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The Neurotransmitters: Clinical Neurology Education
Pediatric Headache Care with Dr. M. Ismail K. Yousaf
Join us for an insightful conversation with Dr. Yousaf on pediatric headache care. Discover how his journey from adult neurology to specializing in pediatric headaches is reshaping transition care, and the unique psychosocial and developmental factors that influence young patients.
Learn about the different ways migraine can present in children and how the management varies from adults. We also explore the critical importance of addressing trauma, psychiatric comorbidities, and sleep issues to ensure a smoother transition into adulthood for these patients.
Dr. Yousaf is also involved in Headache Disorders advocacy both nationally and internationally.
You can find him on Twitter/X at @ismail4fanty
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Hello and welcome back to the Neurotransmitters, your source for everything about clinical neurology. I'm very happy to have another guest today and we are talking about headache, but not just adult headache, like we have in the past, a mixture of pediatric and adult and all things in between. Would you care to introduce yourself?
Dr. M. Ismail K. Yousaf:Hey everybody, my name is Dr Yousaf. I am a headache fellow at UT Austin Dell Medical School and I am doing a subspecialization in pediatric headache. But I also see adult headache because I am an adult neurologist trained at University of Louisville, kentucky, where I did my four years, was chief resident and also did a mini-fellowship in clinical neurophysiology.
Dr. Michael Kentris:Excellent. Now, when you reached out to me when we were first talking, I was very curious because, as you said, you did an adult neurology program and now you're doing a pediatric headache fellowship. Now that is very unusual. What led you to that pathway?
Dr. M. Ismail K. Yousaf:Yeah, absolutely. I think when I was doing my neurology residency and I did a couple of months of child neurology rotation, I was clear that I want to do headache. It was something that really interested me. I wanted to work more on it and it has a very good overlap with mental health as well. So that really led me to a clear path. However, when I did those rotations, I saw a huge vacuum and the vacuum lied in the transition clinic. I had patients and adolescents coming 16, 17. And since there are very few adult headache providers as well maybe 700 plus board certified or fellowship people didn't know where to go.
Dr. M. Ismail K. Yousaf:The pathophysiology is kind of the same For headaches that's an edgeysiology is kind of the same for headaches that's an edge. The medications are kind of the same, though clinical data is derived from different age groups. But that really led me that if I want to do headache, I want to do both. I have my own kids and that gives me a little bit of sensitive portion because I want every kid to do strong, academically, athletically. That also led me to that portion Plus. When I saw kids in the clinic, I felt there was a huge need of counseling. I felt that I might be able to help them with that aspect as well, as they grow up in the adult side what to expect, how these diseases will act up where they have to lead themselves. So I think that transition might help the community as well, and that was my goal and that is my ambition as well.
Dr. Michael Kentris:No, those are great points and that's something I think we've seen. A lot of subspecialties in neurology I know in my own background with epilepsy. Those transition clinics or those transition stages can be pretty rocky in some situations and I was actually just talking with a pediatric epileptologist about that self-same thing just recently and it can be quite challenging. So it sounds like you're really looking to provide that lifelong spectrum of care.
Dr. M. Ismail K. Yousaf:Absolutely so. When a kid becomes 18, they stay with me, we're not leaving you, hopefully if they outgrow it.
Dr. Michael Kentris:Yeah well, yes, yeah, it sounds like you'll be in very high demand. But I'm curious Now. A lot of times we've talked on this show about how different types of headaches can present in the adult population, but I'm sure there are some idiosyncrasies in terms of how migraine or other headache disorders might present in the pediatric population. Both in the very top three. Presentation is pediatric headache.
Dr. M. Ismail K. Yousaf:So it's that common, though underfunded. Still. I hope we have more resources for that. And when they come in, before they come to the pediatric headache specialist, they have already tried a couple of medications. So that goes the same with the adult clinic as well. But what really differs from them is, I think, the psychosocial, economic status. That we really have to dig deep into that Trauma-enforced histories.
Dr. M. Ismail K. Yousaf:As we say that that the headache in kids, how I see it, is like the tip of the iceberg, I need to uncover the base as well. I really have to focus on my history and make sure there is no trauma. Child isolation, broken families are big another issue that really gives them not a great grasp of things, what is happening. And the other thing is that we need to understand that they're little humans, children, and their brain is still progressing, it's still developing, so they might not be able to interpret pain or associated symptoms as well as adults do. So we need to be really providing that care and also giving that repo that hey, we are here to take care of you and we need to talk more and more at the subconscious, subliminal level as well. So I think that really differs from adults as compared to kids. And as we go deeper and deeper, we realize that those psychosocial issues are really deriving those headaches, Although migraine is a genetic condition with more than like 171 genes that we know of.
Dr. Michael Kentris:So far but that predisposition from those factors we really need to work on to get a better result overall. A role does that play let's say you have a child with pediatric migraine or something else when we're looking at someone who comes from a home that is split versus one that isn't?
Dr. M. Ismail K. Yousaf:what kind of factors typically play into inability to get those under better control for the child? Absolutely, I think. Just to put it in perspective, in adults, the top two risk factors that could create episodic and chronic is our depression and obesity. In kids, psychiatric comorbidities play a huge role, huge role, especially anxiety and depression being top two of them, and another, if I have to add, which I was surprised, is actually obstructive sleep apnea.
Dr. Michael Kentris:Oh, that is interesting.
Dr. M. Ismail K. Yousaf:Yeah, it's more common than I thought. So if those are undiagnosed and we are treating the migraine, we might not be hitting the root really. That's why we have all these scales MEDAS scale and it is very much now a kind of standard that we have to make sure that depression anxiety skills are in place when we see patients, like for every patient, every new patient. It's that important. Let me give you another interesting study fact. It was in 2003 by Dr Powers and Dr Hershey.
