Podcast: Diagnosing, treating and living with migraine
Transcript
Dr. Mojola Omole: Hi. I'm Mojola Omole.
Dr. Blair Bigham: I'm Blair Bigham. This is the CMAJ Podcast.
Dr. Mojola Omole: So, Blair, today we have four articles that we're looking at in the CMAJ around migraines. Two are patient perspectives that describe what their journey has been in terms of getting treatment for their migraines, and-
Dr. Blair Bigham: Or not getting treatment for their migraines.
Dr. Mojola Omole: That is also very true. And then the two other ones describe diagnosing acute management of migraines, and another one discussing prevention of migraines and talking about some of the new novel medications that are out there.
Dr. Blair Bigham: Yeah. It sounds like this is a pretty rapidly advancing area. Certainly there are more treatment and prevention options than I had ever realized. And so we've decided to go ahead and interview a panel of people who have dedicated their lives to headaches. And I don't think I've ever had a migraine, but I've certainly had terrible tension headaches that are debilitating. They're awful. And I see migraine patients in the ER all the time. And I feel like outside of my little cocktail of medication, some of which have some evidence, some of which doesn't have evidence but at the bedside seems to have some effect ... Once I go beyond that cocktail, I often feel ill-equipped to help people when they're having these terrible bouts.
Dr. Mojola Omole: For me, I occasionally get headaches, and when I do, I think the world is going to end. But I would say that two of the closest people to me in terms of my best friends are chronic migraine sufferers, and watching one over the last 24 years has been really, really challenging in terms of her - both of them are female - of them getting the proper treatment and just watching how their life has evolved and changed because of their migraines.
Just one anecdote, for one of my friends, her children remind her to take her medication, because they want to have a fun mom around, and this is someone who prides themselves on being a great mother. And I think oftentimes as physicians we see just the disease and we don't see how debilitating and how it affects just the whole person. And so for me, I thought that this would be just a great episode just for us to just go deeper into first just management of migraines from a clinical point of view, but then just moving more into the whole person of what it's like to have migraines.
Dr. Blair Bigham: Absolutely. Well, let's get right into our panel. Dr. Velina Tzankova is the lead author of the two papers. She's a neurology resident at the University of Toronto. Dr. Werner Becker is a neurologist and the founding director of the Calgary Headache Assessment and Management Program and, currently, professor emeritus in the Department of Clinical Neurosciences at the University of Calgary. And Dr. Tommy Chan is a neurologist and director of John H. Kreeft Headache Clinic at University Hospital in London, Ontario. Tommy, I want to throw the first question to you. Everyone seems to know someone who suffers from migraines. How prevalent are they?
Dr. Tommy Chan: Yeah. I think migraine is a definitely underdiagnosed condition. [It] affects about one in six female and one in 16 male. But often they may not be bothersome enough that they will seek medical attention, so that's why I feel like that number is under-reported. And approximately 5% of those patients suffer from the chronic form, hence usually that's when they end up in a specialist's office.
Dr. Blair Bigham: Yes, Werner. Go ahead.
Dr. Werner Becker: One of the problems that migraineurs have is that most people have headaches at some point in their lives, and it's not appreciated that a migraine is a specific kind of headache which can cause significant disability, as opposed to the so-called ordinary headaches or tension type headaches. So yes, we think migraine is generally quite underdiagnosed, and it's not clear why, except we may have a problem with physician-patient communication. The diagnostic criteria are now well known, but I think many primary care physicians still aren't really aware of them.
I think that education has to be the best solution to addressing that. As an example, there was a time and there probably still are some doctors who think that migraine sufferers have to have an aura, and that's not true. Only but a third of migraine patients ever have an aura with their attacks. Then there's the issue of chronic migraine that Tommy alluded to. Now, people with chronic migraine have headache all the time or at least 15 days a month, and not all those headache days are migraine days. Although, in general, most of them have some migraine features. So if the doctor picks up on a few tension-type headache days, they may think, "Oh. This is not migraine!" but in fact it is a chronic migraine.
