MS. DIANE REHMThanks for joining us. I'm Diane Rehm. Thirty-six million people in the U.S. suffer from migraine, but doctors and patients say the disease is misunderstood and under-diagnosed. We'll talk about the search to better understand and treat migraine.

MS. DIANE REHMHere in studio is Dr. Perry Richardson, neurologist at George Washington University Hospital. Teri Robert is author of "Living Well with Migraine Disease and Headache," and joining us from KJZZ in Tempe, AZ, Dr. David Dodick, neurologist at the Mayo Clinic and chair of the American Migraine Foundation.

MS. DIANE REHMI invite you to join us with questions and comments, 800-433-8850. Send us your email to drshow@wamu.org. Follow us on Facebook or Twitter. We'll try to get to as many of your calls as possible. Good morning to all of you.

DR. PERRY RICHARDSONGood morning.

MS. TERI ROBERTGood morning.

DR. DAVID DODICKGood morning.

REHMGood to have you all here. Dr. Richardson, if I could start with you. A migraine is not just a headache. What's the difference between an ordinary headache and a migraine?

RICHARDSONWell, actually, ordinary headache is a difficult topic for me because I always get suspicious if somebody is telling me that they have headaches that are disabling that are different from their normal headaches. If somebody reports headaches that they interpret as normal, but they occur on a continuing basis or an episodic basis, I actually start asking questions about migraine predisposition.

RICHARDSONThe migraine also classed as a headache, as you said, is actually a brain disorder. It's not a blood vessel disorder. It has phases that have been recognized to occur before pain, although it is the most disabling type of benign headache syndrome.

RICHARDSONNot so benign because many people are put to bed with headache, disabled, cannot work, cannot enjoy their family functions, and cannot socialize. The diagnosis is lacking any kind of formal scientific test. You know, we use the term bio-marker so that when someone is diagnosed with migraine, it's based on a description of the event.

RICHARDSONThe headache pain may or may not be unilateral, one side of the head. That was the origin of the term. It comes from a Greek word for one side of the head. It is often associated with sensitivity symptoms and there's now good evidence that it is an excessively sensitized brain. Before pain occurs, there may be a warning sign that's often a visual change. That's called a visual aura, sometimes tingling.

RICHARDSONAnd even before the aura, there's a premonitory phase that many people recall if you ask them about it, which consists of an odd malaise a day or two before, sometimes yawning, food craving, mood shifting. And some people actually are wrung out for a day or so after the headache. So I ask for panoply of these symptoms that help me recognize that this is migraine.

REHMDr. Perry Richardson, he's a neurologist at George Washington University Hospital here in Washington, D.C. Dr. Dodick, I heard Dr. Richardson use the words brain disorder. I had certainly previously thought that migraines were thought to be vascular disorders. Has the entire outlook regarding migraines changed over the last decade?

DODICKAbsolutely, Ms. Rehm. I mean, for three centuries...

REHMPlease call me, Diane.

DODICK...Diane, okay, Diane.

REHMThank you.

DODICKI mean, over the past three centuries, migraine has been considered to be a vascular disorder, a problem with dilation of blood vessels. But we now understand over the past decade or two that migraine is a neurological disorder and that has tremendous implications for drug discovery for new treatments, if you will, because now instead of targeting the blood vessel, that new pipeline of medications that are becoming hopefully available in the near future will target the brain and nerves themselves.

DODICKSo, yes, this is, as Dr. Richardson said, a genetically-inherited disorder due to sensitization in the brain or hyper-excitability of certain brain networks.

REHMAnd what does that mean, this shift? What does it mean to the patient to begin to understand that he or she has a brain disorder and not simply an expansion or compression of some vein in the brain?

DODICKWell, what it means to the patient and any patient will tell you that, you know, headache, I often say we should take the headache out of migraine because migraine has been defined by the headache for millennia. But there are so many neurological symptoms that accompany the headache and disable patients almost equally as badly as the headache itself.