Dr. M. Ismail K. Yousaf:They did a great study on quality of life of kids that live with headaches and this will stir a lot of people that the quality of life of a kid living with episodic, chronic both were in the study was not it was at par with a kid living with cancer, rheumatoid arthritis, and that really shakes up the whole system that we really need to treat them well. We really need to see what are the factors which are really affecting them and the score which came up was kind of the same, except there was some far different associations. But school absenteeism is another one, academic performance, sleep. And which really bothers me the most are the relations with friends, because those friends the school friends everybody knows are for life. They remain with you whatever it is, and if you are not having that rep with friends at a very early age, you're losing people, so that really bothers me as well it kind of ties into that social isolation leading to depression.
Dr. Michael Kentris:So it kind of all just snowballs down from there yeah and I am curious, you know, a lot of times I know children are referred to neurology clinics for, like you know, inattentiveness or poor performance in school or things like that. So kind of flipping it around, what percentage if you just had your own anecdotal experience do we see that children who are having these performance issues in school or behavioral changes at home that are kind of unexplained, that we find out, oh, they're actually having migraine? They just don't have the language to describe what they're experiencing to their parents or caregivers.
Dr. M. Ismail K. Yousaf:That's a very good question and you know I'm glad you asked that because when the referral comes to the headache clinic, they've already been to PCP, maybe to a GI specialist as well, because of abdominal pain which could be functional, or abdominal migraine. And when they come to us and we're like, oh, this is, you probably are having migraine and we look into more into that, so I say in my experience it's almost 30 to 50%. Wow.
Dr. Michael Kentris:Wow, that's a lot.
Dr. M. Ismail K. Yousaf:That when they have been rerouted for long and then the headache has been underdiagnosed or being under, you know, not being taken that seriously as much as it is, because, see, sinus headache and tension type headache are other prime. You know these are orders which could be misdiagnosed, right um, and in some intention headache you can, by the ichth you can have one of photosensitivity or phonophobia, so that's another one. But how I see is that if a headache is being aggravated by routine, any activity like climbing stairs, walking, it's probably migraine. We need to work more on it. We need to rule that out. The other interesting part of this question is that when they hear the diagnosis, the migraine, then when the parents state that yeah, at this age I used to have those headaches as well, the light bulb goes off.
Dr. M. Ismail K. Yousaf:Yeah, exactly, and they're like we wish we knew how to treat at that point. Because then it's like a deja vu and they're like if things you know got better for us, we maybe we had also academically pursued better things athletically. Um, and then you tell them that hey, if one parent has migraine, there is a 50 chance that the kid will have migraine. If two parents have, there's like a 75 chance. It's a genetic condition, with almost two-thirds of children being diagnosed with migraine have a family history of migraine. So that is that high.
Dr. Michael Kentris:That is, yeah, that is a very important historical fact and I know, even in adults. I ask still people in their 30s and 40s like, do your parents have migraines or any of your siblings? Because it is such a useful piece of information in terms of coming to a diagnosis.
Dr. M. Ismail K. Yousaf:Another piece to the puzzle is the periodic syndromes that are associated with migraine, which include abdominal migraine, cyclic vomiting, proxismal torticollis. And another interesting fact by a study shows that if a kid has abdominal migraine, there's a 70% chance that he might develop migraine.
Dr. Michael Kentris:Now for those who might not be as familiar, could you talk just a little bit about what abdominal migraine is?
Dr. M. Ismail K. Yousaf:Exactly so. These are recurrent abdominal pain attacks, not including headache, and they're more like peri-embolic, mid-embolic, dull and sore, moderate to severe intensity, and they can have migraine features to them. So this is another thing which kind of goes misdiagnosed A lot of times. A lot of GI workup has been done, can be associated with nausea as well, but what really works out well for them is the treatment for migraine, the way we treat migraine. And when a lot of people come to us parents, especially that when he was like eight or nine, he will have these really bad abdominal pain attacks but we did not know what to do. Bad abdominal pain attacks, but we did not know what to do. And then, interestingly, when you go back as well, you will say, hey, he had infant colic as well.
Dr. M. Ismail K. Yousaf:So that's another associated and with an infant colic. The data so far shows that there's a three to four chance that you will develop migraine in the future and 20% of infants do have infant colic. That's another data point. So we really work on data points that how the progression is and we have to make sure our history is really up to the mark to know what's going on.
Dr. Michael Kentris:Yeah right, it's one of those things. 90% of the diagnosis is going to be in the story before you do any testing. Now we were talking a little bit about different kind of migranous phenomena before we hit record and I was wondering if there are any kind of things. I know there's several things that can show up more in the pediatric population than the adult, and some of them can be quite bizarre. But what are some of the more common or more notable things that people should keep on their radar? If someone's coming in with unusual symptoms, that should point them maybe towards considering migraine.
