This week, in the first of two episodes discussing brain health for women, Drs. Daniel Correa and Audrey Nath speak with neurologist Dr. Amy Hessler about neurologic challenges that women may face throughout their lives. Dr. Hessler defines the field of women’s neurology and discusses how female hormones like estrogen and progesterone can affect stroke risk as well as risk for seizures and migraine. She also discusses lifestyle considerations that impact overall brain health for women of all ages and how to focus on improving modifiable risk factors.
Listen to Brain Health for Women, Part Two.
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Episode Transcript
Dr. Nath:
Welcome back to the Brain & Life podcast by the American Academy of Neurology. It's our second brain health episode. Last time we talked about sleep, and today it's all about women.
Dr. Correa:
Wait, is being a woman a perilous, neurologic condition?
Dr. Nath:
Kind of. I could tell you all about how my pregnancies went. But to keep this short, essentially, there's all sorts of ways that female hormones like estrogen and progesterone can affect stroke risk and also conditions like epilepsy and migraine headaches. It's scary, but also fascinating and we've learned so much about these issues recently. There's more treatments available now than ever before.
Dr. Correa:
Absolutely. And we had such a great discussion with women's neurology expert Amy Hessler.
Dr. Nath:
Yes. And since women are so complicated and amazing, we've split this episode into two parts. And in part two coming up soon, we'll discuss epilepsy and multiple sclerosis and special issues with these conditions in women.
Dr. Correa:
And next week, also stay tuned for an interview with Jimmy Choi about competing on American Ninja Warrior with Parkinson's Disease to fundraise for the Michael J. Fox Foundation.
Dr. Nath:
Now, for our discussion with Dr. Hessler.
Today, to learn more about the unique challenges that come with neurological conditions in women during pregnancy and throughout the lifetime, we are joined by a women's neurology expert, Dr. Amy Hessler. She's double-boarded in neurology and epilepsy, soon to be a triple-boarded neurologist with headache specialization, as well. She's passionate about the intersection of OBGYN and neurology and she's in the process of developing a women's neurology clinic Universal Neurologic care in Jacksonville, Florida. She is also a mom and a good friend. Welcome to the podcast, Amy Hessler.
Dr. Hessler:
Thank you so much for having me. It's a pleasure.
Dr. Nath:
To start off, in very broad terms, what is women's neurology?
Dr. Hessler:
Women's neurology is not yet a definite subspecialty of neurology. This is one of my career goals and some of my mentors'. There's actually only two women's neurology specialty practices in the country. One in Pittsburgh and one in Boston. But what someone who specializes in neurology care of women does, is it basically takes care of a woman across her life spectrum. This can be from adolescence to preconception, considering becoming pregnant during pregnancy, and then that postpartum period, and then into that perimenopause and menopausal and older time during life.
What we do, is there are some unique things with women's neurology. These are neurologic diseases that we as neurologists take care of all the time. But what happens is that you superimpose hormonal influences over these disease processes. Obviously, becoming pregnant is specific to a woman, but that's a very small time in her life.
Dr. Nath:
It felt long. But yes.
Dr. Hessler:
I guess it depends on how many babies you had.
Dr. Correa:
Dr. Hessler, what are some of those neurologic problems that a neurologist who has a special attention to treating women and women's health in neurology that they really work on and help their patients manage?
Dr. Hessler:
Unfortunately, there are some neurologic problems that come up in a women's reproductive years, and that's in their twenties to forties. And they're trying to do everything, and be everything for everybody, and work, and have babies and take care of families. And so, diseases such as headaches and the most common type of primary headache is migraine, that can be really problematic. And seizures, but seizures can go across a life course, and so a young girl can develop seizures as an adolescent, but then those can be lifelong. Not always, but sometimes. And then, also disease called multiple sclerosis that occurs more commonly, unfortunately, in women. And during those years where they might be considering starting a family, getting married and having kids.
Dr. Nath:
What are some key considerations that women of all ages need to focus on for their brain health, if there are any that can go throughout the lifespan like that?
Dr. Hessler:
What's really exciting was September 15th, we just had National Brain Health Day, and there was actually a Brain Health Summit for the very first time. And I guess I'm excited about this because I'm part of the American Academy of Neurology's Education Committee and I was just in Minneapolis this weekend and we talked about brain health. And so, your question is really important. It's not just about taking medicines. And we as neurologists think that the brain is the most important organ. And we jokingly say you can have a transplant for a heart, can have a pancreas, you can have kidney transplants, but you can't have a brain transplant.
