Behavioral Therapies for Migraine

Episode 248: Behavioral Therapies for Migraine

Lindsay Weitzel, PhD:
Hello everyone, and welcome to HeadWise, the videocast and podcast of the National Headache Foundation. I'm Lindsay Weitzel. I'm the founder of Migraine Nation, and I have a history of chronic and daily migraine that began at the age of four. I am super excited to be here today with one of our favorite guests. I am here with Dr. Dawn Buse. Hello, Dr. Buse, how are you?

Dawn Buse, PhD:
Hello, Dr. Weitzel. I'm well. How are you?

Lindsay Weitzel, PhD:
I'm good. Dr. Buse is a psychologist specializing in headache and migraine, and a clinical professor of neurology at the Albert Einstein College of Medicine. She is a very popular guest. We are always so happy when she's here. Most of everyone who watches this knows who she is. Today, I am really excited about this episode. No matter how much you know about these topics, I think we're all going to learn something new. We want to talk about all the behavioral therapies that we have available to us for migraine management and prevention. So, we're going to just jump right into it, because it's a kind of a lot to talk about, so everybody tuck in, get ready. Dr. Buse, let's just go. What are the scientifically supported behavioral therapies for migraine management?

Dawn Buse, PhD:
The big three are going to be cognitive behavioral therapy [CBT], biofeedback, and relaxation therapy. And then those with emerging evidence would be acceptance and commitment therapy [ACT], and mindfulness-based cognitive therapy [MBCT]. And when I say emerging evidence, they are well established in other disease states, decades of evidence. A little newer to migraine, although we have some really nicely done studies of mindfulness-based cognitive therapy that we can talk about. These are all options. They are all a little different from each other, but they all do have some overlap. And so we are going to talk about some of those details about them today.

Lindsay Weitzel, PhD:
One of the things I always like to say is if you are one of the people who has been in chronic pain for years, you have managed to function, you find as you read about these therapies, learn about them, go through them, that some of these things you have automatically figured out on your own. And then other ones are just so exciting when you learn them because you're like, oh my goodness, this helps so much. Why didn't I learn about this earlier. I do want to ask just a broad question, first of all, in case people are wondering. Who should consider these therapies? In other words, if you haven't tried medicines yet, should you be considering them? If you already feel like you've failed every medication out there, should you be considering them? Who's really a good candidate for them?

Dawn Buse, PhD:
Both of those people and everyone in between. These are great learning experiences and tools for anyone living with migraine at any stage in the journey. They are therapies kind of like going to physical therapy. You go for a limited amount of time, maybe 8 to 10 weeks, once a week. And you'll learn and practice specific skills that then you can take on with you really through the rest of your migraine journey, the rest of your life, which makes them really great therapies for kids because they use them throughout their life.

They're terrific options for someone who is planning a pregnancy, pregnant, or postpartum, where your medication options are limited. They're also great for someone who has other contraindications to medicine, like perhaps someone who has had some cardiac issues, a heart attack, a stroke, where some of the medications are limited. We want to be more careful. They can be used independently or combined with all of the medication, non-medication therapies, the acute and preventive medicines, as well as neuromodulation. They can be combined with everything we've got in our therapeutic armamentarium for migraine.

Lindsay Weitzel, PhD:
Let's go ahead and discuss what these therapies entail.

Dawn Buse, PhD:
Let's start with relaxation training. Relaxation training helps you be aware when your nervous system is more activated and learn how to calm it. The nervous system has two branches, the parasympathetic and the sympathetic. Those are both part of the autonomic nervous system, which is, I like to think of as automatic, the things that happen in your body, your heart rate, your breathing rate, sweating, all of these things, muscle tension, where the blood goes in your body. That's all controlled by this autonomic nervous system. And there is a wonderful reason that when you feel stressed, this sympathetic activity kicks in. It's because this is our fight, flight or freeze activity, and it gets you ready to get out of danger in a physical way. Your heart rate speeds up, so blood pumps through your body. Blood is shunted to your big major muscle groups, your biceps, your legs, so you can run, you can fight, you can climb. Because of that it’s not really doing things like digestion in that moment because that's not really important in that moment of survival. You get goosebumps and sweaty palms because you start to sweat to cool your body. You start to breathe faster so you get oxygen in.

