Dr. Lipton Interview Transcription
Paula:I was curious, how did you get into this in the first place?
Dr. Lipton:How did I get into migraine in the first place?
Paula:Yes.
Dr. Lipton:So, I did my neurology residency at Albert Einstein and was a junior faculty member studying aging and dementia, and my wife and I bought a co-op on the Upper East Side and were having trouble with the mortgage payments. And the only legal moonlighting job I could do was moonlighting at the Montefiore Headache Center, and my wife said, “Oh, don’t do that. You’ll get distracted.” And she was right, I got distracted.
Paula:Distracted for life.
Dr. Lipton:Yeah. Distracted—still distracted 30 years later.
Paula:Distracted, but very focused. So, I’ve got to say thank you, first, for the research that you’re doing, because I think we’re all benefiting from it every year.
Dr. Lipton:Thank you so much.
Paula:This particular article that I’m interviewing you about today, that we ran last week, has been one of our most popular. We’ve reached, I think as of this morning,over 37,000 on Facebook alone, and it’s been shared hundreds and hundreds of times. That’s the only way that happens. It’s obviously very interesting to a lot of people, not just to me.
Dr. Lipton:A lot of people have migraines.
Paula:Yeah, and the research that you did on stress and the let-down affects, so a lot of great stuff that we really appreciate.
Dr. Lipton:Thank you so much, I appreciate you saying that.
Paula:Good. Okay are we good? Okay, so we’ll go ahead and get going. I think that you know that this is not live, so if you say anything and you say, oh I wished I had said it that way, differently, just say, let’s take that over again, and we’ll do it over again and just cut it together in post-production.
Dr. Lipton:Very low pressure.
Paula:Low pressure, as low as it gets.
Dr. Lipton:Thank you.
Paula:Alright, so let me go ahead and get started.
00:02:44
Welcome to Migraine Again. I’m Paula Dumas, founder and editor of our online community, focused on helping migraine sufferers suffer less and live more. Most migraine patients desperately want the pain to stop, but kind of think that migraines are just agonizing episodes that come and go and not really anything serious. But a recent research study published in the Medical Journal of Neurology changed all that. Today’s interview is about that study, which revealed every untreated migraine attack is actually changing the structure of our brains. And for me, and maybe for you, it’s a wake-up call to start treating migraines more aggressively.
It’s not just about taking a pain pill for the symptoms, but about a lifestyle of disease prevention. So we’re fortunate to have one of the study’s authors here with us today. Dr. Richard B. Lipton.
As a Director of the Montefiore Headache Center in New York City, Dr. Lipton is one of the leading authorities of headache and migraine in the world. The center he directs is internationally recognized for its research on and treatment of headaches. A prolific researcher and writer, Dr. Lipton has published eight books on the subject for patients and healthcare professionals. Dr. Lipton serves on the Advisory Council of the International Headache Society and is a former president of the American Headache Society. Thank you for joining us, Dr. Lipton.
Dr. Lipton:Thank you so much for your invitation.
Paula:So our Migraine Again audience was really intrigued by and a little bit alarmed by the implications of this research. When you initiated the research, your goal was to understand how the brain was affected by each migraine attack, looking at people who get migraine with aura and people who get classic migraines. Is that correct?
Dr. Lipton:Well so, our goal was to really understand the brain correlates of migraine attacks within individuals over time, yes.
Paula:Great. And did you find a difference between the two patient groups?
Dr. Lipton:Yeah, so we do see—our study I neurology was a meta-analysis meaning we pulled results from many previous studies to try to get a systematic summary of what’s known. And what we see is that people with migraine, particularly people who have migraine with aura are prone to what are called deep white matter legions which are bright spots on MRI that appear in the white matter, the part of the brain that connects one brain region to another. We also found that there was an increased risk of stroke-like legions in people who had migraine.
Paula:So that’s serious. The initial report indicated that every single migraine attack is actually contributing to the early onset of cell death and brain tissue loss that usually happens with age. So if you are a migraine sufferer does that mean that your brain is aging faster than your body?
Dr. Lipton:Probably not, actually. I mean, the—so it is true that the more attacks of migraine with aura a person has, the more likely it is that there will be structural changes in the brain. But I don’t think people should worry about every individual migraine attack that they have, although I do think that traditionally we’ve said the reason to prevent migraine attacks with daily medication is to prevent pain and prevent disability. The reason to treat acute attacks with medications is to treat pain and relieve disability, and now we can say in addition to the immediate benefits that people get from treatment in the short term, there is at least a possibility that more effective treatment will also convey benefits on a longer term basis.