We have to take care of our brains because we only get one of them and they make us unique people who we are, and have personalities, and get upset, and get happy, and all those things. Besides just taking care of diseases is a big push in medicine is to not be medical, but look at lifestyle. How we eat, the nutrition. What's the fuel we're putting in our bodies? Are we eating a good diet? A colleague of mine actually said she was horrified with what somebody who just had a stroke was getting when they were in the hospital. They were getting fried chicken and biscuits and gravies. And so, do we exercise? Yes, we all know these things, but do we exercise? Do we get good sleep? Paying attention to our bones and making sure we're getting calcium and getting aerobic exercise.
I think all these things as far as lifestyle are really important. Then contribute to brain health. And of course, not using tobacco products. I mean yes, we as doctors preach these things, but I think that this is really important for us. Oftentimes, we as doctors just talk about giving somebody a medication. And I think these lifestyle issues are super duper important and we just really need to focus on those.
Dr. Nath:
This comes up absolutely throughout the lifetime. You mentioned tobacco and cigarettes. When we're counseling young women about birth control and hormonal birth control, we do specifically speak about the link between cigarette smoking and some types of hormonal birth control in the risk of stroke. Can you tell us a little bit more about that?
Dr. Hessler:
Actually, the use of oral birth control worldwide in 2021. 49% of women use oral birth control. In the US, 25% of women that are age 15 to 44 use contraception in the form of oral. Obviously, there's lots of different kinds of birth control now available, but use the pill, as most people call it. And there is increased risk of stroke associated with those hormones that are in birth control. The important thing is with the estrogen containing birth controls, the ones that are just progesterone only don't increase risk of strokes. But we, as neurologists, we always have to be mindful of other risk factors, as well. High blood pressure, and obesity, and diabetes, and cholesterol, and smoking as you were mentioning. We have to be cautious of that and be mindful. And this actually comes up with our patients with migraine, and especially migraine with aura. And you have to be cautious because they have a risk of having stroke, just by the fact that they have this disease process of migraine with aura.
Dr. Nath:
I think I ended up reading about this, because I have migraines, and I started to see those flashing lights, the beginning of the headaches. It's like, "Oh, look at that. I have a migraine with aura now congratulations to me." But it's definitely something that I wanted to bring up again, in case there's patients out there wondering, "Man, why do they keep stressing whether or not I see flashing lights?" That's part of the reason why, is because there is an increased risk of stroke and then with women we then have to think about hormonal birth control, and smoking, and anything else that might further increase risk of stroke.
Dr. Hessler:
And that's why we always ask as neurologists, "Have you ever had this this?" Because if you have it two times you're considered migraine with aura. And this is really important in women because again, it increases your risk of stroke if you have migraine with aura. As I counsel patients with migraine in pregnancy, there are things to be done. And I think sometimes women feel like, "Oh, well, I can't take anything, I just have to suffer." And we want to have healthy moms because if we don't have healthy moms we're not going to have healthy babies.
Dr. Nath:
Along the lines of the stroke, it can be easy to think of stroke as being something that happens in older people. But we hear about cases of stroke happening in younger folks and even in celebrity gossip. We recently heard that Hailey Bieber reported having a transient ischemic attack, a TIA, and she's in her twenties. Essentially, what you're saying in this stroke risk that we keep harping on can affect people in all age ranges, and that's why we really focus on these risk factors.
Dr. Hessler:
I think that sometimes patients feel like we're being a broken record, if you will, talking to them about obesity, and hypertension, and diabetes, and their cholesterol, and smoking. But I think it's important because there are what we call modifiable risk factors. There are things that we can change and there's things we can't. We can't change our age. We can't change our family history. The things we can change is things we can modify. Working on blood pressure, working on controlling diabetes.
Dr. Correa:
Now, previously you mentioned migraine. And one of our production team members, Nicole, had a question about migraine in women's health.
Nicole:
I'm wondering what happens to migraines over the course of a woman's lifespan.
Dr. Hessler:
Nicole, that's an awesome question, because it comes up. And unfortunately migraine affects us as women three times as much as it affects men, which really isn't fair. But there are 35 million people in the US that have migraines, so this is a really common thing that happens. In childhood and adolescence, it's even. And then as a young girl starts her menstrual cycle, her menstrual period, then her risk of headaches and migraine goes up around menarchy, as we call it, and then up through her forties and then it declines after that. The world of headache medicine is actually really exciting. We've had lots and lots of new medicines. Since 2018, there's been seven new headache medicines, and these are headache medicines that they work specifically in the brain and they work specifically for migraine.