Now, all of these things and more are wonderful when we need to survive something dangerous. We're getting out of a burning building, we're getting away from a car accident, or we hear footsteps behind us in a dark street and we're by ourselves. These are great things. However, we have a lot of stress or activation which is not physical danger. Now we're in a rough spot. Now we're worried about taking a test, doing a live performance, giving a speech, going on a first date, whatever we're worried about, reporting to your boss, or either a migraine has started or you feel like my one might be coming on. Now, the first things I mentioned now are more emotional, cognitive stressors, and now you've got sweaty palms, goosebumps, your heart is pounding, you're breathing shallow and rapid. Now these things that evolutionarily were so wonderful in a physical survival situation are working against you in fact and you're activated and it feels like a panic attack. It feels like anxiety and it is working against calming the nervous system.

So, in relaxation therapy, we learn ways to, one, notice when we're activated and two, calm and relax the nervous system. And these are very traditional ways, often starting with the breath, often controlling the slowing, deepening the breath. That's really where a lot of it starts. And this is something that we know instinctively as you said. You already know, okay, I’ve got to calm down. Or you're trying to soothe your child, okay, take a deep breath. We think about Lamaze for pregnancy. We've been using that for about 80 years now. What is that, focusing on the breath, deep breathing. Ancient practices of yoga and mindfulness and prayer all include these sorts of calming, focusing, breathing techniques. So that is mindfulness.

That can be incorporated into pretty much everything else we're going to talk about. So that's often an element. But that is something you could practice on your own. There are oodles of wonderful videos out there for free, podcasts for free, things you could pick up at the library, books you can find, audio, so many ways to learn and practice relaxation, breathing, and relaxation technique. And it's really a lovely feeling, something that we all should do throughout the day. I prefer not to leave it to the end of the day. I prefer to do many relaxations throughout the day, throughout your workday, throughout your school day. Take ten seconds and exhale and let a nice inhale come in. Ten seconds every half an hour or hour throughout your day, in between each meeting, or in between each class so that we kind of keep tending to our nervous system as the day goes on.

Lindsay Weitzel, PhD:
Do people usually need to learn that first? Do you think that that is one of the therapies they should learn first so that they can utilize it along with the other therapies?

Dawn Buse, PhD:
It's a great thing to learn for starting, because you can learn it really well on your own and practice on your own. And then once you go into a different therapy, you are already going to have that skill. But if you haven't learned those skills yet already, that's okay. It'll be part of any of these therapies I'm going to talk about.

Biofeedback adds a really interesting layer on top of that relaxation therapy. It's literally feeding back biologic processes, giving you information. And we have a lot of modes of biofeedback. When you were a kid, you may have had a mood ring. What was that mood ring doing? It was telling you how warm or cold your hand was. Why did that relate to stress? Well, when you go into that fight, flight, or freeze response, blood is shunted away from your hands, because those aren't the most important. It goes into those big muscles. Your hands get colder when you're stressed. Mood ring, very inexpensive biofeedback.

We have all sorts of technology today between wearables that track our health metrics, as well as learning to be more in tune ourselves. If you were to go into a biofeedback session, you would have different leads put on, just sensors attached with a sticky, depending on what modality. If you came into my office, I'm going to do half a dozen things. I want to measure your muscle tension on some of the big muscles, so I'll put some leads back there, maybe on your jaw if you're someone who clenches or maybe up on the neck and shoulders, if that's one of your tension places.

Lindsay Weitzel, PhD:
I'm laughing because I'm sitting here clenching as you said that. I was like, oh no.

