00:00
Hey everyone, it's Mikki here, you're listening to Mikkipedia, and this week on the podcast I speak to Dr Azare Christian.

00:12
Dr. Azare Christian and I talk about chronic pain, chronic pain management, and migraines. We discuss particularly what chronic pain actually is and the connection between the mind and the body, where conventional medicine gets it wrong with pain, the important questions that Dr. Azare asks his patient to better understand their pain, and more specifically, we also delve into

00:41
migraine pain. We talk about the trias for migraine, treatments that are available and also other supplemental support that Dr. Azare recommends his patients take. So he really blends the conventional sort of western medicine with more integrative and rehabilitative practices, which makes him just a wealth of information in this space. Dr. Azare Christian is a board-certified

01:11
He specializes in pain and musculoskeletal medicine. With a previous role as outpatient medical director of Good Shepherd Rehabilitation Network in the High Valley, Pennsylvania, and an academic appointment at the University of Pennsylvania Department of PM&R, Dr. Christian has the expertise to provide the best possible care. He earned his board certification through the American Board of Physical Medicine and Rehabilitation.

01:38
and he is the owner and medical director of Ether Medicine in the Wayne Mainline Philadelphia, Pennsylvania area. And we talk about, in addition to what I've already mentioned, how Dr. Christian got into medicine in the first place and just a bit more on his background and his philosophy. So as per usual, I've got links to Ether Medicine in the show notes for you to be able to connect.

02:06
and he provides super awesome educational content on their Instagram handle as well. Before we crack on into the interview, I would just like to remind you that the best way to support this podcast is to hit the subscribe button on your favourite podcast listening platform.

02:23
that increases the visibility of Micopedia and amongst literally thousands of other podcasts that are out there. So more people get the opportunity to listen to guests that I have on the show, including Dr. Azare Christian. All right team, enjoy the conversation.

02:42
Thank you so much for taking the time to speak with me this morning, New York time. Can we start with a little bit of your backstory and how you got into medicine in the first place? Yeah, well, thank you so much for having me. I'm honored to be here and to learn from you and hopefully contribute to your audience as well. So my background, I grew up in Ghana in West Africa. And my

03:09
My interest in medicine actually started at a very young age. I was maybe four or three, some very young age that a friend of mine, a very good friend of mine, he died. And I was not exactly sure. This is still something that I can still remember. And I was not sure what happened to him. And I was asking questions. Why did he die? And I, I didn't die, you know, and, um, they were, they explained to me that he has sickle cell and one of the things that we deal with with sickle cell, and then I go.

03:39
why did he die and he have sickle cell, why am I still alive? And basically it relates to this idea of something called heterozygote advantage. So basically in an environment like Ghana, Africa, where you have less health infrastructure, the environment, people that have sickle cell, they are kind of protective against malaria. We also have malaria there. And because of poor infrastructure and sickle cell is a complicated disease, people will die.

04:08
And then the people have the regular blood type AA. So SS is sickle cell. AA is a people who are now more prone to mosquito infections and they can also die from it. So the people that the environment selects for, something called heterozygote advantage, I was one of those, is the people that have the carrier, so AS. So that was a very fascinating idea. And started asking more questions and became more interested as I.

04:37
went through my medical, my undergraduate training. I wanted to be an organic chemist and subsequently work with patients and here we are doing medicine. Oh, oh wow. And so when did you move to the United States then? I moved to the US in 97. So this is when I was done with high school in Ghana. So I came here to go to college, medical school and the rest of my training. Yeah, amazing. And you know, Azare, I was super interested to see that you are a

05:07
Physiatrist. Have I said that correctly? Like honestly, I haven't come across that term before. And people might be thinking, Miki, you've just misspeak, you've misspoken. But actually, what is it? What is physiatry? So what actually is it that you do? Yeah. So physiatry, you pronounce it correctly, is the same as physical medicine and rehabilitation. So that's the field of medicine that really focus on diagnosing, treating,

05:37
disease, disability. And physiatry is a field that is actually relatively new. So it came about, I think after second world war, there was a lot of wounded soldiers and we have to figure out a way to take care of them. So physiatry kind of focused on really function. So we don't have like an organ specific where, cardiologists may take care of the heart or nephrologists will take care of the kidney. Physiatrists take care of the whole person and really looking at how do we get you to function your best irrespective of

06:07
whatever disease that's affecting your kidney, your liver, all of those things, you still wanna be able to get up in the morning, go to the bathroom, clean yourself, walk, eat, so all of this fundamental basic functional things that we take for granted, and when people become a disease or when there's trauma, all of that become complicated or implicated, and the physiatry focus on how do we get people to become very functional, irrespective of, whether it's stroke, spinal cord injury, brain injury,

06:35
neurological issues, MS, Parkinson's, we still have to kind of work on that. And part of that training really gets us to really understand musculoskeletal issues. So, physiatry, a simple way to kind of look at it. We do multiple things. It's mostly musculoskeletal and neurological issues that we put together. So, it learned itself to really understanding how to treat pain, and that's kind of how I got to where I am now. Yeah, and what is it, something in particular led you down the path of physiatry, or was it just sort of,

07:04
choosing multiple different rotations and then thinking, huh, this makes sense to you. Yeah, so I got into physiatry by accident because I actually did not even know much about physiatry throughout my medical training. So my 30th medical school, I couldn't get into a certain type of rotation, so I did a physiatry rotation just to kind of check it out. And it was really interesting, meaning one,

07:31
The physicians there were super nice, super calm. I was coming from like a CT surgery, cardiothoracic surgery rotation where it was very intense and people are miserable and it just didn't fit my personality. So I got to this physiatry and all the doctors were happy. They were nice. The patients were happy and all of these things. And the thing that kind of actually pushed me there was my grandmother actually in Ghana had a brain injury. She was having some symptoms that was suggestive

08:01
a brain injury. So she was having all this dizziness and vomiting and confusion and some bladder incontinence. So all of those were symptoms of hydrocephalus or fluid buildup in the brain. So I have been exposed to that during my physiatry training and I call them and say, hey, this sounds like she has a brain injury. So they actually took her to the hospital based on that knowledge I have from medical school. And it turns out she had all this bleeds in her brain and she got surgery that

08:30
corrected the problem, she got stent or shunt pudding to help with draining the fluid, but she ended up becoming disabled because we didn't have developed rehabilitation medicine in Ghana and even at that time, most of South Saharan Africa. So that kind of made it clear for me like, hey, I want to do physiatry because, you know, Ghana, which is a place that I want to go back and practice, does not have physiatry. And even at that time, most of South Saharan Africa didn't have it.