DODICKSo what it means for patients is that when we say that a patient has a disease, not only does it mean necessarily that they have abnormal structure of that organ but abnormal function. So normally, when we do an MRI scan or scan of the brain of someone with migraine, generally speaking, it's normal.

DODICKThe problem is that if we did a functional scan of the brain, we see how abnormally the brain is behaving. So it's a disorder of function, if you will, rather than structure. Patients shouldn't get alarmed that they have a brain disease, but by the same token, when any patient who sits in my office and tells me that they can't concentrate, they can't remember, they have trouble speaking, they have trouble understanding, they have dizziness and so on and so forth, one recognizes very clearly that this is so much more than a bad headache.

REHMDr. David Dodick, he's a neurologist at the Mayo Clinic in Arizona. He's chair of the American Migraine Foundation. I can see that we've already got a great many callers and I know that we won't be able to respond to each and every listener's question on the air ,but Dr. Dodick has agreed to answer some questions about migraines after the show if you will submit your questions on our website, drshow.org

REHMYou can email or send us a tweet or leave a Facebook comment and Dr. Dodick will try to get to your question. Now, turning to you, Teri Robert, you are a patient educator and advocate. You're the author of "Living Well with Migraine Disease and Headache." Tell me about your own experience with migraine.

ROBERTI had my first migraine that I remember when I was six. My father used to say he would come home from work and find me in my closet with my blanket and pillow because it was dark and quiet there. Through most of my school years, they were infrequent, they were episodic and they weren't a big deal.

ROBERTBut as I got into my mid-30s, they became more frequent. Then when I got to my early 40s, they were almost daily, five and six days a week and I was flat on my back in bed all day and nothing worked. And unfortunately, no doctor within 100 miles or so of my house seemed to be able to help me.

ROBERTSo after nearly two years of this, realizing I had no life, I decided to hit the internet looking for information and I couldn't find anything, any real consistency. One website would say this, one website would say that. It became really aggravating beyond belief.

ROBERTI went to about.com because I'd used their diabetes site to great success, but they had no migraine site. So I finally was looking at things like the American Headache Society and the National Headache Foundation and was finding finally some good information and decided, well, you know, if I'm having this much trouble, there have to be other people.

ROBERTAnd about.com was looking for someone to start writing a migraine site for them so the old English teacher in me decided, well, this is interesting so I'm going to apply for the job and I got it. Not something that I could do a lot of, but it was the kind of job that maybe I could do at home on my own when I -- those few hours a week that I was up and felt like work.

ROBERTSo once I started that, I discovered neurologists are not necessarily migraine specialists, but there are migraine specialists out there. Well, that was news to me. So as we worked on this site, I met someone who had gone to the Jefferson Headache Center in Philadelphia and seen Dr. William Young. That's eight hours from my house. I decided I didn't care. I wanted to cut to the chase.

ROBERTI waited nine months for my first appointment because he was that booked. But working with him, I got my life back and I'll never forget the first day in his office, sitting there in tears after he said to me, if you don't give up on me, I won't give up on you. You do not have to live this way.

REHMTeri Robert, she's patient educator and advocate, author of "Living Well with Migraine Disease and Headache." Dr. Richardson, why is it that there's so few migraine specialists out there?

RICHARDSONWell, this is a condition that has flipped over in so many ways, was thought to be stress-related, even by my colleagues in neurology. And now if you look at the International Headache Society classification, there's no such headache that is defined as stress headache. Instead, things like that can be a trigger for underlying migraine and also there are people who do not...

REHMYou've lost your train of thought.

RICHARDSONLost my train of thought.

REHMThat's all right. We'll come back to it after a short break, Dr. Perry Richardson of GW, here in Washington.

REHMAnd welcome back. Just before the break, Dr. Richardson, you were about to make a point about why there are so few physicians to treat migraines out there and I also want to understand what a migraine looks like in the brain.

