S2 E2: Migraine past, present, future

A National Migraine Centre Heads Up Podcast transcript

Migraine past, present, future

Series 2, episode 2

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[00:00:00] Did you know migraine has been around for thousands of years. This is not a new condition. Welcome to the Heads Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.


Dr. Jessica Briscoe [00:00:19] Hello and welcome to the second episode of season two. I’m Dr. Jessica Briscoe and I’m here with Dr. Katy Munro.


Dr. Katy Munro [00:00:25] Hello.


Dr. Jessica Briscoe [00:00:26] And we’re doing a special episode today on the Past, Present and Future of Migraine. So we’re joined by three special guests today. First of all, we’ve got Dr. Mark Weatherall who’s a consultant neurologist and chairman of the BASH Council.


Dr. Mark Weatherall [00:00:40] Hello. Hi.


Dr. Katy Munro [00:00:42] We’ve also got Dr. Katherine Foxhall, who is a historian and the author of a book called Migraine; A History.


Dr. Katherine Foxhall [00:00:48] Hello.


Dr. Jessica Briscoe [00:00:50] And we’ve got Izsi Lawrence who’s presenter of Radio Four’s Making History, the British Museum member cast and author of The Unstoppable Letty Pegg.


Iszi Lawrence [00:00:58] Hello.


Dr. Katy Munro [00:00:59] So where should we start? I think we probably should start back in the darkest, deepest times of early Roman times. So Kat, can you tell us when do people first start thinking that there was such a thing as migraine?


Dr. Katherine Foxhall [00:01:13] Well, one of the long questions is whether or not migraine is even a kind of feature of humanity, whether it’s something that is just inherent to the human condition. But the first written evidence we have of people talking about the thing that they understood to be migraine was in around the second century A.D. And we have the famous physician, Roman physician Galen, and he described Hemicrania, and that literally means half the head. And he talked of a very powerful disorder that was caused by evil vapours or bad vapours or excess vapours rising up from the stomach and getting trapped in the head. And he recommended a whole host of treatments for this, primarily consisting of herbal remedies and bloodletting to get rid of the bad humours. So this is based on this humoral system which understands illness as a imbalance or trapped, bad humours within the body.


Dr. Katy Munro [00:02:17] And they used to talk about four different humours, didn’t they? I can never remember what they are. There’s a black one.


Iszi Lawrence [00:02:24] It’s easy. Black, yellow, that’s the bile.


Dr. Katy Munro [00:02:26] Red.


Iszi Lawrence [00:02:26] Red is blood. And phlegm. The most important thing. Any child will tell you that is a vital, important part of the body.


Dr. Katy Munro [00:02:34] We don’t see a lot of phlegm in a migraine clinic…


Dr. Jessica Briscoe [00:02:36] Depends on the time of year.


Dr. Katy Munro [00:02:36] But the trapping of the humours in the head is a very interesting concept. And that kind of- you’ve talked about a gut-brain connection already and we know that there is a big link. The other thing that you’ve mentioned, which I’m aware of, is that we- Jessica and I say ‘my-graine’ . But Galen said hemicrania so really we should be talking about ‘mee-graine’.


Dr. Katherine Foxhall [00:03:00] Well, this is probably the question I am asked most often about ‘mee-graine’ slash ‘my-graine’ as to what we should call it. Now, I always grew up- I grew up in Devon and my mum always said ‘my-graines’. So I’ve always said ‘my-graine’. I think I probably switch depending on who I’m talking to. But really the reason I think that we tend to use ‘mee-graine’ is more because up until about the 18th century in England we use the English term megrim. But in the 18th century, physicians started to adopt the French ideas of ‘mee-graine’, as well as the terminology. And in the 19th century, there was a very well-known physician called Dr. Liveing who tried to, kind of, revive in this kind of patriotic way this use of the English term megrim and everybody ignored him, which is why we tend to use the French term ‘mee-graine’ now. So I guess technically we should probably all say ‘mee-graine’, but.


Dr. Katy Munro [00:03:57] Basically, it doesn’t really matter as long as we know what we’re all talking about.


Dr. Jessica Briscoe [00:04:00] And I think trying to stay with a- I tend to switch like you, depending who I’m talking to, I’ll say ‘my-graine’ or ‘mee-graine’ and actually probably just sticking with the same one every time you’re saying it is probably more important than switching. So I probably need to remember that a bit more.


Dr. Katy Munro [00:04:13] One of the things that I wanted to ask you about, which I think I’m guilty of putting out false information on some of our social media, was the trepanation.


Dr. Katherine Foxhall [00:04:23] Yes.


Dr. Katy Munro [00:04:23] The trepanation as a treatment for migraine was something that we- I certainly believed until I read your book!


Dr. Jessica Briscoe [00:04:30] Yeah. And we’ve definitely talked about it in the podcast actually so, sorry.


Dr. Katherine Foxhall [00:04:34] This is where I’ll start banging the table, because trapanation is the hill that I am prepared to die on. And we have no evidence that trepanation is ever used. And in fact, the idea that trepanation is used for migraine comes solely from a physiologist, a Victorian physiologist, called Lauder Brunton. Dr. Lauder Brunton. And there’s lots of fascination in the late Victorian period of digging up all these skulls in France and in other countries all around the world, and they’re finding these skulls that not only had holes drilled in the skulls but evidence that the holes had started to heal, which meant that these holes hadn’t been drilled in death, they’d been drilled while the person was alive. So the question is, well, why would you drill or cut- sometimes they’re quite square, beautifully square holes. Why would you cut these in someone’s head? So the theory was and this is the time when everybody’s getting obsessed with brain surgery, you know, the possibilities of the new knowledge about the brain and the possibilities of curing illnesses in the brain and of looking for lesions in the brain in the Victorian period so they’re getting really excited about brains. And one of the theories was, well, these skulls, the holes must have been cut in them to let demons out to cure something like epilepsy. But then they’re like, ‘but we’re finding a lot of these skulls so it must have been something more common then’. So one of the ideas then that Thomas Lauder Brunton comes up with, he’s like, ‘look, everybody knows when you have a migraine, all you want to do is drill a hole and let it out. So maybe trepanation was a migraine’. And from that idea, I mean, he makes this argument in a journal article and actually the journal article is hilarious because he also says that the reason people believe in fairies is it’s to do with the auditory hallucinations of migraine.


Dr. Jessica Briscoe [00:06:23] So fairies are because of migraine?


Dr. Katherine Foxhall [00:06:26] Yes. So when you put that together almost in kind of paragraphs next to each other and then he’s saying, ‘oh, also, these trepanation must be because of migraine’. It actually starts to become a bit silly.


Dr. Katy Munro [00:06:38] But what were they doing? If it’s not migraine and it’s not something- surely logically to me it seems perfectly reasonable that that’s a- because otherwise ‘ oh, let’s just randomly cut holes in people’s heads really neatly’.


Dr. Katy Munro [00:06:50] Also, if they thought things were trapped in the head with the humours and things like that you kind of-


Dr. Katy Munro [00:06:55] Well, this is before the humours, isn’t it?


Dr. Katy Munro [00:06:57] Oh, yes. This is much more ancient.


Dr. Katherine Foxhall [00:06:59] These are ancient skulls. And I think the point is that we really don’t know.


Dr. Katy Munro [00:07:01] We don’t know.


Dr. Katy Munro [00:07:02] Crazy.


