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This is Fresh Air. I'm Terry Gross. If election anxiety has been giving you headaches, my guest may be of some help - not politically, neurologically. Dr. Carolyn Bernstein is an expert in the treatment of migraines. And if you think your headaches aren't migraines, you may be wrong. She says most people with migraine illness don't realize they have it. Only half of people with migraines have sought a doctor's help, and half of these get the wrong diagnoses. Dr. Bernstein's new book, "The Migraine Brain," draws on the latest research into the biochemical basis for migraine, the influence of hormones, and the newest drugs and why they work.

Bernstein has been on the Harvard Medical School faculty and a practicing neurologist for 17 years. She's treated thousands of men and women. In 2006, she founded and became director of the Women's Headache Center at the Cambridge Health Alliance, which is the teaching hospital for Harvard Medical School. Dr. Carolyn Bernstein, welcome to the Fresh Air. What separates a migraine from a plain old headache?

Dr. CAROLYN BERNSTEIN (Neurology, Harvard Medical School): I think that, if you took a group of, let's say, 100 people and lined them up and described the classic headache, just a plain old tension or muscle-contraction headache, I think a lot of people would raise their hand if you said, have you ever experienced a band of tightening and pressure around your head, some throbbing maybe? And that might just be a plain tension headache.

But I think, in terms of a migraine headache, you do have to meet the diagnostic criteria in order to make the diagnosis, and those include a variety of different factors, including unilateral pain that's throbbing, has to last a certain amount of time.

GROSS: What do you mean by unilateral? Is it on one side of your head?

Dr. BERNSTEIN: Unilateral means on one side of the head or the other. So, the pain will grip you on the right or grip you on the left. For most people, it's the same side. But every so often, it may switch sides. Pain is throbbing. It is often accompanied by nausea, vomiting, lights bother you. That's called photophobia. Sounds bother you; that's called phonophobia, stomach pain, and then other symptoms that may be less frequent.

For a number of people, not all people with migraines, sometimes they'll have what's called aura, and they'll have changes in their vision most commonly. They may have difficulty getting words out. They may have numbness and tingling on one side or the other before the headache actually starts. Really important to recognize that - to know that that's actually part of the migraine because it helps with treatment and it helps with diagnosis once you figure out that's what the explanation is.

GROSS: You say migraine isn't a type of headache. It's a complex neurological disease that affects the central nervous system. Would you explain that?

Dr. BERNSTEIN: Sure. I think the thing to remember there is that it isn't just a headache. So, people say migraine headaches, and to be honest, sometimes I slip and say migraine headache, but it really involves more than that. So, there are number of changes that are happening in the brain that are triggering off the whole migraine process.

There are changes that are going on on a real cellular basis. And by that, what I mean is, the nerve cells in the brain are becoming a little bit unstable, and they are sending out messages, which are transmitted through the brain, triggering off pain nerves, sometimes hitting what's called the nausea and vomiting center in the brain. They may create some of those other symptoms - numbness and tingling, sometimes even weakness on one side of the body or the other. So, there's a cascade of events that take place that cause all the different migraine symptoms, and they are more or less pronounced from person to person. Everybody is a little bit different.

GROSS: Your book is called "The Migraine Brain." And you make the case in the book that people who get migraines have certain characteristics in their brain chemistry that's a little different than the average brain. You say people who get migraines have basically a super-excitable brain. Would you explain what you mean by that?

Dr. BERNSTEIN: Sure. People who have migraines, who are unfortunate enough to have migraines, have cells in the brain that are hyper-excitable. And by that, what I mean is that the cells in the brain will become activated in a way that the brains of other people may not.

GROSS: So what makes the migraine brain more excitable?

Dr. BERNSTEIN: Cells in the brain usually are pretty stable, and they have to get certain kinds of messages in order to fire off the signal, let's say, to move an arm or move a leg or a thought process or whatever else may be happening. For someone with migraines, something triggers off this impulse, and it could be a certain food. It may be a glass of red wine or poor night sleep. The cells will begin to depolarize. And what that means is that they'll send off their electrical responses, releasing certain kinds of chemicals and deploying all the different nerve responses that then become the migraine.

GROSS: Now, does this super excitability of the brain pertain in other areas, too? Somebody who gets migraines because of the super-excitable brain, are they also prone to depression or anxiety or feeling more physical pain with any kind of, you know, spinal injury or nerve injury?

