June 10, 2024 • 57 mins
Join us for an insightful conversation with Dr. Yousaf on pediatric headache care. Discover how his journey from adult neurology to specializing in pediatric headaches is reshaping transition care, and the unique psychosocial and developmental factors that influence young patients.
Learn about the different ways migraine can present in children and how the management varies from adults. We also explore the critical importance of addressing trauma, psychiatric comorbidities, and sleep issues to ensure a smoother transition into adulthood for these patients.
Dr. Yousaf is also involved in Headache Disorders advocacy both nationally and internationally.
You can find him on Twitter/X at @ismail4fanty
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The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr. Michael Kentris (00:01):
Hello and welcome back to the
Neurotransmitters, your sourcefor everything about clinical
neurology.
I'm very happy to have anotherguest today and we are talking
about headache, but not justadult headache, like we have in
the past, a mixture of pediatricand adult and all things in
between.
Would you care to introduceyourself?
Dr. M. Ismail K. Yousaf (00:20):
Hey everybody, my name is Dr Yousaf.
I am a headache fellow at UTAustin Dell Medical School and I
am doing a subspecialization inpediatric headache.
But I also see adult headachebecause I am an adult
neurologist trained atUniversity of Louisville,
kentucky, where I did my fouryears, was chief resident and
(00:42):
also did a mini-fellowship inclinical neurophysiology.
Dr. Michael Kentris (00:45):
Excellent.
Now, when you reached out to mewhen we were first talking, I
was very curious because, as yousaid, you did an adult
neurology program and now you'redoing a pediatric headache
fellowship.
Now that is very unusual.
What led you to that pathway?
Dr. M. Ismail K. Yousaf (01:03):
Yeah, absolutely.
I think when I was doing myneurology residency and I did a
couple of months of childneurology rotation, I was clear
that I want to do headache.
It was something that reallyinterested me.
I wanted to work more on it andit has a very good overlap with
mental health as well.
So that really led me to aclear path.
(01:24):
However, when I did thoserotations, I saw a huge vacuum
and the vacuum lied in thetransition clinic.
I had patients and adolescentscoming 16, 17.
And since there are very fewadult headache providers as well
maybe 700 plus board certifiedor fellowship people didn't know
where to go.
The pathophysiology is kind ofthe same For headaches that's an
(01:46):
edgeysiology is kind of thesame for headaches that's an
edge.
The medications are kind of thesame, though clinical data is
derived from different agegroups.
But that really led me that ifI want to do headache, I want to
do both.
I have my own kids and thatgives me a little bit of
sensitive portion because I wantevery kid to do strong,
(02:07):
academically, athletically.
That also led me to thatportion Plus.
When I saw kids in the clinic,I felt there was a huge need of
counseling.
I felt that I might be able tohelp them with that aspect as
well, as they grow up in theadult side what to expect, how
these diseases will act up wherethey have to lead themselves.
(02:30):
So I think that transitionmight help the community as well
, and that was my goal and thatis my ambition as well.
Dr. Michael Kentris (02:38):
No, those are great points and that's
something I think we've seen.
A lot of subspecialties inneurology I know in my own
background with epilepsy.
Those transition clinics orthose transition stages can be
pretty rocky in some situationsand I was actually just talking
with a pediatric epileptologistabout that self-same thing just
recently and it can be quitechallenging.
So it sounds like you're reallylooking to provide that
(03:01):
lifelong spectrum of care.
Dr. M. Ismail K. You (03:04):
Absolutely so.
When a kid becomes 18, theystay with me, we're not leaving
you, hopefully if they outgrowit.
Dr. Michael Kentris (03:13):
Yeah well, yes, yeah, it sounds like you'll
be in very high demand.
But I'm curious Now.
A lot of times we've talked onthis show about how different
types of headaches can presentin the adult population, but I'm
sure there are someidiosyncrasies in terms of how
migraine or other headachedisorders might present in the
pediatric population.
Both in the very top three.
(03:34):
Presentation is pediatricheadache.
Dr. M. Ismail K. Yousaf (03:37):
So it's that common, though underfunded
.
Still.
I hope we have more resourcesfor that.
And when they come in, beforethey come to the pediatric
headache specialist, they havealready tried a couple of
(03:58):
medications.
So that goes the same with theadult clinic as well.
But what really differs fromthem is, I think, the
psychosocial, economic status.
That we really have to dig deepinto that Trauma-enforced
histories.
As we say that that the headachein kids, how I see it, is like
the tip of the iceberg, I needto uncover the base as well.
(04:21):
I really have to focus on myhistory and make sure there is
no trauma.
Child isolation, brokenfamilies are big another issue
that really gives them not agreat grasp of things, what is
happening.
And the other thing is that weneed to understand that they're
little humans, children, andtheir brain is still progressing
(04:44):
, it's still developing, so theymight not be able to interpret
pain or associated symptoms aswell as adults do.
So we need to be reallyproviding that care and also
giving that repo that hey, weare here to take care of you and
we need to talk more and moreat the subconscious, subliminal
level as well.
So I think that really differsfrom adults as compared to kids.
(05:06):
And as we go deeper and deeper,we realize that those
psychosocial issues are reallyderiving those headaches,
Although migraine is a geneticcondition with more than like
171 genes that we know of.
Dr. Michael Kentris (05:19):
So far but that predisposition from those
factors we really need to workon to get a better result
(05:39):
overall.
A role does that play let's sayyou have a child with pediatric
migraine or something else whenwe're looking at someone who
comes from a home that is splitversus one that isn't?
Dr. M. Ismail K. Yousaf (06:02):
what kind of factors typically play
into inability to get thoseunder better control for the
child?
Absolutely, I think.
Just to put it in perspective,in adults, the top two risk
factors that could createepisodic and chronic is our
depression and obesity.
In kids, psychiatriccomorbidities play a huge role,
huge role, especially anxietyand depression being top two of
(06:22):
them, and another, if I have toadd, which I was surprised, is
actually obstructive sleep apnea.
Dr. Michael Kentris (06:27):
Oh, that is interesting.
Dr. M. Ismail K. Yousaf (06:29):
Yeah, it's more common than I thought.
So if those are undiagnosed andwe are treating the migraine,
we might not be hitting the rootreally.
That's why we have all thesescales MEDAS scale and it is
very much now a kind of standardthat we have to make sure that
depression anxiety skills are inplace when we see patients,
(06:52):
like for every patient, everynew patient.
It's that important.
Let me give you anotherinteresting study fact.
It was in 2003 by Dr Powers andDr Hershey.
They did a great study onquality of life of kids that
live with headaches and thiswill stir a lot of people that
the quality of life of a kidliving with episodic, chronic
(07:13):
both were in the study was notit was at par with a kid living
with cancer, rheumatoidarthritis, and that really
shakes up the whole system thatwe really need to treat them
well.
We really need to see what arethe factors which are really
affecting them and the scorewhich came up was kind of the
(07:37):
same, except there was some fardifferent associations.
But school absenteeism isanother one, academic
performance, sleep.
And which really bothers me themost are the relations with
friends, because those friendsthe school friends everybody
knows are for life.
They remain with you whateverit is, and if you are not having
(08:02):
that rep with friends at a veryearly age, you're losing people
, so that really bothers me aswell it kind of ties into that
social isolation leading todepression.
Dr. Michael Kentris (08:11):
So it kind of all just snowballs down from
there yeah and I am curious, youknow, a lot of times I know
children are referred toneurology clinics for, like you
know, inattentiveness or poorperformance in school or things
like that.
So kind of flipping it around,what percentage if you just had
(08:32):
your own anecdotal experience dowe see that children who are
having these performance issuesin school or behavioral changes
at home that are kind ofunexplained, that we find out,
oh, they're actually havingmigraine?
They just don't have thelanguage to describe what
they're experiencing to theirparents or caregivers.
Dr. M. Ismail K. Yousaf (08:50):
That's a very good question and you
know I'm glad you asked thatbecause when the referral comes
to the headache clinic, they'vealready been to PCP, maybe to a
GI specialist as well, becauseof abdominal pain which could be
functional, or abdominalmigraine.
And when they come to us andwe're like, oh, this is, you
(09:11):
probably are having migraine andwe look into more into that, so
I say in my experience it'salmost 30 to 50%.
Wow.
Dr. Michael Kentris (09:18):
Wow, that's a lot.
Dr. M. Ismail K. Yousaf (09:19):
That when they have been rerouted for
long and then the headache hasbeen underdiagnosed or being
under, you know, not being takenthat seriously as much as it is
, because, see, sinus headacheand tension type headache are
other prime.
You know these are orders whichcould be misdiagnosed, right um
, and in some intention headacheyou can, by the ichth you can
(09:42):
have one of photosensitivity orphonophobia, so that's another
one.
But how I see is that if aheadache is being aggravated by
routine, any activity likeclimbing stairs, walking, it's
probably migraine.
We need to work more on it.
We need to rule that out.
(10:03):
The other interesting part ofthis question is that when they
hear the diagnosis, the migraine, then when the parents state
that yeah, at this age I used tohave those headaches as well,
the light bulb goes off.
Yeah, exactly, and they're likewe wish we knew how to treat at
that point.
Because then it's like a dejavu and they're like if things
(10:26):
you know got better for us, wemaybe we had also academically
pursued better thingsathletically.
Um, and then you tell them thathey, if one parent has migraine
, there is a 50 chance that thekid will have migraine.
If two parents have, there'slike a 75 chance.
It's a genetic condition, withalmost two-thirds of children
(10:46):
being diagnosed with migrainehave a family history of
migraine.
So that is that high.
Dr. Michael Kentris (10:51):
That is, yeah, that is a very important
historical fact and I know, evenin adults.
I ask still people in their 30sand 40s like, do your parents
have migraines or any of yoursiblings?
Because it is such a usefulpiece of information in terms of
coming to a diagnosis.
Dr. M. Ismail K. Yousaf (11:09):
Another piece to the puzzle is the
periodic syndromes that areassociated with migraine, which
include abdominal migraine,cyclic vomiting, proxismal
torticollis.
And another interesting fact bya study shows that if a kid has
abdominal migraine, there's a70% chance that he might develop
migraine.
Dr. Michael Kentris (11:30):
Now for those who might not be as
familiar, could you talk just alittle bit about what abdominal
migraine is?
Dr. M. Ismail K. Yousaf (11:36):
Exactly so.
These are recurrent abdominalpain attacks, not including
headache, and they're more likeperi-embolic, mid-embolic, dull
and sore, moderate to severeintensity, and they can have
migraine features to them.
So this is another thing whichkind of goes misdiagnosed A lot
(12:00):
of times.
A lot of GI workup has beendone, can be associated with
nausea as well, but what reallyworks out well for them is the
treatment for migraine, the waywe treat migraine.
And when a lot of people cometo us parents, especially that
when he was like eight or nine,he will have these really bad
(12:21):
abdominal pain attacks but wedid not know what to do.
Bad abdominal pain attacks, butwe did not know what to do.
And then, interestingly, whenyou go back as well, you will
say, hey, he had infant colic aswell.
So that's another associated andwith an infant colic.
The data so far shows thatthere's a three to four chance
that you will develop migrainein the future and 20% of infants
(12:43):
do have infant colic.
That's another data point.
So we really work on datapoints that how the progression
is and we have to make sure ourhistory is really up to the mark
to know what's going on.
Dr. Michael Kentris (12:57):
Yeah right, it's one of those things.
90% of the diagnosis is goingto be in the story before you do
any testing.
Now we were talking a littlebit about different kind of
migranous phenomena before wehit record and I was wondering
if there are any kind of things.
I know there's several thingsthat can show up more in the
pediatric population than theadult, and some of them can be
(13:20):
quite bizarre.
But what are some of the morecommon or more notable things
that people should keep on theirradar?
If someone's coming in withunusual symptoms, that should
point them maybe towardsconsidering migraine.
Dr. M. Ismail K. Yousaf (13:31):
Right, that's a great point.
I think we'll discuss this as aprimary and secondary headache,
why we should be looking for asecondary headache as well, and
what are the symptoms or redflags?
I'll say that that we have tokeep in mind when we are looking
into the history.
So, obviously, when a parentcomes in with with a kid with a
(13:53):
headache, the first apprehensionis and I I might have to say it
loud is is that a tumor that iscausing those headaches?
So every parent, like everybody, is really apprehensive about
it.
So that's where, first of all,you have to make a very good
formal diagnosis Is this aprimary headache disorder or a
secondary?
