A National Migraine Centre Heads Up Podcast transcript
[00:00:06] 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 [00:00:15] Hello and welcome to this edition of the Heads Up podcast. I’m Dr Jessica Briscoe and I’m not joined by Dr. Katy Munro. We’ve got a special guest this week, Professor Paul Booton, who used to work for us at the National Migraine Centre. Hi, Paul.
Dr Paul Booton [00:00:30] Hello there. Hi. It’s very nice to be back again.
Dr Jessica Briscoe [00:00:33] Yes.
Dr Paul Booton [00:00:33] Although back virtually as it turns out.
Dr Jessica Briscoe [00:00:36] Well, eagle eared listeners may be aware, eagle eared is not a phrase. Pork eared? Whatever. Listeners may be aware of, may have heard Paul before. As he helped us, or he was our special guest on our Cluster Headache podcast. And Paul used to work with us at the National Migraine Centre, but is now happy in his retirement and comes in to consult with us every so often.
Dr Paul Booton [00:01:00] Come and interfere on a regular basis.
Dr Jessica Briscoe [00:01:03] Interfere in a pleasant way. So we thought we’d do, given the time of year that it is. Well, it’s a little bit after this time of year. But we thought we’d do a podcast on taking your migraine to university. And this is sort of been inspired by the fact that there’s been a lot I mean, obviously this year there’s been a lot of change, what with the coronavirus pandemic. But also we’ve been struck by the fact that people have been heading off to university, their first time away from home. And it can be a really tough time if you’re someone who is prone to getting migraines. Wouldn’t you agree?
Dr Paul Booton [00:01:39] Yeah. It’s I mean, I started thinking about this because my son, although he’s been away for a couple of years, when he came back for a week or so ago, he was suddenly telling me about his various exploits and I thought, gosh, what a sort of vast change that is from living at home and the things which are going on there. And that’s really going to change things for people with migraine and could really upset your migraine. So I thought it’d be very useful to have a discussion about that on the podcast today.
Dr Jessica Briscoe [00:02:10] Yeah, absolutely. I mean, I think it’s also worth saying that this information, this sort of advice could be extrapolated for any major change. But I think I think going to university tends to be the first big life change that people go through, sort of that having been at home, having been to school with a very regular routine, you’re suddenly in the big wide world looking after yourself. I think that sort of tends to be people’s first sort of life change that could affect their migraine in quite a major way.
Dr Paul Booton [00:02:37] And instead of mum and dad looking after you, whether you like it or not, you’ve suddenly got unlimited freedom or so it seems.
Dr Jessica Briscoe [00:02:44] Absolutely.
Dr Paul Booton [00:02:46] I was just thinking of the French motto slogan, what’s it called? Liberté, Égalité, fraternité. I’m not sure there’s too much Égalité, but certainly you get a lot of Liberté and probably too much fraternité once you start university.
Dr Jessica Briscoe [00:03:02] Yes.
Dr Paul Booton [00:03:04] They are not without their problems.
Dr Jessica Briscoe [00:03:06] No, no. I mean, obviously there are pros and cons, but particularly from a migraine point of view. In our Triggers podcast, we talked about how important it is to keep everything a little bit boring if you want your migraines to be quite controlled. And unfortunately, one reason or another going to university and being free and spending time with your fellow man or woman can be quite problematic.
Dr Paul Booton [00:03:35] Yeah, I mean, should we start there with talking about triggers?
Dr Jessica Briscoe [00:03:38] Yeah, I think so. That’s always a good place to start, I think.
Dr Paul Booton [00:03:41] I always call them the big four with triggers, which is fluids, food, sleep and exercise. And we might, for the sake of argument, start with fluids. And the fluids you need to take in if you’ve got migraine are plenty of water and the ones you want to watch are alcohol and fresher’s week often entails drinking your own weight in alcohol.
Dr Jessica Briscoe [00:04:05] Mm hmm.
Dr Paul Booton [00:04:06] And also not so talked about, but also quite important if it builds up is caffeine.
Dr Jessica Briscoe [00:04:13] Absolutely. It’s actually one of Katy’s favourite topics to talk about, caffeine. And but also often at university, sometimes alcohol and caffeine are mixed together, which can cause all sorts of problems on their own.
Dr Paul Booton [00:04:28] Yeah, yeah. So you sort of drink in the evening to have a good time and you fill up on caffeine the next morning to kick start you back to lectures again. And after a while it stops being such a great idea if you’ve got migraines.
Dr Jessica Briscoe [00:04:42] Absolutely. I always think of caffeine a bit like- well actually I always think of alcohol and caffeine as more like drugs, actually. So whenever people talk about specific triggers, which as everyone who listens to this knows, I don’t put much stock in. But caffeine and alcohol, I always think of more as sort of like a drug effect. So they’re both toxins essentially and caffeine, there is a little bit of evidence that it seems to work in a similar way to medication in a sense, it can cause like a medication overuse headache type effect. If you have too much caffeine in certain people that are susceptible to that, it can build up and and cause that sort of daily headache, that sort of medication overuse type headache. Because as we are aware, caffeine can help migraines in the acute phase, caffeine can actually be quite helpful. So I tend to think of it a bit like a bit like a drug or a painkiller in its effect. So having too much on a regular basis can be a problem and also stopping caffeine abruptly. So going from sort of, as you said, using your caffeine to help you in the morning. But also when you take it in the evening, if you’re sort of working hard on your paper that needs to be in or something like that, and you’re using caffeine to keep you awake, if you then stop taking altogether people can also get a sort of a rebound headache afterwards.
Dr Paul Booton [00:06:01] Well, I know I certainly do. Not so much a headache, but I get migraine, but not a very headache-y version of migraine. But certainly if I, if we run out of coffee at home, essentially I just have a hopeless day when I can’t do a thing. I’m completely brain fog all day. And that’s not a rare thing. How much coffee is it reasonable to drink on a regular basis, Jess?
Dr Jessica Briscoe [00:06:30] I mean, for people without migraine, I say three to four cups a day is the maximum. Always before noon. People with migraine, I say you don’t really, really want to have more than one cup of strong coffee. There is a number of grams that Katy’s very hot on that you’re supposed to have. And also being aware that not all coffees are equal. So if you get these strong coffees from various coffee shops, they’re likely to be-
Dr Paul Booton [00:06:58] Posh Coffee shops.
