House Call Highlight: The Functional Medicine Approach To Ending Migraine

Mark Hyman, MD

Full Transcript

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Dr. Todd Lepine: There are certain foods which can trigger a migraine. Is it the food that's doing it or is it something in the food or it's how the food is actually being metabolized? That's a really key important feature is the connection between the gut, our food and the brain. Dr. Mark Hyman: Welcome to The Doctor's Farmacy. I'm Dr. Mark Hyman. That's Farmacy with an F, F-A-R-M-A-C-Y. A place for conversations that matter. If you've ever had a headache, you better listen up, especially if you've had a migraine because today we're having a special episode of The Doctor's Farmacy called House Call with my colleague and friend, Dr. Todd Lepine here at the UltraWellness Center in Lenox, Massachusetts. We see so much migraines. Todd has been a colleague of mine for over 25 years. Worked with me at Canyon Ranch, now at the UltraWellness Center for 10 years. We've just been at the forefront of this whole movement of functional medicine. I would say migraines are among the worst condition that people can suffer from. But from a functional medicine perspective, they're probably the easiest things to treat, wouldn't you say, Dr. Lepine? Dr. Todd Lepine: Absolutely. Yeah, exactly. Dr. Mark Hyman: How do we think about this condition in traditional medicine? What is the normal approach to diagnosis and treatment, and what's wrong with it? Dr. Todd Lepine: Interesting thing is when I look back, I can remember when I was practicing mainstream medicine, I always looked at migraine patients. There were so many different things that were offered by mainstream medicine for migraines, and it sort of made me question like, there's no such thing as one migraine. There's so many different flavors of migraine. You can have a patient who has periodic migraines, you can have someone whose got menstrual migraines. To me, that was telling me that migraines, there's a lot of pathways to developing what we call a migraine or they also call it a vascular headache. I found it really is an interesting approach to know that each individual, their presentation for migraine is unique. The interesting thing is I would never treat two migraine patients the same because they all have different features. Dr. Mark Hyman: That speaks to a very central idea in functional medicine, which is this. Just because you know the name of your disease, it doesn't mean you know what's wrong with you. Dr. Todd Lepine: Absolutely. Dr. Mark Hyman: You have a migraine. That just describes people who have a certain type of headache with certain types of symptoms like light sensitivity, noise sensitivity, maybe on one side, maybe visual pre-aura symptoms, nausea, vomiting. These are just the typical things. Okay, you have a migraine, and then we divide into classical migraine and this migraine, and they're all just different ways of describing the kind of migraine. But none of them tell you the cause. Functional medicine is about focusing on the cause which is what you're talking about, these different flavors. Dr. Todd Lepine: Exactly. Dr. Mark Hyman: There may be up to 29 different factors that can drive a migraine, and traditional medicine uses a one-size-fits-all approach. What is a typical approach to treating migraines? Dr. Todd Lepine: In mainstream medicine, it's really just basically abortive therapy. You might take Advil or Aleve or an Excedrin. You might take a triptan. You might take an opioid- Dr. Mark Hyman: Like Imitrex or something like that. Dr. Todd Lepine: Imitrex, yeah, Imitrex. Exactly. Or opioids in severe cases. Steroids in other cases. It's basically treated abortive therapy, which is when you get an attack, you treat that attack. For people who get them more frequently, it's about trying preventive therapies. They're all over the place. I found that actually quite interesting when I was looking at how do neurologists approach migraines. These headache neurology specialists. They use everything. They throw everything in there. They'll throw in beta blockers, they'll throw in calcium channel blockers. Dr. Mark Hyman: These are to prevent migraines. Dr. Todd Lepine: To prevent migraines. Exactly. The preventive role is really important I think because when you look at someone who's suffering from migraines ... People can lose a lot of work over migraines- Dr. Mark Hyman: Debilitating. Dr. Todd Lepine: Absolutely. Sometimes for some people it might be two, three days or a whole week that's lost. They've got to stay in bed and turn the lights off and just wait until the whole episode passes. Then other medications that are used in mainstream medicine are antiseizure medications. Dr. Mark Hyman: Antidepressants, seizure medications, blood pressure medications. Dr. Todd Lepine: Calcium channel blockers. Dr. Mark Hyman: All this stuff that they're kind of throwing like spaghetti against the wall. Dr. Todd Lepine: Antidepressants. Tricycle antidepressants. You name it. Dr. Mark Hyman: There's no way to actually figure it out. It's like spaghetti on the wall. These doctors try this, try that, try this, and I can't tell you how many patients I've seen that have been through the whole mill of these medications. It might help a little, it might- Dr. Todd Lepine: Botox. They're using Botox now. Dr. Mark Hyman: That's right. Dr. Todd Lepine: They're using botulinum toxin. Dr. Mark Hyman: Yeah, well that's to paralyze the muscles in the back of the head, right? Dr. Todd Lepine: Exactly. Yeah. Right. Dr. Mark Hyman: It's a terrible condition. I've had people who have chronic daily migraines or 20 days a month