Migraines Versus Post-Traumatic Headaches: What is the Difference? | E3

This podcast dives deep into the complexities of post-traumatic headaches and migraines, exploring the differences in symptoms, triggers, and treatment options. Insights introduce listeners to medication overuse headaches and emphasize the importance of accurate diagnosis and holistic approaches for recovery after a concussion.

• Exploring common types of post-traumatic headaches
• Migraines as a risk factor for poor outcomes
• Defining migraines and associated symptoms
• Migraine "triggers"
• Understanding the neurological basis of migraines
• Examining the interplay of hormones and diet
• Discussing medication overuse headaches and their impact
• Emphasizing the value of a multidisciplinary approach to treatment
• Discussing alternative therapies and lifestyle modifications
• Encouraging patients to advocate for appropriate care

Research papers discussed in this podcast:
Sufrinko, A., McAllister-Deitrick, J., Elbin, R. J., Collins, M. W., & Kontos, A. P. (2018). Family History of Migraine Associated With Posttraumatic Migraine Symptoms Following Sport-Related Concussion. J Head Trauma Rehabil, 33(1), 7-14. doi:10.1097/HTR.0000000000000315

Leung, A. (2020). Addressing chronic persistent headaches after MTBI as a neuropathic pain state. J Headache Pain, 21(1), 77. doi:10.1186/s10194-020-01133-2

Gosalia, H., Moreno-Ajona, D., & Goadsby, P. J. (2024). Medication-overuse headache: a narrative review. J Headache Pain, 25(1), 89. doi:10.1186/s10194-024-01755-w

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Chapters

• 0:00 Understanding Post-Traumatic Migraines and Headaches
• 13:49 Managing Migraines Through Hormones and Diet
• 18:51 Understanding Migraines and Stress Management
• 33:34 Addressing Post-Traumatic Migraine Misconceptions
• 39:12 Migraine Treatment and Supplement Safety

Transcript

Ayla Wolf: 0:00

Most of the patients that I see are people that are coming to me because they've had these horrible headaches they can't get rid of after their concussion. And the headaches are usually a combination of some kind of tension type, pressure headache, along with moments or episodes of these throbbing headaches that are sometimes unilateral, sometimes bilateral, but they can't answer yes to those four questions that we just talked about.

Sophia Bouwens: 0:28

Welcome to the life after impact podcast where we do a deep dive into all things concussion and brain injury related. We talk about all the different symptoms that can follow brain injury, different testing methods, conventional and functional, and different types of specialists out there, as well as different therapies available. I'm Sophia Bowens, and I'm here with Dr Ayla Wolf, and we will be your guides to living your best life after impact.

Ayla Wolf: 0:59

Well, Sophia, episode number three. We've made it this far.

Sophia Bouwens: 1:02

Here we go. We're gonna keep going too. We're just getting started. That's right. How are you doing today? I'm great, good. I'm excited for our discussion today. We're gonna dive into post traumatic headache, migraines, migraine like, headaches, medication overuse and kind of deciphering those things with post traumatic headache after an injury,

Ayla Wolf: 1:25

let's just dive right in. Great. There was a paper that was published in 2018 that was looking at athletes with concussions, and it had some interesting findings differentiating people that had a post traumatic migraine versus people who didn't. And one of the things they found was that the concussed athletes with post traumatic migraines were seven times more likely to have a longer recovery time than those without headaches at all, and two times more likely to have a longer recovery than other types of post traumatic headaches.

Sophia Bouwens: 2:03

So is that saying that if you had migraines before an injury, that you're going to have a more complicated recovery, or what they're finding?

Ayla Wolf: 2:11

So the literature says that people that have a history of migraines before their concussion, it's a risk factor for poor outcomes or a more prolonged recovery, and so I think that is important to recognize, and that presence of migraines before the concussion is also a key differentiating factor between trying to figure out whether people are indeed having true migraines or if they're having a post traumatic headache That is migraine-like in nature, it resembles a migraine, but it's actually not.

Sophia Bouwens: 2:44

Sounds complex.

Ayla Wolf: 2:45

We'll get into that because there's kind of four simple questions that can get to the bottom of that for a lot of people.

Sophia Bouwens: 2:51

I'd like to ask you or find out more about those questions, but first, I want to know what is a migraine?

Ayla Wolf: 2:59

Yeah, so I think right out of the gate, a lot of people who have never had a migraine don't have a good sense of just how awful they are.

Sophia Bouwens: 3:09

I can attest to that.

Ayla Wolf: 3:11

Yeah, and I currently do not have migraines, but there was a brief period of time that were definitely hormonally triggered. So I had migraines probably between the ages of 13 and 15, and I'll never forget the very first migraine I ever had. I went to my best friend's house. This is somebody I've been friends with since they were three years old, and I was at Elsa's house, and her mom had made chocolate chip pancakes for breakfast, and my mom was, of course, like this crazy health nut. So we never got, never getting chocolate chip pancakes at my house.