Dr Jessica Briscoe [00:06:58] Yeah, they’re likely to be stronger. So you certainly don’t want to have more than one cup of strong coffee per day. Essentially, you also kind of want to- you want to just be a bit- some people do find that cutting out coffee altogether, having any coffee can can trigger a migraine. Some people are very, very sensitive to it. And also being aware that having caffeine’s got a very strong Half-Life. So the amount time it takes to break down is a long time. And so it’s between 8 and 12 hours, depending on who you are. Everybody metabolises it slightly differently. So I often say try not to have it after about three or four p.m. But again, if you’re someone who gets migraines, try and avoid having it after midday because it can really affect your sleep, and that in itself can then be a migraine trigger if you’re not having good quality of sleep or having difficulty getting to sleep.
Dr Paul Booton [00:07:50] And then alcohol. If we talk about that for a bit, there’s really two ways that alcohol affects your migraine. There’s the sort of acute way when you, um, well I was going to say you have a skinful but for quite a lot of people it’s not having a skinful. It’s fairly small amounts just trigger off a migraine. And the sort of coloured forms of alcohol, like red wine and brandy are often quite a lot worse than the clear forms like, vodka and white wine. And so some people are just triggered by those really quite small quantities. And a colleague of mine- or of ours talks about these unfair hangovers.
Dr Jessica Briscoe [00:08:27] Yeah, I call them disproportionate.
Dr Paul Booton [00:08:29] Tiny amounts of alcohol. Disproportionate. That’s got too many syllables for me. But that’s the trouble. You can have quite small amounts of alcohol and it can really whack you the next day. The other thing which I think people don’t think so much about is just the regular quantities of alcohol can just increase the level of your migraine. So you may not if you’re drinking alcohol regularly, that regular alcohol can just sort of up the amount of migraine you’re getting. So you may not relate it to the alcohol, but it’s there. It’s there. So, again, it’s a thing to be careful with. Not very encouraging advice if you’re just starting university and want to cut loose a bit, but it’s true. Moving on.
Dr Jessica Briscoe [00:09:16] Yeah, so I think that actually brings us nicely onto- we started speaking about sleep. I know we’ve just jumped past food because we were talking about actually both alcohol and caffeine do affect sleep quality as well. So we talked a lot in our sleep podcast with Dr David O’Regan and Dr Alex Nesbit from St Thomas’s Hospital. They explained that both caffeine and alcohol can really affect sleep quality. Alcohol people often use actually often use it, probably not so much at university, but people do use it sometimes to try and help them get to sleep. But actually it does affect the sleep quality and people can find they can have migraines secondary to that. People in university obviously use alcohol for a different reason. But sleep can be really, really affected at university, partially because of all of these fun nights out that people have, possibly not so much at the moment, what with the pandemic. But people might be having late nights in with their housemates or their bubble or whoever they’re with. And people may find that they’re having fun getting to know their their compatriots. And things start to keep going for a lot later and then they’ll just shift their sleep patterns. So you might end up going to bed later. You might have lectures later in the day and then another day you’ll have a lecture early. So you’ll be getting up earlier and then you won’t get that regular sleep pattern. It’s not like school where you have that 9am-5pm or 8.30am/9am-4pm whatever it is the school hours are when you have that regular time and it’s a little bit more- depending on what degree do- most people don’t have lectures all day. So people’s sleep pattern can be quite significantly affected.
Dr Paul Booton [00:10:54] And it’s not just lack of sleep, but to much sleep can as well. So there’s the- what used to be known as Sunday morning headaches. When you have a lie in on the Sunday and you have a cracking headache and that’s a migraine. That’s a migraine doing that. So oversleeping is a big trigger for migraines just as much as under sleeping is.
Dr Jessica Briscoe [00:11:12] Yeah. That catching up.
Dr Paul Booton [00:11:14] Mhm. Yeah. And what you’re really aiming for is a regular pattern of sleep. So the same time to bed, same time up. Now without making university completely boring, you’re not going to do that all the time. But just trying to do that as much as you can, keep it as regular as you can and you’ll reap benefits from that.
Dr Jessica Briscoe [00:11:32] I think food is quite a good thing to talk about next because it is quite linked to sleep actually. People tend to, you know, when you’re eating is very much aligned to when you go to bed and when you wake up in the morning. So I think with food as well. So the big change actually at university is a lot of people suddenly have to fend for themselves and people have to start cooking when they may not have been used to cooking before. And also what people can afford, depending on what their budgets are, are very different. So, I mean, I know lots of people who essentially subsisted on noodles for most of their university career, or at least for the first year. And so I think we have talked before about how what you eat- well when you eat is really important. But also there is a bit of an importance about what you eat. So eating things that will burn very quickly and give you lots of variations in your blood sugar level tend to not be great for migraines because your brain prefers a much more steady state of sugar level. So eating noodles all the time is not great.
Dr Paul Booton [00:12:34] That’s of course a very easy thing to do when you’re first a student and you’re not used to cooking for yourself is to rely on instant foods, to rely on snacks, particularly, you know, lots of chocolate bars, so-called energy bars, that sort of thing. And they’re not great because you’ve got a lot of sugar in them and it’s metabolised very quickly. And this swinging up and down of blood sugars is a big, big trigger for migraine.
Dr Jessica Briscoe [00:13:02] I completely agree. And I think also there is that sense of freedom you get when you first go to university, but you’re suddenly not being told what you can and can’t eat all the time. And maybe that’s just me. So you do suddenly start saying, oh, I’m going to have this treat, which I wouldn’t have been allowed at home. So you probably do it a few more chocolate bars or your you know, if you are on the go a bit more, you think, oh, I won’t have a proper lunch, I’ll quickly just grab this. And, you know, that can be a bit problematic.
Dr Paul Booton [00:13:29] Yes. I can remember my first week living away from home at university and it got to the first Sunday and I suddenly thought Sunday lunch? Where does the Sunday lunch come from?
Dr Jessica Briscoe [00:13:40] Absolutely.
Dr Paul Booton [00:13:40] And the answer is it doesn’t come from anywhere unless you cook it yourself. So I went home.
Dr Jessica Briscoe [00:13:45] Sadly, I was four hours away from home, so I couldn’t do that. And then your last big one was exercise.