and it's just so awful for people. Dr. Todd Lepine: Especially in women. I probably see more women with migraines as opposed to men and then women also get menstrual migraines, which is another sort of flavor of migraines, which is probably related to estrogen detoxification. It really is. It really keeps me on my toes in functional medicine when I see a migraine patient because it's not like, "Oh, here's your problem. Just do this and it's fine." I've got to play detective. I've got to figure out what are the factors that are driving that person's unique presentation of their migraines. Dr. Mark Hyman: That's absolutely right because what we do in traditional medicine is, "Okay, you have this type of headache." I ask these questions and it meets this criteria for what a migraine headache is according to the Neurological Society criteria. But once you make the diagnosis, there's no more thinking involved. It's like, okay, here's the cocktail of drugs I get to pick from. Start with these, try this. If it doesn't work, we'll try this. It's kind of merry-go-round of drugs, and it often is so difficult for people to get better because they're not asking the right questions. Dr. Mark Hyman: In functional medicine, we don't just name and blame, which is what our mentor, Sidney Baker talks, we name it, blame it and tame it. You name the disease and say, "Oh you have a migraine. That's why your head hurts. No, that's not why your head hurts. That's just a name of why your head hurts." And then we try and tame it with a drug instead of actually figuring out the cause. Dr. Mark Hyman: Let's talk a little bit from a functional medicine perspective about what the causes are and then let's get into some cases because I think we've both seen so many cases. It's one of the most satisfying things for me as a doctor to actually treat because it's so easy usually, and people do so, so well with simple approaches that deal with the root causes. Dr. Todd Lepine: Yeah, absolutely. Yeah. Dr. Mark Hyman: Tell me what are the things that you think of when you're coming to see these patients that could be driving the migraines? Dr. Todd Lepine: One of the things that I think is missed by a lot of mainstream doctors, even neurologists, is to understand the role that mitochondria play in migraines. Interestingly, mitochondria, which are the powerhouses of the cell, basically when our body consumes food we produce energy from the food in the form of ATP. Mitochondria are not really tested by mainstream medicine. They are not well understood. It's something that you learn about in medical school and then you forget about it. The interesting thing is that people how have migraines also have a higher incidence of seizures. That's why to some degree antiseizure medications can actually have efficacy in some patients who have migraines. Important to realize that connection between mitochondrial dysfunction and migraines. Dr. Mark Hyman: Mitochondria make energy in your cells. Dr. Todd Lepine: Make energy in your cells. In fact, I've actually seen some patients interestingly, and I don't treat children, but I've seen some adults when I go into their history, they had a history of what is called cyclic vomiting syndrome. That's where a young kid is vomiting for no particular reason. Turns out, cyclic vomiting syndrome is actually a mitochondrial problem and as a person gets older, they sort of outgrow that vomiting episodes but they actually then present with migraines. Interestingly, the gut is connected to the brain, so a lot of people can have what we call abdominal migraines. Dr. Mark Hyman: Yes. Dr. Todd Lepine: Exactly. Right, right. Dr. Mark Hyman: That reminds me, Todd. I had a patient who struggled with headaches and migraines and she had terrible SIBO, which is overgrowth of bad bugs in your small intestine that was causing all this fermentation and creates these toxic byproducts. They were clearly creating inflammation in the brain. We treated her gut with antibiotics to cure migraine, but who would have thought of that as a neurologist? Dr. Todd Lepine: Exactly. It's also the other interesting, we're going to talk about that in one of the upcoming episodes is on histamine, the role of histamine. That's actually a very interesting thing. When you look at histamine, because people who have SIBO, they actually have bacteria that are producing toxins like you're talking about, and one of the problems in excess amounts of histamine. Normally our bacteria will degrade histamine and we have enzymes that do that and there's all these different pathways. When you look at some people who have migraine headaches, there are certain foods which can trigger a migraine. Is it the food that's doing it or is it something in the food or it's how the food is actually being metabolized? That's a really key important feature is the connection between the gut, our food and the brain. Dr. Mark Hyman: It's such a big problem, Todd. The amount of people with migraines. There's over 10 million people have migraines. It costs about $17 billion a year to society in healthcare costs, just direct healthcare costs. That's medications, emergency room visits, hospitalizations, doctor visits, testing. And then even managing the side effects. And then the loss of productivity to employers because like you're saying is $15 billion. About half that's- Dr. Todd Lepine: Huge. Dr. Mark Hyman: Due to absenteeism and the other half's due to just people being at the job but not on the job. They're just sort of there but not functioning. Over the years in functional medicine I've seen so many patients and like you said before, there's so many flavors. Tell us about some of the other flavors. We