08:59
It was mostly in South Africa, and there's a lot of trauma. And so since then, I went and did research there and have actually worked with the team to establish a rehabilitation medicine residency in Ghana and other places. So it was meant to be to really contribute to that environment, and my grandmother had that push to get me here. Amazing. And the way that you speak about medicine in your field in particular, I always

09:28
it's a shame that the medical system does tend to work in silos. So you have the cardiologists working with the heart and you have the neurologists working with the brain. Like, is there, like, I don't know, like if I think about like the future of medicine, I feel like it should actually have much more of a holistic model. But I mean, I guess that might actually a little be a little bit too high in the sky or, you know, I'm not sure. What do you think?

09:56
Yeah, so I mean, you bring a very important concept because as we understand, this body is one system and it's all connected. And one of the things I've come to, and that's actually what we learn in medical school, you learn about physiology where every system, the body is a system of systems and every system influence of a system. So if we are solving problems or trying to solve health, and we focus on one aspect of that system, we know that as in solving. So

10:24
I am with you and I think there is now clinicians who are now coming to that realization that even if I'm a specialist, and for example, I'm a pain doctor now and I specialize in pain, but now I understand that if I don't understand endocrinology, if I can't modulate HPA access, my patient's pain is not going to get better. If I don't know how to solve the GI system or the microbiome, my patient's pain don't get better. If I don't know how to manage...

10:50
Hormones, my patient's pain don't get better if I don't know how to manage sleep. So all of these systems are really connected. And we as clinicians and providers have to get to a place irrespective of specialization. We do need specialization, right? You want somebody who knows how to do brain surgery to do brain surgery. But the outcome of brain surgery will depend on how healthy a patient is. The outcome of a spine surgery will depend on how healthy a patient is. The outcome.

11:18
of medications would depend on how healthy a patient is. So I've come to this place where my approach is, let's figure out how to get people healthy. When people are healthy, all of this specialization and interventions that we do gets better. So I think the ophthalmologist should be asking about nutrition and metabolic health because that will implicate the eye, not just the eye. So I think this is something that patients are also looking for because they get the opportunity to see doctors and we just solve.

11:46
the pathology or the symptom and not really get to what's driving that underlying issue. So definitely this is something that I'm hoping that at some point we'll get there, forget all of our doctors. And it should be simple because we all learned that in medical school. Ask about nutrition, ask about sleep, ask about stress, ask about exercise. Those are basic. Every specialist should be asking those questions and to kind of learn how to figure out how to get patients to get there. But I also understand that.

12:14
This is not something that we learn so much because, especially in America, in medical school, we learn physiology and pathology. We know how things work or we know how to solve health. But once you become a resident and become an attending physician, most of the time you're solving sickness, you're not solving health. We are trying to keep people alive. We're trying to, you know, and that's a different focus than really solving health.

12:42
And most people to prevent sickness, we have to figure out how to solve our health. And that's a different sets of knowledge. And even for me, who's been a doctor for eight years, and I wanted to open this practice to talk about how I use health to solve pain. I did not even know how to make people healthy. I knew how to read MRIs, I know how to do procedures, I know how to prescribe medications, I know how to send people to physical therapy.

13:07
but I couldn't guide a patient on nutrition, sleep, and all of these basic fundamental things that actually translates to health. So it's a different approach, and hopefully more providers will get to that level. For sure. And Azare, so where did you gain the knowledge in the health area post your actual medical degree? Yeah, so I think a lot of it comes from our patients. We are always, I'm so privileged that as a clinician, your patients are always teaching you something. So if you pay attention,

13:37
you will learn a lot. So a lot of patients will ask questions about things that I didn't know about and I'll go look into it. But one of the things that I recognize as a pain doctor was I have all these patients that I see, some get better outcomes, some don't. And the realization was the people that were getting better outcomes from physical therapy or acupuncture were people that were healthy. They were doing some things that were healthy. So that kind of baseline was the inception. And then subsequently,

14:05
I have to go back and pull up my medical school books and read physiology and understand the cell and mitochondria, all of these things that influence health. And I've also taken multiple courses. And in America, we are so fortunate, I don't know how it is in New Zealand, there's so much information in different organizations and providers doing really, really amazing things. So I have followed the A-Forum, as you can learn about, I'm actually gonna be presenting there. Follow the functional medicine group.

14:34
I've also followed the International Peptide Society. I've done some work with SEADS Research and Performance Institute. So there's all of these places to go learn, but you have to push yourself there. And then you also have to listen to your patients. And that has been the guidance. A patient comes to me, they have this problem, and there's somebody who knows how to solve it. And I go learn and be able to make that available to my patients. Yeah, nice one. And Azare, I did read that when you first met a client or a patient, you were

15:02
you have a couple of questions which you feel are critical to sort of developing their treatment plan and I'm talking about the chronic pain here which is where obviously you spend a lot of your time. So one is the what is your understanding of why you have pain and the other question is what has your pain prevented you from doing? So can you talk me through just how these questions help inform you of this patient's treatment plan?

15:31
Yes, absolutely. And even those questions came about from seeing patients over and over. And the realization was that my patients who are in pain for many years don't understand pain. So if you don't understand pain, this is a very subjective complex phenomena. How are you going to solve it? So one of the places that I, and we already recognize now that pain education is actually a form of treatment.