Dr. M. Ismail K. Yousaf:Right, that's a great point. I think we'll discuss this as a primary and secondary headache, why we should be looking for a secondary headache as well, and what are the symptoms or red flags? I'll say that that we have to keep in mind when we are looking into the history. So, obviously, when a parent comes in with with a kid with a headache, the first apprehension is and I I might have to say it loud is is that a tumor that is causing those headaches? So every parent, like everybody, is really apprehensive about it. So that's where, first of all, you have to make a very good formal diagnosis Is this a primary headache disorder or a secondary? For that history, history, history, look for the red flags. Snoop is a good one, but to be on the fingertips, make sure there is. The bigger ones are that patient is not waking in the middle of the night. It's not having vomiting in the middle of the night. The headache is not making the patient wake in the middle of the night. The key point is that if the patient is sleeping with a headache and waking in the middle of the night, it might be the same headache which is causing it. So that's another thing that you have to keep in mind. Then, positional component, just to make sure there is no component of the posterior fossa or you know anything that is increasing the intracranial pressure. Carry one is another one which again comes in positional if the patient stand up, start having dizziness or vertigo. You have to make sure that's not the one. Remember when a patient sleeps and he and he is telling you about morning, you have to make sure that's not the one. Remember when a patient sleeps and he is telling you about morning headaches, just to make sure there's no increased intracranial pressure, because when you lie down the pressure builds up and when you wake up with a headache in the morning it's probably you might want to make sure with a fundoscopy we are not having any papilledema around that. If a patient stands up and if he's dizzy and has headaches, then you have to make sure intracranial hypotension is being ruled out. And another one is carry one again that needs to be ruled out. So these are all like stringent questions that we need to ask them.
Dr. M. Ismail K. Yousaf:I'll give you one interesting example which we just talked about, like different scenarios that can cause these headache types. So I have a patient who came in and the mother was like I don't know what's going on. He at night, when I'm reading a storybook, tells my mom your head becomes small and small. I don't know exactly how to tell about it. And I asked her how many times? And she's like it happens like once or twice a week now.
Dr. M. Ismail K. Yousaf:And when I went deeper into the history if there's anything else that is different she's like yeah, he goes to karate classes and for some reason he's just throwing punches in the air and kicking in the air, although the person he has to grapple is like at least two to three feet behind, and it doesn't make sense. But it lasts for like 10-15 seconds and then it goes back to normal. Then he told me that, uh, dr you, so when I, when I'm walking, sometimes I feel the earth is curving up and I can walk on the wall as well, and I was like that's classic alice in wonderland syndrome. What's going?
Dr. Michael Kentris:on there.
Dr. M. Ismail K. Yousaf:We need to, you know, rule out more things. Um, and infrequent headache was in those episodes as well. So headache was a tiny component. Because of that they came in. But then when you go into the history, there was so much going on and when such things come into play, you really want to rule out tumor, infection, seizures, anything that is out of the ordinary. So out of the ordinary symptoms need out of the ordinary workup as well. That's how I put it. Ordinary symptoms need out-of-the-ordinary workup as well.
Dr. Michael Kentris:That's how I put it. I always find that, personally, I struggle with patients who come in with some of these strange phenomena, like the Alice in Wonderland with the visual distortions or abdominal-type symptoms or even vestibular things that might be migraine, particularly when they don't have headache associated with the actual episode. How do you go about differentiating a migrainous phenomenon versus, say, some other kind of as you said, like a secondary disorder that might be related to more concerning pathology? Dr Justin Marchegiani.
Dr. M. Ismail K. Yousaf:That's a good question. First, basically, again, the history itself and we really look for those pertinent points photosensitivity, phonophobia, osmophobia, movement sensitivity. A great example is a patient who comes who might be on autism spectrum, has developmental delays like one of my patients. He's non-verbal, he's young, he's like six or seven. I don't have a lot of history but a pcp thought that hey, he might be having migraine. Why?
Dr. M. Ismail K. Yousaf:because he recently started wearing glasses outside interesting so these are some clues that you might look after it. Um, so when I asked mom, why mom? What's going on? What is the whole event that happens during that? She's like he starts tapping on his head like this and then he doesn't look at light and he wears glasses whenever he goes outside. The other thing is the change in the behavior of the patient. That is something that really gives us clues, like if the patient stopped eating, for that it means he's having probably anorexia, and then that could be nausea itself, that he's not eating. Another clue that is that he just goes towards and turns off the light and snuggles into mom. This is another migraine phenomenon. It means that he's photosensitive. Another thing that I've noticed is that kids start whenever they hear loud sounds. They start making loud sounds Because they're like just stop it, we can't the phonophobia is overwhelming them.
Dr. M. Ismail K. Yousaf:They don't know how to convey it. So really, the history and the clues give those referrals, but it's challenging overall to differentiate migraine, migraineous phenomena, with other symptoms. Like we talked about GI symptoms, most of my patients with abdominal migraine have been done a lot of GI workup, including some of them had endoscopy, a lot of GI workup, including some of them had endoscopy. I mean, it's that challenging just to make sure that it's not something that is GI related. So I think the workup, the thorough workup, is as natural to rule out things, and it should be as well, so you're not missing. And sometimes it's as simple as an anemia, which might sound as anemia. But to rule out anemia and to go towards anemia requires a lot of work because these are again phenomena which you can't see, but only through lab testing. Um, and that's why another thing important in the history is the social history and sleep history, which is a a very, very important point. I can't stress more.
Dr. M. Ismail K. Yousaf:In sleep history what we like to ask is what time do you go to bed, what time do you wake up and what's the sleep latency? How long does it take you to sleep? If a patient says more than 30 minutes or 25 minutes, you should like the bulb should be lit up. It's like what's going on? Five minutes, you should like the bulb should be lit up. It's like what's going on? Are you having a lot of screen time? Or are you thinking Some patients will tell you, surprisingly no, my legs hurt. I just feel like there's something going on in my legs. And then you're like is it restless leg syndrome? Do I need to do an iron pal? Is that really deriving? Some patients then tell you that, hey, I can sleep, but I wake multiple times at night. And then you're like is headache waking you up? It's like no, I really have to go to pee. I can't control my pee.
