62. Deconstructing Head Pain with Rudrani Banik, MD

00:00
Dr. Rudrani Banik
It is a journey and it's a very steep uphill slope initially. But once you get there, once you figure out what regimen is going to work for you, whether it's only lifestyle and supplements or maybe and diet or maybe it's superimposed on that medications, once you figure it out, hopefully that will carry you through and improve your headache severity and frequency, but also your quality of life. That's really what we're talking about here, is quality of life. And so find a provider that you feel comfortable with who can walk you through this journey. 

00:43
Jennifer Milner
Welcome back to the Bendy Bodies podcast, where we speak with experts bringing you state of the art information to help you improve your well being, enhance your performance, and optimize career longevity. This is co host Jennifer Milner, here with the hypermobility MD linda Bluestein. 

00:59
Dr. Linda Bluestein
We are so glad you are here to learn tips to help you self manage your conditions and live your best bendy life. This information is for educational purposes only and is not a substitute for medical advice. 

01:11
Jennifer Milner
I'm Jennifer Milner, a former professional ballet and Broadway dancer, and I struggled my whole career with hypermobility based injuries and issues. Now I train dancers and want to be sure that the next generation of hypermobile artists are better equipped to work to their full potential. 

01:27
Dr. Linda Bluestein
I'm Dr. Linda Bluestein and I started Bendy Bodies as my second podcast to educate the hypermobile community. Despite being a physician, I experienced decades of symptoms before being finally diagnosed with hypermobile Eds, and I too have been gaslit and felt completely alone in my journey. 

01:44
Jennifer Milner
Our guest today is Dr. Rude Ronnie Bannock, neuro ophthalmologist and founder of Envision Health, New York City. Hello, Dr. Bannock, and welcome to Bendy Bodies. 

01:54
Dr. Rudrani Banik
Thank you so much, Jennifer. It's really a pleasure to be here with you both. 

01:57
Dr. Linda Bluestein
We are so excited to chat with you. 

02:00
Jennifer Milner
We are we have a lot that we want to cover today, but first, could you tell us a little bit about yourself? 

02:06
Dr. Rudrani Banik
Absolutely. So I am a board certified ophthalmologist and a fellowship trained neuro ophthalmologist. So I deal with all the conditions that connect the eyes to the brain. There are many nerves that are responsible for our vision, how we move our eyes, how we move our face. So I deal with all of that. And as part of what I do, I treat a lot of migraine, various types of migraine, because many migraine patients have visual symptoms that go along with their headache symptoms. Now, in addition to that, I recently got a second certification in functional medicine. So I layer that on top of everything else I do, I look at the root cause of various chronic diseases and then I address the root cause rather than to just put a Band Aid on the problem, really, to try to get to where it's coming from and address it that way. 

02:55
Dr. Rudrani Banik
And in functional medicine, the basis for a lot of what we do. The foundation of treatment is usually nutrition as well as lifestyle. So I use a lot of those strategies in the treatment of my patients with neuropathalmic problems as well as eye problems because I still do comprehensive ophthalmology. That's great. 

03:12
Jennifer Milner
And it's really nice to see someone that sort of does the whole person. Even though you're working with the specialty with the eyebrain connection, it's great to see that you look at the whole person and everything that could be going on. So, as we said, we wanted to talk about headaches today. Our podcast is about all things hypermobility related and chronic headaches and migraines seem to be a pretty common comorbidity in people with hypermobility disorders. Have you noticed that in your own practice? 

03:36
Dr. Rudrani Banik
Absolutely. If people are asked, most often the answer is yes. If you're not asked, then we don't know. So it's really important, I think, to be aware of the various range of conditions that can occur in hypermobility and Eds patients and ask those important questions. And there are specific types of headaches that may also occur in these patients who have a history of hypermobility. So we can definitely talk about that as well. 

04:05
Dr. Linda Bluestein
Sure, that's so true. There are so many different causes of headaches in this population. Right. So today we're going to dive, I think, pretty specifically into the migraine portion, but obviously feel free to comment on any of the other types and we just want to give people some ideas as to sometimes people use headache and migraine interchangeably, but we know they're not the same thing. And of course there are other different types of headaches. But could you describe some of the common types of headaches that you encounter in your practice and how migraine might be different from other types of headache? 

04:38
Dr. Rudrani Banik
Sure. So that's a really important point, is that not all headache is migraine and not all migraine is headache. I say that a lot in my practice. So there are different types of headaches. For example, there are tension headaches, there are migraine headaches. Some people use the term sinus headaches. So officially it's not a medical term. Even though the pain may seem like it's originating from the sinuses, it's probably a different form of headache syndrome. Then there are cluster headaches, there are headaches that we call cervical genic headaches, and there are other, more, I would say less common headaches called trigeminal, autonomic cephalgias. So there's a whole range of different types of headache syndromes and each has their own symptoms and the diagnostic criteria, et cetera. But one thing I just did want to say is that it's important if you have headaches, especially if you have headaches on a regular basis, that you seek out medical care to figure out which of these different types of headache syndromes it may be. 

05:40
Dr. Rudrani Banik
Because sometimes the treatments can be quite different and the workup may even be different. It is really important to seek out a doctor if you're not sure. It seems like it's a sinus headache, but what is it really? And one other thing I did want to mention is that within the brain, there's really only one nerve that is responsible for pain, and that nerve is the trigeminal nerve. And no matter what type of headache you have, whether it's a tension headache, a migraine headache, a cluster headache, it's the same nerve that gets activated. So there may be some overlap between these various different types of symptoms syndromes, because the same nerve is being activated perhaps in slightly different ways. 

