Migraines and Concussions: Advocating for Diagnosis and Treatment - Dr. Briar Sexton
Dr. Briar Sexton - Bio
“I am grateful every day for the opportunity to work as an ophthalmologist. Vision is a precious commodity, and it is a pleasure to work with my patients to protect and care for their eyes. Staying on top of new treatments and maintaining state-of-the-art equipment is another source of pride for me at the clinic. I am active both in attending and teaching at Continuing Education events. Since 2010, I have been actively fundraising for the Foundation Fighting Blindness. The research projects they fund bring hope for a cure for many retinal diseases.”
Dr. Briar Sexton is a licensed and registered physician in British Columbia and regulated by the College of Physicians and Surgeons of British Columbia. For more information please visit: Registrant directory | College of Physicians and Surgeons of BC (cpsbc.ca).
Contact Link:
Summary:
In this podcast episode, Dr. Briar Sexton discusses migraines and concussions, two prominent diagnoses in Canada and the US. She explains that migraines can take various forms, with chronic migraines being characterized by severe and debilitating headaches that occur daily. Migraines can be caused by genetic factors or triggers such as low blood sugar or stress. Dr. Sexton emphasizes the importance of keeping a headache diary to identify triggers. She also addresses the challenges of diagnosing migraines, as many doctors are not well-informed about chronic migraines. She advises patients to advocate for themselves and consider seeking a second opinion from a headache specialist if needed. In this conversation, we talk about the challenges and treatment options for concussions and migraines and emphasize the importance of active rehabilitation and lifestyle modifications in managing these conditions.
We also discuss the barriers to treatment, including the cost of medications and the need for approval from drug plans. The conversation concludes with a discussion on how to end the stigma surrounding invisible conditions through education and advocacy.
Takeaways:
Chronic Migraines: Chronic migraines involve severe, debilitating headaches that can occur daily.
Headache Diary: Keeping a headache diary helps identify and manage triggers.
Self-Advocacy: Many doctors may lack detailed knowledge about chronic migraines, so self-advocacy and seeking a second opinion from a specialist is crucial.
Concussion Diagnosis: Concussions are often overdiagnosed and misdiagnosed, leading to confusion and invalidation. The new diagnostic criteria for concussions aim to provide clearer guidelines.
Communication and Empathy: Sensitive and empathetic communication is essential when discussing diagnoses and changes with patients.
Rehabilitation and Lifestyle Modifications: Active rehabilitation and lifestyle changes are important for managing both concussions and migraines.
Treatment Effectiveness: Changes in facial expressions can indicate the effectiveness of a treatment.
Medication Barriers: The cost of medications and the need for approval from drug plans can be significant barriers to treatment.
Ending Stigma: Ending the stigma surrounding invisible conditions requires education and advocacy.
Definition, Resources and Example Accommodations:
Definition: Migraines
Migraines are a type of headache characterized by intense, throbbing pain often accompanied by nausea, vomiting, and sensitivity to light and sound. Chronic migraines involve headaches occurring 15 or more days per month for more than three months, with at least eight of those days involving migraines.
Resources:
American Migraine Foundation: Comprehensive information on migraine types, triggers, treatments, and patient resources.
Migraine Trust: Educational materials, research updates, and support for migraine sufferers.
National Headache Foundation: Resources, include a headache diary app, support groups, and educational materials.
Example Accommodations:
Flexible Work Hours: Allowing for flexible scheduling can help accommodate migraine sufferers, especially when migraines are triggered by certain times of day or stress.
Quiet Work Environment: Providing a quiet space with minimal noise and lighting can help reduce triggers and allow for better concentration and comfort.
Remote Work Options: Allowing employees to work from home can help them manage their environment and reduce the stress associated with commuting and office triggers.
Breaks and Rest Periods: Allowing for additional breaks or rest periods can help employees manage migraine symptoms and return to work more effectively.
Definition: Concussions
A concussion is a mild traumatic brain injury caused by a blow to the head or body that shakes the brain inside the skull. Symptoms can include headaches, dizziness, confusion, memory problems, and sensitivity to light and noise. Chronic post-traumatic headaches can persist after the initial injury.
Resources:
Centers for Disease Control and Prevention (CDC): Provides detailed information on concussion symptoms, treatment, and prevention.
Brain Injury Association of America: Offers resources, support, and advocacy for individuals with brain injuries, including concussions.
Concussion Legacy Foundation: Focuses on concussion research, education, and patient support.
Example Accommodations:
Reduced Cognitive Load: Providing tasks that require less concentration and cognitive effort can help those recovering from a concussion.
Rest Periods and Breaks: Allowing for frequent breaks and rest periods to reduce symptoms and aid in recovery.
Modified Work Schedule: Adjusting work hours to allow for a gradual return to full duties and responsibilities as recovery progresses.
Environmental Adjustments: Reducing exposure to bright lights and loud noises, providing a quiet and dimly lit workspace to accommodate sensitivity issues.
Remote Work Options: Allowing employees to work from home can help them manage their symptoms in a controlled environment and reduce the stress associated with commuting.
Concussion Diagnosis Criteria Referenced in Episode:
The new diagnostic criteria for concussions have been developed by an international group of experts, including researchers from the University of British Columbia and Harvard-affiliated Spaulding Rehabilitation Hospital. These criteria aim to provide a clearer and more consistent standard for diagnosing mild traumatic brain injury (TBI) across various settings such as sports, civilian trauma, and military contexts. The criteria include assessments of cognitive impairment, balance issues, and oculomotor function, incorporating blood tests and tests of thinking skills and vision (Med Xpress). For more detailed information, you can refer to the publication in the Archives of Physical Medicine and Rehabilitation: Link to the criteria.