Paula:Good. Okay. Well a few of our readers were actually a little more concerned about this. They feel like there was some fear that was created by the research that they need support and stress relief to better manage their migraines, not scary or stress inducing reports. Any response to that?
Dr. Lipton:Yes, and my response is the research is a little bit scary, but think about the way the world has changed over the last 20 years for cardio-vascular disease. So saying that people who have high-blood pressure or diabetes or high cholesterol are at increased risk for stroke and heart attack, is scary if you have hypertension or diabetes or high cholesterol, but the reality is those are remedial risk factors and the nature of the progress we’ve made is that first it was shown that high blood pressure, diabetes and high cholesterol were risk factors for having a stroke, and then we showed that better treatment of high blood pressure, diabetes and cholesterol reduced the risk that those conditions carried.
And at this point, the science has not yet been done showing better migraine therapy protects people against the structural changes that occur in the migraine brain, that isn’t proven, but I think the risk will motivate research and ultimately give people better control over their health and overall sequeleaof migraine if that’s what they happen to have.
So I consider it a positive step and certainly migraine is a risk factor, migraine with aura in particular is a risk factor for stroke, just like hypertension, diabetes and high cholesterol are stroke risk factors, and the hope is that as we learn more we will be able to help people control their health better by protecting them from the consequences of whatever illnesses they happen to have.
Paula:Great. We like to say, the more you know, the healthier you’ll be.
Dr. Lipton:Certainly the more you know, the more informed you can be in the choices you make to promote your health.
Paula:Right, right. Well one of our priorities at Migraine Again is to help migraine suffers stay on top of relevant migraine research that is actionable for them. That it matters, and that there’s something they should be doing differently because of it. So, let’s talk for a minute about what we should be doing differently. So should chronic migraine sufferers get a brain scan to see if their brain has been damaged by attacks?
Dr. Lipton:So the major clinical role of brain imaging for migraine is to identify or exclude other causes of a current headache. So on occasion migraine-like headaches can be produced by vascular malformations in the brain, brain tumors, and other sorts of diseases that can be detected by MRI. If someone has the new onset migraine, if someone’s headache is getting progressively worse, if someone had one kind of headache and now they have a completely new type of headache, brain imaging may be worthwhile to identify or exclude causes of the new type of headache or change in headache profile.
For someone who’s had a persistent stable pattern of headache, I don’t think repeating diagnostic imaging, without a specific reason for doing so is worthwhile. I think it’s better particularly with people who have migraine with aura to say what can I do to control my headaches today and at least my mindset about it is, by better controlling your headaches today, you’ll improve your life today and next week and maybe on a longer term basis as well. Because the reality is all the steps we would take to improve migraine management are steps everyone who is suffering from migraine should take, whether or not they have white matter lesions on an MRI.
Paula:Good. Thank you. The summary of your research report said migraine induced volume loss is reversible with treatment. So what kind of treatments?
Dr. Lipton:Yes, so those are studies that show that people who have frequent migraine have demonstrated shrinkage of the brain in particular regions and then then the migraine is treated with preventive medicines on a daily basis that reduce attack frequency, the shrinkage actually reduces and that’s really very encouraging because it suggests that at least part of the impact of migraine on the brain is reversible with affective treatment.
Obviously I’m a clinician first and a researcher second, so I’m always most interested with things that will help patients with migraine.
Paula:Great. So let’s talk about preventative treatments for a minute. You mentioned some of the preventative medications. I’d like to suggest some popular preventative treatments, and then ask you to give me a thumbs up or a thumbs down on how effective you believe it is in preventing migraine frequency or intensity.
Dr. Lipton:OK, good.
Paula:Yoga or Pilates?
Dr. Lipton: I think, broadly, relaxation methods are an effective preventive strategy, particularly for people who have stress-related migraines. I do yoga myself a few times a week, and love it, and the stress reduction benefits of yoga or cognitive-behavioral therapy or biofeedback may not only help prevent migraine, but help promote successful brain aging, as well. So, for yoga, cognitive-behavioral therapy, and biofeedback, for all relaxation and stress management modalities, it’s thumbs-up, particularly for people who note that stress is a trigger factor.
And I do want to say that we had a recent paper in Neurology showing that it’s relaxation, after stress, that’s the most prominent migraine trigger. So, when you’re really stressed out, preparing for the presentation, filing a brief if you’re a lawyer, or writing a paper, or studying for an exam if you’re a college student, that’s usually not when people get them. People usually get their headaches when they have a chance to relax afterwards, and of course, by practicing with stress management techniques, that prevents the stress peak, and therefore prevents the declining stress that becomes the headache trigger. So, thumbs-up for stress management and yoga.
