Brain Function and Migraine Treatment: Answering Your Questions

Episode Transcript

Dr. Correa:
From the American Academy of Neurology. I'm Dr. Daniel Correa.

Dr. Peters:
And I am Dr. Katy Peters. And this is the Brain & Life Podcast.

Dr. Correa:
Welcome back to the Brain & Life Podcast. Once again, we're getting lots of great questions from all of you. So this episode's going to be highlighting some of a discussion with Katy and I about the questions that you are submitting. We want to hear more of those questions and we'd love to hear them in your voice. So please do go ahead and send us voice texts or give us a call. The phone number to call in and leave a voicemail message is in the show notes, and we'll also leave it at the end of the episode. But Katy, we've got so many great questions. What do you think?

Dr. Peters:
I think we just have amazing listeners, and I think it's wonderful that they want to be engaged with us because we want to engage with them. So keep the questions coming.

Dr. Correa:
And I think it's great to answer these questions and have a discussion here for everyone, because we can all learn from each other's questions. And also the Brain & Life magazine at the beginning of every issue, it also addresses questions from the community and readers. So that's another great place where you can take a look at the types of questions other people have and responses that they're getting back from many of our different editors.

Dr. Peters:
It reminds me a lot of our episodes, particularly with our social media influencers like Cole & Charisma and Brooke Eby. They've benefited from having the dialogue with their audiences, and this is a similar situation. And so thanks listeners. Keep on giving us those questions.

Dr. Correa:
Now let's start with a question from Devin, and maybe in these upcoming times when you submit your questions, let us know where you're submitting your question from and where you are. And we'd love to call out our towns and homes, but Devin B wrote to us and asked, "My husband has Alzheimer's late stages. He's now having a hallucination and becomes very agitated with them. I'd like to know how to help and support him with these hallucinations. Thank you."

Dr. Peters:
Well, I think this is a really important point about the non-memory symptom of Alzheimer's disease, Devin. And thank you again for your question. Patients with Alzheimer's disease can have hallucinations, delusions, and paranoia, and all these symptoms are very distressing to the patients and to their loved ones.
And hallucinations are essentially in a phenomenon that involves hearing, or seeing, or smelling, or feeling things that aren't really there. So I did a little research. I also asked my husband who's a psychiatrist, what his thoughts were on this, and I found a nice YouTube link at the National Institutes of Aging about the symptoms and how to manage them. And we'll include the link in our show notes for you.
But I like these five tips. And the first one I think is really critical, and that is to definitely talk with your doctors about new symptoms or illnesses that patients with Alzheimer's can have and any new changes in medications. Sometimes, this could be an illness that may be deemed as simple as a urinary tract infection or possibly maybe new use of antibiotics.
These scenarios could be associated with having hallucinations, delusions, and a condition called delirium, which we see in the hospital. I know Daniel, I've even had a patient with Alzheimer's that had severe constipation and started to have hallucinations. But once we fixed the constipation, the patient's hallucinations got better. So we need to make sure everything is working. Don't you agree?

Dr. Correa:
Yeah. It brings attention if there's a sudden change, particularly in people who have Alzheimer's, other types of neurodegenerative diseases like dementia that is affecting their mental status, or how aware they are of things, or causing hallucinations and illusions, especially if they're disturbing. That's something that just makes sure that it's not a sign of another infection, a medication change, something else throwing things off. Urine being stuck in the bladder or what we call urinary retention and constipation, so our stool being stuck are also major triggers that often people aren't as aware of.
So those are things to be considering. Now, if it's a recurring symptom of another condition that's going on, then I love these kinds of tips and points that Katy was talking about.

Dr. Peters:
So the tip number two is try not to argue with the patient or the person who is seeing or hearing something. You want to comfort the person and make sure they feel safe and they don't feel afraid. Next is you can also try to distract the person. You can move them to another room, maybe going outside for a walk could help, and putting them in really a calm environment.
And this next step is really important too. If they're watching something on television that is violent or if it's an upsetting program, you maybe want to consider not showing those types of things to someone with Alzheimer's, because they may actually interpret that what's happening on the television is happening in the room with them. And this is because they have dysfunction of a particular part of their brain called the parietal lobe, that they misrepresent space and where something is happening.
So definitely think about if the stimuli is overly aggressive, or violent, or upsetting is to make a better environment for them. And really, the most important is make sure the person is safe and also that you're safe, and that person who has Alzheimer's can't use anything to hurt anyone, or himself, or herself. And this includes things like cutlery, a stove potentially, or other objects that could be sharp.