Dr. BERNSTEIN: So, we do know that there's an association between migraines and depression, even though I can't define for you precisely what that is. In other words, people who have migraines are more likely to suffer from depression than people who don't. There may be other associations with other sorts of pain. There may be a link with what's called irritable bowel syndrome. But again, research at this point is in the earlier stages of really understanding that.

GROSS: Can you see the differences in a migraine brain if you do, you know, imaging through MRI or a CAT scan?

Dr. BERNSTEIN: There's one study that we reference in the book which is really interesting when - and it's a very small study, but when MRI scans of patient suffering from migraines were compared to patients who don't have migraines, there was some thickening in what's called the somatosensory cortex. And that's the part of the brain that relays pain and sensation. And there's a lot of research now, as I mentioned, that's in preliminary stages, but it does indeed look like the brains of people who have migraines probably are different and probably function differently. And so as we continue to get information back, we'll be able to define this better.

GROSS: But that's a sign that something is different?

Dr. BERNSTEIN: Correct.

GROSS: That there's a part like physiological or neurological explanation here.

Dr. BERNSTEIN: That's correct.

GROSS: My guest is Dr. Carolyn Bernstein. We're talking about her new book, "The Migraine Brain." She is the founder and director of the Women's Headache Center at the Cambridge Health Alliance, which is a teaching hospital of Harvard University.

What about serotonin? And, you know, I think we've heard about the role that serotonin might play in depression. Does serotonin play a role in migraine as well?

Dr. BERNSTEIN: It probably does play a role. Some of the medications that we use to treat migraines actually make serotonin more available to certain receptors on cells. And what the receptors do is, they use a chemical. They receive a message from a chemical that tells them how to act in sequence. And so not having enough serotonin may be a trigger for certain people with their migraines.

GROSS: So, what does that have to say about the possible connection between migraine and depression?

Dr. BERNSTEIN: Well, it's very interesting for people who have what's called co-morbidity, where they both have migraines, and they have depression. Sometimes one kind of medication, such as an antidepressant, may treat both. And what you see is not only that the depression improved, but the migraine may improve as well.

GROSS: I think a lot of people who get migraines find that the over-the-counter medications that people typically used for headaches, whether it's like aspirin or acetaminophen or ibuprofen, just aren't going to do the trick. Migraines, I think, usually require special migraine prescription medication. Why don't the over-the-counter remedies work?

Dr. BERNSTEIN: Sometimes they do. For example, ibuprofen is one of the best migraine medications that you can buy. If you're stuck somewhere, and you really don't have anything else to take, it can be really helpful at kind of quieting down all these chemical changes that we've been talking about.

The problem with the over-the-counter medicines is, a lot of them have caffeine in them. So, I encourage people to actually - if you're taking an over-the-counter medicine for migraines, go home and look at the bottle and see if it's got caffeine. Caffeine can make a migraine stop. It can make you feel better, but it's notorious for causing what's called rebound. So when the caffeine wears off, the migraine is still there, and it comes back full force.

There are also some guidelines that are really important to think about concerning what's called medication overuse headaches. And for a lot of these medicines, it's - if you use them 10 or more days a month, which is a lot of days out of the month. You're a set up for having withdrawal kind of a syndrome. So, in other words, if every other day, you're taking some over-the-counter acetaminophen and caffeine together, and then you miss it for a couple of days, or you feel a bit better, you may get a headache that comes roaring right back. So, it's hard.

You know, I think that a lot of people who have migraine can actually do some self-education, hopefully get help from their primary care providers and understand how to treat an occasional migraine. But for people who are requiring a lot of medicine and find that they're going to the pharmacy and buying a lot of things, you're set up for the overuse syndrome. So that's where you really need to seek some help.

GROSS: So, how do the migraine medications work compared to, you know, your typical, you know, Advil or Tylenol or aspirin approach?

Dr. BERNSTEIN: So, they probably work on serotonin receptors specifically, and they stop some of this cascade of events when the migraine, the impulse that's causing the migraine has actually began to irritate the nerve that's causing the pain and causing a release of some of these, what are called neuropeptides, pain transmitters. They probably stop the impulse right at that point.

The trick with them is, you have to have them with you everywhere, and I joke with patients, I've got them in my gym bag. I have them in my brief case because you have to take them as soon as the migraine starts, and if you wait too long, they really don't help. So, if you're somebody who is already in the throes of a migraine, or something that can be really disabling for people, when they wake up in the morning with the migraine, the triptians aren't going to help with you at that point.

