Introduction to Dr. Monica Esposito

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Welcome to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller. Today, I'm joined by Dr. Monica Esposito, a board-certified family medicine physician and founder of Ascend Concierge Medicine.

The Four Phases of a Migraine

Kerry 0:13

So what are those four phases of the migraine?

Monica 0:16

Yes. The first phase is the prodrome, and we'll go into that. The second phase is the aura, which not everybody goes through them. Only 25 to 30% of patients actually have aura. Then the third one is the actual headache phase, which is truly what we recognize most of the time as our migraine. And then the fourth phase is the postdrome. I like to think of migraine, again just like we had mentioned before, migraine is really not just a headache. It is a neurologic disorder of brain hyperexcitability, and I like to think of it as a storm. So before it starts like the sky changes, the pressure changes, the wind changes, and eventually the rain comes. So the same happens with the migraine. In the prodrome, which is that warning phase, that can occur anywhere between 24 to 48 hours before the actual headache occurs. And in this phase we know now with the newer the new migraine pathophysiology that we know that it's not just a vascular disorder. It's really a brain a neurologic disease that starts at the hypothalamus getting activated, and then it goes and activates the brain stem, the trigeminal vascular system, and the pain pathways. So i- in this first phase is where the hypothalamus gets activated, and our patients start experiencing excessive yawning, fatigue cravings. A lot of patients say that they, they say that it's the chocolate triggers the migraines, but it really, we know now that it's not really chocolate triggering the migraine. It's that hypothalamus activation that increases the craving. And a lot of patients may crave carb rich, like foods rich in carbohydrates sugar, and it's because of that the brain uses glucose as a way of being active in the metabolism. And also it has magnesium, so it's also craving those. But it also in the prodromal phase, we also have mood changes, irritability, depression. Neck pain is a big one in this phase. Brain fog, difficulty concentrating one that is also very interesting is the increase in urination and increase thirst. So all of these happen again in this prodromal phase. Then after this, then we have the aura, again, that it can occur in twenty-five to thirty percent of our patients. And in this part is where the cortical spreading depression occurs, and this is a slow electrical wave that moves across our, across the brain, and that's where we can get most of our symptoms of this visual disturbance that we had talked about prior. And we can see in those the zigli- zigzag lines, flashlights, blind spots, shimmering vision. Other sensory disturbance that, that can occur is the tingling and numbness sensation. And then in some patients hemiplegic migraine also can occur, which is more of the motor, that they can't move part of their body. This aura phase only lasts about five to sixty minutes. And and then after this is when the headache phase or the third phase occurs. And again, this is what most of us recognize as our migraine because it's like the pain where it becomes disabling. And at this point is where the trigeminal system becomes activated, and then all the inflammatory neuropeptides are released. And in that cascade of neuropeptides is where we find the CGRP, the PACAP, which is one of our newest neuropeptides that are being... and we have medications already being designed against this one. We still don't have any out there, but this is the next target for the future. And then substance pain and these are all pain pathways that become sensitized. In this phase, then we have the head pain. And not only the head pain, but also the nausea, the vomiting, the light sensitivity, the sound sensitivity, the smell sensitivity. Although it's not in our ICHD criteria smell sensitivity is something that we see with our headache patients, our migraine patients, very significant. And then movement sensitivity, right? We know that migraine gets worse with movement. after we have gone through the headache phase, then we end up in our postdrome phase, which is what most patients feel like a migraine hangover and it occurs after the pain resolves. And the worst part is that this also can last up to 48 hours. So if you think about it these are... Again, this is a very disabling disorder because it can last 72 hours as it is or more. In this phase, we see fatigue, brain fog. We see, again, difficulty concentrating, moo- mood changes, and a lot of dizziness as well. So it's like then the storm has passed, but then the cleanup crew is still working. So a- and this is exactly what happens, and that's why patients need time to recover from this phase as well

Can Weather Changes Trigger Migraines?

Kerry 6:03

So f- funny with your analogy, you mentioned the weather and, ...the storm coming. A, lot of patients sometimes say that the weather change and the pressure changes causes migraines. How... Can you explain that?