Dr Paul Booton [00:13:53] Yeah, exercise, we know, is good for us for all sorts of reasons, exercise is the cheapest way of gaining health across a huge wide range of parameters. It’s good also for things like anxiety and so on. So exercise is a good thing in capital letters. And with migraine, people who exercise regularly get less migraine than those who don’t. So it’s one of those things which is straightforward to do which has only really got benefits. That said, if you don’t do a lot of exercise and suddenly get up and run a marathon. Sudden exercise can trigger migraines and some people feel that’s quite a problem. The trick with exercise, I think, is to find some sort of exercise you like. So I never thought of myself as sporty when I was at school, because sporty meant standing in shorts in November in a rugby field while the local thugs bore down on you. And it wasn’t until I discovered things which didn’t involve a ball of any shape that I began to enjoy doing things. And so for me, I’m a keen cyclist. Jess, you’re always down the gym aren’t you?
Dr Jessica Briscoe [00:15:10] Or running sometimes, it depends. Probably less now with the virus, but. Yeah.
Dr Paul Booton [00:15:15] Yeah, yeah. But the trick is find something you enjoy and do it regularly. Just keep yourself that bit fit and it will help your migraine.
Dr Jessica Briscoe [00:15:24] Yeah. And also I think that’s the great thing about university, that there are so many things that you’ve got the opportunity to try. All sorts of sports that you wouldn’t have been aware of or wouldn’t have had the opportunity to try before. And I think it’s quite a nice opportunity to do that. As you said, though, Paul, I think it’s really important. I always say this, to people exercise can be a trigger. And I think it is when you start doing something more intense when you’re not used to it. So I always say to people, build it up slowly. I think it’s I personally think it’s a cortisol response for some people. Doing intense exercise gives you a massive shoot up in your cortisol levels. And if you’re not used to that, I think it can then trigger a migraine later on. Also, it drains your energy and fluid levels. So it gives you a drop in blood sugar level and your fluid levels go down. So whenever you’re doing any exercise, making sure you’re hydrated, that you’ve got enough fuel on board before and after is really important if you’re someone with migraine, because those can be actually simple things that allow you to to keep doing exercise, which, as Paul said, can only be good for you.
Dr Paul Booton [00:16:31] Yeah. And some people as Jess says do get very easily triggered by exercise. And I think if that’s you, you should probably seek professional advice on that. Yeah, there are lots of strategies you can adopt which help that. The simplest ones as Jess says, make sure you’re well hydrated, make sure you’ve got enough calories on board when you exercise, because there are two big triggers in their own right.
Dr Jessica Briscoe [00:16:54] Yeah. And I think the one thing that struck me when I was talking to a patient was actually certain types of exercise are more likely to trigger certain people. So some people find- some people love running when they have a migraine because actually, especially if it’s outside, it’s probably something to do with the cold air I actually sometimes think can be helpful because we talked about biofeedback and the improvements it has for that. But some people find that the thumping when they have a migraine is really jarring and can sort of it can cause a headache to be worse. Some of that movement sensitivity, whereas other exercises like swimming, I mean, I talk about cold water swimming seemingly endlessly, but cold water swimming can be really good for migraine. Some people find things where don’t have to move their head so much like climbing actually can be quite good. All sorts, I mean, there are so many different types of exercise. I put in inverted commas, which isn’t great for a recorded voice recorded thing, but there are some sorts of types of exercise that we don’t think of as exercise, usually there’s something that people can do that wouldn’t necessarily trigger attacks or make attacks worse, but might be beneficial.
Dr Paul Booton [00:18:04] But don’t retreat to the couch is the message.
Dr Jessica Briscoe [00:18:06] No, no. And I think you also want to have a chat about things that aren’t really triggers. So a lot of the myths, because I know I always think it’s a good idea to reiterate these. I don’t think we can reiterate them enough personally.
Dr Paul Booton [00:18:19] Yeah, that’s right. So there’s lots of ‘triggers’ out there. So chocolate is the classic one. Chocolate, cheese and red wine are the ones we always-.
Dr Jessica Briscoe [00:18:29] Citrus as well.
Dr Paul Booton [00:18:29] I actually had a student sitting in with me in a clinic one day he said, we’re told always to ask about chocolate, cheese and red wine. Well, actually, they’re pretty unusual those and I think the jury is out for chocolate is actually a trigger at all.
Dr Jessica Briscoe [00:18:46] I think it’s been completely refuted actually. I mean, I always quote about I think about- I was taught twenty percent. Only twenty percent of people have specific food triggers, but I actually think it can be attributed to something else. So chocolate the whole reason that people think that chocolate and cheese are triggers is because before we knew about migraines being- about how migraine developed, before we knew that it took 12 to 24 hours before the pain started.
Dr Paul Booton [00:19:17] You’re going to tell them about the prodromes aren’t you.
Dr Jessica Briscoe [00:19:17] I am. It’s my favourite subject. It’s 12 to 24 hours before migraine actually develops into what we call the migraine, the pain phase of migraine, proper phase or symptom phase, depending whether pain or symptoms are your migraine. And that’s when the whole thing starts. So you get this prodrome, this whole area before was premonitory phase. The bit before the migraine proper and about two hours before a migraine attack, people’s blood sugar level drops. And so people often crave things that push the blood sugar up. So cheese, chocolate, citrus, orange juice, things like that are quite common things to take in that time because the body is quite clever and it tends to crave- if your blood sugar goes down, it can crave things that push it up. So I think that’s why everyone thought that those were triggers. And then if people cut out cheese and chocolate, there are good reasons why that could be beneficial for migraine. As we discussed, keeping a steady state blood sugar level generally can be helpful. So cutting out cheese or being careful about what you’re eating tends to make you eat more regularly and will improve migraine. So I think it’s one of those myths that’s been able to propagate because of that. So, yes,.
Dr Paul Booton [00:20:28] But I think the message is with all these very specific triggers, is by all means, take that out of your diet for a while and see what difference it makes. And if it makes a difference, great. If it doesn’t make a difference, you don’t need to have migraine plus no chocolate. You know, go back to your ordinary lifestyle, which isn’t affecting the migraine. And there’s quite a lot of sort of new rather dodgy triggers out there. So people are going gluten free and wheat free are both terribly popular at the moment. The research suggesting they cause migraine is, I think, pretty minimal, although from time to time you hear a patient tell you a very persuasive story about that. So by all means, try it, but don’t spend the rest of your life eating rice cakes and water for things which aren’t- were never really affecting a migraine.