16:01
So when it comes to chronic pain, people need to come up and realize what keeps them in chronic pain, okay? Because chronic pain is not normal. Pain is a protective mechanism. It's there to help us be aware of injuries and move away from things. But when it goes past a certain amount of time, then it's pathologic or it's not helpful. So what keeps you in chronic pain is very different than what actually starts your pain. And simply, it's a function of your health.

16:29
Again, going back to the fundamentals, right? Nutrition, what you eat will implicate your pain, your sleep, stress, cortisol is pro-inflammatory. You will push pain forward, not exercising. All of that will implicate pain because muscles are weak and other things like that. So the idea was to get individuals to really a place of understanding pain. And there's a lot of misinformation. Patients don't understand it. A lot of clinicians don't understand it because we're just looking at MRIs and x-rays.

16:57
but we know that pain is way beyond all of those things. So that's a place to kind of start some education for the patient and even kind of debunk or change their belief systems because they have this pain and in their head, I'm gonna deal with this pain forever, only surgery can fix it. And they've had multiple surgeries and they're still in pain, right? And they're still eating junk and nobody has talked to them about nutrition playing a role in their pain chemistry. And then the second part is really trying to get individuals to move away from talking about the problem to get into solutions.

17:27
What is it that you want to do? Pain, prevent people from doing too many things. So get in a sense of, oh, the pain doesn't allow me to go out and have dinner with my friends. Let's come up with some strategies. Let's get you there. Because all of those things actually becomes more painful. It's the painfulness, not being able to hang out with your friends, not being able to go to church, not being able to sit down for too long. All of those are the things that actually people are worried about, not so much about the pain sensation.

17:56
So those two questions helps me to get to a place of providing some education before we even talk about medication and then also giving people strategies on how to improve function. Nice. And you know, when I'm listening to you talk and thinking about those questions, Azare, I'm thinking that the patient of course then feels heard. And so often with, I don't know, I just think about what I hear about chronic pain and as

18:26
who listens to them and understands, I guess, the feelings that they've had must go a long way, I guess, to helping with the treating of the pain. I'm not sure. Yeah, absolutely. Because chronic pain is very complex, right? So if you're a patient and you've been dealing with these issues and you've seen doctors, you've seen everybody, they've done MRIs, they've done metabolic workup, they've done all these things, and nothing is really showing up, right? They start really start messing with you as a patient. Am I crazy? Am I making this in my head?

18:54
And there's also cases where patients have had experiences where there's nothing that we can really see on our diagnostic testing when it comes to imaging or any other workup we do, and patients are getting dismissed. This is all in your head. But there is factors that perpetuate that pain cycle. And we're not asking about it, right? People are coming in and just looking at their labs, but we're not asking about their trauma experience, which we know influence pain.

19:21
They're not asking about what they're eating. They may be sensitive to something in your house. There could be specific taxing that you're getting exposed to. That's keeping that pain cycle in place. And that's not going to get picked up by MRI. That may not get picked up by seven things. So really getting to this place where we can get people to understand what keeps them in pain, all these factors. And pain is complex. It's an emotional sensory experience. It's also cultural. Even, you know, where you grow up, influence your pain. I'm from Ghana. How we talk about pain.

19:51
is very different from how we talk about pain in America, and even perhaps in New Zealand. So the culture even influenced pain. So pain has this dynamic features that when we want to get to solving pain, we have to look at all of those things. We talk about multimodal approach. So not just using the medical side of things to really try to understand it, but going beyond all of that. I've had patients who have developed all kind of issues from specific trauma.

20:19
you know, something traumatic happened to them. All of a sudden they become, they develop autoimmune issues. And we understand at the cellular level, there is specific things that are happening that are leading to all of these things. So it's really, really important for us to validate the pain for patients and to let them understand that there's a lot more than just x-rays, MRIs, and what we see on your labs when it comes to pain. Yeah, yeah, for sure. And you know, my next question was going to ask you about how you think about

20:48
chronic pain and where does it come from? And of course, you've just told me cultural, environmental, genetic and cellular. Is there anything else that you would add that would allow for a deeper understanding of chronic pain, Azare? Yes, and that's a big question. What causes chronic pain, right? Because the point is we've all had issues or we know people who, you know, they twisted their ankle.

21:16
Two people, one person, they take some ibuprofen or some NSAIDs, they go to physical therapy, they get better. And then there's another person who will do all of those things, they're not getting better. And they will get surgery and they will do all of these things and you're still in pain. So actually when it comes to chronic pain, we don't know what causes chronic pain, what transition somebody from acute to chronic pain. We know there are specific factors. You mentioned some of the genetics. So some people have some genetics to pre-substitution to chronic pain.

21:46
And then beyond that, at the cellular level, there's all of these other theories that we understand. There is neuroinflammation. So there's actually inflammation or specific microglia, astrocytes. These are cells in the brain that actually take the pain information or make you aware of pain that become activated. So a simple way, maybe let's step back a little bit and talk about simply what pain is. Pain is a signal. So for example, you catch yourself.

22:14
There's inflammation that happens here. And then your nerves take that inflammation to your spinal cord, and it goes all the way to your brain. It gets to the front of the brain. And then your brain interprets the pain signal. And it tells you it hurts. It feels this way. That interpretation of the pain is influenced by the very things we're talking about, the genetics, where you grew up and what's going on in your life. Because sometimes you may even catch yourself and you're doing something fun. You don't even think about it. So emotions, other things, please.

22:42
But when it comes to chronic pain, there is that neuroinflammation where the cells that are making that interpretation, they are actually interpreting that signal in a very magnified version. So instead of a signal like this coming to the brain, the brain sees that signal and makes it look like this. So it's chronic. There is also something called glial cell activation. This is a little technical. There is neurotransmitter imbalances. When the signal is going up to your brain, there are specific neurotransmitters.