Dr. Correa:
Yeah, and there's other organizations that you may find resources that could be helpful. That includes the Alzheimer's Association. They help support resources for all dementias, not just Alzheimer's. And this is often a discussion that we even help train and teach nurses and other support care providers, what we call basically deescalating and reorienting the person. And this is usually often the first step before thinking about medicines to treat hallucinations, because more medicines might come with more side effects and complications. In some cases, that might be needed to help manage a person's safety and help them have a better quality of life. But we first of course try things without additional medication unless it's necessary.
And I like how these tips focus on supporting the person, redirecting their experience away from the uncomfortable and disturbing experiences. And really, the key thing often and whether that's in the hospital, sometimes in the clinic, or even at home is that that point that you mentioned about moving to a lower stimulating environment or in a safer setting.
And if it's safe, that might mean outside. Like you said, it might just mean a different room in the house. It might be a time for a nice quiet meal or prompting for something, like let's have some tea.
But these are all hopefully some initial helpful ideas. I really encourage you to take a look at the resources from the National Institute on Aging and the Alzheimer's Association.
But for all of our listeners, you want to hear more and learn more about Alzheimer's and other dementias, we've had several different episodes. And I would really like to draw your attention to an episode we did with Greg O'Brien, who he himself is living with Alzheimer's and was a former journalist, and so he kind of gives us an embedded perspective of that. Lauren Miller Rogen talks about supporting her mother and her family's support and time in her life with Alzheimer's and their efforts for advocacy, along with Cynthia Stone and Walt Dawson talk about a documentary that they worked on and many other advocacy initiatives so that more people can learn about Alzheimer's. There's that information and many others on the Brain & Life website.
At the top of the website you'll see that there's a link for disorders A to Z, and under that, you can click a condition that you want to learn more about. And it'll give you a menu of all the different articles from the Brain & Life magazine and also podcasts for that topic. And sometimes, there's more there to click through than I think anyone has time, but it's a place to start and find some topics you're interested in.

Dr. Peters:
All great tips. So our next question is from Jason M. He says, "Hi. Three years ago I had a brain infection that my MRI now shows is gone. I'm still having brain fog and some visual issues. Was hoping you could give me some insight and others who are walking through this." Daniel, what are your thoughts?

Dr. Correa:
Yeah. I mean, a key thing to know is that the MRIs can be helpful early on because they might show us the inflammation. They might show us other changes of swelling and/or even possible scarring that's occurring in the brain. Unfortunately, it's not always the thing that's going to tell us whether or not an infection is there or not.
So it's great that the MRI has improved. That probably means that whatever swelling or inflammation was going on in the irritation of the tissues of your brain has seemed to have gone away. It doesn't necessarily mean that there might not be some still effects. So if you're still noticing symptoms, then that's something to continue to work towards with your rehabilitation.
And this frequent brain fog and other visual symptoms can both be very frequent symptoms that are reported with a variety of different infections that affect the brain, especially if they cause inflammation in the brain. And it's common also as symptoms with other neurologic conditions, but you work with many patients receiving different chemotherapies. It's another thing that people will often describe brain fog and a whole variety of other symptoms. How do you discuss this with your brain cancer patients?