Monica 6:15

Yes, so there are many theories for why weather changes is a stressor. There is a theory that it's like our sinus have receptors for this barometric pressure changes. And there, again, there's multiple theories. I don't think that there's any that has been proven, but it's for sure that weather changes in many of the patients that suffer from migraine can be a trigger. And again, it's more of what we were talking about this homeostasis. our migraine brains like having everything at a balance, and weather changes is a change again. And the thing, those hormonal changes and everything, it will... it can trigger already a very hypersensitive brain. And there is treatment for that. I was gonna say, headache, headache specialists definitely, we know our tricks to help with that

Kerry 7:12

Okay. What's an example?

Monica 7:14

So we use acetazolamide, methazolamide, but it's an it's not for every patient, right? And of course, we know for, especially for this storm season as we are... we just started hurricane season. So we always advise our patients the same thing, make sure that you're sleeping well, that you're hydrating well, that you're exercising, making sure that our threshold is not very low so that any change can actually cause a, migraine. So we want everything to be at its best so that when these changes occur, then also we have a a cushioning phase where not everything is causing the migraines. But some patients really just get, they're very much affected by it, and acetazolamide or methazolamide can also help prevent he- headaches in this phase

Kerry 8:13

That's interesting. Obviously, that's like the altitude sickness medication, so if patients, relate to more of that comment, I guess then maybe they would realize that, it's treating the pressure, the altitude. I don't know. That's interesting that is used

Monica 8:26

And with weather changes, ...it really is the rapid drop in the barometric pressure that that ch- that causes most of these migraine symptoms

Sinus Headaches vs. Migraines

Kerry 8:37

We also have a lot of patients, in, in our practice that, we do a lot of allergy, right? So they have nasal congestion and, I think sometimes they also think that maybe, with a, the sinus type headache can turn into a migraine. Do you ever see something like that?

Monica 8:55

Yeah. So that's a very good question, and a lot of our patients come saying that they were misdiagnosed, right? Or just... or they just come complaining or wanting help for their sinus headaches. So ...that is a, it's a good point that you bring. You mentioned allergies, so let me just... A- allergies don't really cause migraine, right? It can just be, it can trigger migraines but it doesn't really cause the migraines. The same as a sinus headache. So sinus headache by definition is a headache that is obviously in the sinus areas, but it is linked either to allergies or to a sinus infection with, purulent mucus. And it has, we have multiple studies that have shown that over 85 to 95% of patients when they are talking about their sinus headaches, they really meet the criteria for migraine. So they end up actually having light sensitivity, sound sensitivity. The headaches last f- for more than four hours. And the reasoning is because the trigeminal nerve, which is the t- the nerve responsible for headache pain, also innervates our sinuses. So it very much feels like it's in our sinus areas, the, this pain. Migraine does not have to be unila- u- unilateral, does not have to be throbbing, right? These are specific features that migraine can have, and yes, if you have those features are most likely that it is a migraine, but it can also be bilateral. I think you have to, take into account that light sensitivity, sound sensitivity, the duration of the of the headache, if it gets worse with movement, as well if there is nausea associated with it or queasiness because there is with migraines we get what's called g- gastric stasis, which is like our, motility slows down. So not every patient actually gets nausea and vomiting, but they just may feel queasy and lose their appetite. So yes, so it's important to differentiate what true sinus headaches are from migraines.

Kerry 11:20

Yeah, I think that perhaps those patients are already at risk for migraine or they just like you said, maybe a little bit of misdiagnosis or maybe there's both. But I also was gonna have the question of, where, to tell the listeners where does the trigeminal nerve innervate and things like that because I think that's pertinent for where we feel our pain sometimes when we have a migraine. So that, that was a great observation. Yeah. The other thing I think you mentioned was, with the hypothalamus and the cravings, and I just don't think we talk about the prodrome about it very much at all.

Why the Prodrome Phase Matters

Monica 11:52

Enough, right?