23:10
that are taking the pain up. So glutamate is stimulating or excitatory. Substance P, there's all of these things that play a part in how the signal is perpetuated. And then you also have specific neurotransmitters that decrease how much pain is coming to your awareness because your body have all this mechanism to modulate all of those things. So in chronic pain, that system has actually flipped around where there is more activation of the ascending signal. And then there's a decrement.

23:37
of your own ability to really decrease pain. There is also even epigenetic changes. Their brain actually changes. We can see changes on imaging of what a chronic pain looks like, even in fibromyalgia, back pain. These are all things that are documented. And one of the things that we also see is that when people have chronic pain, they actually don't make their own endogenous opioids have been downregulated. So your body has its own mechanism to decrease pain. And when you have chronic pain, instead of

24:07
that working very well that has also shift around. So there's all of this other cellular mechanisms that goes on in chronic pain. And then there is habits, there is behavior changes because of pain, people are not moving, especially if it's musculoskeletal, right? Your body competency and that leads to muscle weakness and that will influence that pain cycle. And then other habits, people are depressed, people are anxious because of the pain. So is this complex phenomena? But we do understand all of those things.

24:36
And it all comes back to really trying to optimize in health. If people are not sleeping, pain does not get better. If people are not eating well, pain doesn't get better, especially chronic pain. They're not exercising, they're not managing stress. So all of those things have to be put in place to help people to get there. So chronic pain, it's a complex thing, but we do understand some of the theories or some of the things that lead to it, but it all comes to let's get your body to be healthy. And when it's healthy, some of this stuff will work itself out. Yeah.

25:05
But what about Azare, like you talked about that, like the brain is giving this amplified message of pain. And I, when you said that, I was thinking of stories of people who get their limbs amputated, yet they feel a pain in the limb that is no longer there. I wonder whether that's sort of a related concept. Yes, that's a great point to bring up because a lot of times when people come in and they have chronic pain and you say that

25:33
The pain is actually an output from your brain. They don't believe it. They kind of think, you know, how could my knee, my knee is hurting and you're telling me it's coming from the brain. So that is, it's just that people need to understand that pain is complex. And the concept you talk about is something that I'm able to use that to actually educate patients that we have individuals, something called phantom pain. And part of that cellular process is neuroplasticity. So the brain has also learned the pain. So when you have pain, the brain also lends it

26:02
And even in the absence of any input, the brain can create that pain. So that's why we can cut off your limbs and you can still feel the pain because the brain has learned it. So that's an important concept and that helps people to kind of feel like, oh my gosh, yeah, there is something a lot more to what we're talking about because this is a complex phenomenon. Yeah, I actually, I interviewed Dr. Howard Schubiner. Yes. Yes, a couple of years ago. And you just actually said, you know, your brain learns pain. And we chatted about the brain

26:32
Unlearning pain. Is that something you obviously know of his work? Yes, Dr. Shubhna is an amazing person in this neuroscience, neuro-affective area of pain, because I think it's such a huge part of chronic pain. When chronic pain comes in, it's not what's happening in the periphery. It becomes a function of what we can do to modulate brain health. And if the brain lends pain, it can also unwind the pain. So there's pain reprocessing therapy and all of this other.

27:01
therapies that are out there, especially even some of you guys from Australia. So I got into even pain science through reading the work of Dr. Mosley. I think, yeah. And that has been very influential in how I care for my patients because none of the systems I had before was working. But now, if patients can understand some of these concepts, they are able to apply to get to a better place. Yeah. So, Azare, how...

27:30
do we traditionally treat chronic pain? Yeah, so traditionally pain is not managed well, especially, you know, specifically in the US because we have two ways of treating pain. One is the biomedical model. This is when we use medicines, injections, surgery to address pain. And that works very well when people have acute pain, which is pain that's less than three months. When...

27:58
pain goes on beyond three months, we get into chronic pain, which is what we are talking about here. And chronic pain is very different. Even though the same kind of cellular mechanisms happens in acute pain, at some point, all of that turns off and people can go back to not having pain. But in chronic pain state, that state, all of those cellular mechanisms perpetuates. So when it comes to chronic pain, we can't just look at medications, injections, and surgeries because we know it doesn't work.

28:26
So we have to use what we call a biopsychosocial model. This is where we are looking at people's psychology because we know pain get influenced by their various degree of psychology, their biology and their social environment, right? So if people are living in an environment where it's very stressful, that will perpetuate pain. So chronic pain has to be looked through that lens. And people are aware of this biopsychosocial model. Sometimes it's kind of hard to execute, but the simplest way I kind of come to that

28:55
is really less focused on health. When you're healthy, everything works a lot better. And chronic pain is not done well in the US because we're using the biomedical model to solve chronic pain, which is not the case. So in the US, we have about, I think, 4.23% of the world population. Yet we use 80% of the world opioids. We do 40% more spine surgeries than any other country.

29:23
And we actually don't have the greatest outcomes. We're like the ninth. When you look at the first 10, you know, like India, South Korea, Japan, Canada, they all have better outcomes. So the problem is that we do more surgeries, don't even have better outcomes. We use all these medications and still have other issues because we actually know that even the opioid crisis is a big issue in the US, even costs more than the cost of pain itself. So it's a mismatch of

29:52
using the wrong treatment for the wrong condition, and fundamentally not focusing on health and the person dealing in pain. Because part of that equation is the individual dealing in pain has all the factors. They can connect the dots. People don't tell us everything that's going on in their lives, right? When they come to the doctor's office, if you get lucky, maybe they will share everything. But there's all of these other factors that people need to wake up to, to recognize that all of that, your thoughts influence your pain. When you're thinking about pain, pain actually goes up.