Dawn Buse, PhD:
Take a breath. You should take a deep breath. Relax those shoulders, relax that jaw. So, I would measure your muscle tension. I want to measure your heart rate. And I'm going to do that with just a little lead that goes on your finger. I want to measure your goosebumps and sweaty palms. We call that skin conductance. I love to measure skin conductance because it goes up real fast, even when we're not aware of it. It goes up surprisingly fast, and then we kind of bring it down. We want to measure your respiration. I'm going to put a belt around your belly. And we want to really work on belly breathing. So instead of breathing up high in the chest, we want to breathe where we expand the belly with the inhale and then deflate with the exhale. That takes a little practice. It's easier to do when you're lying down and children and babies do it more naturally. So, I'm going to put a belt around the waist. And then we're going to see all of this on my computer screen. Or biofeedback can be done with a smartphone. Maybe you're looking at your own smartphone. The therapist is looking at their smartphone. There's a lot of ways. Or as I mentioned with all these wearables. We might see the output on our smartwatch or another kind of method.

One thing I really like to do when I'm teaching biofeedback in my office is I like to have the person talk about something. But even before they talk about it, think about it. Don't even tell me out loud what it is yet. And I'll say, tell me about something that was stressful today and they'll be already hooked up. And even before they speak, as they start thinking through what I want to tell her about, I see things and I'll say, oh, what was that? What were you just thinking? They'll say, oh, that was something that happened at work today, but it wasn't really that big of a deal. And I'll say, okay, well, tell me about it. And as they're talking, we see all these metrics of their biology going into this fight, flight, or freeze mode and really increasing. It's very interesting to learn about ourselves that sometimes we'll say that wasn't a big deal. I'm okay. But we'll see that our body is reacting with a real protective, sympathetic reaction, like we're going into battle, or running away from something dangerous, getting out of a burning house.

So, in biofeedback, it's really interesting. You will see your own metrics. Usually as a therapist, I want to get someone a little activated to see what that looks like, a little stressed out, a little angry, whatever activation you want to go with. And then we'll work on those relaxation methods to help calm and relax the whole body, the muscles, the breathing, the heart rate, the whole nervous system. So that's biofeedback. And you can see how that easily lays right on top of relaxation training.

Lindsay Weitzel, PhD:
Something that is going through my mind Dr. Buse as you are discussing these therapies as awesome as they are and they can be so great for so many of us, I have heard some people say that there are certain therapies that can either trigger them, make them feel worse. For example, if you have difficulty breathing through your nose, depending on where your allodynia is located, or you don't want to think of certain things, that there's certain areas as you're trying to relax that just hurt more if you think about them. I don't know if there's words for that or anything, but can you comment on that? Because I do know some people are afraid to bring it up with their therapist because they feel weird, because they think they're supposed to feel better and they don't.

Dawn Buse, PhD:
Absolutely. What an important question. Thank you, Lindsay. There are safety considerations and comfort considerations with all of these therapies. One of the things that can happen with the paced breathing, the slow breathing, it might feel too slow and someone might feel like they're gasping for air or even start to get those early feelings of panic. In all things, trust your body, trust your feelings. If you're working with a therapist, please tell the therapist. I can assure you, you will not be the first person. These are just how humans work. So absolutely, people can feel a panic, a shortness of breath with that very slowed breathing. And that's an easy one to manage. We just pick up the pace of the breathing. Instead of requiring only nose inhale, we could do nose and mouth inhale, let the person kind of choose their own pace and their own approach. The patient, you, are the expert on your body. So, all the listeners, you are all the experts on your body. And in all of these cases you would say, I'm not getting enough air. This doesn't feel good. And just modify so it works for you and move up from there.

There's also safety and comfort situations that we think about in progressive muscle relaxation. I didn't mention that one yet, but that's a relaxation therapy where you tighten and relax muscles of your body successively, so kind of moving from the top of your head and into your jaw, up to the shoulders, all the way down to the toes. And you hold each muscle group for maybe 30 or 45 seconds or 60 seconds. The idea is that it's relaxing because you hold it, and when you let go, you really feel a deeper sense of relaxation in that muscle. But especially when we're talking about chronic pain and migraine and other headache diseases, there may be places that feel too tender that you worry that clenching them could even increase pain or trigger an attack or trigger a headache.