06:22
Jennifer Milner
That's so interesting. And that's really interesting to think about that. And as we're talking about this and we're talking about the importance of going to see a doctor and getting looked at, we're not talking about the casual brain freeze or hangover headache or any of those sorts of things. That can happen. Or if you have a sinus infection and you've had a headache and it clears up and goes away. We're talking about some sort of chronic headache, pain or something that seems to recur somewhat regularly. So it's important to make that distinction for everybody so nobody feels like they have to run out and go see a doctor just because they had a little too much to drink the night before. So how do you diagnose migraines versus other headaches? 

07:03
Dr. Rudrani Banik
Yeah, that's a great question. There are specific criteria for migraine, and so I always tell people, you may self diagnose yourself with migraine, but definitely see a professional. And so what are these criteria? Well, first of all, there needs to be at least five attacks of a particular type of headache. And this type of headache usually is unilateral. So one side of the head, maybe behind the eye, extending sort of one hemisphere of your head, it tends to be of a throbbing nature or a stabbing nature. So just kind of or pounding. Some patients could describe it as a pounding sensation. And usually the episodes, there are five episodes total that are required for the diagnosis, but each episode can last anywhere from four to 72 hours. So that's much longer than your typical hangover headache or tension headache, et cetera. And then not only that, there are additional criteria that need to or symptoms that need to occur during the headache. 

08:08
Dr. Rudrani Banik
For example, light sensitivity, sound sensitivity, nausea, vomiting. These all play into the diagnostic criteria for migraine. So again, some people may presume that they have migraine, but if they don't meet all of those criteria, it could be something else. 

08:26
Jennifer Milner
And that's important to distinguish. Not because we want to say, well, you don't have a migraine, so it's not a big deal. But it's important to distinguish because it changes the treatment, right? So it may change the approach to it. So it's really helpful for people to be able to sort of see the difference in them. Again, our population does seem to have a larger share than normal of chronic headaches or migraines. So let's look at the non migraine headaches for a second. What could be some of the common culprits of a non migraine headache? 

08:56
Dr. Rudrani Banik
Usually it's lifestyle factors. For example, dehydration, stress, heat stroke, for example, can be associated with a headache. And in the majority of those cases we typically call these tension headaches. And they tend to occur bilaterally, usually in the forehead area, sometimes in the temple area, sometimes it may even go down the shoulders into the neck. But it tends to be a bilateral process and it's more of a pressure sensation. And it's really interesting in that tension headaches, again, they're usually triggered by lifestyle factors, but activity makes them better. So I know a lot of people, when they get a headache, they feel like they just want to lie down and take a rest. But sometimes actually engaging in some kind of activity can improve your headache. Now, that's kind of the opposite of what happens with a migraine. In a migraine, actually, if there's too much activity, it makes things a lot worse. 

09:54
Dr. Rudrani Banik
So it's actually better to rest during a migraine. So that's one important feature to distinguish between the two. But again, just going back to your question, if you do have frequent tension type headaches, think about what's going on in your life. Is it that you're dehydrated? Is it that maybe you're not sleeping well enough? Sometimes irregular sleep patterns or lack of enough sleep can lead to attention headache as well. And again, stress is kind of the elephant in the room that I always ask my patients about. Are you stressed more than your average level of stress? Where is it coming from? What can we do to mitigate that to help with your attention headaches? 

10:30
Dr. Linda Bluestein
So what are some common triggers of migraines? 

10:33
Dr. Rudrani Banik
So that's a great question, and a lot of them are similar to those triggers that I just described for tension as well. Many people it is lack of sleep dehydration. Another interesting feature of migraine is that people may have food sensitivities and that can sometimes trigger a migraine. For example, foods that are processed that may be rich in a compound called Tyromine that people have trouble processing and then that could lead to headaches. For example, fermented products, fermented cheeses, certain alcohols, even certain types of bread can trigger migraine headaches because of their products, including Tyramine. Other things that can trigger migraines usually I shouldn't say usually, but in a lot of people, their brains, people who have migraine are very sensitive to their environment. So changes in their environment, for example, light, bright, sunny days or sunglare coming off of the snow or off of the water can trigger a migraine. 

11:35
Dr. Rudrani Banik
Flashing lights can trigger a migraine. Loud sounds. So for example, the other day I get migraines myself, so I'm very familiar with the symptoms. The other day I was in a concert and those flashing lights and those loud sounds, they triggered a pretty severe migraine for me. So I just have to be very cautious about what type of environment I'm in. And then because, again, the brain is very almost hypersensitive to changes, people with migraine are really sensitive to weather induced weather fronts coming in. For example, changes in barometric pressure. Usually when the barometric pressure falls quickly with the onset of a storm, that's when people may discover that they're suddenly getting more migraines. So it's important to think about all this and maybe keep a diary if you do have migraines, if you've been diagnosed or you may think you have migraines, keep a diary of your symptoms, what do you think the patterns are, and that way you're better equipped to know what to do to prevent them. 

12:32
Dr. Rudrani Banik
But also when you go see a provider, you can take that information with you and it can be quite helpful. 

12:37
Jennifer Milner
That's really a great list of things, and I couldn't help but notice that several of them sort of fall alongside issues maybe like mast cell disorders. So it's great for people with a common comorbidity like mast cell activation disorder to be able to see that those sorts of things line up. Definitely not my area of expertise, but we have had several people in to talk about it and it seems to be something that is kind of a common theme in a lot of people. 