30:22
This is all the chemistry of pain. So I think really educating patients and getting clear on what type of modality needs to be used and using different and broad lens of evaluation, not just like maybe orthopedic lens or not just through rheumatological lens or not through just functional lens, which is what I do, physical medicine. But to be able to figure out what type of lenses we have to look through to understand our patients and then providing integrative and broad

30:51
treatment plan to address that focusing fundamentally again on health. Yeah, like I think about friends of mine and clients who, you know, when we're just chatting and then they sort of tell me that they're on something like amitriptyline or some sort of medication that they've been on for years, like five or even 10 years for some back problem they had back then, and they've just continued to take it.

31:20
without any sort of plan of in their mind of ever coming off. Like is that a usual strategy that is used? Yeah, so this is something that, yes. So ideally medications are supposed, a lot of the medicines we have are actually supposed to be used short term, okay? Yeah. And one of the biggest thing that we need to recognize or one of the things I'm sure most people know is pain is a symptom. Pain is not a diagnosis.

31:49
Pain is a symptom of something. So what is that something? What's causing that pain? Is it your gut? Is it your stress? Is it your thoughts? Is it your trauma? Is it toxins? Is it immune dysregulation? What's causing it? Is it hormones? So really when we're using any of those medicines, we are actually not addressing the underlying cause of the pain. We're just blocking the pain signal. So we talk about pain being a signal. What is creating that signal is where we need to focus on.

32:18
Because when we're just blocking that signal, then we are not changing what's going on. We are not changing the phenotypes. And those medicines, as you've talked about, they do have side effects. They don't really get rid of it. People have to take it for a long time. It depletes a lot of vitamins in the body. It causes constipation. It causes diarrhea. It implicates brain health and all of those things. And because we are not addressing the underlying issue of what's actually causing that pain signal, we are actually putting people more at risk for more issues. So really get into a place of

32:48
What I educate my patient about is like, okay, this is the medicine that we're going to use. This medicine is just only blocking the pain signal. It's not addressing the other issues. The other issues, can we improve sleep? Can we improve nutrition? Can we improve other things? And when we can do all of those things, at the cellular level, the cells and your body has this intelligence to modulate and change its phenotype. So it becomes really necessary to educate patients about, you know, the medicines that we're using.

33:14
And even also going beyond that to try to figure out how do we mitigate some of the risk related to the medicines? There's times where people have to use medicines and can we protect their gut? Can we optimize nutrients? So then they're able to kind of utilize this in a healthy way. So yes, using a lot of these medicines that we have basically just blocking the pain signal. And long-term, they tend to have a lot of side effects. Yeah, it's so interesting. Like I think, like, cause I...

33:41
Imagine that people coming to see you, they know how you practice. And so they're there to work with your team and yourself for that specific purpose of that holistic approach. Whereas I wonder how many people might actually go along and the idea that the pain is that they need to do anything other than block that pain signal might almost be foreign to them. They're like, no, just give me that. That's all I need. I don't have time to do X, Y, Z.

34:11
Do you think that that, I don't imagine it's an issue that you see, but do you see that issue broadly speaking? Yes, I do. And in fact, I do see a lot of that because people come to me and they see me as a pain doctor. And the next five pain doctors they've gone to, they've just looked at their MRIs and I'm asking about what they're eating. I'm asking about their sleep. And they're just looking at me like, why are you asking me about those things, right? So yes, really.

34:38
it becomes very educational for individuals to understand. And then also, you know, it's just like, you know, you have to take the time to educate people because people don't know. So I wish people have come to me and go, oh my gosh, help me with my nutrition. No, they come in and they want me to block the pain signal. So, and there is also a place for all the tools that we have in medicine, which is what I like, because, you know, I can do injections, I can do all of these things that can take away the pain signal, which is great. But the point is I educate patients and say, hey, this is what pain is, it's a signal.

35:08
I'm going to block that signal with the lidocaine, or I'm going to block it with, you know, steroid, whatever I'm doing. But what's driving the pain is that your muscles may be weak and we have to go to therapy and we have to strengthen things. What is driving that pain state is that maybe cortisol is too high because you have stress. So let's figure out how do we bring the stress down, okay? Because I can keep doing the lidocaine, you keep coming back, the pain is still going to be there. And patients already understand that. They've done injections, they've taken medications, and they've done surgery, and they are still in pain.

35:37
So this is a place where I'm able to kind of open things up, but sometimes patients are not even open to those ideas, because the whole system focus on X-rays, MRIs, and everything else. And when people come in, the first thing they want me to look at is their MRI. And I go, I will take a look at it, let me get to know you. Sometimes they don't like it. And then the whole idea is really stepping back as a provider and understanding who the patient is in front of you, what kind of information they have, who they are and trying to meet them where they are. You don't want to lose them.

36:07
So sometimes it's challenging and I'm at a place where, you know, I just tell people we have to focus on health. And if that's not something that jive with, you know, individuals, and there's plenty of other doctors there that you can go see. But it's always a challenge. But the point is right, trying to meet people where they are and building trust because part of this is also, you know, is the fault of the providers. Patient comes to us and they trust us and people have been misled, people have, you know, had injuries, all of this thing. So

36:37
Why should they trust me? So I have to prove to them that I care. And then when you care, then you talk about nutrition and they go, okay, yeah, I will look into that. Yeah, how about the exercise? Okay, so it's really trying to get people to trust the process. And once they're there, then you can get them on some of these habit changes, because ultimately it's about really trying to change habits, which is one of the things I've come to recognize as a doctor, and that's why this is hard. And you as a clinician also, it's habit change. And we have this inherent,

37:06
human behavior economics where we are not rational. We are particularly irrational. So really trying to put some way to change habits is something that I've actually become very interested in in the science of habit change because when people can change their habits for healthy habits, then they're gonna have the outcome of health. Absolutely. And I often, I have these other conversations and in my field, like people, I work a lot in weight loss.

