S3 E9: Exercise

Exercise

Series 3, episode 9

Heads Up is the award-winning podcast series on all things headache, brought to you by the National Migraine Centre.  Produced by leading headache doctors, it’s the trusted source of information and support for all those affected by migraine and headache.

You can find our episode transcript below. Want to listen to the podcast? Just head over to our Heads Up section here for hours of episodes that can help you manage migraine and control your headaches.

Need personalised treatment and advice? We can help! Book a not-for-profit consultation today with a world class headache doctor through the National Migraine Centre, the leading UK migraine clinic. 

Transcript:

[00:00:00] Did you know some well-known sportsmen and women have migraine too? Five time Olympic gold medallist swimmer, Ian Thorpe, Serena Williams, the World-Class tennis champion and Paul Scholes, who played football for Manchester United, have all shared publicly that they have migraine. People with migraine can go far with the right support. Welcome to the Head’s Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.

 

Dr Jessica Briscoe [00:00:36] Hello and welcome to this fortnight’s episode of the Heads Up podcast, I’m Dr Jessica Briscoe and I’m joined by my lovely colleague, Dr Katy Munro.

 

Dr Katy Munro [00:00:45] Hello. Good to be actually chatting. Good to be chatting again.

 

Dr Jessica Briscoe [00:00:50] I know. Yes. We’re back again. Virtually still sadly, because here in England, we’re still in lockdown, but we’re doing actually an episode that’s really dear to my heart today on exercise and migraine. We’ve talked generally- we’re always very sort of widely saying exercise is excellent for migraine. But actually, I was sort of inspired by this topic by a Thursday tip that one of our colleagues from Northern Ireland did, Dr Louise Rusk, and she mentioned exercise and actually the fact that a lot of people, you know, she always feels a bit bad saying, you know, suggesting exercise. And I thought actually it would be good to talk about the challenges and some of the evidence behind the benefits of exercise properly and outline them in a podcast. And actually, we found quite a lot, didn’t we, Katy?

 

Dr Katy Munro [00:01:44] There’s a lot of stuff out there, isn’t there? And I think exercise is a really interesting topic because it can go both ways, can’t it? So it can be really helpful but it can also- it’s often one of the things that people say, I was triggered by exercise, my headaches came on after i did exercise. So we’re going to talk around all of why that might be and what kind of exercise would be helpful and which things to avoid.

 

Dr Jessica Briscoe [00:02:11] So it’s really interesting to know that exercise is actually suggested in all of the sort of guides on  managing migraine and actually other headache, but particularly migraine we’re talking about here, and exercise is recommended as a non-pharmalogical tool for managing headache. And it’s been shown to be beneficial for lots of pain conditions. So back pain always springs to mind. We’re always telling people to exercise for back pain. Fibromyalgia I believe that there’s some evidence for exercise, too, but also specifically for migraine it is recommended. And there’s not always much more about what type of exercise to recommend. So we’re going to talk a little bit more about this. Traditionally, the mechanism of why this helps was slightly unclear. But hopefully we managed to find some some information from some fairly recent papers to sort of clarify this a little bit more.

 

Dr Katy Munro [00:03:09] I think the other thing that it’s recommended for, which is also something we see commonly with migraine, is for your mental health as well. So mood, anxiety, depression, all of those kind of things benefit especially from green exercise so going out into nature. It’s generally thought to be a good thing for all of us. We should all be moving more, shouldn’t we, really?

 

Dr Jessica Briscoe [00:03:32] I think sometimes it can be- I had the same sort of reaction as Louise said in that video actually about sort of mentioning exercise with a bit of a heavy heart to people, because it’s quite difficult when someone’s in pain or physically exhausted or feeling that brain fog, to say, right, well, now you need to do exercise. And obviously I mean, I usually say a little bit more than that. I’m a bit more structured about what I say I usually give suggestions, but I think it’s really important to acknowledge that, you know, we do understand that it can be difficult to motivate yourself to get outside and do exercise. But hopefully we will talk about some of the, you know, some of the proven benefits of it, how it does help in migraine and maybe give some tips about the sort of exercise that people should be doing.

 

Dr Katy Munro [00:04:21] Yeah, I think people are often very movement sensitive aren’t they when they’re in migraine attack. And I know personally, I’ve had migraine attacks where I’ve just literally wanted to sit completely still, barely able to reach over to get a glass of water to take my medication. So when in extreme cases, you know, when your migraine is very severe, obviously we’re not saying that that’s the time you should get up and go for a jog. That would be unrealistic and ridiculous wouldn’t it. But it’s more about kind of building it into your routine of life. And we talk about routine and regularity of routine and eating and sleeping and regularity of exercising and starting gently and kind of building it up according to your capabilities is what it’s about, really, isn’t it?

 

Dr Jessica Briscoe [00:05:09] So important. And make it- it’s something we’re always harping on about, but making sure that your body is prepared for exercise, so eating regularly, fuelling yourself as you said. Make sure you’ve had enough sleep, although exercise helps with sleep, as I will discuss a bit later, and also making sure you’re hydrated as well. So, you know, if you’re running on empty, don’t, you know, pound out a run, but, you know, start gently as you said. I think it’s also important to mention that migraine is a significant risk factor for cardiovascular disease, so exercise is also important as a general lifestyle advice for migraine, because it is important. You can’t modify the fact that you have migraine. It’s genetic, you have it. But actually, if you can try and control some of the other risk factors, which exercise can help with, so blood pressure, cholesterol, weight and actually just heart health in general, getting your heart pumping, that’s also why it’s important. So I think maybe we should start with talking about the type of exercise, the main one that’s really advised. I mean, we will talk about the other types of exercise soon. But a lot of the  papers that I read, a lot of the summary papers, were talking about aerobic exercise. So that’s the more cardiovascular type exercise. Now, I always want people to say, well, what do you mean by a session of exercise? What is exercise? When you say exercise, what do you mean? So aerobic exercise is more like cardio. It’s the cardio exercise really the type that gets your heart pumping. And I tend to use the NICE, the English guidance on exercise to help with this. So they advise, so this from heart health point of view, they advise five sessions of moderately intense exercise per week where moderately intense is described as something that gets your heart pumping. You’re sweating a little bit and that will vary according to your baseline exercise. So for one person, that will be a brisk walk. For a lot of people, that will be a brisk walk actually. For someone else, it might be a little bit more intense. And then a session, according to that is something at least 30 minutes. So just as a general guideline, those are the kinds of- that’s a kind of terminology that we’ll be using generally today.

 

Dr Katy Munro [00:07:21] So that is a kind of goal for people to aim towards. And the aerobic part means basically that you’re using oxygen, doesn’t it? So by doing that kind of exercise, you’re increasing the amount of oxygen that your muscles need. As opposed to anaerobic exercise, which is more, you know, what you get when you’re doing something which is very intensive, overworking your muscles and then you start to build up lactic acid. And that is probably not what we’re aiming for. Keeping in that right sort of zone where you’re just doing enough exercise to build up your heart rate and give your muscles plenty of oxygen seems to be helpful.

 

Dr Jessica Briscoe [00:08:10]  I was just going to say about the anaerobic exercise, you usually know when you’re there because that’s when you get the cramp, that’s how you can tell. So that’s sort of a little rule of thumb. If you’re starting to cramp up, you know that you’re pushing it too hard. You’re going into anaerobic. Sorry, carry on.

 

Dr Katy Munro [00:08:24] And we’re going to come on to a bit more of the sort of static exercises like stretchers and things like that, but the aerobic exercise is probably the first one to consider, isn’t it? So what would you suggest to people to do in terms of if they haven’t been doing any aerobic exercise, what would you say is the best way to start then, Jess?

 

Dr Jessica Briscoe [00:08:47] So I would actually probably start with walking. So it’s interesting because they looked at the- in the studies they looked at aerobic exercise and they usually use things like brisk walking was a very common form of aerobic exercise. Cross training, so using that cross trainer, that sort of one way, you’re moving your arms, sliding your arms and legs, it’s a bit gentler on the knees. That’s quite good if you’ve not done much exercise. Or some form of a static bike or I mean, I’d probably go with a static bike before I went out on the road personally but I’m a bit risk averse and swimming also counts as aerobic exercise as well. But I have to say, I would start with walking. If you’ve not done very much before, I would start by walking whatever pace will get your heart pumping. I probably made a thumping sound because I always feel that I need to to press my chest so that people know what I’m talking about. Something to get your heart pumping and possibly starts you sweating. I think a good rule of thumb when you’re thinking about how much exercise you’re doing when you’re walking is how can you hold a conversation? So if you’re chatting away like we are, then you’re probably not doing enough. If you’re starting to struggle to hold a conversation, that’s when you’re kind of getting into exercise zone really.

 

Dr Katy Munro [00:10:09]  I suppose the other measurement, which I found personally, is when you start going for a walk with a friend and you can chat away quite nicely, but you start going up some hills and then you start to get warm. And so you may find that you, you know, if you’re having to take off a layer or two, you’re probably doing all right because you’re warming everything up and your breathing will be getting a bit more, sort of, maybe frequent to keep the oxygen levels and you may be puffing just slightly. We don’t want people collapsing at the top of the hill or anything like that, but just start slow. Start slow. So I would normally say to people, if you’ve done nothing at all, you know, even if you just do a walk around the block to start with and maybe every day try and do it, either a little bit faster or a little bit longer. And just pacing yourself is really important, isn’t it?

