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7. Migraine: Tackling this Persistent Neurological Disease with Christie Tait

Updated: Aug 9, 2022

Hi everybody, today I'm speaking with Christy Tait, she is also called the Headache NP. She is the founder and director of Structure Clinic Headache and Wellness Center in Toronto, Ontario.

One intriguing statement on Christie's website is that if a patient's headaches are significant enough to work mentioned in your clinic, there is probably a bigger story about the impact these addicts are having on their life.

Christie offers private consultations to patients who suffer with headaches, clarifying the diagnosis and providing treatment strategies with the aim of improving their quality of life.

She acknowledges how tough it can be to address patient's headaches in primary health care.

I definitely agree. And thankfully, Christie has a wealth of information to assist us and helping our patients with their headaches. And that is what we will be discussing today.

So welcome Christie. Would you begin by telling us more about yourself?

Thanks, Roberta, thanks so much for having me on the podcast. I'm excited to be here.

So, I am a nurse practitioner who's trained in the area of primary care. Although I haven't actually worked in primary care as an NP. I started my RN journey, working in the emergency department and I spent about 10 years between pediatric emergency department in Toronto, and then also adult Emergency Department again in the, in Toronto, in the city. And then I returned to school to do my Masters; a combined program with the nurse practitioner Primary Health Care certificate at Ryerson, now Metropolitan Toronto University.

And so, starting my career, I actually went back to the emergency department and spent about a year working there, and it wasn't quite the right fit for me as an NP it just, yeah so I was kind of looking for something a little bit different. And I ended up in a community neurology clinic, and that's where I started working in the area and kind of general neurology and then quickly focused in on the headache.

So, that was where my interest really began and that was probably around six years ago and I've kind of never looked back and I'm very very, very focused in specialized in the area of headache and particularly, migraine now.

Goodness! You're one of those registered nurses, and now nurse practitioners, that really likes to move around to find the best fit for your career, and I can appreciate that because that but that's definitely what I did as well. So, you focused on headaches. What was it that made you interested in caring for people with headaches?

Yeah, you know, I, that's a good question. I think that very different from emerge right where you see people transiently, you're kind of dealing with things in a very acute manner. I really found my niche as an NP providing more continuity of care. The area of headache disorders and particularly migraine which is really the most common primary headache that seen in the healthcare setting, this is a really under service population so there's a lot of really interesting statistics that migraine isn't very well diagnosed. It's often misdiagnosed as things like sinus headache, or tension headache or sometimes it's just kind of called general or chronic headache. So there's a huge sort of spectrum of presentation for migraine. I don't think that that's something that's really conveyed very well to us and education and there's data related to, you know, physician education and how much time is actually spent on migraine. These were individuals who were really struggling, you know. Oftentimes by the time they made it to a specialist referral or neurologist many of them were unable to work it was impacting their family life. It does disproportionately affect women, so three times more women than men suffer from migraine. So I would meet, you know, a lot of women who were maybe making decisions to go down a different career path, or their careers had been even shortened due

to their migraines, or they would change their plans around having a family because of their their struggles in in juggling this. It's largely invisible. I think probably most of us know somebody given, given the prevalence 15% of the population has migraine as a neurological disease. So it's, it's very prevalent but it's not always understood. It's very stigmatized and somebody can go from, you know, seemingly fine and functioning and then experiences migraine attack that can be quite disabling.

So I was very, very intrigued and the stories that I heard, so although it's sort of one unifying diagnosis migraine, every individual that I encountered had a very unique story and it just really kind of captivated me and I felt like they're just got be a lot more done for these patients, yeah.

Well, if we circle back to the quote that I read from your website. I think you're absolutely right. Not only do we just, I think, hit the tip of the iceberg when it comes to the impact of migraines on the lives of the patients, but I for one feel quite a little lost sometimes to how to address it with, with the patient in in the primary healthcare setting. So, can you walk us through some of the first steps to take in headache management?

Yeah. So I think, you know, I always describe it as kind of painting a picture or seeing a story right? You, you have to kind of go back to the beginning and in some in in kind of all circumstances. So, when did you first ever have a headache? Is this something that started in childhood? It might be surprising but many of those with migraine actually starts experiencing these symptoms in childhood. It can look like carsickness, a lot of you know what we call kind of functional abdominal pain, you know, or the frequently sort of nauseated tummy aches, things like that. We know that simply vomiting is kind of a variant of migraine and then it evolves.