37:35
And people absolutely want to lose weight. Yes. But little people often say, well, surely the pain of being overweight, pain of being overweight is less than the pain of going through this behavior change. But the default is what they're used to, and it's quite safe. And so it's the unknown is actually harder for them to grasp. I'm sure you must see stuff like that all the time in your clinic.

38:02
Exactly, because even for pain, where pain is this huge motivator, but people are used to certain things. You talk about the fact that people are familiar, you know, people don't like the unknown. Right. So at least they know how their pain feels and they know how their food and everything else feels to say change something and potentially get a better outcome. It's hard for people to do. But again, just having the patience and continuing to educate is how you get there. Yeah, yeah, sure. Azare, I'd love to.

38:31
focus specifically on migraine actually, just in light of the conversation around chronic pain, because you know, like I'm lucky enough never to have suffered from migraines, but I have a lot of clients who do. And I understand that you also see a number of people with migraines. So can we sort of start with what we know are sort of identifiable triggers or causes of migraine? Yes, so wonderful.

39:00
I'm glad that we're talking about migraine. Migraine is a big public health issue also, as you know, and it tends to affect women more than men. But when it comes to migraine, in terms of the pathophysiology, we know there's some genetics, right? But we have all these theories, but we don't have one theory that explains all the phenomena that occurs in migraine, because migraine is not just a headache. There's headache, there is autonomic changes, there is aura, there is central sensitization, there's all of the things that people that experience migraine go through.

39:29
So we don't have one theory per se that explains it, but we have some good theories that have been put up. So previously we used to think it's a vascular issue, that vasoconstriction is what causes, the aura and the invasor dilation causes the migraine, but that's not always true. So there was other theories, we're not gonna get into it. There's like corticose spreading depression, there is CGRP, we'll talk a little bit about that because that relates to medicines. But-

39:58
One of the things that we know is that migraine, irrespective of the pathophysiology or what causes it, it is starting with a trigger or a nausea stimuli. So a good way to really understand migraine as a patient is to really try to figure out what are these triggers or risk factors, the very question you're asking. So risk factors, women, hormones plays a role. That's one of the biggest one, but in a retrospective study,

40:28
really recognize is emotional stress is a big trigger for migraine, hormonal changes, poor sleep, nutrition, weather changes, smells. So there's all of these triggers that are there. So if you're a person that is dealing with migraine, it becomes very important to really understand your triggers. That takes some work on your side.

40:56
Because people will come in and say, oh, I don't know what's causing my migraine. I don't believe what happened. And my migraine just went off. And it becomes really getting people to deconstruct. So I always tell my patients, what have you done in the last 48 hours? Did you eat something different? Were you in a different environment? The weather can influence that. Were you around somebody who says something that you were not happy about? Because that will trigger a stress response. Because sometimes patients don't even know that this thing is the body keeps score, right? So all this physiology.

41:25
is taking place and any nausea stimuli, anything that your body perceives as stressful, whether it's a chemical, whether it's a thought, a toxin, all of that create chemistry will push individuals to migrate. So it's really important for people to really step back to understand some of those triggers and mostly stress what people are eating, whether other things that we can control. But it's important that people become aware of all of those things to be able to help prevent.

41:53
the migraine from happening. But as I understand it, there are the medications for migraine, like there is a preventative medication that people can take. And then if they feel something coming on, they can take something to reduce the severity or shorten the period. Is that like how effective is migraine treatment actually? Yeah, so we're talking about, yeah, so migraine treatment, we talk about the first part. First one is how do you prevent the migraine from even happening, right? So those are the triggers. Know your risk factors.

42:23
prevent it from coming. And then the second portion of it is two-prong, three-prong approach, prevent it. And then when it comes, what do you take for it? And then if you have chronic migraine, then something that you can use as preventatives. So when it comes to migraine treatment, migraine treatment has evolved over the years. So when it comes to just getting rid of the migraine or abortive therapy, previously we didn't even understand what migraine was. So in the 1990s, we discovered tryptans.

42:52
So people may say sumatriptan, resatriptan, there's all these triptans that works on really causing vasoconstriction because the idea of migraine is that there's vasodilation. And that can be very effective for stopping migraines, but those medications may not be safe for people that have cardiovascular issues or stroke or other type of peripheral vascular disease because vasoconstriction will then make that potential disease worse.

43:21
And then beyond that, we also have the NSAIDs, ibuprofen, any of those things that we can use. Again, there's potential side effects. And traditionally also in terms of prevention, we have used antihypertensives, antidepressants, and anti-convulsants. And these are all medicines that are not specific for migraines, but they do help. The issue is that there's a lot of side effects.

43:49
in 50% of the people where it doesn't work. And then, you know, about a year, 80% of people will stop because of the side effect. So migraine has gone through this evolution where now we are at a place where we have some new, other new medicines called G-pens. It's based on something called CGRP. So CGRP is this neuropeptide that get released when there is a nausea stimuli. Again, the trigger, whatever it is, will lead to this...

44:17
release of CGRP or something called casitone gene related peptide. And it can come from the trigeminal nerve, it can come from the vagus nerve, it can also comes from the dorsal root ganglia, which is in the spinal cord. So when that becomes activated, it leads to migraine. So now, in 2000s, we've kind of come up with molecules that are very specific for either blocking the CGRP itself, or blocking the receptor that the CGRP binds to. And that's

44:47
manage migraines and we have medications in that class that can be used as an abortive therapy or preventative therapy. So there's all of this class of medicines and even there's more that we are discovering because migraine as we talked about, we don't have one pathophysiology that explains it. So there's all of these things that are connected to it, but it all boils to this nausea stimuli and how does that nausea stimuli get activated? It's a function of health. The gut.

45:16
place a role in that, right? Stress, everything else we're talking about will lead to a nausea stimuli. And if somebody already have the predisposition to migraine, then that get triggers and we have migraine. And then beyond that, there was also supplements that people can take. There are specific supplements that are very good for managing migraine. There is butterbur, there's coqutane, there's B vitamins, because we also understand there's a metabolic dysfunction when it comes to migraine as a theory. So...