RICHARDSONSorry about that. I thought almost a migraine might have been coming on to me. But the point I was going to make is it does not have a traditional nook around on the body or even on a standard MRI scan. And many neurologists go into the field because they're interested in documenting where is there a problem in the circuitry. But it's changing. It's turning upside down. There's now evidence that there is an anatomy and there is a chemistry of migraine.

RICHARDSONIt's picked up on functional MRI, which is not a standard procedure in most radiologist's office and it's often used for research. Inside the brain, though, there is a cascade of neurotransmitter changes that are activating the pain nerves in the body. One of the biggest advances is an animal model of a headache is now available. And that's leading to understanding more.

REHMWhat kind of animal?

RICHARDSONRats that are subjected to inflammatory chemicals can be recorded to have pain experience by microelectrodes that are implanted in the nerve cells. And medications can be developed to reduce and correct this activation.

REHMOf course, pity the poor rats. But one hope that for the sake of scientific research, we can move forward here. Dr. Dodick, what does that brain look like under a PET scan when someone is having a migraine?

DODICKWell, Diane, when one does a functional scan, like Dr. Richardson just talked about, whether it's a PET or a functional MRI, we see activation of certain regions in the brain and certain networks in the brain, particularly those networks that process sensory information, like light and noise and pain and emotion. So we see activation of all of these networks during migraine. And indeed what we've come to recognize now is that not just during a migraine attack.

DODICKBut even in between attacks the brain is processing all of that sensory information in an abnormally excitable way. So, migraine was thought to be just a disorder that comes and goes and you're perfectly normal in between. But we now recognize the fact that it's an abnormal processing -- abnormal network processing in the brain that continues even between attacks.

REHMAnd here's an email follow up on that comment, Dr. Dodick. It's from John in Cleveland who said, what is the possibility that people suffering from migraines are also predisposed to other mental health issues?

DODICKThat's an excellent question. And that's one of the reasons why we, as a medical community, absolutely must take this to sort of more seriously. Migraine sufferers are three times more likely to have psychiatric disorder such as depression, anxiety, bipolar illness. They're twice as likely to have epilepsy. They're twice as likely to suffer an ischemic stroke. They're six to 15 times more likely to develop brain lesions.

DODICKThey're four and a half times more likely to have attempted suicide in the past year. So, you know, it's not just migraine, but it's all of the company in the (word?) disorders that migraine keeps.

REHMHere's another email. It's from Zanad (sp?) who says, "My daughter is five years old, suffers from migraines about once or twice a month. Her triggers are exhaustion and dehydration. How often do you see migraines in children? What are the treatment options for young children and especially interested in natural remedies." That five-year-old child must resonate with you, Teri.

ROBERTWell, she does and especially since I now have four grandchildren with migraine. The first thing I'd say to this parent is you know the triggers. Right there is a very first major step in migraine management is managing the triggers. If you know the triggers, avoid them when possible. With dehydration and exhaustion, regular sleep patterns are extremely important to migraine horrors, and avoiding that exhaustion and avoiding the dehydration.

REHMDr. Perry, are the treatments for children different from those for adults?

RICHARDSONWell, there's not a lot of evidence about medication use in children. So we would try to emphasize non-medication treatment until we get more data that shows that drugs can help. Now, in adolescents, some of the triptans, which you'll hear about, had been found to be useful if the headache is bad enough to warrant it. In adolescents and I think in children also, headaches tend to be shorter than in adults.

REHMAnd Dr. Dodick, Teri mentioned something else that her grandchildren now have migraines. Are migraines hereditary?

DODICKAbsolutely, Diane. You know, there are now five genetic mutations and over a dozen genetic variants that have been identified with migraines in various subtypes of migraine. So it's unquestionable that is an inherent disorder that's modulated or modified by the environment. And that's an important point. Some people think that stress is causing the headache or changes in barometric pressure are causing the headache.

