S3 E3: Midlife and Migraine

Midlife and Migraine

Series 3, episode 3

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.

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Transcript:

[00:00:00] Did you know some people’s migraine makes them temporarily unable to walk or use their arm? It’s definitely not just a headache. 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 [00:00:24] Hello and welcome to this week’s episode of- or fortnights episode of the Heads Up podcast. I’m Dr Jessica Briscoe and I’m joined by Dr. Katy Munro.

 

Dr Katy Munro [00:00:34] Hello.

 

Dr Jessica Briscoe [00:00:36] And this week’s topic is about migraine in the middle ages and beyond.

 

Dr Katy Munro [00:00:42] Yes, and we’re going to be covering other kinds of headaches that might be confused with migraine as people get older. So we discussed how to call this episode because my definition of midlife is, you know, any time around 60, because I’m planning to live to a ripe old age of 120. But of course, for most people, they would say it would probably be around 50 or menopause time. And then later.

 

Dr Jessica Briscoe [00:01:08] Yeah, I mean, obviously we have actually extensively discussed a migraine and the menopause in our first episode of our second series. So please go back and have a listen to that if you’re interested in knowing more about how your hormones affect migraine. So we won’t rehash that here. We’re probably going to focus a little bit more on life after menopause. Yes, 60s and beyond probably.

 

Dr Katy Munro [00:01:33] One of the reasons we’re doing this episode is because we had a patient request it didn’t we?

 

Dr Jessica Briscoe [00:01:37] Absolutely.

 

Dr Katy Munro [00:01:38] She said, ‘please, would you talk a bit more about how to deal with migraine as you get older?’ And of course, some people have been told ‘once you get through the menopause all your migraine will disappear’. But of course, that’s not actually true for everybody.

 

Dr Jessica Briscoe [00:01:53] No, I’ve had people come in and plaintively say ‘I was promised that when I went through the menopause, it would get better’. Actually, it’s quite staggering. We’ve been guided- we should actually mention this now. We’ve been guided by this excellent paper ‘Headache in the Older Population: Causes, diagnoses and treatments’ by Jennifer Robblee and Rashmi Halker Singh as well. I have to say, that’s been invaluable to us for preparing this podcast.

 

Dr Katy Munro [00:02:24] Such a clear overview.

 

Dr Jessica Briscoe [00:02:30] Yeah, it’s sort of it’s given us credence for our thoughts on what’s happening with migraine.

 

Dr Katy Munro [00:02:36] Yes, because we had a bit of an impression about this already, Jess, didn’t we? So we’ve had a number of people who’ve come in who are in maybe late 60s, 70s saying, ‘well, I thought my migraines should have gone’. But in fact, it has been found that probably about a third of patients with migraine still do get attacks. But sometimes the severity eases or the frequency eases off as they get older.

 

Dr Jessica Briscoe [00:03:05] And it can actually change the- apparently much more likely that people get bilateral pain. So pain on both sides. Get fewer symptoms of sensory sensitivity so that light and sound sensitivity that we often associate with migraine. And something that we were actually talking about when we were preparing for this, I was saying I see a lot of people who get aura without headache: acephalgic migraine. And actually it seems that 13 percent of people who have migraine with Aura in that age group actually have aura without headache and it seems to be much higher than earlier on in life. So it does seem that this is an established fact.

 

Dr Katy Munro [00:03:49] Things are changing as you get older. And there is a figure that about 4.2% of patients have new onset migraine. But then, as I’ve often said to colleagues, when you’re talking to somebody about their new onset migraine, it’s important to really drill down onto what has happened in their previous life. So if they were children, did they get travel sickness? Were they having recurrent abdominal pain? Did they have occasional headaches that they thought were, in inverted commas, ‘just the normal headaches’, which you know, I hate that expression. And, of course, they may have just had an episode which is more typical of migraine as they’ve got older but do have a lifetime history of recurring headaches that just haven’t been diagnosed.

 

Dr Jessica Briscoe [00:04:38] But if it is genuinely a new onset migraine, then we do worry about other things that could have caused it in that age group, don’t we? So we’re often a little bit more cautious about things like stroke, often stroke actually being the main concerning thing.

 

Dr Katy Munro [00:04:55] Yes because that certainly mimic it. But the other thing about migraine in patients who are in their sort of 50s plus is that we are a little bit more cautious about what we use for treatments. And also they’re often not included in the studies for new medications. So quite often the studies will look at 18 to 60 year olds. And so anybody over that, they just haven’t looked at, which means it’s quite hard to know whether things work, whether they’re safe.

 

Dr Jessica Briscoe [00:05:25] Yeah, I think two good examples of that are actually triptans. I think we get asked about this a lot. Triptans and the CGRP monoclonal antibodies, neither of these have had published data on over 60s, which is difficult. So a lot of GPs get quite cautious when they look in the books that I’m always discussing, the BNF, the formulary that everyone looks at and it says is a caution in over 65. And interestingly, this paper also says that age should not be a reason to limit treating migraine. So you shouldn’t really discriminate on someone because of age if they’ve got no other- if you have no other, you know, other medical problems, such as I always think of high blood pressure, a history of heart disease and stroke. Heart disease not so much. But you worry a little bit about stroke and heart disease then actually there’s no reason that they shouldn’t be offered if you’ve never had a triptan before.

 

Dr Katy Munro [00:06:33] Yeah. And people who smoke or, you know, who have had a family history of heart disease and are, you know, relatively sedentary, not exercising, they may have higher risk of developing those kind of conditions. So I think we’d probably be more cautious with Triptans. But I, I don’t know about you Jess, but if I’ve seen somebody who’s been using a triptan, you know, for the majority of their adult life maybe, and they suddenly turn 60 or 65, I wouldn’t stop that if they’ve been otherwise perfectly fine with them.

 

Dr Jessica Briscoe [00:07:04] I completely agree.

 

Dr Katy Munro [00:07:05] I don’t draw the line quite as definitively as the BNF might suggest, but it’s about assessing their other risks isn’t it.

 

Dr Jessica Briscoe [00:07:12] And I think that’s the thing is actually, as doctors, we know these are guidelines actually. They’re not absolute rules. It’s a guidance. And again, the BNF is telling us to be cautious. I think we should bear that in mind rather than sort of thinking, you know, discriminating just because someone’s a bit older. And then it says in the books that they should be having it if they’ve had it safely. Actually do assess the risk factors, be cautious. But actually it’s fine to continue if everything- if nothing’s changed.

