Migraines can be absolutely debilitating, and many people with migraine live in fear of the next migraine attack. But when they try to talk about their symptoms, they may not be believed … or they might be told to take some ibuprofen and get over it. C. Michelle Lindley shows us what it’s like to live with migraine in her novel “The Nude.” She joins us with Mayo Clinic expert Dr. Rashmi Halker Singh to talk about migraine and its common misconceptions.
Migraines can be absolutely debilitating, and many people with migraine live in fear of the next migraine attack. But when they try to talk about their symptoms, they may not be believed … or they might be told to take some ibuprofen and get over it. C. Michelle Lindley shows us what it’s like to live with migraine in her novel “The Nude.” She joins us with Mayo Clinic expert Dr. Rashmi Halker Singh to talk about migraine and its common misconceptions.
This episode was made possible by the generous support of Ken Stevens.
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Dr. Denise Millstine:Welcome to the “Read. Talk. Grow.” podcast, where we explore women’s health topics through books. In the same way that books can transport us to a different time, place or culture, “Read. Talk. Grow.” demonstrates how they can also give us a new appreciation for health experiences. Books can also provide a platform from which women’s health can be discussed.
At “Read. Talk. Grow.,” we use books to learn about health conditions in the hopes that we can all lead happier, healthier lives. I'm your host, Dr. Denise Millstine. I'm an assistant professor of medicine at Mayo Clinic, where I practice women's health, internal medicine, and integrative medicine. I am always reading and I love discussing books with my patients, my friends, my professional colleagues, and now with you.
Our book today is “The Nude” by C. Michelle Lindley. Our topic today is a common one faced by women: migraine headaches. C. Michelle Lindley's work can be found in “Conjunctions,” “The Georgia Review” and elsewhere. She is a National Endowment of the Arts Fellow for 2024 and has an MFA in Creative Writing from Cornell University and a BA in English and Art History from the University of California at Berkeley. Most recently, she's the recipient of the 2024 Friend Prize for Creative Writing. “The Nude” is her first novel. Courtney, welcome to the show.
C. Michelle Lindley: Thank you so much for having me.
Dr. Denise Millstine: Dr. Rashmi Halker Singh is a neurologist at Mayo Clinic in Arizona. She studies primary and secondary headache disorders, including migraine and chronic daily headaches. This includes understanding the underlying pathophysiology, establishing clinical phenotypes and exploring new treatment options for headache disorders. Rashmi, welcome to the show.
Dr. Rashmi Halker Singh: Thank you so much for having me as well.
Dr. Denise Millstine: “The Nude” is literary fiction at its finest. Set on an island in Greece, the novel follows an art historian as she assesses a found, potentially nearly priceless work of art. She quickly becomes entangled with a cast of characters and some questionable ethics around who has the right, to which cultural artifacts. We are not, however, going to talk so much about art, but we'll focus on the protagonist who manages migraines in the middle of her whirlwind, high-pressure adventure.
Courtney, tell us about Elizabeth and give our listeners an idea what she's navigating in this book.
C. Michelle Lindley: Yeah. Thank you. The idea for this podcast is so exciting to me. I think being given this platform to discuss this aspect of the novel, which is really near and dear to me, is important, and this is a book built on bodies, specifically the female body, women's bodies. And Elizabeth is someone who's struggling with migraine headaches. She's been afflicted with them for a long, long time, since she can really remember. And I was thinking a lot about how someone would navigate this while still trying to be accomplished and have ambition and when it would show up, like in the workplace. I know that migraines are something that a lot of women deal with, but because it is an invisible disease, they find it very hard to be believed for having that. At certain points in the novel, I think she's told, you know, just take ibuprofen or various other common refrain that we give to people who suffer from this. Yeah. Does that answer the question?
Dr. Denise Millstine: Yeah it does. Thank you very much. Rashmi, tell us your reaction to the book.
Dr. Rashmi Halker Singh: So I was really interested in this because there is a strong push in really trying to share what the lived experience of migraine is like. There have been some studies demonstrating that we are not, as a society, doing a good job of sharing that. There was a study published a couple of years ago looking at what is mass media tell us about who has migraine. And that study showed that if you were to just Google the word migraine, the typical picture that comes up is a white woman who's sitting with her hands on her temples. And as we all know, migraine does not discriminate. It affects all genders, all ages, all skin tones. Everybody can be impacted by this. And the lived experience of migraine can vary.