went through the mitochondria. Let's just go down the list. What are the most common things because there could be 29 things, but there's a few that are really common. Dr. Todd Lepine: Stress. Dr. Mark Hyman: Stress. Okay, tell us about stress and migraines. Dr. Todd Lepine: Stress by itself does not cause any diseases, but stress can turn the volume up on all different kinds of conditions. We see that in autoimmune conditions. How our bodies respond to stress and some people have I would call it a genetic predisposition to be more stress resilient, and some people don't. Some people are more prone to the effects of stress. Time after time you see these people who they'll go through a very stressful period and all of a sudden they get a full-blown migraine. What is that? What's going on there? I think it is how that person perceive the world and how they detoxify their stress. Absolutely. That's why beta blockers, which block adrenaline, which you get high levels of stress- Dr. Mark Hyman: That might help, right. Dr. Todd Lepine: Makes a big difference. Dr. Mark Hyman: Things like yoga, meditation. Dr. Todd Lepine: Exactly. Dr. Mark Hyman: Breathing can help. Dr. Todd Lepine: Sometimes when you have patients who have migraines and you measure their cortisol levels, they've got higher levels of cortisol. That's telling you they're having some more chronic stress. Sometimes they'll be Type A where they're very, very driven, those kinds of things. Dr. Mark Hyman: You mentioned gut issues a little bit earlier, and I think that's another big one and not just SIBO. There are a lot of symptoms that people get that could be related to leaky gut and food sensitivities, which seem to be a huge factor with migraines that are really undiagnosed. We know traditionally that scientists and doctors say stay away from tyramine foods, cheeses, foods that contain certain chemicals like MSG or aspartame. There are some recommendations. Chocolate, caffeine. There are doctors who do say some of these things and that can be helpful for some patients. But it goes much deeper than that. There's food sensitivities and gluten. Tell us about how that works. Dr. Todd Lepine: I think that the connection between the gut and the brain is huge and the leaky gut component you oftentimes will see leaky gut in patients who have increased risk for migraines. There's definitely a two-way communication that's going on there. Again, sleep is another thing that plays a huge role. Lack of sleep is huge in migraines. When you look at when somebody comes to see me, I ask them, "How's your stress level? How are you sleeping? What are you eating, and who are you feeding," which is what's going on with the gut bugs. You have patients who will tell you that when they eat certain types of foods like sugar, they'll trigger a migraine. It's huge. I suspect that some of those foods are actually affecting the gut microbiome in a very rapid fashion that's causing migraines. Dr. Mark Hyman: One of the biggest things I've seen ... I'm sure you've probably noticed this too ... Is that gluten tops the list when it comes to migraines. If anybody has a migraine, the simplest thing to do is an elimination diet. Dr. Todd Lepine: Absolutely. Dr. Mark Hyman: Get rid of the most common allergens, so gluten, dairy, eggs. I had one woman she was married to a Mafia don, and she had headaches for 40 years. Was incapacitated, in bed very often, and it turned out that it was eggs. We found this on a food sensitivity test. That's not to say everybody's migraine is caused by eggs, but hers seemed to be triggered by eggs. She stopped eggs and her migraines went away. Dr. Mark Hyman: Everybody's different like you said, and we have to treat the person, not the disease. William Osler said that we should treat the person who has the disease, not the disease that the person has. I think that's the mistake we make in medicine. Dr. Mark Hyman: Doing an elimination diet, getting food sensitivity testing, checking for gluten, that's all important. Chemical triggers. We talked a little bit about that. Talk more a little bit about some of these chemical triggers that we notice with migraines. Dr. Todd Lepine: You mean like exogenous chemicals? Dr. Mark Hyman: Things like aspartame, artificial sweeteners, food additives, sulfites for example, tyramine. Dr. Todd Lepine: I would say that those are basically excitotoxins. These are certain types of foods which can cause excess activity. Like monosodium glutamate. You get excess glutamine in the [inaudible 00:14:51] because glutamine gets converted into glutamate, which is an excitotoxin. Definitely there are those types of foods. Even if you give somebody glutamine, which we use a lot to help with patients ... I've had these patients who they'll metabolize their glutamine directly into glutamate and taking glutamine will be just like taking MSG. They'll get very agitated and get a headache. Dr. Mark Hyman: Aspartame is bad. I've seen so many patients who- Dr. Todd Lepine: Oh aspartame, yes. Dr. Mark Hyman: Swig back those diet sodas and they get- Dr. Todd Lepine: We have somebody in the White House who does about I think 10 a day. Dr. Mark Hyman: I don't know if he's getting migraines, but he's giving everybody else a headache. I think you're right. We have to really look at these things. Nitrates that are in, for example, deli meats, sulfites that are commonly added to salad bars to keep the vegetables fresh or the dried fruit in wine. Tyramine, which is in chocolate, cheese. These are really significant. Getting rid of all the processed food, all those chemicals super important. Dr. Mark Hyman: Hey everybody. It's Dr. Hyman. Thanks for tuning into The