 

Dr Jessica Briscoe [00:11:02] Mm hmm. Yeah. And I always also say to people with migraine is try not, I mean, it’s pretty difficult to do this stage, but don’t force yourself out when you’re in that acute- the peak of your pain or the peak of your symptoms (as we’ve discussed before, pain isn’t always the main symptom). Sort of try and do it when you’re feeling- when you’re not too motion sensitive. If you’re Vertigo’s not too bad. If you’re not feeling too sick because you’re much more likely to stay motivated if you’re not sort of struggling against your other symptoms as well. It’s obviously far more difficult when you have chronic migraine because if you’re constantly having symptoms judging that period of time, when your symptoms are less severe can be difficult. But as you said, it’s about pacing and starting gently and gently increasing.

 

Dr Katy Munro [00:11:53] I think achievable goals are what you need to aim for, aren’t they? So if you feel that if you set yourself a target, you’re going to get out every day and do a 5K run and you’ve never done exercise it’s not an achievable goal in the short term, it may be in the long term. But I think it’s also things like if you decide that you’re going to try and do it even just three times a week, if you do that regularly, that might feel more manageable than saying, well, I’m going to go every day because I don’t know about you, but I find it really hard to do anything every single day because there’s always so many other things happening in my life. So make an achievable goal.

 

Dr Jessica Briscoe [00:12:37] Especially in winter.

 

Dr Katy Munro [00:12:38] Yes.

 

Dr Jessica Briscoe [00:12:38] So I think it was really interesting to actually look at some of the studies about why exercise is helpful. So essentially, it seemed the theory was that aerobic exercise was thought to sort of change the way that the nerves processed pain essentially, that was the first way it was thought tp help. There’s also in some historical studies that have been short term pain relieving or analgesic effect on the central nerves and the peripheral nerves, all of which are important in migraine. So when they really drill down to this, there was a systematic review last year where they had to look at lots of different studies and they looked at sort of three things. They looked at the number of migraine days after sort of a programme of exercise. What the pain scores were like. And the migraine duration. And they were quite interesting, according to the studies. So on average, the reduction in number of migraine days, there’s quite a wide reported range of this, but the reduction in migraine days vary between 22% and 78%. The reduction in pain intensity in studies vary between a reduction in 20% and a reduction of 54-55%. And the migraine duration reduced by roughly about 30%, 20-30% in the studies.

 

Dr Katy Munro [00:14:01] That’s pretty good.

 

Dr Jessica Briscoe [00:14:01] Yeah. I mean, it sounds small probably if you’re, you know, in isolation. But if you’re comparing it to preventative medication, which is always, you know, that’s the easiest thing to measure, if I’m honest, because it’s very easy to have a control or, you know, a normal arm and a modifying arm in a study. Actually in practise, we aim for 50% reduction in frequency and severity. But in clinical practise, 30% is deemed successful. So a 30% reduction is deemed successful. And actually that looks to be equal in exercise, which is, I think, quite encouraging.

 

Dr Katy Munro [00:14:38] Very encouraging. Yeah. And when you think of the other benefits that you get from exercise and you don’t, if you do it right, you don’t get side effects. I’m thinking, you know, if you don’t fall over and break your leg or something daft like that. I think that’s really encouraging. And, you know, I think we probably, as doctors, need to be mentioning it more frequently and encouraging people to use that before we reach for our prescription pads. But I think that study was also looking at the low intensity aerobic exercise, wasn’t it? Because I found it very interesting that if people were doing high intensity like spin bikes or, you know, sprinting or things like that, they tended to be more likely to be triggering their migraine. So it seems to be important, not just the aerobic type of exercise, but how intensely you do that.

 

Dr Jessica Briscoe [00:15:35] Yeah, and I sometimes wonder if that’s the problem, that we as clinicians, I mean, I think it’s partially because we’re not- we aren’t taught about this. This is stuff that we sort of have to learn for ourselves. And it’s really about how interested you are. I mean, you and I are both quite interested in movement in general so have educated ourselves. But actually, if you’re not that interested in it, you’re not, you know, we’re human. You’re not likely to learn about it yourself. And so I think sometimes people are- we’re not necessarily giving clear advice saying, OK, actually you can do low intensity because low intensity exercise, you know- the intensity of the exercise yes, it’s important from a sometimes from a weight loss point of view, but actually it should still be valued from our heart health point of view and from a pain modulation point of view. And I think that’s really key to put across. And actually, sometimes you can start with low intensity and move on to higher intensity.

 

Dr Katy Munro [00:16:33] Yes. As your fitness level increases. And the other thing I think they suggested is if you’re getting the benefit of the low intensity aerobic exercise, you may also reduce the amount of painkillers that you need to take. And then if people are kind of overusing painkillers a little bit, which we know is a problem in brains that have that sensitivity to medication and people with migraine, they often take a lot of medication and end up with medication overuse headache. So anything that brings them back from the overusing situation is really helpful as well, isn’t it?

 

Dr Jessica Briscoe [00:17:10] Absolutely. It was actually interesting because they also looked- they did a little bit of analysis into whether combining preventatives- medication preventatives would be helpful. And there was some evidence that using a combination of pharmacological so medical preventatives and also exercise as a preventative, which is also what we’re always saying, you know, you need to look at the whole picture, not just look at one thing, can be helpful. I think also it’s really important to mention that some of, you know, you might want to have a look at which preventative you’re using because some of them can actually reduce your exercise tolerance. So it’s worth sort of thinking about that. I’m thinking about things that slow down the heart rate particularly so beta blockers can make it more difficult to do more high intensity forms of exercise. But actually, generally, that’s quite encouraging, too. So talking of higher intensity exercise, there was a very interesting thing. I got quite excited when I saw this, there was a really interesting paper about our old friend CGRP. So we’ve talked a lot about CGRP. So that’s calcitonin gene-related peptide, which is a protein, a neuropeptide, which listeners to our podcast will know is a key protein in the migraine pathway. And obviously some of our new medications target this and some of the medications that are coming. So this can cause headache usually in susceptible individuals. It causes dilation of the vein, vasodilation, it causes affects the mast cells and it causes inflammation in the nerve systems. And so in this slightly small study, they looked at 48 male amateur runners before and after a half marathon. That’s quite interesting because it was people of all fitness levels and they measured the CGRP levels, the blood levels before they ran this marathon and afterwards. Now, over half of them had been headache free for the six month period before the race and 45.8% of them suffered a headache following the run. Generally, this was migrainous. I think there were a couple who’d had something called exertional headache, where you get more of a sudden- it’s a very different type of headache to migraine. Now, when they looked at the levels of CGRP in after the race, there had been a 1.5 fold increase across all participants. So that was even in the people who were headache free. So this is quite interesting because everyone had done- this was deemed as being some form of high intensity exercise. It was medium distance. I’d actually call it a long distance personally. A medium distance. And, you know, no matter what your fitness level is, that is high intensity. But the conclusion was that there’s a significant increase in CGRP serum concentration, which seems to trigger migraine type headache in susceptible individuals. So this this shows that actually high intensity exercise, that’s possibly why people develop headaches following high intensity exercise, which is new, to be honest. We’ve postulated the fact that we think CGRP is involved, but this is the first study I’ve seen that actually goes into looking into this in more detail.

 

Dr Katy Munro [00:20:40] It’s a couple of things were interesting about that. And one is I wonder why they just did men. It was all male, wasn’t it? Why did they just do men?

 

Dr Jessica Briscoe [00:20:49] Yes, I thought was interesting in a headache study. Yeah, I don’t know if it’s just to control it. I don’t know if it was for control purposes, but it doesn’t. I mean, surely it would make sense to- I mean there are more females who suffer with migraines. So you’d think you get a more meaningful result. I noticed that. That’s why I specifically highlighted that it was males because i found that quite interesting.

 

Dr Katy Munro [00:21:09] Exactly. We find this a lot in studies, don’t we? You do need to look for the gender balance. And obviously more research is needed on this in women as well to see if the same thing happens again. Really fascinating. But it asks more questions i think than it answers in a way, because at the end of it, you start to wonder, well, does that mean that the new CGRP drugs will be even more effective in this kind of headache? And at the moment, we’ve got the CGRP preventer’s coming available, hopefully on the NHS very soon. And that’s that monthly injection, which I have certainly got some patients who’ve started on that privately and they have said to me, well, not only am I feeling better, but I can exercise again. So anecdotally, I would say that that, you know, does back up the findings from this study. But there are also some more CGRP acute treatments which are already available in the states, the Gepants and the Ditans, and hopefully in the UK we’ll get those soon. And it may be interesting to see whether they work better for exercise induced migraine than the triptans do. So, yeah, I want to ask so many more questions about that and we need more studies, don’t we?

 

Dr Jessica Briscoe [00:22:30] I know. That always happens though, you find an exciting new study and you get a million and one questions after it.

 

Dr Katy Munro [00:22:37] Which is good,.

 

Dr Jessica Briscoe [00:22:37] Which is good.

 

Dr Katy Munro [00:22:38] Hopefully somebody will be looking at that. So what we think is happening is these kind of endogenous opioids are being produced during exercise. So the beta endorphin, which is often a bit lower in people with migraines. Some people have measured that and found that it’s generally a bit lower and so by doing exercise, that tends to increase the painkillers that we naturally make. So, again, this balance between the lower intensity and the higher intensity, because if you push it too hard then you’ll be releasing probably more CGRP, which will trigger pain. So, yeah, really interesting. What about the runners high, Jess? We’re you going to talk about that. It is probably something you may have felt more than I have because I’m very much a novice runner. I’ve been doing the couch to 5K last year, but it’s on my list of things to restart now that lockdown is ending.

