EP. 065: More than Meds - Exploring Physiotherapy for Migraine Management with Kerstin Luedtke

Hi and welcome to Physiotutors Podcast episode 65 with Dr. Kerstin Lütgei. Kerstin is a physiotherapist, maniotherapist and professor at the University of Lübeck, Germany. She has published over a hundred papers on a variety of topics and has done extensive research on migraines, which is our topic of today's episode. Hi Kerstin, welcome to the podcast and great to have you. Thank you for having me. Sure, I have prepared a lot of questions, so let's start. Let's start out. Could you please give us a brief definition of migraine headaches? Yes, migraine headaches are classified within a very comprehensive overview provided by the International Headache Classification, or the International Headache Society's Classification System. And a migraine headache exists if you've had five, you need to have five attacks and they need to fulfill certain criteria. And the criteria are that the headache lasts four to 72 hours. It needs to be unilateral, moderate or high intensity. It needs a pulsating quality and it gets worse with physical activity. And the other issue that you really need to have to fulfill migraine criteria is you need to have associated symptoms. And these could be nausea with or without vomiting or it could be phonophobia and photophobia. And only if you fulfill these criteria, this is called a migraine headache. All right, and there's also a special category within the migraine sufferers. And that's a migraine with aura. What is that and how many people who have migraine also experience or are symptoms? Yes, sure. This is an interesting question, because I think one of the mysteries about migraine are that only if you have aura is migraine, which is absolutely not true. Migraine with aura is only one subcategory of approximately 30 different migraine subtypes. And so if you have migraine with aura, what you usually have is visual symptoms, most of the RS are visual. And it can be like a unilateral flickering or it could be colorful lines through your field of vision, different types of visual phenomena that people describe. This occurs before the headache comes on, usually like 30 to 60 minutes before the headaches comes on. In rare cases, this can be sensory, so something like pins and needles. There's a very rare type of aura, which is like a hemiplegic aura. This is one subtype of migraine, which is the only one that we know the genetics of. It's strictly familiar and it's called hemiplegic migraine, so this is a very scary aura, but this is extremely rare. Or you said, "How many?" I forgot a part of the question. It's approximately 10% of migraines are first that do have aura. Okay. And at the moment, what is the leading path of physiological theory behind migraine headaches? I think there's still a bit of a discussion going on, right? There is some discussion, although we have to say, compared to other pathologies, we have understood migraine fairly well. The main driving physiological changes occur in the central nervous system. And there's one structure, which is even sometimes called the migraine generator, which is the hypothalamus. And to the reason why it's called that is in one study where people have been migraines have been scanned for 31 days, each and every day in the MRI scanner. And receiving visual or olfactory or painful stimulation in the scanner, the outcome was that even before people knew they're going to have a migraine, around about 48 hours before the headache comes on, the hypothalamus was the first structure to react to these stimulation. So it's the first structure of our body that we know of where migraine tech starts. And this is why they're called the migraine generator. From here, it's triggered all over. One of the main areas is the trigeminal nervous system. This is responsible for all the symptoms that we know, responsible for the pain. Because it elevates the duamata, which is the structure that calls headaches, also responsible for anything that we feel in the face. Possibly triggering something to the neck, which is probably something that we're going to talk about later. And also triggering other structures in the brain, responsible for the hypersensitivity, responsible for the feeling of dizziness or nausea and all the known symptoms of migraine. So it's starting in the center of the brain. And it spreads from there, changes the vascular system, for example. But that's not the course, but the consequence. Okay. And maybe as a follow-up question, how is the hypothalamus of migraine sufferers different to the hypothalamus of people who don't have it? It's probably the key question that we're still trying to understand. Well, I think the most accepted theory at the moment is that the brain is constantly adapting to anything. And the brain is constantly active. So there might be cyclic changes within the nervous system, which are totally normal. And it swings up and it swings down. It becomes more sensitive. It becomes less sensitive, which is probably a very normal procedure. But what changes the system or what explains why people with migraine then develop an attack at other people's don't is probably because there's a lack of inhibition. So there's