Dr. Blair Bigham: Velina, what do we know about what causes migraines?
Dr. Velina Tzankova: Sure. So migraines in general is characterized as a disorder of neuronal hyperexcitability, and while there are a number of genetic variants that have been associated with the condition, it's multifactorial, multigenetic: there's not one gene that's been identified, but there is a strong genetic basis for it, which is why we see that often patients with migraine often have a family history of migraine in close relatives, in their parents or grandparents or their children.
In terms of the actual pathophysiology, it's generally thought that migraine results from the activation of the trigeminal vascular pathway, which consists of nerves that innervate the dura and the large cerebral arteries. And when these neurons are activated or stimulated, they release vasoactive neuropeptides such as calcitonin gene-related peptide, or CGRP, which animal studies and human studies have shown that CGRP increases during a migraine attack and then it decreases with treatment and between attacks.
And, it's also been shown that if you infuse CGRP into a patient, it can actually trigger a migraine attack. So there's a very clear sort-of causal relationship there, and that hypothesis that migraine can be aborted by preventing or blocking the action of CGRP is central to all of the drugs that have been developed in recent years that either target the CGRP ligand or the CGRP receptor.
Dr. Mojola Omole: Dr. Becker, Dr. Chan had mentioned that the prevalence was different when you compare the two genders and that it was more common in women than it was in men. If we're talking that this is multifactorial and there's a genetic component, why do we see it more in women than we do in men?
Dr. Werner Becker: Migraine's about three times as common in women as in men, and I suppose it's fair to say the real reason is unknown, but probably hormonal factors play a role. Although migraine has a genetic component to it - if you look at identical twin studies, about 50% of the migraine risk is genetic - environmental factors also play a big role in how many migraine attacks a person will have and how big a problem their migraine will be. So hormonal factors are probably important, and many women do lose their migraine after menopause.
Dr. Blair Bigham: Tommy, how should migraines be diagnosed?
Dr. Tommy Chan: I think, when somebody presents with a headache, we do want to run through a list of questions to ensure that there's no reflex to suggest that this is a headache due to a secondary cause or something that's sinister. So a mnemonic that we use in our field is SNOOP, so systemic symptoms, neurological symptoms, acute onset such as the thunderclap headache, an older age nuance that people would think about like giant cell arteritis, and then P stands for a lot of different terminology including progressive headache, posture, papilledema. And over the years, this pneumonic has expanded to more Ps, including pregnancy, post-traumatic headache, and et cetera.
And I think that, once comfortable after running through the list of symptoms and their neurological assessment is reassuring then, the most common things being common, the most likely primary headache disorder, meaning a headache that's not related to a structural problem, is likely going to be a migraine attack. I often like to clarify or explain to patients and my colleagues that migraine is something that you already have, and what really brings you to the hospital or seek medical attention that really bothers you ... It could be the migraine attack, which is associated with the pain symptoms or non-pain symptoms that sometimes people endure such as the aura, the visual disturbance, et cetera.
Dr. Blair Bigham: Velina, you've offered to share your story. In addition to being a neurology resident, you are a migraine sufferer. Tell us a little bit about your journey to getting diagnosed with migraine.
Dr. Velina Tzankova: Sure. So I think many patients with migraine, myself included, will go for many years suffering through their headaches and just popping Tylenol and Advil when it's really, really bad or sleeping the day away and saying, "It's not that bad. It's not that big of a deal. I'll just deal with it," and never actually seeking out appropriate treatment, because there's a little bit of a stigma around it. Right? What are you complaining about? It's just a headache. We'll hear that all the time.
If you call in sick from work, you get an eye-roll. And it's because people at large don't really understand what migraines are, so we're often not taken very seriously by our coworkers, by our peers, even by our own family members. So you brush it under the rug, and you deal with it and suck it up and just keep going. So for myself, I always knew I had migraines probably since I was about 15, and I didn't get my first triptan prescribed until I was 35, and that was also-
Dr. Blair Bigham: Wow. You were diagnosed when you were a neurology resident. Is that right?