 

Dr Jessica Briscoe [00:23:40] Yeah, no, I think it’s excellent. I think that I really like that sort of programme actually that helps people to again, it’s that pacing. You don’t want to go out and start doing a 5K straight away. Anyway, we’ll go into runner’s high otherwise I’ll start talking about pacing forever. So yeah, the runner’s high. It is interesting because you do- I think once you’ve got through, everyone always talks about the wall, everyone talks about the wall with running. Again, that completely depends on fitness levels. But once you’ve got through the wall, which is the point where you think, oh God, I can’t do it anymore, this is it, I’ve reached the end. You suddenly feel a euphoria when you’re running. And you sort of get this feeling like you’re on top of the world and you feel quite relaxed. And they talk about this in one of the exercise papers and they think that this is due to a substance called AEA, which is an endocannabinoid, which is released following exercise, particularly running. And it does cause euphoria, sedation, has a painkilling analgesic effect and it reduces anxiety levels, but this only occurs in high intensity exercise. So it looks like you’ve got a few things going on in high intensity. So we’re going to talk about triggers in a bit more detail anyway. But this is possibly why some people find that high intensity exercise is helpful and others find that it’s not, it really can make things worse. It really depends on because one of the things they also discussed is that they didn’t look at thresholds at all, so they didn’t look at what you know, in a lot of the studies they took people from all different baselines of fitness, but they didn’t look at other health risk factors because you or other lifestyle problems, because you can’t in these studies. You know, that’s one of the limitations of these studies often you have to look at things in isolation as much as possible. So I think that kind of supports a lot of our- it sort of depends what else is going on in your life, how much you’ve eaten, what sort of situation you’re in, how much sleep you’ve had.

 

Dr Katy Munro [00:25:33] And I think the other thing to emphasise, we’re always saying this to patients in clinic aren’t we? That everybody’s different, and so the importance of different chemical pathways will vary from person to person. I think our brains are a great big mixture, a soup of neurochemicals, and which one of them predominates at any one time will vary and whether your fitness levels are there and what else is happening, you know, it’s a lot more complicated than just saying do this and you’ll be fine, isn’t it?

 

Dr Jessica Briscoe [00:26:06]  It’s the same as with the preventers in the same way that we don’t know which one’s going to for you because we don’t know which pathways are predominant in you. It’s exactly the same with exercise and types of exercise. So I think we’ll move on to a bit more about the triggering aspects of exercise, because there were some interesting studies about that. So actually, generally, there have been limited numbers of studies that actually demonstrate exercise as a trigger. It’s self reported by just under 40% of people with migraine during their lifetime and, this is anecdotally or self reported, 56% of people find the attacks start during exercise. A very small number of studies showed that migraine can be triggered by intense aerobic exercise. So that’s intense bike or watt bike usage or running, but they only looked at very low numbers of patients. There also tends to be a very high dropout rate in this type of study. Largely if people are getting headaches during that will skew the numbers quite a lot. But there was a lovely paper from Cephalalgia from November 2020, so just as we’re recording this, which looked at the effect of neck muscle resistance training on migraine. And this is quite interesting because I couldn’t see lots of studies on strength training. And nowadays there is a lot of emphasis on combining cardiovascular exercise and resistance training, because strength training, whether it’s body weight or, you know, using free weights or machines, is very important really from a weight loss point of view as well. You know, I know there are benefits to heart health as well. And we always talk about that bidirectional relationship of neck pain and migraine so it’s very chicken and egg, which comes first is it the neck pain causing the migraine, is it migraine causing the neck pain? And I think the answer is both if i’m honest.

 

Dr Katy Munro [00:28:20] Mmm Hmm. I’d agree.

 

Dr Jessica Briscoe [00:28:22] And so they did this really focussed study where they got people to do just neck exercises and they sort of looked at the neck tension and they palpated the muscles and all sorts of things like that. So then they found that there was an increase in migraine attacks in the exercise group, so the people who did these neck exercises, with increased symptoms of neck stiffness and muscle tightness. So the peak onset of the attack, so this was the attack proper where people would say they were in their migraine, was approximately 16 hours after the training had occurred, which fits with our migraine model. The fact that migraine, that migraine proper, that attack phase tends to hit 12 to 24 hours after an attack. It also tended to coincide with something that people who do resistance training know a lot about, DOMS, delayed onset muscle soreness, which is a particularly well, we say unpleasant. If you do lots of resistance training you get weird enjoyment of DOMS after a while. People equate it with meaning that you’ve worked properly, whether or not that’s true. So that’s according to sports medics is defined as occurring 12 to 24 hours after resistance training. So I thought that was quite interesting, that actually this delayed onset muscle soreness seems to occur at the same time as this. Some people also noted a prodrome, sort of pain in the neck starting immediately after exercise and this has been postulated a lot as part of the prodrome, or premonitory symptom where the neck pain is part of that symptom or is it directly because you’ve got neck pain causing migraine. So that still hasn’t been fully ironed out. But I think that sort of fits within the current model. So the reason that they think that neck soreness causes problems with migraine is that neck pain causes an increase in the pain fibre input, the nociceptive input in the neck region, the C2 to C5 region, which is thought to trigger attacks. So this increase in sort of nerve fibre input, actually, it sort of triggers the trigeminal system and the greater occipital nerve system. Interestingly, in other studies, they’ve looked at what happens if you block that greater occipital nerve system with something that we’ve talked about in previous podcasts about injectable treatments, the greater occipital nerve blocks. And this actually directly opposes that neck pain, that neck stiffness and neck tightness, nerve modulating the process that happens during neck stiffness. And I wondered, does this mean that greater occipital nerve blocks are a potential treatment for people who get a lot of exercise induced headaches, who do sort of a lot of neck training or have a lot of neck pain? And they didn’t answer that in the study.

 

Dr Katy Munro [00:31:29] More questions.

 

Dr Jessica Briscoe [00:31:30] Well, that was one of the questions I had, because I thought that’s quite interesting. And there are a few more studies on greater occipital nerve blocks. And I know you’ve looked a lot into this, Katy. And I’ve certainly used it in people who get neck pain or who think that neck pain the cause of their migraine and it does anecdotally it seemed to help. But I think that would be quite an interesting thing to look at.

 

Dr Katy Munro [00:31:51] Yeah, I think this is a really interesting study and it ties in with what I hear in clinic, which I’ve certainly had patients who come in and said, well, I went to the gym and I did a lot of using the weights and then I got a headache. Every time I do that, you know, I do a sort of two hour session in the gym and then I get a lot of migraine occurring over the next couple of days. And so it’s interesting, isn’t it, that sort of triggering now, you also have to make sure, as we mentioned earlier, that you’ve eaten enough and that you’ve drunk enough. But I think that physical stimulation of the neck and shoulders is really important. And I found a study which used an interesting, this is from the Danish Headache Centre, again, a recent study, 2020, and it was using shear wave elastography, which is basically an ultrasound that puts a little pulse into the neck muscles and measures how stiff they are. And they looked at a number of migraine patients and found that neck stiffness was already present. So people tend to have stiffer necks. So if you imagine your neck is already a bit stiffer and then you go and do some neck and shoulder exercises you are kind of lining yourself up for a bit of trouble potentially. So working on the flexibility of the neck, we’re going to talk about stretches and things a little bit in a minute, I think is really helpful. So, yeah, really important. I’ve also definitely you know, people are always saying, oh, is it my neck that’s giving me my headache or is it my headache that’s giving me my neck pain? And of course, I totally agree with you. The answer is probably both. It’s a bit of both.

 

Dr Jessica Briscoe [00:33:41] I think so, because, I mean, it’s definitely something I’ve observed, not particularly with exercise but in lockdown, people working from home desk up posture not being quite as good as it should be and possibly doing at home workouts where it is less supervised. So technique might not be as good. You might be doing things with your posture that aren’t optimal because you’re doing the right thing and trying to stay active. I think all of that can feed in- it can all work together as well as, you know, some of these other neck stiffness, you know, the increased neck stiffness that seems to be observed, to trigger migraines. So I really think it is both ways round.

 

Dr Katy Munro [00:34:25] I think you’re right. I mean, I’m very conscious that I’m sitting with a laptop on a cushion on my lap at the moment because my Internet only works in the sitting room and my nice set up in my office, which is much more better for my posture, unfortunately, I can’t do Zoom calls. So what I say, I think I said this an earlier episode, is if you want to check your own posture, there’s a couple of ways of doing it so you can get a friend or partner or whomever to take a picture of you standing sideways and just look and see how far forward your head is. Because if your head is jutting forward and this is a common posture, you probably have round shoulders, your probably your shoulders are sloping down too much. And that is going to make your neck and shoulder muscles quite tense because your neck and shoulder muscles have to hang on to your rather heavy head. So the other thing I do is I get people in clinic, when I used to see them in clinic rather than on Zoom, is to just press their bicep muscle and see how squishy that is and then compare that with the tension of their neck and shoulder muscles, particularly those trapezius muscles. Now, if that’s a little bit tender or if you’re finding that that’s really much firmer than your nice floppy relaxed biceps, and we’re both doing this as I’m speaking.

 

Dr Jessica Briscoe [00:35:48] Alarmed at how tense it is.

 

Dr Katy Munro [00:35:49] Mine is quite tender.It’s just worth thinking about trying to focus on improving the oxygenation of that muscle because a tense tight muscle that’s working is not going to have a full oxygen supply. So the more relaxed so self massage or putting heat pads or even alternating heat and cold on those muscles. Correcting your posture, there’s loads of videos and books available to show you what a good posture should be. Even, you know, just standing up with your heels at the back of the wall and then putting your back and just wriggling your shoulder blades and seeing whether they can go flat against the wall. These are little tricks for just checking. Is my posture good or is my head sticking forward? And I think it’s just worth working on.