Dr. Peters:
Thank you so much for asking that. This is something we see day to day. And oftentimes, it's a scenario that is similar to Jason's in that the MRI may look good, but the patient still has symptoms. And I think that that's a challenging thing, because they could often use the MRI is almost a visual of something that would be going on, and it is bad or deleterious.
So what I always sort of harken back to is that your brain needs time to recover, whether it's from an infection, or a chemotherapy that caused inflammation, or immunotherapy. Often with brain tumor patients with radiation, which we give, that can cause some acute effects. It also can cause some latent effects, but there is a time of one to six months where they can have some latent inflammation that's not necessarily reviewed on the imaging, but the patients can talk about having some slowness in their memory, some problems with attention.
And so what I go back to is that every patient is different, that recovery doesn't take place in a vacuum, that it's one path. It is several different paths, and it depends on the person, the type of infection, or the type of agent they received. What part of the brain is affected, the extent of the infection in the brain. And this is true also for brain tumors, and also the functional status at time of diagnosis. And this means, how well was your brain working before you went into the situation and what you're getting back to?
And I again, did a little bit of research. And so I was searching online. I found a really interesting article from [inaudible 00:12:03] and colleagues that talks about the neurologic recovery from a virus called West Nile, which many of us have heard of.
And what it talks about, and what I thought was particularly interesting is it really showed that it really needs to be a personalized approach to recovery. So I would encourage Jason M. to look into neurocognitive testing, cognitive rehab, because these are all things that can make those symptoms better over time. And remember that your journey is a personal journey.

Dr. Correa:
That's right. And for some doctors, what we mean by cognitive rehab might be done by what's called occupational therapists. So if you're speaking with your primary care doctor and they're not sure where to send you for that, sending you for occupational therapy may be a great place to start.
And since Jason's question was about brain fog in relation to a brain infection, it reminds me of a discussion we heard on a past episode that we had where we featured a guest host Dr. Payal Patel, she's a pediatric neurologist at the University of Washington who interviewed Dr. Janna Friedly also at University of Washington, where they shared and discussed some of the personalized and rehabilitation approaches that they've been taking towards long Covid, another condition that many people will report and describe brain fog and memory and cognitive changes.
So Jason, this might be of interest to you, and we hope to cover more on different areas for this condition and other areas within cognitive rehab. But please let us know if you have other questions. I'd really appreciate your question and your information.
Now the next question we have is from Casey D. She writes, "How do you feel with short-term memory loss after a brain tumor removal surgery? Is it correctable or improvable at all? We are really looking for help." Casey, I think you teed up a perfect question for Katy, so I'm going to just let her have it.

Dr. Peters:
Thank you, Casey. Hey, this is like a plan. This is a great question for a neuro-oncologist. So Casey D., thank you, thank you, thank you. And of course, as a brain tumor doctor, also known as a neuro-oncologist, short-term memory problems after brain tumor surgery can be helped. And similar to the last question on recovery from a brain infection, recovery varies from person to person, and it depends on some of the same factors.
Things in particular are location of the tumor, the type of tumor, the type of surgery you had, the age of the patient, and the underlying medical conditions, and where your cognition was before you had surgery. And the first important step, and I think Daniel will agree with me on this, is where we have to define what are your personal cognitive challenges and what are your strengths?
And we do this with the help of one of our team members called a neuropsychologist, and they can use a series of neurocognitive tests that are used to determine if what you're describing is a short-term memory issue, or is it really in fact an issue with another part of your cognition? Particularly attention.
I explain this often time in clinic, where it doesn't seem to be a problem with retrieving the memory is that we never had a chance to put the memory in the vault. We never attended to the task that we needed to do to retrieve it.
So after this assessment, we can offer cognitive rehab like we mentioned before. Sometimes, we can do medications that can help with attention. I am so honored and blessed to work alongside our amazing neuropsychologists and psychiatrists that help with our brain tumor patients with this issue. I would also say check out a great article by my colleagues at UCSF. They do a whole article on post-acute cognitive rehab for patients with adult brain tumors, and it's all about what happens after surgery. So definitely check that out, and we'll put a link to that article in the show notes. Daniel, what are your thoughts on this?

Dr. Correa:
I mean, I think it's a great resource, and I like that. Again, we're talking about an individualized approach, getting some more details about where someone was and the challenges that they're having. I think another really important aspect for all of these things, about managing and living with your condition, and improving your quality of life across a variety of different neurologic conditions and symptoms, is you need to also have a clear discussion with your doctors and the other team members that are involved, about what are your goals?
So not just where you were functionally and cognitively beforehand, and the challenges you're having. But right now, where are you thinking that you want to be? With each challenge, where do you foresee yourself getting? And then that way, sometimes that can really help focus, and start off, and say, well, if your real main goal is to make sure that you're not forgetting things around the house or you're having issues managing your calendar, this can help both the neuropsychologist and the therapist really tailor the exercises that you should be doing and to start off with.