 

Dr Katy Munro [00:07:39] It’s the risk and benefit equation really isn’t so often is the case when we’re deciding which medications to use. Going back to the new CGRP injections, I have certainly had experience with a lady who was well into her 70s and she wanted to try them and she has found them really remarkably helpful for her with very, very low side effects and she never wants to come off them. The current guidance isn’t to stay on forever and ever, but is to reassess after a year. So we do have that conversation. As far as we know, there’s no long term safety issues. But of course, we haven’t had them very long.

 

Dr Jessica Briscoe [00:08:18] No. So we do tend to be cautious. So I always reiterate what we’ve said that they haven’t been tested on people over 65, isn’t it?

 

Dr Katy Munro [00:08:28] Yes, I think so, yeah.

 

Dr Jessica Briscoe [00:08:30] So I always say that to people if I’m prescribing it. But as you know, it’s that risk benefit thing again.

 

Dr Katy Munro [00:08:35] The other things that we sometimes use in migraine are the neuromodulation devices and those, well, I was going to say those can be used, but in fact, the two that we mainly use. There’s only one at the moment available. So the sTMS Mini is not available at the moment because the company has had some financial difficulties I believe. I don’t know what the long term future is for that, but that was the news we had last week.

 

Dr Jessica Briscoe [00:09:03] Absolutely.

 

Dr Katy Munro [00:09:04] And that was the one that gives a magnetic pulse. So I think, you know, we would advise caution for anybody who was using that if they had a pacemaker or anything.

 

Dr Jessica Briscoe [00:09:13] Yes, so pacemaker tends to be the main contraindication. Also the I mean, we don’t use the gammacore, which is the vagul nerve stimulator, so much for migraine. There is, you know, there’s limited evidence for use. But actually, one of the things that you do have to think about with that neuromodulation device is if there’s any history of plaques or blockages in the carotid artery, that big artery in the neck, you should be very cautious about using any vagul nerve stimulation, because the worry is that that could detach and cause a stroke.

 

Dr Katy Munro [00:09:49] But the Cefaly dual device would be fine to try, wouldn’t it? Very very safe. Well tolerated.

 

Dr Jessica Briscoe [00:09:56]  I often do try it in people where I’m a bit more cautious about other medications, not just older people, but anyone that I’m cautious about medications. It might be worth talking about a few other types of of headache that are common and in older people, unless there’s anything else you wanted to mention about migraine.

 

Dr Katy Munro [00:10:14] Yeah I think that’s that’s covered really. So tension type headache. We haven’t talked very much about tension type headache, and that’s probably because we don’t really see it in our clinics, do we?

 

Dr Jessica Briscoe [00:10:27] No. Because tension type headache is typically a featureless headache and it’s one of those other things, it’s one of those things that headache specialists are forever debating: does it exist? Does it not exist? I think it actually- I do think it exists to be honest. I think we just don’t see it, because usually if it’s got any sort of features that are bad enough, then by its nature then it’s not tension type headache.

 

Dr Katy Munro [00:10:51] If there’s any light sensitivity or sound sensitivity or nausea and vomiting, then it’s by definition a migraine more than tension type headache. But if it does occur and is out there, we would find no difference in younger patients or older patients it’s the same kind of featureless phenotype where people just basically feel this maybe a tight band. .

 

Dr Jessica Briscoe [00:11:17] They do say- The interesting thing about that paper, as it did say that the risk of tension type headache is higher with people who have other types of chronic pain also other pain conditions, other forms of headache disorder, depression, and also, the thing that we’re always talking about, medication overuse.

 

Dr Katy Munro [00:11:35] Yeah, and medication overuse can be quite a common cause of headache at any age, really. And it can be confusing because it’s sometimes medication taken for other conditions, which of course does become a thing as people get older. So they may have been put on to some opiates like codeine compounds or something like that. They may be taking antiinflammatory medications for arteritis on a regular, maybe too frequent basis. And of course, it does affect the brain as well. And so we are always on the lookout for patients who their episodes of migraine have changed to a kind of constant, dull background pain with episodes of severe pain overlayed. And that is often a clue to medication overuse headache.

 

Dr Jessica Briscoe [00:12:25] Ways of managing tension type headache? I think it is basically being careful about medication overuse, isn’t it? That’s the thing that people need to be careful of. It does tend to respond to analgesia quite well. And that’s one of the other features that tends to make me think it’s tension type. If paracetamol works then it’s probably tension type headache. But actually being mindful of the fact that you shouldn’t, if you do have a tension type headache, you shouldn’t be taking too many painkillers. It’s the days of painkillers, not doses, as we’ve discussed before. But there are other things that people can try, such as cognitive behavioural therapy, mindfulness. We’re always a big fan of mindfulness and also some of the biofeedback techniques that we’ve discussed in other other podcasts. So ice packs, heat pads, cold water swimming, open water swimming.

 

Dr Katy Munro [00:13:11] Yeah, we had a patient flag up to us the other day how useful they found that cold water swimming. And that their migraines had really helped so obviously wherever you’re going cold water swimming, be safe in the water. Some people definitely have reported that’s a helpful thing.

 

Dr Jessica Briscoe [00:13:29] The next type of headache that we often think about- next most common type of headache is the trigeminal autonomic cephalalgias. Now we discussed this in our cluster headache topic and hopefully we’ll be discussing it in other podcasts, too. Cluster headache is the most common form of this, but it also includes paroxysmal hemicrania, short lasting unilateral neuralgia form headache with (such a long one) with conjunctival injection and tearing (SUNCT) and also the same thing SUNA, that’s with cranial autonomic symptoms as well. And there’s also Hemicrania Continua. And now these are all- usually these are all pain, often slightly more facial pain disorders, but they’re counted as headaches, which all arise from the trigeminal nerve which we will have discussed in a different podcast. Now these often present in patients younger than 65, but actually SUNCT/SUNA, often present in more middle ages. So exactly the topic of this podcast, between 40 and 70. However, the advice if you’re getting any of these new headaches. So these are usually one sided headaches. They can be very short lasting or they can last a bit longer according. With the SUNCT and SUNA they’re very, very short acting and you tend to get multiple in one day. You get these autonomic symptoms, such as eye watering, nasal blockage, drooping of an eyelid, sometimes lots of sweating on one side, sometimes changing in the pupil or you can get redness of the eye as well. If these symptoms do occur, usually if you’re an older person, we would advise that you should have a scan and actually be seen by a headache specialist to get further work up to make sure that something else hasn’t caused it.

 

Dr Katy Munro [00:15:23] Yes, I think the severity of the pain is such that people will go and seek help because these are excruciatingly painful. Cluster headaches, one of the most painful conditions known to man really. ‘Person’ I was going to say being politically correct. And the SUNCT and SUNA tend to be sort of almost on a spectrum with cluster headache in terms of similarities of symptoms, but much shorter duration of pain, but then repeated and repeated, repeated. So very few patients, I think, would sit at home and put up with that. I think they’re going to come and speak to their GP. And if the GP has met a person who’s just having that and they’ve only just developed it, I’m pretty sure that they would get referred on quite smartly to neurology for the investigations.