GROSS: My guest is Neurologist Carolyn Bernstein, author of the new book, "The Migraine Brain." We'll talk more after a break. This is Fresh Air.

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GROSS: My guest is Dr. Carolyn Bernstein, author of "The Migraine Brain." She's the founder and director of the Women's Headache Center at Cambridge Health Alliance, which is one of Harvard's teaching hospitals.

You write that three times as many women get migraines as men. Is that because of changes in women's hormones during menstruation and pregnancy and menopause?

Dr. BERNSTEIN: Well, here's an interesting fact, Terry. Kids up until about the age of 12 - and kids do get migraines - it's probably equal boys and girls or maybe even a little more common in boys, and then after that, girls just take off. And that figure that you quoted a minute ago with the three to one ration becomes more and more apparent.

So, I think that hormones are part of that and certainly changing hormone levels in the body and in the brain, all these different things that go on as women begin to have monthly cycles, those things, for a brain that is irritable, that is sensitive to any kind of changes, in other words, a migraine brain, are probably migraine triggers. But more research is beginning to tell us that women's brains actually just may be different than mens', and I don't have more specifics at this point, but that's really something that I'm excited about understanding.

GROSS: People that get migraines know that there are certain things that can often trigger a migraine. For some people, it's certain foods, like wine or chocolate. For other people, it can be being very tired or stress? Is there an explanation why something like a certain food, like chocolate for some people, could actually trigger a migraine?

Dr. BERNSTEIN: The specific trigger that we really understand the best is red wine, and that's probably because it has an amino acid called tyramine that's very migrainugenic, very likely to cause a migraine. The old thinking was that, if you had migraines, you should avoid cheese. You should avoid chocolate and red wine for sure, white wine, preserved foods, all kinds of other things. And now, as our understanding gets better and better, we realize that it's different for everybody.

In other words, everyone's migraine brain is a little bit different. So, some people do fine with chocolate, and, in fact, because chocolate raises serotonin a little bit, it may actually make them feel better. But other people will find one specific trigger, and they really have to avoid it. And that's where you have to do a little bit of work to be able to understand that.

One patient, with the help of our nutritionist at the Women's Headache Center, was able to figure out that tomatoes were her trigger, and I have never seen that before. But when we talked about it and went through - there's a substance in the skin of tomatoes, what's called the lycopene, that for her was a trigger and set off her migraines. And as soon as she began to avoid tomatoes, her headache frequency really dropped substantially. So, it's where being a detective is going to pay off.

GROSS: Why is hunger or changing levels of blood sugar sometimes a trigger?

Dr. BERNSTEIN: Again, migraine brains are very, very sensitive, and they like what's called homeostasis. They like things to be the same all the time. There's a specific kind of headache called the starvation headache that's classified and coded a little differently than a migraine, but for lot of people, having a change in their blood sugar makes these cells that want things to just be the same, it can trigger off a migraine. It can be a very potent signal for them.

GROSS: A plane trip can really set off a migraine? What is different about a plane trip? Why should that trigger a migraine?

Dr. BERNSTEIN: Well, I think there's probably a lot of different reasons, and again, for an individual person, you could probably do some homework and try to figure it out one way than the other. First of all, let's face it, plane travel is stressful, especially in this day and age, and stress is a potent migraine trigger and just a plain old headache trigger, people with tension headaches. So, there's the stress piece.

Then there is the piece of changes in the air quality on the airplane, lack of food when you're flying. Nowadays, you either have to pay a lot of money, and you get a little tiny bag of chips, or you have to be proactive and bring your own food. Changes in the altitude as well are - the air is thinner when you're flying, and so that may be a trigger for people. So, try to understand all of those different things, doing whatever you can to feel relaxed before you get on the plane and kind of having your own little bag of goodies to bring with you may really decrease the migraine frequency for flyers.

GROSS: You know, you pointed out that people with migraine, their brains don't like changes. So, whether it's a change in blood sugar or a change in hormones, it's not going to make your brain happy, and it might set off a migraine. So, what does that say about, for women, oral contraceptives or using hormones during menopause?