DODICKThey are simply triggers. And anything that upsets the internal homeostasis or balance in the body, be it sleep deprivation or eating certain foods or taking certain medications can trigger a genetically susceptible brain to activate these networks in the brain and cause the symptoms of migraine. I'll also say that children, 17 percent...

REHMSorry.

DODICKSeventeen percent of children are affected by severe and recurrent headaches in this country, 17 percent. And while there's a broad spectrum of suffering, some may experience one attack a month, other may experience pain and other symptoms of migraine continuously, 24/7, and they're terribly disabled.

REHMAnd women are more susceptible than men?

DODICKYes, women are three times more likely to experience migraine. This past year in the United States, 22 percent or basically 1 in 5 women will experience and suffer from recurrent migraine, which is an amazing statistic. Over the lifetime of a women, over a third will experience migraine. So it's three times more likely. But in children, the prevalence or how common it is seems to be equal between boys and girls.

DODICKAnd it isn't until sort of adolescence and teenage years that it seems to become more prevalent in girls and women.

REHMTeri, do you think that doctors are now taking migraine much more seriously?

ROBERTOh, absolutely. I see a world of difference just in the 12 years that I've been working in this field. They're taking it far more seriously and, you know, it's a privilege for me to sometimes meet with and work with doctors such as Dr. Dodick and Perry here and Dr. Young who first treated me who have so much knowledge, but also so much compassions for the patients. If 12 years ago someone had told me that kind of doctor was out there, I'd have laughed myself silly.

ROBERTBut, yes, I think things are being taken more seriously. We just need more doctors like these fellas.

REHMAll right. And here's an email, "Five years ago," this individual says, "I suffered from a series of debilitating rebound migraines that left me incapacitated. Dr. Richardson figured out I was having an allergic reaction and put me on a series of Botox shots, which were experimental at the time, and the only thing that made me better. First, I want to thank Dr. Richardson for figuring out what was wrong with me. And second, please comment on where the Botox studies are now."

RICHARDSONSo, FDA has approved one type of Botulinum toxin called OnabotulinumtoxinA for very specific subtype of headache that's called chronic migraine. It's defined by 15 or more days per month of headache and four hours per day of migraine. Now, there are a lot of patients who develop this kind of transformation from episodic headache to a chronic migraine, probably about 14 percent of people who have episodic migraine can fall into that pattern, like Teri.

RICHARDSONSometimes it's because there is overuse of the analgesic. So we have a long way to go to educate physicians and patients not to just rely on overused medications, like analgesics. Some drugs, for example, barbiturate-containing drugs like butabarbital with caffeine can subject somebody to chronic headache as a rebound effect and with as little as five days per month of use of that drug.

RICHARDSONMore often, about two to three days maximum per week is recommended lest we put somebody over into chronic migraine. Botulinum toxin has been a bridging drug to help us wean patients off of analgesics that are overused.

REHMAnd how are those injections given?

RICHARDSONSo after a lot of early phase studies, a consensus for distributing the Botulinum toxin in the scalp muscles, in the forehead over the eyebrows, in the temples and in the back of the head and then the neck muscles. This has now been standardized and patients will often get a reduction in the frequency of the headache that last about three months.

REHMAnd what that does is to paralyze the muscles?

RICHARDSONWell, it's not -- the mechanism is not precisely known. It may be that it is having to do more with the sensory nerve endings in the muscles, even though it's injected into muscle because the trigeminal nerve, which is the nerve of pain -- and I said there is anatomy now of migraine -- is bathed in the Botox also. And so, there may be -- a theory goes that the sensitization of the sensory nerves is affected by Botulim toxin.

REHMDr. Dodick, the migraine drugs available today are called triptans. Tell us what they are and how effective they are.

