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We will be starting a three-part series discussing migraines. Migraines fall under the umbrella of fibromyalgia and other central pain sensitivity syndrome problems. Dr. Sarah Chayette. She is a pediatric neurologist. She also loves treating ADHD patients because it's so rewarding to make interventions that can change a trajectory towards success. She graduated magna cum laude in cognitive neuroscience from Princeton University. She received her medical degree from the UCLA David Geffen School of Medicine.
Following specialty training in pediatrics at Cedar Sinai Medical Center in Los Angeles, she did pediatric neurology at Seattle Children's Hospital. She now practices at the Palo Alto Medical Foundation, where she focuses on treating ADHD in both children and adults. She has been a top doctor in San Francisco for the last five years.
She also has written three books on ADHD, which explore its common behavioral symptoms, the biology behind it, and what research has revealed about it, as well as issues faced by parents when considering prescription medications and other treatment approaches. Dr. Cheyette treats people with ADHD, with medication and non-medication strategies such as those outlined in her three books, ADHD in the Focused Mind, winning with ADHD and ADHD, and me.
She and her husband have four children and live in the San Francisco Bay area.
Thank you so much for having me. It's a pleasure to be here. We're going to be talking about ADHD and migraines, and ADHD and migraines are important because many people who have fibromyalgia also have migraines. Research has shown a connection between fibromyalgia and ADHD, and some studies have shown that treating ADHD helps reduce fibromyalgia symptoms. But before we get into that today, can you give us your background? Yeah, Michael. I am a pediatric neurologist by training, which means I deal with the nervous system and stuff that affects the nervous system, mainly kids.
That includes migraines. It also includes ADHD, autism, and several other things. But interestingly, I got into treating ADHD through treating migraines because kids and teens who would come with these really awful headaches sometimes found that they had the ADHD causing them.
And so, in terms of treating headaches, I had to get good at treating ADHD and pay attention to how it influences somebody's life. For those listening, how would you define what a migraine is and how common are they? Well, for both fibromyalgia and ADHD, migraines are probably underrepresented in terms of how common we think they are.
We probably underestimate that because many people with migraines don't go to doctors, so I would say that in America, the official numbers include something like 46 million people with migraines and somewhere along the lines of 15 million with ADHD. Sometimes I feel like they're all coming to my office today, but those numbers are probably both under-represented.
However they're both common, but migraines are more common than ADHD. But these things also overlap with other things that are super common. For example, at least 60 million people are walking around America with sleep disorders, 50 million with anxiety, and 20 million with a significant amount of depression.
Are these all different people? I don't think so. There's a lot of overlap between all these conditions, some of which are found in the same people. Some people may never have had a migraine. Can you describe what a migraine is like and the pathophysiology of a migraine? Sure can. So a migraine is a headache that's intrinsic to the brain.
It's called a primary headache disorder. So it's not a headache because of a tumor, sinusitis, meningitis, or other bad things you can think of. You can think of a migraine as your brain having a little sensitive area, a nest of cells deep in your brain that we can't see, and in certain circumstances, it gets upset. For some people, the circumstance may be not eating, someone else not sleeping, or for someone else, not drinking, stress or where you are on your period, or other things. There are a lot of different factors that could trigger off that little nest of cells. When that little nest of cells gets triggered off, it sends messages to different parts of your brain. Sometimes it sends out pain signals.
The pain is from nerves that go from your brain to your forehead or other parts of your head. Your brain doesn't have any pain sensors, so the pain part of a migraine is from the activation of a trigeminal nerve. But people also can have other symptoms with their migraines.
Some people have vision disturbances, so they might see little spots or be unable to see part of what they're looking at. So, if I were looking at your face, maybe I only see the right side of your face. Kind of strange stuff like that. What's happening in your brain? That nest of cells sends signals to the visual processing area, making that not work.
If you had a machine that measured electrical activity, you would see that the brain's electrical activity would be. Negative at that point. It's just not working very well. It's called a spreading depression, where the brain sort of goes to sleep and doesn't process. Other people have the vomiting center, or the parts of their brain that deal with thinking aren't working.
