The Migraine Doctor: Botox, Supplements, Hormones & What Actually Works

0:00Hi friends, I am so glad you're here. Well, I've had, I think, only one migraine in my life, one, but it was absolutely debilitating. And the whole time I kept thinking, how in earth do people live with this? When I asked all of you about migraines and headaches, I was overwhelmed by the response. You literally shared hundreds of questions about hormones, about aura, vision changes, dizziness, whether or not what you're experiencing is actually a migraine. So today I'm going to let your questions dictate our episode. My guest is Dr. Huma Shake, a board certified neurologist, Harvard trained headache specialist, one of very few out there. And I'm going to ask her the questions you've been sending me. The questions I know so many of you have been carrying around for years. And today we're going to get some early answers for you. As you head into this next chapter, my hope always is that you'll walk away feeling more informed, more empowered, and maybe a little more hopeful about what is possible. And I'm going to ask you one small favor. If you could, please leave a review for the Tamsen show.

1:00It helps us more than you could possibly ever know. It helps us figure out what guests are going to come on the show and I so, so appreciate it. Let's go ahead and get into it. I remember the exact moment I realized something was actually wrong. And it wasn't gradual. It hit all at once. Night sweats, racing hard at 3 a.m. And doctors telling me to just deal with it. Nobody explained what was happening in my body or what to actually do about it. That's what got me to midi health. And it was the first time I felt like somebody understood what I was going through. Midi isn't another one size fits all telehealth platform. It's virtual care built exclusively for women's hormonal health by clinicians who understand this firsthand and it's covered by most major insurance plans. Getting started is easy. You visit joinmitty.com, share what you're experiencing and get matched with a trained clinician with appointments available in days, not months. I use midi health and if any of this sounds like you, I really think you should try it too. It's time to get back to feeling like yourself again. Join mitty.com right now to book your first

2:01visit today. That's join mid.com to book your first visit. Join mitty.com. Propel Fitness Water with Gatorade Electrolites, Zerosugar, and Vitamins. Propel hydrates better than water to help you get the most out of your workout and get back to your best self. What propels you? Propel with Gatorade Electrolites. Dr. Shake, I'm going to give you migraine relief methods that women swear by. One to ten, I want you to rate them. Okay. Perfect. I can't believe I'm going to say this one. McDonald's fries in a diet coke. I would say a three. The salt in the french fries and the caffeine in the drink is probably what's helping. But if you're going to be doing that very often, it's not very healthy. That's higher than I thought you were going to say. Yeah. But once in a while. Okay. Putting your feet in hot water with an ice pack on your head. I would say zero or one. There's really no evidence. And it can be obviously very dangerous to do that. Botox. Botox, I would say ten. There is it's FDA approved for chronic migraine.

3:04There's a lot of good evidence. We have been doing it for over 25 years and it does work. And there's really no side effects from it. There's good side effects from it. Yeah. Yeah. They're different ways. Yeah. Yeah. Drinking a ton of water. So I would say five or six. You want to obviously stay hydrated. That can be a very big risk factor for triggering a migraine. But you also don't want to overdo it. And when you are hydrating with water, you want to make sure you have some electrolytes. You're keeping the water inside your blood vessels. Going to a thyropractor. Zero. Zero. I've just seen a lot of side effects. I've seen strokes happen from going to the chiropractor and neck manipulation. So I would say there's a lot of other treatments that you can try. And this is just a risk benefit. It doesn't make sense for me. Bouncing a water bottle on your head. Zero. I've never really So it's my brain tension caps. So I would say a nine. I love these. There are a few that we know that also are ice packs inside of them. And it number one, it helps kind of force you to go and lie

4:09down, which is very helpful when you have a migraine. And the coolness can be very calming and soothing for the irritated nerves. So I really like these. And a dark room in sleep. A 10 out of 10. That's the way that your brain is going to kind of rewire itself and reset. And that can be really great for a migraine. All right. So I want to back up into why this is actually all happening. And thank you for coming today because we've had so many questions that headaches and migraines online that we're like we're finding the expert to bring in. No, I mean, this is great. So I've been a migraine specialist for at least 15 years. And I just it's amazing that you have taken on this topic because it's so underdiagnosed, so rarely talked about, but it's so common. So many women, especially suffer from migraine. And a lot of times they feel like they just have to deal with it on their own. And this is actually perfect because June is migraine awareness month. So this is the perfect time to get lots of information and education out there. So I need to be educated on this. What is actually the difference between a migraine and a headache? That's a really great question. I think this is why so many people just deal with it on their own because they do think