Kerry 11:53

definitely interesting

Monica 11:55

yes, and I think it's extremely important to, like you said, talk more about it, educate more about it, because now with the newer medications and the CGRP antagonists they have... They're doing studies that if you actually treat in that prodromal stage or phase, then you actually can prevent the f- the further on the aura, you can prevent the headache phase, and you can prevent the postdromal. So again going back to how important is to the acute treatment, and we'll talk about the acute treatment in a second is treating super early. The earliest that you can treat, the better it is. And so understanding, recognizing your own, because everybody's prodromal stage and symptoms is different, is extremely important so that you can treat properly and treat early

Kerry 12:54

Yeah, absolutely. I think you were also mentioning some of the older diagnostic features of it, like the unilateral must be throbbing. And I, as once again we've learned more about migraine that it doesn't have to be like that. I thought that was very pertinent as well.

Monica 13:11

Yes, and they are still... So if you look into the international classification of headache disorders are like this is our book for diagnos- criteria, it still names them, right? But it doesn't have to meet all the criteria in those. That it doesn't as long as it, it combines the nausea, the light the light sensitivity, the sun sensitivity, it doesn't necessarily have to be ...unilateral

Acute Migraine Treatments Explained

Kerry 13:40

So you mentioned, acute treatment and that it's important to be treating early. So what kind of things do we use for acute treatment of migraine?

Monica 13:48

The acute, just to make sure that we are understanding acute treatment is the treatment that we use to stop the migraine when you already started having it, right? Even in that prodromal phase or it's like putting out the fire. And then the prevention treatment, again it's preventing the fire from occurring. Again, we, in this is where we want to u- use the medications as early as possible, and we have multiple to choose from. From simple analgesics like acetaminophen that's mostly used for mild headache pain, pregnancy, although I know there's have been, discussions with the pregnancy and acetaminophen. But it's still used. And then we have the nonsteroidals, anti-inflammatories that they help block the inflammation. And these we have the ibuprofen, the naproxen, the diclofenac, the celecoxib. And then the, we have the more specific acute medications like triptans, and in this we have all the triptans, sumatriptan rizatriptan, eletriptan, sulmitriptan, naratriptan. And they work in the serotonin receptors. So interestingly the reason why they work is because they reduce the CGRP uh, release. So in another receptor they are actually doing what the newer class of medications are doing, which is the newest is the CGRP uh, or gepants that are CGRP blocking agents. And this is, CGRP is like the main chemical right now that fuels the migraine. And again, these medications kinda block that. And that one is we have the Ubrelvy, the Nurtec, and the Caystropren, which is the nasal spray. And so we have all of these, right? And patients may get overwhelmed "What do I use?" "When?" And so I think the beauty I think and this is the art of the headache medicine, is that as headache specialists we formulate plans for our headache patients where we are combining medications because we know that again, this m- migraine pathophysiology, it, it starts in one place, and it activates a lot of molecules. And it's really the combination and attacking the migraine from different angles and at different receptors and blocking different pain pathways where we get the best result and we improve the quality of life of the patient. We use a specific migraine medication, but then we may combine it with another NSAID. In addition, we may combine it with an anti-nausea medication we may combine it with Benadryl as well. So it depends on the patient's comorbidities, the patient type of pain and the symptoms that they have that we make our headache cocktails specific for each patient

Kerry 16:56

It's funny you say the headache cocktail, 'cause we always use that term, like migraine cocktail. Yeah. And it's great you mention the combination, right? Because, I mentioned that I once went to a neurologist for my migraines, and all I needed was to be told to take the NSAID with my triptan, and that was it. I've been pretty decent since then. So now I always come, obviously treat earlier than I used to, 'cause we were hoarding them so much because they only give you nine a month. So how, why is that, and how do you work around that? Or do you automati- automatically, make sure they try to do the prophylactic if they're needing them?