Dr. M. Ismail K. Yousaf:Sometimes I wet my bed as well, so that gives you another direction, then the most commonly I hear is snoring, which has not really been taken care of or asked about a lot because most kids sleep in their own rooms. And then, when I asked about snoring specifically, this is the first time but he does snore and then obviously the next question does he gasp or wakes up in the middle of the night due to that, or wakes up in the middle of the night due to that? And when that happens, obviously then you're like okay, we need to ask more about OSA fatigue in the morning. And tonsillar hypertrophy is another big one that in kids might not be seen in adults, that we need to rule out to make sure they're not having a lot of OSA.
Dr. Michael Kentris:I know there's been in the news over the last few years more reports of increasing childhood obesity. Do you think that factors a lot into kind of increasing risk for different types of headache disorders as well?
Dr. M. Ismail K. Yousaf:Yes, yes, especially, we are always worried about pseudotumor, about a pseudotumor, that's something more than obesity. It's like the weight gain in short time that we really are concerned about as well when mom says that, hey, in six months he gets 20 pounds and he's starting having these headaches. It could be atypical, like in male as well. So that's where we our red flags come up and we ask all those questions. But definitely, habits eating habit is something we promote as well. Do not skip your breakfast One. We don't really.
Dr. M. Ismail K. Yousaf:I think we should talk a lot more about saturated food, which we don't really do. But what we talk about is hydration. Our rule of thumb kind of, is one ounce per kilogram, that you should be drinking that much water. Migraine is extremely sensitive to dehydration as a trigger, so we talk about that, which brings to me an interesting point that during summer we are mentally prepared that more patients are going to come. And an interesting point that during summer we are mentally prepared that more patients are going to come Because dehydration, outside activity, that leads to these phenomenas. And I kind of have started telling my parents that, hey, things are good. It's January, february, march, it's outside, it's good. But let's take it as a win, but with a grain of salt, because we want to continue these habits in the summer as well, or maybe better habits. Both schools have their baseball season, volleyball season. That starts kicking around that time and then they really trigger up the migraine over there.
Dr. Michael Kentris:That's a great point. Obviously, hydration very important in so many aspects of health, but I think you mentioned the sports aspect too. Do you find, especially for the adolescent patients, that when they go from their off-season for their sport of choice to the on-season, do you see typically an increase in headache frequency in those who may have a pre-existing diagnosis?
Dr. M. Ismail K. Yousaf:Yes, we definitely do, and that's where not only counseling of kid is important. Counseling of parent is very important. To set the expectations that these headaches could work, especially with athletic kids, that hey, there's a big chance that these headaches might worsen, so we need a good cup of water all the time. We need a plan in place with the school as well, especially with the coaches, that hey, we have pre-existing diagnosis which might get worse with time, especially dehydration. So we have to make sure that we have all the accommodations in place.
Dr. M. Ismail K. Yousaf:Secondly, another thing that has helped my patients is 504 plan in school, which is basically an accommodation, but that if the migraine happens, they can go to the nurse. They have the medications in place. They should rest for 30 minutes in a dark room, because the ultimate goal for both athletes and people who go to school is that they should not come back from school to home. Their academics should not suffer. So in place in house. Those accommodations are super important because school absenteeism leads to a lot of other problems Peer pressure, domestic pressure and more migraine. To start with, another thing, and just to pearl in athletes we try to avoid propranolol. That's another one that makes sense. That's something as a first line. We don't give it. We ask them that, hey, when your season is coming, are you an athlete?
Dr. Michael Kentris:We haven't touched much on the pharmacologic. I've certainly been talking a lot about the non-pharmacologic aspect of treatment. For instance in the adult world, the CGRP class of medications, ben you know kind of the hot stuff for the last you know five, seven years or so. How much of that is trickling into the pediatric headache literature and management practice in your experience.
Dr. M. Ismail K. Yousaf:I'll change the word from crickling to brewing. Oh, that's how I want to. Because I'm a big, I have to be an advocate for CGRPs in kids as well. So, you see, they're more recognized in above 18. That's where the FDA comes in, right? But my question is what happens at 18 that suddenly, from 17 to 18, the turn on button happens? That it's, you know, the pathophysiology is still. We just have to make sure the safety and tolerability. And that's where a lot of clinical trials I'm also involved in some. We are doing our trials, both preventive and acute Very excited, especially after the American Headache Society policy that came out, which is that anti-CGRP should be used as first line.
Dr. M. Ismail K. Yousaf:So that's, yeah, it just came out like two months ago. That's very exciting. That was very exciting news. Yeah, I saw that we are seeing amazing growth. See, the evolution of headache itself is like just like 5,000, 6,000 years ago the headache was thought to be due to a demon tau and they used to do trepanations to make sure the demon goes out of the head. And now we have, like once in a month, shot which can also be affiliated with Botox. And just recently, fermanizumab and Botox had a great trial published in cephalalgia, which showed more, better, headache freedom days. So we are going in the right direction. I want my kids and adolescents to go into that direction. We have to fill the train in the same direction. Having said that, we do—.
Dr. Michael Kentris:Not advocating for the trepanation as much anymore.
Dr. M. Ismail K. Yousaf:No, no, no, we don't want that. So we do use off-label, like most in medicine. That happens and we see good results. We see, sometimes we have to change medication as well. We have to use the same anti-CZR, like G-pans. We have Remagipan, rujipan, so we can change them as needed if we do not have great results. But really that's the future, that's the present.
