Deconstructing Head Pain with Rudrani Banik, MD

[00:55] Jennifer Milner: Welcome back to the Bendy Bodies Podcast, where we speak with experts bringing you state-of-the-art information to help you improve your well-being, enhance your performance, and optimize career longevity. This is co-host Jennifer Milner here with the Hypermobility MD, Linda Bluestein.

[01:11] Dr. Linda Bluestein: We are so glad you are here to learn tips to help you self-manage your conditions and live your best bendy life. This information is for educational purposes only and is not a substitute for medical advice.

[01:22] Jennifer Milner: I'm Jennifer Milner, a former professional ballet and Broadway dancer, and I struggled my whole career with hypermobility-based injuries and issues. Now I train dancers and want to be sure that the next generation of hypermobile artists are better equipped to work to their full potential.

[01:39] Dr. Linda Bluestein: I'm Dr. Linda Bluestein, and I started Bendy Bodies as my second podcast to educate the hypermobile community. Despite being a physician, I experienced decades of symptoms before being finally diagnosed with hypermobile EDS, and I too have been gaslit and felt completely alone in my journey.

[01:56] Jennifer Milner: Our guest today is Dr. Rudrani Banik, neuro-ophthalmologist and founder of Envision Health New York City. Hello, Dr. Banik, and welcome to Bendy Bodies.

[02:05] Rudrani Banik, MD: Thank you so much, Jennifer. It's really a pleasure to be here with you both.

[02:09] Dr. Linda Bluestein: We are so excited to chat with you.

[02:09] Jennifer Milner: We are. We have a lot that we want to cover today, but first, could you tell us a little bit about yourself?

[02:17] Rudrani Banik, MD: Absolutely. So I am a board-certified ophthalmologist and a fellowship-trained neuro-ophthalmologist. So I deal with all the conditions that connect the eyes to the brain. There are many nerves that are responsible for our vision, how we move our eyes, how we move our face. So I deal with all of that.
[02:34] And as part of what I do, I treat a lot of migraine, various types of migraine, because many migraine patients have visual symptoms that go along with their headache symptoms.
[02:45] Now, in addition to that, I recently got a second certification in functional medicine. So I layer that on top of everything else I do. I look at the root cause of various chronic diseases, and then I address the root cause rather than just put a Band-Aid on the problem — to really try to get to where it's coming from and address it that way.
[03:05] And in functional medicine, the basis for a lot of what we do, the foundation of treatment, is usually nutrition as well as lifestyle. So I use a lot of those strategies in the treatment of my patients with neuro-ophthalmic problems as well as eye problems, because I still do comprehensive ophthalmology.

[03:22] Jennifer Milner: That's great, and it's really nice to see someone who does the whole person even though you're working with a specialty focused on the eye-brain connection. It's great to see that you look at the whole person and everything that could be going on. So as we said, we wanted to talk about headaches today. Our podcast is about all things hypermobility-related, and chronic headaches and migraines seem to be a pretty common comorbidity in people with hypermobility disorders. Have you noticed that in your own practice?

[03:48] Rudrani Banik, MD: Absolutely. If people are asked, most often the answer is yes. If you're not asked, then we don't know. So it's really important, I think, to be aware of the various range of conditions that can occur in hypermobility and EDS patients and ask those important questions. And there are specific types of headaches that may also occur in patients who have a history of hypermobility. So we can definitely talk about that as well.

[04:16] Dr. Linda Bluestein: Sure, and that's so true. There are so many different causes of headaches in this population. So today we're going to dive, I think, pretty specifically into the migraine portion, but obviously feel free to comment on any of the other types. And we just want to give people some ideas — sometimes people use "headache" and "migraine" interchangeably, but we know they're not the same thing. And of course there are other different types of headaches. Could you describe some of the common types of headaches that you encounter in your practice and how migraine might be different from other types?

[04:50] Rudrani Banik, MD: Sure. That's a really important point — not all headache is migraine, and not all migraine is headache. I say that a lot in my practice. So there are different types of headaches. For example, there are tension headaches, there are migraine headaches. Some people use the term "sinus headaches," though officially it's not a medical term, even though the pain may seem like it's originating from the sinuses — it's probably a different form of headache syndrome. Then there are cluster headaches. There are headaches that we call cervicogenic headaches. And there are other, more uncommon headaches called trigeminal autonomic cephalgias. So there's a whole range of different types of headache syndromes, and each has their own symptoms and diagnostic criteria.
[05:39] But one thing I just did want to say is that it's important, if you have headaches — especially if you have headaches on a regular basis — to seek out medical care to figure out which of these different types of headache syndromes it may be, because sometimes the treatments can be quite different and the workup may even be different. So it is really important to seek out a doctor if you're not sure. It seems like it's a sinus headache, but what is it really?
[06:02] And one other thing I wanted to mention is that within the brain, there's really only one nerve that is responsible for pain, and that nerve is the trigeminal nerve. And no matter what type of headache you have — whether it's a tension headache, a migraine headache, a cluster headache — it's the same nerve that gets activated. So there may be some overlap between these various types of syndromes because the same nerve is being activated, perhaps in slightly different ways.

