate on the brain and they can bring about brain fog, antidepressants I always have to put this caveat in that if you’ve been prescribed medication, don’t stop taking it because you think it’s impacting or causing brain fog, but do go and speak to your prescribing doctor and ask them is there an alternative that might not have that side effect that you can try out. Hormonal issues then are another factor and again that tends to disproportionately affect women because our hormones fluctuate. So basically hormonal imbalance or hormonal fluctuations can impact and bring about brain fog. And I think a lot of that is people aren’t aware that you have and people tend – I’ll track back — so basically brain fog, I’m sure some of you have experienced it, I certainly did, I alluded to it earlier, to premenstrual tension, I would get brain fog. I also in hindsight only in later life realised that not everybody has to go to bed for three days before their period with a horrific headache.
00:24:10 Dr Katy Munro
I know people sometimes don’t realise that they’re getting menstrually related migraines–
00:24:14 Dr Sabina Brennan
I had no idea, that was just–
00:24:16 Dr Katy Munro
“Just their normal headaches that people get around their periods” and I’m like–
00:24:18 Dr Sabina Brennan
I thought everybody had to go to bed and pull the curtains and go to sleep until their period came, it was like my head was exploding till the period came. And pregnancy brain, baby brain, and then there’s menopausal brain and I know some people, maybe kind of from a feminist perspective, get a bit sort of “Oh, you know, that’s putting women down in some way or other, that our brain goes to mush”. My brain certainly went to mush when I was pregnant. I did crazy things like drive the wrong way up a street and wonder why people were flashing at me. Do you know what I mean?
00:24:52 Dr Katy Munro
Yeah, absolutely, yeah.
00:24:52 Dr Sabina Brennan
I mean just brain not working but actually the thing is you have hormones and you have receptors. Hormones act like a lock and key mechanism, so the hormone is released and there is a receptor that it locks into and whatever action is instigated and we tend to think that our sex hormones are associated with reproduction and lactation and sex, all those kind of things. But oestrogen receptors are widely distributed in your brain. So, the hippocampus is a part of your brain involved in learning and memory. The amygdala is involved in your sphere and your stress response, and the cerebral cortex is involved in your thinking, organising, planning, language, all of those complex activities and you have oestrogen receptors in all of those parts of your brain. And so, when the sex hormones are released, they’ll be picked up by those receptors and they influence how they and you function and that relates to how our mood changes sometimes and how we can be irritable and more sharp and in terms of irritability et cetera. So, in particular, your hormones actually influence your sex hormones, influence your thinking, your memory, your emotions, and other cognitive processes, and that fluctuates over our lifespan. But when you get to menopause and you have this drop in oestrogen there can be quite a significant change, and that’s a key reason I wrote the book and devoted a whole chapter to hormones and the relationship with hormones and brain fog, because I was really concerned about a cohort of women of a particular age who are experiencing brain fog but might be looking after a parent who has dementia and are absolutely terrified that they’re getting early stages and there are two very different things.
00:26:46 Dr Katy Munro
Yes.
00:26:51 Dr Sabina Brennan
You know, brain fog is temporary. It’s reversible. It’s not a neurodegenerative disease.
00:26:58 Dr Katy Munro
Yeah.
00:26:59 Dr Sabina Brennan
The symptoms of dementia to watch out for — and often the person themselves doesn’t notice them — would be repeating the same story or asking the same question over and over again without realising it, getting lost in a place that you would ordinarily be familiar with.
00:27:12 Dr Katy Munro
Yeah.
00:27:18 Dr Sabina Brennan
Confusion and that’s really not brain fog. You know, you’re very aware that you’re not working properly, you know, in this very specific thing and it comes and goes.
00:27:27 Dr Katy Munro
But do you think with women going through the perimenopause and I’m aware there’s been a lot recently. We did a podcast episode with Louise Newson recently about the perimenopause. And I see a lot of women in my clinic who are getting worsening migraine around the perimenopause. Do you think that’s a tendency for women to say “Well, I mean, that’s just normal, isn’t it? Everybody gets that” and not seek help for it and not realise how much can be done to help the brain fog at that stage in their life.
00:27:54 Dr Sabina Brennan
Yeah, I think so. And I agree with you. I mean, there’s some research that suggests that migraines lessen in perimenopause and now mine have got worse in a sense.
00:28:06 Dr Katy Munro
Yeah.
00:28:11 Dr Sabina Brennan
It’s different for everybody. You know, that doesn’t necessarily be the pace a lot, an awful lot of people come out of menopause and just, oh, they’re gone, which is fantastic. I think the thing is with perimenopause as well and I will move on to those more lifestyle factors. You’re not just talking about the hormonal issues, you are also talking about the fact that that impacts on your sleep so you have disrupted sleep and you’re fatigued and also you’re probably at a point in your life where you’re in that sandwich generation. You’re working to put kids through university or dealing with teenagers and ageing parents, or even caring for parents and trying to hold down a job and be super mum. And so, the stress. So, it’s the multiple factors I think that can come together. I think you can address some of them and lessen the impact. And I did talk to Louise Newson actually, when I was writing the book and when I was writing this hormone chapter. I think it’s very important that women do seek help with perimenopausal symptoms. I wish I knew back when I was perimenopausal what I know now, because I didn’t really seek help and then the help I got wasn’t appropriate to me. Hormone replacement therapy can be hugely beneficial. And if taken within 10 years of menopause it can actually help protect cognitive function and seems to have a protective factor against dementia risk. But unfortunately for me I couldn’t take HRT. It just completely – my mood — just within a week of taking it I was through the floor. And I rang my GP and I went, oh my God, she just said it can be a side effect and took me off it completely. And my father had manic depression. So, it’s something that I would be very aware of. And then also later I took a different medication, the hot flushes were terrible for me. Another thing that it’s really impossible to think with.
00:30:14 Dr Katy Munro
Yes.
00:30:15 Dr Sabina Brennan
I thought a flush was just where you just get a bit hot, but oh my God, I thought I would keel over each time I had one, I got a vasosuppressor, so that I think dilates the blood vessels and rather than dealing with the hormonal ‘cause it actually helps with the hot flush itself but then later on my gynaecologist then suggested that I take synthetic HRT and he said it wouldn’t have the same effect and it didn’t make me depressed, but it actually reactivated symptoms of an autoimmune disease and fibro that had been under control for ages. So, they’re all interrelated.
00:30:54 Dr Katy Munro
Yeah, like migraine, so when I’m seeing patients, I’m often there’s not just one thing that you can do to improve the symptoms. And you give a very clear number of strategies in the book about what kind of things to be looking at. So, should we talk a bit about those? Sleep is one and I’m very aware that sleep is so important for people with migraines. In regularity and the quality.
00:31:23 Dr Sabina Brennan
So that’s a nice segue way in because of the other factors. So, I’ve mentioned the underlying health conditions, the medications, the hormones, the other factors then are lifestyle factors like sleep and also nutritional deficiencies. So yeah, if there’s one thing that you can do to help minimise brain fog, it is to prioritise your sleep. Now obviously when migraine is at play there’s a funny relationship between migraine and sleep. For migraine, sleep can be a therapy almost, you know, go to sleep, feel better, but also too little or too much sleep can bring about migraines. So, it really is a balance.
00:32:00 Dr Katy Munro
Yeah.