Dr Jessica Briscoe [00:21:22] I completely agree, and I would also say that my other caveat for this is if you have food intolerances, so IBS (irritable bowl syndrome) that is triggered by certain foods like gluten or dairy, actually having the intake in those foods will probably trigger your IBS, which in turn could potentially trigger a migraine. It’s not a direct cause and effect. It’s like any chronic illness, something that puts stress on your body. Having a flare of it will trigger your migraine. So that’s why I’m not to- I’m never absolute about these things. I think if you are someone who has found that cutting out dairy improves a migraine, probably because it improves your digestive health, then by all means that’s fine. But it’s not a specific trigger for your migraine, if that makes sense.
Dr Paul Booton [00:22:07] But I have to say, the number of patients who’ve said to me, I’ve never touched chocolate for 20 years, Doctor. And you say to them, has it made a difference? They say, no, I don’t think so. And, you know.
Dr Jessica Briscoe [00:22:19] So sad.
Dr Paul Booton [00:22:20] What is life without chocolate.
Dr Jessica Briscoe [00:22:21] I know. It’s really sad. It’s the best thing that everyone says to me when I say ‘I get migraines’. ‘Oh, so you don’t eat cheese, chocolate or drink red wine’ And i say well for me, actually, red wine is a trigger. I also don’t really like it so that’s by the by. But actually you just find yourself nodding and smiling because it tends to be easier to just agree with them than to go through my big argument about why I do eat cheese, well i don’t eat cheese but why I do eat chocolate.
Dr Paul Booton [00:22:47] By the time Jess’ finished talking for 40 minutes about it, they’d never raise it again.
Dr Jessica Briscoe [00:22:51] I know they’d never speak to me again.
Dr Paul Booton [00:22:54] Are we’re going to talk about threshold theory?
Dr Jessica Briscoe [00:22:57] We can do. I’ll let you talk about it because I think they’re sick of me talking about threshold theory so your version.
Dr Paul Booton [00:23:04] Ok. Well, it’s not difficult this. The sort of classic teaching about triggers which I certainly got at medical school, was that there’s a trigger and that triggers off your migraine. And actually that may be true, as we’ve discussed. But generally what happens is you get a bunch of things and it’s like you’ve got a threshold for what’s going to kick off the migraine. And so, you know, you’re out the night before and have had a few pints too many, you get up the next day. You kick yourself into action with some caffeine and you’re just sort of adding one trigger to the next one. And sooner or later, that’s it. Off goes the migraine. I can remember quite a number of women in the clinics saying to me, I’m fine with red wine anytime except the week before my period. And that’s quite a good example of the fact that you’ve got either of those triggers didn’t trigger the migraine, but when you’ve got the two together, off the migraine goes.
Dr Jessica Briscoe [00:24:06] I think it’s very important to point out that no matter what you do, however well you I think that actually is a really nice lead in to whatever you do to manage your triggers, to minimise your triggers and people with migraine are always susceptible to getting migraine. Now, that threshold can move up and down at any time. And I think sometimes we don’t because it’s not just internal factors. There are lots of external factors that also feed into where that threshold lies. So whatever you do, however much you minimise the triggers, however, however boring your life is being, even if you’re, you know, however many invitations to parties you’re-.
Dr Paul Booton [00:24:43] Turning down.
Dr Jessica Briscoe [00:24:44] Turning down. Some attacks are inevitable. And, you know, it’s really important to be able to manage those attacks as well as possible when you do get them. There’s a real problem in work life and I think actually in student life as well with something called presenteeism, which is where people are suffering with a migraine, where actually they can carry on well enough that they’re sort of there in body, but not necessarily in mind. And people just turn up to lectures, turn up to work when they’re in the middle of an attack and are not actually performing at 100%, it’s taking more effort to get through it. And that sometimes can just push an attack on for longer or trigger another one. So I think it’s really important to listen to your body when you have a migraine and try and manage it as well as possible so that you are functioning properly and not causing yourself too much stress or pressure.
Dr Paul Booton [00:25:37] Yeah, I can think of an example of that from again, from a patient in the clinic who was having problems with her boss, who said she’d got to come in, although she’d got a migraine. And she said, well, look for me, what works is if I’m allowed to stay at home, I can go to sleep with some painkillers for a couple of hours. It knocks out the migraine and I’m fine to work for the rest of the day. If I go into work with a migraine, it drags on through the whole day and into the next day. And she was saying, my employer doesn’t realise that you’d get a lot more work out of me if I was allowed a couple of hours to recover from a migraine properly. And I think that was a very sane thing to say.
Dr Jessica Briscoe [00:26:16] I think that’s such an important point. I know that sometimes we, I mean, for people who maybe have quite demanding courses where they have quite a lot of contact time actually having a place that they can go if an attack hits them in the middle of a lecture or in the middle of some form of university activity where they can actually go and sit quietly in a dark room. It’s bit I think sometimes it’s harder at university than it is at school or at work, actually, or if you’re nearby, being able to go off and take your painkillers, rest if you need to, and then be able to go back and actually be there present 100% can be really, really useful. But it’s also about taking the right type of treatment for your migraine. So I know a lot of people and I was guilty of this, too, in my university years, spent a lot I spent a lot of time taking sub-standard medication. It didn’t really work for my migraine too late so my migraine would carry on. And but I’d feel better because I you know, I’d feel better myself because, you know, I’ve taken my paracetamol. It didn’t do anything. But, you know, at least I knew I’d taken it. And I think it’s really important to take the right type of medication to the right quantities early, if you can.
Dr Paul Booton [00:27:31] A lot of people say to me, I carry on for as long as I can before I take the medication and actually that is a disaster.
Dr Jessica Briscoe [00:27:37] To decide whether it is migraine. Yeah.
Dr Paul Booton [00:27:41] Yeah, Because if you take it late, it’s much less likely to work than if you take it early.
Dr Jessica Briscoe [00:27:46] You have to hit it hard, quickly, basically. So I mean most people take nonsteroidal type medications, so that’s ibuprofen-like medications, aspirin or ibuprofen, depending on which one works for you at a high enough dose. So usually higher than it says in the packet. I usually say for aspirin, 600 to 900 milligrams.
Dr Paul Booton [00:28:08] So that’s three standard tablets.
Dr Jessica Briscoe [00:28:10] Yeah. And I like aspirin because it’s dissolvable. So it, it’s much more easy – it will absorb more easily in your stomach, which doesn’t tend to absorb things properly at the time that you have migraine. If you get sickness, taking an anti sickness tablet, the number of people who are very, very nauseated or vomit and have never been given an anti sickness tablet is really quite astoundingly high.