[06:34] Dr. Linda Bluestein: That's so interesting. And as we're talking about the importance of going to see a doctor and getting looked at, we're not talking about the casual brain freeze or hangover headache or those sorts of things that can happen, or if you have a sinus infection and a headache that clears up and goes away. We're talking about some sort of chronic headache pain or something that seems to recur somewhat regularly. So it's important to make that distinction for everybody so nobody feels like they have to run out and see a doctor just because they had a little too much to drink the night before. So how do you diagnose migraines versus other headaches?

[07:15] Rudrani Banik, MD: Yeah, that's a great question. So there are specific criteria for migraine. I always tell people, you may self-diagnose yourself with migraine, but definitely see a professional. So what are these criteria? Well, first of all, there needs to be at least 5 attacks of a particular type of headache. And this type of headache is usually unilateral — one side of the head, maybe behind the eye, extending up, sort of one hemisphere of your head. It tends to be of a throbbing or stabbing nature — some patients describe it as a pounding sensation.
[07:58] Usually there are 5 episodes total required for the diagnosis, but each episode can last anywhere from 4 to 72 hours. So that's much longer than your typical hangover headache or tension headache. And then not only that, there are additional symptoms that need to occur during the headache — for example, light sensitivity, sound sensitivity, nausea, vomiting. These all play into the diagnostic criteria for migraine. So again, some people may presume that they have migraine, but if they don't meet all of those criteria, it could be something else.

[08:37] Dr. Linda Bluestein: And that's important to distinguish — not because we want to say, "Well, you don't have a migraine, so it's not a big deal," but because it changes the treatment and the approach. So it's really helpful for people to be able to see the difference. And again, our population does seem to have a larger share than normal of chronic headaches or migraines. So let's look at the non-migraine headaches for a second. What could be some of the common culprits of a non-migraine headache?

[09:08] Rudrani Banik, MD: Usually it's lifestyle factors. For example, dehydration, stress, heat — heat stroke, for example, can be associated with a headache. And in the majority of those cases, we typically call these tension headaches. They tend to occur bilaterally, usually in the forehead area, sometimes in the temple area. Sometimes they may even go down the shoulders into the neck, but it tends to be a bilateral process, and it's more of a pressure sensation.
[09:35] And it's really interesting that tension headaches, again usually triggered by lifestyle factors, are actually improved by activity. I know a lot of people, when they get a headache, feel like they just want to lie down and rest. But sometimes engaging in some kind of activity can actually improve your headache. Now that's the opposite of what happens with a migraine — in a migraine, too much activity makes things a lot worse, so it's actually better to rest. So that's one important feature to distinguish between the two.
[10:11] But again, going back to your question, if you do have frequent tension-type headaches, think about what's going on in your life. Is it that you're dehydrated? Is it that maybe you're not sleeping well enough? Sometimes irregular sleep patterns or lack of enough sleep can lead to a tension headache as well. And stress is kind of the elephant in the room that I always ask my patients about. Are you stressed more than your average level? Where is it coming from? What can we do to mitigate that?

[10:42] Dr. Linda Bluestein: So what are some common triggers of migraines?

[10:42] Rudrani Banik, MD: So that's a great question, and a lot of them are similar to those triggers I just described for tension headaches as well. Many people find it's lack of sleep or dehydration. Another interesting feature of migraine is that people may have food sensitivities, and that can sometimes trigger a migraine. For example, foods that are processed and rich in a compound called tyramine can cause trouble, and then that could lead to headaches. Fermented products, fermented cheeses, certain alcohols, even certain types of bread can trigger migraine headaches because of their tyramine content.
[11:24] Other things that can trigger migraines — people who have migraine are very sensitive to their environment. So changes in their environment, for example, light — bright sunny days, or sun glare coming off of snow or water — can trigger a migraine. Flashing lights can trigger a migraine. Loud sounds. I get migraines myself, so I'm very familiar with the symptoms. The other day I was at a concert, and those flashing lights and those loud sounds triggered a pretty severe migraine for me. So I just have to be very cautious about what type of environment I'm in.
[12:07] And because, again, the brain is almost hypersensitive to changes — people who have migraine are really sensitive to weather fronts coming in. For example, changes in barometric pressure, usually when the barometric pressure falls quickly with the onset of a storm, that's when people may discover they're suddenly getting more migraines.
[12:30] So it's important to think about all of this, and maybe keep a diary if you do have migraines. What do you think the patterns are? That way you're better equipped to know what to do to prevent them. And when you go see a provider, you can take that information with you, and it can be quite helpful.

[12:49] Dr. Linda Bluestein: That's really a great list of things. And I couldn't help but notice that several of them sort of fall alongside issues like mast cell disorders. So it's great for people with a common comorbidity like mast cell activation disorder to be able to see that those things line up. Definitely not my area of expertise, but we have had several people in to talk about it, and it seems to be a common theme in a lot of people.

[13:19] Rudrani Banik, MD: Absolutely. Part of what I do as a functional medicine practitioner is to try to get to the root cause of why somebody may be predisposed to something like migraine. And mast cell activation syndrome is definitely one of those conditions that may contribute to migraine, as well as others, which we can talk about later perhaps.