Medication Overuse (Rebound) Headaches

Monica 17:32

Correct. That's a great question. So they give you very little amount. I... Sometimes I think they give you less amount that is permitted. But it is, There's a science behind that as well. It's, I know insurance has, its reasoning, but it also it's also we are trying to prevent medication overuse headache. And medication overuse headache is a headache. It was called the rebound headache. It's a headache that is caused by e- exactly that, the overuse of the medications. And then each of these classes actually have a different amount. So for triptans, we don't wanna use it more than 10 days per month. We know that using it 10 days per month or more increases the risk or predisposes you to get medication overuse headache. The same for NSAIDs actually is 15. For NSAIDs it's actually up to 15 head days per month. So this one is more that is allowed. Which is good because a lot of our patients that are later in their life, they, they have arthritis, and they have other pain disorders that they need to use the NSAIDs more regularly. So at least with the NSAIDs it's a little bit more flexible and more days. with the other medications, this like the Fioricet, which is a combination medication, or the Excedrin, which again is a combination medication these are medications that we can only use 10 days or less. Or again, if not, it increases the risk- Of the medication overuse. With the Fioricet or the Butalbital products that we were saying we really don't... We try to avoid it. I know some of our patients absolutely need it as a rescue. And it's okay, but definitely try to limit it less than five days per month the maximum. I don't think that... as headache specialists, we never will probably never use more than eight pills a month as a prescription, and that's if nothing else worked, then that's a second that we like to do, like plan A, plan B, plan C, try to avoid patients to end up in the hospital. So we have multiple plans for the patient to go through in order to avoid a visit to the ER. 'Cause it just it's a place where there's the lights are bright the noise. It's really not where a migraine patient really wants to be. So this is why it's the medications per se are limited. Again, sometimes really is insurance because sometimes they end up giving us less triptans than what we actually want or need. And and we know that amount will not cause the medication overuse. Interestingly, for the GePans we have not seen that they are causing medication overuse headaches, which is a really good thing so far.

Triptans vs. New CGRP Medications

Kerry 20:43

That is good, yeah. I've had some patients who say that the triptans work a lot faster than the newer medications. Do you see that too?

Monica 20:51

And I think it's true, and I think all the studies, if you compare the triptans to this gepants it's true. The triptans are still much faster, I think. And this is why the Zafspred, which is the gepant and nasal spray, came out, so that to bypass some of that system and make it work faster. But I would agree. And we still use triptans in our population, so I don't think gepants came to completely remove and take triptans out of the market. I think it's, it, I think they're specific for a certain population, and the triptans are specific for other population, right? Like in patients who their migraine escalates extremely fast and they can and they don't have cardiovascular risk factors, they can use triptans, and that is perfectly fine, and that one will work better, right? Because again the gepants really do take much longer. Sometimes they can cause also more GI symptoms, and upset stomach, and constipation issues. So there are, So I don't think it's a one fit for all, right? I- that's when we talk to the patient, assess their risk factors, really understand the the history of how the migraine, their migraine evolves if they notice that there is a prodromal phase and what they actually experience, and if we can treat right then and there. So yes, the, it's to your point, I still think that triptans work faster

Kerry 22:32

Before I ask the next question, is there anything else you wanna say about the acute treatment?

Monica 22:37

So in, in addition of those medications per se, then we have we still use the the DHE. We use nerve blocks. And for severe attacks we use the greater occipital, the lesser occipital, the supraorbital, auriculotemporal. And then we also have the neuromodulation devices. Oh, and we have... I'm sorry. Before I move to the neuromodulation devices that also can be used for acute treatment, we also can use SPG or sphenopalatine ganglion blocks

Kerry 23:09

so earlier in the episode you mentioned, constipation, and all I'm thinking is there's a supplement out there that actually treats, constipation, but it also, some people think, helps prevent migraines. So I'm

Magnesium and Other Migraine Supplements

Kerry 23:21

referring to,

Monica 23:21

magnesium yes.