Dr Paul Booton [00:28:34] Yeah. My sister said to me the other day, she said, you know you said take an anti sickness tablet for your migraines. Yes. I did that and it worked. In the slightly surprised tone.
Dr Jessica Briscoe [00:28:43] Yes. It’s very funny. The amount of- the number of symptoms that people will just power on through always surprises me. And I think it’s this idea that you’re masking. This whole idea of masking a symptom. And actually, with anti-sicknesses- with the right type of anti-sickness tablet, you’re actually reversing the process that causes the sickness and then you’ll help your painkillers to work better. So we’ve talked before about the fact that the sickness is caused by your stomach slowing something called gastric status, which is caused by the migraine itself, stimulating one of your nerves, the vagus nerve, which innervates the stomach and that causes your stomach to slow down altogether. So that then means that your medication can’t be absorbed properly because it’s in the wrong part of your gut to be absorbed. And then often people will just feel horrible or vomit. And you don’t need to get to that stage if you catch it quickly enough. So the medications that I like, which are only prescribable nowadays, which is very annoying, domperidone, is an anti sickness that you used to be able to get over the counter, but you can’t anymore or metoclopramide is another example, but you can get something over the counter which helps with the sickness that doesn’t necessarily reverse that process, but can be really helpful, prochlorperazine or buccastem people can get as well. And that’s just something that sits underneath the gum or just over the gum and absorbs that way.
Dr Paul Booton [00:30:03] Yeah, it’s not really as good, but it does have some of the effects of the other ones. So it’s worth seeing your GP for a supply of those. GPs are a bit nervous about prescribing some of them because they recently had a big thing about some of the side effects, but to be honest, people who are using these things occasionally, the side effects are pretty unlikely to be a problem. I’d go further- most unlikely to be a problem.
Dr Jessica Briscoe [00:30:28] Yes, yes. I agree with that. And then the other thing is triptans. The other thing that people- a large number of people have never tried. So we do have a specific podcast on Triptans. But in summary, these are a migraine specific painkiller that have been around for about 30 years now? A bit less than that?
Dr Paul Booton [00:30:47] Yeah, about 30 years in fact it was the last specific thing designed for migraines until these new things with a funny name, these monoclonal antibody treatments.
Dr Jessica Briscoe [00:31:01] The MABs.
Dr Paul Booton [00:31:01] Came along just in the last year or so but for some people they’re a complete game changer. Again, you need to take them early on in the migraine attack for them to work best. And for some people, it means you’ve got to take a cocktail of the triptan, the anti sickness drug and the painkiller to really sort of BLAM that migraine out of the water at the very earliest stage. And then an hour or two later, you can pick yourself up and carry on.
Dr Jessica Briscoe [00:31:30] Mm hmm. I would also add that there are- because i’ve seen a lot of people who’ve said, oh, I took one or two sumatriptan (they’re the generic one or the first one that’s available over the counter). I didn’t work so I’ve never tried one again. There are seven triptans, some people- there’s no real rhyme or reason why some work in some and some work in others. I’ve seen people in the same family who have different ones that work for each individual. It is worth going to your GP and saying, look, I’ve tried this one, can I try a different one? And just cycling through them until you find one that works for you.
Dr Paul Booton [00:32:05] They they actually work for the majority of people. So it’s worth persisting with them until you find one which works for you.
Dr Jessica Briscoe [00:32:11] Yeah. And the other thing I’d like to just say quickly is about side effects. So a lot of people say that there are some quite- there can be some quite scary side effects to triptans, sometimes some jaw tightening and a bit of chest tightness as well, which can be quite alarming. It’s often not a- it’s quite a common side effect, I’d say, and it doesn’t happen with all of them. So it is worth trying another one, maybe a slightly different formulation, and it’s worth talking to a GP if that happens.
Dr Paul Booton [00:32:43] What about painkillers we should avoid?
Dr Jessica Briscoe [00:32:45] Oh, yes, that’s a really important point. So one thing that I know some people try is alcohol is a painkiller because for some reason people think that alcohol works to kill pain. It doesn’t really as we said, it tends to-
Dr Paul Booton [00:32:58] Kill you.
Dr Jessica Briscoe [00:32:58] Me? No it never has done. But things that makes things worse-
Dr Paul Booton [00:33:04] Oh you claim to stil be alive do you?
Dr Jessica Briscoe [00:33:07] But codeine is the big one. There’s a specific mixed painkiller that’s been formulated and marketed towards migraine, which contains codeine. And I always advise people to avoid it. It’s confusing because it has something related to migraine in the title of the painkiller. And I just always if you’re getting any any kind of painkiller for migraine- I don’t particularly mix formulations anyway because you don’t know how much of each medication you’re getting, but always just check the back and make sure it doesn’t have co-codamol or codeine in it. So codeine hits the wrong- opioids generally, hit the wrong receptors for migraine. So wrong pain receptors so don’t particularly help with the pain. They tend to just knock people out, which means that people can sleep off their migraine, but also they can cause rebound headaches very, very quickly, and you don’t have to take very many to get a headache off the back of the codeine based medication. So I would always avoid codeine.
Dr Paul Booton [00:34:12] Yeah. And do ask the pharmacist if the medication contains codeine, because all these branded things and the list is endless of things you see on the chemist shelves with the name attached to them. And a lot of them have got codeine or codeine derivatives in them.
Dr Jessica Briscoe [00:34:29] Yeah.
Dr Paul Booton [00:34:31] They never work very well anyway, because they most of them have not got quite enough of anything to be effective whatever you’re going to use them for. But in addition the codine really messes up your migraines, so avoid it.
