TRANSCRIPT:

Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.

This episode is brought to you by our generous sponsor, AbbVie.

Molly O’Brien: Hello and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Thanks so much for joining us today. So today we’re going to talk all about CBD and migraine. To help us get all the information we need, I’d like to welcome our guest, Dr. Bonni Goldstein. Dr. Goldstein is the medical director of Canna-Centers Wellness and Education. Dr. Goldstein, thanks so much for joining us today.

Dr. Bonni Goldstein: Thank you for inviting me.

Molly: We’re super excited to have you. You’re very knowledgeable in this topic, and you also have a recent book that we’ll talk about a little bit later. So let’s dive into this conversation. We’ll start off super basic for people out there who just need to get caught up to speed. Can you tell us a little bit about what CBD is?

Dr. Goldstein: Sure, Molly. So CBD stands for cannabidiol, and it is a natural compound that comes from the cannabis plant. And so the way to think about the cannabis plant — there’s over 500 different compounds in the plant, and there’s a family of compounds called phytocannabinoids, which really means plant-derived cannabinoids. There’s about 140 of the phytocannabinoids that have been described. 

The main phytocannabinoid that everybody’s heard of and knows is THC. That’s been around for a long time. And CBD was actually discovered in 1940, but its chemical structure was then discovered in 1963. THC was then discovered in 1964, and then most of the focus was on THC and how it impacts the brain and so on, and CBD was kind of ignored. 

And then when we had the discovery of the endocannabinoid system at the end of the 1980s, early 1990s, now research started to look at CBD and THC a little more closely. And it’s really over just the last two decades where we’ve had this explosion of interest into the medicinal properties of this compound called CBD from the cannabis plant.

Molly: And I do feel like it’s been fairly recent where we’re hearing more and more about CBD, and now it’s almost like you can’t get away from it. So we’ll talk more about the exposure and that kind of thing in just a minute. 

So now we know a little bit about what CBD is. What effects can CBD have on the body, and do we know how it can help ease pain?

Dr. Goldstein: Well, so what we’ve found in this explosion of research is that CBD is what we might call polypharmaceutical. It has multiple targets. Every drug that you take, every medicine you take has a target in the body. So if you have a strep throat and you take penicillin, I mean, the target’s not your cells, but it’s to attack the bacteria, right? 

So the way to think about CBD is when it goes in your body, it’s hitting all these different targets. There have been over 65 different targets identified so far, and that’s why it’s very hard to predict somebody’s response, because it’s hitting different areas of the brain and body.

It acts both within the endocannabinoid system to help maintain balance and to help us kind of get back into balance when there’s an insult, infection, or injury of some sort. But it also works at many targets outside the endocannabinoid system. And the way that it helps to ease pain is that — kind of think about CBD targeting a certain receptor, which is like a lock and CBD is a key. And when the key hits that lock, it sends a message to certain cells: decrease inflammatory compounds being made, or decrease the pain message that’s being sent to the brain.

That’s the way you have to think about it is CBD is acting like a message changer. It goes in, it hits the target, and it changes the message of pain as well as inflammation and anxiety and all kinds of other things.

Molly: It’s fascinating to figure out how these things can help and function within our body. It is really cool to learn. 

Can you tell us a little bit about how the endocannabinoid system relates with migraine?

Dr. Goldstein: The endocannabinoid system is a physiologic regulator of the messages that I just mentioned. So if there’s too much message being sent, your body makes your natural inner cannabis — endocannabinoids — to help balance that message. So if you tip out of balance, which we all do — we live in this world where there’s external trauma, there’s internal trauma, and things go off balance, and we have all these mechanisms to help get us back in. And it’s a protective system. 

And so the theory behind the endocannabinoid system in migraine is that certain people may not make enough of their own endocannabinoids, their own inner cannabis. So if you’re deficient and your body has this trigger — so you think about triggers for migraines. So it triggers you, and really what’s supposed to happen is your endocannabinoid system should go into action and balance that, and you shouldn’t have that what I call an over-pain message, right? Because that’s really what it is, right? 

And so what happens is since you don’t make your endocannabinoid to help balance that message, that trigger now throws you into pain and the nausea and everything else that goes along with it.

Now, we don’t have a lot of research into the role of the endocannabinoid system in migraine, but it definitely seems clear that there’s a relationship, because, certainly, we know many migraine patients, including patients I’ve worked with, find less severity when they’re using cannabis — or CBD, THC, whatever — less frequency, less duration. Some patients even have elimination of their migraines because their endocannabinoid system is functioning better. So there’s a range of response. Not everybody responds the same way.