13:07
Dr. Rudrani Banik
Absolutely. I think well, part of what I do as a functional medicine practitioner is to try to get to the root cause of why somebody may be predisposed to something like migraine. And mast cell activation syndrome is definitely one of those conditions that may lead to certain conditions like migraine as well as others, which we can talk about later, perhaps. 

13:30
Dr. Linda Bluestein
Yeah, migraine is definitely one of those. I can't remember what year the paper was published, but they talked about different conditions that could be mast cell related, and migraine was definitely on that list. So, yeah, definitely something to think about. What are some of the other types of migraines that we might want to be aware of? Migraines that could occur maybe in other parts of the body. 

13:50
Dr. Rudrani Banik
Yeah, so not all migraine has a headache. That's the unusual feature of migraine. People think, oh, it's a headache where you just have to kind of go into a dark room and go to sleep. But not everybody has those symptoms. Some people have just visual symptoms, which we call aura, where you may see flashing lights, kind of it's quite scary, actually, when it happens, because if you think, oh, my goodness, am I having a stroke? What's going on? Because people see these flashing lights, they have a zigzag pattern. It almost looks like a kaleidoscope, and it's multicolored kind of geometric patterns. And that aura, that visual aura can last anywhere from 15 to 30 minutes before it subsides and usually it's followed by a headache, but not always. Some people just have the aura. Other people may have other types of aura. For example, this can be quite scary as well. 

14:37
Dr. Rudrani Banik
Numbness and tingling one side of their body, or even weakness one side of their body. Again, of course, we need to rule out stroke. But let's say the first time it happens, the stroke workup has been done and it's not a stroke, it's a specific type of migraine. We can call it hemiplegic migraine. Again, usually it's followed by a headache, but not always. And then there are other people who get what we call vestibular migraines. And these are episodes, they're quite hard to diagnose because they're very sporadic and people have this sudden onset of dizziness vertigo where the entire room is spinning around them. And they may not get the typical migraine symptoms, but perhaps they have a history of migraine, perhaps they've had migraine many years before and now it's better. But now they're getting these different types of migraines that we call again, vestibular migraine. 

15:28
Dr. Rudrani Banik
And then one other thing I wanted to point out is that migraine in migraine, not only is that trigeminal nerve activated, that nerve I was explaining to you about earlier, but the vagus nerve is involved as well. So the vagus nerve connects basically our whole body from the brain down through our heart, our lungs, into our digestive system. So many people, when they have a migraine, actually have digestive issues. They have gastrointestinal symptoms like bloating, cramping I mentioned earlier, nausea, vomiting, even loose stools. So there may be this gastrointestinal component of their migraine symptoms without the headache that makes it really hard to diagnose. And actually, in children, the GI type of symptoms is much more common than the headache. So many kids will actually have those symptoms and have this huge gastrointestinal workup with endoscopies and colonoscopies and biopsies, and everything is negative and it may actually end up being a form of migraine. 

16:30
Dr. Rudrani Banik
So I think it's important for people just to realize that it's a spectrum and it's not just the headache, it can be many different manifestations, which. 

16:38
Jennifer Milner
Is yet another reason why it's so good to go in and get things checked out. And it's great to go to a doctor who is open to try to sort of explore everything and figure it out. I've had two dancers diagnosed with what they called stomach migraines, as you said, and like you said, there was a huge workup trying to figure out what was going on, what it was, and they're both pre professional teenagers and that was the diagnosis. So, yeah, as you said, not every migraine is a headache and not every headache is a migraine. 

17:09
Dr. Rudrani Banik
It can be very elusive, especially when there are these unusual symptoms. And sometimes it's best to actually go to see a headache specialist. You can start with your primary care doctor, but it's sometimes best to see a specialist who deals with this on a regular basis. 

17:25
Jennifer Milner
So if someone suspects that they do have migraines, what steps would you suggest they take to get relief? Sounds like the first step to you would be to go get it checked out. 

17:35
Dr. Rudrani Banik
Yes, get the diagnosis, make sure it's not something else. There are more serious brain issues, neurologic issues that can mimic a migraine. So definitely you want to make sure it's not one of those things. I have patients take a headache diary to try to figure out what their triggers may be. And I always start with the things that they can control. So if they know that dehydration leads to their migraines, stay extra hydrated, especially if you're going to be doing any kind of physical activity, strenuous activity, make that extra effort to hydrate aggressively. And I always try to approach things more holistically before starting a medication, prescription medication. So I always talk to patients about things they can do, maybe some dietary changes. If they think that they're sensitive to certain foods, eliminate those foods. Again, those processed foods or foods high in sugar content, perhaps foods rich in Tyromine. 

18:30
Dr. Rudrani Banik
Try to exclude those foods. See if that helps. And then I'm a big believer in certain supplements for migraine, and there are studies to back this. There are many studies to show that people who have migraine do benefit from certain supplements, including magnesium, which is a huge benefit for many of us, for other reasons as well. Most of us are magnesium deficient, so it's good to take a supplement. Also B complex, particularly B two, which is riboflavin. There are studies that show that in patients who have chronic migraine, 400 milligrams of riboflavin taken daily for at least three months can make a big improvement in the frequency and severity of their symptoms. Now, most multivitamins will have a very small amount of riboflavin, maybe anywhere from two to ten milligrams. So you have to take kind of a separate, high dose riboflavin supplement if you do want to pursue that route. 