5:12that migraine is just a headache. So a headache is a symptom of another disease. Right. So if you have a stroke, if you have a tumor, you're going to have headache as part of your presentation. But migraine is actually a chronic neurological disease with a genetic basis for it. So it's actually a disease like asthma. I like to make the analogy for asthma because it's similar in how they present. Someone with asthma, same as someone with migraine, they have the genetic disposition to have that disease. And then it's things in the environment either internally or externally that bring on each attack or trigger a migraine attack. So it's something that you have all the time, but once in a while or for many women very often, it's going to affect you and give you a migraine attack. Do you know if it's a migraine or a headache, like I don't know if I got a migraine that I would have? Yeah. I would, would I know that? So there is a way to diagnose migraine and it's very simple.

6:14If you have headaches on and off that have been going on for at least three months that are severe enough that cause you to have to go lie down in a dark room, have to, you miss work or social activities. And there's at least nausea or sensitivity to light or sound associated with it. You likely have migraine. Wow. But a lot of times if it's just a headache, you won't have a lot of those other symptoms. Okay. So you're going to realize whether or not it's a migraine. You're not just going to have a headache and say, oh, it's bad enough that it might be. Right. Exactly. I mean, migraine, the headache component is very, very severe, but they come with a lot of other symptoms. It's a whole constellation of things. And it's very individualized. Some people have a lot of dizziness. Some people have trouble thinking, concentrating brain fog, sensitivity to light, to sound. In some cases, you have numbness or even weakness on one side of your body. So it's very different than having a headache because you know, you're dehydrated or you know, are hungover. Yeah. I guess I'm hungover. But obviously, like I get sinus headaches all the time.

7:16But I know what those are. I know how I know how it rocks my head and makes me feel, but I don't get nausea. I don't have to go lay down in a dark room. Right. So they're very, very different. So correct me if I'm wrong. Women get more migraines than men. Is that right? The prevalence of migraine is three to four times more in women. And essentially, I know we're going to talk a lot about this, but essentially, it's the hormone, the hormones that are driving that. Yeah, let's dive into that and talk about that. Yeah. Sure. So when, so if we look at the lifetime of prevalence of migraine, they usually start in some people when they're children. And when you are pre-pubescent, boys and girls get migraine at the same rate. But as soon as someone hits puberty, so for women, when they hit puberty, the rates of migraine increased dramatically three to four times more than boys their same age. And for women, then they develop migraine into the reproductive years. As they go into parimenopause, there is a lot of times, a lot of increase in the frequency and severity of their migraine. Most women will start to have decrease in their migraine symptoms

8:21as they get into menopause and then postmenopause. So the lifetime, kind of the story of migraine for women follows the story of their hormones throughout their life. And so it's very interconnected. And it has to do primarily with estrogen that's driving this. But there is some role for progesterone as well. So it's fascinating that that's not top of our list of things to talk about because so many people get migraines and then start to get them, I guess later in my, are migraines genetic? Yes. Yes. So we do know some of the genes that cause migraine, specifically hemiplegia migraine, where it's a very dramatic type of migraine where you almost look like you're having a stroke, you can't move one side of your body. And for that, we know the specific genes that relate to that. However, there's a lot of other genes that we haven't actually identified. And that's why one of the reasons that if you, a mom used to get migraines, she might only get them once a week, but you might present with, you know, almost every day. There can be a wide variety in how you present, even if you