00:32:04 Dr Sabina Brennan
We hear a lot about not getting enough sleep, but getting too much sleep is detrimental both to brain fog and to migraine. Brain function, migraine aside, is absolutely critical upon you getting sufficient good quality sleep every night. Because when you go to sleep, your brain doesn’t sleep. It has several jobs of work to do, but those related to brain fog are related to learning and memory. So, when you go to sleep at night, the information that you’ve taken in during the day is stored temporarily in the hippocampus, which actually has a limited capacity, and that’s often what I think about when I say no, my brain is full, can’t take any more in. Your hippocampus is actually full. It’s reached its capacity. It can’t take any more in without sleep because when you go to sleep, then that information that it has taken in is sorted, some of it is discarded. In the early part of the night we see activity between the hippocampus and the frontal part of your brain, and that’s sorting information around what you should keep and what you can discard. Then the information that is kept as you go a little bit further in the night, you see diffuse activity across lots of areas of your brain. And that’s the memory starting to be consolidated.
And then later in the night, what I would call early morning when you have more REM sleep, dream sleep, that new information is integrated with your existing knowledge, experience, memories, everything. And that’s why you have funny dreams where you have a bit of something from today and then something from when you were five, but that also is without that part of sleep you won’t find solutions to problems, you won’t have new ideas or creativity because that’s all happening in your brain when you sleep. And then another thing that’s critical that happens when you sleep that really impacts on brain fog is your brain is a really high energy organ. It only comprises about 2% of your body weight, but it consumes about 25% of the nutrients that you take in. That then produces a lot of metabolic waste and metabolic waste is produced by the other organs in your body. But that’s dealt with as it’s produced by your lymphatic system.
And it’s dealt with and cleaned and whatever, you know, through your liver and all the rest. But your brain cannot clear away the waste and be you at the same time. It only has enough resources to carry out your cognitive activities, and so it has to do like a nighttime street clean, you know, when the roads are cleared, and it clears away all that waste and debris. And if you wake up in the morning feeling groggy that’s still some of that waste in your brain. It hasn’t been cleared away. And one key point is that one of the things that does get cleared away at nighttime is beta-amyloid and that is you know, a key hallmark of Alzheimer’s disease.
00:35:02 Dr Katy Munro
Yeah.
00:35:02 Dr Sabina Brennan
You know, aside from brain fog and they are distinct things, but disrupted and poor sleep increases your risk of developing Alzheimer’s disease. So, if for that reason alone, but migraine aside, you will function much better cognitively the next day if you’ve had a good night’s sleep because that’s part of the issue. So, then the next day when you’ve had a good night’s sleep, your hippocampus can take in new information and it can learn things. But if it hasn’t been cleared away the night before, there’s that feeling of. No, sorry, I can’t. I can’t take that in. What? What are you saying? Sleep is just absolutely critical and the tip’s really on — looking at you, you said it there — regularity is really absolutely key. And that’s just going to bed and getting up at the same time every day, irrespective of weekends. If you do think that you are going to have a late night, you can use napping strategically.
00:36:01 Dr Katy Munro
Oh yes, I was interested to read that about napping and because occasionally you get a dip in energy in the afternoon and I sort of think, oh gosh, I’d better try not to sleep now because I’m going to not sleep tonight. But actually, a short nap can be quite helpful by-
00:36:17 Dr Sabina Brennan
Yeah, absolutely. So, there’s a natural dip in alertness for everybody mid-afternoon. That’s, you know, that’s our cycle. And there is a suggestion that we should be bi-urnal, that perhaps we would do better if we had two sleeps during the day and in fact some groups of people still have two sleeps during the day, a long one in the night time and one in the afternoon. So, anyone experiencing perimenopause or raising young children or having disrupted sleep due to stress or whatever. You can consider a nap to catch up on your lost sleep, but you have to do it, as I said, very strategically. So, either have a 10 minute nap and I often have that actually when I’m writing books and that sort of way, I do find that because of the nature of the work, that dip in alertness really affects me more because my focus kind of goes, do you know, if I was doing something physical, I probably wouldn’t notice that dip in alertness. And so often I have that little 10 minute nap, just close my eyes and it’s amazing how restorative it can be. Alternatively, you can have a longer nap, but it should be about 90 minutes, so don’t nap for any period between 10 and 90 minutes because you will wake up feeling worse. You will feel sleep drunk. And the reason for that is that sleep cycles are on average 90 minutes long. You have about 5 of them during the night and they go through an actual cycle. So, in the first 10 minutes you won’t have gone into deep sleep. That’s why that’s OK. You can actually just have a restorative nap.
00:37:49 Dr Katy Munro
Yeah. So is there a risk that you would go for a 10 minute nap and… Do you set an alarm, or do you just hope that you will–
00:37:59 Dr Sabina Brennan
Sometimes I do, yeah, but actually I tend to find that I’ll just wake after 10 minutes and you see you don’t go in a deep sleep.
00:38:09 Dr Katy Munro
Catnap.
00:38:11 Dr Sabina Brennan
I said to my husband, he’s just an unbelievable napper, but I’ll say to him, you know, he’d be watching the football on the telly, and I say, “You’re asleep.” “I’m not. I’m just resting my eyes.” But I think it’s more like that. It’s more like just resting your eyes. Yeah, not doing anything. If you are worried you’ll fall into a deeper sleep, set an alarm or actually acknowledge you know what? I may need this sleep and I will set an alarm for 90 minutes. Do you know what I mean? And take that sleep. Also, you can get your retaliation in first if you know that you’re going to have a late night to have a prophylactic nap, have a nap that day beforehand, because really to keep your brain functioning properly you need to repay your sleep debt, so you can. You’re going to have a late night, have a little sleep before that late night or the next day, to kind of try and catch up on it. But exposure to light is also absolutely critical for starting to develop good sleep habits.
00:39:15 Dr Katy Munro
You inspired me from reading the book. I know that, I’ve learned that before. People have told me, get out in the morning, get the daylight. It really helps set your circadian rhythm. And this morning, having read your book I was like, right, I’m doing it today. I’m going to start doing that in the morning, get out for 15 minutes and walk around, feed the birds or do some gardening. Whatever.
00:39:34 Dr Sabina Brennan
Yeah. And I mean, it doesn’t have to be, you know, instead of having your cup of coffee at the kitchen table, if it’s the wintertime put on your coat and just walk around the garden with your cup of coffee. You know. But exactly that, it sets your circadian rhythms. There’s multiple factors influence sleep, including body temperature and various things. But light is one of the critical things. So, what I say to people in the book – the book has a 30 day plan. So, Week 1 is sleep. It’s all about sleep. And to be honest I was acutely aware, having lived through it myself, that when you have brain fog, you do not want a complex 30 day plan. And so, it’s not that. Week 1 really is just about focusing on ways that you can promote good sleep.
And one of them is when you wake up in the morning, open your blinds to white light. Now we’re in the wintertime now, here in the northern hemisphere. So turn on a white light. Don’t open your blue light, your laptop or your phone, but a white light. Get out in morning light or any time of daylight for at least an hour if you possibly can and that can be over the course of the day, but you can do multiple things together, so you know you can go for your walk and get your daylight. You know, just switch, if you tend to walk at nighttime will maybe consider doing your walk during the daytime. Those kind of things. Decide to walk to the local shop and get your daylight at the same time. Or take phone calls outside in your garden, if you’re working from home, do you know what I mean? It’s just the little ways to get daylight in.
00:41:08 Dr Katy Munro
Think about changing things up a bit, isn’t it? Just changing things around? Yeah.