DODICKSo, Diane, the triptans represent the only class of medication that were specifically designed to treat migraine in the past 60 years. That's it, one single class. The first one was approved in 1991. There are now available triptans on the market, available from pills to injections to nasal sprays. When the triptans were developed, they were developed on the premise that they were to constrict blood vessels.

DODICKBecause 20 years ago, as we discussed, migraine was thought to be a blood vessel disorder. What we didn't realize is that these drugs actually bind to the nerve endings and also get into the brain and bind to centers in the brain that shut pain off. So the triptans are very effective. They really revolutionized the acute treatment of migraine, but we still have a long way to go. There are a lot of patients who can't take these medications if they have heart disease or high blood pressure or had stroke.

DODICKThere are certain medications that they can't be taken with. And, really, while I say they were revolutionary, 60 percent of patients will have some response to them. But most patients when they take a medication they want to be pain free, symptom free very quickly and not have to take another tablet within the next 24 hours. If we consider that as an endpoint, only about one-fifth of patients will actually respond in that way consistently to the triptan. So we have a long way to go.

REHMDr. David Dodick of the Mayo Clinic and you're listening to "The Diane Rehm Show." And joining us now from the studio of the National Institutes of Health in Bethesda, Dr. Story Landis. Good morning to you, Dr. Landis.

DR. STORY LANDISGood morning. I'm glad to be able to join you and sorry that I missed the first half of the show.

REHMAll right. And Dr. Landis is director at the Institute of Neurological Disorders and Stroke at the NIH. Dr. Landis, part of the problem with migraines apparently is that NIH has not been able to adequately fund migraine. Is that correct?

LANDISI would have to agree that it is correct. I think both headache and migraine warrant greater investment than we've made in the past. In fact, I have migraines as does my son. I'm fortunate among migraine sufferers that Verapamil, a calcium channel blocker that may have been discussed earlier has actually stopped them.

REHMSo, why is it that more resources have not gone to a problem that apparently affects a great many people in this country?

LANDISSo, one of the important aspects of having a well-funded research area is that there be a reasonably large group of investigators, dedicated scientists with novel ideas. And for a variety of reasons, that may or may not have been discussed earlier. The headache research community is actually rather small. Fortunately, this has been changing. NIDS in particular has focused on supporting career development awards for junior investigators with an interest in migraine and headache.

LANDISIn fact, in the past six years, we funded 12 such junior investigators to grow the community. NIH staff will have to watch carefully to make sure that their careers develop well and that they, as their careers progress, actually submit grants to the NIH which fall within a fundable range.

REHMDo you think that NIH has been primarily interested in disorders or diseases that actually kill people and that that's why there has been less interest, less funding?

LANDISThat's an interesting question. Maybe I could say a little bit about how decisions are made about what grants will get funded and what areas?

REHMSure.

LANDISSo, NIH -- most of what NIH funds depends upon selection of applications for funding that individual investigators have submitted.

REHMSure.

LANDISInvestigator-initiated research. Researchers write applications. They send them into NIH. They're reviewed by study sections made up of scientific peers and they're given a priority score that ranges from 10 to 90. We then take that score and turn it into a percentile for each grant. And the institutes fund as many of the grants as their budget allows. Now, given constraints in our budget, that's been fewer grants than we would like to be funding or have in the past.

LANDISAt NIDS, if the grant has a 15 percentile or better for a particular year, this last year, then we fund it. So, it's obvious that the more investigators work in a particular area, who have good proposals, it's more shots on goal and more likely that additional dollars will be invested.

REHMDr. Story Landis, she joins us from NIH in Bethesda, MD. Short break. We'll be right back.

REHMWe've been talking about migraines. In this hour we're going to finally open the phones to take your calls, 800-433-8850. Let's go first to Fort Lauderdale, Fla. Good morning, Denise, you're on the air.

DENISEGood morning Diane. Thank you very much for taking my call.

REHMSure.