And just as you share, people of all different professions are trying to live with this disease as well. And so it was really refreshing for me to see that in literature and to really see what day-to-day life can be when someone is trying to navigate migraine and also trying to succeed in their professional and personal life, too.
I do have a question for you, though, because of that, and because it's so underrepresented in literature and other forms of art, what was your inspiration? Why did you choose to highlight migraine as a disease process for your protagonist?
C. Michelle Lindley: Well, thank you so much for saying all that. It's very gratifying to hear. I have a personal history with migraine. My mother also had them. But I was finding that, as you said, the sort of typical representation is just a woman with a bad headache and that is not my experience at all. And it's hard to bridge that gap in knowledge with someone who has never experienced migraine.
So I wanted to show sort of this other side of it, where it becomes almost like the threat of having an episode is its own sort of pain and turmoil. I was thinking about it almost like a predator sort of stalking this character throughout the book. So the inspiration came from that, but it came up quite quickly and pretty naturally while I was drafting.
It just made sense to me for this woman who is so cerebral and so in her head, to have this affliction that seemed poetic and fitting. But every time that she sort of gets away from her body, she's forced to reckon with it again. And from a narrative standpoint, I just thought that would be interesting.
Dr. Rashmi Halker Singh: So I relate to so much of what you just said, and I just want to share about that for a moment, because there is a big push right now to better understand what the lived experience of migraine is like for people. And it's not just those attacks, but I love the phrasing you just used, which is the predator of migraine and the fact that it might happen. And we think about that as being part of the disability of migraine as well. So the disability of migraine is not only as you just so eloquently described, when someone is in the midst of pain and the other symptoms of that specific attack, but also in between, because as you just shared…people with migraine, it's like a it's a situation where that individual does not know when that next attack is going to happen.
And so they're planning their life around that they might be agreeing to commitments, their family commitments or professional opportunities. Thinking if I were to have a migraine attack, will I be able to proceed with that? Can I be successful or do I have to back out? All those thoughts are going through that individual's mind.
And this has been borne out in clinical research as well. We actually know that if someone is having, say, four days of migraine per month, that individual's lived experience with migraine, the disability that they have with their disease is equivalent to someone who has migraine attacks almost every day. Because it's the threat of migraine that can be just as disabling. And I love that you were able to share that so well, because my patients come and tell me this, and they also share that their community, you know, whoever that might be, their family, their friends, their professional colleagues, don't always understand that. They might think, well, you just have like a couple attacks here and there. How are you so disabled by this? And it's everything you just explained.
C. Michelle Lindley: I just recently heard someone speak about this and the management of migraine is almost like a second job to the one full time job that they have. So they're sort of working those two circles at the same time. It's easy to see how you would become absolutely exhausted and debilitated by that.
Dr. Rashmi Halker Singh: We even think about starting people on migraine prevention now. This is like a shift in the last several years, not only based on how often someone is having an attack, but rather what their lived experiences with their disease.
So if someone is having, say, three attacks per month, to an outsider, somebody who does not have migraine, that might not sound like a lot. But if to that individual those attacks are disabling, they feel like they're not in control of their disease. They don't have good medication that's reliable, consistent, effective, well tolerated without side effects, then that person might benefit from a preventive medication too. So it's a real shift in how we think about all of this.
Dr. Denise Millstine: Let me just highlight what you said there, because we're going to talk about treatment a little later. But the strategy for migraine management often is multi-pronged in that somebody typically will have a medication or an intervention that they'll do when they get a headache. But for many people, they would take a daily or a regularly taken medication to prevent headaches from happening. So it's very common. You would call that a preventive strategy and an abortive strategy is how we often will term the medications that are taken at the time of headache. But let's hold that for a minute.
I want to read a description, Courtney, there’s a scene in the book where Elizabeth is really stressed. She's in a small room in a museum. She's in Greece. Things are kind of messy. Things are very messy for her. There’s all these men who are related to the situation in the room, and she thinks, “Suddenly the room's corners went dark, leaving only a small prism of light in front of me. I blinked and everything returned to normal. But another second in that room, and I was sure the dark corners would return, and then would come the pain. A drum line in my temples and I would embarrass myself, maybe faint or worse, cry.”