Dr. BERNSTEIN: It's a very individual question, and I always encourage people and really feel strongly that women need to consult with their gynecologist in terms of making these decisions. But for some migraine patients, it's not safe to use oral contraceptives. It's not safe to use extra hormones. And so, yeah, need to be aware of that and think of some other solution if that's going to be an issue for you.

For example, women with aura, specifically with visual auras, there may be a slightly increased risk of stroke. And so, that is a situation where you'd want to be really careful, but for other women, stabilizing their hormones so that they don't have the fluctuation each month and maybe skipping a period every month or every couple of months can really cut down on what are called menstrual migraine, for women who suffer from them. So, again, an individual decision, but something that I asked about that we talked about in the book is understanding, if you're female, how hormones actually affect your migraines.

GROSS: So, you founded the Women's Headache Center in Cambridge. How did you set up the clinic so that just like the environment itself is sensitive to people who get migraines?

Dr. BERNSTEIN: Well, I had some great people that I was working with at the Cambridge Health Alliance tossing these ideas back and forth. And what we decided to do was really try to focus on patient-centered care, which is something that the alliance works to provide for all of its patients. So, what I did was to invite a group of women who had migraines, and it was open to anybody who I was seeing and treating at that point, to become a part of an advisory panel.

These women would meet with me. We'd serve some food so that nobody would begin to develop a starvation headache and sit around and talk about what makes up the perfect headache center? Where would you want to go and what would you want the care to be like? And the women were fabulous. It was a chance to really be a designer of something and from their own experiences of what it was like to have a headache, what it was like to have a migraine.

They brought that with them and said, we need dimmers on the lights. We need soothing colors. We want background music that's relaxing. We want furniture that's women's size that we can sit in. Don't put fragranced magazines. Provide as many different kinds of care as you possibly can in that one site. If we're going to come and see you, we want to be able to do everything. We want to see you and the nutritionist and talk to the nurse at the same time. And so we had a list of different things that were important and sat down and worked through and tried to achieve as many of those as possible.

GROSS: What do you think of alternative therapy for migraine - biofeedback, acupuncture? Have you had success with those?

Dr. BERNSTEIN: I have. I, again, think that anytime you can either use, add in, incorporate into care of a person something that's not a drug, it's a good idea. So I think medications can be great for a lot of people. They can really be extraordinary helpful. But I also think that, whatever you put in your body, from an aspirin right on up, is going to have some kinds of other effects on how you are and how you function, how your body works. So people will say, does this drug have side effects? And I always say, of course. Everything has side effects.

Now, if you're learning biofeedback, which is a very specific set of relaxation techniques, mind-body techniques that you can start when you feel a migraine coming on, it also works when anxiety works and some other conditions as well. If you can start to do these relaxation exercises when you feel the start of a migraine, you may actually be able to abort the migraine right there or certainly cut down on how severe and how painful it's going to be. So maybe that lets you use less medication. Maybe that lets you stay longer in the work that you're trying to accomplish without having to stop and go lie down. So I think that that can be really helpful.

In terms of acupuncture, there are lots of non-Western ways to treat different kinds of pain, and acupuncture's one of them. I think we don't fully understand every part of the pathophysiology. And I think that we don't fully understand precisely how acupuncture works, and for some people, it may not be something that they want to consider. But for a lot of people, it can be extraordinarily helpful, and a series of 10 acupuncture treatments may decrease the frequency and intensity of their migraines, even if it doesn't get rid of them altogether.

GROSS: A lot of people have been so anxious about whether their candidate will win the presidential election. I wonder if you've seen a surge in the number of migraine patients coming into your clinic during the campaign season?

Dr. BERNSTEIN: Well, I can tell you that the Women's Headache Center is pretty much busy all the time, and I think there are a lot of women out there with migraines looking for some help. So I haven't noticed an increase in frequency. I have noticed that a lot of women come in, and they do want to talk about their political feelings and the stress that they feel, just as you mentioned, when it gets hard for people to fall asleep at night, when they're anxious about their money, losing their job, losing their house. Those are all things that can trigger off more migraines.

GROSS: Well, Dr. Bernstein, I want to thank you so much for talking with us.

Dr. BERNSTEIN: Oh. It's been my pleasure. Thank you so much.

GROSS: Dr. Carolyn Bernstein is the author of "The Migraine Brain." She's the founder and director of the Women's Headache Center at Cambridge Health Alliance, which is one of Harvard's teaching hospital. I'm Terry Gross, and this is Fresh Air.

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