9:26have a family history. But if you have a family history of one parent having migraine, you have almost a 30 to 50% increased risk of developing migraine. And that jumps up to almost 75, 90% if both your parents have migraine. That is shocking to me. Yeah. Cause I think my mom used to have them because she just had debilitating headaches, but I don't know if I knew the word at the time. And my brother gets the same thing where he actually gets sick. Oh wow. So that's very interesting because I developed migraine when I was in medical school. And so I kind of had an idea about what was going on. But it was the same thing. It wasn't until later when I could give it a name. And then I happened to talk about it with my parents and my dad used to get them. And we never knew because he grew out of them. So a lot of people don't actually talk about it with their family members, with their parents. And they might have just dealt with it as a headache on their own. And it never comes out that there's a family history. So what should you do if you start developing migraines like this? I mean, do you need to go see a doctor? Do you do? Do you see you? Yeah. So I think what I would say is if

10:28they are keeping you from work, if they're keeping you from your social activities, if they are happening more than two or three times a month, that's the time to start to get evaluated and speak to someone. So you become educated on when should you start taking something called a preventive? How should you be taking pain medications? How often? Because sometimes pain medications can actually make the situation worse. So I think if they are getting in the way of your job, your social activities, your time with your family, it's important to at least get educated about what could be going on. And are there long-term risks associated with migraines? So that's a really great question. We do know that there is a specific type of migraine called migraine with aura that does have an increased risk of developing a stroke. The overall risk is very small, but it is higher in people, women who have migraine with aura compared to women who don't have migraine. So what do you do with that? You have to just continue to be monitored. You have to be continued to be monitored. You have to make

11:32sure that you are controlling your other risk factors. You definitely don't want to smoke. You definitely want to make sure that if you have high blood pressure, that's well controlled. And you want to make sure that your migraines, your migraine attacks are well controlled. So you're on a good preventive. You have a good medication to take when you do get a migraine. There's no reason right now to start taking things like aspirin or extra medication, but it is important to just be more healthier, exercising, eating healthy so that you can decrease your risk of stroke in other ways. What is migraine with aura? What does that mean? So that's a great question. So there are two. I know nothing about migraines. I just know that we get lots of questions about them. So these are viewer questions. Yeah. I'm sure a lot of the viewers will pick up on some of these things. So I think migraine with aura means that before you get the headache portion of your migraine, so migraine actually has four distinct components. And the second component is an aura. And that is

12:32a neurological symptom prior to the headache portion. So the most common one is called visual aura. And so essentially when the migraine starts, some women will start to see colors at the side of their vision. A lot of women describe them as a kaleidoscope or lightning in their side of their vision. And it can grow over 20 to 30 minutes into their vision. And sometimes there's a blind spot behind it. So they can't see for a while. And then they'll develop their headache. So it's essentially relates to how a migraine starts, which it activates neurons in a part of your brain. And in this particular aura, visual aura, the brain processing center that's processes vision becomes activated. Are there other types of migraines to be aware of? So essentially migraine with aura. And then without aura are the two main ones. And then there's hemiplegic migraine where your aura is weakness on one side of your body. And then there's menstrual migraine where women get

13:37migraine attacks only around the time of their periods. So we give that a specific name. And then there is vestibular migraine where the main component or the main symptom is really bad dizziness. So we have there essentially all migraine, but sometimes depending on what the main symptom is, we will identify them in a different way. Can we talk about socks for a second? Because they genuinely did not know I was a sock person until bombas came about. Summer is fully here. I'm between my walks, the gym traveling to Italy with my dad. I am on my feet constantly. And I'll say the difference between a good sock and a bad sock is something I underestimated for most of my adult life. Bombas has sports socks for literally everything running yoga, the gym, soft and cushioned exactly where you want it. Airy sweat wicking. My feet feel as good at the end of the walk as they did at the start. And I know that sounds like something you say in an ad, but actually minute, the compression socks for travel are also something I will not get on a plane without anymore. They look nothing like those compression socks you're picturing right now. Actual colors