Dr. Mark Weatherall [00:07:03] But the other thing about the humours is that the nature of the humours that we call blood and phlegm are not the things that we see these days as blood and phlegm. They’re more of a sort of concept, an idea. And the point about the humours is that the problem is not necessarily that they get trapped, but they are in excess. They are not mixed properly in different parts of the body.


Dr. Katy Munro [00:07:26] So the balance is wrong.


Dr. Mark Weatherall [00:07:27]  The balance is wrong. So hence, bloodletting is to get rid of excess blood and as you say, the whole of the trepanation is something that is, you know, tens of thousands of years before any of these theories and we have not a Scooby Doo what trepidation is all about. Everything is pure speculation.


Dr. Katy Munro [00:07:47] I just want to say that all the kids listening who are picking their noses right now, you’re doing the right thing.


Dr. Katy Munro [00:07:54] Clearing things.


Dr. Katy Munro [00:07:55] Exactly. The balance.


Dr. Katy Munro [00:07:58] It may have been- I suppose it could have been religious or it could have been some sort of ritual or anything couldn’t it?


Dr. Katherine Foxhall [00:08:04] It could have been but the really the point is is that we have absolutely no evidence that it’s ever used for migraine.


Dr. Katy Munro [00:08:07] So somebody musing about what it might have been then got taken to be the gospel truth about what it was with no evidence.


Dr. Katherine Foxhall [00:08:14] Yes. I mean, he was a prominent physiologist and his ideas got picked up and they got reported and it went from, you know, supposition to people assuming that that was what happened. And then by the 1930s, it’s being repeated absolutely as medical fact.


Dr. Katy Munro [00:08:32] So you are really an evidence based historian where we are evidence based physicians. That evidence of things working or having been actually why they were done is very important isn’t it?


Dr. Katherine Foxhall [00:08:45] And I think that’s part of the difference in my approach as a cultural and social historian who’s trained as a historian rather than as a physician, is to say, instead of using our knowledge now, what do we know about migraine and what is our neurological knowledge and can we find examples of that in the past? Is to say, actually, what did people in the past think when they used the word hemicrania or megrim or ‘mee-graine’ or, you know, ‘megran’ in Wales, what were they actually doing and why were they, you know, why were they putting earthworms on people’s heads? Why were they using these herbs? What did they think migraine actually was? And what does that tell us about not only how our knowledge comes to be, but also, how does that history take in history on its own terms? How does that help us take migraine seriously? Which is kind of what I was trying to do with the book.


Dr. Jessica Briscoe [00:09:44] And it’s also quite interesting because I do get asked a lot ‘Why do I have migraine? Why has it come?’ We always say, ‘well, it’s genetic. You know, it runs in families’. People say, ‘but I don’t understand why’. And actually, if you look at the patterns in history, it can sort of help you to even figure out why a little bit. We don’t know why people have migraine, but we don’t really know why anyone has any medical condition in truth. But I still think it’s quite interesting to look back and try and find out what people did because it does inform what we’re doing now and whether things are likely to work or not.


Dr. Mark Weatherall [00:10:14] It’s also- I mean, history teaches a bit of humility because these people in the past, although it seems weird to us some of the stuff that they believed and they did. They were no less intelligent than any of us. They are just using the knowledge they have at the time to try and interpret what they saw and to try and do the best they could for the people in front of them. The same as we do now. And we have a tendency to sort of think that, you know, the modern age is somehow special in a way, somehow much better at understanding these things and that treatments are, you know, somehow much more, you know, quote ‘evidence based’ but actually, all of these treatments were ‘evidence based’. It’s just the nature of the evidence that has changed. And it’s quite likely that future historians, looking back in a couple of hundred years time, will look at us and go, ‘wow, these people were sticking toxins in people’s heads. How peculiar and how weird is that? Why didn’t they know about X, Y or Z?’.


Dr. Katy Munro [00:11:02] Yeah.


Dr. Mark Weatherall [00:11:02] So history is really important, you know, I think for society generally and specifically for the medical profession, because it acts as a very useful counterbalance to the, if you like, the sort of triumphalism of science.


Dr. Katy Munro [00:11:19] I don’t know. I mean, has anybody around this table ever got a clay crocodile, stuffed its mouth with grain and strapped it to their head? I think that’s what ancient Egyptians did for headaches. Do you do that?


Dr. Katy Munro [00:11:32] If it works?


Dr. Katy Munro [00:11:33] Because ancient Egyptians, you know, words were magical. This is why you have so many- if you go into an ancient Egyptian like, you know, thing so many of them have their noses cut off. And that isn’t- it’s literally because they want to stop the spirits from breathing.


Dr. Katy Munro [00:11:46] Right.


Dr. Katy Munro [00:11:47] So it’s a literal thing. Like they’d never- they have euphemisms of serpents and things like that because you don’t want to actually carve a serpent because it’s too powerful. So what they would do is they’d write the name of the Gods round a bandage and wrap it around your head, which apparently might have worked according to some people, because it restricts, you know, the blood vessels there and gives you that- I don’t know. Maybe. Maybe if you’re suffering right now putting like a nice tight bobble hat on or something.


Dr. Katy Munro [00:12:12] Well we do that, yeah.


Dr. Jessica Briscoe [00:12:13] Yeah.


Dr. Katy Munro [00:12:13] You do do that? Yeah?


Dr. Katy Munro [00:12:15] We have patients who say, ‘I really find it helps if I press in my head’.


Dr. Katy Munro [00:12:19] Well there you go.


Dr. Jessica Briscoe [00:12:19] It’s a biofeedback thing, isn’t it?


Dr. Katy Munro [00:12:19] So yeah, a lot of these things- but then we have the other thing which is a thing called allodynia, which is where patients have got more severe, perhaps more chronic migraine and they get really sensitive scalp and they can’t bear anything to pull or touch their head. So it depends on how severe it is, I guess, as to whether that would help or not.


Dr. Katy Munro [00:12:40] I just think for me it would just be put it on right over my eyes.


Dr. Katy Munro [00:12:43] Yeah.


Dr. Katy Munro [00:12:45] Just complete darkness, please.


Dr. Katy Munro [00:12:47] Yeah, shut out the light.


Dr. Katherine Foxhall [00:12:48] One of the examples I’m always asked about is again and again and again in the 17th century recipe book. So we have all these wonderful recipe books which are kind of family collections of veterinary and medical and culinary recipes. You know, they’re handed between families and one of the common remedies that I’ve found quite a lot was making these earthworm plasters. You’d kind of mash them all up and you’d mix them with some herbs that you grabbed out of your garden and you put it on a cloth or a piece of leather, and then you’d wrap it around your head. And for ages I was thinking, ‘Why on earth?’ And for ages I thought that the earthworms were simply- because they often used egg as well- I often thought that the earthworms were just the kind of- the stickiness that would help it stick and actually that it was the herbs that were the product or the…


Dr. Katy Munro [00:13:36] The active ingredient?