Dr Jessica Briscoe [00:34:44] I think that’s a good point to discuss medication overuse headache as well, which I think is a really, no matter how few or many migraines you’re having. It’s important to be aware of this phenomenon. So medication overuse, it’s a specific type of headache that is mainly present in people with migraine, but other types of headache you can get it to. It’s this odd phenomenon where taking the very thing that can help you get rid of your migraine pain can cause further headaches. And it’s quite a curious thing and doesn’t happen in everyone. In the studies they quoted between 40 and 70 percent of individuals with migraine can develop medication overuse headache, which is quite a wide margin. But it’s very difficult to study this type of thing. It’s hard to define how many painkillers it is, it’s different for different types of painkillers. But I always think for a good rule of thumb is to try not to go above 10 days of painkiller usage not amounts of painkillers you use. So you try not to take painkillers for more than 10 days a month, roughly. So the odd month you might get over it slightly. But if you’re consistently taking using painkillers for more than half the month or around half the month, I’d be slightly concerned that you’re going to develop medication overuse headache. And it’s one of the better things to try and avoid because being in medication overuse headache is horrible. The management of it is essentially withdrawing all painkillers for quite a long period of time. And it is nasty. And it’s the thing, I think, us headache specialists hate treating the most.
Dr Paul Booton [00:36:20] Yeah, yeah. And it’s this drip, drip, drip of painkillers into your system, often quite small amounts. I mean, we didn’t mention that. But triptans can themselves cause medication overuse and we get patients who say, my doctor won’t give me many so I just break them in half or breaks in quarters and take a little bit each day. And sooner or later, before you know where you are, it’s those painkillers, those triptans have started causing the headache rather than curing it. So the best advice is don’t get there.
Dr Jessica Briscoe [00:36:54] I think also the other thing that people do is they’ll take the painkillers initially, which will help, and then the pain will come back and they’ll go, oh, but I’ve already taken it today, so I won’t take it again, I’ll just go to sleep. And then it goes on to the next day. And then as you said, it’s a drip drip. So the headache is allowed to continue on. You are much better to hit it hard on day one to stop it from lingering into day two. So you can as I said, it’s a number of days, not doses of painkillers. So if you’re taking within the recommended amount of painkillers in one day, so, for example, with ibuprofen, if you are taking up to three doses in one day, that’s better than taking one dose in the morning. Oh, It’s come back a bit. Take another dose the next day. Oh, it’s still there. Take another dose the next day. So hitting it hard and quickly is the key.
Dr Paul Booton [00:37:41] What about if you’re getting quite frequent migraines in spite of taking all our good advice and living an upright, sober and boring life in your hall of residence, what can we do then?
Dr Jessica Briscoe [00:37:56] I think this is a point that’s really important and something that’s often missed. So it’s talking about preventing I think we’re talking about preventing migraines. So there are two scenarios that I think about preventing migraines. If you’re having infrequent but very severe attacks, so if you are having sort of less than four attacks per month but the ones that are really stopping you from carrying on with your daily life. And If you’re having really frequent attacks, that are stopping you from carrying on with your daily life. So the rule of thumb is more than four to six attacks per month. I mean, how do you define an attack? Is it days? Is it discrete attacks? But if you’re having more than four attacks per month, we should start about giving something that will prevent the migraines from occurring. So these aren’t painkillers, I think of them as things that lift up that threshold that we were talking about, so that you are less likely to trigger attacks. And we were talking actually before this about different types of preventatives, the ones that we always think about are the long term ones, so those are sort of daily medications that can be helpful. And what the what piece of advice would you give people about taking a daily preventative, Paul?
Dr Paul Booton [00:39:06] Well, they’re very, very helpful for the right people. And once you’ve got the right drug. I have to say, I was never very prescriptive about how many headaches per month. There’s lots of guidance about how many headaches a month before you use preventers.
Dr Jessica Briscoe [00:39:23] I’m not either.
Dr Paul Booton [00:39:25] The main thing is about how much is that migraine affecting you? How much is it interfering with your daily life? And so for some people, they may not have particularly frequent migraines, but they sort of BLAM them so hard when they get them that it’s you know, in that circumstance you might want to try a preventative drug. What you do with preventative drugs is you’re taking something every day, which as Jess says raises the threshold. So you’re much less likely to get an attack. They don’t mean you’ll never get an attack. Preventer, which is working well, will reduce the number of attacks by about 50 percent. So it’s you know, and to get that benefit, you may well have to put up with some side effects of the medication. It’s also true that not every preventer works for everybody. And so you may have to try two or three different ones before you find the right one for you.
Dr Jessica Briscoe [00:40:17] And I think the other important thing is ensuring that you don’t just stick to the starting dose. Some people start a preventer- so two things: trying it for long enough. So sometimes well-meaning doctors will start people on a preventative and after two weeks at the starting dose, it’s not helped so they’ll try another one. That’s not really effectively trialling it. I usually say it takes about four to six weeks for the effects of a preventative to be seen, can be quicker than that. I mean, I’ve seen people who’ve had effects within two weeks. That’s fine.
Dr Paul Booton [00:40:55] And that’s four to six weeks at a decent dose.
Dr Jessica Briscoe [00:40:56] Yes.
Dr Paul Booton [00:40:56] It’s not four to six weeks at a starting dose.
Dr Jessica Briscoe [00:40:59] Absolutely. And, you know, so pushing- making sure you’re getting to an acceptable, tolerated dose because some of the side effects are also dose dependent. So if you’re getting to a dose, if you’re finding that you get to a dose, it’s improved the frequency and severity of your attacks by 50 percent. But actually, you can’t get out of bed in the morning and you’re missing all your lectures, that’s no good. You probably need to find a happy medium where maybe you’re on a slightly lower dose, but you’re actually, you know, you’re having slightly more attacks, but they’re more manageable. It’s really about finding that balance between what’s acceptable from a side effect point of view. And as Paul said, not everybody gets side effects. And also what’s acceptable from a migraine point of view, bearing in mind that the preventatives are not going to cure your attacks. We can’t do that. We’re trying to bring it down to an acceptable level. So whether that is reducing the frequency, so you are having 50 percent fewer attacks or whether actually the attacks you’re having a much easier to manage, then that’s sort of the end point we’re looking for.
Dr Paul Booton [00:42:00] Yeah. I think the other thing it’s worth talking about with preventatives is when you stop. Again I’ve had loads of patients over the years say I’ve been on whatever it is for 15 years. And you think, well, actually, that’s not necessarily a terribly good idea. Generally, what we advise is to go onto these things, to stay on for about six months, something like that, and then wean yourself off them. It’s worth cutting it down in stages, not just stopping it absolutely. And when you stop taking it, generally people that good pattern of migraine persists for a number of months, you can’t say how long, but a variable length of time. and then if it starts to come back, then you can have another course of the preventatives. Migraine goes up and down over the years. Maybe you fall into a quieter patch then and you could do without it for however long it is. So when we’re talking about these, we’re not talking about a forever and ever thing. We’re talking about taking it for a limited period of time to get your migraine into check. And then once that’s happened, you can stop it and see how things are.