Because I work with people with painful conditions and migraine headache all the time, I kind of have that in my awareness and might say, you may not want to clench and relax any muscles of your head or face. You may or may not want to do your neck and shoulders. But if you're working with a therapist or working on your own and feel like, oh, that is not a good one for me, just skip that. Again, follow and trust your own judgment. And when we get to mindfulness, I'll talk about also some concerns and safety nets we want to put in place for someone who has a trauma history or a PTSD history to make sure they feel safe and don't enter kind of a dissociation with some of the mindfulness practice. And before we leave, I'd like to do a quick exercise, a grounding exercise, that someone can do if with any of these therapies on their own or with the therapist they do feel this out of body experience or a panic experience come on, there's something we can do to reground you in your body and in your space.

Lindsay Weitzel, PhD:
Well, thank you. I just want to take a break in case anyone was thinking that, so we've interjected that little bit of information. Let's move on to our next therapy. We have done biofeedback and relaxation, so I think next, we should probably move into CBT. That is probably my favorite one. I really love talking about CBT, so let's do it.

Dawn Buse, PhD:
Absolutely. Cognitive behavioral therapy includes both cognitive aspects, the way we think about things, and behavioral aspects, practices habits things that we do or don't do. And it seeks to look for anything that is not serving your best interest, be it the way we think about something or what we do. And we do have CBT that has been adapted for migraine and headache diseases that is specific to life with migraine. It includes the traditional approaches to cognitive behavioral therapy. But a lot of the examples and the strategies and skills are geared towards living well with migraine.

Lindsay Weitzel, PhD:
I think everyone has certain things that they've already sort of figured out on their own and they're like, oh wow, I knew that and stuff. When I read my first book on CBT, while there might have been an element of that, that was my place where I was like, wow, this is amazing. I wasn't already doing some of this and it really, really changed things for me. So that's why it was my favorite thing to do.

Dawn Buse, PhD:
Me too. I remember learning CBT as a graduate student and just thinking, oh my, wow, this is me. So you've learned about common, we're going to call them dysfunctional ways of thinking. I know that sounds a little judgy, but that's what we call them, like black or white thinking, mind reading, thinking you know what someone else is thinking, catastrophizing, thinking, oh my gosh this is going to lead to that and snowballing down the hill and eventually I'll be homeless and alone. And there's about a dozen of these common ways of thinking that humans think that lead to feeling anxious, feeling depressed, feeling helpless and hopeless. And so that's one of the big elements of the cognitive side of cognitive behavioral therapy, is noticing how our thinking patterns are leading to us feeling certain ways and improving on those.

Lindsay Weitzel, PhD:
I love that one. So, maybe go pick up a book on that if you haven't done that already. So, what do we want to talk about next Dr. Buse.

Dawn Buse, PhD:
So, we've also got two, I'm going to say newer, but we've been using these therapies in migraine for, I don't know, a couple decades now. We're going to talk about mindfulness-based therapies and acceptance and commitment therapy. The only reason I'm calling them newer to migraine is because our work in research establishing cognitive behavioral therapy and biofeedback for migraine goes back more than 50 years now. So that's something that's kind of been our regular go to. Whereas the mindfulness-based therapies were first developed by John Kabat-Zinn in about the 1990s, and Herbert Benson, more starting in the 80s and into the 90s, and started coming over. They were really used for chronic pain management, so it wasn't a big leap from chronic pain, low back pain, to migraine and headache diseases.

But we did over the past 20 years, create mindfulness-based cognitive therapy for migraine. And that's some work that multiple researchers around the world have done. Dr. Melissa Day and Dr. Betsy Seng. And Dr. Seng and I worked in New York doing a nice study of mindfulness-based cognitive therapy. And Rebecca Wells, Dr. Rebecca Wells has done that as well. So, even though we're saying newer, we're talking like 20 years in migraine now, so we know a lot about how mindfulness-based cognitive therapy works in migraine, and we have specific protocols for migraine. So, it's going to bring in the C part of cognitive behavioral therapy, those cognitions, how we think about things. But it's deeply rooted in mindfulness-based therapies which is two things.