Dr. Katherine Foxhall [00:13:38] The active ingredient to counteract. So they’d often use hot and dry herbs, things like sage and rosemary, which are also quite perfumed, but to counteract what they understood to be the cold and wet humours causing the migraine. So for ages I thought it was just the herbs that were the main ingredient. And then I found an explanation, which was that- by another author who said, ‘Well, all of these- why do we use creatures of the Earth in medicines?’ And what she said was, ‘if you look at things like wood lice and earthworms, their job in life is to deal with rotting matter, and putridity in the ground. So why wouldn’t they? It’s perfectly logical. And why would they in death have a similar function if you put them on your head?’ The idea of drawing out something putrid and rotting within the brain. So as Mark says, it’s not that they’re stupid and they’re no less intelligent than us, but their logic and their evidence and their argument is unfamiliar.


Dr. Katy Munro [00:14:38] Of the time.


Dr. Katherine Foxhall [00:14:38] And it’s easy for us, you know, to laugh at. But for me, what I found particularly fascinating, particularly with these recipe books in the 17th century, there’s hundreds of them. But I thought, actually, do you know what these people are doing is they’re simply taking migraine seriously. I think all of these recipes which say if someone comes to you with migraine or if you have a migraine, here is how you treat someone and you lie them down and you put them in a dark room and you wrap something around their heads and you care for them. And actually. For me, it was simply the evidence of people taking migraine seriously in the past that actually, I found really important and kind of powerful in a way that actually we sometimes tend not to do in our modern culture.


Dr. Katy Munro [00:15:19] Yeah, so they didn’t just say pat them on the back and say oh, it’s just a headache, off you go back to the fields or whereever they were working. They actually cared for them.


Dr. Katherine Foxhall [00:15:27] No, exactly. They had some really powerful explanations for what migraine was and why it was there.


Dr. Mark Weatherall [00:15:34] And from the point of view of actually the history of medicine more generally, so much of the history of medicine is written as the sort of history of great men and it is nearly always men. And actually so the type of history that Katherine’s written in this book is really refreshing because actually it’s what Roy Porter called, sort of, doing medical history from below. It’s actually the history of ordinary people and their ordinary problems. And so we get sort of very fixated on, you know, certain aspects of history and sort of, you know, great diseases and typhoid and cholera and all of these things. But people still had these conditions. People still had to toothache, they still had migraines. They still had, you know, gout and arthritis and all of these things. And it’s all there. And people did take them seriously. And again, you know, coming back to the present day, one of the things that we struggle with when we’re trying to talk about migraine in society generally is the fact that it’s an invisible disease. It’s not taken seriously. And so to, you know, to have a demonstration of how people were trying to deal with this and that this is actually, you know, almost a universal part of human experience that people have grappled with for centuries is really important and really helpful.


Dr. Katy Munro [00:16:48] The view changed, didn’t it? One of the things I took from the book was that, you know, in medieval times perhaps, they took it very seriously but then as time went on, perhaps into the 17th, 18th centuries, they began to almost be sexist about it? That women were flaky, neurotic.


Dr. Katy Munro [00:17:07] We do complain a lot.


Dr. Katy Munro [00:17:12] It was always the men who were very bright.


Dr. Katy Munro [00:17:14] We complain in such high voices. It’s very irritating.


Dr. Jessica Briscoe [00:17:18] I definitely got that. That was something I took away. The, sort of, fact that it became seen as a hysterical problem a bit which is also a phrase I have issues with anyway.


Dr. Katy Munro [00:17:29] Doesn’t your uterus wander around all the time? Mine does all the time, I get proper narked.


Dr. Jessica Briscoe [00:17:34] I mean, obviously it’s known that- I mean, statistically, more women get migraine than men anyway. But there is that sort of idea that it’s- you wonder if that’s why it’s not taken as seriously. I mean, as you said, it’s not something- it’s very common, but it’s not something that will kill you necessarily.


Dr. Katy Munro [00:17:49] Hopefully.


Dr. Jessica Briscoe [00:17:50] Hopefully not. But you do wonder if part of the reason is because it does affect women more. I don’t know if that is something that’s been shown a lot?


Dr. Katherine Foxhall [00:18:01] Oh, I could talk for days. We could be here til April.


Dr. Katy Munro [00:18:03] I said you were all going to stay the night.


Dr. Katherine Foxhall [00:18:07] Yeah, certainly so ideas about migraine start to change in the 17th and 18th century. You get the emergence of new knowledge about the causes of disease, and particularly locating many diseases in the nervous system. So migraine starts to become associated with diseases of the nervous system and therefore of nerves as well. It’s really only in the late 18th century that we start to see people or we have evidence of- which is not to say that it’s not been ridiculed before, but it’s really in the 18th century we start to see clear evidence of this happening. And interestingly, it’s not- the first evidence I found is not that it’s women who are being joked about in terms of migraine, but it’s the French. So in the late 18th century they’ve got all kinds of dangerous ideas coming over from France. And actually the French papers start to talk about how, you know, people with migraine. And so there’s this report in the English paper, about, ‘oh, half of Paris has the migraine’.


Dr. Katy Munro [00:19:06] Is that just a joke about, you know, the guillotine and curing them? Because it’s the same time it’s coming in.


Dr. Katy Munro [00:19:14] That’s one cure isn’t it.


Dr. Katherine Foxhall [00:19:17] So the first evidence I have of people not taking migraines seriously is associated with these kind of dangerous French ideas coming over, political ideas. But of course, actually in the late 18th century, it’s the French physicians who actually got the most advanced knowledge about migraine anyway. So then physicians start to actually adopt continental knowledge about migraine. And that’s when you start to see it becoming a neurological illness. The continental physicians are the first to talk about aura in any kind of meaningful, consistent way. So then why does it come to be associated with women? This is one of the things I was mainly interested in and it is because of this association with nervous diseases, with hysteria, the late 19th century, it’s to do with discussions about neurasthenia. So migraine starts to be seen as this kind of gateway to neurasthenia as part of this spectrum of problems.


Dr. Katy Munro [00:20:13] Explain neurasthenia to those of us who are-


Dr. Katherine Foxhall [00:20:16] Neurasthenia is just this kind of archetypal late 19th disease of modernity and urban American cities and luxury and work.


Dr. Katy Munro [00:20:27] Burnout.


Dr. Mark Weatherall [00:20:29] It’s essentially the sort of late 19th century equivalent to chronic fatigue syndrome. So it’s a sort of ennui, you know, fatigue, headaches but as Katherine says, it is framed as a disease caused by modern life.


Dr. Katy Munro [00:20:49] Millennial burnout is what I’m thinking of. Yeah.


Dr. Katy Munro [00:20:54] So was it typified by the sort of the smelling salts era, you know, and-.


Dr. Katy Munro [00:20:58] That’s a bit before isn’t it?


Dr. Mark Weatherall [00:21:02] It’s quite interesting because what you’ve got alongside all these sort of developments in the sort of medical literature, you’ve also got, you know, migraine starts to become present in literature generally. And it’s a sort of trope of migraine as a female condition. And there’s a marvellous line in one of the Wilkie Collins novels where he writes of his heroine, he said that ‘she takes to bed with a headache, which of course was a heartache in disguise’. And actually, Collins is fascinating because he was- you know there’s a marvellous biography of him. He was quite an ill man for much of his life. Now, the biography doesn’t mention migraines, but I think he must have had migraines because migraines are everywhere in his writings. And he uses them as plot devices to sort of get his characters away from each other at certain points. So somebody goes off with a migraine so that they don’t meet people at a point and then they meet them later on. And there’s all sorts of stuff going on. And you see this. I mean, there’s a little bit of sort of Jane Austen and even earlier in Richardson right at the end of the 18th century. So there’s a lot of this idea of, you know, migraine as something that is used by people perhaps  particularly women.


