#406 ‒ Migraine, cluster headache, and tension headache: symptoms, causes, prevention, and treatment | Brian Grosberg, M.D.

**Peter Attia** (0:11)
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My guest this week is Dr. Brian Grosberg. Brian is an internationally recognized headache specialist. He's the Director of the Hartford Health Care Headache Program and a Professor of Neurology at the University of Connecticut School of Medicine. He's one of the leading experts in migraine, cluster headache, and other complex headache disorders, and has spent his career treating patients who are often profoundly impacted and debilitated by these conditions. In this episode, we talk about how headaches are classified and what distinguishes a migraine from a tension type headache and a cluster headache, why migraine is often misunderstood and underdiagnosed despite affecting tens of millions of people, the phases of migraine including prodrome, aura, headache, and post-drome, the genetic, hormonal, and environmental factors that influence migraine risk especially in women, the societal and economic burden of headache disorders including its impact on disability, how clinicians think about diagnosis when there are no obvious biomarkers or imaging findings, lifestyle factors, triggers, and risk modifiers that influence headache frequency and severity, preventive versus acute treatment strategies and how treatment decisions are individualized, advances in migraine therapy including CGRP targeted medications, neuromodulation devices, and even Botox, and when headaches may signal a secondary more serious underlying condition. So without further delay, please enjoy my conversation with Dr. Brian Grosberg.
Brian, thank you so much for coming. And I didn't realize until a few minutes ago that not only had you never been on a podcast, which these days is pretty unusual, especially if you're an expert in something which you are, but that you've never listened to a podcast. Yes, it makes me a unicorn. Yes. Okay, this is a topic that I think just affects so many people. I want to maybe understand the landscape a little bit about the field of neurology. What fraction of neurologists specialize in headache? How did you decide that this is what you wanted to do?

**Brian Grosberg** (2:59)
So first of all, thank you very much for having me. I really appreciate it, Peter. It's important to understand that headache is one of the most common neurologic symptoms.
Nearly at some point in every person's life, they're going to experience a headache. Surprisingly, in medical school, maybe medical students and residents get a few hours across entire medical school of lectures.

**Peter Attia** (3:20)
I actually don't recall any of it. It's possible I had it and I just don't recall it, but I actually don't recall anything.

**Brian Grosberg** (3:26)
Yeah. And so that's a gap in education. And then in neurology residencies, that is similar, where people are only, neurology residents are, depending on the program, of course, may only get a few hours of headache lectures or education. And then they're experts.
And so for my journey, if you will, into headache medicine was actually by accident, complete serendipity. My first year of a neurology residency, I took care of a litigator who was out of work for six weeks due to a prolonged migraine that had been going on for six weeks straight. And without knowing, the person who was caring for her turned out to be my future mentor. And so I had called this person and-

**Peter Attia** (4:08)
And you were a resident at this time? I was a resident.

**Brian Grosberg** (4:10)
I was probably a month into my neurology residency.

**Peter Attia** (4:12)
So it was really early on.

**Brian Grosberg** (4:14)
So the patient took a history, read up on it, and then detailed the history to him.
And he said, thank you so much. Are you in your last year of residency?
I said, no, I'm a month in. He said, well, that was great. Why don't you come by my office and let's talk? And so I did that. I got very interested in seeing patients with him. He offered to see patients with me. Residency at that time, when you were on call, the hours weren't restricted. And so if you were in the hospital 30 or 34 hours, whatever the case was, I would change out of scrubs into a shirt and tie. And then I would go see patients with him in the office, even though I'd already been in the hospital for that prolonged period of time. So my training in headache medicine was very expedited, if you will, during my residency. And then from there, after I finished my pursuit, advanced training in headache medicine, and there are just a limited number of programs in the country that offer fellowship training in headache medicine.