Dr Jessica Briscoe [00:43:06] I always think there are certain periods of time as well when students particularly are much more likely to get attacks. And I think we’re talking about exam time at the moment. And I often see some very well organised people a good few months before their exams. And they say, oh, you know, I always notice that my migraine attacks increase when I’m under a lot of stress. Which is a really common time to have attacks increase. And what can I do about it? I think you’ve got your strategies for how you manage that with prevention.
Dr Paul Booton [00:43:41] I mean, it’s in a way, it’s pretty obvious why your migraine is going to get worse. Exam time you’re feeling stressed quite rightly, in my case, when I was doing exams. And you’re probably putting in a lot more hours on revision and you may be working into the night. There’s all these sort of things, all of which make it more likely to have it. Again remember, these triggers, try to keep to a regular working pattern and don’t go working all night the night before an exam, that’s really a recipe for disaster. It’s a recipe for disaster even if you don’t have migraine actually. And so try to keep a calm, a steady lifestyle in the run up to exams. And if you’re going to try a preventative for migraine, if you know, you get them before exams, you need to get there, as Jess was saying, plenty of time beforehand, because you may have to try different drugs before you find one which works for you and which doesn’t give you, you know, it doesn’t knock you out with side effects.
Dr Jessica Briscoe [00:44:42] Yeah. You don’t wanna be falling asleep in the middle of your exam because you started a new preventative.
Dr Paul Booton [00:44:47] No, no. So but the other thing is, what do you do when you’re running up to the actual exam itself and you’re kind of worried you might get an attack, especially if you’ve got a history of this sort of thing happening? And one of the things we use is what sometimes gets called short term preventatives, which you can just take over a short time, surprisingly enough. And so they’re things- there’s a thing, same family as ibuprofen called naproxen. Now that’s got a good track record in menstrual migraine where we know there’s an attack on the way. And so you can take that before, you know, with menstrual migraines, before somebodies period starts and carry it through that vulnerable period. And it’ll prevent the attacks from coming. That works very well, although there’s not much research on it the chances are you can do the same thing with trying to prevent migraines at other times. So you might say three days before the exams, start taking Naproxen and carry it on until a couple of days after the exam. There’s a fair chance that’s going to stop you getting the attack.
Dr Jessica Briscoe [00:46:00] The other thing I quite like to use, which depending on where we are in the pandemic situation, may or may not be available. But greater occipital nerve blocks, if people respond to them because not everybody does, it’s about a 50 percent chance of people responding to them. They can be quite useful in the run up before an exam. So in some people where they work well, they can last for up to 12 weeks. So actually, sometimes I’ve had people who have found it useful in the past to make sure they come in advance and say, I need my nerve block before my exam period of time. They have their nerve block. And then that’s also, in a way, some of it’s obviously the medication. But there is, I’m sure there’s a bit of a placebo effect, you know you know that you’ve done what you can to prevent your migraine. And actually that can be helpful in itself, that sort of taking control over it a little bit.
Dr Paul Booton [00:46:53] And just to say a placebo effect, people go ‘err placebo’.
Dr Jessica Briscoe [00:46:57] No it’s really important.
Dr Paul Booton [00:46:58] There’s nothing wrong with placebos. There’s placebo effects that we all get whenever we take a pill.
Dr Jessica Briscoe [00:47:02] Absolutely, incredibly important.
Dr Paul Booton [00:47:04] And it’s just part of part of the human response to taking medication. The other nice thing about nerve blocks is that they have very few side effects. You can get a bit of a bump on the back of your head from the injection. If we’re very unlucky, it’ll trigger a headache. But in general, you know, they won’t make you feel washed out or knocked out. You can just carry on afterwards. But, you do need to be at a specialist clinic usually to get one of those. And those are in short supply whilst we have this wretched pandemic.
Dr Jessica Briscoe [00:47:38] Yes. I mean, I know that we’ve had issues delivering them at the moment. And I think with the NHS being completely overrun, it’s very hard for people to get into their clinics at the moment. So possibly at the moment, the naproxen route, a better way to go from that point of view.
Dr Paul Booton [00:47:56] Can I talk a bit about, apart from being a sort of headache doctor, my more professorial, academic role. I used to be undergraduate dean at one of the London medical schools.
Dr Jessica Briscoe [00:48:09] Yes please do.
Dr Paul Booton [00:48:10] So I also saw this from the other side of the desk, as it were, students saying to me oh, I can’t do the exam I’ve got migraine. You should let the college know if you get regular migraines, if you’re missing sessions regularly at college through migraine, and you may well if you’ve got migraine, you may have to. Then make sure the college know about it. If you’re just not turning up, the college may conclude you’re not interested in the course. You don’t want to be there. They need to know that. You may need to get a sick note from your GP to take to them as much as GP’s grit their teeth about endless sick notes for no very good reason. And the college will need evidence that this is the situation. It’s also very important in the run up to exams that the university know if you’re vulnerable to getting an attack, especially if that’s going to stop you doing the exam, or make you do much worse in the exam. Again, you may need a certificate from your doctor to establish that. One of the things that as a student, if you’re running into problems, coming up to an exam, you’ll be asked to provide a what’s called a mitigating circumstances forms, and you complete a form to say, I can’t do the exam or something might happen. And it’s very, very important to get that in inn advance. It’s much more difficult for the college if after the exam you say well, I had a bit of a migraine on the day and I couldn’t do it. And I say, well, anybody can say that. So be upfront with your college about it and work with them to help them help you. Don’t hide it from them. Don’t try to ignore it yourself they’re bad strategies.