Doctor's Farmacy. I hope you're loving this podcast. It's one of my favorite things to do and introduce to you to all the experts that I know and I love and that I've learned so much from. Dr. Mark Hyman: I want to tell you about something else I'm doing, which is called Mark's Picks. It's my weekly newsletter, and in it I share my favorite stuff from foods to supplements to gadgets to tools to enhance your health. It's all the cool stuff that I use and that my team uses to optimize and enhance our health. I'd love you to sign up for the weekly newsletter. I'll only send it to you once a week on Fridays, nothing else I promise. All you do is go to drhyman.com/picks to sign up. That's drhyman.com/picks, P-I-C-K-S, and sign up for the newsletter, and I'll share with you my favorite stuff that I use to enhance my health and get healthier and better and live younger, longer. Dr. Mark Hyman: Now back to this week's episode. Dr. Mark Hyman: Let's talk about hormonal factors because these are really common. Often, women we see this whole phenomena of premenstrual migraines. How do you know if this is an issue for you with your patients? Dr. Todd Lepine: Just by history. The history will tell you that, and I typically will see that those types of patients who have menstrual migraines tend to have problems with estrogen detoxification. As men, our hormones tend to stay relatively stable. They go up in the morning but they're pretty stable. Women's hormones, they go up and down like the tides. That's normal. That's part of the menstrual cycle. When women are menstruating, some women have great fluctuations in hormones and when the body is done with those hormones unless you're pregnant, the body has to detoxify those hormones. There are certain pathways that help with estrogen detoxification. When women have problems with those pathways ... One of the genes that's important in there is the catechol-O-methyltransferase or COMT gene, and typically that gene is oftentimes associated with increased sensitivity to pain. It's also associated with increased sensitivity to migraines, seizures and headaches. It's definitely one of those pathways that you want to support for the detoxification or the methylation of- Dr. Mark Hyman: With B vitamins, like B6, B12- Dr. Todd Lepine: Magnesium. Dr. Mark Hyman: Magnesium. Dr. Todd Lepine: Magnesium. Dr. Mark Hyman: Often the classic story that I've seen with these premenstrual migraines is women get PMS-y symptoms. So they get bloating, fluid retention, they get cravings, irritability, breast tenderness, menstrual cramps and they get heavy bleeding. These are signs of too much estrogen and not enough progesterone. Dr. Mark Hyman: I remember one patient who had a migraine in my office, and I had a sample tube of topical progesterone that I had been given by the company that made it. I literally said, "Well, let's just try this." I took the progesterone, I just put a little cream on her arm, rubbed it in, and her headache went away right there in the office. It was the most striking thing I'd ever seen. I think we often will prescribe topical progesterone or other things to help. We'll prescribe dietary changes to help with PMS. Detoxifying these hormones can be really helpful. Also, using an overall strategy of diet and exercise and stress reduction to balance women's hormones because I think they're totally influenced by diet, even the microbiome. Dr. Todd Lepine: It's interesting you say that because I remember distinctly when I had a patient when I was practicing mainstream medicine who had menstrual migraines, and the only thing that worked for her was Xanax. Now Xanax is a benzodiazepine, which is a tranquilizer- Dr. Mark Hyman: Like Valium. Dr. Todd Lepine: Yeah, like Valium. Exactly. It works on the GABA receptors. Guess what? Progesterone is working on that system. That's why progesterone is so powerful. Dr. Mark Hyman: Just to recap that, what you're saying is that basically progesterone is women's natural Valium. Dr. Todd Lepine: Exactly. Dr. Mark Hyman: It works in the brain on these receptors called GABA that Valium works on and makes you relax, which actually helps women sleep, calms their nervous system, deals with some of this mood fluctuations that happen with high estrogen. By the way, our whole lifestyle drives estrogen. Sugar, stress, lack of exercise, bad gut microbiome, environmental toxins, all these things will drive ... Dairy, for example drives excess hormone in estrogen production, being overweight, sugar. All those things can be managed easily with lifestyle and diet. Dr. Mark Hyman: Let's talk about some of the nutrients because there are some key nutrients that are often low in people who have migraines. Dr. Todd Lepine: Absolutely. Dr. Mark Hyman: What's the number one nutrient that you would be thinking of? Dr. Todd Lepine: I would say magnesium. Dr. Mark Hyman: Yeah, magnesium. Dr. Todd Lepine: Magnesium. The interesting thing ... This is also another thing where you can sort of connect the dots here is magnesium, which is such a powerful ... It's involved in 500 enzyme pathways in the body is magnesium when you get to high enough level is actually a calcium channel blocker and guess what doctors use to prevent migraines? Calcium channel blockers. Dr. Mark Hyman: It's a natural muscle relaxant. I remember when I was an ER doctor, it was one of the things we used. When none of the drugs worked, we would use IV or intravenous magnesium for migraine patients. Remember that? Dr. Todd Lepine: Absolutely. Not only that, but we use, in the ER, we use IV magnesium for heart arrhythmias, life-threatening ones like Torsades de pointes and V-tach. We also use it for status