nothing stopping that sensitivity. Usually in our system, when things become more sensitive, at the same time, the inhibition system is starting to work. And so it keeps things in balance. And this is probably what is disturbed in people with migraine. That is, this sounds a bit like chronic pain to me. If we talk about central sensitization, like a lack of inhibition. Definitely. Definitely, there are similarities between what we know about chronic low back pain, for example, which is probably more study disease. And people with migraine, there's one big difference. And that's in between attacks. Migraine patients are probably very similar. Or you have to look very hard to find any differences to people without migraine. While we know from people with chronic neck pain, chronic low back pain or CRPS or phantom limb pain, all those other chronic pain models that have been studied that there's no in between attacks. There's probably changes which are more or less intense, but it's tonic. Very interesting stuff. And I think we already started discussing a little bit about risk factors. So what could be a reason that people, first of all, develop migraines, but also what are risk factors that trigger migraine episodes? I don't know if you want to split your answer. Probably study with your first question. Not really know. There is people who say that everybody can develop migraine attacks. There's another pool of people who says it's a genetic disease. There has been genetic studies where they found, I think it's about 130 or something gene genetic changes on people with migraine compared to people without. Most of these are known genes, so they're known changes that we know from depression, from chronic pain, from other diseases. So there's nothing specific for migraine, except for that one type of migraine, which is the familiar hemiplegic migraine. That's the one that we know. But in terms of normal migraine, there is no real genetic explanation, but there's genetic differences. One of the hypothesis could be that if you have got all these differences, you might be able to develop an attack, but you don't necessarily have to. That probably explains why there's a high prevalence in families. Usually people who have migraine have at least one first line family member who also suffers from migraine, which is a difficult thing to say because there's a prevalent disease. The likelihood of somebody else having migraine is high. So there's no real explanation, but there could be one. So a genetic predisposition and then other things occurring in life. Maybe there's even a learning factor to it, but I think starting a discussion if I say that. Question number two was what triggers the attack, right? Well, if you ask people with migraine, I think everybody can tell you triggers. And these are the common things that everybody knows, like stress, but people with migraine don't have more stress than other people. Everybody has got stress. That's normal. But it's what people say. So a high levels of stress, or even the dropping from a high level of stress, which triggers that very unpleasant sensation of weekend headaches. The other thing that people say is weather, but then again studies were not able to confirm any weather changes, at least not any sort of pressure changes from a high to a low or from a low to a high, did not correlate with migraine diaries. The other thing that people say are specific foods or drinks like alcohol or coffee, that sort of thing, chocolate, citrus fruit, these sort of foods. The problem is that researchers would really like to trigger migraine attacks. So attempts have been made to trigger migraine with let's say it will be very useful to give somebody a piece of chocolate, then put them in a scanner and be able to record a migraine aura. Migraine aura is very understudied because it's very difficult to catch it. And if we could do that by triggering it reliably that we're really good, but it never worked. So one of the explanations at the moment is that possibly what people call a migraine trigger is a symptom of the prodromal phase of migraine, which means that let's say if the migraine is coming on and we know your hypothalamus is already very active, this might trigger the desire for specific foods, for example. I've had a patient and I think I have to tell you because it was very, for me, it was very convincing because she said she never drinks any alcohol for years. She's never had any alcohol, but when she knows she would like to have a glass of red wine, she knows on the next day she's gonna have a headache. And this could either be a self offering prophecy or it could be the desire for red wine, which is part of her normal migraine attack. The other thing is that people are more, this is something that's indefinite, more hypersensitive in the prodromal phase of the attack, and maybe then sort of the same level of stress or the same weather or anything that sort of surrounds us all the time is maybe just perceived as more stressful or more unpleasant or and that might be or that might lead to the interpretation of this being a trigger to an attack. But this is hypothetical. It makes sense though. Okay and by the way I forgot to mention this in a beginning if you have any