45:45
supplying the body with specific mitochondria nutrients can also and has been validated to help address migraine as well. So long way to say there's multiple things we can do. There's medications, there's supplement, focusing on preventing the migraine, and then even getting into botulin taxin. We can even use Botax to prevent migraine. And we can also even use devices. There's all this neuromodulation devices that people can use that are not medication-based.

46:14
So when it comes to migraine, we have a lot of options and it becomes, you know, where are those options available? I'm not sure what it looks like in New Zealand, but a lot of options. But the whole point is, how do we get you healthy so you can actually limit that trigger from activating the migraine? Yeah. Azare, do we know the sort of prevalence of people who suffer from migraine? Like, is there a large prevalence of those people also have gut dysbiosis? Like what do we know about that relationship?

46:44
Yeah, so we know that the microbiome is involved in multiple disease states. So when it comes to, I don't have the numbers specifically, but a lot of individuals with migraine have gut issues. And in fact, I've had a patient, this is again, this is not like a richer study where I have a few patients who had migraines, real migraines that was diagnosed. And we did some work up and we had some dysbiosis in their gut. And we solved that and their migraine is gone.

47:13
I've had people who were just dehydration by increasing their water intake, migraine is gone. So coming back to your point, yes, there's a huge relationship between the gut microbiome and migraine because the pathophysiology of the migraine is that specific cells in the brain get activated and doing all of these things. And all of those cells are influenced by what's going on in the gut. So we're talking about neuroinflammation, something that happens in the brain getting activated.

47:41
influencing pain, the same mechanisms also happens migraine. And that cells that are causing the neuroinflammation is influenced by what's going on in the gut. And we also know there is a connection of the gut through the vagus nerve that can send specific signal back and forth. So there is a big relationship and it's been validated in multiple studies on solving the gut as a way to improve migraines. Yeah.

48:08
Yeah, nice. And I read a book actually a few years ago called The Migraine Miracle. And it's a terrible title for a book actually because it seems very sensational. But the information I thought was really solid. I believe it was Dr. Josh Turnkit, maybe. And he had a layered approach to diet when it came to migraine and started with dairy-free and gluten-free for the reasons that you've described around the sort of the intestinal permeability.

48:38
of the gut and then sort of moved his way up to a ketogenic diet for some people. Have you had experience with the diet, that sort of diet side of things, Azare? Yeah, so migraine, as we talked about, diet, nutrition can be a trigger or a treatment for migraine. So this is something that patients need to really dial in. What you eat can actually

49:08
the very things you're talking about, specific food. If it's inflammatory in nature, goes into the microbiome or gets into the gut and it can cause inflammation or activation of specific cells. And that will then lead to that pain cycle starting and causing pain. So there's been some study that has looked at the Mediterranean diet as a way to manage migraine. They've also looked at ketogenic diet, as you mentioned.

49:37
Because all of that is working at a cellular level to control inflammation, right? And then also providing specific factors that are safe for the microbiome. So all of those things can be used. There is specific nutritional things that we talked about, the B vitamins can be used. There's also DASH, this diet that I use actually for hypertensive patients. And maybe you may even know a lot more about some of this other nutritional things. But nutrition is a huge part of

50:06
of managing migraine and it all comes to solving health. All of these things are not just going to improve your migraine. They're going to improve your cardiomyopulic health. They're going to improve your cognitive health. They're going to improve your overall hormonal health. So the goal is to really get people to understand that if I focus on health, a lot of these things will work itself out. So yes, and there is validated studies on all of these nutrients, and then we know for sure alcohol.

50:35
smoke, other things are really bad and processed food, all because they all affect the microbiome. Yeah, yeah, absolutely. And other research which I'm interested in, and it's emerging, but it's the use of exogenous ketones for reducing inflammation. I don't know if you've had any experience with that to date or is it a bit new or? Yeah, so I'm familiar with that data. I just don't remember the details of it. I've read it, but definitely.

51:04
And it's kind of relating to the same idea of, we talk about migraine being a metabolic disorder and having some energy balances, demand supply issues. So ketone esters kind of gives that energy right away without creating the waste, right? Because creating energy, right? We eat something to give us energy for the cells to do whatever we do in the process of making that energy also create waste. So using exogenous ketones kind of give you the energy without the fumes.

51:33
And as we also know, ketogenic diet kind of get people to reduce migraines. So it makes sense. It's not something I've used as a way to treat migraines. But I do take ketone SS myself to work out and to sometimes improve memory health. Yeah, nice one. And also they're in some products for recovery as well, for their sort of ability to reduce inflammation, which I thought was super helpful.

52:03
The thing with migraine, I guess, as you said, there are so many triggers which will affect one person compared to another person. Are there particular tests that people can do that help them understand where their migraine is coming from, like any blood tests or hormone tests or anything like that? So yeah, so when it comes to diagnosing migraine, we don't really have good kind of

52:32
good biological markers for testing for migraine. There's other things that we can use as a proxy, but these are not things that are validated. Because basically when people have migraine, the main point is to try to exclude potential other things that are dangerous. So we wanna make sure it's not cancer, we wanna make sure it's not some other type of rheumatological issues. And beyond that, it becomes really clinically understanding the history, family history, and

53:01
Other things that we can look at that may as a proxy. If you've done all those things, somebody is still having migraines. And if they are menopausal, is it hormones? We know hormones plays a part in the experience of pain as well as migraine. So that could be something that people can check to balance. Dysbiosis, right? The microbiome becoming disrupted as we've talked about could predispose people to migraine. I've already had that experience. So checking the microbiome could be a place to...

53:29
to get a better sense of overall inflammatory status, checking people's cortisol level. If people have a lot of stress, that HPEA axis can also influence that experience. So we don't have specific testing to say this is what causes migraine, but we know that all of those nausea stimuli as a function of too much stress, not enough nutrients, so even checking for B vitamin deficiencies.