Sophia Bouwens: 3:46

No, that was that was unheard of my house, either.

Ayla Wolf: 3:49

Yeah, my mom literally made me bring green beans to McDonald's, and I had to eat the green beans before I could have a happy meal. I had a mom child abuse. It was terrible.

Sophia Bouwens: 3:59

I thought my mom was abusive when my most exotic cereal I was allowed to have was, like, Raisin Bran.

Ayla Wolf: 4:05

Oh, that is bad.

Sophia Bouwens: 4:06

Not Raisin Bran crunch. That was too much sugar. It was awful.

Ayla Wolf: 4:10

Oh, man, okay, so more with more things we have in common. Yeah. So anyway, I'll never forget I ate the chocolate chip pancakes, and then all of a sudden I started to get the migraine aura. And if you've never had that before, it can be frightening, because you have no clue what's happening. And all of a sudden the whole world turns into a kaleidoscope, and you have like tunnel vision, and there's bright colors moving around. And I got very nauseous, and then I started vomiting, and then I had the horrible throbbing headache, and all I could do was just lay in bed and feel miserable and feel like I was gonna puke for, you know, four hours straight, and then you have the hangover after that, where you just feel like crap, awful. So I migraines are terrible.

Sophia Bouwens: 4:54

I got migraines for a while when I was younger, too, and they would always start with this, like taste of. Mouth and the aura that was hard to describe, kind of Kaleidoscope like, but also, just like, the world was different, kind of looked smaller, was fuzzy around the edges, and when those would come on, all I could do would be like, go in a dark room and sleep. Nothing else would help, no medication, because I'd get nauseous, I'd get light sensitive. I didn't want to smell anything. It was horrible.

Ayla Wolf: 5:22

Yeah, did you have food triggers for your migraines?

Sophia Bouwens: 5:25

I did.Cilantro would always trigger migraines for me, and then, like greasy foods would be not good. Caffeine would sometimes help. Sometimes it would make it worse. So it was always hit or miss with that,

Ayla Wolf: 5:38

my trigger was chocolate. I, you know, I finally figured it out that if I ever Well, here's the weird thing, if I ever ate chocolate before lunch, I it would trigger a migraine for me. And so I learned from the age of 13 on. And you know me, I'm addicted to chocolate.

Sophia Bouwens: 5:52

You love chocolate!

Ayla Wolf: 5:55

I am addicted to chocolate, but chocolate before lunch, it's like someone's trying to hand me poison. I do not want to even look at chocolate before lunch, even to this day and again, I don't have I haven't had migraines for a very long time, but to this day, chocolate before lunch. I will not touch it.

Sophia Bouwens: 6:13

I'll never give you chocolate before lunch. Now I know this. I'm learning this thing. So migraines can be really debilitating and have this aura, like component sensitivity, components well.

Ayla Wolf: 6:25

And actually, the research says only about 30% of migraine sufferers have the aura, okay? And so even though we both have had this strong aura, 70% of people that get migraines don't actually have the aura. But so when you going back to your initial question of like, what is a migraine? So there's something called CGRP, calcitonin gene related peptide. And when CGRP is released in large amounts, all of a sudden, it causes vasodilation and blood vessels dilate, and then all of a sudden, people can get this throbbing headache. Originally, they thought that that was just that, that was kind of like the simplistic mechanism of just, oh, blood vessels dilate, and now all of a sudden the migraine happens. But now they're recognizing that there's this whole neural component to that it's not just blood vessels dilate, and because if that was the case, if you just constricted the blood vessels, then that would basically fix it in, you know, 100% of cases. And that's not true. We do know that for some people, they can take caffeine, it can constrict the blood vessels, and it for some people that can help, but it's not like a 100% of the time, all I need to do is take a caffeine pill and my headache goes away, right? So there's this neurological component to it. There's a neurovascular component. It's the interaction of the nerves with the blood vessels that are part of this migraine pathophysiology. All head pain involves the trigeminal system. And I use the word system intentionally, because we have cranial nerve five is our trigeminal nerve, and that has three main branches, and those essentially cover the whole face, all the way up until the top of the head, so it goes into the scalp and even the ear. But all of that information goes into different parts of the brain, so we've got different nuclei in the midbrain and the lower brain stem that all take that information and then converge that information with kind of other nerves from the back of the head. And so there's a very specific part of the lower brain stem and even into the spinal cord, called the trigeminal cervical complex, and that is just a hub of sensory information about the face and the head that is transferring pain information to the brain. And so what happens with migraines is that this very specific part of the brain can become hyperactive, and that's where a lot of therapies are targeted in terms of neuromodulation is, can we do some kind of neuromodulatory therapy on the trigeminal nerve on the face, in order to kind of modulate that information going into that trigeminal cervical complex in the brain stem, to then change this pain perception happening at these higher cortical levels?