00:41:10 Dr Sabina Brennan
Yeah, just find a way so that it doesn’t become an onerous activity. Actually, I really need to get some. My brain needs daylight for it to function properly, so then the sort of the reverse in a way in the evening time. Our brains have been evolving for millions of years and electric light’s only been around for a limited time in response. So electric light has really influenced and probably led to poor sleep in many ways. So, what I suggest to people is that from about eight in the evening, you turn off overhead lights and you start dimming, if you have dimmers on them, or use low lamp light.
And also the blue light is a more recent factor that disrupts sleep because it confuses the brain and disrupts the melatonin in your brain and confuses your brain into thinking that it’s daylight and you really want your brain to get the message that actually, no, this is night time, so you need to lower and you know there is no scientific evidence that says an hour is when you should switch off your blue light, but I suggest an hour as a wind down time before you go to bed. So, switch off those laptops, do something that’s more relaxing, you know, listen to an audio book, listen to music in a calm room, lights and candles, have a bath, you know? Just, you wouldn’t expect a child to go to bed and go asleep if they’ve been running around playing, chasing, or tag, I think you might call it, we go chasing here, before they go to bed, you know that they need to wind down and we do too. We tend to stay doing activities that keep our brain awake and the light keeps our brain awake, but so too does watching Netflix TV. Research shows that just two hours, we’ll often say things like, oh, what, what are you going to do? I’m so tired. I’m just going to go home and chill in front of Netflix or whatever. Just two hours watching something on that or on TV actually increases anxiety levels and depression levels instead of actually relaxing you.
00:43:21 Dr Katy Munro
Ah.
00:43:23 Dr Sabina Brennan
So of course it does depend on what you’re watching, but most of us are watching dramas that involve murder.
00:43:25 Dr Katy Munro
Yes.
00:43:29 Dr Sabina Brennan
Or, you know, even it’s a soap opera, or even if it’s a soppy love story, something that gets your anxiety fully involved and emotionally involved, so you’re being active, so really just kind of switch down. So that’s a good way to control light. Another factor that people aren’t aware about in terms of sleep is temperature. Your core body temperature must drop by 1° in order for you to go into sleep. A lot of us focus on trying to get our bedrooms nice and warm and cosy and some people will have hot blankets on and they’ll turn the heat on an hour before they go up to the bedroom et cetera. Actually, it should be the reverse. You should make sure your bedroom is slightly cool when you go into it, you’ll sleep better. Anyone who has suffered hot flushes at nighttime knows that a cool bedroom is what you really want, and even your windows open. But a trick I mentioned earlier – a bath. A hot bath is a great way to reduce your core temperature. It sounds so counterintuitive-
00:44:33 Dr Katy Munro
Yeah.
00:44:35 Dr Sabina Brennan
But basically, what happens is, you know yourself, you have a hot bath and when you step out because it’s cold, you’re stepping into the cold air. The heat from your core rushes to your extremities to compensate. And that actually means you’ve dropped your core temperature so it’s your core temperature you want to drop, not your extremities. Your hands and that. So, yeah. Dropping that core temperature is really critical to sleep. And, you know, physical exercise is brilliant for your brain. It’s brilliant for addressing brain fog. If you actually take physical aerobic exercise at lunchtime that helps to counteract that alertness dip in the afternoon and the research shows that lunchtime exercise actually boosts your ability to learn, to concentrate and remember. And it’s just generally brilliant for your brain function. But I mentioned it here because exercise will help you sleep and while I’m on exercise, I’ll just continue with that. You know, your brain depends on a healthy cardiovascular system to function properly to get the nutrients and oxygen that it needs.
And so, the fitter you are physically, the better your brain will function. And whilst you might not feel like taking exercise when you have brain fog, actually — and I know this from experience — taking exercise does actually make you feel less tired.
00:46:05 Dr Katy Munro
Yeah.
00:46:05 Dr Sabina Brennan
You know you’ll sleep better at nighttime, but you actually feel less tired, less fatigued. And work up to it. I’ve been in that situation where I could barely kind of walk, at some point.
00:46:18 Dr Katy Munro
Yes.
00:46:22 Dr Sabina Brennan
And working up to it, and if anyone’s listening has had COVID and you know your physical fitness, you’ve become deconditioned, your brain fog, you can become deconditioned as well in your brain function. Work up gradually, you have to start taking exercise again. Otherwise, I use an analogy I think in the book like breaking your ankle or twisting your ankle. There’s a point where rest is absolutely critical, and you keep your foot elevated and you rest it to allow it to recover and this very much applies with COVID. But then there comes a point where even if it’s painful, or even if it feels like you can’t. you have got to start using it again, otherwise you will permanently lose your function. And that really does apply after long COVID. And this isn’t just long COVID. I mean, I should have mentioned earlier, I was mentioning the health conditions. You know, any serious viral infection will bring about brain fog. So, we know that before. And I mean I was only writing my book. You know, I would start to write my book before COVID happened. And I knew instantly we were going to just have this rise in people with brain fog and long COVID because it’s very common after sepsis, people have brain fog for up to a year after sepsis and their brain has been struggling to– you have to understand that your brain’s primary function is to keep you alive. And your brain in a sense makes decisions as to where it directs its resources. And when you’re in a life-threatening situation with a viral infection, your brain is going to direct all resources to fighting that infection. And that means you don’t have resources to do calculus or figure out your mortgage, because it’s not going to save your life, it’s absolutely irrelevant. It is not important. Your brain has to focus on keeping you alive and it makes perfect sense to me. And even if you don’t have a viral illness, whenever you’re sick, you experience illness behaviours which involve go home, go to bed, sleep, do nothing because that’s so that your brain can focus on getting your body to function well.
00:48:36 Dr Katy Munro
So, starting to do exercise when your limbs feel very heavy, your brain feels like it’s telling you “No, no, no, no, don’t do anything because I’m going to completely collapse if you even try and stand”. And do you think it’s something that people need to recruit their friends and family to help them and be with them and go forwards?
00:48:57 Dr Sabina Brennan
Yeah, I think a bit of encouragement can help. I made a special podcast episode back in 2020 in the summertime about long COVID. It was before it was really being spoken about a lot. And I spoke to a neurologist on that and she was in agreement. And this applies to, so I would have to say this, around your cognitive functioning. And she was saying the same around your physical functioning so that you have become deconditioned.
00:49:23 Dr Katy Munro
Yeah.
00:49:27 Dr Sabina Brennan
And as she said, look, a lot of people with COVID couldn’t even sit up in their bed while they’re having it. I know certainly even while I was having it having been vaccinated the way I would describe it as my head was just too heavy to hold up. I had to lie down. So basically, depending on where your baseline is at the moment. So, if you can barely sit up, well, then just sit up for 5 minutes and lie down again. And do that for a few days. So for a lot of people, they will have got to walking again or whatever. And they might feel that they’re exhausted or breathless just walking to the hall door, you know. Well, just do that for a week. Just do that for a week. To the door and back. And then next week, see if you can operate from your own baseline. Can you do another 10 metres? If that’s too much, we’ll bring it back to 5 metres and do that for a week. It’s slow. You’ve got to do it slowly if you’ve been that debilitated. You see the problem I think is, and I’ve had it myself, even just with COVID, and I’ve heard a lot of people with long COVID say, like there was days I thought I was better. Oh, I think I’m OK. then I was, and now I knew not to just still take it easy.