(14:13):
For that history, history,history, look for the red flags.
Snoop is a good one, but to beon the fingertips, make sure
there is.
The bigger ones are thatpatient is not waking in the
middle of the night.
It's not having vomiting in themiddle of the night.
The headache is not making thepatient wake in the middle of
(14:33):
the night.
The key point is that if thepatient is sleeping with a
headache and waking in themiddle of the night, it might be
the same headache which iscausing it.
So that's another thing thatyou have to keep in mind.
Then, positional component,just to make sure there is no
component of the posterior fossaor you know anything that is
increasing the intracranialpressure.
(14:53):
Carry one is another one whichagain comes in positional if the
patient stand up, start havingdizziness or vertigo.
You have to make sure that'snot the one.
Remember when a patient sleepsand he and he is telling you
about morning, you have to makesure that's not the one.
Remember when a patient sleepsand he is telling you about
morning headaches, just to makesure there's no increased
intracranial pressure, becausewhen you lie down the pressure
builds up and when you wake upwith a headache in the morning
(15:15):
it's probably you might want tomake sure with a fundoscopy we
are not having any papilledemaaround that.
If a patient stands up and ifhe's dizzy and has headaches,
then you have to make sureintracranial hypotension is
being ruled out.
And another one is carry oneagain that needs to be ruled out
.
So these are all like stringentquestions that we need to ask
them.
I'll give you one interestingexample which we just talked
(15:41):
about, like different scenariosthat can cause these headache
types.
So I have a patient who came inand the mother was like I don't
know what's going on.
He at night, when I'm reading astorybook, tells my mom your
head becomes small and small.
I don't know exactly how totell about it.
(16:02):
And I asked her how many times?
And she's like it happens likeonce or twice a week now.
And when I went deeper into thehistory if there's anything else
that is different she's likeyeah, he goes to karate classes
and for some reason he's justthrowing punches in the air and
kicking in the air, although theperson he has to grapple is
(16:22):
like at least two to three feetbehind, and it doesn't make
sense.
But it lasts for like 10-15seconds and then it goes back to
normal.
Then he told me that, uh, dryou, so when I, when I'm walking
, sometimes I feel the earth iscurving up and I can walk on the
wall as well, and I was likethat's classic alice in
(16:47):
wonderland syndrome.
What's going?
Dr. Michael Kentris (16:49):
on there.
Dr. M. Ismail K. Yousaf (16:50):
We need to, you know, rule out more
things.
Um, and infrequent headache wasin those episodes as well.
So headache was a tinycomponent.
Because of that they came in.
But then when you go into thehistory, there was so much going
on and when such things comeinto play, you really want to
(17:10):
rule out tumor, infection,seizures, anything that is out
of the ordinary.
So out of the ordinary symptomsneed out of the ordinary workup
as well.
That's how I put it.
Ordinary symptoms needout-of-the-ordinary workup as
well.
Dr. Michael Kentris (17:23):
That's how I put it.
I always find that, personally,I struggle with patients who
come in with some of thesestrange phenomena, like the
Alice in Wonderland with thevisual distortions or
abdominal-type symptoms or evenvestibular things that might be
migraine, particularly when theydon't have headache associated
(17:45):
with the actual episode.
How do you go aboutdifferentiating a migrainous
phenomenon versus, say, someother kind of as you said, like
a secondary disorder that mightbe related to more concerning
pathology?
Dr Justin Marchegiani.
Dr. M. Ismail K. Yousaf (18:01):
That's a good question.
First, basically, again, thehistory itself and we really
look for those pertinent pointsphotosensitivity, phonophobia,
osmophobia, movement sensitivity.
A great example is a patientwho comes who might be on autism
spectrum, has developmentaldelays like one of my patients.
(18:29):
He's non-verbal, he's young,he's like six or seven.
I don't have a lot of historybut a pcp thought that hey, he
might be having migraine.
Why?
because he recently startedwearing glasses outside
interesting so these are someclues that you might look after
it.
Um, so when I asked mom, whymom?
What's going on?
What is the whole event thathappens during that?
(18:50):
She's like he starts tapping onhis head like this and then he
doesn't look at light and hewears glasses whenever he goes
outside.
The other thing is the changein the behavior of the patient.
That is something that reallygives us clues, like if the
patient stopped eating, for thatit means he's having probably
(19:10):
anorexia, and then that could benausea itself, that he's not
eating.
Another clue that is that hejust goes towards and turns off
the light and snuggles into mom.
This is another migrainephenomenon.
It means that he'sphotosensitive.
Another thing that I've noticedis that kids start whenever
(19:31):
they hear loud sounds.
They start making loud soundsBecause they're like just stop
it, we can't the phonophobia isoverwhelming them.
They don't know how to convey it.
So really, the history and theclues give those referrals, but
it's challenging overall todifferentiate migraine,
(19:52):
migraineous phenomena, withother symptoms.
Like we talked about GIsymptoms, most of my patients
with abdominal migraine havebeen done a lot of GI workup,
including some of them hadendoscopy, a lot of GI workup,
including some of them hadendoscopy.
I mean, it's that challengingjust to make sure that it's not
(20:13):
something that is GI related.
So I think the workup, thethorough workup, is as natural
to rule out things, and itshould be as well, so you're not
missing.
And sometimes it's as simple asan anemia, which might sound as
anemia.
But to rule out anemia and togo towards anemia requires a lot
of work because these are againphenomena which you can't see,
(20:35):
but only through lab testing.
Um, and that's why anotherthing important in the history
is the social history and sleephistory, which is a a very, very
important point.
I can't stress more.
In sleep history what we like toask is what time do you go to
bed, what time do you wake upand what's the sleep latency?
How long does it take you tosleep?
(20:58):
If a patient says more than 30minutes or 25 minutes, you
should like the bulb should belit up.
It's like what's going on?
Five minutes, you should likethe bulb should be lit up.
It's like what's going on?
Are you having a lot of screentime?
Or are you thinking Somepatients will tell you,
surprisingly no, my legs hurt.
I just feel like there'ssomething going on in my legs.
And then you're like is itrestless leg syndrome?
(21:18):
Do I need to do an iron pal?
Is that really deriving?
Some patients then tell youthat, hey, I can sleep, but I
wake multiple times at night.
And then you're like isheadache waking you up?
It's like no, I really have togo to pee.
I can't control my pee.
Sometimes I wet my bed as well,so that gives you another
(21:38):
direction, then the mostcommonly I hear is snoring,
which has not really been takencare of or asked about a lot
because most kids sleep in theirown rooms.
And then, when I asked aboutsnoring specifically, this is
the first time but he does snoreand then obviously the next
(21:59):
question does he gasp or wakesup in the middle of the night
due to that, or wakes up in themiddle of the night due to that?
And when that happens,obviously then you're like okay,
we need to ask more about OSAfatigue in the morning.
And tonsillar hypertrophy isanother big one that in kids
might not be seen in adults,that we need to rule out to make
(22:20):
sure they're not having a lotof OSA.
Dr. Michael Kentris (22:22):
I know there's been in the news over
the last few years more reportsof increasing childhood obesity.
Do you think that factors a lotinto kind of increasing risk
for different types of headachedisorders as well?
Dr. M. Ismail K. Yousaf (22:35):
Yes, yes, especially, we are always
worried about pseudotumor, abouta pseudotumor, that's something
more than obesity.
It's like the weight gain inshort time that we really are
concerned about as well when momsays that, hey, in six months
he gets 20 pounds and he'sstarting having these headaches.
(22:57):
It could be atypical, like inmale as well.
So that's where we our redflags come up and we ask all
those questions.
But definitely, habits eatinghabit is something we promote as
well.
Do not skip your breakfast One.
We don't really.
(23:18):
I think we should talk a lotmore about saturated food, which
we don't really do.
But what we talk about ishydration.
Our rule of thumb kind of, isone ounce per kilogram, that you
should be drinking that muchwater.
Migraine is extremely sensitiveto dehydration as a trigger, so
we talk about that, whichbrings to me an interesting
(23:41):
point that during summer we arementally prepared that more
patients are going to come.
And an interesting point thatduring summer we are mentally
prepared that more patients aregoing to come Because
dehydration, outside activity,that leads to these phenomenas.
And I kind of have startedtelling my parents that, hey,
things are good.
It's January, february, march,it's outside, it's good.
(24:02):
But let's take it as a win, butwith a grain of salt, because
we want to continue these habitsin the summer as well, or maybe
better habits.
Both schools have theirbaseball season, volleyball
season.
That starts kicking around thattime and then they really
trigger up the migraine overthere.
Dr. Michael Kentris (24:24):
That's a great point.
Obviously, hydration veryimportant in so many aspects of
health, but I think youmentioned the sports aspect too.
Do you find, especially for theadolescent patients, that when
they go from their off-seasonfor their sport of choice to the
on-season, do you see typicallyan increase in headache
frequency in those who may havea pre-existing diagnosis?
Dr. M. Ismail K. Yousaf (24:47):
Yes, we definitely do, and that's where
not only counseling of kid isimportant.
Counseling of parent is veryimportant.
To set the expectations thatthese headaches could work,
especially with athletic kids,that hey, there's a big chance
(25:08):
that these headaches mightworsen, so we need a good cup of
water all the time.
We need a plan in place withthe school as well, especially
with the coaches, that hey, wehave pre-existing diagnosis
which might get worse with time,especially dehydration.
So we have to make sure that wehave all the accommodations in
(25:30):
place.
Secondly, another thing that hashelped my patients is 504 plan
in school, which is basically anaccommodation, but that if the
migraine happens, they can go tothe nurse.
They have the medications inplace.
They should rest for 30 minutesin a dark room, because the
(25:51):
ultimate goal for both athletesand people who go to school is
that they should not come backfrom school to home.
Their academics should notsuffer.
So in place in house.
Those accommodations are superimportant because school
absenteeism leads to a lot ofother problems Peer pressure,
(26:13):
domestic pressure and moremigraine.
To start with, another thing,and just to pearl in athletes we
try to avoid propranolol.
That's another one that makessense.
That's something as a firstline.
We don't give it.
We ask them that, hey, whenyour season is coming, are you
(26:35):
an athlete?
Dr. Michael Kentris (26:37):
We haven't touched much on the
pharmacologic.
I've certainly been talking alot about the non-pharmacologic
aspect of treatment.
For instance in the adult world, the CGRP class of medications,
ben you know kind of the hotstuff for the last you know five
, seven years or so.
How much of that is tricklinginto the pediatric headache
(27:00):
literature and managementpractice in your experience.
Dr. M. Ismail K. Yousaf (27:04):
I'll change the word from crickling
to brewing.
Oh, that's how I want to.
Because I'm a big, I have to bean advocate for CGRPs in kids
as well.
So, you see, they're morerecognized in above 18.
That's where the FDA comes in,right?
But my question is what happensat 18 that suddenly, from 17 to
(27:24):
18, the turn on button happens?
That it's, you know, thepathophysiology is still.
We just have to make sure thesafety and tolerability.
And that's where a lot ofclinical trials I'm also
involved in some.
We are doing our trials, bothpreventive and acute Very
excited, especially after theAmerican Headache Society policy
(27:46):
that came out, which is thatanti-CGRP should be used as
first line.
So that's, yeah, it just cameout like two months ago.
That's very exciting.
That was very exciting news.
Yeah, I saw that we are seeingamazing growth.
See, the evolution of headacheitself is like just like 5,000,
6,000 years ago the headache wasthought to be due to a demon
tau and they used to dotrepanations to make sure the
(28:09):
demon goes out of the head.
And now we have, like once in amonth, shot which can also be
affiliated with Botox.
And just recently, fermanizumaband Botox had a great trial
published in cephalalgia, whichshowed more, better, headache
freedom days.
So we are going in the rightdirection.
(28:30):
I want my kids and adolescentsto go into that direction.
We have to fill the train inthe same direction.
Having said that, we do—.
Dr. Michael Kentris (28:38):
Not advocating for the trepanation
as much anymore.
Dr. M. Ismail K. Yousaf (28:41):
No, no, no, we don't want that.
So we do use off-label, likemost in medicine.
That happens and we see goodresults.
We see, sometimes we have tochange medication as well.
We have to use the sameanti-CZR, like G-pans.
We have Remagipan, rujipan, sowe can change them as needed if
(29:06):
we do not have great results.
But really that's the future,that's the present.
We have to advocate for them,for kids as well.