[13:41] Jennifer Milner: Yeah. Migraine is definitely one of those. I can't remember what year the paper was published, but they talked about different conditions that could be mast cell-related, and migraine was definitely on that list. So, definitely something to think about. What are some of the other types of migraines that we might want to be aware of — migraines that could occur maybe in other parts of the body?

[14:02] Rudrani Banik, MD: So, not all migraine has a headache. That's the unusual feature of migraine. People think, "Oh, it's a headache where you just have to go into a dark room and go to sleep." But not everybody has those symptoms.
[14:13] Some people have just visual symptoms, which we call aura, where you may see flashing lights. It's quite scary actually when it happens, because people think, "Oh my goodness, am I having a stroke?" They see these flashing lights in a zigzag pattern — it almost looks like a kaleidoscope, with multicolored geometric patterns. That visual aura can last anywhere from 15 to 30 minutes before it subsides. Usually it's followed by a headache, but not always. Some people just have the aura.
[14:44] Other people may have other types of aura. For example, this can be quite scary as well — numbness and tingling on one side of their body, or even weakness on one side of their body. Again, of course, we need to rule out stroke. But let's say the first time it happens, the stroke workup is done and it's not a stroke — it's a specific type of migraine we call hemiplegic migraine. Again, usually followed by a headache, but not always.
[15:09] And then there are other people who get what we call vestibular migraines. These are quite hard to diagnose because they're very sporadic. People have this sudden onset of dizziness and vertigo, where the entire room is spinning around them. They may not get the typical migraine symptoms, but perhaps they have a history of migraine — maybe they had migraines many years before and now those have improved, but now they're getting these different types.
[15:39] And then one other thing I wanted to point out is that in migraine, not only is the trigeminal nerve activated, but the vagus nerve is involved as well. The vagus nerve connects basically our whole body from the brain down through our heart, our lungs, into our digestive system. So many people, when they have a migraine, actually have digestive issues — gastrointestinal symptoms like bloating, cramping. I mentioned earlier nausea, vomiting, even loose stools. So there may be this gastrointestinal component of their migraine symptoms without any headache, which makes it really, really hard to diagnose.
[16:21] And actually, in children, GI-type symptoms are much more common than the headache. So many kids will actually have those symptoms and undergo this huge gastrointestinal workup — endoscopies, colonoscopies, biopsies — and everything is negative, and it may actually end up being a form of migraine. So I think it's important for people to realize that it's a spectrum and it's not just the headache. It can be many, many different manifestations.

[16:49] Dr. Linda Bluestein: Which is yet another reason why it's so good to go in and get things checked out. And it's great to go to a doctor who is open to exploring everything and figuring it out. I've had 2 dancers diagnosed with what they called stomach migraines — as you said, there was a huge workup trying to figure out what was going on, and they're both pre-professional teenagers. That was the diagnosis. So yeah, as you said, not every migraine is a headache and not every headache is a migraine.

[17:19] Rudrani Banik, MD: Yeah, it can be very elusive, especially when there are these unusual symptoms. And sometimes it's best to go see a headache specialist. You can start with your primary care doctor, but it's sometimes best to see a specialist who deals with this on a regular basis.

[17:36] Dr. Linda Bluestein: So if someone suspects that they have migraines, what steps would you suggest they take to get relief? It sounds like the first step to you would be to go get it checked out.

[17:47] Rudrani Banik, MD: Yes, get the diagnosis, make sure it's not something else. There are more serious brain issues, neurologic issues that can mimic a migraine. So definitely you want to make sure it's not one of those things.
I always start by having patients take a headache diary to try to figure out what their triggers may be. And I always start with the things they can control. So if they know that dehydration leads to their migraines, stay extra hydrated, especially if you're going to be doing any kind of strenuous physical activity — make that extra effort to hydrate aggressively.
[18:20] And I always try to approach things more holistically before starting a prescription medication. So I always talk to patients about things they can do — maybe some dietary changes, if they think they're sensitive to certain foods, eliminate those foods. Those processed foods, or foods high in sugar content, or foods rich in tyramine — try to exclude those foods and see if that helps.
[18:44] And then I'm a big believer in certain supplements for migraine, and there are studies to back this. There are many studies to show that people who have migraine do benefit from certain supplements, including magnesium, which is a huge benefit for many of us for other reasons as well. Most of us are magnesium deficient, so it's good to take a supplement. Also B-complex, particularly B2, which is riboflavin. There are studies that show that in patients who have chronic migraine, 400 milligrams of riboflavin taken daily for at least 3 months can make a big improvement in the frequency and severity of their symptoms. Now, most multivitamins will have a very small amount of riboflavin, maybe anywhere from 2 to 10 milligrams. So you have to take a separate high-dose riboflavin supplement if you do want to pursue that route.
[19:35] But these are some simple things people can do. Other things — I mentioned that migraine brains are super sensitive. So maybe just adjusting the lighting in your house, wearing certain tinted glasses when you go outside so the sun doesn't precipitate a migraine, making sure you're on a regular sleep schedule, a regular meal schedule, trying to modulate stress. I always talk to my patients about what they're doing to help their stress levels, whether it be meditation or some other stress-reducing activity. These are all the basics.
[20:06] I always tell my patients: have your foundation set, and then if you still get severe breakthrough headaches, then we can talk about maybe adding prescription medications. It's not my first go-to in most patients.