Additional Conditions Covered in Episode:
Chronic Migraines: Migraines can often be misdiagnosed or undiagnosed. Proper diagnosis involves recognizing the frequency and intensity of headaches and understanding the specific symptoms that differentiate migraines from other types of headaches.
Post-Traumatic Headaches: Following an injury, it's crucial to distinguish between chronic post-traumatic headaches and concussions. Proper diagnosis can prevent confusion and ensure appropriate treatment.
Concussions (Mild Traumatic Brain Injury): Accurate diagnosis using the latest criteria is essential to distinguish concussions from other types of brain injuries and to manage symptoms effectively.
Chapters:
00:00:00 Understanding Chronic Migraines and Concussions
00:12:32 Concussions and Migraines
00:21:27 Treating Concussion and Migraine Patients
00:26:18 Medication and Lifestyle for Managing Headaches
00:31:30 Navigating Medication and Healthcare Challenges
Transcript
Dr. Briar Sexton 00:00
They minimize or underestimate the days where they can function because they want the attention to be on fix the thing that makes my head feel like I'm going to explode. And so they get to me and I take a comprehensive headache history and I go oh my gosh, you're actually having headaches every day. Oh, yeah, yeah. But and right again jump to wanting to only talk about the ones where they can't handle it and then say, no, no, we got to back the truck up. We've got a lot more to talk about here.
Tim Reitsma 00:22
How often has someone dismissed your headache pain or your migraine pain or has tried to compare it to their own? Many of us have struggled or are struggling to get a diagnosis for whatever condition we live with, and while this episode we talk about migraines and concussions, it's for all of us. Tim here, and thanks for tuning into another episode of the Invisible Condition Podcast, where we talk about advocacy and unusually normal things the conditions, diseases and illnesses we live with. We will end the stigma of invisible conditions by empowering voices, and today's voice is brought to us by Dr Briar Sexton. Dr Briar Sexton is a licensed and registered physician here in British Columbia and in today's episode we discuss the complexities of chronic migraines and concussions. Did you we discuss the complexities of chronic migraines and concussions? Did you know that many people with chronic migraines rank their quality of life as low as those with severe strokes or daily dialysis? Yet countless struggle to get a proper diagnosis?
01:18
In this episode, we explore practical strategies for managing these conditions and we're going to empower you with the knowledge to advocate for your health. Have a listen. Well, dr Sexton, I am eager to get into the conversation today, but first, before we get into the conversation about migraines and concussions. Thanks for joining me. I know you're busy and so thanks for taking the time to chat with Invisible Condition about two very prominent diagnoses here in Canada and in the US.
Dr. Briar Sexton 01:52
Well, you know, I'm a fan of your work and also I think this is such an important topic that it behooves us, as physicians, to make time for it and to try and reach as wide an audience as we can, because lots and lots of people who are living with chronic migraine one of the biggest issues is they don't get diagnosed, so they're not even accessing potential treatments.
Tim Reitsma 02:11
Yeah, not even get diagnosed. We're going to get into that because that is, you know, when I hear that and I have friends who have various ailments and are struggling to get a diagnosis and it breaks my heart. And you know I'm doing some work in the self-advocacy space and that's a broad topic and it's a hard topic and it varies for everybody in a different way. But we're going to get into that a little bit. But let's talk about migraines. You know you do a lot of work with migraines concussions, eyes, all sorts of stuff but let's just talk about migraines. Why don't we just provide a definition and what you have seen with your patients?
Dr. Briar Sexton 02:50
So I think the important thing is, most people will have a sense of what a migraine is, and most people who are listening will think of it as being an acute headache that occurs episodically, that puts people on the floor in a dark room, sensitive to sound, sensitive to light, nauseated, generally thought to be only on one side of the head and generally lasting for several hours, and that is a good definition of an acute, episodic migraine. But that's only one of many, many forms of migraine, and the one that I end up treating most often is what's called chronic migraine. Chronic migraine is characterized by having lots and lots and lots of days of headache in a month. It's not just one or two or a few days around your period, or migraine if you had an extra drink at the office Christmas party. These are people who are living with severe, debilitating headaches up to daily. These are people who are living with severe, debilitating headaches up to daily, and these guys are really sick.
Tim Reitsma 04:01
They are sick enough that if you give them quality of life scales, they rank themselves as ill as somebody who's had moderate to severe stroke or somebody who has to have chronic daily dialysis for kidney failure. Wow, so I have experienced that acute migraine and I could tell it happens every couple of years, I don't know. Maybe we could talk about why. Why are migraines caused? You know, it comes on. Usually it's my left eye and it goes. I lose my vision and I know something's coming. And but what causes it? Is there known causes for migraines?
