Amanda (Host): This is MIMO Med Talk. I'm your host, Amanda Wild. Joining me today are Dr. Murraya, a neurologist who specializes in headache care Epileptologist, Dr. Susanna Ula and Director of Ambulatory maternal specialty, Dr. Rodney McLaren, Jr. We're discussing women's neurology highlighting neurological challenges women may face with a detailed look into migraines.

Welcome all three of you. Thank you so much for being here today.

Susanna O'Kula, MD: Thank you for having us.

Rodney McLaren Jr., MD: Thank you for having us.

Murray Choueka, MD: Yes.

Amanda (Host): Dr. Ulid, starting with you. Tell us about the reasons that led to establishing the Maimonides Women's Neurology Center.

Susanna O'Kula, MD: one of the things that really drove us to develop, this was a simple observation. Women's brain health isn't one-size-fits-all. We experienced neurologic conditions differently at different stages of life, and often with unique triggers and risks, that haven't historically been addressed in a focused way. And so we realized there was a gap in care for conditions that are either much more common or present differently in women like migraine multiple sclerosis.

Stroke risk around pregnancy and menopause, seizure disorders, and even unexplained entities like mood or memory changes. And women often tell us they worry about, but don't always get taken seriously. So then we asked, well, what would neurologic care look like if it were truly designed around women's lived experiences?

And that's what led us to build to the first center in New York City that brings together neurologists with ob GYN and women's health specialists to partner on care, not just reacting to problems, but anticipating them in the context of a woman's lifespan from preconception to pregnancy through menopause beyond.

As they say, not every woman will experience pregnancy, but every woman will experience menopause, And so that's a big part of the mission, to really meet women where they are, listen to what they're experiencing and walk with them. Providing expert guidance that really reflects how hormones, life stages, and neurologic health all intersect and interact and instead of then fragmented care, seeing one specialist here, another there, you really get coordinated.

High quality, top of the line support.

Amanda (Host): Dr. McLaren to pick up on that, if you're going to be individually focused on women's particular needs and each woman's needs, how does that relate with the research, which we know traditionally has not included women? How do you deal with your body of research when you are making decisions?

Rodney McLaren Jr., MD: Yes, of course. So, neurologic conditions are, very common, in the United States, A recent, study that was published in Jamma neurology, shown that in 2021, more than 50% of US individuals have a condition that affects the neurologic, system. So, this, center is going to, care for, women, within the Women's health, institute where, they have, certain hormones, affect certain conditions differently, you particularly during, pregnancy, and menopause.

and, a lot of our care is, evidence based based on research and, You know, as you mentioned, the, You know. Women in general, have, less, research, but of the research that we have, we, are able to extrapolate and, continue to push, forward and, contribute to that research.

Amanda (Host): Mm-hmm. Dr. Kula, it sounds like we know that collaborating then with OBGYNs made sense for the Women's Neurology Center. Is this unusual?

Susanna O'Kula, MD: I don't think so, but I think that, Having a, a centralized location really makes it easier for women and, instead of having to go to a couple different offices, the fact that our neurology suite is literally two floors above the OB GYN MFM gynecology practice is. I can see the, the eyes of my patient's light up.

take epilepsy, my subspecialty as an example, it's one of the most common neurological conditions in the us And so you have about 3 million adults in the us alone living with active epilepsy, and women are a large proportion of that group. And so. do think we need to, think critically about how to really optimize care.

and I know we'll focus more on, on migraines, but, their real lives. And so I think that, trying to navigate, healthcare in this country, particularly in Brooklyn, is a challenge. And we need that coordinated, women focused care.

Amanda (Host): Dr. Ula, what are some of the other neurological conditions that primarily impact women?

Susanna O'Kula, MD: Great question. So, something like multiple sclerosis, it's significantly more common in women than men. And in the US. Women make up about 70, 75% of people with MS in the us. and, myasthenia gravis, for example, is about, half and half, both men and women, but younger adults with myasthenia tend to be more often women under age 50.

And then I won't steal Dr. Sikas Thunder, but. Almost half of women in their lifetime will have a migraine. so it's really, This is really relevant to our patient population.

Amanda (Host): And just to add to that, Dr. McLaren, can you discuss hormonal fluctuations such as those related to menstruation, pregnancy, and menopause, how those influence migraine frequency and severity in women

Rodney McLaren Jr., MD: Oh, yes. especially, in the context of, pregnancy, that's, when the hormones are, greatly, fluctuating and increase. even during different parts of the pregnancies, the hormones cause that migraines to be more common or less common, depending on the point. and of course, along with, the neurologic care And in that aspect, that's where, you the center is great, where we'll have the experts just right upstairs, on the latest.

Okay. treatments on how to take care of migraines, and you have our specialists, which, will take into account, whether it's, safe during pregnancy, and, answer those kind of questions.

