Kerry 0:00

All right. Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller, and today we have Dr. Rebecca Jimenez-Sanders. Welcome to the podcast thank you, Dr Reller Thank you for having me here Yes. So why don't you tell us a little about who you are and what you do? Sure. I am a board certified neurologist and a headache medicine and facial pain specialist I I have been in practice for over a decade and I was an attending physician with USF and Tampa General Hospital and then I worked during COVID years Mm-hmm I worked with a as a neuro hospitalist with TeleSpecialist Then I moved to again USF and the James A Haley VA with veterans which was great as well And now I'm venturing out with my own practice private practice in Lakewood Ranch and my practice is called JimenezSanders Headache and Brain Center where I focus on headache facial pain and brain health So you've taken like an extra role, I think, within neurology. Tell me more about why would someone need to do fellowship in what you did? So I mean really headaches are very complex right? When we hear about headaches like early on we always think about migraines or or tension type headaches But interestingly we have the international classification of headache disorders and we are on on the version three right now which includes more than 300 headache disorders and facial pain Oh. So it's not all headache all not all headaches are migraines or tension type headaches For sure migraine tends to be the most common and and and it is as common as one one out of seven people in in the world have a migraine and I like to think of it also as one in in four households in US have migraines So it is a very prevalent disorder. But the reason why I actually went going back into this field is because I think it's where you actually y you make such a dramatic improvement in patients lives and in neurology, as much as I love neurology as a whole, there's not that many conditions that you completely improve quality of life as, Mm-hmm in this headache medicine field Yeah, that's true. I mean, neurology is a definitely a difficult field in that respect and some things it's hard to recover or overcome and you're kinda stuck with it So a headache you're right it's something that you can actually Correct ...improve. Yeah Many many many chronic conditions. Mm-hmm. And, and migraine is still a chronic disease as well. There's, unfortunately, there's no cure for it. There's treatment where Mm-hmm ...patients can live a very normal life without migraines which is great. But unfortunately, there's no cure as of right now either Mm-hmm. Yeah, I mean, so you said is migraine the most common headache, like you said and there's 300 apparently types of headaches so it looks like I need to go back to school and figure out these things. Oh, my goodness. but so tell me more about migraines. Who's at risk? Why is it so common? Yes. So migraine is a, it's a genetic disorder, so it's inherited. And so it's not something that patients do to acquire Mm-hmm migraine Most likely they inherit it from mom dad and women are most I mean women and men both get migraine but women are three times more affected by by this disorder than men and so really everybody it can get migraines and we start seeing this from childhood we know now and in the you know just over five years p papers have been published that who suffer from migraine have noticed that kids with colic start showing Colic is kind of an early sign of migraine But then as they grow in their childhood they can have episodic syndromes like vertigo or dizziness. They can have abdominal migraines. Mmhmm So they don't really present as, the typical head pain that adults have but they can start early on And then in teenagers we see how it starts changing that and then female patients Mm-hmm start having this more erratic patterns of headaches triggered mostly by hormonal changes as well And then as we move on into adulthood right the same hormonal changes stress lack of sleep but we see patients all the way through elderly patients still having migraines Mm-hmm. Sometimes we hear about this thing called aura is that How would you explain that or how does that play into having a migraine Yeah So there is aura can occur with or without headache and it is a part of the cortical spreading depression that occurs within the migraine? pathophysiology after the trigeminal vascular system is activated And it can it can be seen in differing ways So it's a sensory truly is is more of a sensory Mm-hmm Disturbance the most common is visual. So some people will complain of flashes of lights or squiggly lines in their vision they start in one area of the visual field and they can completely cross into all the areas of visual field we see it on both eyes well aura is w we like to treat in in migraines we actually try to treat as early as when patients start having the prodromal part of the four phases of a migraine which is like the very very early or at that aura moment when the patients start having these disturbances some people also will have some motor symptoms or tingling sensation. The most important for us as, as neurologists when we're hearing this the first time, right, is that it has to have kind of a marching distribution not completely sudden with other neurologic changes. Especially in elderly patients, we Mm-hmm we tend to

Rebecca 6:50