A mindfulness therapy program, if we think back to the traditional mindfulness-based stress reduction for low back pain, it was given in about eight sessions in groups. And one part was a way of thinking, a philosophy, being more mindful about the world. And I'll talk about that in a moment. The other part was a practice of mindfulness. That is mindfulness meditation, a meditation where you are very aware of thoughts, feelings, sensations, but you attempt to notice them without judgment. And what that means is you may notice some head pain, but instead of automatically saying, my head always hurts, I can never do anything, this is never going to stop, it's awful, saying, well, today that part of my head hurts, but it's a four out of ten. It's more manageable. Maybe some my treatments are working. So, it's noticing that head pain, but not going to the automatic thoughts that are judging that get us into this negative kind of mental cycle and noticing and letting go. Just like a cloud floats across the sky, it just kind of comes in. You notice it's there and you just let it float away.

So, mindfulness-based cognitive therapy has the cognitive pieces. It has the mindfulness meditation practice. You would probably go to about eight sessions that might last an hour to two hours. In those sessions you would learn how to do mindfulness meditation, and you'd be asked to practice it six days a week during those eight weeks, just as if you're going to physical therapy and you did your exercises in between sessions, same thing. Mindfulness-based cognitive therapy is going to have you do those exercises, homework. And you're going to do them, on a regular basis to learn how to do this, do the skills. We're not going to wait until you are in the midst of a migraine attack or have high headache or high pain.

Now, some people might have daily migraine or headache or constant pain of some kind, and they will be practicing during those times. And other people who have more episodic migraine will be just practicing on a regular basis, so that the nervous system, again, is learning how to kind of calm and soothe. Because a migraine attack is this activation of the nervous system. All of these therapies kind of have in common this learning how to soothe and regulate. So, your nervous system is in training. Just like training for a marathon, you're training your nervous system to respond and heal from activation and attacks. That's mindfulness-based cognitive therapy

Lindsay Weitzel, PhD:
Dr. Buse, before we move on to acceptance and commitment therapy, which is the last therapy we're going to talk about, I do want to ask a question. Does this same pain psychologist do all these therapies, or do we have to go to different people for them?

Dawn Buse, PhD:
What a great question. There are people who specialize in specific therapies, especially when we think about the mindfulness-based therapies and acceptance and commitment therapy. And in fact, to find the mindfulness-based therapy, you may go to an institute that does these trainings all the time, because it’s a group program of eight weeks, and they may have them kind of running around the year. And you just go when you're ready to start and you do this kind of eight-week program with someone. Some psychologists, health psychologists, pain psychologists, headache psychologists, may have experience and knowledge and expertise in all of these therapies, and may combine all of them in one experience. But it wouldn't be the same kind of eight-week mindfulness-based program that you would do in a group. Perhaps you would come into the office and do some biofeedback, learn some mindfulness meditation. So, it's going to vary depending on who you find in terms of psychologists or clinics, and where you find treatment.

Lindsay Weitzel, PhD:
Let's talk about acceptance and commitment therapy. It's funny. I've never loved the name of this therapy, but I love what it is. It sounds almost depressing to me, the name. And it's not a depressing concept. So, let's talk about it.

Dawn Buse, PhD:
I like that. I like that. Is it the acceptance part that sounds a little bit depressing?

Lindsay Weitzel, PhD:
It really is. As someone who's had lifelong pain, when you introduce the name, I always felt like it sounds like I should just accept things as they are and give up. That's really what it always sounded like to me. But then when I was giving one of my talks once, people were pulling out concepts that I believe in and talk about and saying you realize that's ACT. And I was like, you're right. So, I really believe in the concepts and love it, but the name was bothering me for a lot of years.