asthmaticus. We use it for preeclampsia. It's a very powerful element. Dr. Mark Hyman: It's a relaxant. What you're saying is funny to me because I remember when you learn these ACLS courses, the advanced cardiac life support and how to run a code and bring people back from death when their heart's not working. Use all these drugs. Drug, drug, drug, drug, and the last thing if nothing else works, then use magnesium. Why don't you use it first? If someone's heart's not beating right, you give them magnesium and it fixes it. Or if people are coming in, in pre-term labor or have this preeclampsia, which is high blood pressure, pregnancy with seizures, they use IV magnesium. They use it in asthma, like you said, to relax the lungs. They use IV magnesium. It's pretty funny. Even when people are constipated, they give them Milk of Magnesia. It's funny, doctors don't really think about it. Dr. Mark Hyman: Most of us, about 40% of use, are low or deficient in magnesium. I remember this one patient I had who was a radiation oncology resident back when we were at Canyon Ranch. She was just debilitated with migraines. She had the worst migraines. She was on narcotics and Zofran, which is a chemo drug that used for nausea. It was that severe. She could barely work. She came to see me, and I started asking her questions. This is how you find things out in functional medicine. You try to connect the dots. Dr. Mark Hyman: Usually you can find out from a story if it's a premenstrual migraine, if it's a food-related migraine. This is what you're saying. We can actually figure this out as functional medicine doctors. Turned out ... I started asking her questions ... She had muscle cramps, she had constipation. I said, "How often do you go to the bathroom? Are you regular?" She goes, "Yeah, I'm regular." I said, "How often do you go?" She was, "I go every week." I said, "That's not regular." She said, "It's regular for me. I go every week." Severely constipated, muscle cramps, headaches, insomnia, irritability, anxiety, palpitations, sensitive to loud noises. These are all symptoms of low magnesium. It turned out she needed ... Normal dose is 200, 400 milligrams. She needed 2000, 3000 milligrams a day of magnesium and literally her migraines went away. So did her constipation and all those other symptoms. Dr. Mark Hyman: It's often really often very simple if you know what to do. Dr. Todd Lepine: Yep. Absolutely. Dr. Mark Hyman: Are there other nutrients that you would think of that might be helpful? Because you mentioned mitochondria and there's a couple of nutrients there that can really help. Dr. Todd Lepine: Some of the key nutrients are Vitamin B2- Dr. Mark Hyman: Riboflavin. Dr. Todd Lepine: Vitamin B6 and then also CoQ 10. Those are probably some of my key mitochondrial nutrients that really can have an impact, along with magnesium. Dr. Mark Hyman: Tell us about some of your cases that you've had experience with that have really changed your thinking and have helped you understand- Dr. Todd Lepine: I had a patient who came in, and his story was that he first developed migraines starting around at the age of five, which is interesting. When you have a history of somebody who's having headaches ... It's not normal for a five-year-old to have headaches ... That makes me think this person may have a mitochondrial issue and that may be what's going on early on in their story. Dr. Todd Lepine: Also, interestingly, the patient noticed when he was telling me this story, that he would get the worst headaches on the weekends. On further asking him, it turned out that on the weekends he didn't drink coffee. So what he was getting, it was a caffeine withdrawal headache. Caffeine is a double-edged sword. We actually use caffeine to treat migraines. If patients take over-the-counter medications like Excedrin Migraine, guess what one of the major ingredients in there is. Dr. Mark Hyman: Caffeine. Dr. Todd Lepine: Caffeine. In fact, I had a patient ... I'll never forget this ... It was a woman who had refractory migraines. It turned out that she actually was getting rebound headaches from daily use of Excedrin Migraine. She would have to take the Excedrin Migraine to prevent the withdrawal effect from the caffeine. It was like a cat chasing its tail. Dr. Mark Hyman: That's not great because that's got Tylenol in it. Dr. Todd Lepine: It's great for the company because they keep selling it. Dr. Mark Hyman: Can cause liver problems. Dr. Todd Lepine: Right. Exactly. This patient was caffeine sensitive. Some of the treatments you can actually abort a migraine with caffeine, but you can also trigger a migraine. So it's sort of a double-edged sword in terms of the effect of caffeine. Dr. Todd Lepine: But typically, if I somebody who's got migraines, I get them off of all alcohol, all caffeine and give them some magnesium. Just [inaudible 00:25:42] you can shoot from the hip and just do that and you can a huge impact. That was an interesting with the patient. This particular patient also had a history of developing an egg allergy at age 21, which is interesting. Why did he all of a sudden develop an egg allergy? In addition to that, the patient said that they would develop the itching with eggs and then also had itching with bananas, which then makes me think about is there a problem with histamine and histamine detoxification. Dr. Todd Lepine: There are specific genes in the body that have to do with histamine synthesis and also histamine detoxification and you can do some esoteric testing on that to see ... Because histamine I definitely think plays a big role in migraines. Dr. Mark Hyman: What is histamine, Todd? Dr. Todd Lepine: Histamine is the compound that is