Sophia Bouwens: 9:18

Or for me, I would always get pain kind of at the back of my head, the base of it almost like it would feel like kind of throbbing, and I would know, like, this is where this headache is kind of coming from, and working that area would be helpful. And for a while, I thought, Oh, it's on my neck. But it's not just the neck that's involved there. It comes across more systemic,

Ayla Wolf: 9:42

yeah. And in the back of the head, we've got the greater occipital nerve and the lesser occipital nerve and the third occipital nerve. And so all of the nerves in the back of the head also have kind of pathways that go into that trigeminal cervical complex. And so the. That's where it's like, wherever the pain is in your head, it's all still kind of going to that same hub. And because that hub of information is in the lower brain stem and the upper spinal cord, that's why different types of, say, like chiropractic adjustments or manual manipulation, of say, c1 and c2 can have a big impact on these types of headaches, because if those are subluxated or there's nerve impingement happening, that can just be a trigger for all of this.

Sophia Bouwens: 10:31

I think Atlas orthogonal or this upper cervical work for me has been helpful. I also noticed hormone changes would trigger them for me. So I think that there's a metabolic component with hormones and diet and food. Do you find that?

Ayla Wolf: 10:47

All the time? And that's where I think that when people have migraines, we have to look at it as we can't just approach it from one angle. We have to approach it from like, 12 different angles. And right,

Sophia Bouwens: 11:00

like, your initial question of, like, Did you have food triggers? Like, it dives right into that,

Ayla Wolf: 11:04

yeah. And the food trigger thing is interesting, because it kind of goes back to more of this bucket theory of, if your bucket is already full, the food trigger is just like that one extra drop that kind of tips you into the migraine. And so when it comes to kind of neuromodulation and neuro rehabilitation for people with migraines, what you're really trying to do is get that bucket a lot emptier so that the triggers aren't so triggering.

Sophia Bouwens: 11:34

So do you find different diets or different foods are better for people who suffer with migraines, like should they follow a specific type of thinking around eating and food.

Ayla Wolf: 12:48

A lot of times, you can make faster progress with people if they are willing to give up dairy and gluten and sugar and alcohol and caffeine. So a lot of people, you know you can't use caffeine therapeutically to abort a migraine, if you're drinking a lot of it every single day, sure, and so for a lot of people, when we're talking about people that have migraines, like more than 15 days out of the month, like when people have lots of chronic migraines, that's when you have to really kind of pull all the stops and kind of remove a lot of things from the diet and the lifestyle and approach this from all the different angles. But if people can actually go caffeine free, they're going to have three to five days of horrible caffeine withdrawal headaches. But usually, if they can get through those five days, you know, then they are through the worst of it. And in many cases, going caffeine free is actually an important part of addressing the migraines.

Sophia Bouwens: 13:49

I found that for me, hormones and food were important, movement and activity was important. I love caffeine, so I have withdrawn from it before and had it out of my system for a while, and that did help, but after I kind of cleaned up things, I noticed the migraines also got much better and didn't come back so much. So when you live with migraines in a debilitating way, changing your food, sometimes it's the comfort, like all I can have is the food that I like. But if you know that freedom is on the other side, it can really be life changing for that.

Ayla Wolf: 14:27

Yeah, I mean, when I took a course, it was 150 hour course on migraines, taught by Dr Adam Harcourt, who has a clinic specifically in Santa Barbara, where he specializes in people who have serious, debilitating migraines. People from all over the world fly there to his clinic to get treated. And if I hope I'm saying this correctly, but I thought that he said that many times before he even has people come and do like, a week long intensive with him, he will ask them to basically cut out gluten and caffeine and a lot of foods out of their diet completely before they even show up to work with him, so that he's not fighting against some of these inflammatory things that are keeping them in that state,right? what he's doing is he's setting himself and the patient up for success.

Sophia Bouwens: 15:26

Absolutely. How do you see hormones playing a role in migraines?

Ayla Wolf: 15:32

A lot of times, excessive amounts of estrogen can be a trigger for migraines, and there is very often a hormonal component to them, especially with women, but even with men to hormonal imbalances can cause migraines, and I like for any migraine sufferer, patient that I work with to do a Dutch test, or some kind of hormone test where we can really look at the breakdown between the different types of estrogen and how that relates to their progesterone levels, their testosterone levels. Is their DHEA, their cortisol, and just get all that information to say, Okay, what hormonal imbalances might be driving these headaches? I had a woman who was in her 60s who developed migraines, and when we got her Dutch test results back, she was low across the board. So I mean, I mean below the post menopausal range of where she should be, and by and because she was low across the board in everything by simply just having her take DHEA and pregnenolone, which are kind of the building blocks for creating testosterone and progesterone and estrogen, we got rid of her migraines just by actually getting her hormones into the correct post menopausal level. Whereas many people who are still cycling, many women that have excessive amounts of estrogen, by getting those levels down into a normal, healthy range, you can reduce the frequency of migraines too.