[20:18] Dr. Linda Bluestein: That's great. And an overarching theme that we hear with so many of our specialists like yourself is going back to the basics. Are you eating well — not just a healthy diet, but eating well for you and your particular needs? Are you getting enough sleep? Are you exercising properly? Are you taking care of yourself? It's all about those preventative actions and trying to do what you can to not get into a position where you need medication.
[20:46] Migraines do — speaking of medication though — have an overwhelming array of medication available these days. We see celebrities selling it on TV and everything. And at the same time, people with hypermobility disorders can definitely react differently than the average person on medication. So how do you, if you hit the point where you think "let's start looking at medication" — you've done all the things you can, you've taken all those preventative steps — how do you walk your patients through that trial and error process of figuring out a medication that works?

[21:18] Rudrani Banik, MD: So first of all, I always tell my patients that any medication I put you on can potentially have a side effect — anything. And even the ones that have been around for 30 or 40 years can potentially have a side effect. And each person is different. So your side effect may be different from my side effect. And just because something worked for one person doesn't mean it's going to work for everybody with a particular symptom.
[21:39] So I usually start with the classes of medications that, in my experience, have the fewest side effects. And I start with the lowest dose possible and see what their response is. After 2 weeks, if they're doing okay, I try to bump them up to the next level if they need it.
[21:59] As you mentioned earlier, there is a huge armamentarium of different medications we now have for migraine, which is wonderful in a sense, but it doesn't mean that the same medicine is right for everybody. So there are medications — for example, traditional blood pressure medications such as beta blockers or calcium channel blockers — that can be very useful in migraine with relatively few side effects. But for people with hypermobility disorders, as you probably know better than I do, Dr. Bluestein, people don't necessarily react the way that we would think they would. So a medication that you think may not typically have a particular side effect may have a side effect in a particular individual. So it's always best to start low and then go up and see how people respond.
There's also a whole new class of medications that hit the market about 3 to 4 years ago called CGRP inhibitors. These are the medications that are marketed — you see them advertised on TV, celebrities taking them, et cetera. They are targeted at a particular molecule that's responsible for pain in migraine called calcitonin gene-related peptide. And these medications are not first-line medications at all. But if there is no response to other classes, then they can be used. There are different types — for example, once-a-month injectable medications, oral versions, and then one that's an infusion every 3 months.
[23:27] So if you're not responding to the first tier or the second tier of medications, it may be that you need the third tier, in which case, again, see a provider, find out what's best for you — and of those, find out which specific one may be best for you. And it's always best to proceed with caution, especially with hypermobility issues.

[23:54] Dr. Linda Bluestein: Well, that just goes back to another common theme we have so often: slow and low. Whether it's exercise or changing your diet or whatever it is, just going slow and low, moving slowly and cautiously, and having a practitioner who either really understands hypermobility or is willing to learn about it and to be open to figuring it out with you. It's great that, again, you look at the whole body and the whole patient.

[25:24] Jennifer Milner: I was curious if you found with the calcitonin gene-related peptide receptor antagonists, if you found any differences in pain in the rest of the body. Because I treat people with persistent pain — oftentimes it's really widespread — and I haven't really been prescribing those medications. Oftentimes they come to me already on them for migraine, but I was curious if you have noticed that in your patients at all.

[25:46] Rudrani Banik, MD: You know, that's a great question. So these receptors, the CGRP receptors, are found not just in the brain but in other parts of the body as well. I know that they're present in cardiac muscle. I don't know if they're present in skeletal muscle — that's a really interesting question, and I will look that up. But it's possible that this class of medication may help pain in other parts of the body as well. Have your patients with migraine who've taken these drugs noticed a decrease in their overall pain levels?

[26:24] Jennifer Milner: Well, I have such a self-selected population — they're coming because they have uncontrolled pain. A lot of them are on these medications for migraine. And in some cases, they've found a significant difference, and in other cases, they haven't. But I was just curious, since if they're getting relief from other pain, they're probably not coming to see me because they don't need to. I was just curious about that.
[26:51] And also, tricyclic antidepressants are another class that I know sometimes gets used for migraines. Is that something that you prescribe, or not as often now that we have the CGRP antagonists?

[27:03] Rudrani Banik, MD: I actually do prescribe those a lot. My preferred ones are amitriptyline or nortriptyline. Just be aware that everything can have a side effect. This class of medications — they're typically used to treat depression, but they can cause symptoms like dry eyes, dry mouth, sometimes even weight gain, which may not be ideal for other aspects of their health. So it's all a balance between the benefit of the medication and what the patient can tolerate.
[27:33] And if I do use a tricyclic, I start with the smallest dose possible. I usually start with a 10 mg dose. I know some doctors will start patients on 40 or 50 mg, which is a huge dose, and definitely patients come back unable to swallow because their throat is too dry, their eyes are so dry they can't see properly. So I always start with a very low dose and ramp up if necessary.
[27:57] The other potential side effect of tricyclics is drowsiness and sleepiness. I've taken them myself and it made me feel like I could not get out of bed. So it was not the right medicine for me. But just be aware that there are lots of side effects that can happen. It doesn't happen to everybody, but if it happens to you, there are other options. Talk to your provider about what else may be best for you.