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15:43and no flaking. The flexible ones separates every lash, even a little tiny ones in the corner. Modern day makeup that's clean, strategic and multifunctional for effortless routines. For a limited time, our listeners are getting a free full size mascara on their first purchase when they use code tamson at checkout. Just head to Jones Road Beauty and use code tamson at checkout. After you purchase, the last year we heard about them. Please support the tamson show and tell them we sent you. We put something out there to ask people ask questions. We heard migraines got worse in my 40s. I never had migraines now. I do. I thought menopause would help and it didn't help. So what's happening? So why does parry menopause seem to throw gasoline on the fire when it comes to my parents? And that's a great way to kind of use that analogy. So essentially, you know, when you are in parry menopause and this is the period before menopause, that can last for up to 10 years. Women can be in parry menopause for up to 10 years. And essentially, what's happening at that time, estrogen levels are very volatile. Your ovaries are some months making extra extra

16:49gen other months. It's not producing as much. And the migraine brain doesn't like that volatility. It likes everything to be the same. So when it's seeing these changes, that can bring on migraine attacks. So all that chaos with your hormone. It's censoring that time. That's terrible on top of everything. On top of everything else that's going on. But that's essentially what's happening. I've not had migraines before, but I have had friends that do where they're like, lock themselves in a room. I have my brother who like physically gets throbs up and gets sick. How debilitating are migraines like this for your patients? So actually, the World Health Organization for women under the age of 50, it is a number one cause of disability. There are 39 million people in the United States who have migraine. There are 1 billion people worldwide. And it is a significant cause of what we call present-tism, which people will go to work. And they'll try to work through the day, but they're just not as cognitively functional as they would be. So they're not as productive as they would be. And it's actually very, very disabling.

17:55It's the second biggest cause of disability in the world. And then for women under the age of 50, like I mentioned, it's the number one cause of disability. Now, a lot of people, disability in terms of not being able to function. Right. Right. Either at home or at work, social activities, they have to miss out on their schedules, very unpredictable because if they get a migraine and they've made a commitment to be at their child's school for something or plans with friends, they have to call out sick essentially. And for people that don't have it, it's really hard to understand why is a headache causing you to have to not come into work or can't do what you had planned. Because take to aspirin is not the solution. Right. Right. So let's talk about some of the solutions. And I want to hit on hormone therapy too because we're talking about paramedics and menopause. Where does hormone therapy fit into migraines and relief or treatment or support or not able to do it or anything? Yeah. So I think this is a really great question. And I think if someone is thinking about hormone therapy, it needs to be a collaborative conversation between their neurologist and their OB-GYN. We used to be very scared

19:02of hormone therapy in women because we were there was the Women's Health Initiative study that showed there might be an increased risk of stroke or breast cancer. Now we have a lot more evidence and a lot more information. So we're not as scared to use hormone therapy. But it depends where you are in life. Women with migraines. Correct. Yes. There are still some copy outs to that. Their approach needs to be very individualized, depending on if you have a family history of breast cancer, depending on if you have other stroke risk factors. But for the most part, if you are postmenopausal and you're still having migraine attacks, as I mentioned before, in postmenopause most women do get better because the hormone levels are stable. But that's not the case for everyone. So in general for that age group, the FDA did widen the situations in which hormone therapy, the benefits outweigh the risk. But it is still very individualized. So let me just make sure I have understanding.

20:03If you have migraines or start getting migraines and parimenopause, but you're on hormone therapy or you want to take hormone therapy, do you need to talk to your doctor about that? Because that's not one of the contrary indicators, right? Stroke is. Stroke is. And I would say if you have migraine with aura, which can increase your risk of stroke, then I would have that conversation. But if you're migraine attacks or otherwise not that often, if they're happening once a month, I don't think it's necessarily a conversation you have to have. But if they're happening very frequently or if you're migraine changes, if you didn't have aura, now you've developed aura, or they change in the way that they present, then you should definitely have a conversation. So let's talk about what's happening to women in parimenopause and menopause when they get an onset of migraines. So essentially at this time, especially in parimenopause, which can actually go on for almost 10 years before they actually hit menopause, the estrogen levels, your ovaries are not predictably making the same amount of estrogen all the time. So it can vary month to month. And that is why some women will have