 

Dr Jessica Briscoe [00:16:10] Yeah, it’s quite- they’re so frequent that actually I suspect most- I mean, I hadn’t heard of it actually before I was a headache specialist.

 

Dr Katy Munro [00:16:22] They feel quite rare too.

 

Dr Jessica Briscoe [00:16:23] Yeah. That they are rare but I think it’s the sort of thing that you’d be worried about enough that you’d be sending someone to see a neurologist pretty sharpish.

 

Dr Katy Munro [00:16:28] Yeah, definitely. There’s a couple of headaches to come on to, both of which are associated with sleep. And we’ve just done a podcast episode on sleep and we’ve touched on these a little bit, but it’s probably just worth going over them again because they can get more common as people get older. So the first one is Hypnic headache, and that’s quite rare. Jennifer Roblee and her co-author reckon the presentation was less than 1% at a Tertiary Care Headache Clinic. Now of course a tertiary care headache clinic is very specialist. Most people will be seen either in primary care or in secondary care, and some people may not even bother going to talk about it. It depends on how severe the headache symptoms are. Whether they just put up with it. So I wonder if it’s more common than that.

 

Dr Jessica Briscoe [00:17:23] I think it is. And we did discuss this actually in our Sleep podcast and Dr Alex Nesbitt, who’s a neurologist who specialises in sleep and migraine, he was saying he really expected his clinics would be full of Hypnic headache and they’re not. And I do wonder if it is that people aren’t necessarily getting referred actually.

 

Dr Katy Munro [00:17:43] Yeah, maybe.

 

Dr Jessica Briscoe [00:17:45] But I mean, I definitely- I know that we both suspected in a number of patients, and it is a very interesting one because it is much more common in the 60s but it seems to be a very rare headache.

 

Dr Katy Munro [00:18:01] But we did a poll recently on Facebook about when your headache wakes you, and a lot of people with migraine were saying that they wake in the night with their migraine pain. So that’s why I think it’s sometimes tricky to distinguish this particular headache as a primary headache in its own right.

 

Dr Jessica Briscoe [00:18:17] Yeah, it is interesting because it says that actually you don’t need- it says features like nausea and sensory sensitivities are rare. Having actually spoken to a few clinicians, they’ve said, you know, it can present quite like migraine. So whether it’s a crossover or is it more common in people who get migraine? It’s hard to know. I mean, and also one of the things that even though restlessness isn’t in the diagnostic criteria, but people do often get out of bed, don’t they?

 

Dr Katy Munro [00:18:49] Yes.

 

Dr Jessica Briscoe [00:18:49] They have to get up. But it’s not that restlessness. With things like cluster headache, people really are pacing around constantly.

 

Dr Katy Munro [00:18:57] Very agitated.

 

Dr Jessica Briscoe [00:18:57] It’s not that kind of agitation, but it’s more of a ‘I can’t lie here. I need to do something’.

 

Dr Katy Munro [00:19:03] Sometimes getting up seems to ease a hypnic headache and walking around, you know, doing something sort of distracts. And they’ll typically go away if you do something like that. And they may only last anything between 15 minutes and say 3 hours. But some people have reported having them for as long as 10 hours. So it can be quite an impact.

 

Dr Jessica Briscoe [00:19:29] It’s quite a variable amount of time, isn’t it, 15 minutes and 10 hours.

 

Dr Katy Munro [00:19:31] Yeah, it’s a really variable thing. And some patients, about 25% in one study, had sort of vague prodromal symptoms like fatigue or agitation or dull head pressure before that Hypnic headache arrived. And of course, we see a lot of patients with migraine who describe a lot of prodromal and then also postdromal symptoms.

 

Dr Jessica Briscoe [00:19:56] Yeah, I wonder if some of it is actually being diagnosed as migraine if I’m honest, actually. Because a lot of that sounds quite migrainous.

 

Dr Katy Munro [00:20:03] Yeah. I think that’s why it’s a confusing one to isolate on its own. So the treatment for Hypnic headache is caffeine. So pro plus caffeine tablets. Some people take a strong cup of black coffee last thing at night. And interestingly, that doesn’t keep them awake and that’s because I think the time it takes for the caffeine to be absorbed and go into the system is around the time that the Hypnic headache would normally happen. And so the caffeine seems to lighten the sleep stop the Hypnic headache. The person’s already gone into sleep, so then doesn’t keep them awake. So a mystery that to me, it’s quite interesting. If I had a cup of strong black coffee at 7 o’clock in the evening, I wouldn’t be able to get to sleep at all. But I think it’s about that delayed onset of action of the caffeine. And sometimes people use lithium, and that obviously needs quite a lot of monitoring by whoever prescribes it.

 

Dr Jessica Briscoe [00:21:06] It’s quite a specialist medication. So that’s not something that would usually be prescribed lightly.

 

Dr Katy Munro [00:21:11] Yeah. So the other one associated with sleep is sleep apnoea headache. Sleep apnoea Headache is quite common, actually, and apnoea basically means stopping breathing. Obstructive sleep apnoea happens in people as they get older because they lose the kind of normal tone in the back of their nose and throat. The muscles become a little bit more relaxed. And so when they lie down and go to sleep, the tongue falls back and it blocks their airway. And so we get this typical pattern in about 20 percent of middle aged adults, apparently, that when they go off to sleep, they start to breathe a little bit more heavily and then snore and then stop breathing. And then there’s a gasp as the carbon dioxide wakes them up to breathe again, and that’s very typical of a n OSA sleeping pattern, isn’t it? Mostly noticed by partners.

 

Dr Jessica Briscoe [00:22:12] It is quite interesting. Whenever- we ask a lot about this generally actually in the clinic. But whenever I do ask, someone will say, ‘oh, no, no, I definitely don’t have pauses in my breath.’ And the partners will say ‘they absolutely do. Sometimes I’ve been quite worried. I just haven’t mentioned it’. But I like the phrase that they use in this paper here, because the way people essentially wake up a little bit in the night and that’s why they feel tired in the daytime. But it’s not waking up in the sense that you’d wake up and be aware of it. It’s called a micro awakening and i like that phrase.

 

Dr Katy Munro [00:22:46] Yes, I like that micro awakening. But you can have loads of micro awakenings throughout the night it just keeps happening. And I had a patient who reported that he had a sleep study and he was having micro awakenings for about 70 percent of the night. And of course, if you’re not properly having that restorative sleep, then you do wake up feeling really drowsy and sluggish in the morning. And often the headache associated with it is a morning headache and about 18 percent of people with snoring or OSA tend to get that kind of morning headache and increased age is a risk factor, so that’s something definitely worth asking about. Or if you yourself know that you snore, ask your partner, ‘do I stop breathing? Do you ever have to nudge me to make me breathe?’ Because that’s the sort of stories we hear, isn’t it?