Dr. M. Ismail K. Yousaf:We have to advocate for them, for kids as well. Once we have more enough data, which I'm pretty sure we are working on it, I'll tell you one interesting fact that when you have more options, especially these with less side effects, there's a pragmatic approach that comes on for parents and, um, the kids, and then they seek the responsibility and autonomy to choose from them because they know that's more safe, tolerable, that 100 helps the headaches as well, because you are not just going by the guidelines. Hey, top one to fail. Now we're going to give you that, we're not directing you. When we put the options in front of them and ask them and give them the responsibility and autonomy as well, we have to choose one, we have to work with it. That really helps overall and that's that's my approach as well.
Dr. Michael Kentris:That's excellent, and we've been talking about advocacy, but you're also involved with some more official advocacy type work as well, if you'd care to talk about that at all.
Dr. M. Ismail K. Yousaf:Absolutely, and thank you for asking that. So I am involved in both at national level and international level Thanks to American Headache Society. I was this year's American Headache Society Advocate Scholar and I went to Headache on the Hill by the amazing ASDA, which do a fantastic job as an alliance, putting everybody together and advocate for headache, migraine, all type of headaches. Really. We go to Capitol Hill, Washington, where we talk to US Congress, respective Congress and Senate members and their offices. This year we were talking about three bills. We were talking about NIH Safety sorry, NIH Inclusivity Act, Safe Step Act and then Excellence, EAS Center for Headaches, which the bill was passed as well. We are very excited about that and why these bills are so important because they affect me, you and all the specialities really, um, so, those three acts hopefully we have more uh people signing them and then I am involved with gAC, which is Global Patient Advocacy Coalition, which has 24 coalition partners, including AN, EN, AHS, and I am trying to do global outreach, especially for developing countries, to spread advocacy, making workplaces safe for people with migraine, making schools, colleges, universities.
Dr. M. Ismail K. Yousaf:So my first endeavor is in my home country, in Pakistan, in June, inshallah, and I'll be going there and talking to media and places and spreading as much as I can. That's very exciting and I really invite everybody to come to Advocacy Advocacy in clinic. You can help 24, 20, 15 patients a day. With Advocacy you can help maybe more than a million in one day. So that's how I put it.
Dr. Michael Kentris:Excellent and that is a great point. We've kind of skirted around the edge of this where we've talked about how frequent headache is. Now I know in the adult literature it's one of the top probably three or five reasons for missed work days. I assume probably in PEDS it's one of the more common reasons for missed school days as well.
Dr. M. Ismail K. Yousaf:Absolutely so. Headache is the second leading cause of disability years globally. It's that important. And with kids, one of the major questions, which also helps us to know the severity of the headaches, is how many days have you missed in a month? And we get different answers. I'll tell you one thing, though I've seen kids power-throwing headaches better than adults.
Dr. Michael Kentris:They are more resilient in many ways.
Dr. M. Ismail K. Yousaf:Yeah, they are more resilient. So that number might not be the best number or accurate number, but if they tell me, hey, two to three days a month, I won't be surprised, because two to three days a month mean really, really bad headaches. And that gives my overall plan and approach how to really help people with two to three headaches, because we are not looking for the magic number four, that if the magic number four happens, bad days and that's when we start a preventive. We are looking for really bad days which are affecting the school days as well. If there are two or three, I think that's enough data for me as well, because there might be.
Dr. Michael Kentris:Yeah, to yeah. Is that to start a preventive or to make sure that we have a rescue plan in place?
Dr. M. Ismail K. Yousaf:both, both. I mean if they are missing three school days in a month, um, then you have to dig deeper.
Dr. M. Ismail K. Yousaf:It means the less where a moderate headaches might be happening as well excellent point, yeah because then, if it's kids, the severe ones will be, might be associated with moderate ones, and then there might be mild ones, so there are more headache days than which are being represented in the talk. So that really helps me to know what's going on and, with kids, the prevention. We love nutraceuticals. I think they do a great job.
Dr. M. Ismail K. Yousaf:Magnesium it's classified as level one by EN 2019 guidelines, which means less risk of bias, so we kind of taper them up. As for the weight, we like to go up to 400 milligrams if the weight is above 40 kilograms or 30 kilograms, with the caveat that it can cause loose stools or diarrhea, right, right, if the weight is above 40 milligrams, 40 kilograms or 30 kilograms, um, with with the that it can cause loose stools or diarrhea, right, um? And then the good thing about magnesium is that it has like a calming property to it, and then it also affects the nmd receptors, um, which overall helps to sleep them better, gives them less anxiety as well, if I have to really overextend it. So magnesium is like the first line. Then we have coenzyme q, which less anxiety as well, if I have to really overextend it. So magnesium is like the first line. Then we have coenzyme Q, which works great as well, and the third is riboflavin V2. So I think all these three, we see how they work on, act on and then we go from there.
Dr. Michael Kentris:Excellent. No, those are all great. I know there's plenty of people in the adult world who feel the same way. It's like I don't really want to go on a pill. It's like how about some vitamins Absolutely and sometimes that can be an easier sell for someone to see if they benefit from it.
Dr. M. Ismail K. Yousaf:And another interesting thing which I'm glad has come, especially for kids, is the neuromodulation devices like REN or non-invasive vagus.
Dr. M. Ismail K. Yousaf:So why they are important as well, especially the REN or motor electro, is that they give the autonomy to the patient. So REN device is kind of where you just stick on your arm for 45 minutes every second day, as a preventive or as an acute as well for 45 minutes, and it can come underive or as an acute as well for 45 minutes, and it can come under the, under your shirt as well, and you can just do your work while you're getting a preventive treatment. You can play, you can walk, you can talk, and my results have been good so far with it as well. Um, the other thing about these devices is that, um, although they're still getting approved by insurance and they're kind of expensive, still I feel strongly about it is that the patient itself, with a lot of comorbidities, can be safely treated with it In adults as well. The same goes for adults as well. Good point. So this gives me more range of choices, so that really works well as well.