 

Dr Jessica Briscoe [00:36:41] I agree with you. I think it’s really important.

 

Dr Katy Munro [00:36:43] The other thing some of my patients have liked, some of my patients use magnesium oil spray on their neck and shoulders. And magnesium is a relaxing, calming mineral for the brain. So we often recommend it as an oral supplement for migraine. But I have had a number of patients who’ve said that they found the magnesium chloride in a magnesium oil spray, sprayed onto the neck and shoulder muscles can really quite help if you’ve got a bit of crampy tension.

 

Dr Jessica Briscoe [00:37:12] Yeah, I often also advise for runners, so anything if you’re doing quite high intensity exercise. You can become a bit deplete in magnesium generally because you’re doing so much muscle work. So I often think magnesium is quite a good thing to take, either orally or in that sort of more the topical form. So either via salt bath. I mean, athletes are always having magnesium salt baths and ice baths, which maybe we’ll talk about in a little bit.

 

Dr Katy Munro [00:37:39] Yes.

 

Dr Jessica Briscoe [00:37:40] Or the oil, I think it’s a really good idea. And the other thing they did talk about in that paper was the role of CGRP, which is thought to increase in endurance exercise as well. And resistance training does fall into this category. If you’re doing, depending on the type of resistance training, type of weight training you’re doing, you can do endurance resistance training, too. So they didn’t measure it there. That’s another little question there, isn’t it? And that’s another thing that could possibly cause increased pain. And yeah, with that trigeminal cervical pathway that I discussed, that C2, that neck stiffness triggering those pain nerve fibres in that system can actually be modified so can be changed and remodelled through fairly moderate effort neck work. So neck exercises. So possibly even after you’ve finished resistance training in the neck, that pathway could be remodelled so that you’re more likely to get sort of neck and neck trigged migraine attacks even after you’ve ceased doing it. So it’ll be interesting to see whether actually targeted neck stretching exercises, which they also looked at in some studies, might be beneficial. In that case that, again, it kind of follows the rules that we advise of seeing, you know, a physiotherapist or osteopath or other health professional that sort of could help with this, maybe even acupuncture, that could help sort of with that neck stiffness too might be beneficial.

 

Dr Katy Munro [00:39:20] With your experience of going- I know you love a gym. So as a gym bunny and as somebody who’s had a personal trainer, would personal trainers be able to advise on stretching neck exercises because I’m aware if I do too many stretches of the neck, then I can end up getting pain from overstretching. So you do have to be quite careful with stretches.

 

Dr Jessica Briscoe [00:39:44] You have to be so careful with stretches and also technique is really important. And yeah, it really depends on the specialist area of the personal trainer because personal training is very much like most other health aligned sort of jobs. There are some that are very good at running. There are some that are good at sort of different types of aerobic training beginning on a bike. There are some that are really good yoga, more stretching type exercises, and then there are others that are really good at free weights or weights. Just having anyone behind you will be better at making sure your technique is better. You’re much less likely to get stiffness and they will make you warm up and cool down and stretch the right muscles because that’s the problem, a lot of people just, I mean I’m talking from my personal experience, don’t bother to stretch after exercising because, you know, you’re fitting it into the time, but it is actually really important to do. I certainly notice my neck muscles are much worse if I do not bother to stretch appropriately afterwards. But it is worth just seeing someone once or twice or physios are really good actually at this specific thing. They’re really good. I’ve seen a physio actually about neck tension and I think on your advice, Katy and they, you know, just some simple exercise that you can do day to day. You can do them sitting at your desk, can be really helpful. You know, you don’t have to do them immediately after exercise can just really help with that neck tension. Having now felt my trapezius I should probably get back into that.

 

Dr Katy Munro [00:41:20] Yes. There’s also other techniques. I know when I do pilates and we use rollers and things like that, and you can use a little soft either tennis balls.

 

Dr Jessica Briscoe [00:41:33] Or lacrosse balls are quite good.

 

Dr Katy Munro [00:41:33] Even more firmer cricket balls, things like that. Yeah. Just to get massage into muscles and give them a little bit of a gentle rub. But again, not to overdo it, because if you go to mad on massaging with things like rollers, then you can end up with quite, quite nasty pain from squashing the knots in your muscles.

 

Dr Jessica Briscoe [00:41:56] That’s to do with fascia. That breaks down the fascia doesn’t it.

 

Dr Katy Munro [00:42:01] Fascial yes.

 

Dr Jessica Briscoe [00:42:01] I think I’ve had that done in quite an intense way. Some osteopaths will do this as well. And I think, yes, I had quite a lot of neck tension. You can get quite a lot of bruising from it, which looks really alarming, but actually isn’t painful or concerning at all. But it can look quite- if they do that proper fascial breakdown, it can be quite- it can look quite extreme. So there are some other theories about why exercise can trigger migraine. So there’s sort of three. Well, we’ve talked about CGRP, as always, a lot. But there are other pathways that are thought to contribute to triggering migraines from exercise. So a dysfunction of a neuropeptide called hypocretin. I think I said that right. Now that’s produced by the hypothalamus and is also involved in sleep regulation. It’s been noted that functions of this pathway are actually impaired with people who have migraine. And these are thought to cause some of those premonitory symptoms. So particularly excessive sleepiness, something about the food cravings as well, increased yawning and fatigue. And it’s been postulated- well it’s been shown that vigorous exercise can actually modify this pathway and actually cause attacks in that way. So that could be a possible reason for the triggering. And then something you mentioned before about the lactate as well, Katy. So anaerobic exercise, if you’re doing too much exercise and you’re triggering the anaerobic pathway so the production of lactic acid by the muscles when they’re not using oxygen. So if you get a build-up of that in the brain, they’ve done some studies looking at magnetic resonance spectroscopy, which shows raised brain lactate levels, and this is also related with migraine so it could be that if you do slip into anaerobic exercise, you could be triggering migraine that way.

 

Dr Katy Munro [00:44:06] So the other way you would feel that lactic acid is if you’re getting cramps or a stitch. A stitch, that horrible kind ‘ugh’, and you have to stop what you’re doing and take some deep breaths, get some more oxygen into your system, let that lactic acid disperse out through the bloodstream and then you feel better and carry on. But, yeah, that’s really interesting. So multiple different chemical pathways that may be involved in making migraine be triggered by exercise. So we’re going to come on now and talk about a couple of other sorts of exercise, which I’m really quite interested in, which is yoga and Tai Chi. And one of our colleagues is a huge fan of yoga, Dr. Nazeli Manukyan, who’s sometimes a guest on this podcast. And I know she’s been practising yoga regularly to try and help her migraines. So I had a little look to see if there are any studies or any evidence about it and there are. Not surprisingly, probably they are studies from India. Obviously it’s a discipline that’s been very much in that kind of area of the world, but increasingly popular everywhere, really. And there was a couple of studies that showed that people who did yoga regularly, you know, obviously with any of these things, you can’t just do it once or twice and expect that your migraine will settle. You have to be practising it regularly. And and so they did it over at least a six week period and found that yoga did seem to help the headache frequency and intensity to be reduced. And they think that it was something to do with the vagus nerve. So, again, we’ve talked a lot about the vagus nerve and we know that the migraine process affects the vagus nerve and that we’ve spoken about previously with regard to affecting gastric emptying. And so when you swallow your painkilling tablets, if you’ve got affected vagus nerve, then your stomach doesn’t empty properly and your painkillers don’t get absorbed properly. And there are other medications you can take which will help to improve the emptying of the stomach. So the vagus nerve is a really important one. And we are going to talk a bit more about that in a minute when we come to the section on swimming, but yoga seems to enhance the vagal tone and reduces the sympathetic drive and the sympathetic system is that kind of fear flight reaction. So you get rapid pulse, when you’re having some sort of alarm in your environment and you think, oh, gosh, I’m under threat, whether that’s real or imagined, the sympathetic nerve kicks off. So the parasympathetic nervous system is enhanced by increasing vagal tone. And that seems to generally be helpful in migraine.

 

Dr Jessica Briscoe [00:47:14] It’s just nice to actually, you know, these things that we suggest that we anecdotally have found to be helpful, it’s actually just lovely to find that there are some studies that back up are presumed wisdom on these things.

 

Dr Katy Munro [00:47:30] The only thing I suppose about yoga is to be careful about inverted postures or anything that is hyper flexing your neck. And some yoga postures are really quite extreme. So, again, as with our chat about aerobic exercise, it is about starting pacing yourself with yoga, doing it slowly. Make sure you’ve got somebody checking your postures.

 

Dr Jessica Briscoe [00:47:54]  I think that’s really important to remember actually.

 

Dr Katy Munro [00:47:55] That’s hard. It’s hard in a lockdown, isn’t it? Because certainly, you know, doing pilates on Zoom, one of the things that you miss out on is the teacher coming and walking around the class and saying, oh, just put your leg there or just move that a bit.

 

Dr Jessica Briscoe [00:48:12] It’s the same with yoga. I mean, there’s some excellent yoga on YouTube and Zoom and all sorts of things. But actually, it’s quite easy to get it wrong, particularly with some of these inversions, actually. And I always worry about inversions with people who get vestibular migraine or any vertigo, it can be really triggering. I usually advise people against doing inversions. I remember having a patient who was really into yoga and he said, you know what, I know it triggers my symptoms. I just accepted that. I’d rather I’d rather do that. And that’s fine but just be aware that really some of these postures can trigger some of your symptoms too.