21:08a period for a month and then skip it for a few months. But even on a day-to-day basis, the levels of estrogen are fluctuating. And for the migraine brain, that fluctuation is really what is triggering a migraine attack. The migraine brain likes things to be stable and on the same level. And that's actually one reason in pregnancy, especially the second and third trimester, estrogen levels are very stable. Women with migraine will notice no migraine attacks during that time. But essentially, you want to think of estrogen as like a volume knob. If the estrogen is going back and forth, back and forth, that is irritating to the migraine brain. And progesterone, does that have any planie part? So a little bit progesterone, as you get into parimenopause and menopause also starts to decrease. But we really think it's the estrogen that is driving all the migraine attacks. All right, let's talk about migraine triggers. Sure. Are they real? Are there things that really trigger migraines? Yes, for sure. Okay, let's put down the list. So essentially number one, unfortunately, are things like stress and everyone has stress. Everybody comes in here and

22:12tells us to manage stress. And I still don't know how to do it. But stress is a big one. Stress is a big one. Sleep is a big one. Hormones, fluctuating hormones is a very big one for women. Weather is a big one. And these all have to do whether like if it's getting so many changes. Yes, exactly. So a lot of these women will know when the barometer is changing, when there's about to be a storm, when humidity levels are changing. All essentially the migraine brain does not like change. So if there's any kind of change, if there's a change in their sleep schedule, a lot of times people want to sleep in on the weekends, that can bring on a migraine because now they've changed their sleep schedule. And then there are things like foods. And so a lot of these are very personal. This one hasn't been explained very well yet. We don't have a lot of evidence. But MSG is a big one. The nitrites in wine can be a very big one for a lot of people. So there are definitely triggers. And one great way to identify your individual triggers is to keep a headache diary. This can for a lot of women help them to

23:15identify that in addition to when they have their menstrual cycle, ovulation is the time for a migraine attack. And this way you can kind of at least have that knowledge and plan around it. You might not be able to prevent it, but at least you have that information. Let me ask this. I have to assume, thanks to social media. You're constantly dispelling myths out there about migraines. Are there some of the big ones that you would like to dispel here? So we know what people are seeing or reading or scrolling or watching that might not be true. Yeah, so that's a great. So one big one, I don't know how many people will agree with me, but chocolate is not a trigger. Chocolate is not a trigger for migraines. So people think it's a trigger? A lot of people do. And I think what happens is, so there was one study that showed that it was not. But a lot of people when they are about to get a migraine, they crave chocolate. And then they will get the migraine and think it's related to the chocolate that they had. So you know, migraines, you can eat chocolate. You can have chocolate, but I would say maybe it's a trigger for you. Keep a headache diary. If it's happening consistently, then you might want to avoid it. But chocolate, especially that it's very

24:18healthy for you. What else is a big myth? So like I mentioned, it's not just a headache. You know, you don't want to deal with you should get help. You should get educated. And it is a neurological disease. So that's very important to know that shouldn't feel like you need to deal with it on your own. Because there is a big stigma around, you know, like if you're for women, especially if they're at work and complaining about a headache, they might be seen as, you know, trying to get out of work or whining. So it is a real neurological disease. I think that's a big myth. What about histamines? There's some evidence that anti histamines can be helpful. And I think that has to relate to the down the line in migraine, your blood vessels open up and they release a lot of inflammatory proteins or molecules. And histamines is one of them, but it's not one of the big ones that we use to treat migraine. It's not a huge component. And then alcohol is alcohol a trigger. So it depends. A lot of red wines for a lot of people can be a trigger the nitrites and essentially

25:23also you're dehydrating yourself when you drink alcohol. So if you're not keeping up with drinking water, that can be a trigger for you. So among some of the comments, we're just women that said, I've tried everything I've done Botox, I mean, the dark room, I'm doing supplements, I'm taking care of myself and I'm still getting migraines all the time. Is there something we're missing there? So that's a great question. I mean, I have women who, you know, in my headache clinic, we've tried numerous amount of things. And unfortunately for some women, it's something that is very hard to control. I have women who have migraine on a daily basis and are just kind of on a daily basis. On a daily basis, they have some component, either a really bad headache or the sensitivity to light is there, the dizziness is there, affects them essentially all the time. And unfortunately, there are some women like that. It's thankfully a small percentage where a lot of things might not be helpful. The good thing is is that we are coming up with research and we are coming up with new medications, you know, very frequently there are CGRP inhibitors, which are the newest medications.