Dr. Velina Tzankova: I mean, technically I never saw a physician for it until I was 35. I knew I had migraines. I knew my grandmother and my dad had migraines. I watched them suffer my whole life. I had some headaches when I was younger in childhood and as a early teenager, and it wasn't until I was 15 ... I still remember my first migraine, and I was actually with my grandma who has migraines, and initially I thought, "Oh, my gosh. I think I ruptured a aneurysm in my brain." And then I was like, "No. This must be what my grandma's been lying on the couch crying and asking me to massage her neck since I was a little kid ... This must be what she was talking about." But I've just lived with it until a couple years ago.
Dr. Mojola Omole: Velina, do you think there's some gender bias in terms of being taken seriously by physicians and also by neurologists? Because this is not atypical for women who suffer from fibroids or any other complex chronic pain is that often they feel like their symptoms are not being addressed.
Dr. Velina Tzankova: Very possible. Yeah. I guess I've never seen the other side of it. Aside from my dad, I don't know many other men in my life who have migraine and who have experienced that. For me, it wasn't that there was bias towards me because I was a woman or whatever. I just never even sought out the medical attention. Right? I think a lot of patients don't even seek it out, at least for many, many years, until something finally tips them over or it's unbearable or some transition in their life. For me, that transition was actually having a child, and I didn't actually realize what I had been living with until I was pregnant and my migraines actually went away during my pregnancy and lactation. And so I had about a year and a half of no migraines, and when my migraines came back afterwards is when I was ... I just thought, "Oh, wow. What I've been living with is not normal. I've experienced the other side and what it feels like to not have an almost daily headache, and I cannot live this way." So that's when I sought help.
Dr. Blair Bigham: That's interesting. Once you got that help, how did life change for you?
Dr. Velina Tzankova: Drastically. I now probably get four or five migraines a month, which still sounds like a lot, but I've also learned how to use my acute medication appropriately. I take my triptan pretty much as soon as I know that the symptoms I'm experiencing are the onset of a migraine. I take it right away, and it's usually gone within an hour, and I can just carry on with my day, and it never gets to be more than a maybe mild to moderate headache.
Dr. Blair Bigham: Oh, wow. That's great. I want to jump over to Tommy. Tommy, review for us the pharmacologic treatment options for family doctors, emergency doctors, and general practitioners who meet somebody who's in the midst of a migraine.
Dr. Tommy Chan: So when somebody is in the midst of an acute attack, we call it a migraine attack. It's very important to treat it early and aggressively. I think the biggest misunderstanding is, at least for patients and providers, they want to wait to see if this attack, particularly the headache symptom, will eventually become moderate to severe. But sometimes, by waiting longer, it actually makes it more difficult to treat. If it's moderate to severe attack, don't wait.
You can combine treatments with a triptan with a nonsteroidal anti-inflammatory drug. An example could be just let's say a Rizatriptan combined with a naproxen, which is a longer-acting one, as a buffer medication. But sometimes it is trial and error. Patients may try two to three medications before they find the right one. And there are more studies that if you treat a migraine attack early, especially with the newer medication that will soon become available in Canada ... If you treat your migraine attack while the pain is mild, your chance of pain freedom and pain relief is much higher.
Dr. Mojola Omole: Tommy, can you tell us about this medication that you alluded to?
Dr. Tommy Chan: Yeah. Going back to what Velina said with regard to the pathophysiology of migraine, that we know a very important player called the CGRP, and that especially during a migraine attack that the level is high. So in the past few years there have been more novel agents. Both look at this neuropeptide. So for example, recently a medication called Ubrogepant has received notice of compliance in Canada for the acute treatment of a migraine attack, and this specifically targets the CGRP receptor. And so it actually has a high chance of pain-freedom, pain-relief and also addresses the most bothersome symptoms, which sometimes for people could be photophobia, phonophobia, nausea and vomiting.