So it kind of depends on how your brain is wired.
As you said, how your brain is wired is a good segue into looking at the genetics of migraines.
Oh my goodness, you need to pick your parents very carefully because if you have one parent with a migraine, your likelihood of having a migraine is around 50%.
And if both of your parents are migraine people, you have over 90% risk of migraines. So this is something where the genetics of migraines are super important. And sometimes, there's that direct connection with migraines in the family history, but sometimes it is. They may have never been formally told they had migraines, but it might be, well, my mom's got chronic sinus infections.
Neurologists write that 90% of people who think they have sinus headaches are having migraines. You know, it's funny, when they research migraines, they want to be very, very careful to have people with migraines in their studies.
So they're very, very specific about the symptoms that count as. So if you go online and look up migraines, you'll see, you know, they need to be on half your head, have vomiting, or have to last a certain amount of time. Like people in general, I can tell you that migraines don't always fit into the strict research criteria listed. There are many different people with many different migraines, and the connection with genetics is very fascinating.
As a pediatrician and internist, I have seen the whole life spectrum. The migraine is, as you've described.
Some brains are extra sensitive, and when the needed homeostasis is off, such as keeping yourself in a good space, whether it's sleep hygiene, eating healthy, stress, illness, or getting off schedule. Somebody is going to start to have that alarm signal go off, and that threshold for it to go off is at a lower level.
Teenagers and the whole sleepover problem because one of those ten kids are prone to migraines, and you're possibly torturing that person.
Migraines like regular. Regular sleep, and you know what's so frustrating for some people is that they can get through the finals and all the stress. They're fine, and then they get on their vacation, and that change might trigger a migraine.
It's frustrating too. Little sleep triggers off migraines for people, but also, so does too much sleep from people.
Yeah, so many overlaps. And one of the things I wrote about in a chapter in my book is that your fibromyalgia likely didn't start as an adult when it's often diagnosed, often often in childhood.
And interestingly, I'm not sure if you're aware of this, but infantile colic is really on the central pain sensitivity spectrum. And there's a strong connection between babies with colic and other neurologic problems in the family, such as migraine headaches, tension headaches, and restless leg syndrome, which is fascinating.
Colic occurs in about 20% of babies where they're extra sensitive, almost like that post-migraine plateau stage. Yeah. It's hard to get comfortable. This opens the discussion about the family history of other central pain processing problems, awareness of the increased chance of the baby developing these struggles, and the possible need to be vigilant about a healthy, consistent lifestyle.
The baby will likely need a healthier diet and a better sleep schedule. Seeing that connection early and then being aware as you move forward can prevent from an earlier stage instead of waiting until they're 30 years old and feeling helpless.
These migraine attacks seem to come on randomly. Use a headache journal for a few months to determine what causes the headaches.
And, you know, a lot of times, we don't know what causes the headaches. It might be more than one thing.
One way I've heard of thinking about this is if there was a hot air balloon. You know it won't sink if you have a certain amount of weight in it, but if you keep putting different triggers in sinks the balloon, you've got your migraine.
So there are different ways to think about it. I wish there were a pain thermometer. My pain is not your pain. Your pain is not my pain. You know, my ten is not your ten, and your ten is not my 10 in terms of rating scales, especially as you have a kid growing older.
They don't have a good frame of reference. Little kids are very interested in their owies and proud of them. Some people never get past that, of course, but you know, it's hard to understand sometimes what a kid says. You often have to look at their pain behavior with it.
We sometimes wish we had an objective way to look at these things.
It overlaps so much with fibromyalgia because it's highly frustrating for many people feel dismissed that the physician does not fully appreciate their pain.
And there are questionnaires that we can do that look at the impact of chronic headaches, migraines, and fibromyalgia on daily life. And it can be.
And look back to pre-puberty; often, you'll hear a history of chronic abdominal pain. Many people who are listening with fibromyalgia will feel validated because their teachers and parents thought they were trying to escape from school and the classroom.