26:26What is that? In migraine, that is a medication. It comes in very different forms, oral injectables, IV that block a molecule called CGRP, that similar to other inflammatory molecules is released during a migraine attack and these medications block those. So recently, they have been found to be very, very helpful. There's a low side effect profile. So I would definitely say if they haven't tried one of those, that can be a very good addition. Are there a lot of women getting a certain type of treatment in your office right now? Is there something that's most common? Yeah, so the CGRP, and I would say Botox. And I also really focus on lifestyle. So for me, essentially, when I talk to someone for the first time when they're coming in with a migraine, we try to identify what part of their life is not in balance because I think when you're getting a migraine attack, that's your body's way of telling you that something is out of balance. So we try to look at their sleep. Are they having poor sleep? Are they having sleep apnea? Is there something that we can fix about

27:29their sleep? We're looking at their stress levels. Are there things that they can change? If they're not doing things like yoga, mindfulness, that can be very, very helpful. Consistent yoga, consistent mindfulness has actually been shown to change the way our body responds to stress and the cortisol that's released. So that's really, really helpful. I try to get all my patients tried at least. I know it's really hard. You have to be consistent. You have to take time out of our busy lives. But it can be very helpful if it's done consistently. And then I try to look at, you know, where they are with their hormone levels. And if there's things that we can intervene on there. I did a major closet clean out. And I cried a few times for being honest. Years of pieces. I'd held on to for no reason. And once I finally committed to letting them go, I didn't want to deal with photographing everything or listing it myself. That's when I found the real real. And it made the whole thing so easy. They actually came over and picked everything up. I didn't have to do a thing after that. They handled everything. The photography, the copyrighting, the pricing,

28:30the shipping, all of it. I just sent my closet off and got paid. And with over 42 million fashion lovers shopping on the real real, my pieces sold fast faster than I expected. I sold all my items. Resale is what they do. So instead of spending my weekends listing things online, I got my time back completely. The real real is the most trusted name in authenticated luxury resale. With over 10,000 new arrivals daily, no one does resale like the real real. And now get $25 off your first purchase. When you go to the real real calm slash tamson. That's the real real calm slash tamson TAM SEN to get your $25 off. Start shopping now at the real real calm slash tamson. I remember the exact moment I realized something was actually wrong. And it wasn't gradual. It hit all at once. Night sweats racing hard at 3 a.m. And doctors telling me to just deal with it. Nobody explained what was happening in my body or what to actually do about it. That's what got me to MIDI health. And it was the first time I felt like somebody understood what I was going through.

29:30MIDI isn't another one size fits all telehealth platform. It's virtual care built exclusively for women's hormonal health by clinicians who understand this firsthand. And it's covered by most major insurance plans. Getting started is easy. You visit joinmitty.com share what you're experiencing and get matched with a train clinician with appointments available in days not months. I use MIDI health. And if any of the sounds like you, I really think you should try it too. It's time to get back to feeling like yourself again. Join MIDI.com right now to book your first visit today. That's join M-I-D-I-D-I-.com to book your first visit joinmitty.com. You said Botox works really well. Why does that work so well? And how often should you just get that consistently? If you are thinking about Botox, typically it is a neurologist or a headache specialist that will do that for you. There's a very specific protocol and there's very specific places where we inject the Botox. And there's studies that have shown that this amount of Botox

30:31usually every three months does decrease the rate of migraine and the frequency of migraine. Essentially what it does is with migraine, all your nerves are oversensitive and irritated essentially. And what Botox does is we inject it into the muscle and it stops the communication from the tense muscles to the nerves. So now they're not getting that feedback that were tense, were stressed out, and that can really help their migraine attacks. So we talked about lifestyle changes that you really think were really, really important in Botox. Are there certain supplements that you're telling your patients to use? Yeah. So a lot of times supplements are the things that we talk about first. If someone does not want to go on prescription medications, magnesium, especially magnesium glycinate, there is very good evidence that it helps with migraine frequency. There's also vitamin B2, riboflavin. I usually tell patients to take a complex vitamin B so they get also B12 and some of the other B vitamins, but that one can be very, very helpful. And then there's some