 

Dr Katy Munro [00:48:59]  I tend to for people with vestibular migraine, I tend to say, go towards more Tai Chi.

 

Dr Jessica Briscoe [00:49:08] Yes, I was about to ask about that, actually, because you are the one who imparted this wisdom onto me.

 

Dr Katy Munro [00:49:13] Yeah. So I think there’s quite good evidence for Tai Chi in a lot of other areas as well so it seems to be very- So Tai Chi is basically slow and balanced movements in a flow combined with breathing techniques and yoga, of course, does also involve some very careful slow breathing techniques, which can be really helpful. But Tai Chi is a fluid movement, which seems to be particularly good for people who have some balance issues. So you’re not only getting the coordination in your brain, which is really good to keep our brains, you know, sequencing- seems to be helpful to keep our brains healthy. The balance is good, the posture is good and the breathing is helpful. So there are some studies on Tai Chi and migraine and showing that it seems to really help people and especially with vestibular migraine. But I’ve also come across it in preventing falls in elderly people and also it’s beneficial for people who have more generalised body pain like fibromyalgia. So, yeah, definitely worth looking into. Very, very safe. Probably again, you can do it online and a lot of people seem to do Tai Chi out of doors. So they’re combining that kind of green gym idea with Tai Chi. So, yeah, I think it’s a really interesting area to look into. If you’re if you’re thinking of doing exercise, but you can’t face going for a jog or something like that then one of these kind of slower ones is better.

 

Dr Jessica Briscoe [00:50:49] And I was going to say also I suspect the added benefit of pilates as well is core stability and yoga, and probably Tai Chi as well. So one of the things we say to reduce neck and back pain is to try and stabilise your core. Helped with posture, which you’ve talked about a lot. The stronger your core, often, the better, the easier it is to improve posture and pilates does a lot of back strengthening as well doesn’t it? Upper back strengthening. Sorry i just tapped my upper back and none of you can see that. So, you know, that can be beneficial from that point of view too that’s more of an anecdotal thing rather than having some evidence base behind that.

 

Dr Katy Munro [00:51:34] I couldn’t find any studies on pilates of migraine. But if any pilates teachers are out there and they want to do some studies on migraine patients, that would be really great if they’d like to get in touch. The pilates foundation is a good source of information if you want to find a good, well trained and monitored pilates teacher. The yoga with Adrienne is a free online yoga, which is incredibly popular, and she’s amazing Adrienne. But of course it’s not interactive. So it’s just basically you’re having to follow what she does without somebody checking you. So with most of these things, I would say it’s really helpful, once this lockdown is history, to try and find some classes and go and get supervised, especially when you’re a beginner.

 

Dr Jessica Briscoe [00:52:23] You can do that kind of thing outside, actually. I mean, I know it’s quite cold at the moment, but yoga and pilates is possible to do outside. You do just need a mat and maybe some blocks but they’re not necessary.

 

Dr Jessica Briscoe [00:52:36] Cold water swimming. One of my favourite topics and I know you’re going to actually have a chat to some people who are a bit more experienced in this. Well, I certainly don’t have any personal experience as someone who doesn’t swim. But I mean, I can swim, but I just don’t.  But I am actually a really big fan of this generally and we’ve both talked about it a lot, haven’t we, Katy?

 

Dr Katy Munro [00:52:59] Yeah.

 

Dr Jessica Briscoe [00:52:59] And the beneficial effects of cold water swimming on migraine. I’ll let you talk a little bit more about that.

 

Dr Katy Munro [00:53:06] Okay. So I had the great interest to watch a film called 100 Days of Vitamin Sea the other day, which is about Beth Francis and her now husband, Andy Clark, who made this film about her experience of having chronic migraine and seeing whether she could improve her migraines by going swimming in the sea for a hundred consecutive days. I’m going to be talking to her and the interview will be later in the podcast. Fascinating story so I won’t go too much and spoil her tale. But it was something- Jessica, I know you met Beth a while ago when she was originally talking about this.

 

Dr Jessica Briscoe [00:53:48] Yes.

 

Dr Katy Munro [00:53:48] And since we’ve met Beth and know her story, we’ve also had anecdotes from other patients talking about cold water and cold water seems to stimulate the vagus nerve again. Here we go again with vagus nerve. And there’s a professor, Mike Tipton in Portsmouth who is studying the effect of cold water shock on pain and immunity and things, so I’ll be talking a bit more about that with Beth later but the only other thing I would say just about swimming as a general exercise, it is a good aerobic exercise. It’s a general whole body exercise. But going back to what we were saying about the neck, if you are swimming breaststroke, because I’m a bit of a breaststroker, I’m a bit rubbish at crawl. If you tend to stick your head up out of the water, you are hyper extending your neck and that may not be so great. So the idea is to get some goggles and get your face in.

 

Dr Jessica Briscoe [00:54:52] Yes, I think that’s the thing I was actually going to say. It’s quite important to get your face in and not just from a neck point of view, but actually from that vagal nerve stimulation point of view, as we were discussing earlier. I also think swimming is- the thing that’s quite good about it is if you do have other injuries, it is actually better. It’s much gentler on the knees. You are weightless. Well, not quite, but you’re pretty much weightless in the water. So it is a really good form of aerobic exercise, as you said, you can still get the anaerobic function. I mean, I wouldn’t I’m just terrible at swimming, which is why I don’t do it. But I probably took into anaerobic very quickly if I did any kind of swimming and I probably wouldn’t put my face in the water so there’d be no benefit from a pain point of view. Well, that’s a lie. There’d be some benefit, but not enough to weigh out the cons for me. But this is the point that actually there should be a form of exercise for everybody, whether or not it’s something- as we say when we say exercise, we really don’t mean that everyone should lace up their trainers or hop on a bike and, you know, pound the streets for hours. I’m really much more happy with people finding what they enjoy and, you know, I suspect there’s things like if it’s dancing that you enjoy, that’s a good form of aerobic exercise and things that we haven’t talked about. It’s about moving and just being aware of what counts as moderately intense exercise, as Katy said earlier, when you often have to take a layer off, when you start to feel a bit warm. I would think about also how much conversation you can have, whether your heart’s beating, but finding something that you can do regularly is really important.

 

Dr Katy Munro [00:56:39] I was just going to say about dancing when you just mentioned it then, because I love dancing.

 

Dr Jessica Briscoe [00:56:45] Great minds.

 

Dr Katy Munro [00:56:45] I love a bit of a dance and of course you don’t have to go out to classes for that. You can just put the radio on and bop around in the kitchen. So, you know, just anything that gets you moving, do it with the kids or, you know, maybe grab your partner and swirl around and maybe be inspired by Strictly if you’re watching that. I can’t even pretend that I can do any of the steps they show on there but it is lovely to see people moving. So, yeah, it’s finding something that you enjoy that you can keep doing. But I also think it’s quite important not to do the same thing over and over again.

 

Dr Jessica Briscoe [00:57:21] Yes! Big fan of that.

 

Dr Katy Munro [00:57:21]  If you can ring the changes so maybe one day say, right, today i’ll do some stretches tomorrow, I’ll go for a walk, the following day maybe I’ll bop around the kitchen. Whatever you feel fits into your day and is fun. Do it with other people if possible, because the more the merrier. And of course that’s more tricky at the moment. So if you are going to do it now, while COVID is still a thing, do it socially distanced. I’ve been certainly going for a walk with one other friend where we keep away from each other but it’s just nice to chat when you’re walking along rather than on Zoom.

 

Dr Jessica Briscoe [00:57:58] Yeah. Also there is good evidence from a fitness point of view of varying the intensity of exercise too. So I don’t think it’s about not- I think sometimes there’s a lot of guilt involved with not doing high intensity exercise all the time. It’s remembering that varying the forms of exercise so having a bit of resistance training, a bit of cardiovascular training, some low intensity or steady state training, as well as high intensity training or low intensity interval training as well, is really important. So and, you know, these non formal like types of exercise, which we miss out on. The walking between, you know, walking to the office and things like that, actually, you can do that, you know, maybe at the beginning of the day, instead of having a lie in for your commute, getting up and having a walk around the block is a good idea. So just, you know, things like that are really important to remember.

 

Dr Katy Munro [00:58:53] Also simple things like walking up the stairs instead of getting the lift. And when you get to the supermarket, just park at the far end of the car park rather than parking right next to the nearest space to the door.

 

Dr Jessica Briscoe [00:59:05] Or walk to the supermarket.

 

Dr Katy Munro [00:59:06] Or walk if there’s supermarket near enough, and then you get the endurance of carrying the heavy shopping home again which is also good. It’s difficult at the moment, but hopefully by next year, with the vaccines and all of this sort of thing, we’ll all be able to get out and do the things, you know, team sports are really important from a mental health point of view to be meeting up with people and playing, whether it’s, you know, badminton, netball, football, rugby, all of these things hopefully we’ll see a bit more of once we get through this winter. Fingers crossed.

 

Dr Jessica Briscoe [00:59:44] Perfect. So Katy is going to be speaking to Beth and Andy now about their experiences with cold water swimming. So please stay tuned for that.

 

Dr Katy Munro [00:59:58] So I’m now talking to Beth and Andy, who are the makers of an amazing film which I managed to catch last week called 100 Days of Vitamin Sea, and their dog is joining us in the background. We were talking about her just now. OK, so one of the reasons I was interested in listening to you or watching you on the film, Beth, because I had heard your story already about how you tried cold water swimming to try and help your chronic migraine. And I’ve also had a number of patients who’ve come and seen me at the clinic who’ve heard about it and who’ve told us that they found that cold water was quite helpful for their headaches. So tell me a bit about your journey towards the sea and how this all started for you.