I thought that was so precise, the drum line in her temples, and then also that layer of, am I going to embarrass myself, I thought I had so much insight. Can you talk about writing that scene?
C. Michelle Lindley: Yeah. Thank you. She is a character who is very aware of how she's being perceived, and she wants so badly, I think, to be taken seriously as a real contender in these overwhelmingly male spaces that she finds herself in. From various angles, she's sort of contending with not being able to show up, perhaps in the way that she wants to show up.
I have had some readers’ question whether or not she's good at her job, which I think is really interesting because like I said earlier, when you're you have migraine and it's sort of this sort of back in occupation that you're taking on. And so I don't see it in those ways. But I think that, you know, that the, “Will these people see me as the weak woman in the room”? That's something that I could relate to. I think just in general; you feel that way and then you have the added layer of an invisible illness. It compounds that feeling. So that's what I was interested in trying to get at there.
Dr. Denise Millstine: Rashmi, will you talk a little bit about what you see for your patients who are often trying to hide the pain, the symptoms, all of the experience of migraine.
Dr. Rashmi Halker Singh: Yes. I think it has a lot to do (with) the fact that other people, as you know, as you shared, don't understand. And it's an invisible illness. And the fact that we don't have tests to confirm that they have migraine or not. Everything that we do is based on the symptoms that that individual share or so to make a diagnosis of migraine, their physical examination should be normal. Their MRI scans should actually be normal as well.
So it really comes down to the symptoms and the story that person tells us, and whether that story is consistent with a diagnosis of migraine. And so when there's no actual blood test or MRI scan or something like that, that can “prove” they have migraine. It really is an invisible illness and just kind of lends itself to being something that can be misunderstood. And along those lines, just like you shared so eloquently, it can be an isolating illness too, because of that misunderstanding.
Dr. Denise Millstine: There's a really heartbreaking scene in the book as well. Which is a memory that Elizabeth has of having a migraine when she's very early on in her marriage and she goes to an emergency department, and she's sort of patted on the shoulder and told her that she's fine, she's being hysterical, that she should just go home and perhaps draw a nice bath.
Courtney, that is also a very telling scene in how women or people with migraine might be treated when they try to seek medical care. Do you agree?
C. Michelle Lindley: I do agree, and I think it's so interesting to talk about how there are no tests. And I think for a certain type of person that can be so challenging. It just adds this other layer of second guessing, like, is the pain really as bad as I think it is? Is this as damaging as it feels to me? Especially when the world's feedback is sort of, “Go take a nap or take and Advil, you'll be fine. Wait it out.” It makes it worse in so many different ways, I think.
Dr. Rashmi Halker Singh: Absolutely. I hear that echoed over and over again. And as you think about the damage of migraine and the impacts of migraine, I think there's a ripple effect, too, because it can impact so much more than just how that person feels in that moment, but also career paths, career trajectories, because it typically affects people when they're supposed to be at the prime of life, when we're supposed to be high functioning in school, working that stage of life. And it can also impact relationships. Really important ones as well. Personal relationships, all of that.
Dr. Denise Millstine: Let's talk about the first headache that we see. So as we've said, Elizabeth is arriving in this messy Greek island. It's hot. She is feeling a lot of pressure from her job to make a good assessment of this piece of art. Rashmi, can you talk about all the triggers that might be there for her headache? She's changed time zones. She's exhausted. She's hot. She's stressed. Is this a nice summary of some common triggers?
Dr. Rashmi Halker Singh: All of the things that you just mentioned. You know, because people who have migraine, they often do best when everything's consistent. So we talk about consistent sleep, you know, managing big emotions. We talk about all of these things. Travel can be a trigger. Being in different time zones can be a trigger. The heat and sunlight can be a trigger. Work pressures and stress can be a trigger. What you're exposed to visually can be a trigger as well. All of this can be something for someone who's brain is prone already and primed to having a migraine attack can set one off. So it's not unexpected, unfortunately, right?
C. Michelle Lindley: It's so interesting to hear you list out all of those factors. It's like there's almost nothing in that list that is avoidable at a certain point. You know, like it could be a sight, a smell, a sound. Yeah. What can you do to avoid that? I mean, it seems like you can't.