Dr. Nath:
These medications you're referring to, the CGRP inhibitors, these are new medicines. Some are taken orally, some are taken by IV. Can a woman take these medicines while pregnant?
Dr. Hessler:
Because they're so new, Dr. Nath, we really just don't know. What's really vitally important is for a woman to talk to her doctor. Here's the great news about migraine. The great news about migraine is that oftentimes migraine gets better during pregnancy. So, then she wouldn't need those medicines. I guess Dr. Nath, when you were saying you were seeing your-
Dr. Nath:
My spots
Dr. Hessler:
And you realize you had migraine with aura. In migraine particularly, that's why we pay attention to that. Because I counsel women that a third of migraines get better, a third get worse, and a third stay the same. In a woman that has migraine without aura, so doesn't have Dr. Nath's experience of flashing lights, then most of the time those headaches get better. Then, to answer your question, to get better, she doesn't need to take those medicines because the headaches are going to get better on their own during pregnancy. But if a woman has migraine with aura, your flashing light experience, Dr Nath, then there's a chance that those can keep going into pregnancy. Where a woman is at the end of her first trimester, so week 13 of her pregnancy, then that's usually how the headaches stay for the rest of her pregnancy.
Back to your question about these new CGRP medicines, we're not recommending, because we just don't know if they're safe during pregnancy. But this is why it's really important for a woman to talk to her neurologist or doctor.
Dr. Correa:
You pointed out a fact that pregnancy's not a light switch in a static state, there's the trimesters. You mentioned the first trimester is one stage. But how do migraines and headaches change throughout those trimesters in the stages of pregnancy?
Dr. Hessler:
Those migraines are better the end of the first trimester, then it'll probably stay that way throughout the rest of her pregnancy. But if they're still problematic and she hits that end of her first trimester, and she's still having them, then we probably should do something to help her. Because I always counsel patients. We don't want a woman throwing up all the time and then becoming dehydrated, and then at risk for the baby not arriving safely. And there's a lot of people that think, "Oh, well, all I can take is Tylenol, Tylenol's it or I just need to grin and bear it. I can't take anything." And there are some safer medications that we can use during pregnancies.
Dr. Nath:
You were talking about how migraines can possibly get better during pregnancy, for example. But there's other things that can happen in a woman's life that also seem to affect migraines and other neurologic conditions. For example, there are patients who report that their migraines seem to fluctuate with their menstrual cycle. Is there anything that you do for that and do you prescribe birth control and does that help?
Dr. Hessler:
That's a tricky one. We call that, Dr. Nath, menstrual migraines. Sometimes we can actually do a short preventative, because we know that it happens. If a woman always starts her menstrual period, let's say, on the 15th of the month, and it's regular every 15th of the month, then usually when those headaches happen around the menstrual cycle is two to three days before, and then two to three days into the menstrual cycle. And what can be really helpful, and maybe a woman might not even know this, is to keep track of those headaches, keep a calendar. Maybe she doesn't even know that there's a pattern and then she realizes. It doesn't have to be a fancy pattern or a calendar. It just can be a piece of paper, print it off the internet, go find a free calendar, and keep track of it. And then we can give her something right around that, right before, and right into her menstrual cycle that can prevent her from having that horrible time starting her menstrual cycle and getting those really bad, debilitating headaches.
Dr. Correa:
That touches on, I think, a key issue that can be helpful for anyone with headaches. And so, what would you recommend to someone, whether it's a woman, a pregnant woman, or just anyone living with headaches? What should they be keeping track of in the calendar, so that when they sit down with their doctor or their neurologist that they have helpful information to pick out a treatment that will help them better?
Dr. Hessler:
If somebody's going to see a neurologist or their primary care doctor about headaches, the month before, keep track of it. Are there any triggers? There can be environmental triggers. Are there certain foods people notice? Like eating that Turkey sandwich, and different chemicals, and foods. Red wine can be a trigger. Are there certain triggers? I love red wine, but I know that every time I have red wine I'm going to get a horrible headache. But just like we were talking about that, before with stroke, I think that there are other things besides medicines that are really important as far as lifestyle, too.