Dr. Katy Munro [00:22:20] As an excuse.


Dr. Mark Weatherall [00:22:20] As an excuse. And you know, you see that starting to appear particularly in the middle of the 19th century. So this is all going along sort of in parallel with these evolving medical ideas of what migraine is all about.


Dr. Katy Munro [00:22:35] Could it also be as well that, you know, at the time, certainly in Victorian England, you didn’t want to have period pain infront of anybody or a miscarriage or anything like that. You couldn’t even admit to being pregnant, that was, you know- in the family way was not a done thing to say, let alone to admit anything like that. So it could be as well that if you are suffering with anything, you know, below the waistline that was causing you discomfort, then maybe you’d say you had a headache because that’s easier than saying, ‘by the way everybody I’m bleeding and it hurts’.


Dr. Katy Munro [00:23:02] Yes. It’s not socially acceptable.


Dr. Katy Munro [00:23:06] Exactly.


Dr. Katy Munro [00:23:07] But it’s more socially acceptable to say ‘oh, I’m going to go and have a lie down with a headache’. And of course, you probably did have a headache with your period then.


Dr. Katy Munro [00:23:14] Oh, yes,.


Dr. Katy Munro [00:23:16] Because of the menstrual links that we know about now much more. And also, there weren’t really any very good drugs to be treating them with.


Dr. Katy Munro [00:23:24] Well, no. There was laudanum. I’d have been up on that!


Dr. Katy Munro [00:23:25] There was but that’s not good.


Dr. Katy Munro [00:23:27] Oh well no, not for headaches, but for the rest of it, you know, you think a bit of opiate surely.


Dr. Katy Munro [00:23:33] They did used to use cannabis, didn’t they?


Dr. Katy Munro [00:23:35] Oh nice, yeah.


Dr. Katy Munro [00:23:35] They were quite keen on a bit of cannabis weren’t they?


Dr. Katherine Foxhall [00:23:38] Well certainly by the late 19th century.


Dr. Katy Munro [00:23:41] Yeah.


Dr. Katherine Foxhall [00:23:42] So one of the other developments that’s going along in parallel, along with changing ideas about nervous diseases and about who gets certain kinds of diseases and nervous diseases appearing in literature is the divergence between what is lay knowledge of medicine and professional knowledge of medicine. So rather than, you know, much of the knowledge we get from the 17th century, we have astrologers records and we have bloodletting and we have newspaper advertisements. Much of the knowledge we have from 17th century is the same, whether it’s coming from physicians or from ordinary people. By the 19th century, what you have is professional knowledge, and it’s also becoming increasingly specialised. So into neurology and psychiatry, different branches of medicine and the knowledge that ordinary people have is increasingly seen as unreliable or is dismissed. So it’s in the context of these kind of new specialised medicines that you start to get things like therapeutic experiments with substances like cannabis. So one of the main cannabis experiments I found on migraine actually takes place in the Sussex Lunatic Asylum where, you know, it just happened that the asylum physician was kind of into migraine and there’d been lots of discussion about the use of cannabis for various mental illnesses. And one of the reasons was because it was seen as suitable for children because it was kind of mild and calming. The idea was that you could kind of calm people down without using physical restraint, which is kind of problematic in moral terms. So cannabis comes to be seen as kind of the great hope for curing migraine in the 19th century.


Dr. Katy Munro [00:25:28] This is very fascinating because of course, we are quite often asked about cannabis oil now by patients. But back in the day, what sort of cannabis would they’ve been doing? Would they have been growing it in the little herb garden and smoking it or chewing it?


Dr. Katy Munro [00:25:44] There’s quite a big industry?


Dr. Katy Munro [00:25:45] Powdering it up and giving it to the patients that way?


Dr. Katy Munro [00:25:48] Before they were making paper and stuff they used to use cannabis as well to make paper and things like that and hemp. It was a big industry, so I would imagine it would have been quite easy to get from a druggist and that sort of thing.


Dr. Mark Weatherall [00:26:01] Yes. I mean, it’s from India, from the Indian subcontinent. I mean, cannabis is kind of discovered in quotes by ‘William O’Shaughnessy’ in the 1840s and, you know, he’s a physician who writes about the use of cannabis for various conditions, including, you know, some of the big infectious diseases, typhoid and cholera. And then it’s brought back into England and the United Kingdom. You know, a bit like chloroform, it gets this sort of mark of approval when the royals, you know, let it be known that they’re using it and getting on with it. And it was big business. And if you know, any pharmacopoeia, any textbook that includes medical treatments for headaches and migraine all the way up to the 1930s will include mentions of cannabis, indica and sativa products. There’s a marvellous book that I have, which is one of the first books about aeroplane medicine written just after the First World War by somebody that had looked after the pilots in the original, sort of, Royal Air Force. And the author talks about some about the headaches from changes in barometric pressure and the exhilaration that aeroplane flight brings, which he likens to a glass of good champagne. But again, he talks about, you know, cannabis as a treatment for these types of headaches that are created by, you know, rapid ascent or rapid descent. So if you’re being chased by the Red Baron. So, you know, it’s all there until the prohibition movement in the States in the 1930s move on from alcohol to other drugs and that sort of domino effect leads to cannabis being, you know, essentially denigrated as a potential, you know, medical treatment all the way through to just about, you know, now.


Dr. Katy Munro [00:28:07] So we’re hearing a lot in the news about it, certainly for epilepsy and in some people for multiple sclerosis. What do you feel coming into the present about cannabis? What do you feel about it as its usefulness for migraine sufferers now or in the future?


Dr. Mark Weatherall [00:28:20] So I think, this has now sort of started to come back into medical practise, really since the discovery by the Israelis of the sort of endocannabinoid system so, you know, the body is full of endocannabinoids, which are similar chemicals to those that are found in the cannabis plant. And the receptors for those chemicals are more widely distributed within the brain and the nervous system than any other receptors at all so they’re very important. And we know they’re important in pain processing and they also seem to have other properties. So, you know, recently certain cannabis products, particularly containing CBD, have been approved for certain rare, devastating epilepsy types in children and adults. And cannabis products have been used for pain and spasticity in multiple sclerosis for the last 20 years or so. In terms of headache disorders, there is a lot of use and very little data. So if you talk to the Canadians or the Europeans and if you look at some of the registry data they have, there’s a lot of people out there who are using cannabis for headache disorders, including migraine. But actually there’s very, very few trials. And one of the reasons for that is it’s actually quite difficult to do trials with cannabis because it’s a plant based product and therefore you either have to do trials with isolates of CBD and/or THC, or you do trials with whole plant extracts. Now the Israelis in particular will tell you that the whole plant extracts work better because of this thing they called Entourage Effect. And that’s the THC and CBD effects are improved by the presence of other chemicals that are found in the plants, the turbines and the flavonoids. And these interestingly coming back to things like sage and the perfumed things that we were talking about, these are the chemicals that give the cannabis plants their different flavours, the sort of pine flavour or the rosemary flavour or the lemon flavour. And, you know, if you go on the sort of big American or Canadian websites, they’ll tell you that certain sort of strains are better for headaches than others. So there are a few small trials and lots of case reports. And I think this is an area where, you know, we really need more information. And if we’re not going to get clinical trials, then we need registries, you know, where people are starting to prescribe cannabis products.