Amanda (Host): So, getting to headaches, Dr. Ika, um, wanna bring you in Now you sp specialize in headache medicine. does that mean exactly?

Murray Choueka, MD: Right. So I completed my training in, uh, neurology. but then after I completed that training, I did a fellowship in headache medicine where I really focused on treating headaches and primarily migraine. And that's actually all I do every day is I treat people with headaches.

Amanda (Host): And how common is that for women?

Murray Choueka, MD: Right. So, migraine specifically is the most common neurologic disorder in both men and women, but for women, the prevalence is about 20% per year. So in any given year, that means that one out of five women will have a migraine, at least one migraine. So it's a really, really common disorder.

Amanda (Host): And you have expertise. On a wide array of treatments for this, can you provide a overview of treatment options?

Murray Choueka, MD: Absolutely. So for migraines, and This is the same really for men and women, the first thing you always want to focus on is lifestyle modifications. Things that you can do in your daily life that can help. Prevent or treat migraines. Some of those things are drinking a lot of water, making sure you're not skipping meals, getting good sleep, and, addressing any potential anxiety or depression that a patient may or may not have.

And then for medications, there are medications that you could take as needed. Like Ibuprofen or Tylenol, probably the two most common over-the-counter ones. And then there are prescription medications like Sumatriptan, or more lately a class of medications called G Ps. And then for prevention to things that can prevent the headaches from coming entirely.

There are a vast array of medications, monthly injectables, Botox injections even. And what I find is that for most patient's, we can find a treatment regimen that works for them.

Amanda (Host): And that seems to include prevention as well, treating the migraines when they come up, and finding a way to prevent them from building up.

Murray Choueka, MD: yes, for every patient's different And what they need. So if someone is having one headache every couple months, then maybe. What they need is something to get rid of the headache when it comes. But for patient's that are having four headaches a week, that's someone that needs something to prevent the headaches from actually coming.

Amanda (Host): And can you talk about neuromodulation devices and digital devices and how they are used in your field?

Murray Choueka, MD: Sure. So there are a few neuromodulation devices that are FDA cleared for the treatment of migraine. And what FDA cleared means is that it has been tested for safety and found to be safe by the FDA. However, none of these devices are actually FDA approved for migraine, and that's a higher bar where you need to show in very well run clinical trials that the device actually works for that indication.

there are the most common devices are ones that either go on your head. And they stimulate above the eyebrows or in the back of the head, along the occipital nerves. And these are very non-invasive, stimulation devices and they're really, really safe. And they can be used either to treat a migraine while it's happening or it can be used daily to actually prevent headaches from occurring entirely.

And the really good thing about this for women is it is safe even if they are pregnant or trying to become pregnant. And that's a time period for a woman that their treatment options are more limited.

Amanda (Host): And how successful have you seen these? Devices and medications And the tools at your disposal. How successful have you seen these be? Have you measured that?

Murray Choueka, MD: I haven't measured it for my own practice. but from statistically with the devices, we don't have very large randomized control trials for those to say exactly what percent of patient's benefit. There are some smaller trials for those devices, but nothing like the clinical trials being done for new medications where they have thousands of patient's enrolled.

What I can say is overall the overwhelming majority of patient's that come into my practice ev eventually we'll find a treatment regimen that works for them.

Amanda (Host): that's encouraging. Dr. Kula, how are neurologists integrating the lifestyle management that Dr. Shika touched upon, such as nutrition, sleep hygiene, stress reduction? How is that incorporated into comprehensive treatment plans for female migraine patient's

Susanna O'Kula, MD: I think it's. Essentially a lot of what Dr. Schweik has already, touched on. And, something that we go over with all of our, patient's, in terms of that hydration. Sleep hygiene, nutrition. And then, we actually have, one of the neurologists that formed part of our women's neurology center is, board-certified in lifestyle medicine, which is a really burgeoning field that takes a deeper dive into some of the.

interventions long-term that can help, maintain overall health specifically, in terms of, reducing blood pressure, improving mental health, which has a direct feedback loop on, neurological health. So I think that, Regardless of what specific neurological disease or disorder someone has, optimizing lifestyle factors really does, play a role. We see that in epilepsy specifically with, getting better sleep can often improve seizure control, for example.

there's a very strict diet that's often used, for really tough. Seizures, for example. And so I have a lot of patient's coming to me and asking, you know, what can can I do? How I optimize?

Amanda (Host): that's interesting that you mention mental health playing a role in. Migraines and other neurological issues. what are neurologists observing in clinical practice regarding patient adherence to preventive treatments among women, balancing work, family and stress factors

Susanna O'Kula, MD: I think that, I can speak to, epilepsy and seizures since that's my subspecialty, and I'll, I'll let Dr. Ika, fill in on, on migraine. But, we know that, women who have, better control of seizures have, overall, reduced rates of depression and anxiety. Conversely, women with seizures, are three times more likely than women without seizures to have depression and anxiety.