00:50:41 Dr Katy Munro
Yes. Yeah.
00:50:47 Dr Sabina Brennan
But I think that’s what happens with people and it happens with brain fog too. You know that you think you’re better or you have a clear day and you decide to do everything that you haven’t been able to do for the last two weeks. And then you’re going to be scuppered again the next day because you’ve overdone it. You’ve got to resist that urge that on the days you feel well, you mustn’t overdo it, just gently build up because the more you do that gently then you will have more free days and it’s just patience is key in this. It’s very difficult. It’s very frustrating. I mean I had just started, as I said, I gained weight with the stress from selling the house and I suppose all the other stresses associated with COVID but probably the selling of the house was the tipping point for me after a year of all those COVID things. And I had just got back on track. I was in the gym every day. I was walking every day. I was seeing significant weight loss and then I got COVID and I could barely get out of bed some of the days. And I tried walking and I would have to come home. I just have to accept that fact that I have to take it easy and it will happen. So it really is about kind of readjusting your perspective. You just kind of survived a deadly illness, you know? And I mean, that’s not exaggerating. It is a deadly illness and you’ve got to accept that. I mean, people accepted it when — How many books did you read? Historic fiction — someone had consumption or someone was recovering from TB. It takes time and we live in a very fast-paced world and we put an awful lot of stress on ourselves. So I think talking to your family, asking them to understand, that you may take time. You may not be able to do. Get friends, let friends know that actually – That’s something I found actually. I had a meeting there the other day and then was taken to dinner. And like, I really struggled by nine o’clock in. And then some of them were going out afterwards. And I said no, I have to go home. And I was actually exhausted after the three hour meeting. Positively exhausted. Then, as you know, when you go for a business dinner that’s quite cognitively exhausting as well, ‘cause it’s not people that you’re with all the time and if I had had a choice, I would have ended it at that. But I took a rest the next day, I mean I was literally wiped. Now that’s only last week, you know. And I’m a good few weeks in, so. Really you’ve got to listen to your body. It’s a fine balance between knowing when you need to rest and knowing when you need to push yourself a little.
00:53:28 Dr Katy Munro
So, talking about dinners brings me on to asking you about nutrition and the gut brain axis because I know you know. People with migraine, I’m always saying to them, it is actually also really important what you’re nourishing yourself with because if your brain isn’t getting a nice, steady amount of fuel, then it becomes much more irritable and you’re more likely to get migraine attacks, but also in the book you talk about the importance of the Mediterranean diet and keeping on nourishing your microbiome. So that I’m guessing is something that you would also emphasise.
00:54:02 Dr Sabina Brennan
Oh, absolutely. And you know, when it comes to migraine, eating regularly is really very important. Like, it really is. And. And I’ve noticed it since I used in the past to have nausea with migraine and now I have it again. And now I know since my migraines have changed dramatically since COVID, I now know that I cannot allow myself to get hungry. Like, I would be a divil. A bit of a workaholic, if I’m doing something, I won’t stop to eat. Now I know I can’t. As soon as I start to feel that I’d say no, I need, and I often keep like a cooked chicken in the fridge so I can just have a little piece of protein, that’s just something I do. But as you said, the Mediterranean diet has the best evidence in terms of general brain health.
And you know, that’s lots of colourful fruit and vegetables, oily fish, get your fat from olive oil, nuts. To be honest, and I think this works for migraine and it works for brain fog, I mean, just avoid processed foods. You know, you don’t need all those additives that are in that food, anything as close to fresh as it can be.
For Mediterranean– Oh, now I’m just getting a really sharp pain at the side of my head. Now as I speak, I have a headache. But do you ever get those ones? I call them like the ice pick one that just comes down one side and thankfully they don’t generally last very long.
00:55:15 Dr Katy Munro
Yeah.
00:55:17 Dr Sabina Brennan
So, the wonderful thing about a Mediterranean diet is you can chop up a whole load of those ingredients and eat them raw as a salad. Yeah. And throw them in a pot. Soup. I do a lot of soups. It’s a great way to get tonnes of those vegetables in. You can kind of batch cook them. And it really doesn’t take that long to make soup. If you have a soup maker, fine, but I have a really simple one that I use. As I said, I always have a cooked chicken in the fridge. Literally, I chop up some onion, fry them on the pan till they’re just transparent, and then I throw in 100 grammes of chopped chicken, 100 grammes of peas, stock cube, you know, and let it simmer for 10 minutes, and that’s my lunch. Like that does not take as long as going to the shop or anything like that, you know. And that’s my lunch for two days, and it’s tasty and it’s filling and whatever, but yes, you’re right. If your gut, your microbiome is out of balance or out of whack, that influences your brain function, the gut is often called the second brain, because it has tonnes of neurotransmitters and it can directly influence your brain function. I think I talk about cravings in the book.
00:56:24 Dr Katy Munro
Yeah.
00:56:33 Dr Sabina Brennan
And you know, cravings are usually a thought. You know, I hate thinking about this though, because we essentially have another living organ inside our gut in a sense, this microbiome, and it’s a symbiotic relationship. They need our moist gut to survive and they help us to thrive. The good ones help us to thrive. They can help us to fight infection and keep us healthy. Unfortunately, the bad ones can lead us down tracks that aren’t good for us, but they also — if anyone is interested, there is a fabulous book called The Psychobiotic Revolution. I think that’s what it’s called and it really talks about the relationship between the microbiome and depression.
00:57:31 Dr Katy Munro
Oh, yes, I’ve read some books on that. The brain and depression and the gut, yeah.
00:57:35 Dr Sabina Brennan
And the gut, you know, definitely linked. So craving really can be so — You know, if you eat food and that encourages unhealthy craythurs in your system, they can send very, very powerful messages to your brain to crave more of that food. And that’s very hard to resist. And then if you answer that craving, you’re growing more and more of them and basically your gut goes out of balance and becomes very unhealthy and impacts on your sluggishness and you know your depression. If you’re feeling depressed, your brain function is not going to work. So, they really all interact, they really, really do and I know it myself If I eat the wrong stuff. You know, we all know it really.
00:58:23 Dr Katy Munro
But the messages from those little bugs that are telling us to have the cravings. They’re very strong, aren’t they –
00:58:30 Dr Sabina Brennan
Oh, it’s incredibly strong, incredibly strong.
00:58:31 Dr Katy Munro
Very, very powerful. I liked somebody, I read a book called Missing Microbes and I think they talk in that book about the good bacteria being our old friends because they’ve been with us since back in, you know, millions of years and developed with us. But our old friends, we need to nourish our old friends. And keep the mix of them healthy by trying to aim for 30 different plant-based foods per week and all the things that you have just described. So yeah, I like the way you describe in the book as well about cultivating positive cravings and trying to find, I hadn’t thought of it in that way. Oh, I’m going to have a craving for doing some exercise because I like the endorphins or I like the reward that I give myself afterwards, which is having a nice cup of coffee or whatever. Whatever it is.
00:59:27 Dr Sabina Brennan
Yeah. And I do kind of go into detail on that. So, it’s all very well to say that, cultivate this, you know, and I think in the book I talk about cultivating optimism, these things can be cultivated when you understand. And I do have a chapter that in the book that really explains how your brain works in ways that are relevant to brain fog and to habit forming and those kinds of things, because I think if people understood how their brain worked more, it’s much more empowering. You can actually be stronger against those cravings that are going to do you damage because you say actually, they’ve just sent a message to my brain that says eat those, eat those, eat those. Give me chocolate. Give me chocolate. I want more sugar. I want more sugar.
