I'm Dr.
Katherine Hamilton.
I am a headache specialist at
MedStar Georgetown University. Hospital.
And I see only headache patients.
And that consists of patients with
all different types of headaches.
A lot of my
patients have migraine, but there are also patients with tension, headaches,
or musculoskeletal issues.
Also, more rare types of headaches like cluster headaches,
I see all types of headaches.
I try to really
spend the time to listen to the patient and
hear what their desires are
and their goals are coming
into a visit because migraine.
And headache treatment.
Is can become pleasant.
There are a lot of different options.
There are non-medication and medication approaches,
and it really depends on the patient sitting in front of me how I'm going to
treat them for their headaches.
That is a huge
factor in how I end up treating them.
You really want
to work with them to figure out what is the
best way to manage that particular patient's
headaches and migraine.
MedStar Georgetown University Hospital has one of the larger headache
groups in the country and
that larger group allows us to take a
multidisciplinary,
comprehensive approach to our patients.
I have colleagues that I can.
call on or or discuss with if patients case
is more challenging.
And that really allows more comprehensive care.
And along those lines, there are a lot of colleagues,
even outside
of our immediate headache group in other specialties like physical therapy
or ENT, neurosurgery,
that I work closely with here.
And that's another benefit
of getting care at a larger
headache center, and in an academic center,
is that there are a lot of other specialists who
can weigh in
and who we work closely with
in helping headache patients.
It's incredibly rewarding to to help these patients.
These are often patients who are otherwise healthy, who are
pretty high functioning and
migraine and other types of headaches can be really debilitating for them, can
really prevent them from living their life.
So, I've found it incredibly rewarding to
provide them with treatments
that that can help them get back to their life, get back to
functioning and contributing to their family and their work.
Migraine is a specific type of headache.
It's one of the most common diagnoses
that we treat as headache specialists.
A migraine headache tends to
be more severe,
it's often one-sided,
throbbing in nature.
But a migraine is
much more than just a headache.
During a migraine attack,
patients can have a host of
symptoms such
as dizziness, light sensitivity, nausea,
vision changes, cognitive
impairment, fatigue.
So, it's really much more than than just a headache.
And migraine
is really a disease, a disorder of
the brain.
There are certainly a lot of things left to discover about the mechanism
of migraine, but we've made great strides in understanding
some of the mechanisms going on in the brain during migraine.
And we understand that it's a complex process.
There are genetic and environmental factors.
But the more and more
we understand, it allows us to develop new
treatments, more targeted treatments, for migraine
Migraine is
diagnosed based
on the symptoms that a patient experiences.
So, if a patient has a severe,
one-sided, throbbing headache
with
associated nausea and light sensitivity, that's enough
to make the diagnosis of migraine.
We don't necessarily need to look for
a certain imaging finding or certain blood
tests to make the diagnosis. Although sometimes,
if someone is having headaches with
unusual or atypical features,
then we might want to get a brain MRI
just to rule out other causes of headache.
We treat
migraine headaches in a variety of ways.
There are non-medication and medication
approaches.
So, before even talking about medications,
I like to talk to patients
about non-medication
approaches; things like
minimizing
stress, avoiding triggers, keeping sleep schedules
regular, trying to get enough sleep, staying well hydrated.
And then in terms of medications, there
are two different types.
There are
preventive medications or treatments.
The goal of
preventive treatments is to lower the
frequency and severity of migraine.
So, these
are particularly.
important if someone is having very frequent or severe migraines.
And then there are as-needed or acute
treatments. Treatments to take
at the start
of a migraine or to treat a migraine in the moment.
So, typically for
a patient
with migraine, we are using a combination of non-medication and medication
approaches, both for prevention and as-needed.
And in addition to medications, there are also procedures,
there are devices we can use.
So, it's really a wide
range of treatment options.
There are a lot of newer, more targeted
migraine treatments that have come out even in just the
last few years.
And some of
these treatments
are in trials
and are not available to the public,
but could be could be available if
a patient were to enroll in a trial.
So, by having access to those clinical trials here, that
expands treatment options for
patients, especially for patients who have tried a lot of
treatments in the past and not had success.
Migraine is much more common among women.
Interestingly,
in young girls and boys before puberty,
there's equal numbers with migraine.
But after puberty,
migraine becomes two to three times more common in women.
So clearly, there is a hormonal factor at play here.
Migraine can often shift and change over the
course of a woman's life.
Based on hormonal changes.
So, for example, sometimes women
first
start to get migraine when they start to get their periods, and often migraines
can be more frequent or severe around the time of the month of the period.
Migraines often can improve during pregnancy.
And likewise, they can sometimes improve after menopause.
So, knowing this will help guide
our treatment of
women with migraine as we know
what to expect, or potentially
anticipate, as they as they move through
their life span.
Migraine can
often be worse.
around the period because of
the drop in estrogen that occurs.
So, knowing that mechanism, it can help us
treat menstrual-related migraine or prevent menstrual-related migraine.
What we'll do
sometimes is we'll treat
a woman with estrogen-containing birth control
pills to try to keep those estrogen levels more stable.
Sometimes we'll even have them take birth control pills
continuously so they avoid their period altogether.
And that can try to prevent those menstrually-related migraines.
There are also non-hormonal approaches to
treating menstrually-related migraine.
Sometimes we use an as needed medication like an anti-inflammatory, and we
have the
women take it every day around the time of their period
to keep the migraine headaches at bay.
So, for example, if
a woman knows that they're going to get...
that she's going to get a migraine headache at the
first day of her period,
she can start taking the medication the day before and continue taking it
through through that period of time.
So, this is a very
important thing to
bring up with women and to plan and counsel them on
well before they get
pregnant, because you want to have a good plan in place for
migraine treatment.