Dr. Rashmi Halker Singh: So that's an interesting question, because people come in asking that very question about what can I do to avoid migraines. And some people will come in with calendars or charts or graphs or lists of things and there is a big push within the headache community to move away from all those things, because as we just kind of nicely describe here, it's pretty much real life. It's and it's hard to step away from that unless we just live a way that we're not wanting to. And also a lot of these things are just simply unavoidable. Now we finally know that it truly is a brain disease and the problem of pain processing. That is why people have migraine attacks. It's nothing anybody did or didn't do. It's not something that they're causing to happen or, you know, doing to themselves.
And I personally think that having a strong emphasis on trigger avoidance and identifying triggers can actually add to a lot of sense of blame and shame. And people who have migraine, unfortunately, already live with a lot of that just because of what society tells them.
Actually, it's not just me, a lot of my colleagues within the headache community agree with this. There's a big push to move away from trigger identification but really thinking about managing migraine beyond that. And also identification of migraine prodrome because we also know that migraine’s a brain disease, and symptoms can begin even before the pain starts.
Dr. Denise Millstine: Hey listeners, we hope you're enjoying this episode of “Read. Talk. Grow.” If you find our discussions helpful and insightful, please take a moment to subscribe to and rate Read. Talk. Grow.” on your preferred podcast platform and don't forget to tell your friends to listen. Your support will help us reach more readers and those eager to learn about health through books. As always, feel free to drop us a line at readtalkgrow@mayo.edu with suggestions for books, topics or any comments. Thanks for listening.
Dr. Denise Millstine: That's so interesting. I remember reading about triggers as well, and this is not related to the book, but would be interested in your take on it, Rashmi. That if you look at for example, dietary triggers, it's not like I ate something for lunch and then by 2 p.m. I have a headache. It might actually trigger symptoms that take hours, to even a day to present. And so it's very difficult to know what did I do yesterday or 24 hours ago, or what was I exposed to 24 hours ago that is now triggering today's headache? Is that accurate, or has that been something that's been reconsidered?
Dr. Rashmi Halker Singh: Yeah. So the idea that migraine begins before pain even starts, about 80% of people will have something called a prodrome that can begin even maybe a day before the pain begins. And that prodrome phase of migraine can have a lot of different symptoms. Which might include things like trouble concentrating, excessive yawning, increased urination, fatigue, and maybe even food cravings.
So this is where the food question becomes a little bit tricky. So a common one I hear about is chocolate. People might say, well I had this piece of chocolate and maybe six hours later a migraine attack happened. Therefore, maybe the chocolate is what triggered my migraine attack. The new thinking is the craving for chocolate was already part of the migraine, part of the prodrome. So whether or not that individual fulfilled that craving by eating the chocolate, that migraine was going to happen anyway.
And just as a side note, I'm a person who lives with migraine. I get migraine attacks too, but usually chocolate cravings are not part of my migraine attack. But about two weeks ago, I was at work and I suddenly had this, like this intense chocolate craving. I like chocolate, but this is a little bit atypical in this type of craving I had. So I ran down to the physicians lounge to see what was there that was chocolate. I thought to myself, I bet this is my prodrome and I bet I'm going to get a migraine attack. And guess what happened? About six hours later, I got a migraine attack. So it's so funny when, you know, as a migraine specialist, I get migraine attacks because I started thinking about it and thinking about what my patients are going through.
C. Michelle Lindley: That's fascinating. I'm wondering about something I've been told in the past, which is that there might be a hormone component to migraine. Where does that fit? And it does at all.
Dr. Rashmi Halker Singh: So that is true. And that is why migraine predominantly impacts women. About two-thirds of women do have what we consider a hormonal relationship to their migraine attacks. About a third of women will have their first onset of migraine around the time of puberty. And when we talk about hormonal relationship, what we're really talking about is fluctuations in estrogen. So for a menstruating woman, when she has her menstrual cycle, there's a drop in estrogen that triggers that to happen and that can trigger a migraine attack.
So if we think about this for a moment, those times when estrogen is fluctuating, that can be a time when a person might be more apt to have migraine attacks. So when she's in her time of life when she could be more, you know, be able to have children, childbearing years. But during pregnancy, for many women, migraine does get better. During perimenopause, migraine often worsens because hormones fluctuate a little bit more. And then post-menopausal, estrogen stops fluctuating and so migraine attacks often get better. And of course, this is not true for every single person, but looking at big epidemiologic studies, this seems to be the case for a lot of people.