19:24
Dr. Rudrani Banik
But these are some simple things. People can do other things. Again, I mentioned that migraine brains are super sensitive. So maybe just adjusting the lighting in your house, wearing certain tinted glasses when you go outside so the sun doesn't precipitate a migraine. Making sure you're on a regular sleep schedule, a regular meal schedule. Trying to modulate stress. I always talk to my patients about what they're doing to help their stress levels, whether it be meditation or some other stress reducing activity. These are all the basics. I always tell my patients, have your foundation set, and then if you still get severe headaches, breakthrough headaches, then we can talk about maybe adding on prescription medications. It's not my first go to in most patients. That's great. 

20:08
Jennifer Milner
And an overarching theme that we hear with so many of our specialists like yourself, are going back to the basics. Are you eating well, not just as a healthy diet, but are you eating well for you and your particular needs? Are you getting enough sleep? Are you exercising properly? Are you taking a care of yourself? It's all about that preventative actions and trying to do what you can to not get into position to need to take medicine. Migraines do. Speaking of medicine, though, do sort of have an overwhelming array of medication available these days. We see celebrities selling it on TV and everything and at the same time, people with hypermobility disorders definitely can react differently than the average person on medication. So if you hit the point where you think, let's start looking at medication, we've done all the things that we can, we've taken all those preventative steps. 

21:00
Jennifer Milner
How do you walk your patients through that sort of trial and error process of figuring out a medication that works? 

21:06
Dr. Rudrani Banik
Yeah, so first of all, I always tell my patients that any medication I put you on can potentially have a side effect. Anything, even the ones that have been brown for 30, 40 years can potentially have a side effect. And each person is different. So your side effect may be different from my side effect. And just because something worked for one person doesn't mean that overall it's going to work for everybody with a particular symptom. So I usually start with the classes of medications that I, in my experience, have the fewest side effects, and again, I start with the lowest dose possible and see what their response is. And after two weeks, if they're doing okay, then try to bump them up to the next level if they need it. As you mentioned earlier, there is a huge armamentarium of different medications we now have for migraine, which is wonderful in a sense, but it doesn't mean that the same medicine is right for everybody. 

21:57
Dr. Rudrani Banik
So there are medications, for example, traditional blood pressure medications such as beta blockers or calcium channel blockers can be very useful in migraine with relatively few side effects. But for people who have hypermobility disorders, you probably know better than I do, Dr. Bluestein, but people don't necessarily react the way that we would think they would. So a medication that you think may not typically have a particular side effect, may have a side effect in a particular individual. So it's always best to start low and then to go up and see how people respond. There's a whole new class of medications that hit the market about three years ago, almost four years ago now, called CGRP inhibitors. And these are the medications that Jennifer you mentioned are marketed, you see them advertised on know, there are celebrities taking them, et cetera. They are targeted at a particular molecule that's responsible for pain and migraine called calcitonin, gene related peptide. 

22:58
Dr. Rudrani Banik
And these medications are not first line medications at all. But if there is no response to other classes, then they can be used. And there are different types. For example, there's injectable ones once a month injectable medications, and there are oral versions, and then there's one that's every three months. It's an infusion every three months. So if you're not responding to the first tier of medications or the second tier, it may be that you need the third tier. In which case, again, see a provider, find out what's best for you, and of those, find out which specific 1 may best for you. And it's always best to proceed with caution, especially with hypermobility issues. You just never know what could happen. 

23:42
Jennifer Milner
Well, and that just goes back to another common theme that we have so much time is slow and low. Whether it's exercise or changing your diet or whatever it is just going slow and low and moving slowly and cautiously and having a practitioner who either really understands hypermobility or is willing to learn about it and to be open to trying to figure it out with you. So it's great that, again, that you look at the whole body and the patient. 

24:11
Dr. Linda Bluestein
And I was curious if you found with the Calcitonin gene receptor antagonist, if you found any differences in pain in the rest of their body. Because I treat people with persistent pain oftentimes, it's really widespread and I haven't really been prescribing those medications. Oftentimes they come to me already on them for migraine. But I was curious if you have noticed that in your patients at all. 

24:37
Dr. Rudrani Banik
That's a great question. So these receptors, the CGRP receptors are found not just in the brain, but in other parts of the body as well. I know that they're present in cardiac muscle. I don't know if they're present in skeletal muscle. That's a really interesting question, but I will look that up. But it's possible that this class of medication may help pain in other aspects as well, other parts of the body. Have your patients with migraine who've taken these drugs, have they noticed a decrease in their overall pain levels? 

25:11
Dr. Linda Bluestein
Well, I have such a self selected population, right. They're coming because they have uncontrolled pain and a lot of them are on these medications for migraine. And in some cases they found a significant difference, and in other cases they haven't. But I was just curious since if they're getting relief from other pain, they're probably not coming to me because they don't need to come see me, right? So I was just curious about that. And also tricyclic antidepressants are another class that I know does sometimes get used for migraines. Is that something that you prescribe or not too often now that we have the CGRP antagonists, I actually do prescribe. 

25:52
Dr. Rudrani Banik
Those a lot, and my preferred ones are Amitryptylene or nor tryptryptylene. Just be aware that, again, everything can have a side effect. And what I tell people is that this class of medications, so they're typically medications used to treat depression, but they can cause symptoms like dry eyes, dry mouth, sometimes even weight gain, which may not best for other aspects of their health. So again, it's all a balance between the benefit of the medication and what the patient can tolerate. And if I do use a tricyclic, I use the smallest dose possible. So I usually start with a ten milligram dose. I mean, I know some doctors will start patients on 40 or 50 milligrams, which is a huge dose. And definitely patients come back, they can't swallow because their throat is too dry, their eyes are so dry they can't see properly. So I always start with a very low dose and then I ramp up if necessary. 