31:35evidence for coenzyme Q10, which also can help with brain health. And then vitamin D if you're low, vitamin D has been shown that if you are low, there might be an increased risk of migraine attacks. So we usually start with one and then maybe move on to another one once they've kind of adjusted to one. And if you have things like the migraine caps or different things like that, those are just helpful through the course of time. What are you dealing with the situation? Right. So those are what we call acute therapies when you're already in a migraine attack. Supplements the CGRP inhibitors, the Botox, the lifestyle measures, those are to prevent migraine. So essentially what you are hoping to do is increase the threshold at which a trigger might bring on a migraine attack. So if you have a woman out there that's like, okay, I didn't have these all along. And now 43 and all of a sudden I am, I have exactly what you're describing, Dr. Shake. And I want to know what to do. Where would you recommend them start? I would recommend so there are some online resources,

32:36the American Migraine Foundation, the American Hedic Society. But I would start with a very good primary care doctor. A good primary care doctor will have a lot of knowledge about migraine. But if they feel like the primary care doctor is not giving them the education or they're not able to really give them the time to go through migraine, what migraine is and how to treat it, then I would say try to find a good neurologist or a headache specialist. Unfortunately, there's only about six or seven hundred headache specialists. And as I mentioned, there's 36 million people in the US with migraine. So there's a lot of people who aren't able to actually get the specialized care that they need. Why is such a small amount of headache specialists? That's a good question. I mean, it's a specialty that I love and went into. But I think, just in general, there's neurologists don't go into headache. They go into other just seizure treatments or stroke. But we definitely need more. You posted something online recently that

33:36got a lot of pushback talking about people going to chiropractors for migraines. Can you explain that a little bit deeper? Yeah. So I know chiropractors have gone to their own specialized type of training. This is not too bashed chiropractors. I know that it can be very helpful to kind of manipulate the neck and shoulders. Unfortunately, what can happen sometimes? And it's not just with chiropractors, but it's with any type of neck manipulation. Sometimes the vessels in your neck, they can become exposed and they can tear if they're being manipulated. So unfortunately, it's actually more common in people who have migraine. The vessels in their neck. So they're artery will tear. And this can lead to things like stroke or bleeding in the brain. Unfortunately, I've seen it enough that I think it's probably better to find other ways to help with attention in your neck and shoulders, acupuncture, cupping can be helpful. Physical therapy can be very,

34:37very helpful. So yeah, I would probably try to avoid that unless you know you're going to someone who is not going to quickly jerk your neck in different directions. You talked about food a little bit earlier in different types of food that might be good for you. We know about the ones that are not triggering really. Is there a certain type of diet to look at when it comes to migraines? It's important. I know you mentioned inflammation a few times. Yes. So essentially, you know, I know there's a lot of buzz around anti-inflammatory diets and those types of things. I think if you are incorporating whole foods into your diet on a consistent basis, eating lots of vegetables, eating a lot of nuts. If you're not, if they don't trigger a migraine attack for you, you're eating lots of fruits. So you're getting all kinds of vitamins and minerals. That's very important. You want to avoid artificial sweeteners. You want to avoid too much sugar, processed foods, you know. In general, you want to have as much of a healthy diet with

35:37whole foods that are not processed that are low in sugar. So Dr. Shake, let me ask you something. There's a woman listening right now. We want to give them help. There's a lot of new treatments out there. I'm sure a lot of research is happening. I think you mentioned some of it. What do you want people with migraines to know if they haven't gone to a headache specialist? Yeah. So number one is it's not just a headache. You don't have to deal with it on your own. It's okay to ask for help and it's okay to speak up about it. And number two, there are many, many treatments. And the most important thing is to find someone that can help you have an individualized treatment. So they're looking at everything, all your individualized medical issues, lifestyle, family history to find something that fits, you know, for you. Working people find you. So I'm on Instagram, I'm on TikTok, headaches and YC. And my website is the same thing as well. Headics and YC.com, my office is in New York City. So if they're in New York, they can come to the office. We'll put everything in show notes for you. Yeah. Thank you so much. Yeah. Thank you. This was really,

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