And it really is them. They’ve literally just hijacked your communications system and said get me sugar, you know? So, I think it even helps if you know that you can go, OK, now I have to resist that. And actually the thing is they can’t survive without it. So then when you resist it for a period of time, the craving goes. You know it. It does.
01:00:26 Dr Katy Munro
It’s quite a short period of time, isn’t it?
01:00:29 Dr Sabina Brennan
It’s quite short actually. Don’t ask me how long, exactly, but it’s quite short.
01:00:34 Dr Katy Munro
I’ve read things about addiction and addictive cravings, and I don’t think it’s more than sort of a short number of minutes. It’s not like you have to resist for hours and hours and hours then you know. If you just kind of breathe, do something else, distract yourself.
01:00:47 Dr Sabina Brennan
Do something else and you know, things like brushing your teeth. I mean, I’m an ex-smoker, long, long, long time ago. But teeth brushing is a fantastic way because you’ve got this lovely clean mouth and you kind of go, no, I don’t want to put a smoke in it or whatever.
Two things I want to say a tiny little bit about nutritional supplements while we’re talking about diet and nutrition, and then we would be really remiss to go without speaking about stress because that’s critical. So yes, so people often ask me, you know, are there any supplements that they should take to boost their memory or boost their brain function or deal with brain fog? And my absolute categorical answer is no, don’t waste your money. You know, far better off spending it on nice, healthy food. You can get all of the nourishment and nutrition that your brain needs from a healthy Mediterranean diet, unless you are deficient. So vitamin B12 deficiency can bring about brain fog, and in fact the brain fog can be so severe it can be confused with dementia. Now, if you have any suspicions that you have a nutritional deficiency of any form, go to your doctor and be tested. They will then prescribe B12 injections or whatever which sort the issue out. But it’s only beneficial if you are deficient, so do not go to the shop and buy vitamin B12 deficiency tablets to think they’ll boost your memory. They won’t. That’s the way it works. It’s if you’re deficient, you need it.
01:02:23 Dr Katy Munro
I guess maybe the only group that would benefit from that would be people like vegans who may tend to have a low dietary B12 because they’re not eating meat and dairy.
01:02:33 Dr Sabina Brennan
Of course, yeah, and what I do say, so a Mediterranean diet does have fish in it and it does have protein, it’s not vegan. So yes, if you’re vegetarian or vegan, it’s really, really critical for your brain that you are getting sufficient. I mean, I have a son who’s a GP and his opinion is that vegans are absolutely mad because their brain is going to really suffer unless they’re getting the right amount of proteins, et cetera. I’m not an expert in that department. And so really, in my book, I say, you know, actually seek advice and make sure that you are getting the appropriate supplements and nutrients. You know there is no good being a vegetarian who just eats, you know, lashings of bread with butter on it. Do you know what I mean?
01:03:15 Dr Katy Munro
Yeah, you can have an unhealthy diet, yeah.
01:03:25 Dr Sabina Brennan
You can have a really unhealthy diet and be vegetarian or vegan. Being vegetarian or being vegan do not equate with being healthy. You can have unhealthy ones and healthy ones. They’re not mutually exclusive, so the other deficiencies, a folate deficiency and an iron deficiency, even an omega-3 deficiency can bring about brain fog so omega-3 you can get from your diet, from your fatty fishes.
If you think you are anaemic or have a folate deficiency you speak to your doctor and they’ll prescribe supplements, or you can add more green leafy veg into your diet for iron and that sort of thing. But yeah, basically there’s a billion dollar industry on supplements. I’m sure it’s going to explode in the brain fog area, but prior to COVID it was really very much in the preventive dementia. You know, boost your memory and ageing, and I just feel it really preys on a very vulnerable audience of people who are worried about getting dementia. And they would be far better off doing the things that we know are good for your brain health, like eating a balanced diet, maintaining a healthy weight, taking exercise, monitoring your blood pressure. You know, all those kind of things, in the sleep and not smoking and all those kind of things than spending money on supplements.
01:04:43 Dr Katy Munro
Stress, stress, Sabina. Let’s talk about stress. Sometimes I find that patients have been told, oh, you’re getting migraine attacks because you’re just stressed. And it’s not just stress. Just switching off stress, which is impossible to just switch off stress or not. But there are ways to manage stress, and it is a contributory factor to migraine attacks and brain fog.
01:05:03 Dr Sabina Brennan
It is a contributing factor. Yeah, and stress is the most common trigger for migraine. So I do want to say first I think stress gets very bad press, there is actually nothing wrong with stress per se. Do you know if you need the stress response, everything that we have has evolved because it serves a purpose. Even anger serves a purpose, you know. And we’re told that anger is a bad thing. Anger is not a bad thing, you know. But if you try and suppress it and let it come out in the wrong place, then it’s a bad thing. If you feel angry about something, it’s just a signal to take action doesn’t mean you have to take it in and you know yourself, if something angers you and if you take action there and then on the spot, you know, think about it and kind of go. Actually, this doesn’t feel right. Can we do something to change this? That’s quite productive. You can bring about change or you can stop injustice or various things that can serve a purpose. It’s not bad. It’s using it appropriately. So, stress in a way is the same. Stress is not inherently bad, and we need the stress response to achieve our goals, to be motivated, you need the cortisol spike in the morning to get out of bed. You know, without stress what would life be like? If you never went on a first date, if you never went for a job interview. They’re all stress-inducing activities, but really what they’re doing is they’re giving you that bit of adrenaline and cortisol that you can rise to that challenge, and even learning something new can induce the stress response. But that’s how we evolve within ourselves. That’s how we progress and get on with life. So optimal levels of stress are brilliant and it is very, very individual. You know, what’s stressful for you could be just exciting for me. Some people love roller coasters and that’s a “this is brilliant. Can’t wait to do that!” And that’s actually almost a de-stressor for them, because they go on and they feel “Oh, you know, I’ve done that. It’s great.” Whereas, you know, I could be absolutely terrified of them and be worried sick about going on it for days beforehand or whatever.
So, it’s very, very individual and really trying to find your optimal level, your sweet spot of stress really lies just at that boundary between your, erm, how would you put it? Your comfort zone? Yeah. You know, if you just stay within your comfort zone, you’re not benefiting actually because learning and stress can bring about these benefits, they can promote neuroplasticity in your brain, so that’s creating more connections in your brain and more brain cells. So just pushing yourself beyond whatever is your own comfort zone and learning new things and doing new things are all brilliant for that. So then poorly managed chronic stress is where we really get into trouble. And that is basically the stress response, and I’ll just explain this. It’s unfortunate because the same word stress is used to mean the thing that stresses us and the feeling we have and the thing we’re thinking. So the threat, the thing that stresses you. So, if we just take a sensory signal like a loud bang, OK, that sensory information comes into your brain to the amygdala via two routes, a slow route and a fast route.