Once we have more enough data,which I'm pretty sure we are
working on it, I'll tell you oneinteresting fact that when you
have more options, especiallythese with less side effects,
(29:29):
there's a pragmatic approachthat comes on for parents and,
um, the kids, and then they seekthe responsibility and autonomy
to choose from them becausethey know that's more safe,
tolerable, that 100 helps theheadaches as well, because you
are not just going by theguidelines.
Hey, top one to fail.
(29:50):
Now we're going to give youthat, we're not directing you.
When we put the options infront of them and ask them and
give them the responsibility andautonomy as well, we have to
choose one, we have to work withit.
That really helps overall andthat's that's my approach as
well.
Dr. Michael Kentris (30:06):
That's excellent, and we've been
talking about advocacy, butyou're also involved with some
more official advocacy type workas well, if you'd care to talk
about that at all.
Dr. M. Ismail K. You (30:16):
Absolutely , and thank you for asking that.
So I am involved in both atnational level and international
level Thanks to AmericanHeadache Society.
I was this year's AmericanHeadache Society Advocate
Scholar and I went to Headacheon the Hill by the amazing ASDA,
which do a fantastic job as analliance, putting everybody
(30:39):
together and advocate forheadache, migraine, all type of
headaches.
Really.
We go to Capitol Hill,Washington, where we talk to US
Congress, respective Congressand Senate members and their
offices.
This year we were talking aboutthree bills.
We were talking about NIHSafety sorry, NIH Inclusivity
(31:00):
Act, Safe Step Act and thenExcellence, EAS Center for
Headaches, which the bill waspassed as well.
We are very excited about thatand why these bills are so
important because they affect me, you and all the specialities
really, um, so, those three actshopefully we have more uh
people signing them and then Iam involved with gAC, which is
(31:24):
Global Patient AdvocacyCoalition, which has 24
coalition partners, including AN, EN, AHS, and I am trying to do
global outreach, especially fordeveloping countries, to spread
advocacy, making workplacessafe for people with migraine,
making schools, colleges,universities.
So my first endeavor is in myhome country, in Pakistan, in
(31:46):
June, inshallah, and I'll begoing there and talking to media
and places and spreading asmuch as I can.
That's very exciting and Ireally invite everybody to come
to Advocacy Advocacy in clinic.
You can help 24, 20, 15patients a day.
With Advocacy you can helpmaybe more than a million in one
day.
So that's how I put it.
Dr. Michael Kentris (32:07):
Excellent and that is a great point.
We've kind of skirted aroundthe edge of this where we've
talked about how frequentheadache is.
Now I know in the adultliterature it's one of the top
probably three or five reasonsfor missed work days.
I assume probably in PEDS it'sone of the more common reasons
for missed school days as well.
Dr. M. Ismail K. You (32:28):
Absolutely so.
Headache is the second leadingcause of disability years
globally.
It's that important.
And with kids, one of the majorquestions, which also helps us
to know the severity of theheadaches, is how many days have
you missed in a month?
(32:50):
And we get different answers.
I'll tell you one thing, thoughI've seen kids power-throwing
headaches better than adults.
Dr. Michael Kentris (33:00):
They are more resilient in many ways.
Dr. M. Ismail K. Yousaf (33:02):
Yeah, they are more resilient.
So that number might not be thebest number or accurate number,
but if they tell me, hey, twoto three days a month, I won't
be surprised, because two tothree days a month mean really,
really bad headaches.
And that gives my overall planand approach how to really help
(33:26):
people with two to threeheadaches, because we are not
looking for the magic numberfour, that if the magic number
four happens, bad days andthat's when we start a
preventive.
We are looking for really baddays which are affecting the
school days as well.
If there are two or three, Ithink that's enough data for me
as well, because there might be.
Dr. Michael Kentris (33:43):
Yeah, to yeah.
Is that to start a preventiveor to make sure that we have a
rescue plan in place?
Dr. M. Ismail K. Yousaf (33:49):
both, both.
I mean if they are missingthree school days in a month, um
, then you have to dig deeper.
It means the less where amoderate headaches might be
happening as well excellentpoint, yeah because then, if
it's kids, the severe ones willbe, might be associated with
moderate ones, and then theremight be mild ones, so there are
(34:12):
more headache days than whichare being represented in the
talk.
So that really helps me to knowwhat's going on and, with kids,
the prevention.
We love nutraceuticals.
I think they do a great job.
Magnesium it's classified aslevel one by EN 2019 guidelines,
(34:33):
which means less risk of bias,so we kind of taper them up.
As for the weight, we like togo up to 400 milligrams if the
weight is above 40 kilograms or30 kilograms, with the caveat
that it can cause loose stoolsor diarrhea, right, right, if
the weight is above 40milligrams, 40 kilograms or 30
kilograms, um, with with thethat it can cause loose stools
or diarrhea, right, um?
And then the good thing aboutmagnesium is that it has like a
(34:53):
calming property to it, and thenit also affects the nmd
receptors, um, which overallhelps to sleep them better,
gives them less anxiety as well,if I have to really overextend
it.
So magnesium is like the firstline.
Then we have coenzyme q, whichless anxiety as well, if I have
to really overextend it.
So magnesium is like the firstline.
Then we have coenzyme Q, whichworks great as well, and the
third is riboflavin V2.
(35:14):
So I think all these three, wesee how they work on, act on and
then we go from there.
Dr. Michael Kentris (35:21):
Excellent.
No, those are all great.
I know there's plenty of peoplein the adult world who feel the
same way.
It's like I don't really wantto go on a pill.
It's like how about somevitamins Absolutely and
sometimes that can be an easiersell for someone to see if they
benefit from it.
Dr. M. Ismail K. Yousaf (35:33):
And another interesting thing which
I'm glad has come, especiallyfor kids, is the neuromodulation
devices like REN ornon-invasive vagus.
So why they are important aswell, especially the REN or
motor electro, is that they givethe autonomy to the patient.
(35:55):
So REN device is kind of whereyou just stick on your arm for
45 minutes every second day, asa preventive or as an acute as
well for 45 minutes, and it cancome underive or as an acute as
well for 45 minutes, and it cancome under the, under your shirt
as well, and you can just doyour work while you're getting a
preventive treatment.
You can play, you can walk, youcan talk, and my results have
(36:17):
been good so far with it as well.
Um, the other thing about thesedevices is that, um, although
they're still getting approvedby insurance and they're kind of
expensive, still I feelstrongly about it is that the
patient itself, with a lot ofcomorbidities, can be safely
treated with it In adults aswell.
(36:37):
The same goes for adults aswell.
Good point.
So this gives me more range ofchoices, so that really works
well as well.
Dr. Michael Kentris (36:45):
So this might be one of my takeaways
from our conversation today isthat insurance coverage is
causing a gross loss of GDP tothe country overall, due to
their emphasis on escalationtherapy and non-coverage of
effective treatments.
Dr. M. Ismail K. Yousaf (37:03):
Yeah, yeah, that's where one of our
safety acts, safe step act, isas well, which is basically we
are advocating hey, if weprescribe a drug and insurance
prescribes a drug, it says theywill first fail this drug and
then we go to the second.
We're not doing benefit to thepatient, right, we're not doing
(37:29):
benefit to the patient.
We really want to make sure thepatient gets the best treatment
, because I'm using all myclinical acumen, all my med
school, into one place andthat's why the patient is here
to get the best treatment, bestdiagnosis.
But we are really reinventingthe wheel that we are saying,
nah, let's try this first, failfirst, and then we go from there
.
Dr. Michael Kentris (37:46):
Yeah, it's very frustrating, uh, to get
those denials from insurance forwhat you yeah, after much
deliberation and thought andconversation and shared decision
making, have decided is thebest course forward.
Well, let's just tack onanother 30 minutes of
frustrating paperwork to thatthat is true.
Dr. M. Ismail K. Yousaf (38:03):
That is true.
Um, one point I missed onneuromodulation devices, and I
will talk to all my supervisors,and my patients with
comorbidities like potsespecially do well on them.
The pot symptoms get better aswell.
That's very interesting.
Um, I think more research hasto be done.
I talked to some of the leadersin headache about it and they
(38:23):
said it's kind of the samepathways which we are really
treating through those.
So so people who are listening,I think patients with POTS and
bad headaches do think ofneuromodulation devices,
especially Ariane with them.
Dr. Michael Kentris (38:37):
I know, and some of the patients that I
treat, I almost don't evenconsider neuromodulation because
I know their financialsituation is a little tight and
insurance is not going to coverit for the vast majority of them
I think pretty much anyonewho's outside the VA in the
adult world and so it can bechallenging when we know that
(38:57):
there might be this option outthere.
But if they have to shell outseveral thousand dollars it
might as well be on the moon.
Dr. M. Ismail K. Yousaf (39:05):
Yeah, I totally agree.
Agree.
Our job is to be a part of asystem which which has more
accessibility, not more jumpinghurdles to it right.
We have patients which comefrom 70 miles, 60 miles, 80
miles, so if they come here justto hear a denial, after two
(39:29):
hours they leave the office, orthree hours, we're not doing any
service to them.
They might not come the nexttime.
Dr. Michael Kentris (39:35):
Right, right, so we've talked a little
bit about all these issues, asyou said, the entire
biopsychosocial model.
To an extent, I think we'vetouched on a lot of the corners
of that psychosocial model.
To an extent, I think we'vetouched on a lot of the corners
of that.
So we've talked about theinstitutional aspects.
(39:56):
But there's also some otherstigma that comes along.
We've talked about some of theisolation that can happen with
children, the potential loss ofincome in the adult world.
What other kinds of stigma doyou find a lot that people may
be facing, especially in thepediatric, adolescent world,
whether that's from theirschools, the institutions or
even their own family?
Dr. M. Ismail K. Yousaf (40:15):
That's a great question.
I think the inclusivity andequality is another issue.
There have been studies inwhich they show that the Q
treatment might be moreprevalent or given to white kids
as compared to, you know, ofdifferent colors.
That's another stigma that weneed to talk more about and that
(40:35):
, again, is one of the billswhich we talked about is NIH
inclusivity bill.
Why, again, it's important isthat we are requesting and
asking that more people ofdifferent colors and ethnicities
are part of that NIH trials, sothey can come in and we have
more data on it.
Honestly, we don't have data ona lot of.
We don't have data on gendersor ethnicities in different ways
(40:58):
.
One interesting example it's adifferent way to put it, but
interesting example was oximeterduring COVID days, you know.
So oximeter has not been triedwell in people with different
color, so like brown color orblack.
So basically the pigmentationmight be overestimating or
(41:19):
underestimating the oxygensaturation and that's what was
happening.
It's a great point.
Um, so it was giving like plusfour or minus 4%.
Dr. Michael Kentris (41:27):
Which that can be a big deal sometimes.
Dr. M. Ismail K. Yousaf (41:32):
I mean, yeah, from 96 to 92, 92 to 88.
So that model kind of resonatesin headache population as well,
that different genderethnicities might not be coming
up.
Because they might have this,we might not be getting those
adequate treatment options or wemight be taken differently when
we go to the office.
So that's one.
The second thing is thatparents themselves sometimes
(41:58):
think that this is a headacheand it can be treated by
over-the-counter medication.
Or he's malingering or it'sfunctional and they might put
different words to it.
And when it gets really chronicthat they see a school report
coming out that he's notperforming well, then they come
in and then it might be an acutechronic problem.
So I think that responsibilityon parents' part and that's why
(42:22):
awareness is so important alsocomes in In adults.
I would tell you, the stigmalies that are apprehension lies
what if it's something sinister?
Because they have more approachto google or they have, and
sometimes they just want toclose their eyes and don't want
to come.
Dr. Michael Kentris (42:40):
It's like we'll see what happens I know
I've been guilty of that myselfand you know, a lot of times
this happens to doctors yes, I'msure we're some of the worst,
or?
Dr. M. Ismail K. You (42:52):
physicians or health providers.
They're the worst patients, um,so there are a couple of points
that they converge at the samepoint that you need to see a
physician for expertise and see,because, again, migraine is not
curable, we don't have havecure to it, but it's treatable.
Our job is to make sure that,first three months, there's a
(43:13):
50% reduction in your headache,which will resonate in the
quality of life.
Setting the stage is veryimportant here, and once you see
a change in the quality of life, it might be addictive.
That's how we put it.
Hey, I'm feeling better, I'mdoing better, I'm sleeping
better, I can do more work, I'maiming high.
Hope is a dangerous word, butsometimes you have to give these
(43:34):
factual statements to them sothey are more compliant on their
medication, they're workingtowards it and they have the
motivation for it.