Dr. Mojola Omole: And ... it's available? Is it available in Canada now?
Dr. Tommy Chan: It's been approved by Health Canada. But just like any new novel agents, it's going to take some time before it becomes commercially available in market through coverage, through private coverage. And who knows in the future if public coverage would be also included?
Dr. Blair Bigham: Werner, alongside the articles you three have in the journal, there are also two articles from the patient perspective. Both of them talk about the difficulty in getting diagnosed and getting treated and, in some ways, just being believed that their headaches were severe. How would you like to see the conversation change around migraines?
Dr. Werner Becker: Well, I hope that it'll make everybody more aware of what migraine is and the disability it can cause. By everyone, I mean health professionals, the public, and also patients themselves. We had a similar thing over 10 years ago called the Canadian Migraine Forum, where we also had three patients present their migraine story. And I sense that things haven't changed very much. Those three patients also told the health professionals there that it took a long time to get a diagnosis and they also often weren't treated optimally.
There still is a large treatment gap for migraine, even with the best of our current therapies, used in an optimal fashion, some patients can't be helped adequately. So we desperately need more research in migraine to understand it better, so better therapies can be devised. Having said that, though, it's also still true today that the therapies we do have, which are effective for many patients, are often not used optimally, and that's going to require education.
Dr. Blair Bigham: Well, hopefully this conversation helps with that education. Tommy, Velina, Werner, thank you so much for joining us.
Dr. Tommy Chan: Thank you for having us.
Dr. Velina Tzankova: Thank you for having us.
Dr. Blair Bigham: Dr. Velina Tzankova is a neurology resident at the University of Toronto. Dr. Tommy Chan is a neurologist and director of the John H. Kreeft Headache Clinic at University Hospital in London, Ontario. Dr. Werner Becker is a neurologist and headache specialist in Calgary.
Dr. Mojola Omole: As Werner mentioned, there's clearly a need for more education about migraines. So we thought maybe we should just do that from the patient perspective. So we're going to be speaking to two people who have long struggled with migraines. Unfortunately this was a last-minute decision, and Blair, being the jet-setting physician that he is, was unable to join us for this, but he'll be joining us in the closing to discuss what his perspectives are and his takeaways from the interview. Dr. Shanthy Edward is a clinical psychologist joining us from Maryland, and soon-to-be-doctor, Zikra Awosanmi, is a fourth-year medical student at the University of Toronto. Thank you both so much for joining us today.
Dr. Shanthy Edward: Thank you for having us.
Zikra Awosanmi: Thank you for having us.
Dr. Mojola Omole: I'll start with you first, Shanthy. How long have you lived with migraines?
Dr. Shanthy Edward: For a really long time. I actually started having migraines as a pretty young kid. I've had them pretty much as long as I can remember.
Dr. Mojola Omole: And so are you saying back in high school? Were you impacted by the migraines?
Dr. Shanthy Edward: Yes. Definitely. I think that they got worse around the time that I got my period and that phase of life. So after 12 and into high school, I did have a lot of migraines pretty often, and it did affect my daily life.
Dr. Mojola Omole: And, Zikra, for you, how long have you lived with migraine?
Zikra Awosanmi: I started getting migraines probably near the end of high school. So I'd always had headaches previously, growing up. But then right around the end of high school I started to experience episodic migraines.
Dr. Mojola Omole: And I'll start with you, Zikra. What impact has this had on your life?
Zikra Awosanmi: Well, most of the impact for me has actually been throughout medical school because, prior to medical school, they were pretty infrequent. They would be maybe a couple of times a year. And near the end of my first year of medical school, it started to increase in severity. By about my third year it was pretty much every day there was something going on.
Dr. Mojola Omole: So, as a medical student, what does that look like for you? Obviously in the first two years it might be a little bit easier to manage if you're hybrid learning. But when you get into clerkship, what does that look like?