 

Beth Francis [01:00:51] Yeah. So I guess where it all begins is kind of quite a long time ago. So I started with migraines when I was 9 and I was the fifth generation of women in my family to have migraines. So it has a really strong genetic influence, I guess, in our family. And for most of my life, I had migraines occasionally. It would be a case of probably no more than one a month, maybe a couple more in my teenage years, but never really, like, majorly affecting my life. Didn’t really stop me doing anything that I wanted to do. And although horrible when they happened, it wasn’t something that I kind of defined myself by. And then everything seemed to change very quickly. When I was 25, I kind of I’m not really sure what happened. I just returned from some fieldwork in Hawaii, and I wonder if it was maybe triggered by these long distance flights that I was doing or working very long hours. And I got back and I just kept having migraine after migraine after migraine, which was very unusual for me. And I kind of thought, OK, maybe this is just my body saying slow down a little bit. And so I kind of took it a little bit easier and it just kept getting worse and worse. And I eventually had to go to the doctors and say to them, this is becoming a real problem and I’m not able to function. And I think that I probably went to the doctors in June of 2017 with those kind of increasing migraines. And by July, I was getting a migraine every single day.

 

Dr Katy Munro [01:02:36] Oh, gosh. What were you treating them with at that stage? Where are you taking just acute medications, painkillers and triptans and things like that?

 

Beth Francis [01:02:45] Yeah. So at the start that was what I was doing. When they started getting a little bit more frequent my GP put me on, I can’t even remember what the first one was, that stage of like confusion and I think not great memory. Side effect of lots of migraines and the drugs, I think the first one was propranolol. And then I tried topiramate and candesartan and gabapentin and I kind of either- this was over the course of several months, of course. I was either getting severe side effects from them or they were making no difference at all. And so we kept moving on to new treatments. I was referred then to a neurologist because I think my GP realised it was a little bit more complicated than they were comfortable dealing with. And I started to try things like occipital nerve books.

 

Dr Katy Munro [01:03:46] Oh, yeah.

 

Beth Francis [01:03:48] Which didn’t work and also- so I was only given one and then was told that because it hadn’t worked the first time, I wasn’t eligible for any more. But then on examination, they found that it had melted away the muscle in the back of my head so then I was not allowed anymore after that.

 

Dr Katy Munro [01:04:10] It’s a known side effect with steroid injections. You can sometimes just get a little patch of thinning. It’s actually the fat underneath the skin that disappears. We see it sometimes if people have had injections in their shoulders or knees or whatever, you can get that. But yeah, it’s a nuisance. It doesn’t happen very often. But if it didn’t work as well.

 

Beth Francis [01:04:31] Yeah, but then at that point I saw my neurologist again and he basically told me that I was out of options at that point. So I think I tried for- I think maybe three, maybe only three medications and the the one round of the occipital nerve blocks. And he said, that’s it. That’s all we can do and that was quite shocking.

 

Dr Katy Munro [01:05:00] You hadn’t had Botox by then, had you?

 

Beth Francis [01:05:04] No I hadn’t.

 

Dr Katy Munro [01:05:04] And is that because it’s not easily available in Wales? I know you live in Anglesey, isn’t it? Up in Anglesey.

 

Beth Francis [01:05:10] Yeah so I think that the funding is slightly different for Botox in Wales. At that point he was saying that I think I needed to have had migraine, chronic migraine for over a year with no results from any of the treatments.

 

Dr Katy Munro [01:05:27] OK.

 

Beth Francis [01:05:29] And at that point, I think I was maybe seven or eight months in, so I had to wait a couple more months before I was eligible to go for funding.

 

Dr Katy Munro [01:05:38] It’s one of the things we find across the whole country is that getting Botox has, even before lockdown, has been quite difficult. And people, even when they’re eligible according to local policies, they often get put on a waiting list. So it is something we hear. And of course, now the lockdown has made it even harder to get Botox. But so, that was hard to hear, I’m really sure that must have been a bad day for you.

 

Beth Francis [01:06:08] It was. And I think that it probably started a feeling of quite- I think I felt completely hopeless after that. I think that often you go to a doctor or to a medical professional and you don’t necessarily expect them to be able to, like, wave a magic wand to make you better. But I think that the way that he presented that this was basically, my life was over and he was quite upfront in saying that I wouldn’t be able to achieve the things that I wanted to, I would never be able to live a normal life. And I think I came out and I just sat in the car and cried my eyes out and I think that for quite a long time after that, I just felt like there was no hope, there was nothing that I could really do and what was the point anymore?

 

Dr Katy Munro [01:07:01] Yeah, and how did you feel, Andy, hearing or seeing Beth going through that? It’s been really hard for you as well.

 

Andy Clark [01:07:09] It was. I think the feeling of hopelessness that Beth describes there is very fair, because we were told in no uncertain terms by an expert in the field that there is no hope and so unapologetically as well. I am very much an eternal optimist, though, and was really trying to hang on to that at the time, so I don’t think that I quite abandoned hope. I just didn’t know in what direction to point the hope that I had left. I was just hanging on to ‘surely something will come along’. And I guess, thankfully, we did become eligible- you, sorry, did become eligible for Botox.

 

Beth Francis [01:07:52] We!

 

Andy Clark [01:07:52] We became eligible for Botox in the usual time frame. As much as he had assured us that wouldn’t happen anyway, we wouldn’t get funding. And in the months and years that followed that a number of additional medications have evented the circuit, at the very least, the conversation and the, you know, hypothetical, what might be possible. The fact that they didn’t exist at that time, I don’t think should be used as an argument that it was a hopeless situation, even if we had exhausted all the possibilities available to medicine on that date, there’s no reason to say we’re not going to make any more advances in this. You know, the science isn’t going anywhere and that there is nothing else that you can possibly do.

 

Beth Francis [01:08:39] Just wait for the menpause.

 

Andy Clark [01:08:41] Yeah, that was the other one, wasn’t it?

 

Dr Katy Munro [01:08:44] Wait for menopause. I mean, honestly, I just-. Sometimes we hear patients who’ve been told, oh, you should get pregnant, that’s good way to cure migraine.

 

Beth Francis [01:08:53]  I think that was another suggestion he had.

 

Dr Katy Munro [01:08:55]  It’s not really helpful, is it? I think also, going back to what you were saying, Andy, all the new drugs that we have now got, were in studies then, we knew about them. They weren’t in general release, but to not have any hope, I think was a very premature conversation and wrong. So, yeah. There’s always something else to look at and some other strategy. So then you- between you or was it one of you that went, ‘Ha, let’s try cold water swimming’? Tell us about how that idea developed. Did you like swimming in the sea beforehand or was this a new venture?

 

Beth Francis [01:09:34] It was a new venture. We both loved the sea and we both loved being around the sea. And we’ve always been very involved in nature. Both of us, our background is in ecology. Andy is more terrestrial and I’m more marine. So I think that we knew that we got a lot of energy from being out in nature, but we hadn’t tried swimming in the sea. We could both swim. Well, I suppose that through my work I’d swim in the sea quite a lot but more tropical seas and coral reefs than cold water swimming.

 

Dr Katy Munro [01:10:04] A bit different from North Wales.

 

Beth Francis [01:10:07] Quite different. Yeah. And honestly, I can’t really say what triggered it as an idea, it was just one of those things where we I think were saying, like, what else can we do? And we knew about the well-being benefits of being in nature. And that’s really where the idea started. It was more to make us feel like we were more resilient and able to cope with what we were going through rather than as a cure for migraines or even as a kind of treatment.

 

Andy Clark [01:10:41] We weren’t really trying to address migraines directly, more the additional peripheral effects that it had had on our lives in general. Beth was saying the fact that she was having basically a migraine a day, took away nearly everything that she would otherwise have done in a whole month. It was impacting your PHD and your social life and just what you do in your free time and literally everything, for both of us. And I think we were just wanting to do something to kind of fill the hole that had been left in our lives, and it would make us feel more like ourselves getting out and about doing something in nature. We’re also becoming very aware of how much time we’re sitting, doing literally nothing in the house and thought we do need to still get some exercise and move around a bit in the day. So let’s make it as fun as possible.

 

Beth Francis [01:11:40] And I think as easy as possible. I know that when I have a migraine, and particularly if it’s a bad migraine, I really struggle to do anything that has a lot of impact. And being in water is obviously a completely different experience to going for a run, for example. But you can be quite active without any of that impact.

 

Dr Katy Munro [01:12:05] Yeah, yeah. It’s a wonderful thing. I’m interested in the sort of communing with nature, because I know that there are quite a few studies on sort of green therapy and blue therapy, which is basically going out into places where there’s a lot of vegetation and that improves people’s wellbeing and has been scientifically proven to be helpful. And also blue therapy, as in lakes and streams and the sea. So it’s a wonderful thing, I think, to just be even doing that even before you add in the cold water elements and whether that’s an additional benefit.

 

Beth Francis [01:12:45] I totally agree.

 

Dr Katy Munro [01:12:47] The other thing that really comes across in speaking to both of you and watching the film last week is this is very much a partnership decision. This wasn’t Andy saying ‘off you go, Beth into the sea…I’m coming too’.

 

Andy Clark [01:13:03] Yeah.

 

Dr Katy Munro [01:13:04] That was lovely to see. And I think you illustrate very much the impact that migraine has, especially chronic migraine, on the people around us who love us. And watching somebody go through chronic migraine is really hard. To be able to work together to something that would make you both feel that you were positively living despite migraine was such a great idea. That’s how it feels, that it comes across from what you say.