specific articles and mind or authors feel free to throw out names because we always have a transcript and we will link all of the articles in the transcript so people really want to dive deep, they can look them up so no problem. I mean if you mentioned that the they call it the mother of all studies, which is the one where people have been scanned for 31 days. This has been done by a girl called Laura Schulter from the Hamburg Research Group and I think this is a study that's really worth reading because the effort has been put into scanning people for 31 days each and every day at the same time of the day without any medication that is recommitment so I think this is probably the most worthy one to read. Yeah definitely going to read that after our podcast record. And we already touched a little bit on prevalence when we talked about heredity. How prevalent are migrant headaches especially if we compare to other forms of headache? Well numbers change obviously because you can only count people who have entered the medical system somehow and these numbers are always sort of around 15% prevalence globally. One year prevalence is obviously a little higher. Sometimes it's up to 20% but around about that numbers. Okay and comparison to tension type headache. It's basically it's probably number two right? No it's actually the other way around. There's two types of tension type headache. One is the episodic tension type headache which is probably the most prevalent headache type of all. It's what we have when we say we've not slept enough or we hadn't had enough water or something like that. This usually fulfills the criteria for tension type headache if diagnosed according to the international classification of headaches. But this type of headache because it responds to medication it's usually gone within a few days. It's not that high intensity usually never enters the medical system so numbers here are only based on self-population studies. The other type of tension type headache, the chronic tension type headache and chronic in this case means more than 15 days a month. It's a little bit of a different definition to the chronic pain definitions that we know from low back pain. It's not the months that you have had something but the number of days you have headache in each month. That is extremely rare. But these people suffer a lot because a lot of these people have got headache every day which is really annoying. It's not high intensity, they don't have to lie down, they can't function but it's really annoying and it doesn't respond to any of the medication that we know. Not to the acute medication, not to pain medication, not to preventive medication and it's a lot easier or a lot harder, I should say, a lot harder to treat than chronic migraine in comparison. So I would say a episodic tension type headache is about 80% of the population. Chronic tension type headache around about one, possibly. And the headache type that physios really love the cervical genic headache because it's easy to treat and it responds to physiotherapy treatment. The bad news is this is a lot wearer than we think. I always ask groups, what do you think? How prevalent is cervical genic headache? And I usually get numbers between 20 and 50% and it's round about possibly between one and four percent if we follow the international criteria. Yeah, I was aware of that number. Sorry. Through through through Rene Acastin. Yes. And I think the 80% that I had in mind was exactly based on what you said, episodic tension type headache. I think it was a study by Stolfner who did an analysis. And if we look at the typical migraine patient, is he or she male or female? What age group? What are other typical characteristics of this typical migraine patient? Yeah, it's still the case that migraine is more prevalent in females than in male. Not sure whether this is contact to the medical system, whether male suffer in silence, I don't know. But probably two to one that's that sort of numbers are reported. Where the normal sort of migraine career is that a tech start with puberty. So round about the ages of 11 to 13 possibly a bit later in May than in female. And it usually accompanies papers throughout their productive life years, which is the one reason why it's always considered economically very relevant because it reduces sort of work days. The whole productivity, it's also a burden on family life because the years where you raise children and where you're responsible at home, they're affected by the migraine disease. And in a lot of cases stops in females with menopause. So yes, might be a hormonal contribution to it. But that's not the only explanation because then may it wouldn't be able to have migraine. But it usually stops around at age with exceptions. Okay. And if I move on to my next question, I think we already kind of answered it. But maybe you want to add something else to it. And the question was to what degree do we see commonalities between migraine patients and other chronic pain populations? So we talked about migraine basically having an episode than nothing than an episode while in the chronic pain population, it's like an ongoing thing. What else would you like to add to that question? Yes, we've done actually