Dr. Peters:
And I'd also have you recall the episode we had with Craig Russell. He's the actor that had surgery for a tumor called a meningioma, and he describes that after surgery, he did have some cognitive challenges, particularly with vision and driving. But he is undergoing recovery and doing rehab, and is working with also his friends and family to recover. So check out that episode. I really enjoyed talking to him, and I hope it's a helpful episode for you.

Dr. Correa:
Yeah. And for other episodes about other people's experiences with different types of brain tumors, check out our episodes with David Arons. We had an episode with a doctor who he himself had a type of tumor, Dr. Evan Noch, and then Josh Perry. Those are just a few that are coming up. And again, you can find them both through our podcast, anywhere you're listening to us, but also on the Brain & Life website. You can go specifically to our podcast page or by the different conditions to find our different episodes.

Dr. Peters:
So Daniel, let's go to another question. This one is from Alice C. "I just turned 91, and I have always had great functionality, double woo, yay. But recently I find myself becoming a little bit forgetful and confused. Is there anything I can do to increase or save my brain function at my age?"

Dr. Correa:
I'm just honored that she's reaching out to us, that she's listening to us.

Dr. Peters:
Go Alice.

Dr. Correa:
Amazingly, go you. I think we all have to acknowledge that sometimes depending on the stressors and the different things going on in life, we're going to have things that stress our memory and our attention. This becomes more of a challenge at different ages and life stages or even sometimes after different neurologic conditions.
But Alice, I would suggest start off by checking out our past episode about the different areas in the world where many people live like you, and to platinum and excellent at later life stages and very well or what we call blue zones. There's been many different articles about this in various different places, but also included in a feature of the Brain & Life magazine. We had an episode where we interviewed Dan Buettner, who has been a big proponent and a studier of different blue zones.
And one thing that we've learned from many different aging-related studies and some of these areas of the world is that one of the most important targets to improve our brain health include our sleep, exercise activity, so increasing the number of minutes, the kind of exercises that get you a little bit out of breath. And after you're getting to the point where you're already having 150 minutes or so total a week, but you're no longer getting a little out of breath, then challenge yourself a little bit more, walking a little faster, moving a little bit more intensely. All within the safety and capability of our joints and body.
And working towards what is often described as a Mediterranean-style diet. Doesn't mean you have to be eating food from around the Mediterranean. It's more the type and combination of that diet. So you can find different references that give descriptions, and there are lots of different adaptations for every culture for that.
In addition, it looks like also finding a community to regularly engage with. Whether that's a reading circle, different types of other community events, and a purpose and passion to each day have been found to help improve our brain health at all ages and our quality of life.
I imagine you're already doing some of these. So there's probably a lot that we can learn from you Alice, but I hope that those are great places to start. So move more, sleep as much as you can, and then pick up a direction and purpose and a community to engage with are great places to start.
And the American Heart Association, the American Stroke Association, and the American Academy of Neurology are among many of the people that are working together with researchers, and hospitals, and doctors around the world to help improve and understand how we can address brain health for all of us at every life stage.
Now their next question, we are going to sunny California. Lucille told us where she's at. And Lucille writes, "Hi, I'm located in California and I was reading your podcast transcript about migraines. And I noticed that you had some where you were directly speaking to the accessibility of migraine medication. I've been dealing with migraines for years, and mine are very debilitating. I'm at the point where they've given me stuff to keep out of the emergency room. The problem that I'm having is the accessibility to be able to afford anything other than sumatriptan and Imitrex. Those are two different medication names she suggested there. So in my case, it's extremely expensive. And because of my husband working, I'm not falling into the Medicare income bracket. Do you have any tips or advice for people trying to get into clinical trials or explore other new treatment options?"
Lucille, thank you so much for listening and following the podcast. We've had some great episodes, and I think maybe you're referring to the episode that we had with musician Julia Easterlin. Katy also interviewed photographer Bill Wadman who both shared their experience with migraine, and Julia particularly highlighted some of the challenges of her own to get access not only to headache doctors, but some of the headache medications.
And I think these are areas where it's really important to consider and take a look at maybe seeing if you can get in to see a headache specialist, because they can really help you navigate some of the challenges of medication access and opportunities, some of the medicines themselves, and the companies that make them have vouchers to be able to get you at least to start off, and try a medicine, and see if it works for you. But Katy, you also see many other people who live with chronic headaches, right?