Dr. Briar Sexton 04:24
So migraines described as what's called a neurovascular headache, and sometimes they're just hitting your DNA bad luck. Sometimes they're caused by triggers, and triggers work a few different ways. I mean, you're a smart guy. If every time you had a glass of orange juice you got a migraine, you'd figure out not to have a glass of orange juice. But migraines can be multifactorial. So maybe you're okay to have a glass of orange juice, but not on a day when your blood sugar is really low because you haven't eaten lunch and it spikes it right up high and that that causes the migraine. Or maybe you can have a cup of coffee, but not on a day when you're hyper-stressed and you didn't sleep well. So one of the first things I encourage anybody with migraines to do is to keep a diary Because, quite frankly, if you get there every couple of years, I don't think you're going to remember that you had a ham sandwich on the same day two years ago. You know it's just putting it into the phone of what happened that day, how you slept, how you were feeling lots and lots of common food triggers, and so we talked about. You know, trigger could be obvious, what we call kind of dose response Trigger can be multifactorial.
05:30
Things could be okay on some days but not others. But the other kind of classic example would be somebody who's put on a new medication and the most classic example would be birth control, because hormones are hormonal and so somebody goes from having two or three headache days a month till 10 headache days a month, and a lot of times they don't think about being the medication because, well, it's 10 headache days a month, it's not 30 headache days a month, and I take the pill 30 days a month. So that's where the trigger acts to lower your threshold to have a headache, so you get them more easily than you did without the presence of that trigger. So when I'm giving patients triggers things like nitrites in food and nightshades and processed food I say you've got to pull everything like that out for at least three weeks to see if it's playing a role in your headaches or not.
Tim Reitsma 06:20
Three weeks. Yeah, as someone who lives with Crohn's disease, a food journal, knowing it's not just food, it could be other things. Yeah, as someone who lives with Crohn's disease a food journal and knowing it's not just food, it could be other things, it could be stress, it could be sleep, it could be you name it and keeping that all in your mind of trying to remember everything. So that's really important. Jot it down.
Dr. Briar Sexton 06:39
It will. And especially, I mean we've got patients. I've got patients who get weekend migraines and it's because they've changed their sleep schedule and migraines like schedule and they like routine and they don't like it that you've decided to sleep in until 9 o'clock instead of 7 am. So sometimes we get rid of their headaches by having them get up at 7 am, walk around for 15 minutes and then go back to bed and enjoy their lie-in.
Tim Reitsma 07:03
Wow, really so it's. Wow. I did not realize that.
Dr. Briar Sexton 07:13
Lots of visual triggers. I've got patients who reliably will get migraines if they're scanning rapidly on a grocery store aisle under fluorescent lighting. Patients whose migraines will get set up by watching the columns of a bridge flicker by or by dappled light when they're mountain biking and the light's coming in and out of the trees. I mean they're pretty beastly.
Tim Reitsma 07:30
Yes, well, I'm really curious. I've had friends not myself, but I've heard this secondhand, thirdhand people going to a doctor and saying hey, I've been battling bad headaches, migraines. I've been battling bad headaches, migraines, and I've heard and I've had friends who weren't believed by their doctors. How do you even describe this, right, if it's debilitating, whether it's an acute episode or something that's more chronic?
Dr. Briar Sexton 08:10
how do you approach your doctor and say, hey, this is what I'm living with? I mean, I would say that one of the issues is because we think of migraines, and even a lot of really good GPs think about migraines as being acute and episodic. That certainly is what I would have known about when I got out of medical school. When they hear the headaches are daily, migraine just doesn't pop into their head. So part of it is we need to educate our doctors better. They can't know everything.
08:28
My dad was a GP. It's an incredibly broad field. So the estimate is that one in 40 Canadians about a million people are living with undiagnosed migraine and I don't think that they're walking into their GP and saying I have chronic migraines and the GPs are saying no, you're not. And saying I have chronic migraines and the GPs are saying no, you're not. I think that that is one of the issues. And then the other way it gets missed and I see this all the time is I've got patients who get headaches every day. There's maybe three or four out of 10. And so in my world that's a low-grade migraine if they also get five or six days of super painful headache and what they want the GP to do is fix the days where they can't function. So they minimize or underestimate the days where they can function, because they want the attention to be on. Fix the thing that makes my head feel like I'm going to explode.
09:14
And so they get to me and I take a comprehensive headache history and I go oh my gosh, you're actually having headaches every day. Oh yeah, yeah. But and right again jump to wanting to only talk about the ones where they can't handle it and then saying, no, no, we got to back the truck up. We've got a lot more to talk about here. But I would do things like you said keeping a headache diary, looking for triggers, going into your gp with a month worth of data to say this is how often I had a headache last month, and and and to make sure that's the reason you're there. That's what you want to talk.
09:42
Talk about it's not a sidebar to you know, the fact that you happen to have a sinus cold or you're worried that you've got a chest infection, and I think if you're still having trouble, you may say like, look, you're so good at so many things. That's why I'm a GP. But you know, do you think I could benefit from seeing a headache specialist Like could we just get an extra set of eyes on this?
Tim Reitsma 10:06
specialists like could we just get an extra set of eyes on this? Yeah, I was recording with a doctor. We've released the episode months ago and so I was talking about second opinions, asking for that second opinion, and what she said was really struck me. Was both doctors right? If they're? If they don't know, they will send you that specialist. If, if they are confident in their diagnosis, they have no problem sending you for that second opinion.
10:28
It's when a doctor say what you don't trust me or you don't believe in me, that's when you should be like okay, maybe I need to push for this, but what I'm hearing you say is like asking right, keeping that journal and I've heard this for even all the self-advocacy questions I've been asking people is is write it down, bring that to your doctor, present it and say here's what's going on, and don't discount those quote unquote good days. You know in the pains that three or four I know this with arthritis I see my specialist soon and she's going to ask how are you feeling? And it's like well, today's a good day, but two days ago I couldn't walk. But today's a good day it's focusing not just on that one day, but over that collective period of time.