some research ourselves about this because there's common comorbidities, you should say, like depression, anxiety, that sort of thing. I think we need to be a little bit careful with the interpretation because it might be consequence and not cause of chronicity. What we have looked into is whether migraine patients have a larger two point discrimination threshold on the episode I could find. This is something we know from back pain that the sort of tips of a caliper have to be further apart to be able to distinguish them as two separate tips of a caliper. And we've tried that in the episode I could find of migraine patients, and it was indeed larger than in people without migraine. This was published in Journal of headache and pain. Then another study that we did, but that's very preliminary data, is looking at the left right recommendation. of migraine patients compared to hazy controls regarding heads and faces, so and we found that the accuracy of detecting and the speed, so if it was once weight or response time was worse and people with migraine than had the controls and what else have we looked at? Well, but just very recently a treatment approach which was based on education and something that we know that works really well in chronic pain patients and we've adapted that to migraine, so we've included all the knowledge about pathophysiology of pain, but added to that the pathophysiology of the hypothalamus and the trigeminal nucleus and the the connection between the trigeminal and the cervical system, so added physiological knowledge that's important for the migraine disease and we found that adding the education gives us another two days reduction of migraine symptoms which is I think a nice add to what we can do in physiotherapy and if that works that another is probably another proof that we have got a chronic pain aspect to the migraine disease. Okay, so we talked a lot about the backgrounds or we were laying the groundwork so to say let's move on to diagnosis and my first question is always what are red flags that we have to consider? I mean we touched on the hemiplegic migraine, so I think stroke would be one red flag maybe to consider. What else would you like to rule out when you see a patient who presents to you with a possible migraine? Yes, you can see me thinking. There's quite a lot of reported criteria, I think the most well-known are the SNOOP criteria which have got something to do with the severity of symptoms, so if there's a sudden onset of severe headache that could point towards a red flag which might be like a bleeding, for example, obviously stroke is another one. Brain tumors obviously another one that would become obvious of migraine symptoms or headache symptoms change over time and if they turn towards something that's not known. So a person who's got the same attack with the same criteria and known headache is not scary, but it's supposed to be scary if something changes if it gets worse in the density, worse in frequency if there's a sudden new pain and if there's associated things like systemic fever for example neurological symptoms that would be the most common red flags. Okay, thank you for your answer and if we move on and we talk about the diagnosis is there anything else besides the ICD age three criteria that we talked about that you would consider in your in your approach? Well we're in physiotherapy setting you so I think you're probably interested in musculoskeletal structures and and this is how it all started really because I'm not sure how much you want to know about my own biography but the reason why migraine is interesting is because while I did my PhD on dead pine I was working in a workgroup under the head of department of the headache clinic of Hamburg University Hospital and we had discussions all the time. It's the neck contributing to migraine or not and my physiotherapy background screamed yes yes yes headache is always so I can find and and his neurology background was saying no life stops at the Oxford there's no life south of the Oxford and and so we decided we have to look into this and the literature was surprisingly limited there was hardly any information and so we started investigating by developing a consensus-based battery of tests there was so many different tests and it all didn't make sense so we had to ask experts what would you do how would you assess the swikers fine and people with headache so there was 11 tests that experts agreed on in the consensus statement which was published and was a deathy procedure and I will provide you the reference. I've seen and read the paper so I can put it in there so I'm certain of that. If I could just remember the years but yes the other thing that we rendered as we used those 11 tests and investigated approximately 170 people I was the blinded examiner I didn't know whether people had migraine or not half of them migraine people were episodic half were chronic and once it were people without headaches and both of us the neurologist and I were really surprised to find that over 90% of migraine patients had muscular skeletal dysfunction that we can detect as physios and that obviously opened a lot of questions is this important could it be a cause could it be a contributing factor is