[28:23] Jennifer Milner: And I've been on tricyclics numerous times — for CRPS, complex regional pain syndrome; for migraine; we use low dose for POTS, which is a form of dysautonomia. So I was just curious to ask about that specifically because it's something I see prescribed a lot. And I totally agree about starting with a super low dose and going from there. When people tell me they tried such-and-such and it didn't work, I usually ask, "Well, what dose did you get?" Because that makes all the difference. If somebody prescribed 40 milligrams and you didn't do well and you had a terrible morning hangover, it could be the dose, not the drug.

[29:00] Rudrani Banik, MD: Absolutely. Another drug that I found really useful in migraine is Topamax, or topiramate. It is an anti-epileptic, but it's FDA-approved for migraine as well. And the benefit of Topamax is that it has many different mechanisms of action. In certain patients — now this is getting off to a slightly different topic — but certain patients who have high pressure in their brain, a condition called IIH, do benefit from Topamax because it helps their headaches, it helps to decrease the fluid produced by the brain, and it also helps with appetite suppression. And many of these patients are overweight, so it helps with weight loss for them as well. So there are lots of different medications and different types of headaches that may be better suited to certain medications.

[29:47] Jennifer Milner: I'm glad you mentioned that, because high-pressure headaches are something that — well, both high-pressure and low-pressure, because people can get CSF leaks and get low-pressure headaches. But some people with Ehlers-Danlos or hypermobility spectrum disorder can end up with high-pressure headaches. So I'm glad you mentioned that. That's a great tip to share, so thank you.
[30:07] So what about some of the other supplemental things like physical therapy, exercise, working with a nutritionist, working on sleep? What kind of things along those lines do you use?

[30:19] Rudrani Banik, MD: Yeah, so in some patients, they have headaches that actually start at the base of their neck and sometimes either go down into their shoulders or go up into their head. And these are headaches that we call cervicogenic headaches. I do know that cervicogenic headaches are much more common in the hypermobility EDS population, just because of craniocervical instability with ligaments and joints, etc.
[30:45] So it is important if you do have headaches that are kind of focused there, or start there, to consider getting physical therapy. Chiropractic therapy can sometimes be very, very helpful. Myofascial release can be helpful. Sometimes even acupuncture, acupressure. So I try to incorporate these modalities depending on what the patient's symptoms are and what their response is to their previous treatments. And oftentimes, adding on a different member to their care team — for example, a physical therapist or an acupuncturist — can make all the difference in really getting them to longer periods of being pain-free.
[31:32] The other thing I would say is that I am a big believer in essential oils. And I don't know if either of you have experience with this for pain or headache syndromes, but I've found that essential oils, especially when there are cervicogenic headaches or sometimes even tension headaches, can really help to modulate and decrease the pain. Whether it's aromatherapy, whether it's penetration from the skin into the muscles, relaxing them — I'm not sure. But for example, I've used peppermint, lavender, and frankincense. Those are kind of my go-to essential oils. These are used topically in sparing amounts, not a lot, because you don't want to overdo it. And I know some people take them through capsules, but I would be very cautious with that because sometimes it can cause GI side effects. So topically and even inhalation has worked very well for a lot of my patients who have these types of headaches.

[32:27] Dr. Linda Bluestein: I will say that I have used them as well. I also get migraines and tension headaches, and I have found peppermint to be helpful for the tension headaches. And I have actually used — I don't know if you've tried it, but it's ho wood. Ho wood has been a great essential oil for me for headaches as well.

[32:46] Rudrani Banik, MD: Oh, I haven't tried it, but I will definitely look into it. Thank you.

[32:49] Dr. Linda Bluestein: And again, those are the types of things that people should proceed cautiously with, because one person's deep love of lavender may be somebody else's MCAS trigger. So everything affects people differently.

[33:03] Rudrani Banik, MD: Yes. And many people who have migraine are sensitive to smells as well. So their symptoms may actually be triggered by some of these essential oils.

[33:11] Dr. Linda Bluestein: Right, exactly. So what tips do you have for people who might be struggling with headaches, trying to figure it all out, but also really struggling to get the care that they need?

[33:23] Rudrani Banik, MD: Yeah, that's a great question. And unfortunately, there aren't that many headache providers per population in the United States. There's a mismatch between the prevalence of headache syndromes and the specialists who can help.
[33:38] So there are now a lot of telemedicine options which were not available before. I think this is one of the pluses of the pandemic — we realize there's a lot more access to providers through telemedicine and people who've been trained in headache. There are online platforms where you can get hooked up with a provider in your area. If you're not able to get an in-person appointment — sometimes headache doctors are booked out 3 or 4 months, which is really difficult — I would seek out a telemedicine option.
[34:12] And a lot of people use the emergency department as their go-to for severe headaches. That's not the ideal way to manage your headaches. Try to get a provider that you can develop a relationship with, that you can see on a regular basis, rather than going into an emergency department for those severe headaches that just aren't breaking. It's best to try to address them before they get to that severe stage.
[34:45] Now, of course, if you do have a really severe headache that's lasted 3 or 4 days and it's just not getting better, absolutely maybe go into your local urgent care or emergency department. Sometimes there are infusions that can be given to break that headache cycle. So I'm not saying don't do it — but really reserve it. Don't use it as your standard access to care.