They were avoiding that on purpose because they were being naughty. They were making up this abdominal pain, and they might have had some academic struggles and were looking for an escape to go to the nurse's room.
Often, these were more abdominal migraines, which may morph into cyclical vomiting on that continuum.
Yes. But you know, I don't have a test for migraines.
If my leg hurts, I can get an MRI or an X-ray to see if it's broken. At least with other kinds of pain, you can see the harm. But that's the frustrating thing about these pain syndromes that you can't show your friends, you can't show your mom c you know, they, they, they feel validated, but it's still hard to talk to other people about that.
So, it is very frustrating. For reasons I don't think anybody fully understands, the stomach and head are where general pain tends to land. Stress from ADHD or other things lands in your head and stomach often. And so I see kids who have grown up with head or stomach pain or both. They also have a feeling of nausea, particularly nausea in the morning. And sometimes, one of the causes is stress. And you get your conditioned response to it. Like, you even think about school, which will start the pain.
And when you look at migraines, they don't have a stigma.
Some medications can treat them quite well, such as triptans. People commonly accept migraines as real. When you do a thorough neurological physical exam which is normal, and have a history of chronic waxing and waning severe headaches, you can firmly say it is a migraine.
We can say you have these migraines. These are real, and I don't have to argue a lot with patients. I wouldn't argue, but convince them they don't have a brain tumor. Because you know, you've had this for four years, since you've been 14, you're 18 years old. If you have a brain tumor, it doesn't suddenly go away in the summer and come back when school starts, for example. But for fibromyalgia patients who are listening, the stigma is pretty strong. And I often use the analogy that migraines are a regional central pain syndrome under the umbrella of overall fibromyalgia often connected with stress.
And as you use that hot air balloon, multiple factors make migraines and fibromyalgia management more challenging than treating strep throat. A lot of physicians don't like getting into it deep because there are so many different factors that contribute to pain. I like the idea you said about keeping a headache diary, looking at routine behaviors like when you went to bed. When did you get up? What is your diet? What stresses are going on?
What's your exercise? Using activity counters can be a good guide. And like you said, often it's different than the day after the sleepover, but it could be Monday morning after the Friday night sleepover. It catches up. It might not be the day you get home from your one-week vacation, but it might be the second or third day as your body's trying to get into more of a routine.
What is the connection that you found between ADHD and migraines? And I am guessing if you're like me, you never had a supervising physician in your migraine specialty clinic during residency that said, hey, we're, we're seeing this patient who's been on all these prophylactic medications and she's still struggling.
Did you ask about her academic history? Have you screened her for ADHD? Like me, that never came up in conversation with your attending. Yeah, not really. Not so much. But part of that is that when I was in training, people didn't talk about ADHD, especially in reasonably high-performing girls.
ADHD was mainly thought of as really severe behavioral issues. You know, hyperactive little boys running around. Inattention was not really felt to be the major issue, or let me rephrase that. Inattention was not really recognized then as much as it is now as a part of ADHD. And so no. This was something I learned going through the experience with my outpatient practice where I started to ask about ADHD, and low and behold. You know, even if it wasn't diagnosed, it certainly seemed to be something we should look more into.
And so, with some screening questions of your concentration, how's your organization? Do you procrastinate a lot? Are you always feeling behind? And you know, that just opened my eyes to the fact that ADHD can underly the amount of stress problems.
If you are like Dr. Cheyette and me, we had to have our eyes open to help understand the other factors and connections with migraine headaches.
We weren't trained on this, but we were passionate about helping our patients get better. We were curious and always wanted to learn more because half of what you learn in medicine changes every seven years. You have to be a lifelong learner, and that's what's drawn Dr. Cheyette and me into medicine because we are very curious, want to help others, and constantly learn more.
We are going to continue this podcast. Series next week and continue the conversation with Dr. Cheyette. We'd love to hear your feedback, and if you have questions based on this episode or other episodes, please email me. Until next week, go Team Fibro.