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think of stroke-like symptoms if, if it, it's not in that order So you said a marching or margin distribution? Marching Marching, like as it So some patients will complain that it starts like a tingling sensation Mm-hmm ...in the face, and then it, it will, or in the hand, in the fingertips, and it will little by little mar like kinda march Yeah and up. So that associated with a headache it's more reassuring for migraine rather than, you know, completely all of a sudden Mm-hmm we became weak and numb, and now we have like everything sudden with an acute neurologic change and a headache, then that is more concerning for a stroke Mm-hmm. I might have jumped the gun I should have asked you about triggers before going into aura cause I think- Oh you also should explain the you know the phases of the migraine Do you wanna go back to the triggers and things like that? Sure. Okay so when when someone has a migraine the First of all, I think I need to go back right, and and state that the migraine brain is a mi it it's a brain that is more sensitive Mmhmm in general we like to think of it as a hyper-excitability state. So and and from that point we know that the triggers are not what actually is causing a migraine, but

Rebecca 8:25

if we think about our migraine's brain as a bucket right And then there are sleep deprivation will add water to it, and it... Lack of of food or being in for very very long periods fasting can also create ins instability on the glucose metabolism of brain so that adds more water stress our stressful lives adds more water so all of these things can lead I like to think of these like cause this is what patients complain of as triggers but it's not that one per se Mm-hmm is going to cause it It's because the brain is already at a very sensitive state and depending on where it is a anything that you put in addition it may overflow it and will be triggered the migraine so that's why when we talk about like prevention of these triggers is like make sure that you are having a constant sleep pattern Make sure that you are having a routine on your hours that you that that you're eating make sure that exercise that you're exercising regularly exercise not only releases endorphins and helps with pain but it also has been proven to help as a prevention for migraine itself hydration right and and in itself the migraine brains we like to think of it they like homeostasis Everything even keel Mm-hmm So any changes hormonal changes anything because it's already at a hyperexcitable state can throw the these off of balance and then cause a migraine attack Yeah, I would say consistency is a great word It's I mean homeostasis is too but for you know Mm-hmm maybe lay pumps like consistency Yes, yes ...in all of these things Consistency in your sleep patterns right Correct Consistency nutrition and exercise and things like that helps keep the stability of it right Correct Interesting Okay so we talked about it being hyperexcitability and then the the overflowing of the you know bucket if all of these things kind of are occurring at once What is actually kind of going on then in the brain that it would cause all these symptoms for everybody You mentioned like the the cortical spreading and things like that and I don't know I just I there was something you said earlier that I thought was really interesting and technical but I kinda wanted to hear what you were talking about Yeah. So the the theory in the past the theory for migraine was just the vascular ...the... It was a vascular theory. So now we definitely know that it's the trigeminovascular vascular system that gets activated and this trigeminal nucleus in the in the brainstem has pathways sensory pathways to the to the cortex to the hypothalamus in the same brainstem and it is a cascade. We like to think of it as a neuroinflammatory cascade. So that's where, like, the CGRP when it gets activated, it enhances more pain. So the newer medications are blocking the CGRP receptor, To to kind of stop that cascade from continuing and reducing the pain Mm-hmm. Yeah, I feel like so much has come in the migraine research in the past, I don't know 20 years that it's like a totally different mechanism I mean so just in all transparency my mom used to be like getting sumatriptan shots when she was you know sitting around feeling awful awful and we just assumed that it was you know gonna help like vasoconstrict so she would feel better So Right yeah it's interesting but anyway so what that's this is really important I think to understand that there's a new theory I guess so that we understand why there's all these new medications and then why the old ones work and why the new ones work and things like that? So in terms of medications and and treatment we have prevention treatment Mm-hmm which is to reduce the frequency and the intensity of the migraines and then we have the acute treatment medications which is to stop or abort the migraine for the prevention we like to think of not everybody really needs prevention depending on where they're at So I like to start prevention on my patients who definitely these headaches are disabling and they are... it's interfering with their quality of life with their work parenting relationships per guidelines for the American Headache Society guidelines it says four or more migraines per month But sometimes we have patients that have two migraines and then those migraines are extremely disabling They have to miss two days of work every single month or those migraines also are can last up to 72 hours So again we are adding headache days and that Mm-hmm ...ends up being six headache days instead of it's two migraine attacks but it really ends up being six days that they are suffering So I think those patients are definitely great candidates for prevention treatment for