it something that maintains a tax could it trigger a tax or is it just a consequence that just because people half repeated the tax and they have all those pains so do they change because of that and obviously that's a lot a lot harder to answer than just assessing the next of people and the muscular skeletal dysfunction set again is published and here in other years 2016 and the Genoa cephalalgia because this has been cited quite a lot and but does this differentiate migraine from cervical genic head I probably not this is a little bit disappointing because we were hoping to find a test and other groups have repeated and some people say that maybe the flexion rotation test where we are testing C12 mainly in rotation could differentiate between cervical genic headache and migraine but in my sample this was positive too so I sorry this this test also does not really distinguish between the two populations I do still think and it is part of the criteria for cervical genic headache that the headache needs to be able to be provoked by maneuvers that we do so if we let's say hold extension lateral flexion for example whatever you want to do so I could quadrant or any other test or manual test if you want and you can provoke the typical headache that I would say strongly provides information about this might be cervical genic headache and not so much migraine but referred pain to the head not because this is something we found in my patients to eat so there is no real distinction I think the other headache type probably interesting to try to distinguish as tension type headache we know that people with tension type headache have got tension this is in the name in the masses of the neck but again contradicting common knowledge it's not the cause so the tension in the neck is not the cause of tension type headaches tension type headaches are primary headaches so again they are starting in the in the brain and the tension in the neck is a symptom we can help people reducing the symptom but this is probably a different thing you probably got to ask me about approach it's to treat but yeah this is more of a diagnosis so I think as physios we should really rely on the IHS classification based mainly on the unimnestic criteria and assessing the neck makes a lot of sense because it helps us do we treat or do we not treat as physios as if yes how so the test that we have or the the dysfunctions that we can see they are not really different in different forms of headache right that's true this could be summarized like like like that but we do see certain dysfunctions that we don't see in healthy people definitely yes yeah that's a very shot off a long answer yeah that's very generous so what kind of dysfunctions if you can briefly summarize what kind of dysfunctions do we see in then let's say the headache sufferers so migraine migraine nurse and other headache sufferers and compared to the healthy population yeah and that study in Safer Aljad 2016 we found that six of the 11 proposed tests were statistically significantly different between migraine and has the controls and that was the assessment of the opposite I guess fine using manual testing and we added a manual test that we a lot of you probably know from Dean Watson which is called reproduction and resolution and it just generally means that we hold a manual test ask whether this is provoking typical symptoms and if it's sustained the pressure whether those symptoms disappear again very similar to trigger point assessment really just sort of more focused on on joints so that's the second test and the trigger points and the neck and the face, they were significantly different. What was not different maybe changed to the other side as posture, I had forward posture, a range of motion, that sort of thing, the shoulder muscles were not different, the physiological testing was not different, so I think mainly the most prevalent finding really was the joint and the muscle dysfunctions, that was my great. Looking at tension type headache, I would expect the joints not to be that significantly different from healthy people, but I would expect pronounced findings and neck tension and the trapezius muscle and probably levitis-capular muscles, possibly other muscles, not really that well described. I think Tisa Fernandes de Las Panias did some studies on tension type headache and looked at trigger point assessment and treatment. So if it could Janic, I would expect a reduced range of motion, clear unilaterality and easily provoked headaches through cervical postures, I think this is the easiest distinction between those three. Okay, and I also read a paper where you were involved in your group, so you as a group of authors recommended to also assess vestibular function and postural control impairments. Can you talk to us about that? Yeah, that's a very interesting line of research. I'm not the leading researcher on that, that's a colleague or former colleague of mine, Gabriella Cavallio. She is from a study group in Sao Paulo in Brazil and a SNOW professor in Germany in the south of Germany in Freiburg, Fort Fangen and her interest was on postural control of migraine patients because they found that indeed dizziness is one of the very common associated symptoms