Sophia Bouwens: 17:00

I remember, Dutch test is your favorite hormone panel to do that kind of analysis. Why is it your favorite?

Ayla Wolf: 17:06

Because it gives you all of that information. Whereas many people, if they just go in and have their blood drawn, all you get is just basic numbers for where their levels were at in terms of their e2 but it doesn't give, oftentimes, it doesn't give the breakdown of e1 e2 and e3 and so what I like about the Dutch test is it gives you the ratios between the e1 two and three, to see if they're in the correct ratios. And then you can also really easily see if the metabolites of progesterone are approximately the same as the metabolites of testosterone. And so you can look at how the body is breaking down different hormones and their metabolites, because that highlights very specific enzymatic pathways that might not be functioning or be functioning too high. And so the Dutch test just gives you so much more information than a general blood test does. That can help to figure out okay, if this one enzymatic pathway is out of balance, I know the different kind of natural therapies that can help to bring it back in balance.

Sophia Bouwens: 18:10

And what's it? What do you do for a Dutch test? What's it? How is it different? Where do you find it, or what kind of provider would you go to to get a Dutch test?

Ayla Wolf: 18:19

Usually a naturopathic doctor, a functional medicine practitioner, an integrative medicine doctor or different acupuncturist based on kind of where they're practicing, or what their backgrounds are. And chiropractors, too. A lot of chiropractors order the Dutch test. So a lot of kind of holistic practitioners and people practicing Functional Medicine and integrative medicine tend to rely more on tests like the Dutch test, and one similar to that, and it's a combination of taking some saliva samples for measuring cortisol throughout the day, as well as taking urine samples. And so it's actually measuring these hormone metabolites that are in the urine, to give you a sense of kind of the levels in the body.

Sophia Bouwens: 19:02

And different parts of the system and how they're being utilized or disposed of too. Yeah?

Ayla Wolf: 19:08

What do you mean by that?

Sophia Bouwens: 19:09

Like, if you're catching what's in the urine you're catching, kind of like the waste products of things, and how much is there, and then in the saliva? Is that more active in the system?

Ayla Wolf: 19:19

They are pulling different information from the saliva versus the urine, and so they're pulling different cortisol levels from the saliva, but then they're looking at cortisol metabolites in the urine, sure, and so they're kind of getting two different pictures. Exactly.

Sophia Bouwens: 19:35

Cool. So what about stress? Can stress play an impact on the I know stress can impact hormone regulation. It can impact cortisol in particular. What do you see for stress and migraines?

Ayla Wolf: 19:48

Well, quite simply, Stress makes everything worse!

Sophia Bouwens: 19:51

Oh, really!

Ayla Wolf: 19:52

yes. And you know, it's so easy to say to somebody, oh, you just need to reduce your stress levels, but it's so much harder, in reality, to to make that change. Because the I think the truth is that we have some things that we have control over, and we have many, many things that we don't have control over in our lives. And so our stress, you know, can come from both places. Sometimes people's mindset, you know, is set up so that they're perceiving many things to be stressful, right

Sophia Bouwens: 20:21

Way of thinking, right!

Ayla Wolf: 20:22

Sometimes it's a process of just being more aware of your own thoughts and your own thought patterns and how you might actually be creating stress in your life by how you choose to react to things, versus, you know, being really aware of what you have the ability to control and then letting go of the things that you don't. And so, you know, when it comes to stress management, I think that counseling can play a huge role in helping people to just be more aware of their habits and their thinking patterns and the role that they may be playing in the stress in their lives.

Sophia Bouwens: 20:58

Perception is everything. So much of it is, yeah.

Ayla Wolf: 21:02

And I think that, you know, we live in a we live in a world now where there's so many internet trolls and so many people making hateful, mean comments on social media, and so, I mean, there's a reason why I don't like social media and why I don't like being on it is because I just don't, personally, don't like being attacked, and I don't like people who don't know me making these weird statements about like that don't even make sense, but they're just clearly trying to be negative or hateful or mean, and I just don't understand it. It's like, I, you know, I feel like I have to be on social media because I own different companies and businesses, but I don't want to because of all the strange stuff that goes on that I just don't want to be part of.