Dr. Briar Sexton 11:08
And I think you know one of the things that's worth noting is from a patient health and well-being perspective. By only focusing on the days you can't get through and minimizing the days you can, you are doing the best thing you can to look after yourself by being positive and finding the good and doing all the things we'd encourage you to do.
Tim Reitsma 11:28
It just doesn't help us, as your doctor, to figure out what's going on. Yeah, yeah, you're absolutely right. If you just go to your doctor and say, oh, today's a great day, but you know, you discount those those other days, it doesn't make your job any easier, does it.
Dr. Briar Sexton 11:38
No, and to add to the idea of asking for a second opinion, I'd say a couple of things and the first thing I would say is that it is all about how you, you know, it's not that I, it's not that I'm second guessing, I'm just wondering could there be a new treatment that you know you're on top of a million other things and maybe this neurologist would know about that? You haven't yet, like I, you know? Is there any way that I could just go once and get some questions answered by somebody who sees a huge number of patients with this type of condition? And certainly for anybody who's listening who has concussion, I would say that at a baseline, excellent, brilliant GPs don't get training on how to treat chronic migraines, so a lot of them either don't know how or aren't comfortable with some of the medications, and that's said with a lot of respect.
12:24
But the second tier is I have all these patients and I mean this happened to me when I was first really treating a lot of patients with migraine. I would think about the migraine patients one way and the concussion patients with headache another way, until it kind of went wait a minute. These guys walk and talk and behave just like my migraine patients. They just happen to have the problem start after they hit their head rather than when they hit their period. And how are these two different subtypes of patient? And there seems to be very, very few practitioners who are aggressively treating post-concussive headaches that, last past the 30-day, mark the way that they would treat chronic migraines, even though, as I said, they both walk like a duck and talk like a duck.
Tim Reitsma 13:09
Well, that's a great segue, because concussions is something I'm passionate about. I've never experienced one I was actually thinking about this this weekend have I experienced a concussion, and I can think of one scenario where I had a terrible accident and I'm sure I had some damage. There's something going on, but I never sought medical attention for it. Is there an overlap, as you said? There is that overlap between migraines and concussions and how have you seen maybe a misdiagnosis or how does that overlap? How is that prevalent in the work that you do?
Dr. Briar Sexton 13:46
so I would say um, I'm going to start with just some definitions, so everybody's on the same page so the first thing is you can have chronic headaches after an accident and not have a concussion or mild traumatic brain injury. You can have something called chronic post-traumatic headaches, where the headaches are started by the accident. The accident's the cause, whether that's a sport accident, motor vehicle accident. It banged your head on a top shelf in your house. So you can have headaches without jumping to concussion or mild traumatic brain injury. A lot of time presenting complaint is headache. People start to call it concussion. That's a dangerous rabbit hole for a lot of reasons. The first is when you tell people they have a concussion, then memory loss because their head is pounding becomes memory loss because they have a brain injury. Word finding difficulties because their head is pounding becomes word finding difficulties because they have a brain injury. So you can spiral somebody into thinking that they are sick for a different reason than they are. Concussion and mild traumatic brain injury is overdiagnosed and the new diagnostic criteria for it are quite clear, and so to meet the threshold for that diagnosis you have to have amnesia that dates back from the accident or for a period of time after the accident, a loss of consciousness or something called an altered state of consciousness, and historically, before the new diagnostic criteria came out in May of 2023, people will go how did you feel after? And you'd say I was dazed, I was confused, I couldn't figure out what happened. Those are all normal ways to feel after you've been rear-ended by somebody going 80 kilometers an hour. That's not a mild traumatic brain injury.
15:24
If somebody came into my office and said I knew exactly what had happened, I was crystal clear on my thinking and I immediately started to. You know track my ICBC claim in my head. Or I knew that I'd been hit by this big linebacker. I remember. You know it's even like athletes they get hit from nowhere, they get hit from behind. They're completely confused about what happened. But an altered state of consciousness is somebody who can't follow two-step commands, who isn't oriented to day or place, who has an acute confusion or irrational anger. I know you pretty well. If you get rear-ended, you're not the guy I think is going to get out of his car, run back and start punching the person behind them in the face through the window. If you did that, I would diagnose that as an altered state of consciousness. Now, some of my other patients maybe not. Maybe that's just a Wednesday right, but that's clearly out of character.
Tim Reitsma 16:18
Yeah, interesting. So it's really that something, not just out of character, something that is when you lose that consciousness. And so you said has concussions been overdiagnosed then, or has it been underdiagnosed?
Dr. Briar Sexton 16:32
I would say that concussion is overdiagnosed and it's often retroactively diagnosed wrong. So I'll see somebody who didn't have anything other than headaches initially, and then they get deconditioned, the headaches are bad. They're not going to the gym, so they're not in the same shape that they were. So pain is getting worse and not getting better and as time from the accident when they can't go to work lengthens, they can't return to sport, can't do the things they love with their loved ones. Often that causes very legitimate depression, very legitimate anxiety. Often they become progressively stressed. Sleep becomes progressively poor.