during an attack and even interictually, so in the time without any symptoms. And when they started to investigate, they were really surprised that if you put them onto a balance board or if changing virtual reality environments around migraine patients, they sway a lot more than people without migraines. So that was the start of a line of research and one of the most convincing studies was done in the MRI scan also, functional and brain imaging, where they showed a simulated roller coaster right, not a very nice thing to watch, so it makes you feel that if you're writing on a roller coaster. And migraine patients reported a lot more dizziness in nausea while watching that video. And also you could see that the cerebellum responded more. And this sort of links nicely in another line of research of another colleague from the Hamuk study group that has already looked into anatomical changes in the cerebellum in migraine patients and now functional changes. And we can indeed see that parts of the cerebellum are altered in migraine patients which nicely explains why there are these postural and dizziness associated symptoms that people report. Okay. And as a follow-up question, but this is different than vestibular migraine as a diagnosis I guess. Thank you for asking, I forgot about that part of the question, and vestibular migraine is a subtype of migraine, so this is classified. Has only recently actually been introduced into that classification system. And in vestibular migraine, this is real vestibular symptoms, meaning the room is spinning around you while the posture is way, it's just a very subtle change that people might not even be aware of. And you only find it when you are very specifically investigating it, so this is two different things. The research that I was talking about was done in normal, not vestibular, subtypes of migraine. And it's more pronounced, again, as surprising in migraine with aura than it is in migraine without aura. Okay. Interesting. Okay, we talked quite a bit about diagnosis and about differences between different headache forms. Let's move on to treatment. How effective is physiotherapy or manual therapy in a treatment of headache? Are we better than other professions or approaches? Better, no, but we can contribute. I think if we agree that this is not a neck disease, it makes a lot of sense that physiotherapy will never be a cure for migraine. And this is important to acknowledge and it's important to tell patients because we don't want to raise any expectations that we cannot further. So I think this is a good starting point. And every migraine patient needs to be able to treat attacks with working acute pain medication and it would be unethical to take this away. We have got the triptoms which are very effective in a majority of patients. Some patients respond to enzymes, so and sometimes triptoms are more effective, so this is something that has to be tried out. If the attacks become more frequent than preventive medication like antidepressants or anti-epiletic medication works really well in some patients, there's a new medication for severe sufferers which is based on antibodies, CGRP antibodies, which seems to be very effective. So this is the baseline. What can we do as physios? If there are dysfunctions in the neck, I will treat them. The theory behind this is if there's no deception coming into a system which is already sensitized by ongoing pain or by repeated pain experience, that cannot be good. And I'm sure that this contributes. And we know from research that people who have neck dysfunctions, they have a high level of disability and a higher frequency of attacks, so it does make sense to treat neck dysfunctions if they are there. This is why we need that battery of test because we need to find out what's there and how we can approach it. And from that study that we did last year, published 23 in Sephiraya Ja by a doctorate student of mine, Ruth Meiser. She added education, as I already mentioned a little bit earlier, and she found that adding education to Menus therapy reduces headaches by another almost two days. So we have got a reduction through Menus therapy. There was no control group, so everybody got better, which could be the effect of being in a study. So we kind of really claimed that that worked. But adding education made a lot of sense. And there's another study, a little bit older, 2020 in Sephiraya Ja reports. Where we compared guideline-based aerobic exercise, it's a recommendation found in every migraine guideline internationally, and we compared that with Menus therapy, but this was open labels, so people could choose what they wanted to do. And we found that both interventions reduced migraine or headache days from approximately eight to ten days a month down to six to eight days, so by another, by two days, which I think is nice because people say every headache day less a month is worse coming, so yeah, so we can contribute, but we cannot cure. Okay. And would you say that physiotherapy or Menus therapy or by those approaches, we are trying to remove or reduce triggers that could potentially trigger a migraine attack, or is the migraine there, and we accept it, but we also know those people have a lot of issues in the neck, so