 

Beth Francis [01:13:32] Yeah. Thank you.

 

Andy Clark [01:13:33] Thank you.

 

Beth Francis [01:13:33] I think that that was something that was really important to us because I think it became really evident early on that whilst I was the person who was getting the migraine, it wasn’t just affecting me. It was I think if anything worse for Andrew and I don’t envy your position at all because I don’t think that I would be able to sit and watch you go through something similar.

 

Andy Clark [01:13:56] It is difficult.

 

Beth Francis [01:13:58] And as well as kind of taking up all of my time, being so incapacitated by the migraines, it was taking up a lot of your time as well. And I think that it’s easy to overlook the impact on the people who care for us, but I think that kind of by taking on that challenge together and deciding to do something together to benefit both of us, I think it was really positive. I think it helped both of us get through it rather than, as you say, one or the other of us doing something for ourselves.

 

Andy Clark [01:14:32] Yeah.

 

Beth Francis [01:14:32] And it made it a lot easier on the very, very cold or difficult days when you thought, no i’ve got to do this for the other person as well.

 

Dr Katy Munro [01:14:40] Yes.

 

Andy Clark [01:14:40] It would often flip actually between which one of us was more or less inclined to go in the sea. So there’d always be one of us willing to give the other one a pep talk.

 

Dr Katy Munro [01:14:49] Oh, excellent.

 

Andy Clark [01:14:51] Often it was needed, one way around or the other. But we got there together.

 

Dr Katy Munro [01:14:56] Yeah. So tell me about the experience of plunging into the briney. Did you initially think what are we doing or was it immediately kind of, Wow, this has given me a buzz? How long did it take you to kind of get into because you did it for a long time, didn’t you, over three months?

 

Beth Francis [01:15:12] Yeah. I think now it’s over three years that we’ve been swimming and it is amazing. Yeah, I think that as soon as I get in, every single time, I just feel lifted in like spirit and also in terms of pain. I I love the water and I know that it’s not something that everybody kind of resonates with. I know a lot of people are very scared of the water, and I think that that has got to be appreciated to. But for people who love the water I think that it’s just an unbeatable feeling.

 

Andy Clark [01:15:54] And I think we were very aware of how good it felt from day one. We’d both swum in the sea in various parts of the world, including Britain, various times before. So we both knew that we loved swimming but weren’t had never pursued it in quite such a dedicated manner. But we have like 90 minutes of footage of us swimming in fairly shallow water, well bouncing around more than swimming in fairly shallow water on the first swim of 100 days. And we were saying within minutes of that how excited we were to carry on with the challenge. What a great idea it was, how good we were feeling. And it was also a very nice day to do it. I think it was October. So that’s the nicest time of year in terms of water temperature around here.

 

Dr Katy Munro [01:16:37] Yes.

 

Andy Clark [01:16:38] It was a fairly still day. It was fairly warm still. So it was a very easy thing to just get into and to keep indulging. And it was nice then- I think less immediately it emerged over time that there was a lasting benefit to it as well. And we would feel better throughout the day or throughout the next few days after a swim. And then we tested the water slowly with going in or Beth going in whilst experiencing a migraine as well. And so that was quite a slow and very remarkable discovery that it really did benefit how she was feeling in the midst of a migraine as well, not just in the time surrounding it. And that’s incredible.

 

Dr Katy Munro [01:17:24] That’s really interesting because so in some ways it was a preventer, but in some ways it was an acute treatment. If you could get yourself down to the beach. And I recognise that because being a migraine sufferer personally and having taken the plunge on Christmas Day last year while I was having a migraine and my family insisted we all go for a Christmas dip in the sea. I suddenly had no migraine. And then I went back to the house to cook the Christmas lunch and the migraine gradually came back again. But it was quite nice to have a breather.

 

Andy Clark [01:18:00] It’s great to hear that you experienced that too.

 

Dr Katy Munro [01:18:01] Yeah, and the tingle after going in. We didn’t stay in for very long.

 

Beth Francis [01:18:08] Yeah.

 

Dr Katy Munro [01:18:09] I want to talk to you about that. Have you kind of worked out an optimum time or does it depend on other things like the weather and how bad you’re feeling? Is it like run in, run out or is it splash around for 20 minutes?

 

Beth Francis [01:18:23] I think that it varies a lot, particularly on very cold days. It is a run in and run out kind of a job and we always submerge our heads. And I think that that seems to make a big difference for me.

 

Andy Clark [01:18:38] It does for me as well.

 

Beth Francis [01:18:38] Yeah, yeah.

 

Dr Katy Munro [01:18:40] I found that as well, actually, I agree with you. Yeah, what’s very interesting, listening to Professor Tipton speaking after your film and I learnt such a lot from- he does cold water shock research in Portsmouth, doesn’t he. And he was saying that there’s a lot of cold water shock receptors around the face.

 

Beth Francis [01:19:02] Yeah.

 

Dr Katy Munro [01:19:03] And that that is stimulating the vagus nerve, which we know helps the calming parasympathetic system, which helps migraine. So I was fascinated to hear that. But I know, Beth, you also tried one time from the film that you tried instead of going to the sea, you tried getting a really cold bath. And I have to say, it didn’t look like a comfortable experience.

 

Beth Francis [01:19:26] It was not.

 

Dr Katy Munro [01:19:26] Did that work just as well?

 

Beth Francis [01:19:30] I think that- so when I when I got in that bath in the film, I was having a particularly bad migraine and I was, I think, just completely out of it in the way that you sometimes are with migraines, I think a 9 out of 10 pain. And it was the only thing that we could think to do. And it did make a difference. It was amazing. So I don’t think it makes as big a difference is going in the sea. And I wonder if that’s because of things that are kind of inherent to the beach, so like some of the smells and some of the other stimuli and that being active in nature kind of thing as well. But in terms of the kind of cold shock and also that kind of pain inhibiting pain response or negative stimuli, I don’t think it’s painful, but it’s not nice. I think that it did make a huge difference. And I was able to kind of get out of that really, really deep, deep pit that I was in with that migraine. And I didn’t go back down to that terrible level of pain again, it wasn’t completely gone, but it definitely made it more manageable. And it is something that I still try and do if I’m having a particularly bad migraine, is get in a cold bath or a cold shower and it seems to be that the sea is the best and then the bath is not as good, but still works. And then a shower is less effective than a bath because you can’t really submerge but still will make some difference.

 

Dr Katy Munro [01:21:01] So in the bath, do you put your face in as well?

 

Beth Francis [01:21:03] Yeah, I just went completely under the water.

 

Dr Katy Munro [01:21:05] Yeah, that’s really interesting. So I think it would be great to have more research about this wouldn’t it?

 

Beth Francis [01:21:14] Defintiely.

 

Dr Katy Munro [01:21:14] We need to kind of try and tease it out because as a headache specialist, trying to advise people, you know, I can say to them well, I’ve heard about some people like yourself and I’ve tried it myself, who do try cold water. And we know that a lot of people use ice packs on their heads and that can be really helpful. But again, I was reading a report that Professor Tipton and his team had written about not just the benefits, but also the risks. So, you know, you do have to be safe. And obviously you two were together. But he was saying in that paper that, you know, there is a number of people that might go and plunge into cold water and it can cause gasping hyperventilation or even heart irregularities. So it’s a tricky thing to just say to people, oh go and jump in the sea.

 

Beth Francis [01:22:06] It definitely is.

 

Dr Katy Munro [01:22:07] They need to be careful.

 

Beth Francis [01:22:09] Yeah, I think being careful is definitely- it’s got to be the first advice when it comes to cold water. It’s so amazing what the sea can do in terms of its therapeutic effects. But you can’t overlook the fact that it is a hazard as well. And for some people, I don’t think that it would be suitable, especially if they had a kind of heart conditions or if they were really, really scared of the water. I imagine that it would do absolutely no good at all. Even if there was the same kind of response, I think that it would be different. But I think the kind of advice that we try and follow is that we would never go alone and that we never jump into the water. So it’s always kind of easing in very slowly. So that it gives your body time to adapt. And I think that that’s good advice for anybody to follow, not even if you’re concerned about your health. Cold water can be very dangerous. And I think that you have to be very in tune with your body and listening to your body’s signals of how long is enough.

 

Andy Clark [01:23:15] We’re also very, very conscious of where safe water is around our island. So we only swim in safe swimming areas. And very humble in the face of the elements as well. There’ve been a good few days where we’ve really wanted to swim. But the waves have been bigger than us and we’ve politely walked away, just left nature to it. So it’s very much as you were just saying, about knowing your own limits and just respecting that.

 

Dr Katy Munro [01:23:42] Yeah, yeah. I think I was listening to something on the television yesterday and it was Bear Grylls talking about some project that he’s involved with and they were asking him about what he does. And he said, Oh, I like to sit, I’ve got an old cattle trough and I like to plunge myself into the cold water of the cattle trough for three minutes every day. And I thought, OK, it’s not just people with migraine doing this it’s other people. And there is some evidence that a short, sharp immersion in cold water, it’s really quite useful and stimulates the immune system and gives you that endorphin release and that endocannabinoids that we also get from exercise. But what Prof. Tipton was saying, I think, was don’t be staying in for too long, because actually then you can tip into hypothermia and then you get the sort of very negative, dangerous effects as well. So it’s a topic of great fascination to me, but lots, lots of things around it to be considering. Have you tried swimming in lakes as well?