 

Dr Jessica Briscoe [00:23:45] It’s kind of- it’s actually worth having them record you as well, because that’s really useful as a doctor, I find that quite useful to sometimes hear because you don’t forget the sound of that apnoea, do you? The other thing that’s quite useful, we did discuss this actually in our sleep podcast, but there’s a screening tool that we much prefer now and they use something called the Epworth sleepiness scale, which we all agreed isn’t always the best measure. There’s one called the stop bang measure where they can just go through a quick screening questionnaire and it will show you whether you’re high or low or medium risk of having sleep apnoea and whether you need to have further investigations.

 

Dr Katy Munro [00:24:27] Yes, there’s a list of things that are part of the stop bang questionnaire. You just type that into Google it’ll give you the questionnaire. But basically you add up your risk. And if you’ve scored 3 to 4 out of 8 then you’re positive and you have an intermediate risk and anything higher than that, then you definitely need to go and get your GP to refer you for a sleep study.

 

Dr Jessica Briscoe [00:24:51] Absolutely. One of the other things that there are a couple of- We want to talk about cough headaches, actually, sorry I nearly missed one out. Skipping ahead there and this is actually one I don’t know so much about, I have to say. It’s an interesting one. It’s actually- it’s, again, a very rare headache. It only affects about one percent of the population, most of it can be- there are cases that we don’t know what the cause are or it can be caused by structural abnormalities or lesions in the brain. So the first one- we’ve talked about chiari malformations before, but this is a different chiari malformation that causes this one. So there’s a chiari one malformation which is the most common cause of cough headaches about 65 percent of these headaches and then about 15 percent are caused by lesions right at the back of the- it’s called the posterior fossa lesion. So actually, this cough headache is much more likely- is much more common in the older population with the average age of onset being 43.

 

Dr Katy Munro [00:26:03] I don’t call that old.

 

Dr Jessica Briscoe [00:26:04] No, I don’t actually. I was reading it and I thought, oh I said older. I’d say that’s before the middle ages so it’s actually earlier than this podcast.

 

Dr Katy Munro [00:26:14] Earlier onset seems to be more associated with the secondary causes that you’ve just mentioned, Jess. The primary cough headache, which we don’t really know why it happens, seems to come on more in the more elderly, I think is what it’s saying. And it’s more men than women. So that’s why that is, I don’t know.

 

Dr Jessica Briscoe [00:26:33] So it’s described as it can be mild or severe pain, usually on both sides. Quite a sharp pain lasting for a few seconds, but can last up to 30 minutes. And it doesn’t usually have any other symptoms, but it’s usually triggered by a cough, which is where it gets its name from.

 

Dr Katy Munro [00:26:54] Hence the name.

 

Dr Jessica Briscoe [00:26:55] But also other valsalva manoeuvre, so any kind of straining manoeuvre. I always thing of it as bearing down is how we always describe it in medicine, which I always think is very difficult to describe. But it’s that thing that increases your intra-abdominal pressure, basically.

 

Dr Katy Munro [00:27:11] That’s the one. If you’re just doing exercise, normal exercise it doesn’t seem to cause it. Where we know that often exercise can be a trigger for people with migraine.

 

Dr Jessica Briscoe [00:27:22] Absolutely.

 

Dr Katy Munro [00:27:23] But not for cough headache. It actually has to be something that raises the pressure. Imagine, sort of, closing your nose and mouth and breathing out so that you’re stopping yourself breathing out. That’s kind of a valsalva isn’t it?

 

[00:27:35] Yeah, absolutely. And interestingly, it’s another headache that responds to indomethacin. So there are a couple of other types of headaches that do. Paroxysmal hemicrania and hemicrania continua are both types of headaches that respond to indomethacin. But this type of headache does, too. Don’t think we know why.

 

Dr Katy Munro [00:27:54] There’s a lot of other medications can be used? If somebody had a persistent cough headache, it’s certainly worth going and getting that looked at by a headache specialist.

 

Dr Jessica Briscoe [00:28:05] Absolutely. Perfect. So I think now we can move on to some of the other headaches I was really keen to get into.

 

Dr Katy Munro [00:28:12] So which one do you want to talk about next?

 

Dr Jessica Briscoe [00:28:14] I would like to talk about temporal arteritis or giant cell arteritis, depending on which generation you’re from, getting ageist again, aren’t I. But giants cell arteritis, it’s a vasculitis. So vasculitides are inflammatory processes of blood vessels as it would be described. Now, giant cell arteritis affects the temporal artery, which is quite a large artery, at the side of the face. Again it’s much more common- well, it’s essentially it’s much more common in those aged 70 or older. But it can and I’ve certainly seen it in younger people. It can be present in those aged 50 or older. Now, headache is the primary symptom, usually unilateral. I don’t think I’ve ever seen bilateral temporal arteritis, but I think you can get it. Yeah, usually on one side. Pain is inner temple. Right in that temple over where the artery is. The thing I always ask people is, do you find that chewing- do you find it you get jaw pain with chewing? Do you find that you get something called jaw claudication or do you get pain when you’re brushing your hair with a comb- combing your hair? That’s what we were always told to ask people. It can also be associated with tongue claudication as well, which is where you get pain- tiring of the tongue, pain in the tongue.

 

Dr Katy Munro [00:29:38] It’s almost like a cramp.

 

Dr Jessica Briscoe [00:29:39] Yeah, like a cramp feeling.

 

Dr Katy Munro [00:29:40] In your tongue or in your jaw. And the tenderness over the artery is really a typical thing, isn’t it?

 

Dr Jessica Briscoe [00:29:48] I always feel for that when I see people with this type of headache.

 

Dr Katy Munro [00:29:51] It can cause changes in the vision as well and it may be sort of patchy loss that comes and goes or even rarely it can cause double vision in some people.

 

Dr Jessica Briscoe [00:30:06] We do worry about that, don’t we? That’s the main risk of temporal arteritis, blindness, because it can be a permanent change in 10 to 15% of patients.

 

Dr Katy Munro [00:30:16] So this is really a medical emergency. If you think somebody has got a giant cell arteritis, they need to be sorted out that day. Because it can cause blindness very suddenly. It comes on maybe overnight. And the treatment is to get them on some steroids really quickly, because that can be sight saving.