Dr. Michael Kentris (43:43):
So that's counter stigma, how I put it
Something I see a lot in youngadults, with that exact
situation where you've started atreatment plan, things are
going well, they're doing great,and then six months to a year
later, all of a sudden they getworse again and you find out
they stopped doing what got themthere in the first place.
They stopped their medicationsor they picked up other bad
(44:06):
habits.
Their medications, or you knowthey picked up other bad habits
and it's like you know.
Then you have to so in the, inthe child population.
Dr. M. Ismail K. Yousaf (44:11):
I think this is fairly common in
adolescence as well, but I wasjust curious what your
experience has been I think withum, I would say less than
adults, um, because they have asupervisor named called peter on
them, so they, they kind of doa good job on that on them, so
(44:33):
they, they kind of do a good jobon that um.
And then I feel I'm gonna say abig word here, but I feel that,
um, the kids are more,adolescents, are more honest as
compared to adults to themselvesthat's, that's a fair statement
.
Dr. Michael Kentris (44:42):
I would say yeah, yeah.
Dr. M. Ismail K. Yousaf (44:44):
So they're more honest, they want
to do well.
It's a competitive as comparedto like 10, 15 years.
It's a pretty competitive worldout there.
So they want to make sure theyreally believe that body is
their temple kind of thing andthey have to take care of that.
So, like I'm in Austin rightnow, it's like the new hub for
software engineers and you knowit's Silicon Valley and brewing.
(45:09):
So over here we see a lot ofadults who are like software
engineers and they have to workall night or work from home.
So they are very cognizant thattheir work is getting affected
by this early 20s.
So they take care well ofthemselves and without any like
a lot of delay, they come to youthat hey, I started having
headache two months ago or onemonth ago as compared to adults.
That hey, I started having aheadache two months ago or one
(45:29):
month ago as compared to adultswho will come.
I've been dealing with eightmonths.
I've been taking a lot ofNSAIDs.
I've been taking maybe anopioid as well from a friend and
it's not working well for me.
And then you start going intotheir history and you'll realize
I've tried this, I've triedthis, I've tried this, but you
don't have any good you knowgood documentation on that?
(45:49):
Yeah, so that's a problem withadults.
Dr. Michael Kentris (45:52):
I will say I'll be guilty about it, they
tend to get themselves into alittle more trouble than the
kids do.
Dr. M. Ismail K. Yousaf (45:56):
Right, right, and I'm sure I mean even
in epilepsy.
Sometimes you will hear aboutpatients who've had these
episodes, sometimes that theymight not report it.
Dr. Michael Kentris (46:07):
Oh yeah, patients who had these episodes,
sometimes that they might notreport it, oh yeah, um so.
So since you mentioned epilepsy, one one thing we were chatting
a little bit about was the, thephenomenon of microlepsy.
Um yeah, now this is a, even inneurology, I think, a bit of an
unutilized, under studiedphenomenon.
But right, uh, just kind of abrief background definition, if
you would Just kind of a briefbackground definition, if you
(46:29):
would?
Dr. M. Ismail K. You (46:29):
Absolutely so.
I totally agree.
It's not used that often, it'snot recognized as well, but it's
something that my supervisors,like Dr Samantha Irvin and Dr
Pavit I've seen them use theword and that's how I got
cognizant about it as well,because if a patient comes and
he says, hey, I'm startinghaving these atypical symptoms
(46:53):
in which I see flashes of light,right like an aura symptom, but
I see with colors, I also seedistortion of objects and with I
have after that I have reallyintense pain but then my head
becomes foggy.
I have to.
(47:14):
Really I don't know what'sgoing on and I lose time.
That doesn't sound reallymigraine to me.
I mean, there are some aspectsto it with an aura, but losing
time, foggy brain and thentaking another two to three
hours to get back to myself, Imean the prodrome is there in
migraine.
You can have fatigue, butamnesia coming along.
(47:35):
It really should make you thinkabout post-tectal headaches
versus my microlepsy oxbow.
So in these patients I have avery low threshold to rule out
microlepsy and and get an EEG.
Dr. Michael Kentris (47:48):
It's really challenging because we know
that, for someone who hasfocal-aware seizures, the
sensitivity of EEG can be quitepoor.
Dr. M. Ismail K. Yousaf (47:57):
Right, I totally agree, and that's why
I have patients where I wentfrom routine to sleep-deprived
to EMU.
I really had to escalate slowlyright to find something because
, as you said, the sensitivityis low.
But somehow or the other, whenI ever talked, epileptology is
like this this discharge looks alittle concerning, right.
(48:20):
We need to dig more into thatbecause I have to be cognizant
that epilepsy drugs might be along-term commitment.
So before starting that, if thesymptoms are not that grave, I
have to make sure that I'm doingmy homework.
So I don't shy away fromtesting in these instances,
(48:43):
because if I get that right,that's more benefit than I get
it wrong or leave it as it is.
Because again, again, theneurologist appointment you
might not get for three to fouror six months right.
So I have to make sure that I'mdoing my work and I'll try my
best to justify in my notes.
Dr. Michael Kentris (48:58):
Insurance doesn't deny it right, like he's
here for a headache.
Why are you wearing all theseegs?
Exactly, exactly but I meanpathophysiologically, there is
some reasonable mechanism.
Right, we have the spreadingcortical depression with
migraine, absolutely Obviously.
We know cortical hyperactivityis something we see with
epilepsy and then like apostictal suppression.
So why couldn't they looksimilar theoretically?
Dr. M. Ismail K. Yousaf (49:21):
Exactly , and that's what made me think
more about migraine lepsi,because if the CSD is what we
think is deriving the aura andthe migraine itself, it could be
deriving the seizures itself aswell.
So there is an overlap andagain, the threshold is low to
make sure that because, see,with migraine drugs you can't
(49:43):
treat seizures.
With seizure drugs you might betreating some of the headaches,
some of them.
Dr. Michael Kentris (49:48):
Yeah yeah, drugs.
You might be treating some ofthe headaches.
Dr. M. Ismail K. Yousaf (49:50):
Right, some of them, yeah, yeah,
exactly.
It could be worse, but it'sbetter to find the answer or be
in the pursuit of an answerquicker than later.
Just again, you never know Oneof the parents comes in and he
says yeah, when I was in my 20sI had these symptoms, but I wish
I had the diagnosis before Ibecame vocally generalized.
Dr. Michael Kentris (50:13):
Yeah, there's definitely all these
borderland types of syndromeswhere it's like well, is this a
migraine, is this a seizure?
I just had a conversation aboutamyloid spells and seizures
recently.
Dr. M. Ismail K. Yousaf (50:26):
Yeah, that was very fascinating, and
seizures recently and it's likeall these, yeah, that was very
fascinating.
Dr. Michael Kentris (50:28):
There's all these things that you know it's
all related, right?
There's only so many ways thebrain can manifest these kind of
epiphenomena to our sensorium,so it's just fascinating.
You get these convergence ofdifferent phenomena presenting
in very similar ways fromperhaps markedly different
(50:49):
underlying causes 100% agreed.
Dr. M. Ismail K. Yousaf (50:54):
I mean, I tell my friends who are very
interested in neurosciences Isay that as much of a powerhouse
brain is, with 10 trillionnerves in it, it's kind of a
little bit of a dumb existenceof it as well, because it
doesn't know when to ask forhelp.
Brain doesn't know.
(51:15):
It's a brain right.
So that really, um.
And then another good examplewhich I heard from one of my
supervisors is that hey, what'sthe natural phenomena of skin if
it gets injured, it's that itwill swell or it will bruise.
Brain doesn't have a naturalphenomena.
When it gets stressed, it cangive you a ray of symptoms, and
(51:39):
that's why neurosciences is socomplex and challenging at times
, especially epilepsy, um, thatyou really have to dig out what
symptoms you might get.
Dr. Michael Kentris (51:50):
Yeah, just an angry bowl of pudding up
there, I agree.
Now, obviously, it seems likeyou derive a lot of satisfaction
from helping these patientsgetting quality of life improved
across the entire spectrum ofthe lifetime.
What's your, beyond just thosemeager pieces?
(52:12):
What is your pitch for peoplewho might be considering going
into headache medicine?
Dr. M. Ismail K. Yousaf (52:17):
Thank you for asking that.
So a lot of doctors look forsatisfaction in the results and
they think with headache youmight not not get results and,
if I may dare say that, headachemight be a stigma, neurologist
as well.
Like seeing headache patients,I've I've seen that that they're
(52:37):
not really excited about itdefinitely is.
I can assure you you'll seeresults.
I'll assure you people will befull of gratitude because you
helped them.
The most common comment youmight hear from people who you
really are able to help is that,due to better treatment, our
(52:59):
whole household has changed.
We are better as a home, as afamily, and there's not once
I've heard that it's like now weare looking for vacation.
Now we are looking for vacation.
Now we are looking to forbetter, you know, ambitions for
our kids.
So you're not helping oneperson, you're helping a lot of
people.
Then, luckily, we're not in theera of trepanations anymore, we
(53:19):
are in the era of ccrps.
So since 2018 we're, we havebetter options and headache is
really evidence andresearch-based.
If you are looking for both,this is the way forward.
We have ever-newcoming research, researches every day, almost
(53:40):
every day.
Cephalalgia headache is doing agreat job, which kind of is
interesting for our headacheboards because there's so much
going on that we have to read alot as well.
But if you want both clinicaland research acumen, the way
forward it is, and the otherthing is that it's a great
practice.
You can do outpatient all year.
You can really fabricate yourpractice the way you like.
(54:03):
You want to do procedures.
We have nerve blocks, we haveBotox, with great results as
well.
The satisfaction rate is goodas well.
And then the patient populationwhich you see is some
population which be only betreated by you.
That's another interesting partof it that they might be coming
(54:25):
from different referrals, butyou are the person who might be
able to help them.
So I think there's a lot ofgratitude involved in that as
well, and some patients mightgive you free cookies as well.
Dr. Michael Kentris (54:35):
That's excellent.
I always like to emphasizeright headache is one of those
multidisciplinary specialties,right, we tend to think of it as
a neurology subspecialty, whichI'm biased, I do think of it as
that.
But it's also open to peoplewho have done residencies in
internal medicine, familymedicine and various other like
anesthesia, I think even ENT.
(54:56):
So there are a broad range ofspecialists who, if they, over
the course of their training,become fascinated with headache,
they can further their clinicalskills and become one of these
very rare headache specialistsin the country.
Dr. M. Ismail K. Yousaf (55:13):
I totally endorse that.
Our last fellow was a familyphysician who did headache.
Cleveland Clinic Ohio chairmanis a psychiatrist who did
headache.
So there are so many examplesaround who people who do
headache offer differentspeciality because there's so
much overlap.
Again, it's the tip of theiceberg.
Seize this that way you have somany aspects to cover,
(55:35):
comorbidities to cover, and thenthe interesting aspect is,
despite all these comorbidities,aspects, again, you might be
the person who's going to helpthem and derive and get better
at all those comorbidities, evenwho's?
Dr. Michael Kentris (55:49):
going to help them and derive and get
better at all thosecomorbidities.
Even that's excellent.
It's been a very upliftingconversation, Dr Yusuf.
I really appreciate you talkingabout your perspective on
headache.
It's always very refreshing tohear from someone who's so full
of passion about what they do.
If people want to find youonline or find some resources
where, would you recommend thatthey look around or?
Dr. M. Ismail K. Yousaf (56:08):
find some resources.
Where would you recommend thatthey look around?
Absolutely so.
I'm on X, formerly known asTwitter.
I'm I-S-M-A-I-L, the mark forF-A-N-T-Y.
I do a lot of advocacy forinternational medical graduates.
I have a group as well.
30% of neurologists areinternational medical graduates
in the US.
We all work together.
(56:29):
We have a great fraternity as aneurologist as well, so you can
always direct message me overthere.
I have my email that isyusafgpaccom.
You can email me there.
So I'm always always happy tohelp people together.
(56:51):
Um, so I'm always always happyto help people.
Um.
Whoever want to get in touchwith me regarding future
counseling, career counseling,headaches, we can have a chat.
Maybe the coffee is going to beon you, but we can have a chat
that's excellent.
Dr. Michael Kentris (57:01):
Thank you so much, uh, and like uh, dr
yusuf, you can find me also on x.
Uh, I'm at dr kR-K-E-N-T-R-S.