[35:06] Jennifer Milner: I had an infusion of DHE after having a migraine that lasted for a very, very long time. I was in the hospital for several days, and that was rough. But I do have a follow-up question about imaging. It seems like patients that I see very commonly have different kinds of head pain, and some of them have had quite extensive imaging and others have had none. I had a patient the other day who said she's had head pain since she was 8 years old, she's now in her early 20s, and her mom says she has never had a scan of her head. So what do you think in terms of indications for imaging?

[35:48] Rudrani Banik, MD: Yeah, so if there's anything unusual in the history, I will image without a doubt. If there's a new symptom, especially things like numbness or tingling — these are unusual symptoms that really should be worked up with imaging. And if you're going to get imaging, my go-to is always an MRI of the brain rather than a CT scan, because MRI has much better resolution of soft tissues.
[36:14] Now, if you're looking for more structural issues — for example, joint issues or sinus issues — then a CT scan may be the better modality. But in the vast majority of patients, an MRI is really the best choice.
[36:28] Now, in some cases — for example, if someone has high pressure in the brain, this condition called IIH, idiopathic intracranial hypertension — I will also get an MRV, which is an MR venography, looking at the veins that drain the brain to see if there's any obstruction. And sometimes, yes, there is a structural issue. So it's important to know that it's there and then to address it appropriately if it's significant.
[36:57] In some patients, especially if they have a lot of cervicogenic pain, neck issues, shoulder issues, I will get an MRI of the spine as well — the C-spine — because that will best show if there's any kind of joint dislocation, subluxation, herniated disc, all those types of things. It's important to know because perhaps the treatment would be different from your standard migraine or tension headache treatments.
[37:23] So I think there is a role for neuroimaging. But not every patient needs it. For example, many patients come in with new onset — let's say a young woman in her 20s or 30s — new onset visual aura. They've seen those flashing lights and they get the headache afterwards. If it's a stereotypical symptom like that, where there's aura followed by headache, I typically don't get imaging. Of course, I do an eye exam to make sure there's nothing else suspicious — that the optic nerves are not swollen, that there's nothing going on in the retina that may have caused those symptoms. But as long as that's normal, I typically forgo the scan.
[37:59] But certainly, like what you were describing — an 8-year-old with chronic headaches who's never been imaged — I probably would image in that case just to make sure there's nothing structural responsible for the headache. It needs to be decided on an individual basis. My threshold is usually pretty low to image. I don't want to miss anything, especially if it's something that can be treated.

[38:25] Dr. Linda Bluestein: That's great. And one of the things that we sometimes see with people with hypermobility disorders might be a Chiari malformation or something along those lines. So there can be a whole bunch of different things that could be causing head pain, and that imaging can be really helpful to find it. It's great that you have a low threshold without automatically sending every single person to get an MRI when they first walk in.

[38:52] Rudrani Banik, MD: Yes, it's selective, but I have a low threshold.
[38:56] So I'm glad you brought up Chiari, because I know that it has been investigated in the hypermobility EDS population, and yes, there is a slightly higher prevalence of Chiari malformation. What Chiari is, is that the back part of the brain — which is called the cerebellum, our balance center — usually sits at a certain level above the skull base. And in Chiari malformation, it sits lower than it normally should. It's almost like it's being pushed down into the spinal canal, and it can cause certain types of headaches. It can also cause issues with numbness and tingling down the shoulders, or weakness of the shoulders or even the arms.
[39:37] So it is important, if you have any of those types of symptoms, to get an MRI — a particular series called a sagittal MRI, which is a side view of that area of the cerebellum and the spinal canal, to see exactly where the cerebellum sits. And sometimes we also get a spinal MRI as well, just to look for any other changes in the cervical spine that can be seen with Chiari. So absolutely, if you have those types of symptoms, I think it is really important to get that imaging done.

[40:09] Dr. Linda Bluestein: Absolutely. Thank you. And thank you for adding that. I just wanted to circle back really quickly before we wrap things up to the topic of sleep. I know you mentioned it and that it's really important for people to examine their diet and try to be healthy with sleep. But could you expand a little bit more on the importance of sleep and migraines and headaches?