 

Dr Jessica Briscoe [00:30:35] Absolutely. And actually, if there are visual changes. That’s one of the things where I- this is one of the few things where as a GP, I used to pull up my needle and syringe and actually take blood there and then and I never did that.

 

Dr Katy Munro [00:30:47] Yeah, there is a blood test you can do. An ESR or a CRP tend to be very high. Not always.

 

Dr Jessica Briscoe [00:30:54] Not always. But they do tend to be. But it’s one of those ones where if anyone had visual loss, that’s something you’d actually get them straight into the eye department for to A&E.

 

Dr Katy Munro [00:31:03] Just send them into a hospital very quickly. Of course, the definitive thing is to have a biopsy of that temporal artery, which can be done under local anaesthetic. It’s an easy thing to do, but it needs to be done really fast because once they’re on the steroids, that can change the appearance and you can’t not give the steroids because if you have a high index of suspicion that that’s what you’re dealing with.

 

Dr Jessica Briscoe [00:31:27] Steroids actually work very quickly. I mean, it’s one of the most satisfying things to treat. I remember being told that when I was a medical student, and it’s true. I think it’s one of the first cases I remember. Well, obviously, they were all headaches related that I remember well. But I do remember being a medical student, seeing someone with suspected giant cell arteritis and then coming in the next day or the GP phoned in the next day and they’d already felt better.

 

Dr Katy Munro [00:31:50] Yeah, yeah.

 

Dr Jessica Briscoe [00:31:51] But you have to stay on steroids for a really long time. It a slow wean.

 

Dr Katy Munro [00:31:56] Some of the patients- Of course, about 50 percent will also have a single polymyalgia rheumatica.

 

Dr Jessica Briscoe [00:32:02] Yeah.

 

Dr Katy Munro [00:32:02] Which presents it can be without ginact cell. So it’s not everybody with PMR has giant cell arteritis, but you have to look for both, I think, in anybody who’s got some symptoms like that. Both of them are linked with other things like weight loss or fatigue, sometimes shoulder/neck pain you get with polymyalgia or limb girdle.

 

Dr Jessica Briscoe [00:32:25] Yes, pelvic girdle pain.

 

Dr Katy Munro [00:32:26] Pelvic girdle and that sort of thing. And they can be a bit insidious and people can just generally not feel well, maybe have a low grade temperature. And so you have to have your diagnostic antennae out when people come in with these kind of vague symptoms and just think about checking them out for these things.

 

Dr Jessica Briscoe [00:32:44] It’s definitely one of those ones. Polymyalgia is one of those ones that’s definitely caught me out a few times and then, you know. you pop someone on the steroids

 

Dr Katy Munro [00:32:51] And they’re better dramatically, it’s really good as you said. I think they can have temporal artery tenderness or bulging or even sort of indurations, a bit of swelling that dense when you press it gently with the fingers. So it can be a bit puffy around that area. Sometimes they can have noises when you listen with the stethoscope over their large vessels, and they might have an aortic murmur in the heart. I didn’t know that was linked with it. And then if you look in the back of the eye with an ophthalmoscope, which, of course is very difficult for us to do at the moment, being that we’re all on virtual consultations, but the optic nerve can show up as being rather pale or even just slightly swollen sometimes. So. Yeah, lots of things to think about and look for and a really important cause of headache in older people.

 

Dr Jessica Briscoe [00:33:52] Yeah, absolutely.

 

Dr Katy Munro [00:33:54] There is some treatment with steroids we’ve mentioned but some people have suggested adding low dose aspirin as well. And there is a new option called, I’m going to take a run up at this name, tocilizumab, which I’m guessing is a monoclonal antibody, which we’re seeing monoclonal antibodies popping up in all sorts of areas of medicine because they seem to be a really very useful way of targeting things which are causing illness.

 

Dr Jessica Briscoe [00:34:20] And that’s quite good because high dose steroids for a fairly long amount of time. Not everybody can take steroids.

 

Dr Katy Munro [00:34:30] No, they have nasty side effects don’t they. Moon face, thinning of the skin, weakening of the bones. People should be made aware that they need to have something for protecting the strength of their bones.

 

Dr Jessica Briscoe [00:34:41] And their stomach as well.

 

Dr Katy Munro [00:34:42] And their stomach because they can cause gastric irritation, sometimes people put on a lot of weight. They’re not easy things to take really are they?

 

Dr Jessica Briscoe [00:34:49] Some people can get quite significant mood changes as well, which is the other thing I think we sometimes forget about.

 

Dr Katy Munro [00:34:54] People get irritable and angry on them sometimes. The idea is that the high dose in there right at the beginning to nip everything in the bud and then wean down to the lowest effective dose.

 

Dr Jessica Briscoe [00:35:06] And it I can take- I’ve seen people be on it for a year or more. Often more than a year.

 

Dr Katy Munro [00:35:09] Couple of years.

 

Dr Jessica Briscoe [00:35:09] So it’s very good that there is something else available for those people that just don’t tolerate it.

 

Dr Katy Munro [00:35:17] Yeah. Now, we’ve got to talk now a bit about heart disease and headache mimicking heart disease and headache being a sign of heart disease. So we know that as we get older, our risk of heart disease will increase. And the best way of keeping that low is to exercise regularly. Not smoke, eat a good healthy diet with loads of vegetables and low in saturated fats and preferably don’t have a family history of heart disease.

 

Dr Jessica Briscoe [00:35:47] That would be wonderful wouldn’t it.

 

Dr Katy Munro [00:35:47] It’s a bit difficult to arrange that at this stage. And so as people get older, they may start to get angina or even heart attacks. And occasionally heart attacks will present as headache. And this is a thing called cardiac cephalgia. I have to say, I don’t think I’ve seen this.

 

Dr Jessica Briscoe [00:36:06] I haven’t seen it. People get very excited- anothing thing people get very excited about at conferences. It’s really interesting because there’s a medication, GTN, nitroglycerin, which is used a lot in headache studies, actually, it often induces headache, induces migraine, but it’s a treatment for heart attacks and angina. And actually it improves headache, it’s the only time that it improves headache is if you have cardiac cephalgia.

 

Dr Katy Munro [00:36:33] Interesting.

 

Dr Jessica Briscoe [00:36:33] I’m not saying that everybody should spray themselves a spray of sublingual GTN.

 

Dr Katy Munro [00:36:41] When they have headaches, no.

 

Dr Jessica Briscoe [00:36:42] Because I think a lot of people would feel a lot worse. This isn’t actually a particularly common- it isn’t a particularly common type of headache, but it’s important to think about actually. I mean, I don’t know. I mean, I suspect that I don’t know if in a GP setting I don’t know if i’d be doing an ECG in all my patients that came in with a headache who are over the age of 62.5 (the mean age here).