Dawn Buse, PhD:
Well, you said it's kind of depressing, to think about, accept things as they are and give up. Whereas I think acceptance and commitment therapy would say accept things as they are and move forward. So, it's a values-based therapy. It helps people identify what their values and goals are. And then with both behaviors and thoughts, seeing do they line up with getting people to those values and goals or are they working against them. So, the acceptance part has that mindfulness element, noting your particular reality, noting what you feel, noting what you experience, noting what is your reality in your world. And that's the acceptance part. But then working with where you are to move towards the goals that you value.

Lindsay Weitzel, PhD:
Do you have an example of that? I always think of it as, I think that was you that said in the Super Zoe book ,where Super Zoe, it was a graphic novel I wrote for kids with migraine, and she always says, do one thing today that'll put you in a better space tomorrow, even if it's just getting out of bed for five minutes if you're that bad. I think it was you that told me, you know Lindsay, that's acceptance and commitment therapy.

Dawn Buse, PhD:
It is. I love that. I love that, indeed. It really is. So, the acceptance part, again, is accepting where you are and for many of our listeners, it might be that you have a diagnosis of migraine, you've had migraine in your family, your mom, you're aunt, your dad, your grandma, and you've had it since you were a teenager. And it is not magically disappearing despite the best treatments, because it's a chronic condition that tends to be lifelong for most people. Not your whole life. It tends to get better for most people in the fifth and sixth and seventh decades of life, so it's a long journey. That's the acceptance piece. I'm living with migraine.

But the commitment to the values, what is it? Do you want to be more present in your children's life? Do you want to excel at work? Do you want to stop working and find other ways to both have income and increase your kind of purpose in life? What is it? What is your goal? What do you want life to look like? How do you get there with your thoughts and your behaviors, considering, accepting what your current situation is and all those realities. So, it's a constant kind of holding up the mirror to am I doing the things that will get me there. And in fact, one of the things that'll get you there is probably participating in acceptance and commitment therapy or some of these other therapies, as well as seeing your doctor, getting a proper diagnosis, getting all of the kinds of treatments on board that can help you, be they pharmacologic medicine or non-pharmacologic, learning about migraine, getting accommodations at work, at school. What are all the things that can help you get to a better place. All of those take effort and time and sometimes money and scheduling and organizing. Those are all some effort, those things that will get you to the way you want life to look, considering the realities.

Lindsay Weitzel, PhD:
I love that. I'm going to ask some questions about the therapies now. Are there certain people with migraine or certain types of migraine that people have that might respond better to these therapies? For example, people who experience a lot of anxiety along with their migraine, or people who are triggered by stress, or people who became chronically fast, or their migraine started in childhood. I'm just kind of rambling now, but who responds best?

Dawn Buse, PhD:
Well, people respond best who are usually interested and open minded about these types of therapies because you do need to commit to do some learning, some practice, keep it going. Children do great. Youth and kids and teens, as long as they're open to it, usually do really well with these types of therapies. They tend to really like biofeedback. It looks kind of futuristic. It's kind of fun to see what's going on inside their body. And they may not have as many preconceived notions or as many disappointments built up already in their life that they still go into it a little bit more optimistic and hopeful. So, kids do really well with these therapies that also carries them through. A lot of things are generalizable and can help them just with managing anxiety in all aspects of life and managing stress and thinking about the way you think about things, thinking about things in a healthy, functional way.

It's also great when there is a contraindication. So, pregnancy, getting pregnant, postpartum, is a great time for these therapies to be on board when you don't have as many medication treatment options, and other contraindications like someone with cardiovascular history. But a lot of times when people say, should I try it and which one should I try, I'll say which sounds interesting to you. Because if you are interested and motivated, you're going to get a lot more out of this. This is something that requires a lot more effort than a medication therapy where you take the medication and things happen. This is really an effort on your part to engage to get to the benefits.

Lindsay Weitzel, PhD:
These therapies, in the setting of doing them with a headache psychologist or a pain psychologist, are they covered by insurance?