Sophia Bouwens: 21:47

It's not even a real world. It's all electronic, which is so some something so mind blowing to think about in our generation has grown up now with, like, pre social media, and now social media, and then these kids out there who are inheriting a world that has always had social media, and it's a lot so there's a lot of things about how you're structuring your life, or what you're engaging with that could impact this as well. Migraines are complex, as we are learning headaches altogether are complex. What about headaches that are similar to migraines, but not true migraines, migraine-like headache. Maybe you could talk about the questions you would ask if you were trying to have a clarity with experiencing a true migraine. You said there was four questions,

Ayla Wolf: 22:34

yeah, and again this, I like to give credit where credit's due. So this came out of the teachings that Dr Harcourt taught in his course on on migraines that was offered through the Carrick Institute, which offers kind of post doctoral training in applied clinical neuroscience. And so he taught a 150 hour course on migraines, and did a great job of getting into migraine pathophysiology, as well as addressing all these different lifestyle factors, the stress, the hormones, the diet, the sleep, I mean, all of that is

Sophia Bouwens: 23:09

150 hours of that yes, yes. So much That's important. amazing.

Ayla Wolf: 23:16

Yeah, so there are three questions that, if people answer yes to all, sorry, four questions, where, if people answer yes to all four questions, then it's highly likely that what they're experiencing is a true migraine. And the first question is, are your headaches on only one side of the head? Or at least at the onset of these headaches, were they one sided? Because that is a, what a kind of classic migraine presentation is? It is a, you know, throbbing, one sided headache. When people do develop migraines that go on to just become kind of these intractable headaches that are there all the time, then they can start to kind of be bilateral, but at least in the beginning, traditionally, classically, these migraines are one sided, right? So are your headaches on only one side of the head? So if people answer yes to that, you know that's kind of one clue. The second one is, do you have a history of migraines? So if we're talking specifically about people who have had a concussion and then go on to develop headaches, did they have a history of migraines, because usually migraines come on when people are, you know, teenager or early adult. And so it is much less likely for somebody to just suddenly develop migraines in their 50s, 60s, 70s, after a head injury. Yeah. And so if you answer yes to that that you you yourself have a history of migraines, and then you get a concussion, and now these throbbing headaches are worse, right? That can be an indication, yes, this is indeed a migraine. And then also, is there a family history of migraines? Because migraines are there's a genetic component to it. They do run in families. Over 70% of migraine sufferers are women, and so it's usually if somebody's suffering from migraines they also have a sister, a mother, an aunt, a grandma, other people in their family that likely also have migraines. And then the fourth question is, if you take migraine aboard of medications, do they help? And so somebody says yes. Then again, it's very likely that what they're dealing with is a true migraine.

Sophia Bouwens: 25:30

So, if, after a head injury, you have a history of migraines, you have a family history of migraines, it responds well to migraine medication, and it is only on one side, or at least at the onset, then it's likely you're having a true migraine.

Ayla Wolf: 25:46

A true migraine, yes.

Sophia Bouwens: 25:48

And what about the other group of people who might say no to one of those questions, or all four of those questions, but they're still diagnosed with migraines. What do those headaches look like? Or what might decipher that? Yeah.

Ayla Wolf: 25:59

So that brings us to, I think, a very important. One group of people who have had concussions, they develop post traumatic headaches after the concussion, and those headaches are often throbbing. They're pulsing and you know, they're a throbbing, pulsing headache. They often have light sensitivity, sound sensitivity, nausea, but many times in that case, if it's not a cervicogenic headache, if it's not coming from the neck, if it is more of just a migraine like headache, then it is often bilateral. And that's most of the patients that I see. Are people that are coming to me because they've had these horrible headaches they can't get rid of after their concussion. And the headaches are usually a combination of some kind of tension type, pressure headache, along with moments or episodes of these throbbing headaches that are sometimes unilateral, sometimes bilateral, but they can't answer yes to those four questions that we just talked about they didn't have a history of migraines before their concussion. They don't have a family history of migraines. And many times when these people have been given migraine medications, they are telling me that they don't work.

Sophia Bouwens: 27:18

So let's talk about that, because that's interesting. Oftentimes I have patients that come in that have tried different migraine medications and have been on them for a long time, or different ones in different periods, and they're not super helpful. They can actually get headaches from the medication use even, yeah,

Ayla Wolf: 27:38

so there's it is a whole other ball of wax, and I think it is happening more frequently than people realize, because people can get a medication overuse headache from not that much medication. And so I think it would be probably helpful for our listeners if we dive we, if we did a deep dive into this idea of medication overuse headaches, because they can happen not only from certain prescription medications, but also from over the counter medications, sure.

Sophia Bouwens: 28:09

So let's talk about the windows of time like and what are some of the medications that are commonly used prescriptions? I know lots of triptans are used. What are some drug names that people might recognize with this class, the triptan class?

Ayla Wolf: 28:23

So I would say most of my patients that have been prescribed triptans are either on Imitrex, that's probably the most popular Maxalt, Relpax and Zomig.