Dr Kentris, and you can alsofind our podcast feed at neuro
underscore podcast, and you canreach out to us through our
website or find other resourcesat theneurotransmitterscom.
Dr Youssef, thank you again, ithas been an absolute pleasure.
Dr. M. Ismail K. Yousaf (57:22):
Dr MK.
What a great session we had.
I'm so thankful to you.
Thank you very much.
Hello and welcome back to the
Neurotransmitters, your sourcefor everything about clinical
neurology.
I'm very happy to have anotherguest today and we are talking
about headache, but not justadult headache, like we have in
the past, a mixture of pediatricand adult and all things in
between.
Would you care to introduceyourself?
Dr. M. Ismail K. Yousaf (00:20):
Hey everybody, my name is Dr Yousaf.
I am a headache fellow at UTAustin Dell Medical School and I
am doing a subspecialization inpediatric headache.
But I also see adult headachebecause I am an adult
neurologist trained atUniversity of Louisville,
kentucky, where I did my fouryears, was chief resident and
(00:42):
also did a mini-fellowship inclinical neurophysiology.
Dr. Michael Kentris (00:45):
Excellent.
Now, when you reached out to mewhen we were first talking, I
was very curious because, as yousaid, you did an adult
neurology program and now you'redoing a pediatric headache
fellowship.
Now that is very unusual.
What led you to that pathway?
Dr. M. Ismail K. Yousaf (01:03):
Yeah, absolutely.
I think when I was doing myneurology residency and I did a
couple of months of childneurology rotation, I was clear
that I want to do headache.
It was something that reallyinterested me.
I wanted to work more on it andit has a very good overlap with
mental health as well.
So that really led me to aclear path.
(01:24):
However, when I did thoserotations, I saw a huge vacuum
and the vacuum lied in thetransition clinic.
I had patients and adolescentscoming 16, 17.
And since there are very fewadult headache providers as well
maybe 700 plus board certifiedor fellowship people didn't know
where to go.
The pathophysiology is kind ofthe same For headaches that's an
(01:46):
edgeysiology is kind of thesame for headaches that's an
edge.
The medications are kind of thesame, though clinical data is
derived from different agegroups.
But that really led me that ifI want to do headache, I want to
do both.
I have my own kids and thatgives me a little bit of
sensitive portion because I wantevery kid to do strong,
(02:07):
academically, athletically.
That also led me to thatportion Plus.
When I saw kids in the clinic,I felt there was a huge need of
counseling.
I felt that I might be able tohelp them with that aspect as
well, as they grow up in theadult side what to expect, how
these diseases will act up wherethey have to lead themselves.
(02:30):
So I think that transitionmight help the community as well
, and that was my goal and thatis my ambition as well.
Dr. Michael Kentris (02:38):
No, those are great points and that's
something I think we've seen.
A lot of subspecialties inneurology I know in my own
background with epilepsy.
Those transition clinics orthose transition stages can be
pretty rocky in some situationsand I was actually just talking
with a pediatric epileptologistabout that self-same thing just
recently and it can be quitechallenging.
So it sounds like you're reallylooking to provide that
(03:01):
lifelong spectrum of care.
Dr. M. Ismail K. You (03:04):
Absolutely so.
When a kid becomes 18, theystay with me, we're not leaving
you, hopefully if they outgrowit.
Dr. Michael Kentris (03:13):
Yeah well, yes, yeah, it sounds like you'll
be in very high demand.
But I'm curious Now.
A lot of times we've talked onthis show about how different
types of headaches can presentin the adult population, but I'm
sure there are someidiosyncrasies in terms of how
migraine or other headachedisorders might present in the
pediatric population.
Both in the very top three.
(03:34):
Presentation is pediatricheadache.
Dr. M. Ismail K. Yousaf (03:37):
So it's that common, though underfunded
.
Still.
I hope we have more resourcesfor that.
And when they come in, beforethey come to the pediatric
headache specialist, they havealready tried a couple of
(03:58):
medications.
So that goes the same with theadult clinic as well.
But what really differs fromthem is, I think, the
psychosocial, economic status.
That we really have to dig deepinto that Trauma-enforced
histories.
As we say that that the headachein kids, how I see it, is like
the tip of the iceberg, I needto uncover the base as well.
(04:21):
I really have to focus on myhistory and make sure there is
no trauma.
Child isolation, brokenfamilies are big another issue
that really gives them not agreat grasp of things, what is
happening.
And the other thing is that weneed to understand that they're
little humans, children, andtheir brain is still progressing
(04:44):
, it's still developing, so theymight not be able to interpret
pain or associated symptoms aswell as adults do.
So we need to be reallyproviding that care and also
giving that repo that hey, weare here to take care of you and
we need to talk more and moreat the subconscious, subliminal
level as well.
So I think that really differsfrom adults as compared to kids.
(05:06):
And as we go deeper and deeper,we realize that those
psychosocial issues are reallyderiving those headaches,
Although migraine is a geneticcondition with more than like
171 genes that we know of.
Dr. Michael Kentris (05:19):
So far but that predisposition from those
factors we really need to workon to get a better result
(05:39):
overall.
A role does that play let's sayyou have a child with pediatric
migraine or something else whenwe're looking at someone who
comes from a home that is splitversus one that isn't?
Dr. M. Ismail K. Yousaf (06:02):
what kind of factors typically play
into inability to get thoseunder better control for the
child?
Absolutely, I think.
Just to put it in perspective,in adults, the top two risk
factors that could createepisodic and chronic is our
depression and obesity.
In kids, psychiatriccomorbidities play a huge role,
huge role, especially anxietyand depression being top two of
(06:22):
them, and another, if I have toadd, which I was surprised, is
actually obstructive sleep apnea.
Dr. Michael Kentris (06:27):
Oh, that is interesting.
Dr. M. Ismail K. Yousaf (06:29):
Yeah, it's more common than I thought.
So if those are undiagnosed andwe are treating the migraine,
we might not be hitting the rootreally.
That's why we have all thesescales MEDAS scale and it is
very much now a kind of standardthat we have to make sure that
depression anxiety skills are inplace when we see patients,
(06:52):
like for every patient, everynew patient.
It's that important.
Let me give you anotherinteresting study fact.
It was in 2003 by Dr Powers andDr Hershey.
They did a great study onquality of life of kids that
live with headaches and thiswill stir a lot of people that
the quality of life of a kidliving with episodic, chronic
(07:13):
both were in the study was notit was at par with a kid living
with cancer, rheumatoidarthritis, and that really
shakes up the whole system thatwe really need to treat them
well.
We really need to see what arethe factors which are really
affecting them and the scorewhich came up was kind of the
(07:37):
same, except there was some fardifferent associations.
But school absenteeism isanother one, academic
performance, sleep.
And which really bothers me themost are the relations with
friends, because those friendsthe school friends everybody
knows are for life.
They remain with you whateverit is, and if you are not having
(08:02):
that rep with friends at a veryearly age, you're losing people
, so that really bothers me aswell it kind of ties into that
social isolation leading todepression.
Dr. Michael Kentris (08:11):
So it kind of all just snowballs down from
there yeah and I am curious, youknow, a lot of times I know
children are referred toneurology clinics for, like you
know, inattentiveness or poorperformance in school or things
like that.
So kind of flipping it around,what percentage if you just had
(08:32):
your own anecdotal experience dowe see that children who are
having these performance issuesin school or behavioral changes
at home that are kind ofunexplained, that we find out,
oh, they're actually havingmigraine?
They just don't have thelanguage to describe what
they're experiencing to theirparents or caregivers.
Dr. M. Ismail K. Yousaf (08:50):
That's a very good question and you
know I'm glad you asked thatbecause when the referral comes
to the headache clinic, they'vealready been to PCP, maybe to a
GI specialist as well, becauseof abdominal pain which could be
functional, or abdominalmigraine.
And when they come to us andwe're like, oh, this is, you
(09:11):
probably are having migraine andwe look into more into that, so
I say in my experience it'salmost 30 to 50%.
Wow.
Dr. Michael Kentris (09:18):
Wow, that's a lot.
Dr. M. Ismail K. Yousaf (09:19):
That when they have been rerouted for
long and then the headache hasbeen underdiagnosed or being
under, you know, not being takenthat seriously as much as it is
, because, see, sinus headacheand tension type headache are
other prime.
You know these are orders whichcould be misdiagnosed, right um
, and in some intention headacheyou can, by the ichth you can
(09:42):
have one of photosensitivity orphonophobia, so that's another
one.
But how I see is that if aheadache is being aggravated by
routine, any activity likeclimbing stairs, walking, it's
probably migraine.
We need to work more on it.
We need to rule that out.
(10:03):
The other interesting part ofthis question is that when they
hear the diagnosis, the migraine, then when the parents state
that yeah, at this age I used tohave those headaches as well,
the light bulb goes off.
Yeah, exactly, and they're likewe wish we knew how to treat at
that point.
Because then it's like a dejavu and they're like if things
(10:26):
you know got better for us, wemaybe we had also academically
pursued better thingsathletically.
Um, and then you tell them thathey, if one parent has migraine
, there is a 50 chance that thekid will have migraine.
If two parents have, there'slike a 75 chance.
It's a genetic condition, withalmost two-thirds of children
(10:46):
being diagnosed with migrainehave a family history of
migraine.
So that is that high.
Dr. Michael Kentris (10:51):
That is, yeah, that is a very important
historical fact and I know, evenin adults.
I ask still people in their 30sand 40s like, do your parents
have migraines or any of yoursiblings?
Because it is such a usefulpiece of information in terms of
coming to a diagnosis.
Dr. M. Ismail K. Yousaf (11:09):
Another piece to the puzzle is the
periodic syndromes that areassociated with migraine, which
include abdominal migraine,cyclic vomiting, proxismal
torticollis.
And another interesting fact bya study shows that if a kid has
abdominal migraine, there's a70% chance that he might develop
migraine.
Dr. Michael Kentris (11:30):
Now for those who might not be as
familiar, could you talk just alittle bit about what abdominal
migraine is?
Dr. M. Ismail K. Yousaf (11:36):
Exactly so.
These are recurrent abdominalpain attacks, not including
headache, and they're more likeperi-embolic, mid-embolic, dull
and sore, moderate to severeintensity, and they can have
migraine features to them.
So this is another thing whichkind of goes misdiagnosed A lot
(12:00):
of times.
A lot of GI workup has beendone, can be associated with
nausea as well, but what reallyworks out well for them is the
treatment for migraine, the waywe treat migraine.
And when a lot of people cometo us parents, especially that
when he was like eight or nine,he will have these really bad
(12:21):
abdominal pain attacks but wedid not know what to do.
Bad abdominal pain attacks, butwe did not know what to do.
And then, interestingly, whenyou go back as well, you will
say, hey, he had infant colic aswell.
So that's another associated andwith an infant colic.
The data so far shows thatthere's a three to four chance
that you will develop migrainein the future and 20% of infants
(12:43):
do have infant colic.
That's another data point.
So we really work on datapoints that how the progression
is and we have to make sure ourhistory is really up to the mark
to know what's going on.
Dr. Michael Kentris (12:57):
Yeah right, it's one of those things.
90% of the diagnosis is goingto be in the story before you do
any testing.
Now we were talking a littlebit about different kind of
migranous phenomena before wehit record and I was wondering
if there are any kind of things.
I know there's several thingsthat can show up more in the
pediatric population than theadult, and some of them can be
(13:20):
quite bizarre.
But what are some of the morecommon or more notable things
that people should keep on theirradar?
If someone's coming in withunusual symptoms, that should
point them maybe towardsconsidering migraine.
Dr. M. Ismail K. Yousaf (13:31):
Right, that's a great point.
I think we'll discuss this as aprimary and secondary headache,
why we should be looking for asecondary headache as well, and
what are the symptoms or redflags?
I'll say that that we have tokeep in mind when we are looking
into the history.
So, obviously, when a parentcomes in with with a kid with a
(13:53):
headache, the first apprehensionis and I I might have to say it
loud is is that a tumor that iscausing those headaches?
So every parent, like everybody, is really apprehensive about
it.
So that's where, first of all,you have to make a very good
formal diagnosis Is this aprimary headache disorder or a
secondary?
(14:13):
For that history, history,history, look for the red flags.
Snoop is a good one, but to beon the fingertips, make sure
there is.
The bigger ones are thatpatient is not waking in the
middle of the night.
It's not having vomiting in themiddle of the night.
The headache is not making thepatient wake in the middle of
(14:33):
the night.