Dr. Michael Kentris:So this might be one of my takeaways from our conversation today is that insurance coverage is causing a gross loss of GDP to the country overall, due to their emphasis on escalation therapy and non-coverage of effective treatments.
Dr. M. Ismail K. Yousaf:Yeah, yeah, that's where one of our safety acts, safe step act, is as well, which is basically we are advocating hey, if we prescribe a drug and insurance prescribes a drug, it says they will first fail this drug and then we go to the second. We're not doing benefit to the patient, right, we're not doing benefit to the patient. We really want to make sure the patient gets the best treatment, because I'm using all my clinical acumen, all my med school, into one place and that's why the patient is here to get the best treatment, best diagnosis. But we are really reinventing the wheel that we are saying, nah, let's try this first, fail first, and then we go from there.
Dr. Michael Kentris:Yeah, it's very frustrating, uh, to get those denials from insurance for what you yeah, after much deliberation and thought and conversation and shared decision making, have decided is the best course forward. Well, let's just tack on another 30 minutes of frustrating paperwork to that that is true.
Dr. M. Ismail K. Yousaf:That is true. Um, one point I missed on neuromodulation devices, and I will talk to all my supervisors, and my patients with comorbidities like pots especially do well on them. The pot symptoms get better as well. That's very interesting. Um, I think more research has to be done. I talked to some of the leaders in headache about it and they said it's kind of the same pathways which we are really treating through those. So so people who are listening, I think patients with POTS and bad headaches do think of neuromodulation devices, especially Ariane with them.
Dr. Michael Kentris:I know, and some of the patients that I treat, I almost don't even consider neuromodulation because I know their financial situation is a little tight and insurance is not going to cover it for the vast majority of them I think pretty much anyone who's outside the VA in the adult world and so it can be challenging when we know that there might be this option out there. But if they have to shell out several thousand dollars it might as well be on the moon.
Dr. M. Ismail K. Yousaf:Yeah, I totally agree. Agree. Our job is to be a part of a system which which has more accessibility, not more jumping hurdles to it right. We have patients which come from 70 miles, 60 miles, 80 miles, so if they come here just to hear a denial, after two hours they leave the office, or three hours, we're not doing any service to them. They might not come the next time.
Dr. Michael Kentris:Right, right, so we've talked a little bit about all these issues, as you said, the entire biopsychosocial model. To an extent, I think we've touched on a lot of the corners of that psychosocial model. To an extent, I think we've touched on a lot of the corners of that. So we've talked about the institutional aspects. But there's also some other stigma that comes along. We've talked about some of the isolation that can happen with children, the potential loss of income in the adult world. What other kinds of stigma do you find a lot that people may be facing, especially in the pediatric, adolescent world, whether that's from their schools, the institutions or even their own family?
Dr. M. Ismail K. Yousaf:That's a great question. I think the inclusivity and equality is another issue. There have been studies in which they show that the Q treatment might be more prevalent or given to white kids as compared to, you know, of different colors. That's another stigma that we need to talk more about and that, again, is one of the bills which we talked about is NIH inclusivity bill. Why, again, it's important is that we are requesting and asking that more people of different colors and ethnicities are part of that NIH trials, so they can come in and we have more data on it. Honestly, we don't have data on a lot of. We don't have data on genders or ethnicities in different ways. One interesting example it's a different way to put it, but interesting example was oximeter during COVID days, you know. So oximeter has not been tried well in people with different color, so like brown color or black. So basically the pigmentation might be overestimating or underestimating the oxygen saturation and that's what was happening. It's a great point. Um, so it was giving like plus four or minus 4%.
Dr. Michael Kentris:Which that can be a big deal sometimes.
Dr. M. Ismail K. Yousaf:I mean, yeah, from 96 to 92, 92 to 88. So that model kind of resonates in headache population as well, that different gender ethnicities might not be coming up. Because they might have this, we might not be getting those adequate treatment options or we might be taken differently when we go to the office. So that's one. The second thing is that parents themselves sometimes think that this is a headache and it can be treated by over-the-counter medication. Or he's malingering or it's functional and they might put different words to it. And when it gets really chronic that they see a school report coming out that he's not performing well, then they come in and then it might be an acute chronic problem. So I think that responsibility on parents' part and that's why awareness is so important also comes in In adults. I would tell you, the stigma lies that are apprehension lies what if it's something sinister? Because they have more approach to google or they have, and sometimes they just want to close their eyes and don't want to come.
Dr. Michael Kentris:It's like we'll see what happens I know I've been guilty of that myself and you know, a lot of times this happens to doctors yes, I'm sure we're some of the worst, or?
Dr. M. Ismail K. Yousaf:physicians or health providers. They're the worst patients, um, so there are a couple of points that they converge at the same point that you need to see a physician for expertise and see, because, again, migraine is not curable, we don't have have cure to it, but it's treatable. Our job is to make sure that, first three months, there's a 50% reduction in your headache, which will resonate in the quality of life. Setting the stage is very important here, and once you see a change in the quality of life, it might be addictive. That's how we put it. Hey, I'm feeling better, I'm doing better, I'm sleeping better, I can do more work, I'm aiming high. Hope is a dangerous word, but sometimes you have to give these factual statements to them so they are more compliant on their medication, they're working towards it and they have the motivation for it.