Dawn Buse, PhD:
Yes. In many, many types of providers, it could be a psychologist or psychiatrist, physical or occupational therapist, social worker, master's level counselor, these are covered by insurance. And one thing that's very important that I figured out when my biller helped me figure this out about 20 years ago, was that there are codes called health and behavior codes, which are CPT codes, where we specify that this therapy is for a medical issue, as opposed to it being for a psychological issue, being for panic disorder or depression or anxiety.

Either way is terrific and important to do these therapies. It just goes into a different bucket. So, if you use a psychological code, it'll go into a psychological therapy kind of carve out with insurance. Whereas if you use the health and behavior code, which I would use because we're doing these for migraine or headache or chronic pain, it's in a different bucket. So, you can ask your provider what CPT code they're using, and that might help. And then just check with your insurance what the coverage is for that CPT code. And indeed, both whether these therapies are for a physical diagnosis or something that falls into the psychological diagnosis, either one should be covered by insurance.

Lindsay Weitzel, PhD:
This is an important question for some people who feel like they learn best on their own. Is it effective to read about these or use apps at home for these therapies?

Dawn Buse, PhD:
Absolutely. And we have more options today than ever before. So, you can kind of stick your toe in the water a little bit by trying with maybe something that's already on your smartphone or already on one of your apps or wearables and start to learn a little bit. There are whole programs now that are in an app. Some are actually FDA cleared, which means the FDA has reviewed the evidence for their efficacy and safety and has given them that clearance, that stamp of approval. Those might be actually dispensed by or prescribed by your doctor the same way that a medication is. And then others, you might find more in the wellness and entertainment space in an app store, for example. And some of those can be very good for learning a lot of these skills. You can learn the skills of mindfulness and meditation and relaxation. You can learn the approaches of CBT and ACT and MBCT in workbooks, where you fill out checklists or something online. So, there's a lot of ways to start to learn the therapies.

If it feels like that's not enough to really get it for you, or perhaps you start with that and then you want to step up to the next level of finding a health provider who actually would tailor it to you, it is really a lovely experience to be in the office or remote or in a group with a healthcare professional who could say, okay, Lindsay, it looks like you're having trouble with the breathing. You'd say, oh my god, yeah, I can't breathe and it's making my head hurt. And that person could stop with you and say, okay, I've got a different way we can try this. So that personalized experience of course, that's the gold standard. That's the cadillac here that we're going for. But learning about it, trying with any of these other ways, more cost effective, easier for your scheduling, less of a commitment, go for it. Go for any kind of way that you get started, I think it's great.

Lindsay Weitzel, PhD:
Is there anything you would like to add on this topic before we go today, Dr. Buse?

Dawn Buse, PhD:
I'm really glad that you wanted to talk about this today, Lindsay. People are joining us and want to listen, because there are a lot of options out there that have evidence that show that they help people living with migraine in real ways. Quality of life is better. In some of these therapies, we'll see reduction of headache attacks as well as the pain, the severity, and certainly reduction in disability. So, if you haven't explored these, check them out. If you did this ten years ago and you think, oh, I've kind of put those on the shelf, dust it back off, get those skills back out, maybe go to a refresher course or try one of the therapies you haven't tried yet. These are really interesting, valuable for so many aspects of life. And they're relatively lower cost because you learn them and then you're done, but they stay with you. So, I'm really glad that we're talking about it. And I hope people explore what's out there.

Lindsay Weitzel, PhD:
Yes, I hope so too. And if they aren't sure, start reading about it, because I do think that can get you excited about it. I think that even just picking up a book on a couple of these concepts is just a great idea.

Dawn Buse, PhD:
Absolutely. There are some great places to get information. The National Headache Foundation website, the American Migraine Foundation website, and the American Headache Society website, all have information about these therapies. And there's a lot of great resources online as I mentioned, free audio podcasts, free video experiences, a lot of professionals, a lot of people talking about what these therapies are, as well as guiding you through exercises. So, there's a lot of ways to start exploring.

Lindsay Weitzel, PhD:
Thank you so much Dr. Buse for being here. And thank you everyone for listening. Please listen to our next episode of HeadWise. Bye bye.

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