 

Dr Katy Munro [00:37:12] They looked at lots of published cases and 34 published cases were explored in this paper that we’re quoting here, but 60 percent of them had headache without chest pain when they were having a heart attack. That’s quite high, isn’t it, really? Although 32 cases- 34 cases, sorry, is not that many cases. So it’d be interesting to know more about that. But I think it’s just something to have at the back of your mind if you’re looking at particularly doctors working in casualty need to be thinking- because that’s probably where these patients may pitch up if they are looking unwell. The headache resolved with appropriate cardiac treatment. So it is definitely the heart disease causing the headache. But then there’s a confusing thing that sometimes migrainosus thoracalgia has been described where this is chest pain mimicking cardiac disease and thought to be migraine. So I don’t know if we’re just confusing everybody by talking about this.

 

Dr Jessica Briscoe [00:38:16] I think we probably are. May be best to move on quickly.

 

Dr Katy Munro [00:38:20] But basically, if somebody’s got a headache, think about the generalised risk factors for heart disease as well, just to be sure.

 

Dr Jessica Briscoe [00:38:28] Absolutely. Next is one of my favourite topics, actually. That’s an awful thing to say. Shingles. I always found it quite interesting because shingles is a virus essentially. Incredibly painful. Often- I find interesting, because I’ve recently seen it in quite a few people where it doesn’t follow the rules. It usually stays on one side, usually in a strip across what’s called a dermatome, which is- it’s the way that the nerves sort of distribute around the body, it’s called a  dermatome. And essentially it’s caused by the chickenpox virus. So it’s usually in people who’ve had chickenpox. Not exclusive, I think they say everyone has to had chickenpox but here’s always one or two cases where people haven’t had chickenpox and get it.

 

Dr Katy Munro [00:39:13] You can have chickenpox without knowing.

 

Dr Jessica Briscoe [00:39:15] Exactly.

 

Dr Katy Munro [00:39:16] You can have it really mildly if you’re a young child and nobody said, ‘oh, there’s three spots you had were chickenpox’. You have to have been infected with the herpes zoster virus. And it then goes dormant in your spine, basically, in the nerves in your spine. And then something causes it to reactivate and come out just on this one strip usually. And it could be on the face. And it’s quite often it’s around the eyes.

 

Dr Jessica Briscoe [00:39:42] Yeah, it often causes symptoms before the the rash appears. So people often describe a burning it’s a neuralgia, which tends to be a burning and nerve pain. Burning, tingling. It’s quite exquisitely painful. And then often a vesicular rash, a little fluid filled capsule’s will appear. And  it’s not always that obvious actually, it can be quite unsightly or it can be not particularly obvious.

 

Dr Katy Munro [00:40:14] It can be very classical appearance, can’t it. Very sort of red, crusty, and you see that obvious little trail going around the side of somebodys chest or maybe down their leg or their back. But when it’s in the face, of course, sometimes it’s in the scalp. So you may have to hunt for those little vesicles in amongst the hair.

 

Dr Jessica Briscoe [00:40:34] Absolutely. We always debate whether to treat it or not. Essentially, you want to treat shingles with an antiviral. Usually acyclovir is one that we tend to use if you see it within 72 hours. It’s one of the interesting ones. It’s not like taking antibiotics for a bacterial infection where it will make you feel better and it will help things. You don’t take antivirals to make the shingles go away. You actually take it to prevent quite a common, horrible complication of shingles called postherpetic neuralgia. Now, apparently, one fifth of people with shingles will go on to develop postherpetic neuralgia, which is much higher than I thought. Yeah, but acyclovir or another antiviral will actually, as I say, won’t hasten the progress of the shingles, but it will just prevent that horrible burning. It’s usually a burning pain over the area that you had the shingles, incredibly painful, doesn’t really respond to normal pain killers because it’s a nerve pain killer. And if it’s in the face, this will be a cause of facial pain or headache. And as Katy said, you can’t always see the rash. If it’s in the hair, you won’t know about it. And it can be very problematic.

 

Dr Katy Munro [00:41:51] There are ways to treat the postherpetic neuralgia. And it’s definitely worth seeing a doctor and asking about the options for treatment. But your risk of getting a bad pain after this herpes infection is worsened if you’re an older age, if you’ve had a lot of pain before the rash comes out and if you’re immunosuppressed or have diabetes. Often diabetes and immunosuppression is a risk factor for people with chickenpox as well. So it can be very severe, chickenpox, if you’ve got either of those things, it’s quite dangerous. Normally there is a vaccine now for shingles, isn’t there?

 

Dr Jessica Briscoe [00:42:36] That’s for the over 70s I think.

 

Dr Katy Munro [00:42:37] It is. I think it’s licenced for over 50s but in this country we don’t give it to people that young. I mean it is around but, you know, needs must with the NHS. It is very helpful to prevent people getting shingles. But also then the complication of shingles, which both you and I have seen patients who’ve really struggled with the pain.

 

Dr Jessica Briscoe [00:43:00] Absolutely. It’s horrible.

 

Dr Katy Munro [00:43:03] We wouldn’t treat the pain with opioids or tramadol would we? Any of those kind of things. Well as headache specialists we are so allergic to them anyway.

 

Dr Jessica Briscoe [00:43:11] No, we used to actually tend to use nerve pain type neuropathic analgesics, nerve painkillers so things like amitriptyline. I’m not going to mention the others because some of them are not always so helpfully used nowadays, but amitriptyline is usually my go to as long as there aren’t any other medications that people are taking that can interfere with it.

 

Dr Katy Munro [00:43:32] Yeah.

 

Dr Jessica Briscoe [00:43:34] Sort of brings us on to medication related headache I think. We’ve talked ad nauseam about medication overuse headache, but one thing that’s really interesting is that people- one of the things that can cause headaches, if you look in any leaflet of any medication, one of the side effects will be headache. But actually, if people are taking more medications then this is much more likely to happen as people get older, they may have headaches related to what we call polypharmacy, taking multiple medications.

 

Dr Katy Munro [00:44:12] There’s a whole long list of medications that can be linked with headache as a side effect. So a little bit different from medication overuse. So this is headaches that are happening because people are taking the medication quite correctly for something else. But the side effect happens to be also headache. And like any list of side effects, I would say to people, you know, every drug will have a long list of side effects, but it’s not compulsory to get them. So you have to just really kind of tease out whether the headache that person is getting is because of the medication, which may not have been given for anything to do with headache or whether they’ve got a headache due to either primary or second cause of something else. So that’s just worth thinking about. And we haven’t talked about cervicogenic headache, so we’re just going to touch on that shall we, Jess? So cervicogenic headache- we’re were both kind of looking quizzical about that because we again, it’s probably not one that we see so much in our clinics, is it? We tend to see migraine partly because we call the National Migraine Centre.