DENISEI wanted to express that I was a migraine sufferer for many years and I started keeping a log of everything I ate, drank, what did I do and I made a chart after a few years and I have found that my migraines were related to food. Mainly, the sulfites in wine, I haven't had wine for 18 years. MSG, monosodium glutamate which is in soups, salad dressings, barbeque potato chips, everything. Nitrates, which you find in bacon and sausage, which is easy to get without at health food stores.

DENISEFluorescent lights, flickering fluorescent lights are a terrible trigger and also, oddly, the sunglasses that are tinted a pale green or yellow such as the maker Varna or that type. Those were instant triggers, the few times I'd put those sunglasses on. And also coffee, oddly enough, is a terrible trigger for me.

REHMSo I gather in terms of food, you know, it may be one thing for one person, another thing for another person. Dr. Dodick, there is generality or are there generalities?

DODICKNo, there really aren't any generalities, Diane. I mean, the caller describes triggers that are notorious for triggering migraine but for every individual sufferer may report different dietary triggers and then many sufferers can't find any dietary triggers and they go through these dramatic elimination diets where they're eating very little actually, rice and water, and still they suffer. So the triggers for migraine are ubiquitous, they're all over the place both internal and external triggers. Dietary happens to be one of them but as you say, it varies between individuals but I'm very glad to hear that the patient found her triggers.

REHMNow, what about for you, Teri, were there food triggers?

ROBERTNot a one and I did the kind of elimination diet Dr. Dodick is talking about, twice over. Not a single dietary trigger.

REHMDr. Landis, is anyone at NIH looking at dietary factors?

LANDISNot to my knowledge. I checked through the roster of grants that were funded and I don't recall any that were looking specifically at dietary triggers.

REHMAll right. To East Brook, Me. Good morning, Gary, you're on the air.

GARYGood morning, Diane. A question that I have is that are we inadvertently impacting the population by developing and continuing to develop wind turbines all over the United States. 10 to 15 percent of the population all over the world reports that they have migraine type illnesses that they relate to wind turbines.

REHMAnd we heard some of that in our last hour. Dr. Dodick?

DODICKYes, well, you know, environmental factors are a trigger for some patients. While the caller's right, 10 percent of the population suffer from migraine, a percentage of them will report changes in barometric pressure and weather fronts as being a trigger for migraine, not necessarily just wind per se. We're still trying to struggle to find out the mechanism by which, and the consistency with which environmental factors trigger migraine. But we're a ways off from understanding that relationship.

REHMAll right. To Cleveland, Ohio. Good morning Ken.

KENHi, Diane and thank you for taking my call this morning.

REHMSurely.

KENI have two questions for your panel. I've been a migrainer for the past 34 years having common migraine or migraine without aura. My two questions are, number one, what, speak further about prophylaxes for migraine. Verapamil was mentioned and I've been through a number of drugs. I've actually found roughly equivalent protection taking over the counter supplements, specifically massive amounts of magnesium and B2.

KENAnd secondly, if you could elaborate a little bit more on the association that was mentioned between migraine and stroke, specifically stroke in the young. I had a massive ischemic stroke at age 34 and while I have no deficits from it, I also have no more left hemispherical migraine as a result. And I'll take my answers off the air. Thank you Diane.

REHMAll right, thanks for calling. Dr. Richardson, do you want to take prophylaxis?

RICHARDSONYes, I think that's an underutilized treatment for migraine and it, especially in this day and age, when we know that people who take too many acute pain medications can actually invite more chronic migraine. Physicians and patients need to know that there are four drugs FDA approved for prevention of migraine, reduce of the frequency and several others that have fairly good evidence that they work.

RICHARDSONIt's hard to detect which medicine would appropriate for each person so we do what this caller has done. We go through a trial and error process often but we can choose medications that might attack two things at once. One of the medications, topiramate can cause weight loss and someone with obesity or diabetes may benefit from that in terms of weight loss and migraine and other medicines, beta blockers, and Verapamil, hypertension, can be treated by those things. so I individualize that question and supplements are just beginning to get some evidence of their efficacy but it's, they often take longer to work than the standard prophylaxis, pharmacologic agents.