naturally found in the body and it is actually a neurotransmitter. It's also involved in allergies. When we have spring allergies or allergic rhinitis, we treat that with an antihistamine. This is sort of interesting and I'll talk about this when we- Dr. Mark Hyman: It's made by your white blood cells. Dr. Todd Lepine: It's also made by gut bacteria. It's found in food. It's made by the white blood cells, specifically the- Dr. Mark Hyman: The mast cells. Dr. Todd Lepine: The mast cells, exactly. There are certain receptors for histamine. There's four receptors for histamine. Interestingly when you block histamine, what happens to you? You fall asleep. Ever take Benadryl? Benadryl puts you to sleep. Histamine actually activates the body. It wakes the body up. It actually works as a neurotransmitter. Also, it's involved in allergies and itching and things like that. Histamine is one of these things- Dr. Mark Hyman: Where you get hives or things like that. Dr. Todd Lepine: You can get hives. Exactly. Histamine definitely plays a ... It's one of the things that can play a role in migraine headaches. Dr. Mark Hyman: How do you approach a patient who's got histamine sensitivity? How do you diagnose it first and that kind of thing? How do you treat it? Dr. Todd Lepine: One of the things that you can do is put somebody on a low histamine diet because a lot of the foods that we take in can be high in histamine. Normally our body will just deal with excess amounts of histamine. But when the gut bacteria is out like if you have SIBO, you'll have problems with histamine breakdown or histamine degradation or certain bacteria will actually be making high levels of histamine, which in turn can affect the brain and your neurological system. Dr. Mark Hyman: Incredible. I've seen histamine treatment when you do it in the right patient by both dietary changes. Also, there's all kinds of supplements that can help like Coresatin, even medication like Cromolyn that you can take orally. [inaudible 00:28:38], which is various supplements that help with modifying the histamine response. In the diet low in histamine, people can really have radical transformations in their health. It's not something most doctors think about or do, and it's tricky to do but it can be really effective. Dr. Todd Lepine: This particular patient when I did the testing on him, lo and behold he had significant sensitivity to gluten, which he was totally unaware of and had never really worked with a nutritionist. Sometimes they say, "Well, I worked with a dietician." A regular dietician, they're not really all that helpful. Having a nutritionist who's trained in functional medicine and can really look at the diet beyond just calories and the macronutrient proteins, fat and carbohydrates is very, very important. In this particular patient the organic acid testing showed a higher need for the B vitamins, showed some evidence of dysbiosis, which is imbalances of the gut bacteria, had significant gluten sensitivity, some leaky gut on testing, had low normal magnesium ... Was technically normal, but it was on the low side of normal. These are all the different things that you can fix. Then on stress testing, had high levels of cortisol. Interesting. It was very, very interesting. Dr. Todd Lepine: The other thing that I found on the patient ... I'm not really sure because I'm actually still working on that ... I'm going to deal with that later ... Is high levels of mercury. Very high levels of inorganic mercury in this particular patient. The other thing which is also really interesting is I did genetic testing. I like to do genetic testing because it's like lifting the hood on your car. I can tell you what's going on below the scenes. The thing about genetics of migraine is there's not really one migraine gene. We can test for these SNPs and variations, but this particular patient had a variation in the genetics, the polymorphisms of a G coupled protein which has to do with serotonin and stress resiliency. This person's genetic makeup was such that he was more prone towards the effects of stress. It was a particular gene called HTR1A, which is on the testing that do with a DNA mine test. I found that really interesting. Dr. Todd Lepine: Otherwise, the patient had good genes. They had good detox genes, good COMT genes, et cetera, but had problems with stress. The patient's history was consistent with that. That stress was one of the big triggers for that particular patient. Stress management is huge for everything that we see in patients who walk through the door. Everybody is affected by stress. You watch the news and you get stressed. Dr. Mark Hyman: I try not to. Dr. Todd Lepine: That's why I don't have a television. Dr. Mark Hyman: I try not to. Dr. Todd Lepine: Exactly. Anything that we can do to help people to manage and modulate and detoxify their stress goes a long, long way. Huge. Huge. Huge. Dr. Mark Hyman: I think that's right. This case brings up something really important about functional medicine because you listed a whole litany of things. It wasn't just magnesium, it wasn't just the gut, it wasn't just histamine, it wasn't just this and that. It was a lot of different things. Functional medicine's really about being a medical detective and looking for all of the various factors because traditional medicine's okay you have this one disease that you treat with one drug instead of saying where are all the imbalances in the system? Let me correct all those. Because if you correct two out of six, the patient might get a little better but not really. You have to deal with all six. Dr. Mark Hyman: I think that's really the beauty of functional medicine. We're not treating