Dr. Katy Munro [00:30:40] And the legal status in this country makes it difficult to have trials approved I would imagine, is it?


Dr. Katy Munro [00:30:46] Well you could use CBD, CBD oils.


Dr. Mark Weatherall [00:30:49] The problem at the moment is that the over-the-counter CBD oils are quite unreliable. There are some nice studies that show that they almost always don’t have what they say in the tin. So I think, the way forward is going to be, I think for probably rather than clinical trials, is probably for registries where people are prescribed cannabis based products to have a registry of what happens. And as long as, you know, they’re properly diagnosed and followed up, then that will provide some data. And it may be that actually cannabis won’t work hugely well for primary headache disorders or it may be that it will, but at the moment, we just don’t know enough.


Dr. Katy Munro [00:31:28] We just don’t know. But we do have patients who come and say, ‘well, I bought this off the Internet and I’m trying this and I’m trying that’ and asking our opinion quite frequently.


Dr. Jessica Briscoe [00:31:37] And I always find it very difficult because of what you said, the difference between what’s actually on the packet and what it says. I know there’s huge differences between different products, the percentages of each type of isolate that it’s got in it. And we don’t particularly know which bits of the cannabis plant are good for migraines. So I always find it very, very difficult to advise them for that reason.


Dr. Katy Munro [00:31:58] Yeah, we tend to be very cautious. I mean, the other thing, we’re always banging on to patients, which used to be a popular drug in those days with the opiates back in the Victorian Times. And of course, we are now trying hard to get people off opiates and there’s big news about opiate crisis in the US and of course in the UK as well. So why were they- were they using that for headaches in Victorian times and was that a more popular thing than the cannabis or the other herbal remedies, Kat?


Dr. Katherine Foxhall [00:32:37] Yeah, I mean, opiates and drugs with sedative properties have been used for migraine for hundreds/thousands of years. So some of the earliest texts we have from the 9th century from Arabia actually use spikenard or nard. Now you see spikenard then used all the way through medieval remedies you find in 15th century remedies and spikenard is the same botanical family as valerian. And then in the 18th century they start using valerian. And of course, the physical effect of these things is as a sedative. And so, again, it comes back to us kind of looking at past knowledge and we can be really sniffy about it but actually, if you’re looking for the effect of something, then something that has a sedative effect. So something like valerian, which you can still buy as an extract I believe.


Dr. Katy Munro [00:33:29] You can buy herbal teas.


Dr. Katy Munro [00:33:31] You can get teas.


Dr. Katy Munro [00:33:32] Yeah.


Dr. Katy Munro [00:33:31] My cats love them. If you’ve got cats, valerian root, they going nuts for it.


Dr. Katy Munro [00:33:36]  You can get a mixture of valerian and other herbs for sort of night-time helping you with your insomnia. But I have to say, I think you have to infuse it for quite a long time to get any active extracts out. Doesn’t work for me.


Dr. Katherine Foxhall [00:33:47] But we can trace the use of that stuff, you know, for hundreds, if not thousands of years.


Dr. Katy Munro [00:33:51] Yeah.


Dr. Katherine Foxhall [00:33:52] It’s really fascinating so yes, we’ve been using opiates for a long time. I guess the current problem we have, though, is with the political and financial and social context in which opiates are being used, unprescribed and made accessible or not and who they are made accessible to and who they aren’t.


Dr. Katy Munro [00:34:11] So from a migraine point of view, it’s also the problem that they do seem to aggravate and transform migraine.


Dr. Katy Munro [00:34:20] Do they? That’s interesting.


Dr. Katy Munro [00:34:20] Yeah, they transform migraines very easily from episodic into chronic migraine. And you can buy them over the counter as marketed for migraine so we are slightly campaining-


Dr. Katy Munro [00:34:29] Codeine sort of things?


Dr. Katy Munro [00:34:30] Yes and migraleve and codeine compounds.


Dr. Jessica Briscoe [00:34:33] It’s not particularly clear to people as well that it’s a codeine based products. And I think people, if something is marketed as a migraine treatment, people will buy it or people will advise it for obvious reasons.


Dr. Mark Weatherall [00:34:45] But I mean, the issue of analgesic overuse headaches, I mean, that appears in the literature, you know, 100 years ago, around the 1920s, if you look at the Ralston’s Encyclopaedia of Medicine, there’s a whole section there on the effects of taking too many painkillers on headaches.


Dr. Katy Munro [00:35:09] What painkillers would they have been taking?


Dr. Mark Weatherall [00:35:11] Well, so that would- there would have been opiates. Then, obviously, what you’ve got around the turn of the century is an explosion in pharmacology and then pharmaceuticals. So you get the introduction of anti-inflammatories, so you’ve got Bayer’s aspirin, you’ve got the precursors of paracetamol and it’s quite interesting because actually in different parts of the world, you have different sort of flavours of how people take these things. So if you go to the southern United States, for example, everybody takes powders, you know, there are aspirin powders or anti-inflammatory powders, people don’t take tablets, it’s all powdered. And, you know, in other parts, it’s tablet based. So you get a increasing mixture or set of options. In Britain, you’ve got the Gowers’ mixture, which is an interesting concoction that includes things like bromide, it’s got GTN, trinitrate in it, which of course…


Dr. Katy Munro [00:36:18] That makes headaches worse!


Dr. Mark Weatherall [00:36:20] Interestingly, we use as a tool in headache research to set off migraines in people. There’s actually a lot of stuff out there. There’s a lot of options out there. And, you know, again, pretty much every book you read will have a slightly different set of preferred treatments. And then a lot of that calms down with the development of more set national formularies. So the FDA in the States and the sort of the equivalents in Britain and Europe start to hone things down into a set of drugs that are approved and licenced for various treatments. And so you get to the situation, you know, in the fifties and sixties where, you know, you have aspirin and ibuprofen coming through in some of the anti-inflammatories and opiates. And then, of course, what you do have from the 1920s onwards is ergotamine and the ergots. The first reports I think go back to the late 19th century but really as a marketed drug.


Dr. Katy Munro [00:37:24] Ergotamine?


Dr. Mark Weatherall [00:37:25] Ergotamine.


Dr. Katy Munro [00:37:26] These things, I mean- I thought ergot was that sort of mould that turns villages mad.


Dr. Mark Weatherall [00:37:31] Yeah exactly.


Dr. Katy Munro [00:37:32] Ok that’s the same thing?


Dr. Mark Weatherall [00:37:33] It’s full of exciting stuff!


Dr. Katy Munro [00:37:35] They think the witch trials of Salem were all done because of ergot roots. Ergot got into all of the wheat and that sort of thing so they were eating this bread that was laced with it. They all had hallucinations and that’s why they accused all of these women for being witches.


Dr. Katy Munro [00:37:51] Interesting!


Dr. Mark Weatherall [00:37:51] And the sort of dancing madness in medieval Europe. But ergot is full of interesting stuff so you’ve got ergotamine which is migraine treatment and ergometrine which is what you inject women with to encourage the delivery of the placenta in the first stage of labour. So there’s all sorts of stuff in there, but ergotamine is used as a migraine treatment and is, you know, a pretty effective treatment all the way through. The problem with it is it’s a dirty drug and it has nasty adverse consequences.


Dr. Katy Munro [00:38:27] You might end up dancing.


