Top Headache Doc: Migraine Is Not What You Think
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What is the main topic discussed in this episode?
For decades, migraine was explained as a blood vessel problem, swelling, throbbing, treated by shrinking things back down. Turns out, that's mostly a myth. The real explanation is stranger and also a lot more hopeful than the older one ever was. In this conversation, you'll discover why migraine is neuroinflammatory, not vascular, and why some med schools still teach the old version. You'll learn how your brain can start treating chronic pain as normal, like a broken thermostat convinced a hot room is 72 degrees. We'll talk about why only a fraction of people with migraine ever get aura and how differently it can show up in so many different ways in so many different people. We'll explore what's happening while you sleep that either clears your brain out or leaves it inflamed and why headache medicine may be entering its golden age.
We'll talk a lot about cutting edge treatments as well. Our guide is one of the few physicians in the country trained in both internal medicine and headache medicine, Dr. Fred Cohn. So excited to share this conversation with you. I'm Jonathan Fields, and this is Good Life Project. And we'll jump right in after this short break. What is the myth that we have been told or learned about migraines that was either never true to start with or is maybe no longer true today?
Yeah. So that's a really great place because it's still, I would say, a problem if you go today. So first, let me start with the myth and what migraine is still taught us. So migraine, you know, it's actually there's documentation of migraine since like BC times. And I think it was Aristotle actually has in like a log or a diary or whatever him talking about having blinding light in his eyes than a splitting headache, which that sounds like migraine with oar. Yeah, so it's been around for as long as we've been keeping documentation of things. It's not like an occurrence of something new. And the first accepted theory was actually earlier in the 20th century by Dr. Harold Wolfe. It's a very famous forefather of headache medicine that it was a vascular issue.
Migraine is that pulsating, pounding thing. But then later on, towards the turn of the century, we know it's not primarily vascular. That's the myth. It's not a vascular thing. And they still teach that, actually, in some parts of med school and whatnot, that it's a vascular problem. It's a neuroinflammatory condition. That's what it is. And again, it's complex. I always tell someone, if you figure out a migraine, 100%, you win the Nobel Prize in Medicine. We understand a good bit what's going on, but there's still more to do. But it being a vascular blood pressure, so there's a myth. The truth is it's more of a neuroinflammatory condition.
I mean, that's interesting, right? Because I'm somebody who is a migraineur. I have lived with migraines for my entire life since my teens. And I remember hearing early in my doctor visits that this was exactly what you're describing. It's a vascular condition and that a lot of the treatments were designed differently. around that assumption, none of which ever worked for me or helped me in any meaningful way. So you're saying that that was the assumption until not too long ago, but now there's a deeper understanding that there's something different going on here.
And that's actually a big fight in, if you will, my grand education. I still have, I meet trainees, med students, et cetera, that they are still learning in their schooling in like the year 2026, that it's a vascular condition. And there's a concern of like, oh, it's a blood pressure thing or something like that. And again, no. There is a vascular component of it downstream, but the primary... aspect thing that's going on in a migraine is this release, a soup, if you will, of these inflammatory neuropeptides that are released. And then downstream, yes, they can have vascular effects, obviously pain. You have the aura components like flashing lights, anxiety, weakness, all this other stuff. But the vascular part is only one small component.
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Chapters
5 chapters
1
What is the main topic discussed in this episode?
0:00–5:25
2
Why is the old 'vascular' explanation for migraine a myth and what is the neuroinflammatory model?
5:25–17:51
3
How does the trigeminal vascular system and cortical spreading depression trigger migraine attacks?
17:51–25:48
4
How can clinicians tell migraine, tension headache, and cluster headache apart clinically?
25:48–44:04
5
What do migraine prevalence and sex differences tell us about hormonal and epidemiologic risk?
44:04–1:02:47
Speakers
2 identifiedMore from Good Life Project
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