[40:27] Rudrani Banik, MD: Absolutely. Sleep is restorative — it's our body's time to reset and recharge. We need an adequate amount of sleep for all of our generalized health, not just for headaches and migraines. But people who are prone to migraines are very sensitive to irregular sleep patterns.
[40:49] So what I always tell my patients is, first of all, how do you know if you're getting adequate sleep? Well, when you wake up, you should feel refreshed. You should feel ready for the day. You shouldn't feel like you want to go right back under the covers. You should feel reset and recharged.
[41:01] And it's also important to have a regular sleep schedule. I'm guilty of this myself — I'm still working on going to sleep at the same time every night and waking up at the same time every morning. Because, again, migraine brains crave regularity. When there's an irregular pattern, whether it be sleep or diet or stress or exercise, that's when people are more predisposed to migraine headaches.
[41:28] So try to go to bed at the same time every night, wake up at the same time every morning — and that's regardless of whether it's a weekday or weekend. It's harder when you're traveling across multiple time zones, but if it's possible to maintain some kind of regular sleep pattern even when traveling, it's really, really important.
[41:46] Also, try to have your sleep environment be really dark, as dark as possible, because again, people who are migraine-prone are sensitive to lights. When I was younger, I didn't really care about having blackout curtains, but now it's absolutely a must. I have to have those blackout curtains because even a sliver of light coming in will prevent me from getting to sleep easily, or it may even wake me up too early. If the sun comes up super early, it may disrupt my whole day. So just think about those small things as well.

[42:24] Dr. Linda Bluestein: That's great. And I will say I use a sleep mask because I've gotten to the point where I just want complete blackness when I'm trying to sleep. But it's so important — we always go "yeah, yeah, yeah, we know it's important," but we really need to pay more attention to that because it's something we do have control over.
[42:43] So, at the risk of starting a completely separate podcast episode now, I just wanted to really briefly touch on the connection between the eyes and migraines. We know a lot of people with hypermobility disorders can have ocular issues. Could you speak just briefly on that, and we will have to have you back to dive into it more deeply?

[43:09] Rudrani Banik, MD: Sure, I would love to come back. I love sharing this information because I think a lot of people don't realize these connections, and when they hear about it the light bulb goes off.
[43:22] So in terms of the eye and hypermobility or Ehlers-Danlos, there are many ocular manifestations that can happen. There can be changes in the cornea leading to something called keratoconus. There can be changes in the retina — the retina can be very thin, and it can lead to retinal issues like tears or detachments, even high myopia with other issues. So there are lots of different ocular findings in hypermobility disorders, really based on collagen changes and collagen structural issues that can lead to functional problems.
[43:57] So I would love to come back and delve really deeply into that, because I think it's something people should be aware of — the eye issues and symptoms that may occur in hypermobility disorders.

[44:09] Dr. Linda Bluestein: I've also noticed the connection — especially for people with tension headaches or cervicogenic headaches — between how their eyes work and move and their headaches. When I do training with my dancers, sometimes they would do saccades and things like that, and they can trigger headaches. And that lets me know we need to start working on, as crazy as it sounds, eye mobility — to try to loosen up all that connective tissue at the back of the head. And when they work on that regularly, they get fewer headaches. So it's a really interesting connection.

[44:43] Rudrani Banik, MD: Yeah, I actually have a patient who is a physician as well, and she has Ehlers-Danlos and many issues throughout her life, but she developed trouble moving her eye and she felt this tightness in her eye socket. And every time she would move her eye in a particular direction, that would trigger pain — down into her nose, into her cheekbone, and then eventually it would just travel down her neck into one half of her body. So it was all connected. I think it's definitely important to consider all those connections between the tissues in our eye socket and the rest of our body as well. So I'm glad you brought that up. Absolutely.

[45:15] Dr. Linda Bluestein: So we've talked about migraines and headaches, and we've talked about a lot of the things that people commonly use. There are a couple of things that we don't always think of, though. If you could speak really briefly on — there's a new set of devices out that are meant to stimulate the vagus nerve. If you could talk about that, and also the use of Botox in treating migraines and headaches.

[45:41] Rudrani Banik, MD: Yeah, I'm glad you brought this up because I know a lot of people do benefit from these modalities. So these are called neuromodulatory devices, and they are used topically. For example, Cefaly is one of the devices — it's a device that goes across the forehead, and it's believed to modulate the nervous system through the vagus nerve. There are other devices as well. Off the top of my head I don't remember all the names because there's always new ones coming out, but there's one that people wear on their wrist, and another that goes on the neck. So there are various devices that are FDA-approved for migraine that have this neuromodulatory mechanism of action.
[46:24] Now, you also mentioned Botox. Yes, Botox can be used for migraine — it is FDA-approved for migraine. There is a set regimen of how it's given, and Botox for migraine is very different from cosmetic Botox. It's given in very specific locations at a very specific dose — basically 165 units, which is quite a bit of Botox, given across the forehead, under the scalp in the temple area, and then from the back of the head down into the neck. It's quite a lot of injections given just under the skin, and it's given every 3 months.
[47:14] Again, it's FDA-approved and it can work for many, many people. But in my experience, for the patients in whom it works, they usually know within the first 1 or 2 rounds of Botox treatment. If it hasn't had an effect within 2, maybe even 3 rounds, I tell patients it's probably not working for you. Stop it and let's go on to the next thing. Because I've seen some patients who've been on Botox for 3 years — every 3 months going in for their Botox shots — but it's not helping them. Why continue something if it's not working? Try one thing at a time. If it's not working, move on to the next thing. So that's my take on Botox. It's great when it works, but in my experience, it doesn't work for everyone, unfortunately.

[48:11] Jennifer Milner: Kind of like everything, right?