Dr. Katy Munro [00:38:28] I think they’d like to be dancing. I think they feel too unwell to dance.


Dr. Mark Weatherall [00:38:32]  There’s fibrosis, a little bit of scarring in the body in some people and things like that.


Dr. Katy Munro [00:38:37] We tend to use it now for really kind of severe intractable migraine that won’t go away. I had a communication with a patient the other day, not my patient, but we were chatting on Twitter and she was saying, she’s just about to go in for some intravenous dihydroergotamine and she’s fingers crossed because she’s got chronic relentless migraine and nothing is touching it.


Dr. Katy Munro [00:38:57] Good luck to her!


Dr. Katy Munro [00:38:58] I know. I’m so hoping it works for her.


Dr. Mark Weatherall [00:39:00] It’s a really good treatment but we use it very little and it gets used less and less because there are fewer and fewer people who are familiar with it and you know, it is one of those drugs that when people look at the potential side effects and potential adverse effects, people sort of, take a step back and go…


Dr. Katy Munro [00:39:17] Maybe not.


Dr. Katy Munro [00:39:18] Witch trials, quite serious.


Dr. Katy Munro [00:39:19] We don’t use it here. Just want to put that in there, guys. We don’t use it at the National Migraine Centre.


Dr. Jessica Briscoe [00:39:26] I think that probably brings us on nicely to what’s going on at the moment, sort of more the present state of affairs with migraine because there’s been a lot- and I know that people who listen to the podcast are quite interested in the current medications that are out there. And you talked a little bit about sort of approvals of medications, and I think lots of people are talking about the new medications that are out, the CGRP monoclonal antibodies which we’ve talked about a little bit before. We’re going to do a full episode on it later on and actually probably as you’re also the head of BASH you’re probably in a good position to just talk a little bit about that because it’s something that has been around in other countries for a while now. It’s available in Scotland but it’s not available here on the NHS at the moment.


Dr. Mark Weatherall [00:40:09] So yes, so following through on the sort of history and on the past, you’ve come through to the 1980s and a pharmacologist called Pat Humphrey was working for Glaxo and he was given free hand really to sort of choose a project that he wanted to work on. And he chose migraine. And he did so because of family experiences with the condition and also because he really thought that ergotamine was a really dirty drug. And there had to be something better than that. And so he spent much of the 1980s trying to develop models to test new potential migraine drugs. And they eventually came up with this model, which used the venous vein, the vein from the leg of a dog and they looked at drugs that might affect that. And from that, they got some very useful drugs, even though the model was actually completely wrong, as it turned out, but heuristically proved to be very useful. And the first drug that came out of that was imigran/ sumatriptan. Almost immediately when people started to look at the effect of sumatriptan they realised this model of it as a drug that primarily worked through causing blood vessels to expand was wrong and that there had to be something else going on. And work done by Peter Goadsby and Lars Edvinnson in the early 90s showed that it was the effect of these drugs on the release of this neurochemical called CGRP that was relevant and they seemed to work by blocking CGRP. CGRP seemed to be, you know, crucial and released in migraine attacks and cause a lot of the pain effects and the changes in the blood vessels. And so really ever since then CGRP has kind of been the main target both in terms of migraine science and in terms of migraine pharmacology. So the pharmaceutical companies have been trying to develop new drugs that block CGRP. So in the 90s you get a series of triptans and eventually seven of them come to the market. There’s a couple of others that don’t quite make it. And then in the early 2000s, you have a new class of drugs, CGRP Antagonists so drugs that just block CGRP, brought through and they get all the way through to the big phase three clinical trials. These drugs are the gepants, the first generation of them, and they get all the way through and they’re just about to be released in 2007/2008, when three or four patients in the post trial surveillance develop liver problems and those drugs just got pulled. And all the ones that were currently in development at that stage also got pulled.


Dr. Katy Munro [00:42:45] And those were drugs for acute treatment.


Dr. Mark Weatherall [00:42:47] So they were predominantly designed to be acute treatment. So they were kind of designed to be the next generation of triptans. Now, actually, those drugs have kind of made a comeback. So a second generation of gepants have been developed and one of them’s just been licenced in the United States, ubrogepant.


Dr. Katy Munro [00:43:05] I can never pronounce it.


Dr. Mark Weatherall [00:43:06] They will come up with a much funkier name, I’m sure to send to us. So they’re going to probably come online sometime in the not too distant future. Alongside this, the scientists were looking at how CGRP worked and looking at where it was distributed within the nervous system. And one of the tools that they developed to look at that were antibodies against CGRP. It is very useful if you want to know where something is, if you can develop an antibody that binds to it specifically, then you can sort of follow that antibody and see where the stuff is and that’s what they did. It then occurred to somebody that, well, if you’ve got an antibody that binds to this stuff, then potentially that would stop it actually working. So the next step was for them to start to look at these antibodies and see whether they would actually be useful migraine treatments. And it turned out that they were. And it’s quite interesting because if you look back at the sort of literature 10 or 12 years ago because of the failure of the CGRP antagonists, there was kind of this sense that CGRP was kind of played out. And that the future would be something else. And then suddenly by about 2012/2013, you get all these headlines saying, you know, CGRP is back. You know, these great new drugs are coming through. And that’s really been the main direction of travel over the last 5 or 6 years, has been the emergence of these four drugs that are monoclonal antibodies that block CGRP or its receptor, and they are preventive treatments. And three of them have now come through have been approved in the States by the FDA and in Europe by the EMA, and these drugs are given as monthly injections. So they’re aimovig, ajovy and emgality, and there’s small differences between them but basically, they’ve all been shown in, you know, pretty reasonably well done clinical trials to be helpful, potentially in reducing migraine frequency.


Dr. Katy Munro [00:45:08] Certainly when Jessica and I went to the international conference in Dublin, that was all anybody was talking about.


Dr. Jessica Briscoe [00:45:14] Yes.


Dr. Katy Munro [00:45:15] Lecture after lecture about CGRP.


Dr. Mark Weatherall [00:45:16] Yeah. So, this has been coming for the last, as I say, six or eight years. And certainly, you know, for the last two or three years, it’s been kind of the main area of interest, there are other things going on but this is kind of the main area of interest. And of course, there’s an enormous push on this from the companies that have made these things, have invested huge amounts of money and time and effort in getting them to market. And of course, they want to get us all using them.


Dr. Katy Munro [00:45:41] Do you think we’re being overenthusiastic about them being a wonder drug? Because one of the people who spoke was Dr. Loder and she was saying, you know, ‘you must be really careful with new miracle drugs’ because we’ve had this before with many different aspects of medicine that you go, woo hoo, this is the next best thing, and then you start using it, and then people start coming back and saying, well, it didn’t work for me, or I got side effects and things, so we have to be a bit cautious.


Dr. Mark Weatherall [00:46:09] Yeah, no, I think that’s absolutely right. I mean, Elizabeth Loder, you know, will be the person that will stand at the side of the parade and go, the emperor’s got no clothes on. You know, that’s what she sees as a role in life. And, you know, actually is hugely important to have people saying these things. And I think those of us who’ve, you know, had some experience with prescribing and using these drugs, I think that’s what you see. There is no doubt that they are good drugs. You know, they do work well. I’ve had some people who have taken them who have tried almost literally everything else out there and have done well with them. But equally I have had people that have, you know, been disappointed that they haven’t really made a big difference.