So, the fast route goes directly to your amygdala, which is in an unconscious, unthinking part of your brain, and it kicks off the stress response, and will have you instantaneously jumping out of the way or jumping back or crouching down, whatever your instinctive response is. Now that same information, that same sound, sensory information, comes to your amygdala via a slower route. It goes through your frontal lobes, which are a thinking, conscious part of your brain that are extremely well connected, and we call it the executive controller because it has access to most of the information and most of the parts of your brain. And it is involved ordinarily in decision making, that sort of thing. So that thinking part of your brain has access to the entire context, and it can go, oh, that’s a car backfiring. And so it sends a message then to the amygdala that says “false alarm, switch off that stress response, doesn’t need to be activated. There’s no real threat” or “Oh my God, that was a gunshot. There is a gun man. Message to the amygdala. Right. Ramp up the stress response. Switch off, you know, switch off digestion, immune response, let’s get everything into the muscles because you may have to fight or run away here or keep very still or whatever.” Now there is a fabulous feedback loop that when the acute stress situation has passed, a message is sent to the brain and then you know to switch off the release of cortisol, the stress hormone. We’ve dealt with the response, and we’ve dealt with the issue and it’s gone. Let’s go from fight or flight to rest and digest, and then your digestion can come back, your immunity levels, and your breathing can come back to normal. Now when we become chronically stressed, that gets disrupted and the switch off system just seems to malfunction and so you are literally operating in a chronic state of stress.
And unfortunately what happens is in that chronic state of stress, to put it very grossly, your amygdala becomes stronger and your frontal lobes become weaker. And so instead of your frontal lobes overriding your amygdala, or being the boss of your amygdala and saying no, there’s nothing to be stressful of, your amygdala, that instant unconscious reflexive behaviour takes control and your reflective thinking behaviour becomes suppressed and so you just live on the edge, you start to see threat where there’s none. You’re constantly on the alert. And unfortunately, what that does is in the frontal lobes and in your hippocampus, which is involved in learning and memory, neuroplasticity, the ability to grow new connections in your brain, is suppressed, and so the organs themselves actually shrink. The structures actually shrink. So your frontal lobes actually shrink, and so does your hippocampus.
In contrast, and in parallel, neuroplasticity is enhanced in your fear centre, your amygdala, and so it gets bigger, and that’s why it becomes stronger.
01:11:49 Dr Katy Munro
So it’s like a vicious circle really, isn’t it? The more stressed, the more your stress response is kicking in.
01:11:49 Dr Sabina Brennan
Oh, it’s dreadful. It really is. And also the relationship between sleep and stress is a really dynamic relationship. If you have poor sleep you’ll become more stressed, if you have more stress you’ll have trouble sleeping. You need sleep to clear out the stress hormones, and you know yourself if you’ve got high cortisol levels for some it’s either going to sleep at night, you won’t be able to, or you’ll wake in the middle of the night with a spike of cortisol. And then it’s all used up by the morning and you’ve no spike to get you out of bed. So really, really managing stress and prioritising sleep will make an incredible difference to your brain fog, but also to your migraines.
01:12:40 Dr Sabina Brennan
And I suppose it’s all very well to say how to manage stress but there are lots of different ways. Exercise is a great way to manage stress. My favourite is laughter and smiling. Laughter is nature’s natural — and in fact I think that’s that whole week two of the programme is about managing stress and I focus on laughter and smiling. And, you know, ask yourself and just say have a little think, you know, you schedule time in your day for work, you schedule time, maybe for eating. You might even schedule it for exercise. Do you schedule any time in your day for fun? I’m not talking about sitting down watching TV or going for drinks, you know, doing something that you love that’s really just fun to do or that just makes you laugh.
01:13:20 Dr Katy Munro
Yeah.
01:13:20 Dr Sabina Brennan
Schedule time every day for that, because when you laugh, it really is genuinely nature’s natural stress buster, it actually lowers cortisol levels. And it helps absolutely, immensely. And that’s something that you can do anytime, anyplace, anywhere, you can smile whenever you want. And I suggest that people have a laughter stash. You know, where they have a file on their laptop or whatever with funny memes, you know, whatever rocks your boats. If it’s cute kittens, if it’s people falling down on ice, a funny podcast, whatever it is, have a stash of them and instead of waiting till you’re stressed, if you start to feel stress rising, take 10 minutes out and just have a listen or a look at one of those and I think it’s a mechanism. The laughter is a mechanism that I think is like releasing a pressure cooker. I mean, just think about when you’ve been, you know, lost a loved one, been at a funeral, the amount of laughter in those few days. Obviously there’s grief and there’s tears, but the amount of laughter is incredible. And I think it’s just a natural mechanism. This is just my theory, folks. This is not from research. But I just think it’s this natural pressure release that because this is just too stressful, this is just too much, someone so important to me has died. But yet we’ve got these situations where we speak to people and I think that’s why it was so hard during lockdown.
01:14:54 Dr Katy Munro
Yeah.
01:14:54 Dr Sabina Brennan
For people to lose loved ones and have that social support, where the laughter happens and where you remember funny things. You know that was really challenging for people.
01:15:07 Dr Katy Munro
That was really hard. I used to do a lot of work with bereaved patients and things and sometimes people would say I felt really guilty for laughing, but I always used to reassure them to say, you know, that is nature’s way of helping you heal. It’s fine. You will be having laughter, but that doesn’t mean you don’t feel the grief as well.
01:15:17 Dr Sabina Brennan
Oh no.
01:15:28 Dr Katy Munro
But I agree with you. I think that shared, you’ll often find at a funeral or a wake or something that people will be telling funny stories about the memories of that person and that is such a positive thing, isn’t it?
01:15:40 Dr Sabina Brennan
I think it’s a positive thing and I think it’s a great way to cope and often when you – I just had a situation really recently, I won’t share it because I wouldn’t have the person’s permission, but they were really crying and they were holding on to me and then I said something like “Stop, you’re making me laugh”, but crying often turns to laughter, you know, and I think too, you know, I’m all for political correctness and addressing inequalities and you know, being careful about not being exclusive, but I think sometimes what we try to do is actually counteract behaviours that have evolved, that have served a purpose and you often see it after some dreadful tragedy. The jokes aren’t long in coming, and it seems awful, and it seems like a terrible thing to do, but often that is part of our coping mechanism, I think.
01:16:31 Dr Katy Munro
Yes.
01:16:39 Dr Sabina Brennan
The disaster is so awful. Of course, it’s terrible for the people involved to see those, but generally that isn’t how it happens. I suppose it’s just become… Social media opens everything up to everybody. There were ways that when we didn’t have social media that sort of help people take in and process tragedy, that’s just too big to try to cope with in a way.
01:17:01 Dr Katy Munro
Yeah, yeah, a sort of black humour, isn’t it?
01:17:04 Dr Sabina Brennan
It’s a black humour and I think we’ve got to be careful that we balance it that, when it’s appropriate, when it’s not appropriate. And of course, you always with black humour have to be careful when you use it but it can serve a purpose too. But smiling lowers your blood pressure, it boosts your immune function. And it makes you feel good, you know.
01:17:30 Dr Katy Munro
I was reading a book a while ago that said that you can trick your brain even if you’re not feeling very happy. If you just put a pencil in your mouth–
01:17:36 Dr Sabina Brennan
I think I relate to that study. And you don’t actually even have to do that. So all those physiological changes occur in your brain when you smile and basically research is trying to understand this, what we wanted to understand was, do you have to feel happy to smile and is it the happiness that makes that happen but actually exactly as you just said the way they did the research was they got the participants to bite on a pencil and then they measured all those responses. So just making the smile has all those benefits, so I always say you’ve got to smile even if you don’t feel like it or actually, especially if you don’t feel like it. And a lot of people will say, oh god, so facetious, like, life is awful and you’re telling me to smile, but actually what I’m saying to you is, here’s a tool that you have naturally, that will actually help you. And if you do genuinely want to get better and feel better, we’ll try it and employ it and employ it. Fake it till you make it. I was really — I couldn’t figure out. The brain is the most complex structure in the known universe and how was it fooled? You know, how is it fooled by a fake sympathetic smile? And then I actually realised it is because it is such a clever organ, it has given us a little tool that can actually help us. You know, boost our mood, lower our blood pressure, boost our immune function and just feel better.