Zikra Awosanmi: Yeah. A lot of it was navigating how to get the right accessibility, because my life was so unpredictable. And, like you said, clerkship is very demanding, and you don't really have control over your schedule. So a lot of that is just trying to connect with the right people, especially with people in accessibility services and getting all of that in writing and then actually having it implemented on site, because the program administration ... They were aware, but it didn't always trickle down to the preceptor that I'm working with day to day, right? It was always like the onus was on me to have this conversation with them. Like the first day meeting them, say, "Oh, by the way, I have this thing that affects my day-to-day life, and things might be unpredictable for me, so just a heads-up," which is a really tough way to meet a preceptor, someone that you're hoping to impress for the first time.
Dr. Mojola Omole: Yeah. And, Shanthy, what about you? How has migraine impacted your life?
Dr. Shanthy Edward: I think that they've affected pretty much every aspect of my life, because at one period of my life I really had a constant low-grade pain that could get triggered into, or I felt like it got triggered into, a full-blown migraine based on a number of different factors. And so there was the pain that's associated with the migraines that were a huge effect, but there was also an anxiety around whether I'm going to get one today - you know, is it going to blow up into a full one?
And, especially when I have an important day ahead of me or lots of things that I need to get done, there was a combination of the actual pain from a migraine and the debilitating symptoms that you would have, but there was also this fear and anxiety around whether I'm going to get one. And so that added to the pressure and the stress, and I think it was a loop where one feeds into the other, the stress leads to migraines and then migraines lead to more stress.
Dr. Mojola Omole: And how have you found, in your work life, people being able to be accommodating to that? From what I remember, you work in the business field. So how have you found that? Have there been accommodations?
Dr. Shanthy Edward: No. There's no real accommodation for it. I think that generally people think it's just a headache. If you haven't had migraines, they think it might be just a really bad headache. And there's really not much room to have an accommodation around sickness in general, and then something that chronically affects you ... there's still an expectation of a certain level of output regardless of how you feel that day.
Dr. Mojola Omole: And so this question is for both of you. We know that migraines are the number one cause of disability in women worldwide. But, from what both of you are saying, it's really not even viewed as a disability. Do you think part of that is a bit of sexism that we don't view it as a problem, as a disability itself?
Dr. Shanthy Edward: I do. I think so, because when I think about my experience in even getting diagnosed and treated for migraines, I think about that process, and it would always start the same way over and over: food diary, sleep diary, all of these different things, and it was almost any way that it could be characterized in a way that was not something that was a more chronic, disabling type of experience.
Dr. Mojola Omole: And for you, Zikra? What are your thoughts on that?
Zikra Awosanmi: Yeah. I mean, I think it's also interesting that oftentimes a lot of people with migraines, especially women, will also experience worsening of their symptoms around their menstrual cycle. So that also adds to the burden of struggling to talk about it, because it's something that you don't necessarily talk about with your colleagues that aren't your close friends. Right? You don't necessarily share too many details.
Dr. Mojola Omole: I actually do all the time, because I think it's ... No. Because I think we need to normalize it, because they'll go, "What's wrong?" I'm like, "My gut's hurting me. I have my period," because we do need to normalize it, because how am I supposed to be able to operate and be in pain, and not complain about it? Sorry.
Dr. Shanthy Edward: That brings up something really big. I mean, I can't even imagine in my work settings being able to say that, and then also especially - because it's related to women's health - and even in fields where you're doing health research or you're focused in healthcare, there's really not much room on the business side to really talk about women's health issues, including whether it's your menstrual cycle or the migraine that might be associated with that menstrual cycle.
Dr. Mojola Omole: So you mentioned, Shanthy, that migraines are ... it's understood…the general public thinks it's a very painful headache. But oftentimes they come with a cluster of symptoms with them. So to what extent has this been the case for both of you that you have other symptoms besides the painful headache? Zikra, do you want to go first, and then Shanthy?