Dr. Katy Munro [00:46:48] It is heartbreaking when they’ve been told that this is, you know, the golden drug. And it is for some people but not everybody.


Dr. Jessica Briscoe [00:46:57] But that is also what is reflected, as you were saying, that it’s a good drug. But actually, even in the trials, even in the very good clinical trials, not everybody responded to it. And I think it’s- you’re right it’s that fact.


Dr. Katy Munro [00:47:05] Is this because as medical professionals, you’ve got a thing which has the same symptoms, but the causes and the routes are different in everybody?


Dr. Katy Munro [00:47:15]  Yeah, I think with migraine or what I explain to patients is, that if CGRP is the main pathway for your migraine and you block it, it will work very nicely. But there are lots of other pain chemicals and other pain pathways and our mantra is ‘nothing works for everybody’ and that’s really true.


Dr. Jessica Briscoe [00:47:34] That was the thing that I thought was highlighted when people were talking about CGRP. Actually, if you look at what’s been discovered about migraine, there are so many neurochemicals involved in so many different proteins and pathways, but this is just one track that we’re going down. And so yes, for some people it will work really well, but actually for others it’s not everything. And I still say to people, the main state is looking at all your different triggers and your lifestyle.


Dr. Katy Munro [00:47:59] Get back to basics.


Dr. Katy Munro [00:48:00] It’s interesting, I mean, complete medical high, I’ve got GCSE biology. But it’s interesting to me that you talk about antibodies which is part of your immune system and the antibodies are actually helping cure the migraines in some people then maybe looking after your general immune system anyway and making the lifestyle changes which look after that would actually really help the majority of people as well?


Dr. Jessica Briscoe [00:48:22] So the antibody is more of a device to get the medication- well it’s a device


Dr. Katy Munro [00:48:26] Oh I see, it attaches to the medication.


Dr. Jessica Briscoe [00:48:28] It doesn’t do anything.


Dr. Katy Munro [00:48:28] Oh, then ignore me.


Dr. Katy Munro [00:48:29] No, it blocks the pain chemicals. But I think you’re right because I think what people underestimate is how much they can do for themselves to stop their brains making those pain chemicals in the first place. So that’s why we bang on endlessly about you must eat regularly, don’t skip meals, have a good night’s sleep regularly, go to bed at the same time.


Dr. Katy Munro [00:48:53] Oh mummmm!


Dr. Katy Munro [00:48:54] Really boring stuff.


Dr. Katy Munro [00:48:55] This isn’t fun!


Dr. Katy Munro [00:48:55] But it makes so much difference!


Dr. Mark Weatherall [00:48:55] And that just brings you full circle back to, you know, all the stuff that people have been saying and you just see it time and time again. And I think there’s somebody that says that- I can’t remember who it was-  they said, history doesn’t repeat itself, it rhymes. And, you know, you just see these things time and time again. You see them in Galen, in Hippocrates. You see them in all the 17th and 18th century stuff around sort of sensibility of the nervous system. You see it even in the 20th century, you know, ideas of migraine as a sort of neurosis and so on. And again, you know, we come back to this time and time again that it is a lot about about balance. It is a lot about lifestyle. I say to my patients that migraine likes people to be a bit boring, it likes people to eat regulary and to sleep regularly and to sort of live a sort of ordered life. And of course, we can’t all do that. And, you know, the great advantage of having good well-tolerated, effective drugs is that it allows us to not necessarily have to live like nuns or monks to avoid our migraines. But that’s what some people’s lives involve.


Dr. Katy Munro [00:50:16] Can I jump to the suffragettes?


Dr. Katy Munro [00:50:19] Yeah. This has got nothing to do with anything?


Dr. Katy Munro [00:50:21]  Yes it has because if you think about it- I’m talking to Iszi now because she’s got a book about the suffragettes and I’m really fascinated by them and they were such amazing women and inspirational. And of course they had lots of stress in their lives. They had lots of hunger, you know, fasting and things like that. Now, do you know whether the suffragettes had more migraine than other women?


Dr. Katy Munro [00:50:45] Alas, women’s pain is not taken very seriously in Edwardian times. And we have virtually no statistics. Hysteria was still, you know, treated then. Which is a ridiculous, you know, that’s where your womb wanders around your body and causes all sorts of fuss, which might also be caused by living in a patriarchal society which gives you absolutely no freedom and misery. Because, you know, it was not much fun being a girl unless you were a suffragette. So the book I’ve written, nobody suffers from a migraine, but the main character’s mum, she suffers a concussion. And concussion is another very serious thing which knocks you out so very similar symptoms to a migraine. So her doctor doesn’t really take it very seriously, says that’s all in her head, says that she’s making it up because she’s just being dramatic. And this is sort of you know, this is a kids book so I keep it quite light. But the point is, and it’s as you were saying earlier with, you know, early literature, it’s really useful head injuries and headaches gets a character out the way and the kid can go off and do their own thing. It’s quite a useful thing.


Dr. Katy Munro [00:51:50] So she’s lying down with a cold compress on her head.


Dr. Katy Munro [00:51:53] Meanwhile, her little girl is going to train with the suffragettes bodyguard and learning jujitsu.


Dr. Katy Munro [00:51:58] That’s amazing! Did they have jujitsu training for girls in those day?


Dr. Katy Munro [00:51:59] They had jujitsu. There was quite a lot in the late 19th century as well. So you had women training. It was more necessary in certain respects because you did get, you know, picked up by men if you were in the wrong place, it was very odd to have a girl walking on her own. Match girls used to be able to see each other because you would just be, ‘oh, you’re out, you’re mine’.


Dr. Katy Munro [00:52:23] Oh, right.


Dr. Katy Munro [00:52:24] ‘If you’re a woman, and you’re out on your own, I can touch you’.


Dr. Katy Munro [00:52:26] You were fair game.


Dr. Katy Munro [00:52:27] Yeah, yeah, absolutely. Fine. That’s just normal because you were obviously, you know, you’re not a human. So there’s that sort of, you know, element to it as well. But yeah, so self-defence was really important. They actually used it. They actually caused quite serious injuries to some police officers. So they used Indian clubs as well as jujitsu. They also used the beautifully named Bartitsu, which was Edward Barton-Wright developed a gentlemen’s- which is based on, you know, I think schwingen and some Japanese jujitsu and some other martial arts as well. But  if you have ever read any Sherlock Holmes. Sherlock Holmes was an expert in bartitsu.


Dr. Katy Munro [00:53:10] I didn’t know it was called that but I knew he did that sort of thing.


Dr. Katy Munro [00:53:12] The trouble is, this was all done for gentlemen’s fighting. So if you’re a gentleman fighting, you have a cane, you have a bowler hat, you have a cape. For a woman fighting, you don’t have those things. So you had women like Edith Garrard adapting that sort of self-defence for women using what equipment we had. We had umbrellas, we had high heels and we had like, you know- Well, you say that high heels make hip throws a lot easier. Weirdly more stability to get somebody over your head, which they did do. So the big one was when Pankhurst was up in Glasgow, the bodyguard went up, not in a sleeper carriage, but in an all day carriage with all of their Indian clubs concealed on their person. So they had skirts with pockets, right. And they put these Indian clubs in and so Pankhurst beautifully got past the police by buying a ticket to her own show and sat in the audience. The police were waiting to arrest her and then she got up on stage. All the policemen got up to arrest her and all the bodyguard got up and the fight lasted over 11 minutes and several policemen were hospitalised. So these women weren’t-


Dr. Katy Munro [00:54:14] They were tough weren’t they.