Dr Jessica Briscoe [00:50:10] Yeah, I think also there’s a sense of- I mean, you have to remember that when you’re at university, you’re an adult learner. So you have a certain you’re expected to have a lot more responsibility for yourself than you would have done at school. And there’s definitely a lot to be said for showing that you are taking ownership of something and that you’re trying to prevent it in a way. So actually, no one will tell you off for sort of saying, ‘oh, I suffer with migraine and it may affect me on the day’ and then it doesn’t affect you. That’s fine. You’re in a much stickier water. If you go into an exam, having not bothered to tell anybody about this problem, that is likely to occur. I think the other thing is whether you need any special circumstances. So in triggers we didn’t really talk about things like photosensitivity, light sensitivity or other things that can trigger attacks. So, I mean, maybe, again, we’re slightly biased from having been in medical school, which means that we were always under those lovely hospital lights, which were very neon flashing. And but I remember them being- they would really affect my light sensitivity during exams. And actually, if there’s anything that I mean, I’ve also examined for the school, the medical school that you’ve worked for and actually they were very good at sorting out mitigating circumstances. So if they could do anything that would make it be less triggering for somebody. So not actually changing your chances, but actually making sure you’re not in a situation when you’re already under stress that will help you to perform as best you can, then actually they will do what they can. Some people need- if they’re doing lots of close computer work, will need to have extra breaks. Some people find writing or reading paper, sometimes paper will trigger their attacks and you need to get different types of paper. Getting assessed and getting these things in early is really important so that the university can help you as much as possible to perform in the best way that you can.
Dr Paul Booton [00:52:07] So other things, these big examples with all these artificial strip lights and really trigger some people. Exams on computers, a lot of people have trouble with computers. Just be upfront about these things with universities saying this causes me problems and if necessary, back it up with a letter from the doc.
Dr Jessica Briscoe [00:52:28] Absolutely.
Dr Paul Booton [00:52:29] And the university have then empowered to help you.
Dr Paul Booton [00:52:34] There’s a saying what you don’t know can’t hurt you or what you don’t know certainly can hurt you in this situation. So be upfront with your college and they will do their best to help.
Dr Jessica Briscoe [00:52:42] I think the thing to remember is that university- it’s a big change in your life. It’s a very exciting time. You can get drawn into some things that are bad habits anyway, but that can be particularly bad for your migraine. I think the important thing is recognising that you’re having attacks. Don’t ignore them, recognise early, trying to do things in your own routine, keeping everything as routine as possible whilst trying to also have a life is important. But also, if you’re really struggling, seek help early. So see your doctor, speak to university, don’t suffer in silence. And remember, you are an adult now, so you have to take some responsibility for your health.
Dr Paul Booton [00:53:23] And if you’re not getting any joy from your GP, if that’s not working out, do seek specialist help. And widely through the NHS now there are migraine clinics or headache clinics where you can go and get help. And of course, at the National Migraine Centre, that’s specifically what we do to help people.
Dr Jessica Briscoe [00:53:42] Absolutely.
Dr Paul Booton [00:53:43] So make sure you get the help you need and take responsibility for it. And enjoy your student life.
Dr Jessica Briscoe [00:53:51] Enjoy it!
Dr Paul Booton [00:53:52] It’s Great fun, great fun. Glad to hear that Jess was an adult learner. I certainly wasn’t. A sort of failed adolescent learner.
Dr Jessica Briscoe [00:54:03] Brilliant. Well, thank you so much for joining me today, Paul. It’s really useful to have you with both of your hats on today, and I think they’ll be really useful for everyone.
Dr Paul Booton [00:54:11] Great. OK, well, it’s been lovely speaking to all again. Right. So cheerio from me.
[00:54:20] The National Migraine Centre relies entirely on charitable donations and we are not a rich charity. If you possibly can, please give us something to support the work of the charity, which is looking after people with migraine up and down the country. Thanks very much for listening.
Valentina [00:54:41] Today, I’m joined by Nicola who is going to share experience of having migraines while at university. Hello Nicola and welcome to our Heads Up podcast.
Nicola [00:54:52] Hi, thank you for having me.
Valentina [00:54:54] Our first question is, how old were you when you got your first migraine?
Nicola [00:55:00] That is actually a bit hard to say. So in kindergarten, I started to have some issues which is quite typical for a lot of children to start with having abdominal migraine. But I remember that my first migraine with actual head pain was when I started primary school. So I started to have more and more episodes with the typical migraine symptoms. So headaches. But I still have kind of abdominal issues as well.
Valentina [00:55:29] So, how did migraine impact your life during your university years?
Nicola [00:55:33] Well, I think, first of all, you put a lot of pressure on yourself because you want to keep up with everyone and everyone is studying a lot and even just going out and experiencing the student life. It’s sometimes hard to keep up, so to say. So to join everyone for a long nights out and studying because if you’re facing a migraine episode, then you just cannot join. And, you know, you have to study, but you can’t because you’re in pain. So I think it’s a lot of pressure you put on yourself and then you overdo it. You keep on studying because you have an exam coming up and it’s hard to just close your laptop or put your books away and take a break. And in the long term, that would be far better.
Valentina [00:56:17] So how did you manage at that time?
Nicola [00:56:20] Well, at the beginning, I would say I didn’t manage too well. So I really struggled and got more and more episodes as well. But over time, I really learnt how I could prevent them from coming up. So for me, migraine often starts when I have a lot of stress, when I don’t sleep enough, and when I put a lot of pressure on myself. So it took a while to understand that. But now I know that if I take a break, if I admit to myself, OK, today is just another day I can’t study, that’s the best way I found. So when it’s coming up, I close my laptop, I stop working, I do something that relaxes me. So for me, that’s cooking, baking, going outside, taking a nap, whatever feels the best in the moment. And I can often prevent it, which is better than just keep on going and keep on working.
Valentina [00:57:14] I completely agree. What are you doing now? Are you currently working or studying?
Nicola [00:57:19] I’m currently doing both. So I’m doing a part time masters in London, but I’m also working and based on my story, I’m actually working on solutions to support children who suffer from migraines. So me and my partner, we started this project about a year ago and we’re looking into digital methods, how we can help children to learn how to cope with migraine or with other pain conditions. And I think that’s something else to see when I look back at my studying times or school times or see it’s a lot of behaviour and a lot of things you have to learn. So, for example, admitting to yourself that you cannot study today and admitting that you need a break, which sometimes is really hard when you are excited, for example, about school or studying even. And I think these are things you have to learn early on so you can manage better in your university, your work life, and with Happyr Health we’re looking at different strategies. For example, cognitive behavioural therapy, where you can learn as a child in a very child friendly way how to deal with your condition. And we hope to have something to show everyone soon. But until then, everybody can happily follow us on our social media channels as well.
Valentina [00:58:42] Thank you very much for sharing your experience and best of luck with your project.
Nicola [00:58:47] Thank you for having me.
[00:58:51] 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 to next time.
This transcript is based on a past episode of the Heads Up podcast and reflects information available at the time of broadcast – some facts may have changed or new treatments become available since.
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