Zikra Awosanmi: Sure. So, for me the way I see it is that a headache is pain in your head or on your scalp or wherever, and it just stays that way. It doesn't affect your mood, for example, necessarily. It doesn't affect your ability to be able to walk around in your house or make yourself dinner. You may not necessarily experience significant fatigue with a headache. But when you have a migraine, depending on who you are, it's a whole process. The come-on of the migraine could be days, where your mood is low and you're wondering, "What's going on? I've been feeling down. I'm irritable. I'm maybe snapping at my partner," and then you're noticing that maybe you're a little bit more fatigued or feeling a little foggy.
And then maybe you go to bed and overnight it wakes you up as a pounding headache, 10-out-of-10 headache, you feel very nauseous. I've heard of people who are vomiting and needing to go to the ER to get IV fluids. I fortunately haven't experienced that, but definitely the nausea and just overwhelming feeling of just malaise, like I just don't feel well. And sometimes you're not able to get out of bed, because just the movement is too much. I tend to notice I'm like, "Why is my partner moving so much? Why is he moving so much?" I notice-
Dr. Mojola Omole: Oh, wow.
Zikra Awosanmi: Yeah. Just the little movements that you do as a human. I notice them so much more when I have a migraine.
Dr. Mojola Omole: And, Shanthy, for you, what's your migraine, I don't know, thing is your prodrome and the migraine itself?
Dr. Shanthy Edward: Yeah. So I would say it's different than a typical headache, because it does affect everything that you are able to do. So there's a lot of nausea. At least for me, there's a lot of nausea, and there can be vomiting associated with that nausea. The pain is very intense. I think, where you would describe a headache as painful, you may describe a migraine as, "This is it, Charlie. I think I'm going to die." The pain is extreme when it gets to that level, where I have actually gone to the ER when it's gotten really bad, thinking that maybe this is more than what I've experienced in my past migraines, and maybe I should have somebody look at me for something else. And then the aftermath of it is just that fatigue. And even when the pain fades away, there's a lot of loss of energy and fatigue, and some of that might be related to not really being able to eat during that period of time or throwing up, those other related symptoms. But there is just this period of exhaustion afterwards.
Dr. Mojola Omole: That sounds very difficult. So how well are your migraines managed now, Zikra?
Zikra Awosanmi: I think they're significantly better than they were when they were at their worst. And I've been through multiple different therapies. We've worked on lots of things, and now I'm at a point where most of the days I'm okay and I'm able to get through my day, even with a small amount of headache, like a low-grade headache, maybe some nausea, but maybe I'm more at a four. And then I still have a couple of bad days and maybe two bad weeks in general where the whole week is not the best and then some days in that week that are pretty frustrating and can be much worse. But I think I'm definitely much better than I was before. It's not perfect, but it is what it is, and I'm still trying other therapies, and I'm open to new suggestions from my neurologist every time.
Dr. Mojola Omole: And, Shanthy, where are you in terms of your migraine journey?
Dr. Shanthy Edward: I think I'm in a pretty good place now compared to where I was. I was prescribed amitriptyline, and it was something that I joke around and I call them my happy pills, just because I finally have something that prevents, and I don't have that constant, everyday, low-grade pain that then blows up. I feel like probably what everybody else felt like that I didn't know was possible before. And so generally on a day-to-day, things are pretty good.
I still do get migraines around the time of my period. There could be some random trigger where I still may get a migraine. But it is much less often and much less frequent, and I feel like my quality of life has just improved tremendously. I think even my demeanor has improved tremendously. I used to think I was a short-tempered person, but I'm not. I think it was just because I was constantly managing that pain, and that was my baseline, and I didn't realize that my baseline was putting me in a position of feeling irritated constantly. And now I don't have that at all, and I'm pretty easy going. So I think my headache journey or my migraine journey has progressed now to a place where it's much more manageable.
Dr. Mojola Omole: That is amazing. Is there anything you think that physicians need to understand about the experience of living with migraines?