Kerry 23:23

any other ...supplements? And please tell us all about magnesium

Monica 23:27

Yes. So yes, there are other supplements. But going back to magnesium I, and I love magnesium. I love recommending magnesium as well. I think magnesium is one of the brain's natural calming minerals, and just like what we were explaining migraine brains are hyper excitable. And it's almost like children who have had too much sugar, right? They are, like, bouncing off the walls. That's our migraine brains. And magnesium tends to calm it down and relax it. But it, it does this by multiple ways. It's not just one. So it, it stabilizes the nerve cells. It reduces the glutamate, which glutamate it, it kind of counterbalances the glutamate, and the glutamate is actually the brain's major excitatory neurotransmitter. That's where truly the magnesium will help because it helps regulate that, that glutamate, and so that's how truly magnesium ends up helping significantly. It also modulates the NMDA receptors, which NMDA receptors also amplify pain signals. So the magnesium kind of acts almost as a natural break, if you will. And it also helps reduce the cortical spreading depressure, depression. So magnesium also has been in research, we, it has been proven to also reduce aura symptoms. It, it's, it really is a it's good and for reduction in aura, reduction of headache, calming down the brain itself. It has also h- been shown effective in reducing the allodynia, which is the pain that after a migraine or during a migraine, sometimes even just touching, you can't even ...brush your hair or even just touching your hair hurts. So that's the pain amplification, basically. Magnesium helps with that. and it also, it helps with sleep, which helps also, right? So many patients with migraine have sleep disturbances, and so it also helps with regulation of sleep. So again it helps in many ways,

Kerry 25:53

absolutely. It's funny you bring up the allodynia 'cause, like, when I remember learning about migraines in residency, or maybe it was, I'm sorry, med school I remember it's treat immediately to prevent cutaneous allodynia, so like what you just described, which is so true, for sure. I feel like if you get that, you kinda miss the boat on treating the migraine sometimes

Monica 26:13

Correct. Cor- y- you missed the boat on treating it early but there's still... Yeah, you can still get ahead and, yeah, with treatment and still abort it. for sure, yes

Kerry 26:24

All the different, pathways and neurotransmitters and everything, it's no wonder that you need a fellowship in headache medicine because there's so much one, that's like new I think even since I was, in residency and things like that, that it's just amazing all of the I guess the progressions in medicine.

The Future of Migraine Treatment

Kerry 26:41

So

Monica 26:41

Oh and everything, and there's a lot more coming. I'm actually ...gonna be joining the American Headache Society tomorrow it starts in Orlando. And I attended the one in Scottsdale, Arizona in December, and it's now... we have been overwhelmed with the CGRP for the last... it, but they really started coming out in 2018. But now it's like we're dur- we're just talking about the PACAP. So now it's a different receptor and the different new medications that are coming or being researched for these and what kind of... It's gonna be so interesting 'cause now we know that some disorders are actually more have more PACAP than CGRP. And so we're gonna be able to treat post-traumatic headache in a different way than migraine, in a different way than cluster headache, in a different way than... it's to me, it is, it's just fascinating. And with more research we'll be able to target the, a specific therapy for a specific patient. So it's it's exciting. It's definitely an exciting time

Kerry 27:51

Yeah. So are there any other supplements or anything for

Monica 27:55

Oh, yes. So going back to supplements, yeah. So we we have data for vitamin B2 or riboflavin. We also have data for... The- there's actually newest data for thiamine or vitamin B1, but it's not the one that we have. The B2 is the one that we had been recommending in the past. The, this is new, and there's not that... It's only, I think there's only two research studies that have shown improvement in the in patients with vitamin B1. So for now we're still, like I said, B- B2. CoQ10, coenzyme Q10 is another one that, that we recommend. And those are the main three. There are other ones, but then may interact with other medications go through the liver, and so it's, I tend to be a little bit more cautious, like for example, with the feverfew and butterbur and stuff like that. They are they go through different pathways in the liver, and they can sometimes hurt the livers, right? So you wanna try to stay... I o- I usually start with the basic magnesium, B2 and CoQ10, and then move on from there

Kerry 29:11

Awesome. Is there anything else you'd like to share?

Monica 29:14

I think just more of what I said. There is, this is an exciting time to, to be in, participating in the headache world. So if you are someone who suffers from migraine or know someone who is disabled by migraines, please don't hesitate to reach out. There's so much treatment out there, good treatment options with minimal side effects. Again, non-pharmac- non-pharmacologic treatments. There's no, no reason to be suffering anymore in this age. So yes.

29:47

Thank you for listening to the Get Healthy Tampa Bay podcast. A special thanks to Dr. Monica Esposito. If you found this episode helpful, please subscribe, leave a review, and share it with someone who wants to be proactive about their health. Until next time, stay healthy, Tampa Bay