Dr. Denise Millstine: It's good because we talk about menopause a lot on this show and there are a lot of symptoms but maybe if you're somebody who deals with migraine, you could hope that that's one thing that just might get better.
There's another symptom described in Elizabeth, Courtney, that I wanted to highlight because as we've said, migraine is not just about the pain of the headache itself. And it's the visual symptoms. She even has two episodes, both at times of high stress, where she loses vision. Will you talk about that?
C. Michelle Lindley: Yeah. So I've experienced some of the aural symptoms, and I was thinking about this and looking into it. It was hard to find a lot of information. So I hope that I've done it justice. But from what I understand, it's a retinal or an ocular migraine. I think there are different terminologies depending who we're talking to, but maybe one of those is outdated, I don't know.
Essentially that it would affect and potentially block your vision. And I thought that component was so fascinating to me for a character who her vision is dependent on her livelihood. She needs to be able to see and appraise art. So again, it's just me being extra cruel to my character and giving her another battle to overcome.
And there was something about the sort of dramatic (way) it feels to have any sort of your senses taken away from you. You know, I think at one point she does say to her husband at the time, I can't see and he’s like, what do you mean?
I was just interested in also showing a different side to the migraine as we've talked about a little bit before, where it isn’t just a really bad headache can affect you in various ways and affect your vision. I know from experience it can make you fatigued. It can make you dizzy and nauseous. I know that from experience too, and that's something I never see discussed or rarely. So I wanted to just show a different side of what a migraine might look like for someone. So I did sort of push it to the extreme and like I said, I did it medical justice. Fingers crossed.
Dr. Rashmi Halker Singh: Yeah, absolutely. I mean that the visual aura can be extremely debilitating for some people, even for some people, that can be the most debilitating symptom, just like you shared, not being able to see. And it happens so unpredictably, that can be very scary as well. So I agree with you on all of those things. I don't know how to say this, but it was, I guess, nice to see all of these non-headache symptoms portrayed in literature.
I hate that my patients are experiencing symptoms, but I think it was nice to see, I guess a more accurate representation of migraine, where we see all these things that are not just, not only the headache pain but all the other symptoms too.
C. Michelle Lindley: I was wondering, it would be okay to ask, what percentage of your patients experience these visual disturbances, is it?
Dr. Rashmi Halker Singh: About 25% of people of migraine will have aura.
C. Michelle Lindley: Wow. Okay, so that's higher than I would have thought. That's really interesting.
Dr. Denise Millstine: Will you actually slow that down a little bit and talk about ocular migraine versus aura. That is a slightly different component of the what's typically the prodrome.
Dr. Rashmi Halker Singh: Sure. So we think about migraine in terms of the phases of the migraine attacks. So let me just kind of talk about that for a moment. We just talked about the prodrome, which for many people is the first part of their migraine. That's where migraine begins. It can last maybe about 24 hours or so. It can be even a day before the pain starts. And about 80% of people can have a prodrome, whether they recognize it or not.
That's the other catch about prodrome, sometimes it can be so subtle that people may never recognize it, or sometimes they recognize it only after the pain starts. Because the things I mentioned, you know, fatigue or maybe early nausea or trouble concentrating, those are such vague symptoms, and they sometimes are just milder symptoms than what they would have in their migraine attacks. So they can be difficult to identify.
After that some people, as I mentioned, maybe 25% of people with migraine can have an aura. With aura, we typically experience what we call positive symptoms, meaning visual aura is the most common type of aura. People will see things in their visual field. So they'll see bright colors or bright lights. It often is maybe a gray dot or like a spot in their vision that begins in one area and moves or grows. So it's something that they're actively seeing. By definition, aura must last five to 60 minutes. Sometimes people might say, oh, I see something last for like two seconds. That's not aura. It has to last at that length. And that's because we know what's happening in the brain when someone has aura.
What's happening is there's something called cortical spreading depression. We can think about this by, I guess it's kind of like a domino effect over the surface of the brain, where some cells, some neurons, brain cells become activated just on their own, spontaneously activated. And that can cause a ripple effect to activate nearby neurons or brain cells. And then the cells that were initially activated, they quiet down a little bit, and that activation just keeps moving. That moves at a rate of actually, they they've mapped this out to a speed of 2 to 5mm per minute over the surface of the brain. And because it's happening at that slow speed, the aura has to last by definition 5 to 60 minutes.