Dr. Peters:
Absolutely. And I think it's really important, the first point that you mentioned, particularly also what Bill Wadman talked about, is you really want to try to get into a headache program and see a headache specialist, because I do think they have that expertise, and they have that extra next step that they may be involved in some clinical trials or know about some access programs.
And I agree with you, Lucille A. Access to medications, really of many different types of neurologic medications is a huge challenge. Now I did some research. I checked out the National Headache Foundation. They actually have a list and a link for clinical trials. It's headaches.org. There's also the American Migraine Foundation. They also had resources for clinical trials. And I think paying for new medications is really a challenge now. Some people are living paycheck to paycheck. We have a level of inflation. Some of these medications that are new on the market are really just out of reach for our patients.
So it's really fascinating to me that there was this article published in the Neurology Journal in 2023 that even though we have new medications, the utilization of new to market medications in neurology is actually quite small. And some of those limitations are because of the cost. What are your thoughts, Daniel?

Dr. Correa:
Yeah. I mean unfortunately, this is the challenge. We are making great advances in the science, but sometimes, and particularly the way the system is, it's a challenge to get people access to some of those newest treatments and interventions or supportive therapies that are out there. It's something that really needs to be addressed not only within Medicare and Medicaid access, but how our support system is designed through our insurance companies.
It's one we could tackle here today, but I think unfortunately now, it's one where it's partly also a big role of your doctors to help you and advocate for you, to identify the medicines that you need and to get them covered by your insurance companies. And that's sometimes a big portion of a doctor's role is getting on the phone with these insurance companies to help get medicines authorized for you. And that's why one of the things that the headache clinics and headache centers have a little bit more resources and specialization in doing that for our patients with chronic headache conditions.

Dr. Peters:
Access is definitely a problem. So we've got a pediatric question, not from a pediatric listener, but from her grandma. So we have a question from Arlene L. She says, "Hi. I have a granddaughter that's two years old, and they found out when she was three or four months that she had a stroke in utero and she is doing well now." Well, that's wonderful news. "A lot of therapies like seven therapies a week with physical occupational speech. And I just wondered if this is common and if you see this in your practices. She's come a long way walking, and saying words, and understanding. So we're hoping she will have a happy and normal life. Her hand is a little bit, she can't use it very well, but we're working on it. So I just wondered if there's anything that you've ever seen. Thank you." Oh my gosh, Daniel, from a grandma. What are your thoughts? I'm an adult neurologist, but this just touches my heart.

Dr. Correa:
Yeah, and I think highlights just the importance, and care, and support we all receive from our grandparents and our broad families. But yeah, unfortunately this is something that every neurologist sees in training when we learn from our pediatric neurology colleagues about all the different neurologic conditions and types of injuries that can occur for children and infants. And as adult neurologists, we also support many people with various different conditions associated with injuries around their birth or conditions with abnormal development after an injury.
As you noted, the rehabilitation, all the different therapies that she's already getting are going to be the key aspect, and really sticking with them and following with a pediatric neurologist who can help identify any issues as they come up, and making sure that your granddaughter is getting the supportive therapy that she needs for the different developmental and life stages that she's at. Katy, what were your experiences seeing some of these children in training?