So adolescence is kind of the key time period where migraine takes it's more sort of, you know, typical adult form and meets more of some of that diagnostic criteria. This is where there's a bit of a divergence between our male and female patient so around the onset of their periods. This is when a lot of women will start talking about "This is when I started to have headache". So it might be you know through high school, university. Getting a little bit about background is very helpful because we know as NPs when somebody comes in and they're there, you know, have their kind of chief concern, we want to rule it anything more serious right? I think headaches or something that nobody wants to miss something very concerning you know like is there a tumor or a bleed or, or anything else going on?

And that's where our focus is which I think is very important, but once we kind of rule those things out and I think the tendency is to kind of breathe a bit of a sigh of relief but you know and say it's, don't worry it's you know nothing serious.

It's all good!

Yeah. And we just feel that way right I do any anybody that's you know stepped into practice on their first day as an NP or you're just like, you know, you can't even put words to that kind of anxiety. So, um, so I think the first thing is migraine isn't going to be solved in a day in the clinic, right, because we have to remember that this is you know a persisting neurological disease that, you know, largely spans a lifetime with maybe some fluctuations in its impact on function. So, on day one I think it's you know if you have the benefit of having this this patient come back to you again, set the stage, validate what they're saying, you know, and bring them back for another visit. So, cover what you can in terms of a history and look for those you know red flags or concerning features. And then when you sort of reached the end of what maybe you can accomplish in that visit, have them book a follow up before they go. Don't lose them to follow up, because I think the one thing I hear from a lot of patients is "Yeah, you know, I kind of mentioned it" You know that the hand-on-the- door knob and you know I still have these, these headaches, right.

So, have a dedicated visit to discussing that and say let's you know get to the bottom of this. Because I have found that you know them there's a little bit of an under-reporting of the severity as well. They're, they're sitting in your office you know they may look completely fine there's nothing you know no scary neurological deficits going on, and they say they're having headaches. So, you know you ask a few questions and maybe say, you know, make sure you're trying to drink a lot of water and, know, get adequate sleep and eat some good food and there it is. But I do find if you do a little bit of digging, it's always on the digging that they reveal these, these stories of truly what is going on in their lives with their headaches right? Migraine really isn't just a headache but it's you know kind of the, what we label as one of the main symptoms of migraine.

And that's where you see that that impact. There is data around that you know the disabling nature of migraine. It looks a little bit different. I always find it interesting when patients actually have no idea that it's migraine and telling them that for the first time and they say oh but you know my sister has migraine and it's you know it's different she gets an aura, she can't get into bed and that's not me but I'm dealing with, you know, moderate to severe head pain and light sensitivity and nausea, four days of the week. But I still go into the office and I get through my day because I can't stop. So, it takes you know different forms.

But I think taking a little bit of time to hear that story and I think NP is a really good at this you know it's kind of how we're trained as RNs and that kind of client, or patient centered care, so we're good at seeing the people behind, whatever their, their symptom or their illnesses and that I think will give you know 90% of what you need, you hear that and then you can't not be compelled to do a little bit more. And then that's where I do think NPs are so well positioned because we have that scope of practice that we can make the diagnosis.

You know, we can order investigations if we need to. And we can prescribe treatment so it's that whole constellation of care. Yeah.

You've highlighted a few key areas and, of course, really having a thorough history and understanding of the impact of the migraines is, is the bottom line, you have to start there.

And then, if you're like me, you think "okey dokey" now what do I do? I can say that part of the challenge that I found in the brief amount of time that I've spent with patients who have migraines and trying to help them through is that there seems to be quite a bit of homework, if you will, but, and work with the patient has to do. And I'm not sure the best way to kind of facilitate that. But this all wrapped up into my next question about what are some of the challenges in treating headaches?