Paula:Good; I’d like to come back to that in just a minute. But keeping on our preventive treatments, what about eating clean?
Dr. Lipton: There are a number of dietary triggers for migraine. Some of them include food additives: nitrates and nitrites that are added as preservatives to food may trigger a migraine. Bouncing blood sugars are migraine triggers for some people, so trying to eat foods that have a low glycemic index, that don’t dramatically raise blood sugar—that includes chocolate, my favorite, and candy, and other foods that have a high glycemic index. Avoiding those foods is useful.
And then, there may be individual differences in dietary triggers from person to person. Some people are sensitive to the artificial sweetener NutraSweet; other people are sensitive to red wine. Many people, actually, are sensitive to red wine. Some people are sensitive, not just to the sugar in chocolate, but to other chemical constituents in chocolate. And so, my advice, in terms of eating clean, is that everybody should eat a well-balanced diet, avoid food additives as much as possible, and probably eat a low-glycemic-index diet. And then, above and beyond that, people should try to keep diaries to identify the trigger factors that are important to them. So, if I’m sensitive to NutraSweet and you’re not, I should avoid NutraSweet, but you don’t need to, for example.
Paula:Makes sense; so, thumbs-up for eating clean. How about good hydration?
Dr. Lipton:Good hydration is always important; dehydration is a trigger for many people. There are lots of health benefits to good hydration. Probably the best thing to drink is water, and I think many of us don’t drink enough, so thumbs-up for hydration, too.
Paula:OK, a high-Omega-3 diet, or fish oil, or krill oil?
Dr. Lipton:Yes; I think high Omega-3s—those are very healthy for a number of reasons. They may help raise good cholesterol; they reduce the risk of heart attack and stroke; and there’s emerging evidence that they help in migraine prevention, too; so I’m all for them, although I have to say that rigorous scientific evidence for Omega-3s is not as strong as I wish it were for migraine. But there are many reasons to eat a diet rich in Omega-3 fatty acids.
Paula:OK, exercise—aside from yoga and Pilates, just other forms of exercise?
Dr. Lipton: Physical exercise is great; it is effective as a treatment for depression, for anxiety; it’s a stress reducer; and physical activity does appear, not to decrease your chances of having a migraine, but to decrease migraine frequency in people who are regular exercisers. So, I’m all for that, too.
Paula:I’m trying to find a thumbs-down for you, but I’m only finding thumbs-up. How about supplements like riboflavin, magnesium, melatonin, Co-Q-10?
Dr. Lipton:Your list is a good list. The American Academy of Neurology recently published guidelines on drugs and natural products that were useful in migraine prevention. The only one that’s in the same category of effectiveness as the best prescription drugs, like Topiramate and Divalproex sodium, is a supplement called Petadolex, that’s an extract of the butterbur plant. There have been a couple of blind studies showing that it is effective in doses of 75 mg twice daily. I hate to plug a branded product, but if the extraction is not done right with butterbur, then there can be toxic alkaloids in it, so I recommend the Weber & Weber product of medications; it’s a German company; the German government naturally regulates national products; so I know what people are taking when they take the Weber & Weber product.
Other products may be just as good, but I just don’t have a good way of knowing. B2 and magnesium are both in the second category of evidence for natural products in the AAN guidelines, as is magnesium; so B2 is something I recommend very often. I tell people it’s the great free swing in migraine prevention, and by that, I mean you take 200 mg twice a day; effects develop over a couple of months; but don’t expect to see benefits immediately. But it really is quite effective as a migraine preventive in double-blind studies. Melatonin has been shown to work in doses of 3 mg a day, although the best evidence wasn’t available at the time the AAN wrote their guidelines, so it has a lower level of evidence, because guidelines get out of date almost immediately as soon as they’re written. And that’s a good thing because it means we’re making progress.
Magnesium has a role as a migraine preventive, the only challenge with magnesium supplementation is that in some people it can cause cramps and diarrhea, but it’s a useful preventive. Co-Q-10 there’s a limited evidence for Co-Q-10 and riboflavin work through similar mechanisms. I usually have people try riboflavin first because, honestly it’s much less expensive and slightly better studied. But I think that they are equally effective.
Paula:Great. So you mentioned butterbur, that it needs to be extracted properly.
Dr. Lipton:Right.
Paula:To be effective. Feverfew?
Dr. Lipton:Feverfew, the evidence is very mixed and I am not a big fan of feverfew based both on the very inconsistent results of studies and the fact that it may be difficult to active adequate concentrations of the active ingredients in feverfew extracts. So it is helpful in some people and has anti-inflammatory benefits, I’m certainly not opposed to it, but it is lower down on the list than the other natural products we’ve been talking about.