01:19:02 Dr Katy Munro
It also works with hugging. I believe if you hug yourself, your brain doesn’t necessarily worry that it’s you hugging yourself and after 20 seconds your oxytocin, your feel good hormone is released. So I’ve been saying to family and friends, if you’re feeling a bit down and nobody’s around, just give yourself a good hug.
01:19:27 Dr Sabina Brennan
I knew that about hugging, not about hugging yourself. I’m going to go and have a look at the research on that, because I did an animation, I make little animations as well. If people want to visit my website superbrain.ie that will link to other websites that have lots of my materials.
01:19:36 Dr Katy Munro
We’ll put the link in the blurb too.
01:19:38 Dr Sabina Brennan
Yeah, I made a couple of animations a few years ago for people who are caring for people with dementia, and one of them was about self-care. And in it I was talking about the benefits of hugging, which are very similar to the benefits of smiling, very, very similar. And there was something that I was very conscious of during lockdown. And you know, and during the pandemic, we haven’t been able to hug or touch people. I hug within my family now, but other than that, you kind of don’t and it’s very beneficial. So I wasn’t aware that self-hugging does. So I will look up the research on that now and I’ll be adding that in.
01:20:15 Dr Katy Munro
Easy and cheap. Easy and cheap mood-booster.
01:20:18 Dr Sabina Brennan
Yeah. Do you know what? That’s the thing. You know, people. I don’t know what it is about us. We want medication. We want the expensive solution. We tend to think that because we don’t value stuff that’s free. And the truth of the matter is everything that’s beneficial for brain health and that will help, you know, help you to minimise your brain fog are free, they’re free and available. That doesn’t mean they’re easy because they involve habit change. They involve integrating them into your life, so yes, it is far easier to pop the pill than to get in the habit of smiling like I even say on that one, look, just pick several things, smile when you’re waiting for the kettle to boil. Smile when you’re having a wee. Smile when you’re in the shower. No, do you know what I mean? So that’s one of the best ways to introduce a new habit is to tag it on to something that you do regularly every day. So most people boil the kettle. We all have wees. Do you know what I mean? Just tag it on there and then you will start to do it more. And before you know it, you really will experience the benefits and I’m a firm believer, you know when things happen, look, you have to laugh or you’d cry, like really, shit happens, excuse my French, but it does. And really the only thing you have control over is how you respond to that.
01:21:38 Dr Katy Munro
Yeah.
01:21:48 Dr Sabina Brennan
Yeah, terrible, dreadful things happen in our lives. And you don’t have control over most of those things, but you have control over how you respond to it. And that’s the key really.
01:22:01 Dr Katy Munro
I think that’s a really good place to wind up. It’s been an absolute delight to talk to you today and I think your message is really inspiring and I feel very much it’s about empowering ourselves, educating ourselves and then taking responsibility for ourselves to make some of these changes in our life. So thank you so much, Sabina, for having this time with me today and especially when you’ve got all the packing to do for the move, so.
01:22:29 Dr Sabina Brennan
I’ve got boxes all around me.
01:22:32 Dr Katy Munro
Good luck with that.
01:22:34 Dr Sabina Brennan
Thank you so much. It’s been lovely talking to you.
01:22:36 Dr Katy Munro
It’s been so lovely to meet you.
01:22:37 Dr Sabina Brennan
I have to say folks, you don’t get to see Katy’s face during this podcast, but she smiles all the time. And actually that’s just one final tip. People who smile more are considered more attractive.
01:22:50 Dr Katy Munro
I was told once by a patient when I was a GP in partnership years ago and she said do you know what we call you in the waiting room, doctor, we call you Doctor Smiley.
01:23:01 Speaker 4
Oh, that’s fabulous. That’s far better than going into a dour– You feel you can say so, you feel you can approach someone, which means you can tell them, you know, about things. I just wish I’d known it when I was a teenager. When all the rage was to stand with this puss on your face, like as if I’m unapproachable, you know? “It’s making me look gorgeous.” And you think you’d wonder why nobody came to ask you to dance? All you had to do was smile and people are drawn to you.
01:23:25 Dr Katy Munro
You know, hopefully, we’re going to see everybody who’s listened to this podcast on the streets now with either pencils in their mouths or just grinning broadly. So thank you so much, Sabina.
01:23:40 Dr Katy Munro
So I’m chatting today to Anna, who is somebody who’s had personal experience of brain fog. Thank you so much, Anna, for coming on the podcast. Can you introduce yourself please?
01:23:52 Dr Anna Maclean
Yes, of course. I’m Anna Maclean and I’m a GP or I was a GP. Well yes, I’m 58 and it was 8 years ago. I lost my job because of severe chronic migraine. Actually, at the time, I wasn’t even aware that chronic migraine was a disease or a condition. I had episodic migraine which progressed into severe chronic migraine and consequently I’ve never been able to work since, so it has affected me very severely to a stage where I just can’t function on many days, but at the moment I’m much better, which is why I’m here chatting to you today.
01:24:29 Dr Katy Munro
And I know that one of your missions has been to spread awareness of migraine and the fact that we are always banging on about migraine’s not just a headache. And that’s partly why we wanted to do this episode. So migraine comes with an awful lot of symptoms and brain fog I know for you has been particularly troublesome. What does brain fog mean to you personally?
01:24:51 Dr Anna Maclean
Yes, I think one of my bugbears really is for me, when I was sort of 13 to sort of 18/20/20, headache was the big thing. I think people recognise that migraine is a headache, which, yes, is my big bugbear. It’s not a headache, it’s a brain disease. And the thing that bothers me much more than the headache, especially as I’m getting older, all the other symptoms and the brain fog is huge for me in the sense that very often I just cannot function because my brain isn’t functioning and I suppose being a medic I laugh a little bit when I’m feeling positive in that I’ve done so much work on migraine in the last eight years that I know all the different phases and how the brain is affected by this disease and the non-functioning is so horrific that you know you can’t get downstairs really on some days because if your brain is not functioning, you don’t function, the whole of you doesn’t function so the brain fog… I mean the word in itself, you know, is that there’s no clarity, is there? There’s an inability to think. There’s an inability to decide. There’s an inability to concentrate.
And for me, being a chronic sufferer, so often my goodness most days I just have no life, really, and the brain isn’t processing information and that’s brain fog at its worst. I just have to curl up in a ball and I just sleep so in a way, my brain fog at its worst means the brain isn’t even sort of awake if you like. At its less severe I can’t drive because I can’t function well enough to drive, certainly can’t read, and everything is fuzzy and there’s no energy going through the brain. I’m aware that everybody’s brain fog is different. Some people, it’ll just be that they may be, don’t feel as sharp. But for me personally it’s completely devastating.