we treat the neck because it's like a comorbidity or a thing that is often found. Do you know where I'm getting it? Well, I'm not sure what I can answer this because this is really difficult to distinguish by any sort of study design, I mean triggers, it makes sense to record triggers for a certain movement and maybe something that relates to the neck, let's say if you've been in a long meeting and you had to sort of look towards one side of your neck because the screen or the speaker was there and that triggered the attack, if that sort of occurs repeatedly, then it would be easier to say that the neck is a trigger. It's definitely a no-sysception, I mean there's structures that are sending information to the brain, and the brain responds to it and decides whether it's important or not. So I think the answer to your question is I don't know. Okay, so it's probably not fair to say to a patient, okay, you come in with a migraine so I'm going to treat you and our goal is to decrease the triggers. Well, no, no it's not. Our goal is to reduce the additional nosy section that's coming from the neck. OK. Can you maybe take us through your management approach? You touched on aerobic training. We also talked about menuotherapy. What is your approach? Yes. I mean, obviously following guideline recommendations, because this is for guidelines up for. And they recommend the aerobic exercise looking at the literature. Actually, it's surprisingly low effect sizes, but they're there. So there's an effect and recommending this makes sense. Then again, patients always say, I don't want to do any sports because it's triggered my migraine in the past. And that again, it needs explanation. And this is where the education comes in. So doing sports in those 48 hours, where your system is sort of swinging up towards hypersensitivity. I don't think that sports makes a lot of sense. This is a period where if possible, with using any sort of stimulation is good. After the attack or in the sort of safe times in between attacks, sport definitely makes sense. I mean, it always makes sense. And we have physios, we are promoting activity anyway. Working mechanisms not clear, possibly through the immune system, possibly a little bit through endogenous opioids, but it's probably less than we think. Possibly self-efficacy. That's a lot of mechanisms. Then the other thing to recommend is anything to do with relaxation. It doesn't have to be posed as a metric because a lot of people are annoyed by that. But it can be anything that is perceived as relaxing. It can be a walk in the woods, walk with a dog. It can be sitting on a sofa with your partner. But doing it deliberately makes a lot of sense. And also trying to find relaxing times in a stressful day makes a lot of sense. Psychologist, I've just had a presentation where he said that water intake makes sense, but not because of the water, but because the sort of procedure of drinking gives you a few seconds out of your stressful whatever you're doing. And I think that could have a point. So those things recommending is good. Education include anything you know about neurophysiology. The more people understand what they've got, the less fetching it is. So knowing this is not a stroke, knowing this is not a tumor, knowing why it hurts, knowing why it takes so long to disappear, knowing where associated symptoms are coming from, is a good thing for people to have this knowledge and it reduces symptoms itself. Whoops, I'm losing my AirPods. The other thing is definitely looking at the neck and treating what you find. So if there are muscular symptoms, treat soft tissue. If there are joint issues, treat joint. If there's anything else, you find and posture, range of motion, whatever, treat and measure. Measure using a headache diary. I think it's the best thing to do. Have people eat a diary so that you know what you did, whether it may tense and how large the effect sizes. What else can you do? Recommend anything that any large changes of any sort. So don't skip meals because it could be a contributing factor of blood sugar levels go up and down and up and down all the time. Which also means that carbohydrates are probably worse than proteins and fat because it makes the blood pleasure, the blood sugar go up and down too much. Any else, homeostatic sleep, don't sleep longer. It weekends, but get up at the same time if possible every day. Stress, so if the weeks are really stressful, maybe it's a good thing to respond to emails on Saturday morning so that stress is not going down. Oh, that's ugly. So anything that you can do to keep things stable is a good recommendation. OK, yeah, I think it's funny if we talk about treatment approaches and different pathologies, more and more comes down to a holistic approach. If it's a migraine or something else, basically all the recommendations or what experts are saying is, OK, we have the dysfunctions, but also look at sleep, also look at stress levels, also look at alcohol intake and so on. So yeah, it's I think we are broadening our horizon in physiotherapy a lot. Well, can I be bad to recommend that people look after themselves, right? Definitely. And a quick question to the aerobic training, if someone is really active already, is that