The key point is that if thepatient is sleeping with a
headache and waking in themiddle of the night, it might be
the same headache which iscausing it.
So that's another thing thatyou have to keep in mind.
Then, positional component,just to make sure there is no
component of the posterior fossaor you know anything that is
increasing the intracranialpressure.
(14:53):
Carry one is another one whichagain comes in positional if the
patient stand up, start havingdizziness or vertigo.
You have to make sure that'snot the one.
Remember when a patient sleepsand he and he is telling you
about morning, you have to makesure that's not the one.
Remember when a patient sleepsand he is telling you about
morning headaches, just to makesure there's no increased
intracranial pressure, becausewhen you lie down the pressure
builds up and when you wake upwith a headache in the morning
(15:15):
it's probably you might want tomake sure with a fundoscopy we
are not having any papilledemaaround that.
If a patient stands up and ifhe's dizzy and has headaches,
then you have to make sureintracranial hypotension is
being ruled out.
And another one is carry oneagain that needs to be ruled out
.
So these are all like stringentquestions that we need to ask
them.
I'll give you one interestingexample which we just talked
(15:41):
about, like different scenariosthat can cause these headache
types.
So I have a patient who came inand the mother was like I don't
know what's going on.
He at night, when I'm reading astorybook, tells my mom your
head becomes small and small.
I don't know exactly how totell about it.
(16:02):
And I asked her how many times?
And she's like it happens likeonce or twice a week now.
And when I went deeper into thehistory if there's anything else
that is different she's likeyeah, he goes to karate classes
and for some reason he's justthrowing punches in the air and
kicking in the air, although theperson he has to grapple is
(16:22):
like at least two to three feetbehind, and it doesn't make
sense.
But it lasts for like 10-15seconds and then it goes back to
normal.
Then he told me that, uh, dryou, so when I, when I'm walking
, sometimes I feel the earth iscurving up and I can walk on the
wall as well, and I was likethat's classic alice in
(16:47):
wonderland syndrome.
What's going?
Dr. Michael Kentris (16:49):
on there.
Dr. M. Ismail K. Yousaf (16:50):
We need to, you know, rule out more
things.
Um, and infrequent headache wasin those episodes as well.
So headache was a tinycomponent.
Because of that they came in.
But then when you go into thehistory, there was so much going
on and when such things comeinto play, you really want to
(17:10):
rule out tumor, infection,seizures, anything that is out
of the ordinary.
So out of the ordinary symptomsneed out of the ordinary workup
as well.
That's how I put it.
Ordinary symptoms needout-of-the-ordinary workup as
well.
Dr. Michael Kentris (17:23):
That's how I put it.
I always find that, personally,I struggle with patients who
come in with some of thesestrange phenomena, like the
Alice in Wonderland with thevisual distortions or
abdominal-type symptoms or evenvestibular things that might be
migraine, particularly when theydon't have headache associated
(17:45):
with the actual episode.
How do you go aboutdifferentiating a migrainous
phenomenon versus, say, someother kind of as you said, like
a secondary disorder that mightbe related to more concerning
pathology?
Dr Justin Marchegiani.
Dr. M. Ismail K. Yousaf (18:01):
That's a good question.
First, basically, again, thehistory itself and we really
look for those pertinent pointsphotosensitivity, phonophobia,
osmophobia, movement sensitivity.
A great example is a patientwho comes who might be on autism
spectrum, has developmentaldelays like one of my patients.
(18:29):
He's non-verbal, he's young,he's like six or seven.
I don't have a lot of historybut a pcp thought that hey, he
might be having migraine.
Why?
because he recently startedwearing glasses outside
interesting so these are someclues that you might look after
it.
Um, so when I asked mom, whymom?
What's going on?
What is the whole event thathappens during that?
(18:50):
She's like he starts tapping onhis head like this and then he
doesn't look at light and hewears glasses whenever he goes
outside.
The other thing is the changein the behavior of the patient.
That is something that reallygives us clues, like if the
patient stopped eating, for thatit means he's having probably
(19:10):
anorexia, and then that could benausea itself, that he's not
eating.
Another clue that is that hejust goes towards and turns off
the light and snuggles into mom.
This is another migrainephenomenon.
It means that he'sphotosensitive.
Another thing that I've noticedis that kids start whenever
(19:31):
they hear loud sounds.
They start making loud soundsBecause they're like just stop
it, we can't the phonophobia isoverwhelming them.
They don't know how to convey it.
So really, the history and theclues give those referrals, but
it's challenging overall todifferentiate migraine,
(19:52):
migraineous phenomena, withother symptoms.
Like we talked about GIsymptoms, most of my patients
with abdominal migraine havebeen done a lot of GI workup,
including some of them hadendoscopy, a lot of GI workup,
including some of them hadendoscopy.
I mean, it's that challengingjust to make sure that it's not
(20:13):
something that is GI related.
So I think the workup, thethorough workup, is as natural
to rule out things, and itshould be as well, so you're not
missing.
And sometimes it's as simple asan anemia, which might sound as
anemia.
But to rule out anemia and togo towards anemia requires a lot
of work because these are againphenomena which you can't see,
(20:35):
but only through lab testing.
Um, and that's why anotherthing important in the history
is the social history and sleephistory, which is a a very, very
important point.
I can't stress more.
In sleep history what we like toask is what time do you go to
bed, what time do you wake upand what's the sleep latency?
How long does it take you tosleep?
(20:58):
If a patient says more than 30minutes or 25 minutes, you
should like the bulb should belit up.
It's like what's going on?
Five minutes, you should likethe bulb should be lit up.
It's like what's going on?
Are you having a lot of screentime?
Or are you thinking Somepatients will tell you,
surprisingly no, my legs hurt.
I just feel like there'ssomething going on in my legs.
And then you're like is itrestless leg syndrome?
(21:18):
Do I need to do an iron pal?
Is that really deriving?
Some patients then tell youthat, hey, I can sleep, but I
wake multiple times at night.
And then you're like isheadache waking you up?
It's like no, I really have togo to pee.
I can't control my pee.
Sometimes I wet my bed as well,so that gives you another
(21:38):
direction, then the mostcommonly I hear is snoring,
which has not really been takencare of or asked about a lot
because most kids sleep in theirown rooms.
And then, when I asked aboutsnoring specifically, this is
the first time but he does snoreand then obviously the next
(21:59):
question does he gasp or wakesup in the middle of the night
due to that, or wakes up in themiddle of the night due to that?
And when that happens,obviously then you're like okay,
we need to ask more about OSAfatigue in the morning.
And tonsillar hypertrophy isanother big one that in kids
might not be seen in adults,that we need to rule out to make
(22:20):
sure they're not having a lotof OSA.
Dr. Michael Kentris (22:22):
I know there's been in the news over
the last few years more reportsof increasing childhood obesity.
Do you think that factors a lotinto kind of increasing risk
for different types of headachedisorders as well?
Dr. M. Ismail K. Yousaf (22:35):
Yes, yes, especially, we are always
worried about pseudotumor, abouta pseudotumor, that's something
more than obesity.
It's like the weight gain inshort time that we really are
concerned about as well when momsays that, hey, in six months
he gets 20 pounds and he'sstarting having these headaches.
(22:57):
It could be atypical, like inmale as well.
So that's where we our redflags come up and we ask all
those questions.
But definitely, habits eatinghabit is something we promote as
well.
Do not skip your breakfast One.
We don't really.
(23:18):
I think we should talk a lotmore about saturated food, which
we don't really do.
But what we talk about ishydration.
Our rule of thumb kind of, isone ounce per kilogram, that you
should be drinking that muchwater.
Migraine is extremely sensitiveto dehydration as a trigger, so
we talk about that, whichbrings to me an interesting
(23:41):
point that during summer we arementally prepared that more
patients are going to come.
And an interesting point thatduring summer we are mentally
prepared that more patients aregoing to come Because
dehydration, outside activity,that leads to these phenomenas.
And I kind of have startedtelling my parents that, hey,
things are good.
It's January, february, march,it's outside, it's good.
(24:02):
But let's take it as a win, butwith a grain of salt, because
we want to continue these habitsin the summer as well, or maybe
better habits.
Both schools have theirbaseball season, volleyball
season.
That starts kicking around thattime and then they really
trigger up the migraine overthere.
Dr. Michael Kentris (24:24):
That's a great point.
Obviously, hydration veryimportant in so many aspects of
health, but I think youmentioned the sports aspect too.
Do you find, especially for theadolescent patients, that when
they go from their off-seasonfor their sport of choice to the
on-season, do you see typicallyan increase in headache
frequency in those who may havea pre-existing diagnosis?
Dr. M. Ismail K. Yousaf (24:47):
Yes, we definitely do, and that's where
not only counseling of kid isimportant.
Counseling of parent is veryimportant.
To set the expectations thatthese headaches could work,
especially with athletic kids,that hey, there's a big chance
(25:08):
that these headaches mightworsen, so we need a good cup of
water all the time.
We need a plan in place withthe school as well, especially
with the coaches, that hey, wehave pre-existing diagnosis
which might get worse with time,especially dehydration.
So we have to make sure that wehave all the accommodations in
(25:30):
place.
Secondly, another thing that hashelped my patients is 504 plan
in school, which is basically anaccommodation, but that if the
migraine happens, they can go tothe nurse.
They have the medications inplace.
They should rest for 30 minutesin a dark room, because the
(25:51):
ultimate goal for both athletesand people who go to school is
that they should not come backfrom school to home.
Their academics should notsuffer.
So in place in house.
Those accommodations are superimportant because school
absenteeism leads to a lot ofother problems Peer pressure,
(26:13):
domestic pressure and moremigraine.
To start with, another thing,and just to pearl in athletes we
try to avoid propranolol.
That's another one that makessense.
That's something as a firstline.
We don't give it.
We ask them that, hey, whenyour season is coming, are you
(26:35):
an athlete?
Dr. Michael Kentris (26:37):
We haven't touched much on the
pharmacologic.
I've certainly been talking alot about the non-pharmacologic
aspect of treatment.
For instance in the adult world, the CGRP class of medications,
ben you know kind of the hotstuff for the last you know five
, seven years or so.
How much of that is tricklinginto the pediatric headache
(27:00):
literature and managementpractice in your experience.
Dr. M. Ismail K. Yousaf (27:04):
I'll change the word from crickling
to brewing.
Oh, that's how I want to.
Because I'm a big, I have to bean advocate for CGRPs in kids
as well.
So, you see, they're morerecognized in above 18.
That's where the FDA comes in,right?
But my question is what happensat 18 that suddenly, from 17 to
(27:24):
18, the turn on button happens?
That it's, you know, thepathophysiology is still.
We just have to make sure thesafety and tolerability.
And that's where a lot ofclinical trials I'm also
involved in some.
We are doing our trials, bothpreventive and acute Very
excited, especially after theAmerican Headache Society policy
(27:46):
that came out, which is thatanti-CGRP should be used as
first line.
So that's, yeah, it just cameout like two months ago.
That's very exciting.
That was very exciting news.
Yeah, I saw that we are seeingamazing growth.
See, the evolution of headacheitself is like just like 5,000,
6,000 years ago the headache wasthought to be due to a demon
tau and they used to dotrepanations to make sure the
(28:09):
demon goes out of the head.
And now we have, like once in amonth, shot which can also be
affiliated with Botox.
And just recently, fermanizumaband Botox had a great trial
published in cephalalgia, whichshowed more, better, headache
freedom days.
So we are going in the rightdirection.
(28:30):
I want my kids and adolescentsto go into that direction.
We have to fill the train inthe same direction.
Having said that, we do—.
Dr. Michael Kentris (28:38):
Not advocating for the trepanation
as much anymore.
Dr. M. Ismail K. Yousaf (28:41):
No, no, no, we don't want that.
So we do use off-label, likemost in medicine.
That happens and we see goodresults.
We see, sometimes we have tochange medication as well.
We have to use the sameanti-CZR, like G-pans.
We have Remagipan, rujipan, sowe can change them as needed if
(29:06):
we do not have great results.
But really that's the future,that's the present.
We have to advocate for them,for kids as well.
Once we have more enough data,which I'm pretty sure we are
working on it, I'll tell you oneinteresting fact that when you
have more options, especiallythese with less side effects,
(29:29):
there's a pragmatic approachthat comes on for parents and,
um, the kids, and then they seekthe responsibility and autonomy
to choose from them becausethey know that's more safe,
tolerable, that 100 helps theheadaches as well, because you
are not just going by theguidelines.