53:57
could be used as a way to really understand the person in front of you. So I think when it comes to that, it becomes very individualized, who's in front of you, what else have been looked at, and then really trying to get to a place of how do I understand the overall health status of the individual and try to eliminate what type of potential triggers leading to this migraine. So as far as I know, I don't know of a specific one test that will say, you know,

54:25
this is what's causing migraines since this can be caused by multiple things. Yeah, no, that makes perfect sense and the tests that you suggest to either rule out but then also sort of explore more the other related factors like gut dysbiosis, like inflammation, nutrient deficiencies. I mean, that makes sense absolutely to me. Azare, you mentioned briefly and of course you've spoken of B vitamins a couple of times. Can we just, to finish off

54:55
Just talk a little bit about the supplemental support that people might want to look at for migraine, in addition, of course, to the dietary changes that they might explore, working with a practitioner to help them sort of implement them. So in your sort of practice, what are some of the most common supplements? Yeah, so supplements have a place in medicine. Before we even get into that, we want people to understand that.

55:24
we have to, the very thing, work on nutrition before you even talk about supplements, right? Work on sleep before you talk about supplement, or sometimes you need a supplement to help you with sleep. So there's supplements specifically that are recommended or approved or indicated to help with migraines. So one, I think I mentioned it already, butterbur is a plant that I don't know if that's available where you are. And it's basically trying to make sure that it's butterbur that doesn't have some specific toxins.

55:54
So the issue with supplement and all those natural things, yes, there's a place for them, but we need to recognize and understand that natural does not always mean safe. And what is safe for somebody does not mean safe for you. So it's really important for people to kind of understand some of these things and talk to your providers, talk to your healthcare people to understand, what are your risks, right? So bottom bread could be used. CoQ10 supplementation, which actually works on the mitochondria. And again, this is a, we think,

56:24
Migraine is a metabolic issue and energy balance issue. So CoQ10 could be helpful. Magnesium, magnesium is very important for coming out of the nervous system. It also modulates NMDA, some of these other systems that are involved in pain processing. So magnesium is a great supplement. The B vitamins could be explored. L-cannotine can also be used. And all of these things that I'm talking about actually have good literature to support them.

56:54
There is also vitamin D and then there is also even alpha lipoic acid. So those are all supplementations that people can add to their regimen to help with addressing that. And I think I forgot one, feverfew. There is also a plant. Yes. I don't know if, yeah. So those are all great things that have been explored and it can be used as an adjunct to medications or whatever else that you have to help you get there. But fundamentally, like you said, let's get the nutrition better.

57:22
And when you ask those things, it makes it work a lot better. Yeah, nice one. There is a supplement actually from a company called Life Extension. I'm not sure if you're familiar with that brand. Yeah. And I believe it's called Migratease. And I think it's got Butterbur and Feverfuel and B2 or something else. It puts it all together, Taiming. Yeah. Yeah, it puts it all together. Yeah. And there's another one called Migrenol. So Migrenol is made by Designs for Health. That's all this different supplement.

57:52
And it's kind of the same idea. It has the Butterbur, the Feverfew, the magnesium, L-thionine to all work into modulate pain. So there's a lot of options there for individuals with migraines. Nice, so you rate that one, the migraineol? Migraineol. Migraineol, yeah, migraineol. Yeah, so migraineol, I would recommend it for persons. So this is like supplement you recommend and we don't really write for them. So I would say, try migraineol. I see how it works for you. I've had people who it works really well, and then some people, they actually end up having some more side effects. So...

58:21
Everybody's a little different. And sometimes you don't understand why this is happening, but it all is a function of health and sometimes microbiome, right? If the gut is not healthy, we don't process things as well. Yeah, and that's such a good point as well, because there are people who take some supplements and they do actually end up feeling worse rather than better for whatever reason. I guess that's another reason to highlight the idea that they should just supplement.

58:51
the other foundational strategies, which for most people are gonna do a lot of the work. Yeah, absolutely. Yeah, nice one, Azare. Well, thank you so much for your time this morning. I really appreciate it. I understand, as you said, you're speaking at a conference soon. Where else can people, yeah, where can people find you and find more about your clinic and your work? Yeah, so again, thanks for the opportunity to come in.

59:20
Talk to you, I enjoy that conversation. So I am the founder of a medical practice in mainline Philadelphia called Ether Medicine. So we are an integrative medical practice that focus on cellular health. I've come to this place where it's all about the cell. If we can signal the cell in a healthy way, the cell has the intelligence to adapt in a healthy way. And how do you signal the cell? The very things we're talking about, nutrition, sleep, balancing the hormones, all of that signal the cell in a healthy way.

59:49
And people can look at what we do on our website. It's www.aethermedicine. Aethermedicine is A-E-T-H-E-R, medicine.com. And you can contact us through that place. We are also on Instagram. Do you wanna follow us? We do some education over there. It's, you know, one minute, but. Perfect, perfect. But yeah, so that's how people can get ahold of us. And if people have questions, I'm always interested in learning and, you know, hearing.

01:00:21
Yeah, no, that is amazing. And we will absolutely put links to your Instagram handle and of course, your clinic and the show notes as well as Ari. Thank you so much for your time and enjoy the rest of your day. Thank you so much. And thanks so much for what you do.

01:00:47
Alrighty, hopefully you enjoyed that. I certainly did. And also for people who struggle with migraines, hopefully you've got a few gems that you may be able to put into practice, or at least gives you something to go to a health professional with and get a better understanding of what's going on. Next week on the podcast, I speak to Dr. Jen Unwin.

01:01:11
about food addiction. Brilliant conversation that one. Until then though you can catch me over on Instagram, threads and Twitter @mikkiwilliden. On Facebook @mikkiwillidenNutrition. Head to my website mikkiwilliden.com and book a one on one call with me. Alright team have the best week. See you later.