[48:13] Dr. Linda Bluestein: That's exactly right. And that just goes to another point — talking about these two things and how they might work for some people and not others, it's just a great reminder that trying to treat your chronic headaches or migraines is something that should be a journey you're on with a medical healthcare provider, not something you're trying to problem solve by yourself or see a doctor once and then try to get it all figured out. So it's important to be with someone who is invested in being on this journey with you.

[48:41] Rudrani Banik, MD: Absolutely. Yes, it is a journey, and it's a very steep uphill slope initially. But once you get there, once you figure out what regimen is going to work for you — whether it's only lifestyle and supplements and diet, or maybe it's superimposed on that with medications — once you figure it out, hopefully that will carry you through and improve your headache severity and frequency, but also your quality of life. That's really what we're talking about here: your quality of life. And so find a provider that you feel comfortable with who can walk you through this journey.

[49:11] Jennifer Milner: And that's a perfect lead-in to — who can you see as a patient? If you're willing to share that, I think that would be helpful for some people who are thinking, "Oh man, I wish I had somebody who listened that well and could really work up my headaches." Obviously some people can come see you quite easily and others probably not as easily. So are you willing to share about that a little bit?

[49:37] Rudrani Banik, MD: Yeah, absolutely. So as I was saying earlier, there's really a dearth of headache specialists in the US. It's really hard to get an appointment — sometimes it can take 3 or 4 months for a new appointment. So you can maybe see your primary care doctor, a family medicine practitioner. Or if you're lucky, you can get in to see a neurologist who specializes in headache.
[50:01] There are many platforms now that offer telemedicine visits, which is great. I also offer telemedicine visits for people who are in New York State who attest to being in New York State. So there are lots of options now. In a sense, the pandemic has opened up some of these new pathways that we didn't really utilize before. I think care is much more accessible now than it was maybe 2.5 to 3 years ago.

[50:25] Dr. Linda Bluestein: Absolutely. This has been so incredibly informative. I've taken multiple pages of notes and I can't wait for this episode to come out so our listeners can hear all that you've shared with us. Was there anything that we didn't get to that you wanted to make sure we covered?

[50:40] Rudrani Banik, MD: I think we covered a lot. When we were talking about sleep, I was thinking about bringing up blue light and circadian rhythms, but I thought maybe that would be a whole other Pandora's box. So we didn't talk that much about it, but it is something I always counsel my patients on.
[50:56] And nutrition — I'm a big advocate of a healthy diet for vision health as well as brain health. I do have a book coming out soon that I just wanted to mention briefly. It's called Beyond Carrots: Best Foods for Eye Health A to Z. The concept is that it's not just one particular food we need to eat to keep our eyes healthy or our bodies healthy — you have to have the whole spectrum. And this is also true for people who have any condition, including hypermobility disorders: you really need to nourish your body with a diversity of nutrients from various sources, mainly plants. So that's what my book is about. And if anyone's interested in ocular nutrition and how you can best support your eyes, please take a look at that.

[51:44] Jennifer Milner: That's exciting.

[51:45] Rudrani Banik, MD: Thank you.

[51:46] Dr. Linda Bluestein: We'll make sure to put the title of that in our show notes so that people can find it. And the whole eating a full spectrum is so important. Our Bendy Bodies team member Kristin Koskinen, who's our resident dietitian nutritionist, talks about that all the time — there's not just one miracle thing that's going to fix it. So it's not just carrots for the eyes.

Rudrani Banik, MD: Exactly.

[52:08] Dr. Linda Bluestein: The full spectrum. Exactly. Well, we'll have the book in our show notes, but where can people find you?

[52:18] Rudrani Banik, MD: So my website is my full name — www.rudranibanimd.com — and I'm also very active on social media. I think we had connected through Instagram. So I'm on Instagram @Dr.RudraniBanik, and I also have several Facebook groups that your listeners may be interested in. One is called Envision Health, in which I share lots of tips about general eye health. And another is called Eye on Migraine, where I share a lot of migraine tips. So if you do have migraine, please check that out. It's a private Facebook group, and I'd be happy to welcome you into the community.

[52:54] Dr. Linda Bluestein: That is great, and I bet you will have some new subscribers after this comes out. Well, you have been listening to Bendy Bodies with the Hypermobility MD, and our guest today is Dr. Rudrani Banik, neuro-ophthalmologist and founder of Envision Health, New York City. Thank you so much, Dr. Banik, for being here and sharing your knowledge with us.

[53:10] Rudrani Banik, MD: Thank you. It was really a pleasure speaking with you both.

[53:18] Dr. Linda Bluestein: If you love what you learned, follow the Bendy Bodies podcast to avoid missing future episodes. Screenshot this episode, tagging us in your story so we can connect. Our website is www.bendybodies.org and follow us on Instagram at bendy_bodies. We love seeing your posts and stories, so please tag us using #BendyBuddy. Please leave a review and share the podcast to help us spread the word about hypermobility and associated conditions.
[53:46] This information is not intended to diagnose, treat, cure, or prevent any disease. The information shared is for educational purposes only and is not a substitute for medical advice, diagnosis, or treatment. Please refer to your local qualified health practitioner for all medical concerns. We will catch you next time on the Bendy Bodies Podcast.