Yes. So, you are absolutely right. It's a two-way street right it relies on that individual patient or client engagement in the process, right? And I think this is another thing I you know as NPs, we, we want to kind of empower and build capacity in our patients, we can't kind of fix them, and how we can offer sort of support. So, I always think of, I'm very visual and I have all these analogies but I always kind of, you know, think of a template of a treatment plan and there are non-pharmacological strategies. This is one of our three pillars. So, you know, anything related to self-care and wellness, which are not always specific to migraine but kind of span a lot of other things, dietary and sleep and exercise and those kinds of things.

You know, we know that in, in those particularly with chronic migraine, there's much higher incidence of mood disorders so sort of checking in to see how those things are managed.

And there's a number of things there and I think that's where I hear a lot of individuals with migraine are given tons of information, and then we don't get always to the other pieces so the other kind of general category is acute treatment which we do during a migraine attack. And there are a lot of different options out there. The general categories are things like your acetaminophen your NSAIDs and triptans, and always kind of tinkering with that plan, a little bit to find something that truly is effective so that's like their fire extinguisher.

And then there's the prophylactic piece and this I would say in practice is what I see is missing a lot. So preventative treatments of migraine and I hear it in in patients you know when I asked them, have you ever been on anything that you take regularly to help you know prevent an attack from starting and they'll say you know yeah that's my, my triptan,

or I, you know, and ibuprofen or something. So, there is a little bit of a you know a misconception maybe amongst those with migraine about where things kind of sit. So I always sketch this out for them and say, these are your three kind of camps of

treatment and we need to have something in each element. And then the piece that's usually missing is that that prophylactic or preventative piece, and it's not always pharmacological for those with you know infrequent migraine attacks, it could be supplements.

So, there's some evidence around magnesium and B2 and coenzyme Q 10. So that could be something that they take on a daily basis to help prevent things so when they kind of come in to see me, I'll say like okay and what's, what's your, what the goals are somewhere we can work on in the lifestyle piece and we know changes take time, it needs to be a realistic goal and something that's sustainable.

What are we doing for acute treatment and what do we have in the area of prevention.

So that's my approach once you know it's migraine anyway.

I mean that all makes perfect sense. And it's actually really helpful to hear it laid out like this.

You know in a busy clinic, if you have in your mind those three steps and working with the client becomes a lot easier. Okay, I have to say, I looked at your website as well, and you have a mindfulness course. And I, you know, started this journey, oh, a while ago, in other way for other things. And every time I open a book, look at a page. Decide on something, for example, learning to talk about mindfulness, sleep, they talked with mindfulness chronic pain they try to talk about mindfulness so I actually started a practice now I'm not good at it. Because I have this well I had an in my, in my head this idea that mindfulness meant that you had to clear your mind which is impossible for me but then I realized that no you don't have to do that. I found that out. Anyway, I was intrigued when I saw it again on your website and I wonder if you can give us a little bit of information about that?

Yes, I would love to. It is a very interesting area. I'll kind of preface this with, you know, one thing that I like, I think, as clinicians and a piece we always like to see was their evidence is this something that you know is evidence based and there was a study done maybe I can find it for you but it showed comparison groups of mindfulness, and NBSR, weekend NBSR, of course in in migraine individuals with migraine versus sort of routine care which will be health education and you know kind of counseling on lifestyle behaviors. The group that did go through the mindfulness program there were improvements in different scoring tools they use so it was kind of a pain catastrophizing score and quality of life score and it showed some sustained benefit so I like that.

Now I agree with you that I think, you know, first encountered mindfulness meditation, it's kind of woven through all kinds of things we do. I am very busy and active person, my mind my body all the time so I didn't know if this is something I could you know ever achieve. But you're right it's not about clearing your mind we can't clear mind. It's not possible, but it is trying to just really be focused on the present. And can we really direct our attention to things that are going on in this moment and also recognizing that you know this is a skill that has to be developed.

It's like a muscle that kind of strengthens so if you're in sort of a formal practice of meditation, your mind will wander and we expect it and it's not about you can't have a good or a bad kind of meditation you'd sort of gently redirected and you do that it's kind of over and over.

So I love that there are some demonstrated benefits in this area. And there is some evidence to kind of show benefit in those with migraines.