Dr. Shanthy Edward: I do think there's just a ... At least in my experience, there was a rote response to a migraine diagnosis or the complaint of migraines. It was kind of like, "Okay. First this. Let's do this. Then let's do this. Let's try that," instead of listening to what the journey has been thus far and then saying, "Okay. It appears that these things have not helped or these interventions have not helped. Let's start from a different place." So I think that that was a really big thing for me in terms of being able to actually get an intervention that worked for me, because I felt like I kept having to start again, because my doctors just had this ... Like, "Here's the MO for what you do for migraines," and then we go through that. And then when I finally got a doctor who actually listened carefully to the types of symptoms I was describing, when I was prescribed the medication, it did wonders for me, and I think that it was because of a function of really listening and building upon previous experience that I had.
Dr. Mojola Omole: That's wonderful. And you, Zikra?
Zikra Awosanmi: I think also it's ... At least for me, it's been a very expensive journey, and it continues to be very expensive. So also recognizing that there isn't a lot of support for patients as well, especially from the government. And even insurance plans are not the most supportive when it comes to certain treatments.
Dr. Mojola Omole: Wow. I didn't know that.
Zikra Awosanmi: Yeah.
Dr. Mojola Omole: Even the med school one?
Zikra Awosanmi: Yeah. The one that I have now maxes out ... It has a max, and I'm on some pretty expensive medications. So I get Botox every three months, and then I'm also on AJOVY, which is a CGRP inhibitor. So I pay for AJOVY out of pocket, because my plan only allows me to have one of those higher priced items at a time. So my plan covers 80% of my Botox, but they don't cover the injection fee for Botox, and neither does OHIP, so that's $200, the injection fee, every three months, and insurance doesn't cover that. And then Botox is $800, which is only 80% covered. And AJOVY is around $700 to $800 a month.
Dr. Mojola Omole: Holy crap.
Zikra Awosanmi: Yeah. So it's definitely not-
Dr. Mojola Omole: This is actually a huge accessibility issue. Right? Because if you don't have money or any sort of ability to pay, you're just going to live in chronic ... Okay.
Zikra Awosanmi: Yeah. OHIP+, which at the time when I was eligible for OHIP+, they didn't even cover the triptans, which are also ... They're quite pricey. The triptans are around $16 a pill, and those are the ones that you use for an acute treatment, right? So those were not covered under OHIP+, and I think there's some exceptional access programs, but my family doctor tried to fill it out multiple times, it didn't go through, and so I just had to pay for it.
Dr. Mojola Omole: Okay. Thank you. I did not think about that, and that is actually a huge issue. So thank you so much for sharing your experience with us. Dr. Shanthy Edward is a clinical psychologist in Maryland, and soon-to-be-doctor Zikra Awosanmi is a fourth-year medical student at the University of Toronto. Thanks so much, you guys.
Zikra Awosanmi: Thank you for having us.
Dr. Shanthy Edward: Thank you.
Dr. Blair Bigham: Jola, those interviews were fascinating. Tell me. What was going through your mind as you were chatting?
Dr. Mojola Omole: I would say that it's similar to what goes through my mind whenever we talk about health problems is that your proximity to privilege makes a difference. We know that migraines are the number one disability in women worldwide, but when I talked to them, I didn't really get the sense that they've ever lived a life that was viewed as that they have a chronic disability. And so that stood out for me as that people want to be heard, and oftentimes the group that don't get heard often are women and racialized, and there's that overlap again when we're talking about chronic migraine sufferers.
Dr. Blair Bigham: I was just going to jump back to 30,000 feet and look at these articles around diagnosis, and it sounds like there's many biases that prevent a migraine diagnosis from being established on time. But then these new treatments and preventative options don't necessarily seem all that accessible either. They're not all covered. They're expensive. And even if they're effective, they're not curative, right? They're not taking away your migraines completely. Sounds like we still have a long way to go in figuring out that part of it too.
Dr. Mojola Omole: A hundred percent.
Dr. Blair Bigham: That's it for this episode of the CMAJ Podcast. We'd love it if you could like, share, or comment on our podcast wherever it is you download your audio. I'm Blair Bigham.
Dr. Mojola Omole: I'm Mojola Omole. Until next time, be well.