17:13
So a year and a half later they go into a doctor's office who's busy and doesn't have a lot of time. They say what happened after the accident? I got headaches, I stopped sleeping, I lost my memory, no-transcript after an accident. But we didn't want to call it a mild traumatic brain injury. Well, now those terms are interchangeable. So you have to hit that threshold in order to get that medical diagnosis which isn't to minimize people who have ringing in their ears after an accident, blurred vision after an accident and all sorts of other symptoms along with their headaches that often are primarily headache related. And if you treat the headache, you treat the symptoms. You don't need to call it something that it's not.
Tim Reitsma 18:15
Fascinating. So this just came out, this new diagnosis criteria in 2023. And I'm curious have you had any conversations with people about? Well, I've had concussions. So what is this now? Am I getting undiagnosed, or how does that even work?
Dr. Briar Sexton 18:35
It's keeping in mind that concussion is one of the invisible diseases, right? It's incredibly sensitive from the perspective that the number one thing that somebody with chronic migraine or chronic concussion identifies as a fear is that people think they're making it up or they think that they're crazy. So some of the toughest conversations that I have are introducing to somebody that there may be a component of anxiety that's contributing to their headaches, because that doesn't invalidate that the headaches are real and they're awful and they're ruining quality of life. But if anxiety is maybe part of the barrier to the treatment of the headache, would it be worth exploring, just thinking about whether or not treating that might treat the headache? And it might or it might not, I don't know. But why wouldn't we try? And then you know, to tell somebody who's been diagnosed with a concussion hey, the criteria changed. I know that a year ago, when you said you were dazed, we took your word for it and we called you brain injured. But now dazed means something different.
19:35
It's very invalidating, it's insensitive, and so I don't like to have that conversation unless I absolutely have to, because I have to put something down on a form or or or. But I'll try and frame it to some extent as good news. I don't think he did because of this, this and this, and I think that the headache is the primary problem. I think that, and sometimes they've got really good insight, like I'll say how's your memory on the rare days you're not having a headache? Oh, it's good, doc. So that's not what my brain injury patients tell me, that's what my chronic migraine patients tell me. So, yeah, and so it's a trust issue, it's how you have the conversation and it's a hundred percent making sure you don't invalidate the fact that this is somebody who's in pain and having symptoms after a trauma.
Tim Reitsma 20:18
Well, I love that you said that you don't want to invalidate someone. You know, I couldn't imagine if, after many years, my rheumatoid or my doctor said, oh, actually you don't have arthritis, like okay, so we've been treating it with medication, with all this stuff, and all of a sudden like yeah, you invalidate someone, but also then that you break that trust as well. So I think, from your perspective as a doctor, a medical practitioner, there's a lot of sensitivity that needs to go into having these hard conversations, whether it is a diagnosis or a change of path or a change of direction.
Dr. Briar Sexton 20:58
Very much so, and I think it's something, as I said, said, that you can say okay, well, they change the diagnostic criteria, but it doesn't change what's happened for the patient for the last three years in any way yeah, it doesn't invalidate how someone is it's feeling, like if somebody said, hey, tim, well, this is, you don't have x, y or z.
Tim Reitsma 21:18
Well, I still feel that way, I'm still struggling, I still have this pain. So now, what is it? Let's go and explore that. Let's get to the root of that problem.
Dr. Briar Sexton 21:27
And it's interesting, you know, with that concussion diagnosis, a lot of times I will see somebody who's been very fit their entire lives. They're an athlete, they're a weightlifter, they're a runner, and the injury just knocks them out of all of that and so they physically don't feel like themselves. They're more fatigued because they're not getting exercise, which often means they're not getting good sleep. Maybe they're not getting good sleep for other reasons they do. They feel like they're in a cognitive fog. They may have a little bit of depression, which is almost I can't imagine.
22:00
If I woke up every day and my head was pounding and I had to give up my work, I had to give up my friends, I had to give up my activities that even one of our most resilient individuals wouldn't have lower mood than they did before the trauma.
22:13
And, as I said, very difficult, because as soon as you enter that mental health aspect, they think that you're saying there is no other injury, whereas they're saying no, it's running in parallel. Here we want to tackle both things. But one of the most evidence-based things that we know about concussion is that people who are able to actively rehabilitate it do better than people who passively rehabilitate it. But if you used to go to the gym, pick up the bench press and do X or throw the treadmill onto his Y miles an hour and it was nothing. And now that makes you feel like you've been hit with a baseball bat. If you've never been out of shape in your life, you don't know that. That's how out of shape people feel. That's not a concussion necessarily. It's how it feels when you don't exercise regularly.
Tim Reitsma 22:59
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Dr. Briar Sexton 24:17
I mean, I certainly feel more for the patients than I do for myself. But to your point, when I'm able to help somebody with chronic migraine or concussion, it's one of the most gratifying things I get to do. And I can tell you that it wouldn't matter with those patients If I'm running half an hour behind. They're not going to yell at me. They know I'm behind because I'm trying to help somebody like them. And if they've been helped, boy are they happy.
24:46
I can tell when I walk into a room after I've done a medical intervention or a lifestyle intervention for somebody with concussion or migraine, if it's worked. I know before they tell me their their face looks different, that pain mask is gone. You know I, I would reliably say I can tell before they've opened their mouth, 90% of the time if they're going to give me good news. And you and I were talking offline about you know how do you deal with the challenge of treating it, because there are real significant barriers to treating it and I don't know if you want me to get into that a little bit.
Tim Reitsma 25:19
Yeah, let's do it, especially like it's a good segue because you highlighted this, that this is an invisible condition. But also I like how you said you can walk into a room and you can see that pain mask whether it's on or it's off. So, yeah, let's go there.