 

Beth Francis [01:24:54] We have a little bit. I’ve tried some fresh water swimming. To be honest where we live it’s a lot easier to access salt water. And I think it’s quite funny because when people talk to us about this and they see the kind of weather and temperatures that we swam in, they think that we’re absolutely mad, or they think that we’re really, really brave. But I think that people who swim fresh water are just so brave because I’m terrified to swim in cold fresh water, because it feels to me so much colder. Well it is colder than the sea. But I always think whenever somebody says that they swim in fresh water, I’m like, oh, you’re really, really hardcore.

 

Dr Katy Munro [01:25:34] Because you don’t have the buoyancy of course, so much with fresh water, do you? I’ve done a little bit of lake swimming and you feel heavier than you do if you’re in the sea. And also the movement of the sea I think makes it easier to get in. I hate a calm sea, I like a little bit of waves.

 

Beth Francis [01:25:51] Me Too. Make it so much easier.

 

Dr Katy Munro [01:25:55] Not too much.

 

Beth Francis [01:25:57] And you don’t have to actually dunk, you can just kind of like squat down and it gets you.

 

Dr Katy Munro [01:26:04] I suppose the other thing is that we know that small regular amounts of moderate exercise do seem to help migraine any way. So if you were kind of going and exercising, whether in or out of the water every single day for 10, 15 minutes a day, that could also be beneficial as well?

 

Beth Francis [01:26:24] I think so. I think it’s something that I’ve always found. I’m quite hyper mobile as well. And I find that if I don’t exercise, I start to get a lot more kind of joint pains and I think that that was something that we were noticing as well when we first kind of bed bound with the migraines, was that I was also getting a lot of body pain and joint pain. And so I think that I don’t do well for not moving.

 

Dr Katy Munro [01:26:49] Yeah, we see a lot of patients at the National Migraine Centre with hyper mobility. It seems to be a quite strong link between hyper mobility and migraines. It’s really interesting, actually.

 

Beth Francis [01:27:01] I do think it’s interesting. I know that my mum is also hyper mobile and has migraines, but I don’t know about anyone older than that because I think it’s harder to tell when you’re in your eighties.

 

Dr Katy Munro [01:27:14] Yes. You get stiffer anyway, even if you’re hyper mobile you get stiffer as you get older. It was lovely to see your mum and your grandmother in the film as well, chatting about it and obviously you know you’ve got a very strong, obvious family history. But we have a lot of patients who just don’t quite know who else. And often when people are first diagnosed, they go away and start asking family members and they suddenly realise they’ve got quite a crowd of family members who go, oh, yeah, I get migraine. Oh, yeah, I used to get migraine and I never knew that because people don’t tend to share it very easily. If it’s not impacting too highly, they just keep quiet about it, don’t they?

 

Beth Francis [01:27:55] Yeah, I think you’re right. I think that our family history, my mum and my nan are both amazing women and I just think they’ve both been such an inspiration to me and my mum especially. I know that in her twenties she had terrible migraines and my nana as well. And they had children to raise and they had jobs and they did amazing. I don’t know how they coped. I think that they were both quite shocked with the way that my migraines went, I think that they expected me to kind of follow a similar trajectory to them and then it went much worse. But it’s definitely something that my family have always- I can’t remember not knowing about migraines because they are in five generations of my family. I don’t think that there’s been a generation without migraine and in the last four generations, I think there hasn’t been any women who aren’t affected.

 

Dr Katy Munro [01:28:50]  It is more commonly women, three times as many women as men.

 

Beth Francis [01:28:55] I think our sample might be a little bit biased as well, because I actually, I realised when I said that there haven’t been any men in those generations or my generation so but yeah, all my female cousins have had migraine and none of my male cousins or my brother has so very interesting.

 

Dr Katy Munro [01:29:13] Lots more to learn and hopefully lots more new treatments actually on the horizon still. As well as the triptans we’ve got two new medications for acute treatments coming along, but they’re not available in the UK yet. They’re out in the U.S. quite promising. And the CGRP, anti-CGRP injections have been really a very positive step forward. So how are your migraines at the moment? Are you feeling- you sound as if you’re feeling more in control and living life despite migraines?

 

Beth Francis [01:29:46] Yeah, I think that that’s a really good way to put it. I think that when we started doing a hundred days of vitamin sea, migraine was my entire life and it was kind of every moment of the day waking and sleeping. It was consumed by migraine. Now, I think that it’s again, just one of those kind of things that I have, but it doesn’t define my life anymore, which is amazing. So I’m still getting, I think, eight migraines a month, sometimes more, sometimes a bit less. But compared to twenty eight, that’s obviously hugely different. And I feel like that weight has been lifted. I don’t feel that sense of hopelessness that I felt at the start. And I feel as well as kind of like the physical differences, I think that the emotional energy that it takes to have so many migraines, I feel like you never fully recover if you’re having so many, whereas now I feel like I do get good days. I do get those like crystal clear days and so I can plan things and hope for the future and not feel like I am going to stay in the same state forever.

 

Dr Katy Munro [01:31:00] So you’re not just parking your life till the menopause.

 

Beth Francis [01:31:05] Which I am very glad of, because I hope that’s still quite far away.

 

Dr Katy Munro [01:31:11] I’m very glad to hear that. Is there anything else you’d like to say just to the listeners to the podcast? Is there any other message either of you kind of want to sum up?

 

Andy Clark [01:31:25] I would always like to tell anyone related to this community at all, to talk to people about it, because I can atone for I don’t think that’s the right word.

 

Beth Francis [01:31:40] Attest?

 

Andy Clark [01:31:41]  I can attest for what it is like to be completely ignorant to migraine. Because, you know, Beth has known about migraines and experienced migraines to one degree or another her entire life. I’m quite the opposite of that. And I had I’ll say a very average experience of migraines before I met Beth in that I’d probably heard of somebody having a migraine a couple of times in my life, and I assumed it was a bad headache and you just have to go lie down in a dark room for a few hours and then you’ll be fine again. And of course, the reality, particularly when the migraines get into chronic, even if you’re not chronically experiencing anything like the intensity of migraine that so many people do, it is horrendous and tremendously debilitating. And the degree to which that is misunderstood so commonly is a tremendous shame. And people never think less of you when they realise what hell you’re going through. Like everybody who has learnt or had an insight into our life over the last few years has been so supportive and full of love. It’s wonderful and everybody that has been in any way part of this has really helped us through it, just through, I guess, their gratitude for being a part of the journey, just being allowed to know what’s going on. Yeah, they’ve been wonderful. So that’s my advice or the message I would like to share with people is, keep talking because it helps everyone.

 

Beth Francis [01:33:13] Yeah, I would totally agree with that. And I guess to the same sentiment, if anybody is wanting to talk to us at all about our experiences or what we found with cold water swimming or wanting any advice or support, then we’re always happy to talk and help as much as we can. I feel like it’s very, very difficult to be put in that position where you’re given a diagnosis like that, and if other people are experiencing the same kind of thing where they’re being told by medical professionals that there is no hope. I think that reaching out to other people and talking it through and finding that there are other ideas, there are other things that they can try and that not everything is going to work for everybody, and I totally accept that cold water swimming is not this cure for migraine, and it won’t be something that helps everybody. But, yeah, just kind of getting ideas and being part of that conversation in the community. And we’re always here to talk if anybody would need it or if they would like any advice on migraines and swimming.

 

Andy Clark [01:34:25] I think you particularly speaking to other migraineurs as this became such a big part of our lives, really helped us adapt as well because it felt so severe for a very long time, like so much had have been taken away from us. And only in talking to other people who have been going through similar things for years and years, you realise it doesn’t have to cost you as much as it feels like for a long time. We learnt new ways to do things, new ways to live our lives or to engage socially with people. And they helped us see that it was possible to carry on.

 

Dr Katy Munro [01:35:05] It’s reducing that sense of isolation and being the only one, isn’t it, and I really hear that from people of all ages. We see people, children from four and upwards, the National Migraine Centre, and sometimes the kids say, well, I don’t know anybody else. And once they realise that there are other children with migraine, quite a lot of other children get migraine then it does help to know that there’s a crowd of supportive people. It Is a very supportive community, I agree.

 

Beth Francis [01:35:37] I think that the the general public is probably been given a little bit of a taste this year of how isolating it can be to be in your house the whole time. So hopefully they’ll be kind of renewed energy and effort to connect and make those communities. It’s really important.

 

Dr Katy Munro [01:36:02] Brilliant. Well, thank you both so much for doing this interview. I know the podcast audience is going to really love hearing your story, so thank you.

 

Beth Francis [01:36:12] Thank you for having us. It’s been a pleasure.

 

Dr Katy Munro [01:36:13] And good luck.

 

Andy Clark [01:36:14] Thank you very much.

 

Dr Jessica Briscoe [01:36:18] I hope you enjoyed this episode of Heads Up podcast on exercise and migraine, if you have enjoyed it, we’d really appreciate a review or a rating in whichever podcast platform you’re listening to. This helps us to reach other podcast listeners and hopefully improve our audience and the audience that we have and get our message out to more people. The other thing is, if you have enjoyed the podcast, we do work for a charity. We’re part of the National Migraine Centre. And in order to keep doing these podcasts, put out information for people with migraine and other types of headaches and see people in clinic whether virtually or doing any of the procedures that we do, we do rely on donations for this. So please visit our donation website. And the link is in the bio or on our National Migraine Centre web page.

 

[01:37:16] You’ve been listening to the Heads Up podcast. If you want more information or have any comments, email us at info@NationalMigraineCentre.org.uk. Till next time.