prevention treatment we have the older I like to think of the older version of the medications are more antiseizure medications like Mm-hmm ...topiramate Depakote Then we have also blood pressure medications like propranolol and then we have also amitriptyline and nortriptyline which are tricyclic anti antidepressants those are like the most common used. There's obviously more in including candesartan which is also a blood pressure medication that has also very good evidence for for p prevention of migraine Again our goal is always to reduce migraine headache days and and Mm-hmm Reduce a and improve that quality of life. The newer agents are the CGRP monoclonal antibodies and the CGRP antagonists So those are the newer medications that came out to the market in 2018 from 2018 onward Mm-hmm. And we have initially we have those that are subcutaneous injections and we have three of those and one that is IV infusion that is given every three months And then the newer category of the CGRP antagonist now we have the oral medications And and those are also they're all great for for prevention And then for the acute part we have the triptans that you had mentioned that your mom used the s Mm-hmm the sumatriptan So we still have those and those are still great treatment as well the only thing is that if a patient has had a history of stroke or any cardiac history or abnormal rhythms of the heart then we don't use those medications So it's great that we now have Mm-hmm newer agents that also help with the acute treatment of migraine without having to use in the past like they used Fioricet or other Mm-hmm medications that we know now that we limit their use as much as possible because they can lead into into rebound headaches or medication overuse headache Mm-hmm. I was gonna bring that up but I'm glad you did. Yeah, I still have some patients who swear by the Fioricet, and they must, you know, have it, and they've tried other things and don't like it. But yeah, so there's a, there's a whole, obviously, I guess, menu of treating migraines now, which is exciting. I, I know we're not really focusing on any brand or anything particular, but, you know, people hear commercials. Which ones go into what thing, in case somebody is listening? Yeah So for so going for the prevention in the newer Yeah of the newer medications so we use Nurtec ODT every other day as prevention and then Qalyxa and then for the acute or abortive medications then we have the Nurtec is also used as as abortive Mm-hmm. But this is kind of as needed And then we also have Ubrelvy Mm-hmm. And then we have Zaspry which is it's the only one of its class that it's a nasal spray Ah, okay I haven't heard of that one actually. Yes it's yes Mmhmm And then I I did not mention that in that acute category of migraine treatment we also have the DHE that that's Mm. It's an old we call it old vogue goodie It it's actually a still a a old medication that it's very effective Again cannot be used in patients who have history of stroke or cardiac issues. And there is a newer form of DHE now also in a nasal powder it's called Trudessa and it's actually it it works great as well For those patients who triptans don't work as well or, They take too long, so DHE is, is also a great rescue medication When do you think it's appropriate for patients be on one of those bio biologic therapies the monoclonal antibody Yeah so It it the same. It's for prevention, right? Mmhmm So any, any patients who meet criteria for prevention would be a, a good candidate for these Yeah Nice Okay you were talking also about there's new guidelines of treating a headache when you end up in

Kerry 18:46

ER. Can you tell us more about that? Yes correct So in the past we we had more of the same like medications and actually the American Headache Society had not come up with guidelines since 2016 So this is very exciting that in 2025, there were re- revision and newer guidelines. So with number one, it's still pro- prochlorperazine, IV Mmhmm and then the... I think the newest out of all of of this review is that now it's suggested with with level A evidence occipital nerve blocks Mm. Which is A and especially the greater occipital nerve blocks this is my Because with greater occipital nerve blocks you actually are able to stop the pain or get relief without the sedation, Mmhmm

Rebecca 19:41

and because all of these other medications when you start prochlorperazine with Benadryl Ketorolac those are like the most common and then it may add Mm-hmm magnesium But and IV hydration Those are usually like our headache cocktails the the most common But again prochlorperazine and Benadryl they really are great to for for headache cause it they they are targeting histamine receptors dopamine receptors so you're also targeting the the nausea as well and the pain But the problem is that they're very sedating So Mm-hmm the occipital nerve blocks you are able to What what we like to think of the occipital nerve blocks is injections Should I go into explaining what occipital Sure, yeah nerve blocks is I think nobody knows what you're talking about. I'm surprised Yes most ER- Yeah physicians would be trained in it too but that's great. Let me hear more about it. Yes So occipital nerve blocks are injections that are given in the occipital nerves in the back of the head and they are We like to think of these as peripheral extensions from the trigeminal nerve which is the nerve that is activated in in a migraine or these headache disorders. So by injecting we make a mixture of bupivacaine and lidocaine i in some cases you also do dexamethasone Mm-hmm. Some other