Dr. Briar Sexton 25:36
So I mean I would say that the first thing again that's important is treating the patients where they are. So if somebody's been living a pretty miserable life and I start talking to them about lifestyle, which is always where I stop, and they're like, yeah, yeah, yeah, but I need something to help me now, like I'm ready to stick a knife in my head, we'll jump there. But generally speaking, I would say especially practice in kitsilano and british columbia, vancouver, you know, and a lot of my patients are female and a lot of them are wary of overprescription and doctors are jumping to their pill pads. So I will always start with lifestyle modification. Supplementation, very basically with vitamin and minerals, have been proven to reduce migraine and concussion symptoms in about one in five or one out of six individuals, which is a lot. Powdered ginger just a teaspoon of ginger like you'd use to put into baking in a third of a cup of water, can be more effective than Advil or Tylenol in about one in five or one in six patients to get rid of acute pounding headache when it onsets.
26:45
Taking out the list of triggers that I send them, monitoring for things like stress and sleep, trying to get into better routines, trying to incorporate some form of exercise Again. Do I fix a lot of people with it? I don't, but I fix enough that then they don't want to go on medication because life's tolerable again or even pleasant, or they tinker with it for a while and come back to me and say, okay, I can't get any further with lifestyle. Now what do we do? But generally I'll tell them everything I know how to and work with them until I hit the wall where I don't know anymore about how to modify lifestyle to help them, at which point I like to have a conversation about medication, and medication when it comes to migraine, falls into two categories.
27:28
They have what we call our migraine abort efficiency, meaning something you would take as the headache started to stop the headache from getting worse or to make the headache go away. That would be appropriate for somebody like you who gets a headache every day or two. But a lot of those medications, like Tylenol, like Advil, they're hard on our organs, they're hard on our kidney and you don't want to be taking them every day if you have daily headache or multiple times throughout the day, which some of my patients do when they have this type of headache. And there are safer alternatives, much safer alternatives, those fall into. There are a few of our rescue or medications or abort-efficient medications that are prescription, and there are a large number of them that are designed to be what's called preventative, where it's a pill you take every day or an injection that you receive monthly or every three months that is intended to cut the number of headaches down by about 50% and to reduce their intensity by about 50%.
Tim Reitsma 28:26
Yeah, medication, I know, even for myself it can be scary. But I like how you said you start that lifestyle. Because, as somebody who myself I live with Crohn's disease, if I went to my doctor and was complaining that I'm always in flare but I just eat fried food for six meals a day, well I know my doctor will say well, you know, we kind of, we kind of look at your lifestyle first. Let's, let's, let's get that under control and medication doesn't have to be scary. And I think and maybe I don't know if you'd agree with me or not I think, as a patient, it's to understand what is that medication for, what are the risks.
29:07
Like, I have to, as a patient, be able to weigh those pros and cons and be able to say, make an informed decision myself, because you take that medication. You go to the internet, you search it, you Google it, whatever you do, and it could be scary, right, I'm on a medication and I do my research and it's going like, oh, I'm going to die, like 100%, that's what the medication is. And then I actually get to the real sites about the medication, or just some objective opinions, and it's like, okay, it's not that scary, but how do you handle that with patients?
Dr. Briar Sexton 29:39
I mean, I think the first thing is to talk about the risks. And it's interesting because if you go on the internet and you type in any drug, I don't care what it is, I don't care, all of them cause blurred vision. That's the nightmare of every ophthalmologist right. Anytime anybody's staring on something new, they read on it somewhere that it's going to cause blurred vision. They want to check in with me. Am I safe to start it or not? And the actual fact is, when people are listing side effects, they'll often have to list anything that happened during the study whether they thought the drug caused it or not which is different than the true side effects of the medication. So try and make a point of that. I also have to address a really common misconception that the headaches are masking the problem and they're hiding what's really going on In actual fact. In experimental settings we don't have an ability to do it. If you come into my office I can't give you a blood test for it, but in experimental settings, when we go into the brain of migraine people, they have abnormally high amounts of a neurotransmitter called calcitonin gene-related peptide or CGRP, and that's a neurotransmitter that calcitonin gene-related peptide or cgrp and that's a neurotransmitter that makes your head hurt, or if it goes to your nasal tissue in your brain neural factory center, it might make you smell something that's not there. If it goes to your visual cortex, it might show you pictures that aren't there in one eye or both eyes. And and it's all this neurotransmitter. So the drugs that we know work. Some of them lower the level of that neurotransmitter, so they're actually working the same way as our dopamine agonists do for people with Parkinson's who don't have enough dopamine, for serotonin boosts, for myoselective serotonin reuptake inhibitors, for people with depression, and so the drugs aren't hiding things, they're actually trying to heal things. So that is a big open door for a lot of people.
31:30
Some of the older medications that we use that are ordinarily wander around in life as seizure medications or hypertensive medications for people with high blood pressure. I think we have less idea how they work. But migraines often viewed as a neurovascular headache. So controlling how fast the blood pressure can spike and how fast the heart rate can spike is likely naturally modulating the migraine response for some people. So I try and educate. It does take a long time. That's why I want to start with. Lifestyle is if we don't have to have a half an hour conversation about what medications that you may go on six or 12 weeks from now. When you're going to want me to repeat it all again, let's do it then, and sometimes we don't need to.