Dr. Peters:
We definitely had exposure to our pediatric patients, and I really enjoyed that time and those experiences. And at least as a neuro-oncologist, one of the things that we see is we have potentially patients that started to have a brain tumor diagnosis as a child, and now they've become an adult, and sometimes they can have other complications later on.
But in terms of particularly pediatric and utero stroke, those conditions are rare. And it's a very heterogeneous group of disorders, that's really caused by a disruption in the blood flow to the brain during either sometime when they're a fetus or even in that post-natal life up to 28 days.
There is a really serious concern of problems and even mortality for these patients. But I'm just so delighted Arlene now, that your granddaughter is thriving and is doing well. So I would say first of all, congratulations on being a grandmother. You're doing all the right things based on the description, and really rigorous rehabilitation is the key for these patients. Whether it's a patient that had a stroke as a fetus, or a preterm infant, or a term infant. There are many different types of therapy that can happen. There's very early physical therapy. There's also something called constraint-induced movement therapy and non-invasive modulation for those infants and children, because you can't really give them directions like you can give an adult. So you have to think of more innovative ways to interact with the child that may not take verbal instruction. But I'm always so amazed by my pediatric colleagues that know how to make these children recover. So I have all the most hope for Arlene's granddaughter.

Dr. Correa:
Yeah. And to highlight some of the most significant complications and potential injuries that you mentioned, that's in the really short-term period right after the injury. And as I would echo your statement, Katy, that we are so glad to hear that your granddaughter is doing well, and that means that she's already on her path.
I think we can take inspiration from the love and support of the caregivers that help so many different people at all ages with stroke and vascular injuries to their brain recover and live well. And I also take inspiration from some of the podcast episodes that we heard from individuals and/or their family members about how they have survived and lived well.
I interviewed Paola Caruso. She had a childhood vascular injury, and had many complications and challenges with her development along the way. But it's amazing to hear and see her doing so well, and her experiences of how she's taken that to advocate for others.
We also interviewed Timothy Omundson, an actor who had a bad stroke, took him out from his acting for a while, and after rehabilitation has been getting back on screen, along with episodes with Bradley Rose and [inaudible 00:31:30] and her husband Matt, her caregiver, who shared their experience of her stroke and her recovery. So these are all, I think, supportive and inspirational stories that we can look to, to learn more about stroke and other vascular injuries to the brain and really see examples in different paths towards recovery and adapting.
Wow Katy, I think those were some great questions. I'm looking forward to many more, and hopefully hearing the voices of some of our listeners. Really enjoyed that. What did you think?

Dr. Peters:
I thought it was just wonderful, and thank you so much to our listeners for sending in your questions. I agree. Let's hear those voices. You don't want to listen to just us? No, just joking. No. You want to listen to Brain & Life Podcast all the time

Dr. Correa:
And let us know if there's other people in the community that you want to hear from, other individuals, other topics, or even as we said, the questions that you have about living better with different neurologic conditions and quality of life and our brain health for all.

Dr. Peters:
And you can record a voicemail at 612-928-6206.

Dr. Correa:
And you can email us at blpodcast@brainandlife.org, and you'll find all of this in the show notes along with some of the references and resources that we mentioned in this episode. Thank you so much for joining us.
Thank you again for joining us today on the Brain & Life podcast. Follow and subscribe to this podcast so you don't miss our weekly episodes. You can also sign up to receive the Brain & Life magazine for free at brainandlife.org. Don't forget about Brain & Life en Espanol.

Dr. Peters:
Also, for each episode, you can find out how to connect with our team and our guests, along with great resources in our show notes. We love it when we hear your ideas or questions. You can send these in an email to blpodcast@brainandlife.org, and leave us a message at 612-928-6206.

Dr. Correa:
You can also find that information in our show notes, and you can follow Katy and me, and the Brain & Life Magazine on many of your preferred social media channels.

Dr. Peters:
And these episodes would not be possible without the Brain & Life podcast team.

Dr. Correa:
Including Nicole Lucier, our senior manager of public engagement.

Dr. Peters:
Rachel Robertson, our public engagement coordinator. And Twin City Sound, our audio editing partner.

Dr. Correa:
We are your hosts, Dr. Daniel Correa, connecting with you from New York City, and online @NeuroDrCorrea.

Dr. Peters:
And Dr. Katy Peters, joining you from Durham, North Carolina and online @KatyPetersMDPhD.

Dr. Correa:
Most importantly, thank you and all of our community members that trust us with their health and everyone living with neurologic conditions.

Dr. Peters:
We hope together we can take steps to better brain health and each thrive with our own abilities every day.

Dr. Correa:
Before you start the next episode, we would appreciate if you could give us five stars and leave a review. This helps others find The Brain & Life Podcast. See you next week.

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