REHMAnd what about strokes in the young, Dr. Dodick?

DODICKWell, in actual fact the increased risk of stroke that I referred to earlier in patients with migraine, it appears that those who have migraine with aura are more likely to experience an ischemic stroke. They're twice as likely compared to people who don't have migraine and those who have migraine without aura. In fact, in point of fact, it tends to be more common in women and it tends to be more common in younger women less than the age of 45. So it's interesting to hear the caller say that he suffered an ischemic stroke at such an early age, at the age of 34, and it begs the question as to whether or not his migraine disorder was related or causal in some way to the stroke that he had.

REHMAnd from our website, someone sends this. "I've been a migraine sufferer since I was in high school, I'm now 47. In the past four years, I have experienced two complex migraines which mimic having a stroke. They are terrifying to go through. What are your recommendations for these specific migraines?" Can you speak to that, Dr. Dodick?

DODICKSure. People and some physicians use the term complex migraine, the technical term for that is migraine with aura. What that means is that there are reversible neurological symptoms that can either be visual, where you lose vision. They could be sensory where one side of the body goes numb. It can involve language where you lose the ability to speak or understand speech or you can actually become paralyzed on one side of the body. So very closely mimics stroke, although there are some features when a patient presents that allow us to distinguish between those. What to do for them, it depends on the frequency with which they occur, but there are preventative medications that we specifically use to try to prevent them from occurring in the first place.

REHMSuch as?

DODICKWell, such as Dr. Landis mentioned, Verapamil as being one of them, but there are others that used as well. I will make the point that the American Headache Society and the American Academy of Neurology just published and released their new updated guidelines for migraine prevention and I would encourage listeners to go to the American Academy of Neurology or American Headache Society website, to look up those medications which are recommended for the prevention of migraine.

REHMDr. Dodick, you heard Story Landis say that, you know, there hadn't been that many applications for research or from research investigators for migraine and I wonder how you see that. Why do you think there has not been that interest? Do you see that increasing in medical specialists around the world?

DODICKYes, I totally agree with Dr. Landis. Part of the problem, Diane, is that in medical school, for example, I had zero hours of education in migraine and other headache disorders and in my residency, when I was training to become a neurologist I had two hours. So it's hard to get inspired to chase a career in a disease or a disorder for which I've had no education. That's part of the problem. That's changing fortunately and now headache medicine is an accredited specialty of neurology in the United States right now and we're board certifying headache specialists.

DODICKSo we've come a long way, but when you don't have qualified scientists or clinician scientists in the field to competitively, you know, submit grants for research that are competitive with other disease states, then it becomes very difficult for Dr. Landis and her colleagues at the NIH to actually support that. But that's changing and I'm already starting to see now more scientists in the field, much more aggressive research agenda and more money coming from NIH to fund these research projects.

REHMDr. Landis, do you want to speak to that?

LANDISWell, we work very hard to create a cadre of investigators. I know one of the concerns that they headache research community has had for some time is that perhaps their applications are not viewed as well as applications from people working on other disease states. We actually were concerned about that as well and did an analysis and the success rates are very similar. So I don't think it's a question of people being disinterested or thinking that the quality of, reviewers being disinterested or thinking of the quality of the applications is poor because those applications do just well.

LANDISAnd we work with all the headache scientific organizations presenting workshops on how to write a good grant and encourage them to apply and the particular program director who has this portfolio has, I think, been very aggressive in working with the community to encourage applications and to help people make sure that it's the best possible application it can be when it comes in.

REHMI'm glad to hear that. Let's now go to Farmington Hills, MI. Good morning, Roberta.

ROBERTAHi, Diane, thank you and thank your panel. And Diane, I love your show.