Tim Reitsma 32:18
Yeah Well, I love that you start there, that lifestyle approach, and you know somebody who's listening to this. Maybe you're just looking to educate yourself on this topic or you are struggling to advocate for yourself. I think there's some good takeaways here, where you know, write stuff down. But also, if your doctor maybe is just jumping straight, here's a prescription, see you later, you know what are the side effects of this. What is this going to do? Is there somewhere else we can start? Maybe lifestyle like what should I be looking at? Should I see a specialist? How can I see a specialist? Just even some of those quick questions I know, even for myself, have been incredibly helpful and have gotten me to the care team that I have now, which is a phenomenal care team. Didn't always have a phenomenal care team and it took a lot of time, which, when you're suffering or struggling, it doesn't feel like you have time on your side and so it takes time to get diagnosis, to get the treatment, and so just don't give up.
Dr. Briar Sexton 33:22
Well, and then the other barrier that I haven't talked about is the cost of some of these medications, and it's a real barrier. Some of them are not covered by drug plans. Some of them are not covered by provincial drug plans here in Canada, Some of them. In order to access them, you have to try older classes of medication that are less likely to work and have more side effects first, older classes of medication that are less likely to work and have more side effects first. So again back to the trust issue. You know I've got classic case would be somebody with concussion and maybe they can't try some of the other medications and I have to prescribe them something called topiramate, which I know it's nicknamed dopiramate because it clouds thinking, it makes people, some people feel cognitively foggy. Of course it doesn't have that in everybody. So I've got to say to somebody who's walking around in a brain fog all right, the only way I can get you the drug that I'd really like to try for you that I think would help you is to give you this other one for 30 to 60 days first. That might make your concussion symptoms worse. You game for that. And so that trust of making sure they see what the long-term strategy is, and that there is a long-term strategy is an important part. And when the drug does get turned down, I need to make sure that they come back and tell me about it.
34:41
And I had two Olympic athletes and they're under the same drug plan and one of them gets approved for the drug and the other one doesn't for the same diagnosis. And I call the drug company and say what the heck? And they say well, you didn't try this. I said yeah, because you can't use it more than nine days a month and she'd be using it 60 times a month and kill herself. It's not on my table, oh, okay, Well, then we'll approve it. Thanks, no problem, Right.
35:06
And oftentimes it is just a clarification like that. But the patients sometimes think no means no, and if I've prescribed them something I think is going to be approved, and I've planned to see them again in three months, and they come back and say how are your headaches? Oh, terrible. Oh, that drug didn't work, oh, it didn't get approved. And I go oh, how come I don't know? All right, well, let's do our homework, let's get to the bottom of this and oftentimes we are able to either reverse it or put them through the steps. We need to get it approved the second time that we ask for it.
Tim Reitsma 35:37
The thought swirling around in my brain is I know we were talking about concussions and migraines and I think there's just so much insight in this episode for people who are just trying to advocate for themselves. Right, I've had medications not approved by drug plans and then I think how am I going to pay for this? You know, this is thousands and thousands of dollars. And, yeah, we're here in Canada and we have a different healthcare system than other places in the world. But still, just because we have a federal health plan, it doesn't mean everything is covered Medication I'm on now.
36:15
I am grandfathered into this program because I was one of the early people in this plan. I could not afford this. I'm a solopreneur. I don't have health. I don't have my own private healthcare. This would have cost me over $10,000 to $20,000. I can't get an exact price every eight weeks. How can I afford that?
36:35
And so when it's not approved, again it's what do we do? We need to take that back to our doctors. We need to say, hey, what can you help me with? Is there something else that I can get approved? Or hey, I heard that this is going to work, but now what there's options and what I've heard from people who are trying to advocate for themselves is we hear no and you hear that no a few times and it's just, it's hard.
37:00
And a friend of mine who was struggling with living with migraines for many, many years had heard no so many times and they just were like I'm not giving up and got the treatment. I'm going to record with her and release that in a few months. It's going to be a fascinating conversation because their journey of self-advocacy to get that diagnosis, to get that procedure, to get the medication, it's changed their life. And so have you encountered what would you say to someone who's really now at that point where I don't know what to do? Maybe work doesn't believe them, maybe they're struggling to get that treatment. What advice or what would you offer that person who is struggling in the context of, maybe, the work that you do in migraines and concussions?
Dr. Briar Sexton 37:51
I mean, I think one of the things that is helpful is, of course, making sure the patient knows you believe them. One of the things I'll say often is I'm going to start giving out green wristbands, like those yellow Livestrong ones, so people can see that you're really sick and I've endorsed the fact that there is a serious illness there. And then, if there's a treatment reluctance, specifically I try and tackle it head-on, and oftentimes I think it's it's them thinking about what the medication might do for them and their body, which is incredibly valid. But also, to step the picture back and go, are there other aspects that we aren't considering here, like when you're missing your son's hockey games cause the arena is too noisy, or you're missing your daughter's. You know hockey games because you know there's too much motion or artifact on the ice and it's making you feel sick. Like what would your daughter want here and your son want? They want mom back, and if I think I can give mom back, isn't that worth taking the shot for? And so sometimes it's just broadening the perspective. Sometimes it's addressing the fear.