26:44
Dr. Rudrani Banik
The other potential side effect of tricyclics is that it can cause drowsiness and sleepiness. Now, I've taken them myself and it made me feel like I could not get out of bed, so it was not the right medicine for me. But just be aware that there are lots of side effects that can happen. It doesn't happen to everybody, but if it happens for you, there are other options. So then talk to your provider about what else may best for you to switch to. Sure. 

27:10
Dr. Linda Bluestein
And I've been on and off tricyclics numerous times for CRPS complex regional pain syndrome. For migraine, we use low dose for Pots, which is a form of Dysautenomia. So I was just curious to ask about that specifically, because that's something that I see prescribed a lot. And I totally agree about starting with a super low dose and then going from there. When people tell me, oh, I tried such and so, and it didn't work. And I usually ask them, well, what dose did you get? Because that makes all the difference. If somebody prescribed, like you said, like 40 milligrams and you didn't do well and you had a terrible morning hangover, it could be the dose, not the drug. 

27:47
Dr. Rudrani Banik
Yeah, absolutely. Another drug that I found really useful in migraine is Topamax, or Topiramate. It is anti epileptic, but it's FDA approved for migraine as well. And the benefit of Topamax is that, well, it has many different mechanisms of action. But in certain patients now, this is kind of getting off to a slightly different topic, but certain patients who have high pressure in their brain, a condition called IIH, they do benefit from Topamax because it helps their headaches. It helps to decrease the fluid produced by the brain, and it also helps with appetite suppression. And many of these patients are overweight, so it helps with weight loss for them as well. So there's, again, lots of different medications and different indications or different types of headaches that may better suited to certain medications. 

28:34
Dr. Linda Bluestein
I'm glad you mentioned that, because high pressure headaches are something that well, both high pressure and low pressure because they can get CSF leaks and get low pressure headaches. But some people with ehlers. Danlos or hypermobility spectrum disorder. They can end up with high pressure headaches. So I'm glad that you mentioned that. That's a great tip to share. So thank you. So what about some of the other supplemental things like physical therapy, exercise, working with a nutritionist, working on their sleep? What kind of things along those lines do you use? 

29:06
Dr. Rudrani Banik
Yeah, so in some patients, they have headaches that actually start at the base of their neck and sometimes either go down into their shoulders or go up into their head. And these are headaches that we call cervical genic headaches. And I do know that cervical genic headaches are much more common in the hypermobility Eds population just because of cranio, cervical instability with ligaments and joints, et cetera. It is important if you do have headaches that are kind of focused here or they start here to consider getting physical therapy. Chiropractic therapy can sometimes be very helpful. Myofascial release can be helpful, sometimes even acupuncture. Acupressure. So I try to incorporate these modalities depending on what the patient's symptoms are and what their response is to their previous treatments, and oftentimes adding that on adding on a different member to their care team, for example, a physical therapist or an acupuncturist, can make all the difference in really getting them to longer periods of being pain free. 

30:13
Dr. Rudrani Banik
So definitely if you have that, consider a referral or ask for a referral. The other thing I would say is that I am a big believer in essential oils. And I don't know if either of you have experience with this for pain or headache syndromes, but I found that essential oils, especially when there are cervical genic headaches or sometimes even tension headaches up here, they can really help to modulate the pain and decrease the pain. Now, whether it's aromatherapy, whether it's penetration from the skin into muscles, relaxing them, I'm not sure. But for example, I've used peppermint, lavender and frankincense. Those are kind of my go to essential oils. Again, these are used topically in sparing amounts. Not a lot because you don't want to overdose. I know some people take them through capsules, but I would be very cautious with that because sometimes it can cause GI side effects. 

31:07
Dr. Rudrani Banik
So topically or even inhalation has worked very well for a lot of my patients who have these types of headaches. 

31:14
Jennifer Milner
I will say that I have used them as well. I also have get migraines and tension headaches and I have found the peppermint to be helpful for the tension headaches. And I have actually used, I don't know if you've tried it, but it's hood. H O. Hood has been a great essential oil for me for headaches as well. 

31:33
Dr. Rudrani Banik
I haven't tried it, but I will definitely look into it. Thank you. 

31:37
Jennifer Milner
And again, those are the types of things that people should proceed cautiously with, because one person's deep love of lavender may be somebody else's. MCAT's trigger. Right. Everything affects people differently. 

31:50
Dr. Rudrani Banik
Yeah. So many people who have migraine are sensitive to smells as well, so their symptoms may be triggered by some of these essential oils. 

31:58
Jennifer Milner
Right? Exactly. So what tips do you have for people who might be struggling with headaches? Trying to figure it all out, but are also trying to they're really struggling with trying to get the care that they need? 

32:10
Dr. Rudrani Banik
Yeah, that's a great question. And unfortunately there aren't that many headache providers per population in the United States. There's a mismatch between the prevalence of headache syndromes and the specialists who can help. So there are now a lot of telemedicine options which were not available before. I think this is one of the pluses of the pandemic that we realize is that there is a lot more access to providers through telemedicine and people who've been trained in headaches. So I know that there is online platforms where you can get hooked up with a provider in your area if you're not able to get an in person. Sometimes headache doctors are booked out three or four months. It's really crazy that there's such a long wait to get the care that people need. So I would seek out maybe a telemedicine option. And a lot of people this is kind of unfortunate that this is the case, but a lot of people use the emergency department as their go to for severe headaches and that's not the ideal kind of way to manage your headaches. 