And so, we look at interventions that are not just taking a medication, right? So in addition, or instead of, things like cognitive behavioral therapy, group-based therapy, I partner, with the Maimonide Mental Health Center, for many of my patient's to make sure that we have a. You know, a fast track to help, uh, to help because that neurotransmitter imbalance that happens with seizure often, predisposes to, mood disorders, most commonly depression and anxiety.

Amanda (Host): Do you wanna add to that? in terms of migraines, what are you observing in your practice with patient adherences to preventive treatments?

Murray Choueka, MD: I find that patient's are pretty adherent to their migraine treatment plans because the migraines are very often debilitating And The patient gets a reminder of that every time they have a migraine, and they're highly motivated to adhere to the treatment plans in regards to. maybe having a holistic plan, similar to epilepsy.

if a patient has depression or if they have generalized anxiety disorder and it's not well-controlled, that can actually lead to a worsening of migraines and vice versa. Migraines are uncontrolled. They're more likely to have worsening of depression or anxiety. So it's really important to take a holistic approach to migraine care.

Amanda (Host): I wanna ask all three of you to look ahead and. Tell me what are the most promising trends in women's neurology that could redefine how migraines are understood, prevented and treated, or other specialties that you deal with? how do you see that developing over the next decade or so?

As we know, technology and techniques are always just emerging.

Rodney McLaren Jr., MD: I'll say first that the good thing is, is that there's now, more recognition that the conditions, in women may present or need to be treated, um, a little differently to, You know, optimize the care. And, I think that recognition is only, gonna help, promote more of these kind of centers.

where, women can get, both specialty cares of, the ob GYN and, uh, neurologists.

Amanda (Host): Dr. Ula, anything to add to that as you look ahead?

Susanna O'Kula, MD: I think that there's a lot that's on the horizon in terms of, interventions and care. I'll, I'll let Dr. Tika speak to the, the migraine specifics, but, I think that, in terms of, overall There are a, a growing number of devices. whereas before in neurology we had, mainly medication.

And so I think that's a really exciting piece.

Amanda (Host): And

Murray Choueka, MD: to go back to your first question at the start of our podcast. About research and women not being included as much in the past, and that's completely changed. And now in all the new migraine trials, the pharmaceutical companies are including women at very high rates. And in fact, most of the patient's in migraine trials are women, and they're trying to reflect the prevalence of migraine, which is, And in this case, more prevalent in women.

So a lot of all the research studies being done now. are actually including women at very high rates. additionally since IUDs, intrauterine devices for, contraception have become more popular, it has allowed women to take medications that were previously dangerous for them to take, in case they were to become pregnant unintentionally.

And so the fact that so many patient's are have IUDs really opens up a lot of treatment options that wouldn't be available if they were on a progesterone only pill. where the risk of pregnancy of unintentional pregnancy is a little bit higher. Or for patient's that don't wanna take or cannot take an estrogen containing breath control pill, IUDs are a great option.

additionally, there's a big focus now. On going back and figuring out which medications are actually safe during pregnancy and safe during breastfeeding. And there are medications that we previously thought were unsafe during pregnancy and now we're seeing a lot of data that they are safe. For example, sumatriptan the most, the oldest medication that was specifically designed for migraine was previously thought to be unsafe during pregnancy and now.

It's actually becoming one of the first-line medications we're using during pregnancy for migraine.

Amanda (Host): so that's a good example of changes as they happen. So as we look ahead, we'll be flexing with the research. I'm gonna end with you, Dr. McLaren. should an OB GYN refer a woman patient to a neurologist?

Rodney McLaren Jr., MD: Yeah, so there's, multiple conditions. first, an ob GYN should refer, a patient to a neurologist, if they have, a neurologic, conditions such as epilepsy, migraine, multiple sclerosis. Or of course, if they have, any neurologic symptoms, where, you need a neurologist to, help diagnose that. And, here at the women's neur Center, here at M Im o, we have, the full range of diagnostic, capabilities of, pinpointing.

the neurologic condition that a, patient may have And then, directly referring to, one of our neurologists within the women's neuro center where they won't even need to be, referred to another place. It's all in just one center. You know, one stop shop.

Amanda (Host): Yeah, that's a huge takeaway for me today is the importance of the center, and as Dr. Ula emphasized, having everything in one place. That makes so much sense. And it sounds like things are much more streamlined, both for doctors and patient's. Thank you so much, Dr. McLaren, Dr. Shika, and Dr. Ula for joining me today and sharing your time and expertise on M Omed talk.

Murray Choueka, MD: Thank you.

Rodney McLaren Jr., MD: Thank you.

Amanda (Host): Call seven, one eight two eight three seven four seven oh. Option five to make an appointment. For more information, visit MIM o.org treatments and care, And then go to Women's Neurology Center. And if you found this MIMO Med Talk podcast helpful, please share it on your social media channels.

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