REHMThank you.

ROBERTAI have a quick question and a quick comment. I almost came to tears listening to this program because I suffered from being a very little girl and I just hear the things that I went through and I'm calling because my daughter, who now suffers with migraines, she's in the Minneapolis area, and she can't seem to find anyone who knows what to do about this. She suffered with them as a child.

ROBERTAWe've been to doctors throughout Michigan. Medication after medication after medication, I've kept all the medication. I kept them in a bag over the years just because I became so overwhelmed. And she's been calling me for the last week, Mom, I just -- I go to this clinic and they just give me this particular medicine. And, I go this clinic and -- where can she go in the Minneapolis area to get help?

REHMThat's just heartbreaking. Teri, and kind of the same problems you went through.

ROBERTHi darling. Yes, I have gone through this and there are a lot of people going through and quite honestly I don't have the information at my fingertips right now but are you online? Do you, you have internet access, right?

ROBERTAI do have internet access, yes I do.

ROBERTFind me on Facebook. We'll find you someone in that area, we'll find you someone who can help you and we'll get you some support in the meantime, okay?

REHMSo, give me the website.

ROBERTI'm Teri Robert on Facebook and so just find me there and we'll get you some help.

REHMAnd you're listening to "The Diane Rehm Show." Dr. Dodick, any recommendations for physicians out in Minneapolis?

DODICKSure. well, I hesitate to use their name on this show but I have, there are a number of qualified specialists in the Minneapolis area and full disclosure here and obviously I have a conflict of interest but the Mayo Clinic is just up the road 90 miles in Rochester, MN, and I have many highly qualified and expert colleagues up there at the Mayo Clinic. So I would highly encourage the caller to help her daughter seek care perhaps at Mayo Clinic.

REHMDr. Richardson, is there a migraine gene?

RICHARDSONSince it's certainly hereditary there's probably a combination of genes that will be discovered ultimately that render somebody susceptible to migraine.

REHMDr. Dodick?

DODICKYes, Diane, there are four genes now that have been identified where mutations in those genes will render people susceptible to what we call hemiplegic migraine, where they become paralyzed on one side. And as I alluded to earlier, there are now more than a dozen genes, including a couple on the X chromosome which may in part explain why migraine is more common in women.

DODICKBut there are over a dozen genes now where variants or abnormalities within the gene seem to occur more commonly than migraine than in those who don't have migraine. So there are many investigators on the hunt for migraine genes but we're unlikely to find a single gene. We're likely to find a multitude of genes where abnormalities within those genes lead one to be susceptible to migraine.

REHMWe have had so many emails, so many callers, here's one last email. "I have been diagnosed with silent or optic migraines. Other than having no pain, how else do these migraines differ clinically from the more common ones?" Dr. Richardson?

RICHARDSONSo that's very interesting and it shows that there's a brain disorder underlying migraine and pain does not necessarily have to be linked. Migraine often evolves over the lifetime of an individual, sometimes goes away for good but sometimes after menopause in women or middle age in men, the disorder changes into migraine without pain. And one of the most common things is the visual aura which is not followed by pain. If it's very frequent it can respond to the preventive medicines as migraine with headache can.

REHMAnd is brain surgery ever an option for migraines?

RICHARDSONWell, there are some severe headaches variants like cluster headaches, that's not the same as migraine, where deep brain stimulation surgery has been tried with some success. But there are less invasive ways to try to modulate the excitability of the nervous system and this is the new era in migraine.

REHMDr. Perry Richardson at GW Hospital here in Washington. Teri Robert, she's the author of "Living Well With Migraine Disease and Headache." Dr. David Dodick, he's a neurologist at the Mayo Clinic and Dr. Story Landis of NIH. Dr. Dodick has said he'd be willing to answer more of your questions from Facebook, from Twitter and at our website. Thank you all so much and thanks for listening. I'm Diane Rehm.