33:14
Dr. Rudrani Banik
Try to get a provider that you can develop a relationship with that you can see on a regular basis rather than to go into an emergency department for those severe headaches that just are not breaking. It's best to try to address them before the headaches, before they get to that severe stage. Now of course, if you do have a really severe headache that's lasted three or four days, it's just not getting better. Absolutely. Maybe go into your local urgent care emergency department. Sometimes there are infusions that can be given to break that headache cycle. So I'm not saying don't do it, but really reserve it. Don't use it as your standard access to care. 

33:53
Dr. Linda Bluestein
I had an infusion of DHE after having a migraine that lasted for a very long time and I was in the hospital for several days and that was rough. But I do have a follow up question about imaging. It seems like patients that I see it is so common that they have different kinds of head pain and some of them have had quite extensive imaging and others have had none. Like, I had a patient the other day who says she's had head pain since she was eight. She's now in her early twenty s and mom says she has never had a scan ever of her head. So what do you think in terms of indications for imaging? 

34:35
Dr. Rudrani Banik
Yeah. So if there's anything unusual in the history, I will image, without a doubt if there's a new symptom, especially things like numbness, tingling, these are kind of unusual symptoms that really should be worked up with imaging. And if you're going to get imaging, my go to is always an MRI of the brain rather than a Cat scan because the MRI technology is much better resolution, high resolution of soft tissues. Now, if you're looking for more structural issues, for example, joint issues or sinus issues, for example, then Cat scan may be the better modality. But in the vast majority of patients, an MRI is really the best choice. Now, in some cases, for example, if someone has high pressure in the brain were talking about this earlier, this condition called IIH, which is idiopathic intracranial hypertension. I will also get an MRV, which is an Mrvenography looking at the veins that drain the brain to see if there's any obstruction in those veins. 

35:35
Dr. Rudrani Banik
And sometimes, yes, there is a structural issue and so it's important to know that it's there and then to address it appropriately if it's significant in some patients, especially if they have a lot of cervical pain, neck issues, shoulder issues. I will get an MRI of the spine as well, the C spine, because that will best show if there's any kind of joint dislocation, subluxation herniated disc, all those types of things that it's important to know because perhaps the treatment would be different and not your standard migraine treatments or tension headache treatments. It would be something different. So I think there is a role for neuroimaging, but then again, not every patient needs to have neuroimaging. So, for example, many patients come in with new onset, let's say it's a young woman in her 20s or thirty s new onset visual aura. They've seen those flashing lights and they get the headache afterwards. 

36:31
Dr. Rudrani Banik
If it's a stereotypical symptom like that where there's aura followed by headache, I typically don't get the imaging. Of course, I do an eye exam to make sure that there's nothing else suspicious, that the optic nerves are not swollen, that there's nothing else going on in the retina that may have caused those symptoms. But as long as that's normal, typically I forego the scan. But certainly like what you were describing, an eight year old with chronic headaches who's never been imaged. I probably would image in that case just to make sure there's nothing structural that's responsible for the headache. So it needs to be decided on an individual basis. My threshold is usually pretty low to image. I don't want to miss anything, especially something else that can be treated. 

37:12
Jennifer Milner
That's great. One of the things that we sometimes see with people with hypermobility disorders might be like a Chiari Malformation or something along those lines. So there can be a whole bunch of different things that could be causing head pain and that imaging can be really helpful to find it. So that's great that you have sort of a low threshold without automatically sending every single person to go get that MRI when they first walk in your door. 

37:40
Dr. Rudrani Banik
Yes, it's selective, but I have a low threshold. So just I'm glad you brought up Chiari because I know that has been investigated in the hypermobility erlos Danlos population. And yes, there is a slightly higher prevalence of Chiari malformation. So what Chiari is that the back part of the brain, which is called the cerebellum, it's our balance center, usually sits at a certain level above the skull base. And in Chiari Malformation, it sits lower than it normally should. So it's almost like it's kind of being pushed down into the spinal canal and it can cause certain types of headaches. Also, it can cause issues with numbness, tingling down the shoulders or weakness of the shoulders or even the arms. So it is important, if you have any of those types of symptoms, to get an MRI and a particular series of MRIs, which is called a Sagittal MRI, which looks at it's a side view of that area of the cerebellum and the spinal canal to see exactly where the cerebellum sits. 

38:44
Dr. Rudrani Banik
And sometimes we also get a spinal MRI as well just to look for any other changes in the cervical spine that can be seen with Chiari. So absolutely, if you have those types of symptoms, I think it is really important to get that imaging done. Absolutely. 

38:57
Jennifer Milner
Thank you. And thank you for adding on to that. I just wanted to circle back really quick before we wrap things up to the topic of sleep. I know you mentioned it and that it's really important for people to examine their diet and try to be healthy with it, to try to be healthy with sleep. But can you expand a little bit more on the importance of sleep and migraines and headaches? 

39:15
Dr. Rudrani Banik
Absolutely. So sleep is restorative. It's our body's time to reset and recharge, and we need to have an adequate amount of sleep for all of our generalized health, not just for headaches and migraines, et cetera. But people who are prone to migraines are very sensitive to irregular sleep patterns. And so what I always tell my patients is, first of all, how do you know if you're getting an adequate sleep? Well, when you wake up, you should feel refreshed. You should feel ready for the day. You shouldn't feel like you want to go right back and go under the covers and back to sleep. So you should feel like you're reset and recharged. And it's also important for people to have a regular sleep schedule. So, for example and I'm guilty of this, I'm still working on this myself of going to sleep at the same time every night and waking up at the same time every morning. 