So, yeah I myself also Roberta, you're not alone it kind of ebbs and flows how, how much I'm integrating mindfulness into my days. Right now we're in the middle of a house move so any mindfulness aware of the boxes everywhere but ya know,

It's interesting when I first posted that I was working, trying out some mindfulness depression. You know, astounded, and you know, she didn't think that I would ever try anything like that and I'd be kicking and screaming to any kind of stuff. But like you I have found benefit from it so it's quite interesting and it's, it's one of those many tools to have in your arsenal against some of the symptoms that people have from a variety of things so it's fascinating really to see how it works out. So, yeah, go ahead.

I was gonna say there's some you know amazing neuroscientists that really look at kind of the changes that go on in your brain when you're, you're practicing this on a regular basis but i think it's it's accessible right like to some different programs depending on how formal or structured they are, and what is, what is the harm and the risk in it you have to ask. There's a lot of things that we can prescribe that we know have you know it's always weighing this risk benefit and I would say with mindfulness, it can, especially in in those maybe with chronic pain, and depending on you know their past experiences could raise or trigger some, some of that trauma, but I'm there, the outcome and kind of sticking with it is generally very favorable with, you know, minimal side effects.

Excellent. This has been fascinating. Thank you so much, but before we log off. Do you have any other insights, you would like to add?

Oh, Roberta. You know, I think that, um, NPs, you know for I know this this podcast is for NPs, I was thinking of becoming NPs and probably even farther reaching, and I you know the other guests that you have had I love their diverse experiences and I think to kind of bring it back a little bit more generally, just in my trajectory. You know, it's, I didn't ever set out to be in you know now I'm in independent practice or private care. The NP road is, you know, very diverse and there's lots that we can do I think it can seem challenging at times I think, I think we all know that that these rules are not always very well defined by its kind of, you know, persevere if you're an NP in a in a practice setting and maybe it's not quite the right fit or you're not quite, you know well supported I always say NPs, kind of hit the ground running.

I do a lot of education for NPs and NP students in the area of migraine. And there isn't you know this formal sort of residency program that physicians come out of so we were very interesting practitioners that come with, you know, often very established

professional careers as RNs. We then kind of amass this other knowledge that gives us the scope to diagnose and prescribe and do other things, and then we instantly kind of get turned out into the world, to really hit the ground running right. So, you know, from for myself I ended up with this very specific and specialized knowledge and passion around it, but I didn't have a lot of work stability, to be honest, like, you know, when I was listening to your podcast with Dr. Fournier, you know, talking about some of those things that are important. You know inconsistent hours... I lost all of the things that I had in the hospital benefits and you know any pension or vacation. And I felt that I could probably still offer important care to patients with this knowledge so if somebody said to me you know like five six years ago, you know, do you want to be an independent practice and have your own clinic and practice I wasn't on my radar. But sometimes you know a little bit of stress helps us a little bit of stress.

Like that exercising the muscles breaking down. Refresh stronger. You've described. Oh my goodness, I hearing over and over and over again and I heard a saying once that nurse practitioners have to own our space and take our place and I think that that is so true.

Nobody's going to give it to us, we have to carve it out for ourselves and march forward and I think that's exactly what you've done, you've taken your expertise you've taken a giant leap to be able to provide care with the expert knowledge that you have. So, I mean, I think it's amazing personally and I'm, I'm thrilled about it and I will definitely add links to your clinic.

You might get a lot of people asking you questions after that I hope you don't mind that!

You know NPs are usually not high in numbers you know we kind of times in silos. So I think the ability to kind of come together, support one another, and you know even if it's virtually in through podcasts or however we can I think it's amazing so thank you so much for doing this Roberta has been a great conversation with you and you

Oh, you know what? Every conversation I have is just been, you know, a privilege and wonderful and I'm having so much fun doing this. YAY! I get to have fun.

Okay, so on another note, you're speaking at the NPAO conference. Yes, coming up in September, and I will actually be there in my booth, I've got a booth so do come by and introduce yourself in person I'd love to do.

I might wear a mask because I'm a little paranoid but I'll see most of you!

I'm speaking very early so I'll come have a coffee with you after.

Oh, I'm only doing the Friday, though.

That's okay I'll find you.

OK, thank you again!


You can log onto Christie Tait's clinic information and website by clicking these links:

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