 

Dr Jessica Briscoe [00:45:21] Yeah, I mean, it is a definite cause of headache. I often think- my only issue with cervicogenic headache is that a lot of people diagnose migraine as cervicogenic headache.

 

Dr Katy Munro [00:45:33] I think that’s why we worry. But it’s not the right diagnosis and it may be referred.

 

Dr Jessica Briscoe [00:45:38] And it’s definitely a valid cause for headache. And I think it’s something that probably physiotherapist, chiropractors and osteopaths see probably a lot more than we do at the National Migraine Centre.

 

Dr Katy Munro [00:45:51] Yeah.

 

Dr Jessica Briscoe [00:45:51] But I mean, part of my issue with it is that if actually if you scan anyone’s spine over the age of 20, you’ll find wear and tear changes. So you can’t necessarily attribute someone’s headache to the wear and tear changes. However, if you are actually getting you know- there are quite- it tends to be a different type of pain, actually. It doesn’t feel like a migraine.

 

Dr Katy Munro [00:46:18] Yeah.

 

Dr Jessica Briscoe [00:46:18] It’s usually sort of like I referred pain- again, it’s a bit more of a nerve type pain, isn’t it, or a spinal pain.

 

Dr Katy Munro [00:46:23] Yeah, but it tends- the problem is that there’s no consistent diagnostic framework for the different types of practitioners who see people of this kind of possible headache. So it may be that we as headache specialists use ICHD-3, whereas manual therapists will use an examination in their own criteria. So it’s a little bit more tricky. It probably is about one to four percent of people who are getting some element of cervicogenic headache.

 

Dr Jessica Briscoe [00:46:57] It’s quite a low percentage, i think that’s a low presence.

 

Dr Katy Munro [00:47:00] Not that many but it’s around the cervical vertebra, numbers two and three in the neck, which is quite high up.

 

Dr Jessica Briscoe [00:47:10] High pain.

 

Dr Katy Munro [00:47:10] It doesn’t seem to be the lower ones as you’re getting down the neck towards the thoracic spine, which starts at the top of the chest. So neck pain, of course, is quite a common thing in older life isn’t it, but apparently peaks in middle age. I would have thought it would have got worse and worse and worse, but it peaks in middle age and then isn’t quite so bad in the elderly populations. The presence of degenerative disk disease is not a risk factor for this type of headache. I’m reading that out from the paper because I think that’s really important.

 

Dr Jessica Briscoe [00:47:45] Really important.

 

Dr Katy Munro [00:47:46] So just because you’ve had a dodgy looking x ray does not mean that that’s the cause of your headache.

 

Dr Jessica Briscoe [00:47:51] You know my feeling on neck xray- on spinal x rays anyway.

 

Dr Katy Munro [00:47:54] Probably done too much.

 

Dr Jessica Briscoe [00:47:54] They are and I don’t- Yeah, that’s quite a lot of radiation, I think are probably better, better investigations to do. But I think that’s really important because as I mentioned, there are lots of studies where they’ve done MRIs on people from the age of 20 upwards. And I think we all agree that 20 is not in the old age category. You know, people as young as 20 can have, you know, signs of degenerative disease in the spine, largely because we’re not really supposed to stand on two feet. But, you know, so, you know, there are a lot of people who are 20 who are doing all sorts of things, who have probably what would be reported as significant degenerative disease, but wouldn’t be having any symptoms of it. And, you know, same with someone in their 70s, 80s, actually.

 

Dr Katy Munro [00:48:44] Yeah. So the one thing we do know about or some of the things we know about cervicogenic headache is it seems to be that when you move your neck, it triggers off the pain and the pain tends to be on the same side in your shoulder or arm. It may be that there’s restricted movement, but not necessarily. And it’s basically doesn’t really respond to the kind of treatments we use for migraine.

 

Dr Jessica Briscoe [00:49:15] Or for other types of pain disorders. So I think sometimes people try things like indomethacin in case it’s hemicrania continua or something like that as a side locked pain.

 

Dr Katy Munro [00:49:24] Yeah. Botox is not helpful either is it. So it may be useful to have neck exercises. And I think when I’m talking to patients with any kind of neck referred pain, you know, whether it’s their migraine being felt in their neck or whether I’m suspecting cervicogenic problems, I look at their posture and we try and correct that sort of head forward, round shouldered posture, which is so common, isn’t it?

 

Dr Jessica Briscoe [00:49:50] Because, again, we talk about this a lot, actually. The nerves of the face and the neck and shoulders and upper backs are very closely related to the nerves that cause pain in migraine. So, you know, any kind of nerve irritation in the neck and shoulder can trigger migraines or could be one of the many triggers for migraine.

 

Dr Katy Munro [00:50:13] What about strokes?

 

Dr Jessica Briscoe [00:50:15] Yeah Post stroke pain.

 

Dr Katy Munro [00:50:17] Strokes and headaches?

 

Dr Jessica Briscoe [00:50:18] Post stroke headache I’ve seen a lot. Also I mean, I think we did briefly touch on stroke and being worried about people with I guess who are having new headache, it being a stroke. I think generally speaking, stroke. People think of it as that, you know, that FAST, I think is the acronym that people like using. Facial drooping, arm weakness, slurred speech, time I think is the last one.

 

Dr Katy Munro [00:50:45] Time to ring 999. I think that’s it. I’ve seen the adverts.

 

Dr Jessica Briscoe [00:50:53] I’m glad they worked. But, actually, some people- they can be so much more insidious. And I’ve certainly seen people with much- I mean, most doctors have seen people with very unusual signs where something clicks and you think that’s a stroke and you send someone to hospital?

 

Dr Katy Munro [00:51:06] Yes.

 

Dr Jessica Briscoe [00:51:07] One of the things I often worry about and we talked about this on our ‘when should we scan?’.

 

Dr Katy Munro [00:51:12] Yeah, ‘do i need a brain scan?’.

 

Dr Jessica Briscoe [00:51:14] Right back in series one and it’s when people’s aura is very different. Now we mentioned that people who are older are much more likely to get aura without headache. I worry about aura in older people where it’s not going away. So if it’s lasting for longer than a couple of hours, really, I’d be a bit worried without any break at all. Or people getting just lots more aura where they didn’t really get much before. Not always, because people can also just have normal changes in their migraine. But I would worry about that causing stroke and then, you know, a change to their migraine, which doesn’t feel like- doesn’t have the usual features of migraine. That would worry me as well.