40:05
Dr. Rudrani Banik
Because, again, migraine brains crave regularity. And when there's an irregular pattern, whether it be sleep or diet or stress or exercise, that's when people are more predisposed to migraine headaches. So try to go to bed at the same time every night, wake up at the same time every morning, and that's regardless of whether it's a weekday or weekend. It's harder when you're traveling across multiple time zones. But if it's possible to try to maintain some kind of regular sleep pattern even when you're traveling, it's really important. Also try to have your sleep environment be really dark, as dark as possible because again, people who are migraine prone are sensitive to lights. So for me when I was younger, I didn't really care about having any kind of blackout curtains, but now it's absolutely a must. I have to have those blackout curtains because even like a sliver of light coming in will prevent me from going to sleep easily or it may even wake me up too early. 

41:02
Dr. Rudrani Banik
If the sun's coming up super early, it may wake me up and then it'll disrupt my whole day. So just think about those small things as well. That's great. 

41:12
Jennifer Milner
And I will say I use a sleep mask because I have gotten to the point where I just want complete blackness when I'm trying to sleep. But it's so important and we always go, yeah, we know it's important, but we really need to pay more attention to that because it's something we do have control over. So at the risk of starting a completely separate podcast episode now, I just wanted to really briefly talk about sort of the connection between the eyes and migraines. We know a lot of people with hypermobility disorders can have Ocular issues, so maybe you could just speak so fast on that and we will have to have you back to dive into it deeper. 

41:57
Dr. Rudrani Banik
Sure, I would love to. I'd love to come back. I love sharing this information because I think a lot of people don't realize these connections and when they hear about it, they put it together like, oh, the light bulb goes off. I'm like, okay, so in terms of the eye and hypermobility or erlos danlos, there are many Ocular manifestations that can happen. There can be changes in the cornea leading to something called keratoconus. There can be changes in the retina. The retina can be very thin and it can lead to retinal issues like tears or detachments, even high myopia with other issues. So there's lots of different Ocular findings in hypermobility disorders really based off of collagen changes in collagen structural issues that can lead to then functional problems. So I would love to come back and delve really deeply into that because I think it's something people should be aware of some of those eye issues and symptoms that may occur in hypermobility disorders. 

42:57
Jennifer Milner
I've also noticed the connection between, especially for people with tension headaches or cervical genic headaches, the connection between how their eyes work and how they move and their headaches. And I do, when I do training with my dancers, sometimes I will do, like the sakads and things like that, and they can trigger headaches for them. And that lets me know we need to start working on, as crazy as it sounds imobility, to try to loosen up all that connective tissue at the back of the head. And when they are working on that regularly, then they get less headaches. So it's a really interesting connection to me. 

43:30
Dr. Rudrani Banik
Yeah, I actually have a patient who's a physician as well, and she has Erlos danlos many conditions in many issues throughout her life, but she developed trouble moving her eye and she felt this tightness in her eye socket, and every time she would move her eye in a particular direction, that would trigger pain. It would trigger pain down into her nose, into her cheekbone, and then eventually would just travel down her neck into one half of her body. So it was all connected. I think definitely it's important to consider all those connections between also the tissues in our eye socket with the rest of our body as well. So I'm so glad you brought that up. Absolutely. 

44:06
Jennifer Milner
So we've talked about migraines and headaches, and we talk about a lot of the things that people commonly use. There are a couple of things that we don't always think of, though. If you could speak really briefly on, there's a new set of devices out that are meant to stimulate the vagus nerve, if you could talk about that and also the use of Botox in treating migraines and headaches. 

44:28
Dr. Rudrani Banik
Yeah, I'm glad you brought this up because I know a lot of people do benefit from these modalities. So these are called neuromodulatory devices, and they basically are used topically. For example, cephaly is one of the devices. It's a device that goes across the forehead like this, and it's believed to modulate the nervous system through the vagus nerve. So that's one example of a device. There's other devices off the top of my head, I don't remember all the names because there's always new ones coming out, but there's one that people wear on their wrist. There's another one that goes on the neck. So there are various devices that are FDA approved for migraine that have this neuromodulatory mechanism of action. Now, you also mentioned Botox, so yes, Botox can be used for migraine. It is FDA approved for migraine. And basically there is a set regimen of how it's given. 

45:25
Dr. Rudrani Banik
So Botox for migraine is very different from other types of Botox. For example, cosmetic Botox, it's given in very specific locations at a very specific dose. So basically it's 165 units, which is quite a bit of Botox that's given here across the forehead, under the scalp, here in the temple area, and then down from the back of the head into the neck. So it's a lot of injections which are given just under the skin, and it's given every three months. And again. It's FDA approved. It can work for many people. But in my experience in my patient population, what I've seen is that for the patients in whom it works, they usually know within the first one or two rounds of Botox treatment. But if it hasn't had an effect within those first two rounds or maybe even three rounds, I tell patients it's probably not working for you, and if it's not working for you, stop it and let's go on to the next thing because why just keep taking it? 

46:35
Dr. Rudrani Banik
I've seen some patients who've been on Botox for three years. Every three months they're going in for their Botox shots, but it's not helping them. And so why continue something if it's not working? Try one thing at a time. If it's not working, if you've assessed it's not working, go on to the next thing. So that's my take on Botox. It's great when it works, but in my experience, it doesn't work for everyone, unfortunately. 