39:00
Botox is an on-label treatment for migraine in Canada since 2011, and I treat a number of patients with it and when I was first treating. It was somebody whose headaches went from debilitating 15 days a month to zero, and that's not a common response. I'm not trying to say that that's what people should expect, but for that individual, the impact on her quality of life was a miracle, in her words, not mine. She went back to her family doctor who said, oh, my goodness, they're putting Botox that's going to take 10 years off your life. You got to get her to stop that and she said to him I'll take it. If I was told absolutely, it would kill me 10 years earlier, but I can live the next however many years without headaches deal, but I can live the next however many years without headaches deal. And so I think that that's that's an interesting one.
39:51
And in terms of advocacy, when you talk about patient support programs, I was giving a talk for a group of concussion specialists and they were really taken aback by the prices of some of the medications and I was saying, well, there's a support system right now. There's this, there's that, and I said, well, why would I start them on it when I know they're not going to be able to afford it if the program goes away? I said, well, I don't make money decisions for my patients.
40:15
I'm sensitive to the fact that not everybody has money. I'm sensitive to the fact that, even if you have money, $10,000 or $20,000 every eight weeks is probably really a small percentage. But you don't know. You don't know if their parents have money. You don't know if their siblings have money. You don't know if they get on the drug for six months, if they'll go to work and get a job somewhere specifically that's got good benefits that were covered in the absence of it being covered by the government. So I never, ever, make a decision that somebody can or can't afford something, or is or isn't for them. I want to make sure that that is their decision when they're this sick.
Tim Reitsma 40:50
Yeah, it's presenting all the options and, you know, just even just taking a step back into concussions and migraines and specifically, you know, in society, right, we talked about the invisible nature of it. It's you look at someone and go, oh, but they look fine. No, it's just a headache, it takes some Tylenol, it takes some Advil. That's really hard to hear and I know I'm guilty of it. It's like, oh, just sleep it off. And I've been on the receiving end of that. And so, for someone who is specifically living with migraines, living with concussion, what would you say to someone, just to help them articulate what they need for support or what they're even going through?
Dr. Briar Sexton 41:46
that they should share with their family, that the quality of life of somebody with their condition is the same as somebody who's had a moderate to severe stroke or has dialysis for kidney failure every day. That can be a really helpful thing because people understand kidney failure is really bad and they understand that a moderate to severe stroke is really bad. So if their doctor is telling them they have the same quality of life as those people do, that is something their family and friends often can relate to in a way that they couldn't relate to it when they were trying to think about how they feel when they have a bad headache once every couple of weeks or months.
Tim Reitsma 42:15
Yeah, I like that bring a very tangible comparison to this diagnosis that affects so many people here in Canada and around the globe. And I think, as we wrap up, I ask this question to everyone and this is a big hard. I think it's big and hard, but yet I am so. Anyway, let me get into it. The purpose of invisible condition is to end the stigma of invisible conditions, and I know I say this is hard because it's so complex. How can we do this? How are we going to do this? How can we take steps in society, in our workplaces, our families, to end the stigma that often is attached to our invisible conditions?
Dr. Briar Sexton 43:07
I mean, I think, as I say, a big, big piece of the puzzle is education. Educate our GPs, educate our emergency room doctors. Make sure that concussion is not being under or over-diagnosed. Make sure that chronic migraine is being diagnosed. Make sure that when it's diagnosed, it gets treated properly.
Tim Reitsma 43:28
Yeah, that education piece is so important and I like how you said, we need to educate our doctors, our emergency room physicians. We also need to educate those around us. Like you said, if I was diagnosed with chronic migraines or concussion, how to even educate those around us? And that's something that I'm looking to do here. Even at a visible condition, what does that look like? And there's so many great resources. I know you've got a blog as well. We'll put that in the show notes and yeah, again, as we wrap up, I just really appreciate you coming on and sharing with us just the definitions of migraines and concussions and we took a turn into that whole advocacy piece, which is something I'm passionate about, and just even that story of two Olympians diagnosed the same thing, same medications. One was approved, one wasn't, and if that's where the conversation ended, that'd be heartbreaking and it didn't end there and they got the approval. And I don't know who they are, but I'm sure they're doing amazing things and so you know. Any final thoughts as we wrap up, Dr Sexton.
Dr. Briar Sexton 44:40
I'd just say to anybody who's living with it you know, first of all, I'm sorry. It's a really, really tough diagnosis, whether it's concussion, brain injury or migraine headache. If your head hurts all the time, you're miserable. Migraine again is a really good website, very trusted in terms of their resources and recommendations. Lots and lots of lifestyle stuff there for people who don't want to start with medication.
Tim Reitsma 45:06
And we'll have a link to all of that in the show notes. Every time I put together a podcast page. I have definitions, I have resources, I have a lot of information on there, because it's not just about recording an episode and pushing it out. It's about educating ourselves and our loved ones. I've learned a lot about migraines and concussions in this conversation and our loved ones. I've learned a lot about migraines and concussions in this conversation and I hope, if you're listening, that you also have learned something.
45:32
If you have questions for Dr Sexton, we're going to do something a little bit differently. Send them to me on the website, on the show page. I'll just have a link, a contact us link, on there. Send me your question. I'll forward those on to Dr Sexton, because I know even for myself I'm listening to this and I'm like, oh, we could probably record for another hour because I've got so many questions, but this leaves us at a good place. And so if you are listening and you love what Invisible Condition is all about, please tell your friends, your family, subscribe to the newsletter. It comes out every couple weeks. Subscribe to the podcast, share it out. That's how we are going to end the stigma, one way we're going to help end the stigma. And so, dr Sexton, thank you for spending time with us today. I really appreciate you coming on and, again for those who are listening, I hope you have a good one.