Dr. Michael Kentris:So that's counter stigma, how I put it Something I see a lot in young adults, with that exact situation where you've started a treatment plan, things are going well, they're doing great, and then six months to a year later, all of a sudden they get worse again and you find out they stopped doing what got them there in the first place. They stopped their medications or they picked up other bad habits. Their medications, or you know they picked up other bad habits and it's like you know. Then you have to so in the, in the child population.
Dr. M. Ismail K. Yousaf:I think this is fairly common in adolescence as well, but I was just curious what your experience has been I think with um, I would say less than adults, um, because they have a supervisor named called peter on them, so they, they kind of do a good job on that on them, so they, they kind of do a good job on that um. And then I feel I'm gonna say a big word here, but I feel that, um, the kids are more, adolescents, are more honest as compared to adults to themselves that's, that's a fair statement.
Dr. Michael Kentris:I would say yeah, yeah.
Dr. M. Ismail K. Yousaf:So they're more honest, they want to do well. It's a competitive as compared to like 10, 15 years. It's a pretty competitive world out there. So they want to make sure they really believe that body is their temple kind of thing and they have to take care of that. So, like I'm in Austin right now, it's like the new hub for software engineers and you know it's Silicon Valley and brewing.
Dr. M. Ismail K. Yousaf:So over here we see a lot of adults who are like software engineers and they have to work all night or work from home. So they are very cognizant that their work is getting affected by this early 20s. So they take care well of themselves and without any like a lot of delay, they come to you that hey, I started having headache two months ago or one month ago as compared to adults. That hey, I started having a headache two months ago or one month ago as compared to adults who will come. I've been dealing with eight months. I've been taking a lot of NSAIDs. I've been taking maybe an opioid as well from a friend and it's not working well for me. And then you start going into their history and you'll realize I've tried this, I've tried this, I've tried this, but you don't have any good you know good documentation on that? Yeah, so that's a problem with adults.
Dr. Michael Kentris:I will say I'll be guilty about it, they tend to get themselves into a little more trouble than the kids do.
Dr. M. Ismail K. Yousaf:Right, right, and I'm sure I mean even in epilepsy. Sometimes you will hear about patients who've had these episodes, sometimes that they might not report it.
Dr. Michael Kentris:Oh yeah, patients who had these episodes, sometimes that they might not report it, oh yeah, um so. So since you mentioned epilepsy, one one thing we were chatting a little bit about was the, the phenomenon of microlepsy. Um yeah, now this is a, even in neurology, I think, a bit of an unutilized, under studied phenomenon. But right, uh, just kind of a brief background definition, if you would Just kind of a brief background definition, if you would?
Dr. M. Ismail K. Yousaf:Absolutely so. I totally agree. It's not used that often, it's not recognized as well, but it's something that my supervisors, like Dr Samantha Irvin and Dr Pavit I've seen them use the word and that's how I got cognizant about it as well, because if a patient comes and he says, hey, I'm starting having these atypical symptoms in which I see flashes of light, right like an aura symptom, but I see with colors, I also see distortion of objects and with I have after that I have really intense pain but then my head becomes foggy. I have to. Really I don't know what's going on and I lose time. That doesn't sound really migraine to me. I mean, there are some aspects to it with an aura, but losing time, foggy brain and then taking another two to three hours to get back to myself, I mean the prodrome is there in migraine. You can have fatigue, but amnesia coming along. It really should make you think about post-tectal headaches versus my microlepsy oxbow. So in these patients I have a very low threshold to rule out microlepsy and and get an EEG.
Dr. Michael Kentris:It's really challenging because we know that, for someone who has focal-aware seizures, the sensitivity of EEG can be quite poor.
Dr. M. Ismail K. Yousaf:Right, I totally agree, and that's why I have patients where I went from routine to sleep-deprived to EMU. I really had to escalate slowly right to find something because, as you said, the sensitivity is low. But somehow or the other, when I ever talked, epileptology is like this this discharge looks a little concerning, right. We need to dig more into that because I have to be cognizant that epilepsy drugs might be a long-term commitment. So before starting that, if the symptoms are not that grave, I have to make sure that I'm doing my homework. So I don't shy away from testing in these instances, because if I get that right, that's more benefit than I get it wrong or leave it as it is. Because again, again, the neurologist appointment you might not get for three to four or six months right. So I have to make sure that I'm doing my work and I'll try my best to justify in my notes.
Dr. Michael Kentris:Insurance doesn't deny it right, like he's here for a headache. Why are you wearing all these egs? Exactly, exactly but I mean pathophysiologically, there is some reasonable mechanism. Right, we have the spreading cortical depression with migraine, absolutely Obviously. We know cortical hyperactivity is something we see with epilepsy and then like a postictal suppression. So why couldn't they look similar theoretically?
Dr. M. Ismail K. Yousaf:Exactly, and that's what made me think more about migraine lepsi, because if the CSD is what we think is deriving the aura and the migraine itself, it could be deriving the seizures itself as well. So there is an overlap and again, the threshold is low to make sure that because, see, with migraine drugs you can't treat seizures. With seizure drugs you might be treating some of the headaches, some of them.
Dr. Michael Kentris:Yeah yeah, drugs. You might be treating some of the headaches.
Dr. M. Ismail K. Yousaf:Right, some of them, yeah, yeah, exactly. It could be worse, but it's better to find the answer or be in the pursuit of an answer quicker than later. Just again, you never know One of the parents comes in and he says yeah, when I was in my 20s I had these symptoms, but I wish I had the diagnosis before I became vocally generalized.