46:58
Dr. Linda Bluestein
Kind of like everything right? 

47:01
Jennifer Milner
That's exactly right. And it just goes talking about these two things and how they might work for people and might not work for people. It's just a great reminder that trying to treat your chronic headaches or migraines is something that should be a journey that you are on with a medical healthcare provider, not something you're trying to problem solve by yourself or see a doctor once and then try to get. 

47:23
Dr. Rudrani Banik
It all figured out. 

47:24
Jennifer Milner
So it's important to be with someone who is invested in being on this journey with you. 

47:29
Dr. Rudrani Banik
Absolutely, yes, it is a journey and it's a very steep uphill slope initially. But once you get there, once you figure out what regimen is going to work for you, whether it's only lifestyle and supplements or maybe and diet or maybe it's superimposed on that medications, once you figure it out, hopefully that will carry you through and improve your headache severity and frequency, but also your quality of life. That's really what we're talking about here, is your quality of life. And so find a provider that you feel comfortable with who can walk you through this journey. 

48:04
Dr. Linda Bluestein
And that's a perfect lead in to who can you see as a patient. If you're willing to share that, I think that would be helpful for some people who are thinking, oh man, I wish I had somebody who listened that well and could really work up my headaches. Obviously, some people can come see you quite easily and others probably not as easily. So are you willing to share about that a little bit? 

48:24
Dr. Rudrani Banik
Yeah, absolutely. So as I was saying earlier, there's really a dearth of headache specialists in the US. It's really hard to get an appointment. Sometimes it can take three or four months to get an appointment, a new patient appointment. So you can maybe see your primary care doctor, you can see a family medicine practitioner, or if you're lucky, you can get in to see a neurologist who specializes in headache. There are many platforms now that offer telemedicine visits, which is great. I also offer telemedicine visits for people who are in New York State, who attest to being in New York State. So there's lots of options now. So in the sense the pandemic has opened up some of these new pathways that we didn't really utilize before. So I think care is much more accessible now than it used to be, maybe two and a half, three years ago. 

49:12
Dr. Rudrani Banik
Absolutely. 

49:14
Jennifer Milner
This has been so incredibly informative. I've taken multiple pages of notes, and I can't wait for this episode to come out so our listeners can hear all that you have shared with us. Was there anything that we didn't get to that you wanted to make sure we covered? 

49:27
Dr. Rudrani Banik
I think we covered a lot. When we're talking about sleep, I was thinking about bringing up blue light and circadian rhythms, but I thought maybe that would be a whole other box that we're opening up. So we didn't talk that much about it. But it is something I always counsel my patients on. And nutrition. I'm a big advocate of a healthy diet for vision health as well as brain health. And I do have a book coming out soon that I just wanted to kind of just mention briefly. It's called beyond Carrots. Best Foods for Eye Health. A to Z. And it's getting the concept across that it's not just one particular food we need to eat to keep our eyes healthy or our bodies healthy. You have to have the whole spectrum. And this is also true for people who have any condition, including hypermobility disorders, is that you really need to nourish your body with a diversity of nutrients from various sources, mainly plants. 

50:22
Dr. Rudrani Banik
And so that's what my book is about. And if anyone's interested in ocular nutrition and how you can best support your eyes, please take a look at that. 

50:31
Dr. Linda Bluestein
That's exciting. 

50:33
Dr. Rudrani Banik
Thank you. 

50:34
Jennifer Milner
We'll make sure to put the title of that in our show Notes so that people can find that and be able to get to it. And the whole eating a full spectrum is so important. Our Bendy Bodies team member, Kristen Koskinen, who's our resident dietitian nutritionist, talks about that all the time. There's not just one miracle thing that's going to fix it. So it's not just carrots, right, for the full spectrum. Exactly. Well, so we'll have the book in our show Notes, but where can people find you? 

51:05
Dr. Rudrani Banik
So thank you for that. My website, which is my full name, WW Rudranibannockmd.com, and I'm also very active on social media, so I think we had connected through Instagram. So I'm on Instagram at Dr. Ronnie Bannock, and I also have several Facebook groups that your listeners may be interested in. One is called Envision Health, in which I share lots of tips about general eye health. And another is called Ion Migraine, where I share a lot of migraine tips. So if you do have migraine, please check that out. It's a private Facebook group and I'd be happy to welcome you into the community. Absolutely. 

51:41
Jennifer Milner
Excellent. That is great. And I bet you will have some new subscribers after this comes out. Well, you have been listening to Bendy Bodies with the Hypermobility MD. And our guest today, Dr. Rudrani Bannock, neuro, ophthalmologist and founder of Envision Health, New York City. Thank you so much, Dr. Bannock, for being here and sharing your knowledge with us. 

52:02
Dr. Rudrani Banik
Thank you. It was really a pleasure speaking with you both. 

52:05
Jennifer Milner
If you love what you learned, follow the Bendy Bodies podcast to avoid missing future episodes. Screenshot this Episode tagging us in your story so we can connect. Our website is WW bendybodies.org and follow us on Instagram at bendy. Underscore bodies. We love seeing your posts and stories, so please tag using Hashtag Bendy Buddies. Please leave a review and share the podcast to help us spread the word about hypermobility and associated conditions. This information is not intended to diagnose, treat, cure or prevent any disease. The information shared is for educational purposes only and is not a substitute for medical advice, diagnosis or treatment. Please refer to your local qualified health practitioner for all medical concerns. We will catch you next time on the Bendibodies Podcast.