Hey, top one to fail.
(29:50):
Now we're going to give youthat, we're not directing you.
When we put the options infront of them and ask them and
give them the responsibility andautonomy as well, we have to
choose one, we have to work withit.
That really helps overall andthat's that's my approach as
well.
Dr. Michael Kentris (30:06):
That's excellent, and we've been
talking about advocacy, butyou're also involved with some
more official advocacy type workas well, if you'd care to talk
about that at all.
Dr. M. Ismail K. You (30:16):
Absolutely , and thank you for asking that.
So I am involved in both atnational level and international
level Thanks to AmericanHeadache Society.
I was this year's AmericanHeadache Society Advocate
Scholar and I went to Headacheon the Hill by the amazing ASDA,
which do a fantastic job as analliance, putting everybody
(30:39):
together and advocate forheadache, migraine, all type of
headaches.
Really.
We go to Capitol Hill,Washington, where we talk to US
Congress, respective Congressand Senate members and their
offices.
This year we were talking aboutthree bills.
We were talking about NIHSafety sorry, NIH Inclusivity
(31:00):
Act, Safe Step Act and thenExcellence, EAS Center for
Headaches, which the bill waspassed as well.
We are very excited about thatand why these bills are so
important because they affect me, you and all the specialities
really, um, so, those three actshopefully we have more uh
people signing them and then Iam involved with gAC, which is
(31:24):
Global Patient AdvocacyCoalition, which has 24
coalition partners, including AN, EN, AHS, and I am trying to do
global outreach, especially fordeveloping countries, to spread
advocacy, making workplacessafe for people with migraine,
making schools, colleges,universities.
So my first endeavor is in myhome country, in Pakistan, in
(31:46):
June, inshallah, and I'll begoing there and talking to media
and places and spreading asmuch as I can.
That's very exciting and Ireally invite everybody to come
to Advocacy Advocacy in clinic.
You can help 24, 20, 15patients a day.
With Advocacy you can helpmaybe more than a million in one
day.
So that's how I put it.
Dr. Michael Kentris (32:07):
Excellent and that is a great point.
We've kind of skirted aroundthe edge of this where we've
talked about how frequentheadache is.
Now I know in the adultliterature it's one of the top
probably three or five reasonsfor missed work days.
I assume probably in PEDS it'sone of the more common reasons
for missed school days as well.
Dr. M. Ismail K. You (32:28):
Absolutely so.
Headache is the second leadingcause of disability years
globally.
It's that important.
And with kids, one of the majorquestions, which also helps us
to know the severity of theheadaches, is how many days have
you missed in a month?
(32:50):
And we get different answers.
I'll tell you one thing, thoughI've seen kids power-throwing
headaches better than adults.
Dr. Michael Kentris (33:00):
They are more resilient in many ways.
Dr. M. Ismail K. Yousaf (33:02):
Yeah, they are more resilient.
So that number might not be thebest number or accurate number,
but if they tell me, hey, twoto three days a month, I won't
be surprised, because two tothree days a month mean really,
really bad headaches.
And that gives my overall planand approach how to really help
(33:26):
people with two to threeheadaches, because we are not
looking for the magic numberfour, that if the magic number
four happens, bad days andthat's when we start a
preventive.
We are looking for really baddays which are affecting the
school days as well.
If there are two or three, Ithink that's enough data for me
as well, because there might be.
Dr. Michael Kentris (33:43):
Yeah, to yeah.
Is that to start a preventiveor to make sure that we have a
rescue plan in place?
Dr. M. Ismail K. Yousaf (33:49):
both, both.
I mean if they are missingthree school days in a month, um
, then you have to dig deeper.
It means the less where amoderate headaches might be
happening as well excellentpoint, yeah because then, if
it's kids, the severe ones willbe, might be associated with
moderate ones, and then theremight be mild ones, so there are
(34:12):
more headache days than whichare being represented in the
talk.
So that really helps me to knowwhat's going on and, with kids,
the prevention.
We love nutraceuticals.
I think they do a great job.
Magnesium it's classified aslevel one by EN 2019 guidelines,
(34:33):
which means less risk of bias,so we kind of taper them up.
As for the weight, we like togo up to 400 milligrams if the
weight is above 40 kilograms or30 kilograms, with the caveat
that it can cause loose stoolsor diarrhea, right, right, if
the weight is above 40milligrams, 40 kilograms or 30
kilograms, um, with with thethat it can cause loose stools
or diarrhea, right, um?
And then the good thing aboutmagnesium is that it has like a
(34:53):
calming property to it, and thenit also affects the nmd
receptors, um, which overallhelps to sleep them better,
gives them less anxiety as well,if I have to really overextend
it.
So magnesium is like the firstline.
Then we have coenzyme q, whichless anxiety as well, if I have
to really overextend it.
So magnesium is like the firstline.
Then we have coenzyme Q, whichworks great as well, and the
third is riboflavin V2.
(35:14):
So I think all these three, wesee how they work on, act on and
then we go from there.
Dr. Michael Kentris (35:21):
Excellent.
No, those are all great.
I know there's plenty of peoplein the adult world who feel the
same way.
It's like I don't really wantto go on a pill.
It's like how about somevitamins Absolutely and
sometimes that can be an easiersell for someone to see if they
benefit from it.
Dr. M. Ismail K. Yousaf (35:33):
And another interesting thing which
I'm glad has come, especiallyfor kids, is the neuromodulation
devices like REN ornon-invasive vagus.
So why they are important aswell, especially the REN or
motor electro, is that they givethe autonomy to the patient.
(35:55):
So REN device is kind of whereyou just stick on your arm for
45 minutes every second day, asa preventive or as an acute as
well for 45 minutes, and it cancome underive or as an acute as
well for 45 minutes, and it cancome under the, under your shirt
as well, and you can just doyour work while you're getting a
preventive treatment.
You can play, you can walk, youcan talk, and my results have
(36:17):
been good so far with it as well.
Um, the other thing about thesedevices is that, um, although
they're still getting approvedby insurance and they're kind of
expensive, still I feelstrongly about it is that the
patient itself, with a lot ofcomorbidities, can be safely
treated with it In adults aswell.
(36:37):
The same goes for adults aswell.
Good point.
So this gives me more range ofchoices, so that really works
well as well.
Dr. Michael Kentris (36:45):
So this might be one of my takeaways
from our conversation today isthat insurance coverage is
causing a gross loss of GDP tothe country overall, due to
their emphasis on escalationtherapy and non-coverage of
effective treatments.
Dr. M. Ismail K. Yousaf (37:03):
Yeah, yeah, that's where one of our
safety acts, safe step act, isas well, which is basically we
are advocating hey, if weprescribe a drug and insurance
prescribes a drug, it says theywill first fail this drug and
then we go to the second.
We're not doing benefit to thepatient, right, we're not doing
(37:29):
benefit to the patient.
We really want to make sure thepatient gets the best treatment
, because I'm using all myclinical acumen, all my med
school, into one place andthat's why the patient is here
to get the best treatment, bestdiagnosis.
But we are really reinventingthe wheel that we are saying,
nah, let's try this first, failfirst, and then we go from there
.
Dr. Michael Kentris (37:46):
Yeah, it's very frustrating, uh, to get
those denials from insurance forwhat you yeah, after much
deliberation and thought andconversation and shared decision
making, have decided is thebest course forward.
Well, let's just tack onanother 30 minutes of
frustrating paperwork to thatthat is true.
Dr. M. Ismail K. Yousaf (38:03):
That is true.
Um, one point I missed onneuromodulation devices, and I
will talk to all my supervisors,and my patients with
comorbidities like potsespecially do well on them.
The pot symptoms get better aswell.
That's very interesting.
Um, I think more research hasto be done.
I talked to some of the leadersin headache about it and they
(38:23):
said it's kind of the samepathways which we are really
treating through those.
So so people who are listening,I think patients with POTS and
bad headaches do think ofneuromodulation devices,
especially Ariane with them.
Dr. Michael Kentris (38:37):
I know, and some of the patients that I
treat, I almost don't evenconsider neuromodulation because
I know their financialsituation is a little tight and
insurance is not going to coverit for the vast majority of them
I think pretty much anyonewho's outside the VA in the
adult world and so it can bechallenging when we know that
(38:57):
there might be this option outthere.
But if they have to shell outseveral thousand dollars it
might as well be on the moon.
Dr. M. Ismail K. Yousaf (39:05):
Yeah, I totally agree.
Agree.
Our job is to be a part of asystem which which has more
accessibility, not more jumpinghurdles to it right.
We have patients which comefrom 70 miles, 60 miles, 80
miles, so if they come here justto hear a denial, after two
(39:29):
hours they leave the office, orthree hours, we're not doing any
service to them.
They might not come the nexttime.
Dr. Michael Kentris (39:35):
Right, right, so we've talked a little
bit about all these issues, asyou said, the entire
biopsychosocial model.
To an extent, I think we'vetouched on a lot of the corners
of that psychosocial model.
To an extent, I think we'vetouched on a lot of the corners
of that.
So we've talked about theinstitutional aspects.
(39:56):
But there's also some otherstigma that comes along.
We've talked about some of theisolation that can happen with
children, the potential loss ofincome in the adult world.
What other kinds of stigma doyou find a lot that people may
be facing, especially in thepediatric, adolescent world,
whether that's from theirschools, the institutions or
even their own family?
Dr. M. Ismail K. Yousaf (40:15):
That's a great question.
I think the inclusivity andequality is another issue.
There have been studies inwhich they show that the Q
treatment might be moreprevalent or given to white kids
as compared to, you know, ofdifferent colors.
That's another stigma that weneed to talk more about and that
(40:35):
, again, is one of the billswhich we talked about is NIH
inclusivity bill.
Why, again, it's important isthat we are requesting and
asking that more people ofdifferent colors and ethnicities
are part of that NIH trials, sothey can come in and we have
more data on it.
Honestly, we don't have data ona lot of.
We don't have data on gendersor ethnicities in different ways
(40:58):
.
One interesting example it's adifferent way to put it, but
interesting example was oximeterduring COVID days, you know.
So oximeter has not been triedwell in people with different
color, so like brown color orblack.
So basically the pigmentationmight be overestimating or
(41:19):
underestimating the oxygensaturation and that's what was
happening.
It's a great point.
Um, so it was giving like plusfour or minus 4%.
Dr. Michael Kentris (41:27):
Which that can be a big deal sometimes.
Dr. M. Ismail K. Yousaf (41:32):
I mean, yeah, from 96 to 92, 92 to 88.
So that model kind of resonatesin headache population as well,
that different genderethnicities might not be coming
up.
Because they might have this,we might not be getting those
adequate treatment options or wemight be taken differently when
we go to the office.
So that's one.
The second thing is thatparents themselves sometimes
(41:58):
think that this is a headacheand it can be treated by
over-the-counter medication.
Or he's malingering or it'sfunctional and they might put
different words to it.
And when it gets really chronicthat they see a school report
coming out that he's notperforming well, then they come
in and then it might be an acutechronic problem.
So I think that responsibilityon parents' part and that's why
(42:22):
awareness is so important alsocomes in In adults.
I would tell you, the stigmalies that are apprehension lies
what if it's something sinister?
Because they have more approachto google or they have, and
sometimes they just want toclose their eyes and don't want
to come.
Dr. Michael Kentris (42:40):
It's like we'll see what happens I know
I've been guilty of that myselfand you know, a lot of times
this happens to doctors yes, I'msure we're some of the worst,
or?
Dr. M. Ismail K. You (42:52):
physicians or health providers.
They're the worst patients, um,so there are a couple of points
that they converge at the samepoint that you need to see a
physician for expertise and see,because, again, migraine is not
curable, we don't have havecure to it, but it's treatable.
Our job is to make sure that,first three months, there's a
(43:13):
50% reduction in your headache,which will resonate in the
quality of life.
Setting the stage is veryimportant here, and once you see
a change in the quality of life, it might be addictive.
That's how we put it.
Hey, I'm feeling better, I'mdoing better, I'm sleeping
better, I can do more work, I'maiming high.
Hope is a dangerous word, butsometimes you have to give these
(43:34):
factual statements to them sothey are more compliant on their
medication, they're workingtowards it and they have the
motivation for it.
Dr. Michael Kentris (43:43):
So that's counter stigma, how I put it
Something I see a lot in youngadults, with that exact
situation where you've started atreatment plan, things are
going well, they're doing great,and then six months to a year
later, all of a sudden they getworse again and you find out
they stopped doing what got themthere in the first place.