So, I always ask
my female patients
whether they have any plans
for pregnancy in the next six months, because I want to know well in advance
so that we can come up with strategies and plans.
The good news is that,
for many women, migraine gets better in pregnancy.
And this is because they're not having those hormonal
fluctuations that come around the period,
just a rising level of estrogen throughout the pregnancy.
So, particularly in the second
and third trimester of pregnancy, migraine can can be much improved.
However, that's not to say
they won't have migraine during pregnancy.
And for some women, unfortunately, migraine does not improve.
So, we still need to have good treatment options.
A big point I try to make is that
there are options.
We're definitely more limited
when it comes to treating migraine and pregnancy just
because a lot of the medications do have potential risks
for the pregnancy.
But there are
certainly safer options and there are some good non-medication options
as well.
So, I try to counsel women that
We can take a tiered approach.
We have options,
we can try different things,
but they shouldn't feel that there's nothing at all that they can take.
We are more limited with what
medications and treatments we can use in pregnancy.
Because, with a
lot of medications,
there are concerns for their use
in pregnancy, for their effects on the
pregnancy itself, for the fetus.
And unfortunately,
for a lot
of treatments, we just don't have a lot of data.
Pregnant women are usually excluded
from randomized,
controlled trials.
So, we we don't have the same kind of data
that we would have for
non-pregnant patients.
That being said, there are certain
treatments that are considered safer and we do have data
from what we call
retrospective studies or studies that look back
in time at women who have taken medications during their pregnancy.
So, there are certain medications that we we consider safer in pregnancy.
And there are also
non-Medication options that don't have don't lead
to anything getting into the body that are considered safer in pregnancy.
For example, procedures like nerve blocks or
onabobotulinumtoxinA,
Botox, or there are certain devices that we can use for
migraine treatment.
So, I like to go through some of those safer.
options with patients.
The post-partum period can be a challenging time for migraine
because there are a lot of hormonal shifts that happen.
A woman is
usually sleep-deprived, stressed from caring
for a newborn.
So all of
those can be potential migraine triggers.
And the good news is that in the postpartum period, we do have
more treatment options, more safe
treatment options for migraine even if a woman is breastfeeding.
So, while migraine might
pick up a little bit after
a woman delivers
her baby, she at least has more options to use
for both preventive and acute treatment.
Also, breastfeeding itself can sometimes
be protective, can sometimes help to keep
migraine frequency
lower because it
prevents those monthly fluctuations that happen.
That can be a migraine trigger.
These
treatments are newer.
They've been around for a few years now.
These are more targeted
Migraine treatments
that work
based on the mechanisms that we understand about migraine.
They block this certain molecule
called CGRP.
Because they're newer,
we just don't have a lot of data
on their use in pregnancy.
So, we don't know whether they're safe.
We don't know whether they might have adverse effects.
So, for that reason, right now
we don't use these
newer medications for a woman who's
pregnant or breastfeeding.
And usually we want to make sure that that a woman has
stopped it before
she gets pregnant so that
she's not exposed at all
during the pregnancy. For some of these newer medications,
some of them are once a month injections.
We have to stop those months before
a woman gets pregnant because it takes a little bit of time to get out
of the system. So, it's important to know,
if you're on one of these newer migraine medications to mention to your doctor,
if you're at all thinking about pregnancy in the next six months
or so.
Oftentimes, migraine does improve after menopause.
And that's
because the hormones
even out and stabilize at low levels.
So, you're no
longer having those fluctuations of estrogen that can trigger migraine.
That's that's the general or most
common scenario.
for a
woman, especially for a woman who's had menstrually-related
migraines or hormonally-related migraines.
However, that's not always the case.
It doesn't always improve after menopause. And sometimes,
migraine headaches can shift
and a woman might have improvement in
the headache but still have episodes
of migraine involving dizziness, nausea, other associated symptoms.
I've definitely seen that.
So, it's not
to say that after menopause you don't have to worry about migraine.
It's still something that can come up.
And in the period of time leading up to menopause, that perimenopausal period,
that can actually be a time where migraines worsen
because there are more fluctuations
of estrogen.
So, it's important to be aware of that
and counsel
the woman that that period of time,
that perimenopausal period, can actually be quite long.
So, you
don't want to think, 'oh,
I've had my last period, I won't get a migraine again,'
because sometimes if anything, migraine can get.
a little bit worse before it gets better.
This is definitely an area where we need more research.
There have not been a lot of studies on treating
perimenopausal migraine specifically.
In general,
we treat it similarly to how we treat
migraine in other periods of life.
One important concept is
just to understand that migraine can get worse around that time.
So, oftentimes this is a point at which women will need
to start a preventive medication for their migraine.
But typically we use similar
preventive and acute medications as we would at other times.
Some of the preventive migraine medications can actually
also help with other
perimenopausal symptoms.
Sometimes we can target our medication choices
to include other symptoms that
occur during perimenopause.
Sometimes patients will
start hormone replacement therapy.
We usually don't start that simply because
their migraine frequency is higher.
But if
someone is having other symptoms like
hot flashes,
that might be something that they could discuss with their
Gynecologist.
Patients should
choose MedStar Georgetown University Hospital
Headache Center
because we have one of the largest headache
groups in the whole country.
We have many headache specialists
who have different areas of expertise
and that large group allows for really great collaboration
and really comprehensive patient care.
So, a patient will know that,
even if their case is
more complex, they have not just their own doctor, but a whole team of doctors
behind their care and working to
help their headaches. It's also a multidisciplinary group.
There are specialists outside of neurology
that we work closely with, like physical therapy or neurosurgery.
So, we have a very extensive, larger
network of providers
helping to care for headache patients.
And that also makes MedStar Georgetown University Headache Center unique.