physicians will do Ketorolac but with the newest W with the newest research we know ketorolac tends to precipitate more and can cause alopecia in that area so we're trying Mmhmm to stay away from that and just stay more with the dexamethasone. But in any case, the, the idea is that those anesthetics will cause a negative feedback loop and m- basically tell the trigeminal nerve it's okay to calm down. And Mm-hmm and then within, really within about 15 minutes, the pain should be becoming lower and lower and stopping the headache. And so it's a, it's a great additional tool for for, patients in the ER. Mmhmm as headache specialists we do this all the time. We we offer it to to our patients We also do supraorbital nerve blocks supratrochlear auriculotemporal We have all sorts of blocks to be able to help the patient without having to give more medications IV Mm-hmm and these are also specific I mean they're great tools for anybody but pregnant patients are great candidates also for these because at least you're not giving right medications that can affect the the baby at that moment So they they really are not systemically absorbed for our listeners, how is that different than Botox treatment for migraines, and when would you use that? Sure Yeah so Botox is is completely different The Botox is a a treatment that we use for prevention for chronic migraine Chronic migraine patients are by definition they have to have more than 15 headache days per month and out of those 15 headache days eight of them have to be disabling completely disabling So Botox you actually inject it's 31 injections in seven different muscle patterns So we inject in the corrugators procerus corrugators frontalis temporalis, temporalis, occipitalis paraspinals and trapezius So it's completely different We are injecting in the occipital area as well which I think that's why y the the question right How are these different But the idea of the Botox is to reduce the signaling of pain pathways and this is a also a temporary It it only lasts about 10 to 12 weeks and that's why Botox is reinjected every three months Mm-hmm. Yeah But it's too it's not really So Botox is not used as an abortive treatment to stop the headache right then and there as greater occipital nerves are Okay So I guess the the major like to the to your point after that long answer is that greater occipital nerves are used for to stop the pain at that moment and the Botox is used as a prevention of Mm-hmm ...chronic migraine You can't expect to go get Botox in the ER right No that will not happen Yeah So you mentioned women are more at risk and you talked about being worse at puberty I'm assuming you were alluding to you know menopause and perimenopause as well. Can you explain that a little bit more? Yes So with hormonal changes especially the drop in estrogen right before our menstrual cycle occurs It occurs because of that drop in in estrogen So that drop in estrogen is so significant and dramatic in in the menstrual cycle that migraine brains are very sensitive to that And so that's most of our patients will will say that they have an increase in in headache frequency around the time of their menstrual cycle and it's because of that right So that in puberty starts changing and throughout our our adult life And then in perimenopause the fluctuations are very erratic as well and they're not I it's harder also to even kinda track them right Like they're not They start Mm-hmm the periods start getting shorter or longer depending on what stage you are And so this becomes very hard for patients to have consistency and do and and be able to get ahold or or of these migraines We as headache specialists we provide what we call menstrual migraine pro prophylaxis Mm-hmm to patients So and there are there are different and with multiple medications some of you know some mini prophylaxis with naproxen starting five days before your period But again to do that you have to know where you are on your cycle The same with frovatriptan and naratriptan The problem is that once we are in that perimenopause that the the menstrual cycles are not as predictable then it becomes very hard Mm-hmm to be able to To to predict and start that prophylaxis So most of our patients then end up in in just prevention medication as as a whole the CGRP monoclonal antibodies they have actually shown benefit for patients in in this category as well So it's important to start treatment because again it can it can be very disabling. And then that now to, to now to couple it with with, the hormonal changes also causing sleep disturbance causing more the the stress in in our lives it just changes everything in our like, yeah, i- in the, in the life of the patient. So in general, now you're having a migraine brain that is very sensitive to all of these hormonal changes, but then also the sleep patterns also change and, and everything kind of gets out of whack. So again, prevention is really the key in in addition in couple like you said with consistency Mmhmm ...of trying to keep your hours, like of how many hours you're sleeping, your hydration, and everything in order So trying to keep consistent on the things you can actually control is probably Correct maybe the best Now you mentioned naproxen which is you know an antiinflammatory Now why is that used or how does that even help? Yeah. S- So naproxen it W we know again being a neuroinflammatory disorder in this cascade of inflammation, the naproxen it, with it, it, it really inhibits the prostaglandins Really that's really Mm-hmm the the basic mechanism And we know that the prostaglandins continue in the