the disease, we're treating the patient and all their unique variations in their story. There are no two people who are the same. When someone comes with a migraine, it's a blank slate. Then I have to figure out what kind of migraine and what are the various factors and is it hormonal? Is it magnesium? Is it the gut? Is it the mitochondria? Is it food additives? Is it histamine? It may be all of them. Dr. Todd Lepine: Exactly. Dr. Mark Hyman: This is really what's so beautiful about our approach here at UltraWellness Center, which by the way now during COVID, we're taking all virtual patients so we can see from anywhere in the world. You don't have to schlep all the way here. We have an incredible team of physicians here and physician assistants, nutritionists. We've all been doing this for close to 30 years now, which is scary to say. Dr. Todd Lepine: And we're still learning. Dr. Mark Hyman: We're still learning. That's the thing about functional medicine. It constantly pushes you to discover and learn because you're not just learning a rote approach to this diagnosis. Like that patient who had the migraine with all the magnesium deficiency and all those other symptoms, she was at the Mayo Clinic. She saw the top doctors there. She went around to all the headache clinics in the world. She saw everybody, did everything, and all they cared about was her headache. They didn't want to know about her constipation or her muscle cramps or her irritability or her insomnia or any of that. Dr. Todd Lepine: Or her stress being married to a Mafia don. Dr. Mark Hyman: No, that was somebody else. I was not the doctor. That was somebody else. Was one of the good fellas. It's really important for people to understand who are suffering out there from headaches, even regular headaches can respond to this as well. But migraines are the most severe and disabling kind of headaches. Dr. Mark Hyman: I just remember this patient I saw, it was a 24-year-old, young woman who was a nurse who wanted to become a nurse practitioner. Brilliant young woman who was in bed because she had vestibular migraines, which is a certain kind of migraine that makes you not only have a headache and be nauseous but the room spins around like when you're in your beach and you spin around in circles until you can't stand up anymore. It's like that. She was just miserable. She got every treatment for the migraines, every kind of headache drugs, every neurologist. Nothing worked. Dr. Mark Hyman: I started asking her about other stuff. She was very depressed, she was anxious, she had severe bloating, she had acne, she had fluid retention, she had all these other symptoms. It turned out she had really severe SIBO or bacterial overgrowth and severe food sensitivities as well as a bunch of other stuff and magnesium and this and that. I literally just really focused on treating her gut and her food sensitivities and supporting her a little bit of magnesium and some other things and literally within a very short time, within six weeks, she not only had all her migraines go away, not only did she lose 20 pounds, but her depression, anxiety and everything else went away. The gut can lead to all that stuff. It's so unfortunate that we don't think in this comprehensive way with traditional medicine because so many people suffer unnecessarily. Dr. Todd Lepine: It's interesting you talk about that because it reminds me, I think I've seen it in a couple of cases, is there are some patients who have H. pylori, which is specific bacteria. If you clear H. pylori in some migraine patients, their migraines go away, which is very, very interesting. It doesn't happen in everyone, but if you do the testing for H. pylori and if you find it and the patient's got migraine, you go ahead and treat it and it can make a big difference. Dr. Mark Hyman: I just think you're right, Todd. It's really just spending the time to ask the right questions, to do the right kinds of tests. What are the top tests that you might think you want to- Dr. Todd Lepine: As we said, checking for magnesium and specifically red blood cell magnesium because magnesium needs to be the intracellular form. A lot of times patients are tested for regular magnesium. It's the RBC magnesium is what you really should check for. Then we'll do the testing for gluten sensitivity. Cyrex 3 is my favorite. We'll also do testing for increased intestinal permeability, organic acids. Gut microbiome testing can be helpful. Dr. Todd Lepine: I mentioned genetic testing, but there really is ... The genetics play a small role but it's interesting because there really is no one gene for migraines. The only thing I would tend to say is that if you're suspicious for mitochondrial issues, checking for mitochondrial function- Dr. Mark Hyman: That can be helpful. Dr. Todd Lepine: That can be very helpful. Dr. Mark Hyman: Hormonal testing. Dr. Todd Lepine: Yeah, hormonal testing. Exactly. Hormonal testing. Dr. Mark Hyman: You have a lot of tricks and tests that you wouldn't necessarily see in a regular doctor's office to help us sort through what's going on. Dr. Todd Lepine: Cortisol testing. Exactly. Dr. Mark Hyman: Cortisol testing. Hormone testing. Nutritional testing. Dr. Todd Lepine: Absolutely. Dr. Mark Hyman: Food sensitivity testing. It's so, so important. I feel like when I see a migraine patient I'm so happy. Because I'm like, "Oh. Slam dunk. This is easy. They're going to be so happy and make me look good." It really isn't that we're that smart. It's just that we're looking through a different lens that allows us to see the problem in a unique way that's individual to that patient. Dr. Todd Lepine: Exactly. Personalized medicine. It's the