Dr. Katy Munro [00:54:15] We’ve got this idea of the suffragettes, ‘oh, they all starved themselves and they’re really noble, very meek’. No, they weren’t. And who was it? I was reading a thing that’s on Naomi Paxton’s blog, there’s a story of, you know, they were having a fundraiser in a swimming pool and Bertrand Russell’s wife stood on the board, the highest diving board, fully clothed, read her speech, and afterwards jumped off into the water. People threw their money in the water. They were much more exciting. The census, which is, you know, when my book ends in 1911, all the suffragettes protested that by not signing the census because no representation. What they actually did was they went rollerskating. You don’t read about this. And it’s because history wants to present women who, you know, are very meek and mild, they do as they’re told. It’s ridiculous the way that, you know, we’re not taken seriously ever even when we’re being silly. Anyway. That’s got very little to do with headaches.


Dr. Katy Munro [00:55:12] But it is about how society treat women. Women are the major sufferers of headaches, and I think that is partly why migraine is now under-funded and under-recognized and trivialised.


Dr. Katy Munro [00:55:25]  I think pain is with women quite differently treated anyway. I mean, well it’s not just women, as, you know, people of colour as well, they’re not given the same- you can look at and see the statistics. They’re just not given the same amount of painkillers. Their pain is not considered.


Dr. Katy Munro [00:55:40] There’s some evidence about women with heart attacks being underdiagnosed.


Dr. Katy Munro [00:55:44] Well that’s because we have weird symptoms, we don’t have the classic pain in the arm.


Dr. Katy Munro [00:55:46] We do things differently.


Dr. Katy Munro [00:55:49] We just gently sit in a corner and slowly die. Like good meek ladies. But, yeah, it’s weird. I think as well, in general, I don’t think it’s just women. I think it’s certain types of personalities because I read a thing the other day about people who choke and they said a lot of people- choking victims end up dying in toilets because they choke in public and they’re so embarrassed, they go and sit in the toilet to die so they didn’t embarrass- I mean really.


Dr. Katy Munro [00:56:15] Yeah.


Dr. Katy Munro [00:56:15] Embarrassment is worse than death.


Dr. Katy Munro [00:56:17]  It’s that very British thing I wonder. Whether we need to be more loud about our needs.


Dr. Katy Munro [00:56:25] And it is that sort of thing when you’re in with a doctor and you’re like, well, I’ve got this list of problems which I know are wrong, but I’ve got 7 minutes, so I’m going to tell them about these ones and I hope those are the key ones. And you have to sort of self-diagnose before you go in and go let’s fight for this particular one.


Dr. Katy Munro [00:56:39] We hear that a lot, don’t we, Jess, because the beauty of working here is that we have 40 minutes for a new patient, so we have time.


Dr. Katy Munro [00:56:47] It’s not enough guys.


Dr. Katy Munro [00:56:47] But I have to confess, I always overrun.


Dr. Katy Munro [00:56:50] Excellent.


Dr. Katy Munro [00:56:50] I’m not sure that it’s me talking too much. I think it’s me listening too much.


Dr. Jessica Briscoe [00:56:54] Yeah not at all talking too much.


Dr. Mark Weatherall [00:56:56] But you know, it’s interesting. It’s all about, you know, what links Iszi’s work and Katherine’s is recovering voices that are lost. And actually that’s also a part of our clinical work as well because, you know, so many people will come and see you guys, will come and see me, who feel that their voices are lost, that they’ve not been heard. And it’s heartbreaking to come to the end of 40 minutes with somebody and for them to say, look, you know, that’s the first time anybody’s actually listened to to me.


Dr. Katy Munro [00:57:28] Yeah, we get people in tears.


Dr. Mark Weatherall [00:57:32] It’s a huge part of what we can do. So it’s interesting, you know, that it sort of kind of runs across the board.


Dr. Katy Munro [00:57:39] Don’t do fortitude in the doctor’s office. Just don’t.


Dr. Katy Munro [00:57:43] I always say to people, ‘It’s fine to cry here, that’s why we have a free tissue with every consultation’.


Dr. Katy Munro [00:57:51] Just the one.


Dr. Jessica Briscoe [00:57:51] I think that’s probably it.


Dr. Katy Munro [00:57:53] Thank you so much everybody. I think it’s been really fun.


Dr. Mark Weatherall [00:57:58] I’ve got just one more thing to say,.


Dr. Katy Munro [00:58:00] Typical man!


Dr. Mark Weatherall [00:58:03] Well, you asked about where we are in terms of the approval of the new drugs.


Dr. Jessica Briscoe [00:58:06] Yes.


Dr. Mark Weatherall [00:58:07] The answer to that question is we’re not quite there yet. We appealed the negative decision on aimovig and we will hear hopefully in a couple of weeks about that appeal. And then if that is successful, there will be probably another process after that. The second drug, ajovy, obviously has just been approved for use in Scotland for both chronic and episodic forms of migraine, which is great for Scotland. And we expect the meeting- the final meeting for NICE and ajovy will be in March, we expect to hear in April and emgality will be coming later in the year.


Dr. Katy Munro [00:58:43] So emgality hasn’t started on the pathway yet.


Dr. Mark Weatherall [00:58:46] It hasn’t started yet. I think the first meeting is not going to be until July/August time.


Dr. Katy Munro [00:58:51] But it’s being used in the US at the moment.


Dr. Mark Weatherall [00:58:53] Yes, yes. And in Europe. And I think also manufacturers of emgality are holding discussions with NICE about possibly getting approval for it to be used in cluster headache.


Dr. Katy Munro [00:59:03] Oh yes, we did hear that. Which we will be doing an episode on.


Dr. Jessica Briscoe [00:59:08] We will.


Dr. Katy Munro [00:59:08] Later this series.


Dr. Jessica Briscoe [00:59:11] Great. Thank you all so much for coming and having a nice, lively discussion.


Dr. Katherine Foxhall [00:59:16] Thanks for having us.


Dr. Katy Munro [00:59:17] Yes, it’s brilliant. And I think we’re hoping that the reason we’re doing the podcast is to spread information about how to manage your migraine. But it is really interesting to hear about how we got here.


Dr. Katy Munro [00:59:29] You’re not the only ones.


Dr. Katy Munro [00:59:29] And yeah, just as a postscript, all of us sitting around this table get migraine.


Dr. Katy Munro [00:59:35] Woop woop. Club pain!


Dr. Katy Munro [00:59:39] We’re part of your crowd. So our next episode will be on Cluster Headache, so keep your eyes open for that. We do these fortnightly, so thanks for listening.


Dr. Jessica Briscoe [00:59:52] Thank you.


Dr. Jessica Briscoe [00:59:55] We hope you’ve enjoyed listening to our podcast on the history of migraine today. If you did enjoy it, please do donate to our Just Giving page as your donations are really important for us to keep going with the podcasts and keep treating patients for the charity. Our next podcast is going to be on Cluster Headache and we’re joined by Professor Paul Booton, who used to work here at the Migraine Centre. We’ll also be speaking to OUCH.


[01:00:23] You’ve been listening to the Heads Up podcast. If you want more information or have any comments, email us on info@NationalMigraineCentre.org.uk. Till next time.



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