Sophia Bouwens: 28:34

Something like that. And how many days a month do you use those to be considered kind of that overuse time?

Ayla Wolf: 28:42

Yeah. So if people are taking a triptan more than 10 days a month for more than three months, they can develop a medication overuse headache. And because doctors know this a lot of times, they only give people a 10 day supply per month of triptans. But then what happens is that people run out of their triptans, and so then they start taking either ibuprofen or Aleve or these other things. And what the research is also showing is that if you take, say, like Tylenol, more than 15 days per month for more than three months, or ibuprofen or some of these non steroidal, anti inflammatory drugs 15 days per month for three months. Or if you take a combination analgesic like Excedrin migraine, which has caffeine in it as well, if you take that for greater than 10 days per month for more than three months. Or if you take multiple drug classes, right? So if you're now mixing and matching different drugs for more than 10 days per month for more than three months, you can develop medication overuse headaches, or what people call rebound headaches.

Sophia Bouwens: 29:56

That's so amazing that the headache medication can cause headaches and adds another level of complexity there. And those windows aren't always that large, right? 10 days for many of them, right?

Ayla Wolf: 30:12

Yeah. And so once I read this paper, which, you know, let me back up. So when I did the 150 hours of studying migraines, the first 25 hours of that program, we read a 70-page paper. The lead author was a researcher named Peter Goadsby who is a expert on migraines. And so this paper was the definitive paper on migraine pathophysiology. We spent the first 25 hours of the course reading line by line, the 70 page research paper, because it was so important. And it was the definitive paper on migraines. And so when he then published a paper on medication overuse headaches in 2024 as soon as I saw his name on that paper, I paid attention. Because this isn't just some random person publishing a paper on medication overuse headaches. This is Peter Goadsby that is writing a paper on medication overuse headaches, and he is the expert on migraines.

Sophia Bouwens: 31:14

One thing I saw that was really interesting about that paper is that they'd see brain changes in relation to these medications, and if people would stop taking them, they saw a reversal in those brain changes. So this is not something that once it's done, you're stuck with it. It's something that if you work with the right provider to come off of them, you can actually have healing in a bigger way from this too.

Ayla Wolf: 31:40

Yeah. I mean, they talked about different clinics that would take people off of these medications and have really significant improvements in people's headaches. And then they also talked about, like you said, the fact that, when they were doing brain imaging research, people that had medication overuse headaches had what they were calling hypometabolism in different parts of the brain, and hypo metabolism is also one of the things when it's in, when you have hypo metabolism or decreased neuronal firing in, say, the prefrontal cortex, that's what people with ADHD suffer from, and that's why the ADHD medications are stimulants, and why? You take someone who's hyperactive and you give them a stimulant, and all of a sudden they're calmer. They're hyperactive because of actually a Hypo-metabolism that's preventing them from actually having focused concentration. And so you give them a stimulant, you increase the metabolism in the prefrontal cortex, and all of a sudden they can do life better. They can function better. And so when you've got hypo-metabolism happening in the prefrontal cortex that can cause all kinds of cognitive symptoms, and after a concussion, people can also have hypo metabolism. So then, if you're giving them medications that create further hypo-metabolism, you can create further cognitive issues, maybe even depression and things with difficulty focusing and attention and brain fog and all of that. And so that's another reason why these medications should really be used with caution, and should, and especially with say, like the triptans, should not be kind of accidentally given to people that maybe look like they have migraines but aren't actually suffering from true migraines,

Sophia Bouwens: 33:30

and then having the headaches from overusing that medication because it's not working for them, because it's not the right medication. This diagnosis component continues to be so important.

Ayla Wolf: 33:42

and I know I mentioned this in the previous episode, but I had, you know, a patient who was in a very bad car accident, and she had a traumatic brain injury and a lot of headaches, and she had broke her jaws. She'll have facial pain, jaw pain, and as I worked with her, a lot of things were getting better, but her headaches were not getting better. And I kept asking her about her use of ibuprofen, because she would kind of mention it casually, and I think she always kind of downplayed it, because finally, when this paper came out, and it really highlighted to me the importance of this idea that if you're overusing even something like ibuprofen that it can actually cause headaches. I finally took a different tactic, and I basically started talking about the paper and saying, like, hey, this isn't just me, in my opinion. This is, you know, people who are experts that are publishing papers on this, that are saying, if you're taking ibuprofen more than 15 days a month for three months in a row, that can actually trigger headaches. And so she finally took my advice and she stopped taking the ibuprofen, after admitting to me that she took it almost every single day, wow. And so she stopped taking it and I saw her at that point. I was only seeing her, I think, once a month, because everything else was really a lot better. It was just these headaches that were the most stubborn thing that she was dealing with. And so when I saw her month later, she said, Oh yeah, my headaches are, like, practically gone. And it was just, you know, such a stark proof to me that, wow, like, you know, ibuprofen, as innocuous as it may seem, had actually been causing her headaches. And for over a year, she had headaches every single day,

Sophia Bouwens: 35:25

and I'm sure she was probably taking ibuprofen to help with them, not knowing they were driving them. Thank goodness for researchers, nerds that just like, sit up there and do all these investigations, then publish it out there for patients to glean from, because providers and practitioners like yourself are doing the research, reading the research, and what.