They stopped their medicationsor they picked up other bad
(44:06):
habits.
Their medications, or you knowthey picked up other bad habits
and it's like you know.
Then you have to so in the, inthe child population.
Dr. M. Ismail K. Yousaf (44:11):
I think this is fairly common in
adolescence as well, but I wasjust curious what your
experience has been I think withum, I would say less than
adults, um, because they have asupervisor named called peter on
them, so they, they kind of doa good job on that on them, so
(44:33):
they, they kind of do a good jobon that um.
And then I feel I'm gonna say abig word here, but I feel that,
um, the kids are more,adolescents, are more honest as
compared to adults to themselvesthat's, that's a fair statement
.
Dr. Michael Kentris (44:42):
I would say yeah, yeah.
Dr. M. Ismail K. Yousaf (44:44):
So they're more honest, they want
to do well.
It's a competitive as comparedto like 10, 15 years.
It's a pretty competitive worldout there.
So they want to make sure theyreally believe that body is
their temple kind of thing andthey have to take care of that.
So, like I'm in Austin rightnow, it's like the new hub for
software engineers and you knowit's Silicon Valley and brewing.
(45:09):
So over here we see a lot ofadults who are like software
engineers and they have to workall night or work from home.
So they are very cognizant thattheir work is getting affected
by this early 20s.
So they take care well ofthemselves and without any like
a lot of delay, they come to youthat hey, I started having
headache two months ago or onemonth ago as compared to adults.
That hey, I started having aheadache two months ago or one
(45:29):
month ago as compared to adultswho will come.
I've been dealing with eightmonths.
I've been taking a lot ofNSAIDs.
I've been taking maybe anopioid as well from a friend and
it's not working well for me.
And then you start going intotheir history and you'll realize
I've tried this, I've triedthis, I've tried this, but you
don't have any good you knowgood documentation on that?
(45:49):
Yeah, so that's a problem withadults.
Dr. Michael Kentris (45:52):
I will say I'll be guilty about it, they
tend to get themselves into alittle more trouble than the
kids do.
Dr. M. Ismail K. Yousaf (45:56):
Right, right, and I'm sure I mean even
in epilepsy.
Sometimes you will hear aboutpatients who've had these
episodes, sometimes that theymight not report it.
Dr. Michael Kentris (46:07):
Oh yeah, patients who had these episodes,
sometimes that they might notreport it, oh yeah, um so.
So since you mentioned epilepsy, one one thing we were chatting
a little bit about was the, thephenomenon of microlepsy.
Um yeah, now this is a, even inneurology, I think, a bit of an
unutilized, under studiedphenomenon.
But right, uh, just kind of abrief background definition, if
you would Just kind of a briefbackground definition, if you
(46:29):
would?
Dr. M. Ismail K. You (46:29):
Absolutely so.
I totally agree.
It's not used that often, it'snot recognized as well, but it's
something that my supervisors,like Dr Samantha Irvin and Dr
Pavit I've seen them use theword and that's how I got
cognizant about it as well,because if a patient comes and
he says, hey, I'm startinghaving these atypical symptoms
(46:53):
in which I see flashes of light,right like an aura symptom, but
I see with colors, I also seedistortion of objects and with I
have after that I have reallyintense pain but then my head
becomes foggy.
I have to.
(47:14):
Really I don't know what'sgoing on and I lose time.
That doesn't sound reallymigraine to me.
I mean, there are some aspectsto it with an aura, but losing
time, foggy brain and thentaking another two to three
hours to get back to myself, Imean the prodrome is there in
migraine.
You can have fatigue, butamnesia coming along.
(47:35):
It really should make you thinkabout post-tectal headaches
versus my microlepsy oxbow.
So in these patients I have avery low threshold to rule out
microlepsy and and get an EEG.
Dr. Michael Kentris (47:48):
It's really challenging because we know
that, for someone who hasfocal-aware seizures, the
sensitivity of EEG can be quitepoor.
Dr. M. Ismail K. Yousaf (47:57):
Right, I totally agree, and that's why
I have patients where I wentfrom routine to sleep-deprived
to EMU.
I really had to escalate slowlyright to find something because
, as you said, the sensitivityis low.
But somehow or the other, whenI ever talked, epileptology is
like this this discharge looks alittle concerning, right.
(48:20):
We need to dig more into thatbecause I have to be cognizant
that epilepsy drugs might be along-term commitment.
So before starting that, if thesymptoms are not that grave, I
have to make sure that I'm doingmy homework.
So I don't shy away fromtesting in these instances,
(48:43):
because if I get that right,that's more benefit than I get
it wrong or leave it as it is.
Because again, again, theneurologist appointment you
might not get for three to fouror six months right.
So I have to make sure that I'mdoing my work and I'll try my
best to justify in my notes.
Dr. Michael Kentris (48:58):
Insurance doesn't deny it right, like he's
here for a headache.
Why are you wearing all theseegs?
Exactly, exactly but I meanpathophysiologically, there is
some reasonable mechanism.
Right, we have the spreadingcortical depression with
migraine, absolutely Obviously.
We know cortical hyperactivityis something we see with
epilepsy and then like apostictal suppression.
So why couldn't they looksimilar theoretically?
Dr. M. Ismail K. Yousaf (49:21):
Exactly , and that's what made me think
more about migraine lepsi,because if the CSD is what we
think is deriving the aura andthe migraine itself, it could be
deriving the seizures itself aswell.
So there is an overlap andagain, the threshold is low to
make sure that because, see,with migraine drugs you can't
(49:43):
treat seizures.
With seizure drugs you might betreating some of the headaches,
some of them.
Dr. Michael Kentris (49:48):
Yeah yeah, drugs.
You might be treating some ofthe headaches.
Dr. M. Ismail K. Yousaf (49:50):
Right, some of them, yeah, yeah,
exactly.
It could be worse, but it'sbetter to find the answer or be
in the pursuit of an answerquicker than later.
Just again, you never know Oneof the parents comes in and he
says yeah, when I was in my 20sI had these symptoms, but I wish
I had the diagnosis before Ibecame vocally generalized.
Dr. Michael Kentris (50:13):
Yeah, there's definitely all these
borderland types of syndromeswhere it's like well, is this a
migraine, is this a seizure?
I just had a conversation aboutamyloid spells and seizures
recently.
Dr. M. Ismail K. Yousaf (50:26):
Yeah, that was very fascinating, and
seizures recently and it's likeall these, yeah, that was very
fascinating.
Dr. Michael Kentris (50:28):
There's all these things that you know it's
all related, right?
There's only so many ways thebrain can manifest these kind of
epiphenomena to our sensorium,so it's just fascinating.
You get these convergence ofdifferent phenomena presenting
in very similar ways fromperhaps markedly different
(50:49):
underlying causes 100% agreed.
Dr. M. Ismail K. Yousaf (50:54):
I mean, I tell my friends who are very
interested in neurosciences Isay that as much of a powerhouse
brain is, with 10 trillionnerves in it, it's kind of a
little bit of a dumb existenceof it as well, because it
doesn't know when to ask forhelp.
Brain doesn't know.
(51:15):
It's a brain right.
So that really, um.
And then another good examplewhich I heard from one of my
supervisors is that hey, what'sthe natural phenomena of skin if
it gets injured, it's that itwill swell or it will bruise.
Brain doesn't have a naturalphenomena.
When it gets stressed, it cangive you a ray of symptoms, and
(51:39):
that's why neurosciences is socomplex and challenging at times
, especially epilepsy, um, thatyou really have to dig out what
symptoms you might get.
Dr. Michael Kentris (51:50):
Yeah, just an angry bowl of pudding up
there, I agree.
Now, obviously, it seems likeyou derive a lot of satisfaction
from helping these patientsgetting quality of life improved
across the entire spectrum ofthe lifetime.
What's your, beyond just thosemeager pieces?
(52:12):
What is your pitch for peoplewho might be considering going
into headache medicine?
Dr. M. Ismail K. Yousaf (52:17):
Thank you for asking that.
So a lot of doctors look forsatisfaction in the results and
they think with headache youmight not not get results and,
if I may dare say that, headachemight be a stigma, neurologist
as well.
Like seeing headache patients,I've I've seen that that they're
(52:37):
not really excited about itdefinitely is.
I can assure you you'll seeresults.
I'll assure you people will befull of gratitude because you
helped them.
The most common comment youmight hear from people who you
really are able to help is that,due to better treatment, our
(52:59):
whole household has changed.
We are better as a home, as afamily, and there's not once
I've heard that it's like now weare looking for vacation.
Now we are looking for vacation.
Now we are looking to forbetter, you know, ambitions for
our kids.
So you're not helping oneperson, you're helping a lot of
people.
Then, luckily, we're not in theera of trepanations anymore, we
(53:19):
are in the era of ccrps.
So since 2018 we're, we havebetter options and headache is
really evidence andresearch-based.
If you are looking for both,this is the way forward.
We have ever-newcoming research, researches every day, almost
(53:40):
every day.
Cephalalgia headache is doing agreat job, which kind of is
interesting for our headacheboards because there's so much
going on that we have to read alot as well.
But if you want both clinicaland research acumen, the way
forward it is, and the otherthing is that it's a great
practice.
You can do outpatient all year.
You can really fabricate yourpractice the way you like.
(54:03):
You want to do procedures.
We have nerve blocks, we haveBotox, with great results as
well.
The satisfaction rate is goodas well.
And then the patient populationwhich you see is some
population which be only betreated by you.
That's another interesting partof it that they might be coming
(54:25):
from different referrals, butyou are the person who might be
able to help them.
So I think there's a lot ofgratitude involved in that as
well, and some patients mightgive you free cookies as well.
Dr. Michael Kentris (54:35):
That's excellent.
I always like to emphasizeright headache is one of those
multidisciplinary specialties,right, we tend to think of it as
a neurology subspecialty, whichI'm biased, I do think of it as
that.
But it's also open to peoplewho have done residencies in
internal medicine, familymedicine and various other like
anesthesia, I think even ENT.
(54:56):
So there are a broad range ofspecialists who, if they, over
the course of their training,become fascinated with headache,
they can further their clinicalskills and become one of these
very rare headache specialistsin the country.
Dr. M. Ismail K. Yousaf (55:13):
I totally endorse that.
Our last fellow was a familyphysician who did headache.
Cleveland Clinic Ohio chairmanis a psychiatrist who did
headache.
So there are so many examplesaround who people who do
headache offer differentspeciality because there's so
much overlap.
Again, it's the tip of theiceberg.
Seize this that way you have somany aspects to cover,
(55:35):
comorbidities to cover, and thenthe interesting aspect is,
despite all these comorbidities,aspects, again, you might be
the person who's going to helpthem and derive and get better
at all those comorbidities, evenwho's?
Dr. Michael Kentris (55:49):
going to help them and derive and get
better at all thosecomorbidities.
Even that's excellent.
It's been a very upliftingconversation, Dr Yusuf.
I really appreciate you talkingabout your perspective on
headache.
It's always very refreshing tohear from someone who's so full
of passion about what they do.
If people want to find youonline or find some resources
where, would you recommend thatthey look around or?
Dr. M. Ismail K. Yousaf (56:08):
find some resources.
Where would you recommend thatthey look around?
Absolutely so.
I'm on X, formerly known asTwitter.
I'm I-S-M-A-I-L, the mark forF-A-N-T-Y.
I do a lot of advocacy forinternational medical graduates.
I have a group as well.
30% of neurologists areinternational medical graduates
in the US.
We all work together.
(56:29):
We have a great fraternity as aneurologist as well, so you can
always direct message me overthere.
I have my email that isyusafgpaccom.
You can email me there.
So I'm always always happy tohelp people together.
(56:51):
Um, so I'm always always happyto help people.
Um.
Whoever want to get in touchwith me regarding future
counseling, career counseling,headaches, we can have a chat.
Maybe the coffee is going to beon you, but we can have a chat
that's excellent.
Dr. Michael Kentris (57:01):
Thank you so much, uh, and like uh, dr
yusuf, you can find me also on x.
Uh, I'm at dr kR-K-E-N-T-R-S.
Dr Kentris, and you can alsofind our podcast feed at neuro
underscore podcast, and you canreach out to us through our
website or find other resourcesat theneurotransmitterscom.
Dr Youssef, thank you again, ithas been an absolute pleasure.
Dr. M. Ismail K. Yousaf (57:22):
Dr MK.
What a great session we had.
I'm so thankful to you.
Thank you very much.
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