epitome of personalized medicine because there are probably no two migraine patients that I will treat the same. They're all unique. There's a basket of things that you'll do, but you tweak that to that individual patient based upon their history, their testing and everything else. That's the fun part about it. Dr. Mark Hyman: If you're just saying to somebody who's listening and they're saying, "I don't really know any functional medicine doctors. I want to just try some stuff on my own," what would be the top few things you would tell a patient to try? Let's say your cousin had migraines and they didn't want to come in and see you, what would you tell them? Dr. Todd Lepine: Well, first thing is get good sleep. Most people are sleep deprived. Lack of sleep is a stressor, and we talked about stress being a big trigger for migraines. Getting into a good sleep-wake cycle, modulating and detoxifying stress, meditation, whatever different forms that you use for- Dr. Mark Hyman: Relaxation. Dr. Todd Lepine: Relaxation. Exactly. Adding magnesium and then the simple dietary changes. Gluten, sugar, dairy. Those are the big three. If you remove those from a patient's diet, it can make a huge difference. I think those are probably some of the key things that you can do. Dr. Mark Hyman: I agree. I think it's so simple. Just clean up your diet. Gluten, dairy, sugar, processed food, all the additives, chemicals. Dr. Todd Lepine: You're absolutely right because the excitotoxins, a lot of those things that are added to foods that you may not even be aware of. The best thing to do is buy food that doesn't have labels on it. Dr. Mark Hyman: There you go. Dr. Todd Lepine: Right. There you go. Dr. Mark Hyman: An avocado doesn't have a nutrition facts label or an ingredient list. It's just an avocado. I agree. That's something people can try. An elimination diet. Dr. Mark Hyman: We have something called the 10 Day Reset, which is really easy to do. You can go to getfarmacy with an F.com. That is a really simple approach to just cleaning up your diet for a week or 10 days. Often you'll know very quickly ... If your migraines are two or three times a month, you might have to do it longer ... But if you get regular migraines every week or more, you'll see a difference. Magnesium's a super slam dunk. Easy thing to do. Getting stress reduction and sleep. So easy. Dr. Todd Lepine: The other thing is that oftentimes for some people who have really bad migraines, it's not as though they're never going to have a migraine the rest of their life. But if they do get a migraine, it's not disabling. It might be very infrequently and if they get it again, it's very mild and it may be triggered by something but it's really nowhere near as bad as when they first started. It's not like I'm going to cure your migraines. This individual may be susceptible to having migraines and when you make all these changes, their life is much better because they can now function. If they get a migraine, it's not disabling. It's mild. It's infrequent. It's not a big deal. Dr. Mark Hyman: Then they learn what are the triggers for them and they can avoid them. Dr. Todd Lepine: Interesting. Have you ever had a migraine? Dr. Mark Hyman: I have not. I've had some headaches, but I've never had a migraine. Thank God. Dr. Todd Lepine: It's interesting because I- Dr. Mark Hyman: Not fun I can imagine. It's the worst. Dr. Todd Lepine: I very rarely get a headache, and I've never had a migraine. However, when I was working at Canyon Ranch there was one time, it was right before lunch, I all of a sudden had these jagged, sparkling lines in my field of vision. I'm like, "Where does this come from?" Dr. Mark Hyman: I'm having a stroke. What's going on? Dr. Todd Lepine: I was actually having ... Because migraines you can have an aura with a migraine. An aura's what you get before you get a migraine. For whatever reason, I only had it once, I had a migraine aura. I didn't get a headache, but I knew exactly what it was. I said, "Oh, this is interesting. Now I know what the patients are experiencing before they get a migraine." I had it once, didn't have a headache, never had it again. Don't ask me why I had it. It could have been maybe I was low in blood sugar or stressed out. I don't know what. I was just sitting there and it was a good experience because now I can understand what it's like for a person to have a migraine aura. Dr. Mark Hyman: If you've been listening to this podcast and you've had headaches or migraines, don't fret because following these simple ideas can have a profound effect. If you get stuck and you need a little more help, we're here at UltraWellness Center to help you. Just go to ultrawellnesscenter.com. We can see you virtually. Dr. Mark Hyman: Really sometimes it's a bit of a detective job, but simple things to try like we said, diet, elimination diets, magnesium, sleep, stress reduction. Certainly a place to start. It is something that causes so much suffering. 10 million people have it. Probably collectively it costs $50 billion a year to society. It's a big deal. Some things are hard to deal with and you have certain cancers that's really tough, but migraines are an easy slam dunk for functional medicine. Dr. Mark Hyman: If you have a migraine, I hope you never have to have it again after listening to this and follow the instructions we gave. If you loved this podcast, we'd love you to share with your friends and family on social media. We'd love you to leave a comment. Share your experiences about having migraines and what's worked for you, and subscribe wherever you get your podcasts. We'll see you next time on The Doctor's Farmacy. Dr. Todd Lepine: Thanks, Mark.