Ayla Wolf: 35:45

And the reality is that doctors are so busy, they're many of them are very burnt out, and so most doctors are not going home and reading all of the research at night. You know, I mean, they often say it can take the 20 to 40 years for research to make its way into clinical practice, and that's too long, like we don't have time to wait 20 to 40 years. People are suffering now. And so that's, you know, a one of the reasons why I wrote my book as well is, if you look at the dates of a lot of the research papers that I reference in my book, they are literally coming from papers that were published in 2023, 2024 - really up to date. And so we live in, we live in a day and age where you can actually publish a book in 2025 that is based on research that was published in 2024 and I think you know, Never have we lived in a time period where you could do that?

Sophia Bouwens: 36:38

No. They are not always updated or you have to go to libraries and archives and read them and pull them out.

Ayla Wolf: 36:46

So that's I think, another reason why I'm so excited is that my book is really representative of the most kind of recent research that we have, the most cutting edge research that ultimately hasn't fully made its way into mainstream medicine and into the forefront of people's minds yet.

Sophia Bouwens: 37:04

So what guidance would you give a migraine sufferer, post traumatic headache, migraine sufferer, or migraine like suffer, if they suspect these things, what do you think they should do or could do?

Ayla Wolf: 37:16

Yeah, I think the first step is if people answered no to all four of those questions at the beginning of the podcast, and they've been diagnosed with migraines, they should probably go back to their prescribing physician or doctor and have a conversation around whether or not that's the right diagnosis for them, because we, you know, we definitely don't want people to be misdiagnosed or on medications that are for the wrong thing, especially if those medications aren't working. And a lot of people, you know, really do put so much faith into into medicine. And so a lot of people take medications even if they're not helping. I mean, I see that all the time is that people have been on medications for six months to two years, and they are still highly symptomatic, and they haven't gotten any better, and they're not getting relief. And a lot of times, what happens is they're just put on one migraine medication, and if that doesn't work, they're put on a different one. If that doesn't work, they're put on a different one, and it's just, again, taxing to the liver, and if it's the wrong diagnosis to begin with, they've got to try a different approach. So for the people who don't have true migraines and they have, quote, "migraine-like post traumatic headaches", the migraine medications are likely not going to help them. And so there are other medications, like amitriptyline, we talked about that before, where some people get some relief from that, but obviously with us being, you know, acupuncturists and always trying other natural therapies that are non pharmaceutical, you know, we've seen great results with things like acupuncture and even, you know, upper cervical chiropractic care, Massage therapy to help address neck tension. Craniosacral therapy for that, yep, craniosacral therapy, osteopathic manipulation from DOS, peripheral nerve stimulation devices to help modulate the trigeminal nerve and that lesser and greater occipital nerves. So there's a lot of other therapies that I think can do a lot for those people?

Sophia Bouwens: 39:24

Yeah, exercise, dietary changes, like the diet, I can't, I don't think it can be under emphasized, but you have to make sure that the diagnosis is right so you're working with the right set of information.

Ayla Wolf: 39:36

Yeah, absolutely.

Sophia Bouwens: 39:38

Well is there anything else you'd like anyone to know about migraine and migraine, like headache for now, or medication overuse and its complexities?

Ayla Wolf: 39:47

Man, I mean, I feel like we potentially maybe overwhelmed people a lot of information.

Sophia Bouwens: 39:52

Well it wasn't a 150 hour course, but it was a touch into the complexity there, and hopefully people come away with some better clarity around what a migraine is and what can be done for it effectively, or if it's not effective, maybe what other alternatives might be?

Ayla Wolf: 40:14

I guess I will say, you know, one thing for people who are suffering from true migraines, that research paper that we've been referencing with Peter Goadsby that came out in 2024 what they did say is that there are two classes of medic of migraine medications, those CGRP receptor antagonists and then the CGRP antibodies. So the CGRP receptor antagonists are things like Ubrelvy and then the CGRP antibodies are things like Emgality and Ajovi. And many of these are a once a month injectable medication. And what they were saying is that for people that have true migraines, that are dealing with medication overuse headaches, that those are safer medications and that they don't cause. Those medication overuse headaches and so as part of the process of weaning people off of the other medications, whether it's the triptans or the Aleve or the ibuprofen or Tylenol, in the process of helping people withdraw off those medications, these two classes of migraine medications are actually safer and one of the kind of bridge therapies that people can use to still get relief from their migraines while they're getting off of those other medications. So again, that's something that I think people could go to their doctors and ask them about. So that's, I think, important to recognize.