Visual aura is most common because this most often happens over the part of the brain that's responsible for vision. And so those part is activated so people can see things. But it's not the only type of aura. Sometimes people can have what we call sensory aura. Where people might have pins and needles. It might begin over the fingertips and can spread up the arm. Sometimes people might have speech aura, where they have difficulty talking, and sometimes they might even have motor aura, where they develop weakness. There's a whole bunch of there are many different types of aura symptoms that can happen.
After that, the next phase of migraine. It's a pain that that we're familiar with. You know, it's that moderate to severe intensity can be throbbing, pulsating, that drum line pain, can stop people from activity. Sometimes it's more intense on one side, but it can sometimes be both sides as well. And with the pain, people can have nausea or be sensitive to lights and sounds.
And then after that there's something called the postdrome. So that's the fourth phase of migraine, which my patients commonly referred to as the migraine hangover. But the formal name is the postdrome and that can last 1 to 2 days. And that can be manifested by fatigue, the generalized feeling of not well or malaise, or even a milder headache or trouble concentrating. And we can think about that as the recovery period. And then the medical word for how somebody feels between attacks is the interictal phase. So those are all the phases of a migraine attack.
And I think the retinal migraine idea is essentially pain within the eye and sometimes some vision loss with that. It's a little bit different though. Those are essentially the phases of migraine. Most people, everyone has the pain, some people have aura, most have prodrome, postdrome.
C. Michelle Lindley: So retinal migraine is potentially different than a, for lack of better terminology, regular migraine.
Dr. Rashmi Halker Singh: It's different from migraine with aura. Yes.
C. Michelle Lindley: Interesting.
Dr. Rashmi Halker Singh: My patients come in interchanging the words a lot, just because I think the terminologies have changed over the years. But you know, we used to actually, if I think back to like 20, 30 years ago because now the terminology is migraine with aura and migraine without aura. And then people have aura, then we further clarify with the visual aura, with sensory aura, what kind of aura they have. But if we go back to like 20 years, the terminology was common migraine or classic migraine. We had all kinds of different words we were using back then.
Dr. Denise Millstine: And you'll still see that sometimes in the literature, particularly if you're looking at older papers or in a chart, you might still see that nomenclature still being selected, but that's dated.
Dr. Rashmi Halker Singh: Yes. And I think when patients are looking things up, they also are finding different things. And so there's still a lot of language. And so when people come in and they tell me they have retinal migraine or whatever they tell me that they have, my job is to then ask a lot of questions and ask about their actual symptoms so that we can come together for an actual diagnosis.
Dr. Denise Millstine: And treatment plan.
Dr. Rashmi Halker Singh: Yes, that's the second part after your diagnosis. Absolutely.
Dr. Denise Millstine: Yeah. Courtney, you're obviously trained in creative writing, but also in history, art history. Our listeners should know that's a huge part of the book. But I really appreciated that you included a historical description of migraine. It was from Hippocrates, and the quote was, “A glare that shown before him, superseded by a violent throb in his right temple.” Can you discuss the importance of that historical perspective?
C. Michelle Lindley: Yeah, it's because so much of this book is rooted in antiquity, mostly in terms of classical art. I was interested if there had been any visual representation of migraine in the art that I was researching, and I came across that and just thought it was really fascinating to read that, which predated obviously, our use of the word migraine.
And sort of freeing to, I think, always to read that certain pain that you have had been experienced by so many people elsewhere for so long. I mean, maybe not for anyone else. Sort of freeing and then also sort of damning and horrible. But I just thought that it was interesting to find that artifact. I wish that there was more, actually, that I could have drawn on, more visual representation of art or of migraine in art. I can't really think of much that I've seen about that.
Dr. Denise Millstine: I thought it was really interesting. There's a comment that Elizabeth had seen some amulets, headache breaking amulets in the museum. I think it was where she worked or a museum she had been in. So I just really appreciated that journey that it's historically migraine is not new. It might have new terminology, but probably people have been living with this brain disease for all of time.
Rashmi, I want to talk about treatment. So early in the book, she is in her hotel room. She wakes from a nap and she immediately says I need to go get some high dose ibuprofen to get a hold of this pain before it takes a hold of me. Is that a good strategy? The early use of medication when you know a headache has started?