01:27:00 Dr Katy Munro
Yeah, I personally have brain fog sometimes when I have migraine attacks and for me, I feel as if it’s hard work to think. So I can think and I can concentrate, but it sort of takes an extra effort. Exhausting. And do you find that if you’re getting an episode of migraine, do you get the brain fog before you get the worsening phases, or do you get it throughout the whole thing? How long does it last for you?
01:27:31 Dr Anna Maclean
For me it’s the whole four phases have elements of brain fog throughout. It doesn’t come in one particular phase. It’s probably worse in the post-drome, in the fourth phase. I describe it very often as if I feel as if I’m wading through treacle, everything is harder. Everything takes longer. So whereas as a functioning GP I’ve been multitasking like a demon and then I could read a document in, you know 5 minutes, it could literally take me a week to read something that would normally take an hour because that my brain is just not processing things normally. So the most I would do on a brain fog day would be literally to tidy the kitchen and that would be it because my brain fog would be so bad I’d forget everything. I’d forget where I’d put things so I’d feel I’d achieved if I’d managed to tidy the kitchen. I mean that would be it. You know, that would literally be it. And then it was worse than that, I’d have to go and lie down, and worse than that, I’d be in bed because my brain… So I think I’ve probably got very severe brain fog and yeah, it wasn’t around any one part of the migraine, it would be around it all. Intermittently coming and going, affecting all aspects of my daily life.
01:28:49 Dr Katy Munro
Since and I’m very pleased to hear that you have improved recently on the days when you’re feeling a bit better. That’s to just give a message of hope. Do you feel that your brain fog is really manageable now or has it gone?
01:29:06 Dr Anna Maclean
Yeah.
01:29:06 Dr Katy Munro
On some — do you feel clear headed?
01:29:08 Dr Anna Maclean
Yes, I mean I’m on a concoction of medications, have layered in medications with the CGRP injections. I also take regular aspirin. And I’m also on topiramate, another known drug for migraine. The thing that helps me personally mostly with brain fog is aspirin. I know this. You know, research for aspirin and but that’s the thing that within 40 minutes of me taking aspirin, It’s not pain, but my brain clarity improves. And so I think that when migraines are well controlled, the brain fog improves. You know, generally. And so that’s what’s happened to me. So if my migraines are well controlled, which they are at the moment, there’s much less brain fog overall. But then if I’m having a bad day and I take aspirin. Then my brain fog improves. There’s absolutely no doubt about it. But that’s personal to me. But it has. I have known– You know, there are lots of other people I know. I think it’s about 52% of chronic migraine sufferers, aspirin can really help the sort of aura, fog symptoms, they’re not quite sure why that is but there are theories around that. Also, I find that all the lifestyle things also will help, the fluids, drinking plenty of water, you know, de-stimulating and all of that is what I try to do for the sort of non-functioning brain, which I kind of tie in with brain fog.
01:30:44 Dr Katy Munro
Sort of nurturing your brain with good lifestyle choices, with good nutritional choices, getting enough sleep. Yeah, all of those things.
01:30:54 Dr Anna Maclean
Yeah, I sort of feel that the brain is sort of screaming.
01:30:58 Dr Katy Munro
Yeah.
01:30:58 Dr Anna Maclean
It’s tired, it’s not functioning, and you get all these other physicals into the numbness and the pain and all of the auras, and then and then it’s just so tired. It just feels foggy. So you feel as if you’ve got to water it and rest it and anti-inflame it. So all I’ve read is, you know, you’ve got to do as much as you can nutritionally and fluids as well as medication and all of it has got to, you know, until you find the magical combination.
01:31:32 Dr Katy Munro
So just a quick caution to anybody listening about aspirin. Obviously, just be careful if you have any gastric irritation or have had a history of gastric ulcers to check with your GP if you want to try aspirin. But the other thing I wanted to ask you about and it was hormones. So HRT. And I know you know from what you’ve described that your migraine really kicked off in your 50s and we see a lot of women in clinic who are getting worsening migraine right from the very beginning of the perimenopause, which maybe is as young as 40 or even late 30s. So how important do you think getting your hormones sorted out has been to help with your management of your migraine and your brain fog in particular?
01:32:18 Dr Anna Maclean
Again, I think it’s absolutely essential. I think that I didn’t probably realise the time. My migraines went nuts when I was 45 and I’m lucky that I did see a migraine expert then. That was just very fortuitous, but at that point I had very heavy periods and then knowing me I was anaemic and I had hot flushes and sweats and everything. So I was put on good HRT because I happened to see somebody who knew about menopause, so I have luckily been on all of those, on HRT, but the more I’ve learnt the more I know that hormones are instrumental and triggering for chronic migraine. If it’s when you progress, maybe from episodic to chronic?
Something is driving that change and there’s a lot we do know, but there’s still a lot we don’t know. But you can’t deny that, we know we get migraine in adolescence, which is a trigger with hormones and something is happening around the perimenopause.
And what’s happening? There’s a big change in hormones. So I think it is incredibly important to get that checked and you know to stabilise your hormonal environment, you’ve literally got to try and look at everything and that is one area that is really important to look at. I mean, brain fog is a symptom of menopause.
01:33:50 Dr Katy Munro
Yes, absolutely.
01:34:01 Dr Anna Maclean
And a lot of menopausal symptoms are neurological symptoms when you analyse them. So a lot of them do cross over with the symptoms of migraine and it’s important to tease out what is what. But so to get your menopausal symptoms sorted can only benefit, you know what’s going on.
01:34:07 Dr Katy Munro
And I think that’s a good note to close our interview on, because I think both you and I are very conscious of the overlap between menopause and migraine and we’re talking about it all the time. And so if anybody’s listening, we have got some episodes on the perimenopause and migraine and possibly some more coming soon.
01:34:26 Dr Katy Munro
So thanks very much Anna.
01:34:28 Dr Anna Maclean
Thank you for having me.
01:34:31 You’ve been listening to the Heads Up podcast. If you want more information or have any comments, e-mail us on info@nationalmigrainecentre.org.uk. Till next time.
This transcript is based on a past episode of the Heads Up podcast and reflects information available at the time of broadcast – some facts may have changed or new treatments become available since.
Our factsheets provide general information only. They are not intended to amount to medical advice on which you should rely or to advocate or recommend the purchase of any product or endorse or guarantee the credentials or appropriateness of any health care provider. No material within our factsheets is intended to be a substitute for medical advice, diagnosis or treatment. You must obtain professional or specialist advice before taking, or refraining from, any action on the basis of the content on our factsheets. Do not begin a new medical regimen, or ignore the advice of a medical professional, as a result of information contained within these factsheets, our website or from any of the websites to which we may link. Although we make reasonable efforts to update the information on our factsheets, we make no representations, warranties or guarantees, whether express or implied that the content on our factsheets and website is accurate, complete or up to date. Any hyperlinks or references are provided for your convenience & information only. We have no control over third party websites and accept no legal responsibility for any content, material or information contained in them. The information provided in this factsheet does not constitute any form of legal advice and should not be treated as a substitute for specific legal advice. It is not intended to be relied upon by you in making (or refraining from making) any specific decisions. We strongly recommend that you obtain professional legal advice from a qualified solicitor before taking or refraining from taking any action. You may print off, and download extracts, of any page(s) from our website for your personal use and you may draw the attention of others within your organisation to content posted on our site. You must not modify the paper or digital copies of any materials you have printed off or downloaded in any way, and you must not use any illustrations, photographs, video or audio sequences or any graphics separately from any accompanying text. You may not, except with our express written permission, distribute or commercially exploit the content.