Paying attention to your sleep. Stopping using nicotine. Getting aerobic exercise. Actually, relaxation and biofeedback. And you're asking about anyone, but these can be things that can really help. And there are patients that don't want a prescription. They want to try other things. They want to try some supplements. They might want to try magnesium as a preventative. I actually give that one quite often to pregnant women. I think that we can't forget as doctors, and I think that people need to pay attention to what brings on their headaches, as far as triggers.
Dr. Nath:
I'm glad you brought up some of the supplements, since there are some supplements such as magnesium and riboflavin that actually do have a fair amount of evidence for helping headaches, so I'm really glad you brought that up.
Dr. Hessler:
And some of it's really is controversial, and we worry about some. Just because it's you don't need a doctor's prescription doesn't mean it's safe. Just because anybody could go into Costco or Walmart and get the gigantic bottle of ibuprofen or Tylenol and doesn't need a prescription, when you consume the whole bottle, we worry about taking medication overuse headaches.
Dr. Nath:
So common.
Dr. Hessler:
It's really common, and it can take what we call episodic, it happens every once in a while, an episodic headache and turn it into an ongoing, or what the term we use is a chronic problem. And also, there's other organs that can be affected, too. We want to take care of our kidneys and our liver and we want those to be healthy. Although, we did decide and agree that the brain's the most important organ in body.
Dr. Nath:
Yes, we need the other ones to keep the brain alive.
Dr. Correa:
Exactly. They're all contributors to brain health. So, not every headache is migraine. And you brought up one is medication overuse. Now, one of our other production team members, Rachel, she had a question.
Dr. Hessler:
Oh, great.
Rachel:
I have a friend who had a headache during pregnancy that caused the pressure in her head to increase and affect her vision. What is that condition and how is that different from a migraine?
Dr. Hessler:
What that is probably is a condition called idiopathic intercranial hypertension, or we call it IIH for short. Another term that's used is pseudotumor cerebri. But when somebody has increased pressure, we always need to make sure there's not something else in the brain causing that increased pressure. We as neurologists take a special instrument called a ophthalmoscope, and we look in the back of people's eyes. An ophthalmologist does that as well, but we as neurologists carry those around, too. We like toys in neurology. We look to make sure that there's not that pressure. And what that actually brings up, Rachel, is a good thing.
There's two different kinds of headaches called primary headaches and secondary headaches. Primary headaches are when headache is the disease itself. Migraines, and then actually worldwide tension-type headaches. But we as doctors usually don't see tension-type headaches because they go get a little Tylenol. "I'm stressed out, I've been staring at this computer screen too long, my shoulders hurt." We don't often see them.
And then what your friend had is what's called a secondary headache. It's secondary to something else. We, as neurologists, have to make sure that we're not missing another cause for the headache, because we need to treat that cause and not just treat it like a migraine. We've been talking a lot about migraines, but treat that other cause to improve the headache. With your friend, if it was this condition that I suspect, we also want to make sure that high pressure doesn't cause vision loss, because it pushes on the back of the eye and the back of the eye gets unhappy, and people can have permanent vision loss. There's medications, there's procedures that we can do. But it's really important because if you get permanent vision loss, that's not coming back and that can really be a problem.
Dr. Nath:
Well, thank you so much for helping us go over migraines and secondary headaches and the role of contraceptives. We're going to wrap up for now, but please join us again to discuss some more neurologic conditions over the span of a woman's lifetime.
Dr. Correa:
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.
Dr. Nath:
Also, for each episode, you can find out how to connect with us and our guests along with great resources in our show notes. You can also reach out by email at blpodcast@brainandlife.org. And you can call in anytime and record a question at 612-928-6206.
Dr. Correa:
Follow me, and Audrey, and the Brain & Life Magazine on any of your preferred social media channels.
Dr. Nath:
Special thanks to the Brain & Life team, including.
Dr. Correa:
Nicole Lussier, our Public Engagement Program Manager.
Dr. Nath:
Twin Cities Sound, our audio editing team.
Dr. Correa:
And Andrea Weiss, our Executive Editor for Education and News Publications.
Dr. Nath:
We are your hosts,
Dr. Correa:
Daniel Correa, joining you from New York City and online @NeuroDrCorrea
Dr. Nath:
And Audrey Nath, beaming in from Texas and on Twitter @AudreyNathMDPhD.
Dr. Correa:
Thank you to our community members that trust us with their health and everyone living with neurologic conditions. We hope together we can take steps to better brain health and each thrive with our own abilities every day.
Dr. Nath:
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Dr. Correa:
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Dr. Nath:
Thank you.
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