Dr. Rashmi Halker Singh: It depends on how often someone is having an attack. So if someone is having infrequent attacks, absolutely treat early to get rid of the attack. Great strategy. But if, someone is having frequent attacks, frequent is defined as more than one or two per week, maybe not the best plan because these what we call as-needed medicine. --- so things that person takes as needed for pain --- if they're used more than technically ten days per month, more than once or twice per week, we're kind of approaching that limit. Those medicines can have a paradoxical effect and actually lead to migraine attacks happening more frequently. So that's where that catch-22 happens.
Dr. Denise Millstine: And then we hear from Elizabeth's history. She says she's been tried on a variety of medications. And that is a very common component as well, that people will have cycled through a number of medications to see if they've been effective throughout their migraine history. Correct?
Dr. Rashmi Halker Singh: Yes, unfortunately it is. I mean, I think it can be very challenging for patients sometimes having tried so many different medications and not found those medications to be helpful. It can unfortunately cause some feelings of isolation, hopelessness for patients who live with this too.
Dr. Denise Millstine: She mentions that benzodiazepines have always been her favorite. We had an episode with Melissa Bond, who wrote a memoir, “Blood Orange Night,” about her dependance on benzos and the withdrawal and how complicated that issue is. This class of medications is tricky for everybody, but how do you manage using them in headaches specifically?
Dr. Rashmi Halker Singh: So they're technically not recommended for use in the whole part of the migraine treatment plan. They're not something that we use. But I fully understand that in the United States alone, we have about 47 million Americans who live with migraine, and we have about 700 board-certified headache physicians. And so there is a big disparity there. And lack of access and care is a big deal. And so people are might be on a lot of things that they're hoping might be helpful, that don't have the best evidence as well.
Dr. Denise Millstine: Thank you for that. We need to clone you. We need more of you for sure.
Courtney, let's end on a note of hope. So we're not going to spoil the book for any of our listeners. They're going to have to read the book themselves. But in the end, we do see Elizabeth's progress. She goes into a new phase of her life. She does mention that her migraines are now much more controlled and much better.
Is this your hope for people that have migraines, that they'll get to a point in life where they can really manage their well-being and hopefully get there? Or maybe she went through menopause. What was your thought in ending this way?
C. Michelle Lindley: My thought was that my editor was like, we need to give a little hope for this character. But under that, I think there was perhaps that subconscious, if not conscious desire to give her something, give her, let the air in a little bit. And that, of course, that's my hope for everyone who suffers from this. I do, I hope that because this – I was going to say this was written in 1999 - it was not. It takes place in 1999 at a time where I think there is still much to be discovered. It seems like even just the past couple of decades, there's been a lot of headway, forgive the pun. And so I hope that Elizabeth is able to find treatment and medication that has worked for her. And I hope now that people are able to discuss their symptoms more openly and not second guess them and not feel as though they don't matter. Yeah, that would be my hope.
Dr. Denise Millstine: Rashmi, would you agree is migraine management much different in 2024 than it was in 1999?
Dr. Rashmi Halker Singh: Oh, it's much more different in 2024 than it was in 2015, actually. I mean, we have gained a much more deeper understanding of migraine, what we call pathophysiology, what's happening in the brain when someone has a migraine attack in the last several years. And we have actually developed, finally, migraine-specific treatments, we have two brand new classes of medications in the last six years.
And so while I shared just, you know, a few minutes ago that a lot of people are left without hope, I do want to add some hope that with these new medicines that we have available, they have given so much hope to so many more people. This a class of medications that we never had available before that can help people who have tried other medicines and have not found them to be beneficial.
We also have people like you sharing about migraine in very real ways. That lets them know that they're not alone in their disease process, which I think is just as important. You know so I think there's a lot happening within the migraine community.
Dr. Denise Millstine: I simply love that we can end on that note of hope. The book we've been discussing today is “The Nude” by C. Michelle Lindley. Listeners are encouraged to go check it out and learn more about migraine and more by reading it. Thank you both for being here.
Dr. Rashmi Halker Singh: Thank you.
C. Michelle Lindley: Thank you so much for having me. It’s been a pleasure.
Dr. Denise Millstine: “Read. Talk. Grow.” is a product of the Women's Health Center at Mayo Clinic. This episode was made possible by the generous support of Ken Stevens. Our producer is Lisa Speckhard-Pasque and our recording engineer is Rick Andresen.
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