added benefit if they move more? Or would you say, OK, you are a really active person, so don't expect any benefit from that. I remember one study, and I have to give you the name Saita, which found that high intensity training is better than moderate. OK. There's one systematic review while they are manual at all, I think, 2022. They found that strength training is superior, but this is based on a very low level of evidence. And I would say that both make sense. Again, this is people looking after themselves. There's always a good recommendation, yeah. But you don't really have to go and say, people need to run marathon, I don't think so. No. OK, and slowly coming towards the end of the podcast, are you currently researching any particular topic, regarding migraines? And if not, is there any hot topic in migraine research at the moment where everyone's talking about or that is really interesting for you as a researcher at the moment? I think we still haven't really got this point home yet that muscular skeletal system is important. One of the things I'm really upset about is that the German guidelines have not included physiotherapy, or menu therapy, or exercise, or anything like this. That would include us as a profession and to the migraine management. I'm hoping this will change with the next version of the German guidelines. So the other thing that we've just looked into is learning mechanisms, because we have to be a little careful because you cannot say to somebody you have learned to have migraines, that's probably not true. But maybe pain behavior can be influenced by learning. So if you've seen a mum who had migraines, and she always had two days of duties that could be maybe a nice thing to have, or it could be behavior that people copy. So we have just looked into can we induce a noticeable, our placebo suggestion, probably not as much as we thought, which is interesting. So I think that because I'm a physiotherapist, I think my main interest is still in the muscular skeletal symptoms and its contribution. And I really, really, really want to do a large RCT treating migraine patients with physiotherapy. And to either be convinced myself that it doesn't work, or to convince others that it does work. Yeah, looking forward to that. That's a lot of work. OK, I'm going through my list of questions and I've asked it also, I always ask our guests, is there anything that you would like to add to the podcast or is there anything we haven't touched on that you feel like is really important to get out there? I think it's the migraine patients perspective, which I think is not studied enough. So we've done a lot doing medication research and now looking at people's muscular skeletal systems where we haven't asked them enough. We did a survey and asked about experience with physiotherapy, for example, and although it's not on the guidelines, always every migraine patient has been to see a phasal, but what they have received, a treatment is a little bit disappointing. So a lot of massage, a lot of passive, very little education. And I think involving patients in our research as demanded by all the big grant and situations, for example, anything international is always required in patient contribution, but I think we could do this better. Also as far as the hours. OK, so there's some more qualitative studies. Well, yes, it could be qualitative by interviewing our surveys, could be quantitative by just asking for numbers, but hearing them is a good thing. OK, yeah, then I'd say last, where can people find you if they want to? want to know more about you or if they want to get in touch with you. Well, that's very easy. I'm a professor of physiotherapy at the University of Lübeck, which is a very nice mid-eversity in the north of Germany, so come and visit. Never been. Come and visit. It's pretty common summer because it rains a lot. Otherwise, you'll find me on the internet, including email addresses and anything you need to get in touch. Are you on social media? I am not really as much on social media as I should be. We have got a Facebook page from the German Association for Physioscience. The German name is Deutsche Gisele Schaft für Physiotenup. He listened Schaft. Did he appear to be a DGPTW? This is where you can find our activities towards increasing physiotherapy science awareness in Germany. That's another maybe interesting page, but I think a lot of that is German language, so not internationally. Okay, so it's best to reach out to you via email, you'd say? Yes, please. Okay, all right. Kerstin, to close off the podcast, let's say thank you so much for your time and your knowledge, of course, and it was a pleasure to have you. Thank you very much for having me. Sure, it was great. And thanks a lot, as well, for everyone listening out there to this episode. And as always, to access the transcript and additional resources, make sure to download our new and free Physiotutors app and benefit from more useful physio content. Also, if you enjoyed this episode, hit the subscribe button or follow our podcast on Spotify or Apple Podcasts. And also consider leaving a review if you really enjoyed it. And with that being said, this was Kai for Physiotutors and I'll talk to you in the next episode. Bye.