Sophia Bouwens: 41:36

And I think it's also important just to recognize that these migraine medications aren't something you can stop abruptly. You have to use guidance to come off of them in different ways.

Ayla Wolf: 41:47

Yeah, absolutely, because there's, there's a lot going on when you just suddenly stop taking medication. And so obviously, we're not giving people pharmaceutical advice, but recommending they do work with their doctors to make sure that they're doing the right thing for their situation, yeah,

Sophia Bouwens: 42:04

and doing that in a safe way. Because I think that paper that you referenced earlier, too even talked about how an abrupt finish to medications can be helpful compared to slow withdrawal, but that that abrupt finish isn't just cutting it out completely. You have to do that in a safe way that should be managed well with a prescribing provider as well.

Ayla Wolf: 42:24

Yeah, excellent advice. There was also another research paper. It was a meta analysis looking at all the different research papers had been published on omega three essential fatty acids. And what they found is that when people were taking high doses of Omega three essential fatty acids, and we're talking like 1800 milligrams to 2000 milligrams a day consistently, that that actually was effective in helping people reduce the frequency of their migraines. And I often find that people are taking omega three, essential fatty acid supplements, fish oils, things like that, but that they're not taking them at those higher doses. And so the research is really saying that those things can be helpful, but you have to take a high enough dose. And because high quality fish oils are expensive, I think a lot of people are either, you know, for the purpose of saving money, or just because they don't know any better they're they're taking lower doses that aren't actually moving the needle or helping them, as far as reducing the amount of headaches that they're actually experiencing.

Sophia Bouwens: 43:33

And we could get into a whole conversation about the importance of safety around supplements and things you find in health food stores or on the shelves at random stores, and how they're not necessarily regulated. So there's a lot of evidence out there that unless their company is really doing extra work to put forward good, high quality stuff with what it says is in there, in what you're buying, there's a lot of companies that produce things that don't even have the ingredients they say are in there, or they're not in a formula body can use, or they come with all these other toxic components that aren't well processed.

Ayla Wolf: 44:09

And that's especially the case when you're talking about fish oils or any kind of Omega three, essential fatty acid, because if you're taking a low quality, Poor fish oil supplement, A, it might be really high in mercury, which nobody needs in their body. B, it could actually have a rancid oil that's been, you know, oxidized. And you also don't want to take oxidized oils that cause free radical damage in your brain either. And so you do need to know, like, which companies are safe, which companies are reputable. I often recommend that people you know, get their supplements from like healthcare providers who work with companies that only sell to healthcare providers professional brands. Those professional brands usually are really focused on healthcare, and sadly, what's happened is a lot of the pharmaceutical companies have been buying up a lot of the supplement companies only because they want the profits of the supplement companies. They just want a corner of the supplement market, which is, you know, probably in the trillions of dollars at this point, and so they don't care about the quality. And, you know, not to name names, but whenever I see now a supplement company that has a commercial on TV, in my mind, I'm like, Okay, well, if they have enough money to have a commercial on national TV, it probably means that they're owned by a pharmaceutical company that has the budget to do that.

Sophia Bouwens: 45:30

And doing less investment in their product quality than they are the product name brand, yeah.

Ayla Wolf: 45:36

So potentially, the quality is a huge important issue.

Sophia Bouwens: 45:40

For sure, very important. Okay, well, that's awesome. We learned some new things about exactly what is a migraine. Some questions to ask yourself around how to know you're actually having a migraine, and then some resources to consider things you could do in your lifestyle to help with migraines, avoiding those medication overuses and headaches and. Ways to talk to your providers around migraine and migraine like headaches and options for that. I think that was pretty robust,

Ayla Wolf: 46:12

agreed. And then in our next episode on neuropathic pain, we'll also do a further discussion on some of these natural therapies that people can try to help with migraines and migraine like post traumatic headaches. And then in the episode after that, we'll actually get into our own research study that was just published in the Journal of Neurotrauma on acupuncture for post-traumatic headaches. So that's gonna be a super fun episode where we actually get to talk about our own process of doing clinical research.

Sophia Bouwens: 46:44

What a process that was too, and going back, looking at doing it again, or it was a pilot study, so designing something different, really learning and using this information to frame a better question, or maybe a different way of intervening to see if we can even get better results. So that's exciting. I'm excited for that too. Yeah. Thank you listeners for listening. I hope you glean something. Feel free to share this with somebody if you found it valuable, or you think they might find it valuable, share it with your providers and tune into our next episode on neuropathic pain and how that can cause a lot of headaches and be really similar to post concussion symptoms, excellent.

Ayla Wolf: 47:24

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