Dr. Michael Kentris:Yeah, there's definitely all these borderland types of syndromes where it's like well, is this a migraine, is this a seizure? I just had a conversation about amyloid spells and seizures recently.
Dr. M. Ismail K. Yousaf:Yeah, that was very fascinating, and seizures recently and it's like all these, yeah, that was very fascinating.
Dr. Michael Kentris:There's all these things that you know it's all related, right? There's only so many ways the brain can manifest these kind of epiphenomena to our sensorium, so it's just fascinating. You get these convergence of different phenomena presenting in very similar ways from perhaps markedly different underlying causes 100% agreed.
Dr. M. Ismail K. Yousaf:I mean, I tell my friends who are very interested in neurosciences I say that as much of a powerhouse brain is, with 10 trillion nerves in it, it's kind of a little bit of a dumb existence of it as well, because it doesn't know when to ask for help. Brain doesn't know. It's a brain right. So that really, um. And then another good example which I heard from one of my supervisors is that hey, what's the natural phenomena of skin if it gets injured, it's that it will swell or it will bruise. Brain doesn't have a natural phenomena. When it gets stressed, it can give you a ray of symptoms, and that's why neurosciences is so complex and challenging at times, especially epilepsy, um, that you really have to dig out what symptoms you might get.
Dr. Michael Kentris:Yeah, just an angry bowl of pudding up there, I agree. Now, obviously, it seems like you derive a lot of satisfaction from helping these patients getting quality of life improved across the entire spectrum of the lifetime. What's your, beyond just those meager pieces? What is your pitch for people who might be considering going into headache medicine?
Dr. M. Ismail K. Yousaf:Thank you for asking that. So a lot of doctors look for satisfaction in the results and they think with headache you might not not get results and, if I may dare say that, headache might be a stigma, neurologist as well. Like seeing headache patients, I've I've seen that that they're not really excited about it definitely is. I can assure you you'll see results. I'll assure you people will be full of gratitude because you helped them. The most common comment you might hear from people who you really are able to help is that, due to better treatment, our whole household has changed. We are better as a home, as a family, and there's not once I've heard that it's like now we are looking for vacation. Now we are looking for vacation. Now we are looking to for better, you know, ambitions for our kids. So you're not helping one person, you're helping a lot of people. Then, luckily, we're not in the era of trepanations anymore, we are in the era of ccrps. So since 2018 we're, we have better options and headache is really evidence and research-based. If you are looking for both, this is the way forward. We have ever-newcoming research, researches every day, almost every day. Cephalalgia headache is doing a great job, which kind of is interesting for our headache boards because there's so much going on that we have to read a lot as well.
Dr. M. Ismail K. Yousaf:But if you want both clinical and research acumen, the way forward it is, and the other thing is that it's a great practice. You can do outpatient all year. You can really fabricate your practice the way you like. You want to do procedures. We have nerve blocks, we have Botox, with great results as well. The satisfaction rate is good as well. And then the patient population which you see is some population which be only be treated by you. That's another interesting part of it that they might be coming from different referrals, but you are the person who might be able to help them. So I think there's a lot of gratitude involved in that as well, and some patients might give you free cookies as well.
Dr. Michael Kentris:That's excellent. I always like to emphasize right headache is one of those multidisciplinary specialties, right, we tend to think of it as a neurology subspecialty, which I'm biased, I do think of it as that. But it's also open to people who have done residencies in internal medicine, family medicine and various other like anesthesia, I think even ENT. So there are a broad range of specialists who, if they, over the course of their training, become fascinated with headache, they can further their clinical skills and become one of these very rare headache specialists in the country.
Dr. M. Ismail K. Yousaf:I totally endorse that. Our last fellow was a family physician who did headache. Cleveland Clinic Ohio chairman is a psychiatrist who did headache. So there are so many examples around who people who do headache offer different speciality because there's so much overlap. Again, it's the tip of the iceberg. Seize this that way you have so many aspects to cover, comorbidities to cover, and then the interesting aspect is, despite all these comorbidities, aspects, again, you might be the person who's going to help them and derive and get better at all those comorbidities, even who's?
Dr. Michael Kentris:going to help them and derive and get better at all those comorbidities. Even that's excellent. It's been a very uplifting conversation, Dr Yusuf. I really appreciate you talking about your perspective on headache. It's always very refreshing to hear from someone who's so full of passion about what they do. If people want to find you online or find some resources where, would you recommend that they look around or?
Dr. M. Ismail K. Yousaf:find some resources. Where would you recommend that they look around? Absolutely so. I'm on X, formerly known as Twitter. I'm I-S-M-A-I-L, the mark for F-A-N-T-Y. I do a lot of advocacy for international medical graduates. I have a group as well. 30% of neurologists are international medical graduates in the US. We all work together. We have a great fraternity as a neurologist as well, so you can always direct message me over there. I have my email that is yusafgpaccom. You can email me there. So I'm always always happy to help people together. Um, so I'm always always happy to help people. Um. Whoever want to get in touch with me regarding future counseling, career counseling, headaches, we can have a chat. Maybe the coffee is going to be on you, but we can have a chat that's excellent.
Dr. Michael Kentris:Thank you so much, uh, and like uh, dr yusuf, you can find me also on x. Uh, I'm at dr kR-K-E-N-T-R-S. Dr Kentris, and you can also find our podcast feed at neuro underscore podcast, and you can reach out to us through our website or find other resources at theneurotransmitterscom. Dr Youssef, thank you again, it has been an absolute pleasure.
Dr. M. Ismail K. Yousaf:Dr MK. What a great session we had. I'm so thankful to you. Thank you very much.