 

Dr Katy Munro [00:51:53] Yes, I think that’s the thing, isn’t it, that as we get older, so many other things can crop up that we- just because somebody has had a migraine history throughout their life, if there’s any change to that, that’s the key thing, isn’t it? It’s just keeping alert to whether or not there’s something else going on as well. We probably have a lower threshold for scanning people like that or asking them to get referred in to NHS neurology clinics.

 

Dr Jessica Briscoe [00:52:18] Absolutely. I think it’s also quite important to mention blood pressure, other things and thing like that.

 

Dr Katy Munro [00:52:23] Oh, yeah, blood pressure definitely.

 

Dr Jessica Briscoe [00:52:24] I mean one of my bugbears is people thinking that- I mean, you can get headaches because of high blood pressure.

 

Dr Katy Munro [00:52:32] Pretty uncommon though isn’t it.

 

Dr Jessica Briscoe [00:52:33] I mean, it has to be- it’s usually something called malignant hypertension. Which I think is another old fashioned term, but it’s where your blood pressure is incredibly high, it’s causing pressure changes behind the eye usually get visual changes too. Or a hypertensive crisis, I think is the new term for it. Usually, that top number usually has to be above 200 and that bottom number has to be pretty good going over 100 as well. Having just- having your blood pressure be if you’re someone who suffers with high blood pressure and it’s a little bit out of the normal range, it’s probably not what’s causing your headaches. Also, don’t forget, when you’re in pain, your blood pressure will go up anyway.

 

Dr Katy Munro [00:53:09] Tends to go up.

 

Dr Jessica Briscoe [00:53:10] So people often say, but my reading was this when I when I had a headache and I’ll say, well, you were in pain.

 

Dr Katy Munro [00:53:15] Yes. Yeah. So blood pressure, the gold standard way of assessing whether somebody’s blood pressure is a problem is to have a 24 hour blood pressure machine and GPs can refer you to get that investigation done. And that gives a good picture then about fluctuations of blood pressure throughout the day. And quite often it’s seeing the doctor that’s put the blood pressure up isn’t it. A thing called white coat hypertension, which is a bit old fashioned because nobody wears white coats anymore. We should call it scrub hypertension now shouldn’t we? And so the other things that doctors do that can make people’s headaches worse are investigations for heart problems or for blood vessel problems. So angiograms or carotid investigations or carotid endarterectomy, which is where there’s a procedure that sort of clears the carotid blood vessel of any plaques of debris that are clogging it up. And you can get headaches after having those. So those are quite important. The last one we just wanted to mention is burning mouth syndrome, which is pain in the mouth, funnily enough. And everything looks absolutely normal. But the patient complains that their mouth is really, really sore. So it’s about 3.7% with a typical population being middle aged to elderly women. And it usually lasts about two or three years. And of course, you have to exclude all the other things that might cause it like a dry mouth or some of the rashes like lichen planus, which can occur on the skin, can also occur in the mouth, with a sort of typical little white spots that you see in the lining of the mouth. Thrush, mouth ulcers,.

 

Dr Jessica Briscoe [00:55:01] Cold sore virus as well.

 

Dr Katy Munro [00:55:03] Vitamin deficiency. So, yeah, so it’s an unusual one, but it can really happen anywhere inside the mouth, but it’s usually on the front two thirds of the tongue and it needs a lot of blood test work up and an investigation to exclude the other things. But yes, burning mouth syndrome, it does tend to come on after midlife.

 

Dr Jessica Briscoe [00:55:28] Absolutely.

 

Dr Katy Munro [00:55:29] And there are things that can be done to help that. So if your mouth is burning and you’re not sure why, go and see a doctor and get some advice on that? We’ve covered a lot of the things that can cause headache in older age, but I would say this isn’t necessarily an exhaustive, definitive list.

 

Dr Jessica Briscoe [00:55:44] No not at all.

 

Dr Katy Munro [00:55:44] You do have to take particular care that people who are of increasing age haven’t got other things going on.

 

Dr Jessica Briscoe [00:55:54] Absolutely.

 

Dr Katy Munro [00:55:54] So just the diagnosis and the differentiation between primary headaches and secondary headaches is even more important perhaps. Medications need to be used with caution, whether they’re for the headaches or whether they’re for other things. A complex kind of thing to think about but hopefully that’s given people a bit of an idea of what they’re in for as they get older.

 

Dr Jessica Briscoe [00:56:22] It’s probably a good point to put a little plea in. We were so busy enjoying talking about headaches in middle age and beyond that we actually didn’t say this in the middle of our speech. So if you have enjoyed this podcast and if you’ve enjoyed listening to our numerous other episodes which are available on all of the usual platforms, we’d really appreciate if you could donate some money to us, because we are a charity and the only way that we can continue to run our clinic and see people virtually or otherwise and keep doing these podcasts is to have donations. Now, the link to our Virgin Money Giving page is in the blurb below and we’d be really grateful if you could click that and give whatever you can.

 

Dr Katy Munro [00:57:10] And if you’ve liked what you’ve heard and you’d like to spread the word to other people, please leave us a review. Apple podcast, it’s easy to do. Some of the other pod hosting places, you can leave a review and share it with your friends. Thanks for listening.

 

Niamh [00:57:29] Hi, everyone. Today I’m joined by Anna. So Anna, why don’t you tell us a bit about your migraine experience.

 

Anna [00:57:36] I’ve had migraines since I was a small child at primary school and had them all my life, but when I got to sort of past the menopause, they got much worse. And I thought when I retired, perhaps they would get better again, but they didn’t. They got progressively worse and worse and became quite chronic. It meant that for well over half of every month I had a migraine, which meant I had to go to bed and I was continuously sick and couldn’t do anything at all.

 

Niamh [00:58:15] And how did you find this sort of impacted your daily life?

 

Anna [00:58:20] Well, it got to the stage where I couldn’t plan anything. Meeting friends or going away on holiday just wasn’t possible anymore. That impacts on your family and all your friends, and it’s just very, very difficult.

 

Niamh [00:58:38] So how are your migraines now? Are you currently managing them?

 

Anna [00:58:42] They’re cured.

 

Niamh [00:58:43] Fantastic.

 

Anna [00:58:44] I put some of the aimovig or the calcitonin gene-related peptides from the National Migraine Centre as a last ditch attempt, as I tried absolutely everything else. And it’s been absolutely life changing. It’s just amazing. I can do anything now.

 

Niamh [00:59:06] That’s fantastic to hear. And so do you have anything that you would say to other people who are either just getting migraines themselves or maybe their migraines have changed and become more chronic?

 

Anna [00:59:15] Don’t give up, just try everything. And hopefully with the new drugs that are coming online, it may be just the thing that you need to help you.

 

Niamh [00:59:29] That’s fantastic. Thank you so much, Anna.

 

[00:59:34] 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.