cascade of inflammation and patients in the, especially in the menstrually menstrually related migraine- Mmhmm this is very beneficial So it's part of more of the inflammatory cascade prevention Correct. what about like oral contraceptives or hormonal replacement therapy Because I know you s either you used to think that migraine patients would be at a higher risk of a clot or a stroke or anything like that and or how would you- Correct ...use them to control it or what would you say to that? So we, we know that, migraine patients with aura have increased risk of, of stroke, and coupled with oral contraceptives and smoking right So those are Mm really the the data that we have we still have w- if patients have migraine with aura we are re- we, we may recommend, it depends, it's kind of a, right, every patient is different, and that's why we don't... This is not a one fit for all. Every patient has their risk factors and, you know, it, it depends uh, how many cardiac or stroke we may recommend... It depends. It's a patient is different, and that's why we don't... This is not a one fit for all. Every patient has their risk factors and, it, it depends how many cardiac or stroke risk factors the patient also has right Including cholesterol hypertension diabetes and all that But we try to avoid estrogen replacement therapy in those patients with migraine with aura Mm that have other risk factors for most of our patients if they are migraine without aura and they have minimal risk factors hormone replacement therapy with estrogen is completely fine We just try to make this estrogen the lowest as possible that we are giving but we know now with the whole perimenopause and menopause that estrogen is also good for women They they need it right So Mmhmm it it really always becomes a kind of a risk versus benefit in in those patients and what are their symptoms and what are what the what symptoms are disabling them the most Mmhmm But always trying to stratify that risk factors to its minimum as well So but migraine with aura are are patients that we tend to be a little bit more hesitant about adding that estrogen Would that be true also with like transdermal estrogen? It would still be yes Same risk, okay We yes we are still very careful with any kind of estrogen in patients with aura and other Mm-hmm risk factors Mm-hmm. Okay. But I, like you said, it can also be helpful in preventing so the lowest effective dose is probably Correct Mmhmm ...the best choice in there Okay That's important to know. Correct So you also mentioned like vestibular migraines We talked about abdominal migraines a little bit with the kids. What... How can you distinguish a vestibular migraine from, like, just vertigo? So that can be a a topic of its own because Sure, yeah vertigo itself it's you know we have central vertigo peripheral vertigo and there's multiple ways of differentiating But vestibular migraine right in itself tends to be i and patients don't even have to actually have a headache which is this is important for for everybody to know that migraine really is a complex neurological disease Headache is one of the many symptoms that migraine can have because migraines can really be present with dizziness brain fog with instability gain instability cognitive dysfunction lack of concentration So again headache is just one of the many symptoms that migraine can have when we see a patient that has vertigo and has other features of migraine like light sensitivity sound sensitivity nausea andor vomiting can also be coupled with other vertigo symptoms Mm-hmm. No There can't be any neurologic deficits right Like any acute neurologic deficits that would point out to maybe a you know like a stroke and a or hearing loss So all of these but again in a patient with migraine vertigo, light sensitivity sound sensitivity nausea and that is impairing the, the quality of life, that tends to be ver- vestibular migraine. Again, Mm-hmm ...we we, don't diagnose vestibular migraine out of the blue. We always, have to get information about you know the genetics of the patient in terms of do you have history of you know family history of migraine Have you had migraines before When you have this was light sensi did you have light sensitivity sound sensitivity nausea yeah those are are mostly And a lot of patients a lot of our patients not only just have vestibular migraine they have also migraine without aura or with aura and then they also get vestibular migraines Mm-hmm. So we treat it the same way as we would treat just migraine for prevention and and all that We we also know that venlafaxine also has good data for this vestibular migraines. We are seeing more and more CGRP Monoclonal monoclonal antibodies and antagonists that are also helping our patients with vestibular migraine. And also Botox has also had some data with, with improvement of these symptoms Mm-hmm. I was gonna say, you, you said a bunch of symptoms of migraine that overlap a lot with, you know perimenopause How do you differentiate the two If you're talking to a patient? Yes that's a good question because Migraine can occur after 50, but it's, it's actually very rare that patients start having migraines after 50, right? So, a history of migraines before, right? So any... Truly, in one of our red flags is anybody who starts having migraine at the age of 50 50 or over needs a full workup, Cause it's it's very rare that that that occurs So So that is one of the right Yeah of of the questions that w that we have but in so perimenopause in itself right we we you ask questions about is it has it been changing your your period Mm-hmm your