#406 ‒ Migraine, cluster headache, and tension headache: symptoms, causes, prevention, and treatment | Brian Grosberg, M.D.

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Brian Grosberg is a world-renowned headache specialist who joins Peter to provide a master class on the diagnosis and treatment of headache disorders. In this episode, Brian explains the distinction between primary and secondary headaches and breaks down the defining features of the "big three" primary headache types (migraine, cluster, and tension headache)—highlighting how often they are misdiagnosed and how they are treated. He explores the epidemiology of headaches, describing migraine as an invisible disease affecting about 12% of the population, disproportionately affecting women, while cluster headaches more often affect men. He discusses the major gap between demand for headache care and available specialists, and he offers advice on when to see a physician. Brian dives into the multifactorial nature and pathophysiology of migraine, including genetic and hormonal influences, neurovascular changes, and inflammatory signaling, and connects these mechanisms to modern therapies. Throughout the conversation, he emphasizes the individualized nature of headache disorders and the importance of a detailed headache diary. Brian shares practical strategies for treating headaches including lifestyle changes, medications, and neuromodulation devices.

We discuss:

• Brian's interest in headaches and how Peter met Brian [2:15];
• Differentiating the types of headaches: primary versus secondary headache and tension versus migraine headache [7:30];
• The epidemiology and burden of migraine, its disproportionate affect on women, and the shortage of headache specialists [20:00];
• Genetic susceptibility to migraine and the role of hormones [24:45];
• Migraine triggers, the impact of hormones, and the importance of a headache diary [31:15];
• The phases of a migraine: premonitory symptoms, aura, the headache itself, and the postdrome [38:15];
• Tension headaches: symptoms, causes, and prevalence [41:45];
• Cluster headaches: extreme pain, distinctive symptoms, and frequent misdiagnosis as a sinus infection or allergies [43:15];
• Lifestyle interventions to prevent headaches [51:15];
• Pharmacological treatments to prevent headaches [1:05:00];
• What's known about the pathophysiology of migraines: neurovascular changes, release of neuropeptides, and inflammatory response [1:14:45];
• CGRP antagonists for the treatment of migraines: large monoclonal antibodies and gepants [1:20:15];
• Use of calcium channel blockers and Botox to treat cluster headache and migraine [1:28:30];
• Drugs for the acute treatment of migraines [1:32:30];
• Treatment of migraines with electrical stimulation devices [1:40:00];
• Use of THC or cannabis to treat headaches [1:44:00];
• What Brian wants people to know about headaches [1:45:45];
• Brian's advice on when to see a doctor about headaches and how to prepare for that visit [1:49:15]; and
• More.

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