sleep your all of that And then I like for perimenopause and all that I do like getting labs You know I do like checking testosterone free total and and free the estrogen levels so that's kind of more in the perimenopause part Yeah and then with the migraine how do you know if all of these are from migraine Y and and I guess your question was if they are not having a headache Yeah, maybe. Okay 'Cause you said there was the other symptoms that could be Yeah yeah. So I think but I I think specific to the migraine is also that like the the light sensitivity Mmhmm the sound sensitivity Some patients actually have also smell sensitivity Mm-hmm as well with it but you're right Perimenopause is also very much it it. can have many of these fatigue brain fog right cognitive kind of n- Not being able to find the word that you want, all of these, definitely you can, you can find them- Mm ...around that Sleep problems but I I think migraine what changes is that you also have these attacks right Like it's an in it not not just a continuous level of the symptoms and no attacks of any sort of of dizziness or headache pain or visual disturbances or Yeah. I think that makes sense very much so. So when, when do you think it's the time for the patient to come see someone like you, a headache specialist? Yes So mean I think if the if any patient who is really suffering right with headaches or any of these symptoms that is affecting their quality of life I think it's important to see a, a headache specialist. I think u- unfortunately, and again, I, I'm, I'm a migraine sufferer myself I think because we usually start suffering with these disorders so early in life you push through push through push through and you like kind of Just do it But there's no In this day and age there's no need to suffer anymore We have plenty of treatment options and and it's incredible when you are able to have improvement in quality of life and and have this clear right vision and and just feeling like yourself again which is very tough- Mm-hmm for patients when they're always feeling fatigue and with some sort of pain yeah so don't wait Don't I I think anybody who is suffering from these, there is exceptional treatments out there, and there's plenty We didn't even touch on nonpharmacologic techniques Anything that is- Mm-hmm non not medications there's plenty of options out there as well with devices Oh, yeah changes in quality of life and all of that So there there's so many I mean right now I feel like the all our treatment options including nonpharmacologics are are endless. So there's definitely there's hope Mm-hmm. No, that's great. I mean, I know that I also suffer from them and I did you know once upon a time go see a neurologist as well because they were getting worse and surprise surprise it was probably during med school and residency where stress Right lots of stress, My bucket was overflow lot of sleep and Yes Uhhuh Yes. Yes That it's very common yeah. I think one of the devices I can think of before we hop off, but is, is Cefaly, is that one you recommend? Cefaly, yeah So we have Cefaly device, we have Nerivio, Trude- Truvaga, which are vagal nerve stimulators stimulators. There is a transmagnetic stimulation Mm-hmm. The Nerivio is one that you just wear on your on your arm and it's a peripheral stimulator stimulating the C nerve fi pain fibers So there's multimodel Mm-hmm ...approaches Multiple patients many patients will use more than one if they Cause I have many patients just doing no medications at all They're super sensitive They don't want to They just also Mm-hmm want to stay with all the natural But the good thing is that we do have that available nowadays which you know it's looking back 20 years ago w we had very minimal options for patients Mm-hmm. So this is it's a great... We have great tools now. That's great. Yeah, so if people wanna work with you, where can they find you? Yes. So my my office is in Lakewood Ranch, so it's it's located in San Marco Plaza, 8209. It's Nature's Way, Unit 205 in, in Lakewood Ranch, Florida. But I also do telemedicine, so if someone is too far and still located in Florida happy to see them as well via telehealth Perfect. Yeah, the Lakewood Ranch is beautiful down there, so that's a nice spot you've got Oh, thank you It is and people have been lovely. And yes I'm loving having my own practice and being able to, to help patients regain control their lives And yeah, just what is the name of your practice and a website and things like that Yes, If you could say, it's, Jimenez Sanders Headache and Brain Center. The website is is Jimenez so it's JIMENEZ Sanders SANDERS MDcom Perfect. Yeah. Well, thank you so much for being on the podcast today. This was a great conversation. Thank I'm always, you know, excited to learn so much about... I I was gonna say CME, so continuing medical education for me, but obviously the listeners get to hear so much too about, you know every topic and I think this was a great conversation, so thank you for being on the podcast Thank you so much and thank you for having me All right. Everybody stay tuned next week for next week's episode. And we should mention it's June is Headache Awareness Month right Yes Yes Okay. We did forget about that Yes it is Oh we did June is He is Headache and Migraine Awareness Month so we are definitely trying to educate as much as possible and and let our patients know that it's it's good to to tell their experience and how Mmhmm their lives have improved when they have reached out for help Awesome All right. Well, everybody stay tuned next week. Thank you so much. Bye Bye. Thank you