But when we talk about research, there are a few studies that support the idea of endocannabinoid deficiency. There’s not a lot of research because, remember, Schedule 1 status. We’re still not allowed to study it. But there was a study in 2007 that looked at the cerebrospinal fluid, like when they do a lumbar puncture or a spinal tap, it’s called. And they were looking for the levels of endocannabinoids. Patients with chronic migraines have lower levels. So that supports that idea of endocannabinoid deficiency.

And then there was another study in 2008 where they measured, from the bloodstream — which is a very difficult way to measure your endocannabinoids, just to be aware, because they’re mostly in the brain. We can’t really go mucking around in your brain trying to measure levels. But patients that had chronic migraine and what’s called — I’m sure you know about this — medication overuse headaches, they also were found to have lower levels of endocannabinoids. So we have a few hints that maybe there is a deficiency in the endocannabinoids. 

And one thing I just want to tell everybody: your endocannabinoids — very important to understand this — they’re made from healthy fat. What have many of us been told not to eat over the last 30 years, right, because of heart health? Cholesterol, right? Well, you don’t want to eat unhealthy fat, but healthy fat is important to help feed your endocannabinoid system. 

You only make endocannabinoids when you need them. So there’s that trigger, you make them, you use them, and then your body breaks them down. So it’s important to understand that you may have a deficiency. It could be dietary. It could be congenital, meaning something that you’ve had since birth. It could be like — I know people who just start having migraines after childbirth, right? So something throws off that endocannabinoid system. 

So, certainly, we need a lot more research, but there’s these little hints that indicate that cannabis may be the answer here, because all you’re doing is — you don’t have your inner cannabis; you’re replacing it with an external source.

Molly: Absolutely fascinating to learn how the process works and how our body can regulate, but sometimes not regulate. We get out of balance, which we know with migraine, everybody’s body works differently. 

And do we know if there is one method of using CBD over another that might be more beneficial for migraine patients? Again, we all know everyone is different, but there are different ways to consume, whether it’s ingesting or a topical or inhaling. Do we know at all if there’s any better way to help with migraine?

Dr. Goldstein: Right, that’s such a great question, and I get asked this all — what’s the best way to take it? OK, I’ve seen every iteration of taking it. So you can rub topical. I know patients who, if they feel the migraine coming and they kind of feel it creeping up, they rub that topical on the back of their neck or on their temporal area of their head, and they find that it just mitigates some of the symptoms. 

And there’s going to be people out there that say placebo, but I say who cares if it minimizes your pain and migraine, my goodness. If standing upside down does it, go ahead and do it, right? Whatever’s going to help you get through that.

But it’s important to understand that cannabis and CBD can be used as a rescue medicine when a migraine is coming on to try to either abort or minimize the symptoms, but it also, in patients, has been shown to be preventive. Now, preventive would be more of daily use, almost like I just take my little dose every day to get my inflammation down and see if I can regulate my endocannabinoid system, better feed that system on a regular basis and not let it be deficient when I need it to function, right? Or you can take the cannabis medicine right when that migraine is happening. So remember preventive and rescue in terms of how to take it. 

When you take cannabis sublingually, holding it under your tongue or ingesting it, it’s going to have a delayed onset. And we all know that for some people, you need that immediate onset right away, and that would be inhaling or topical. Now, again, topical doesn’t get into your bloodstream, but certainly it touches all the cannabinoid receptors and the other receptors where these compounds can work in your skin. And we know that the skin is loaded with cannabinoid and other receptors that regulate pain.

So to put drops under your tongue and wait a half hour might not work for you, but there are some people who say it does work. So, again, you have to listen to your body when you take cannabis and decide, OK, maybe this method, it’s just — I can’t wait two hours for it to kick in, so now I need to think about a quicker way. And then also listening, “Hey, look, I take every day, and I didn’t get my two-time-weekly migraine. I think I found a preventive that might work.” 

So, again, it is trial and error, but when you think about all medicines, kind of, they are trial and error too. We never know which pharmaceutical is going to work for us and not give us side effects.

Molly: I’m wondering — and this is a tough question to ask, so I can’t assume there’s a right answer. But I’m wondering if there is any dosage information or amount that we know that actually helps and provides benefits for people. Again, everyone is different. But I’m wondering if — do I take a bottle of the tincture? Do I rub the whole thing on? But do we have an idea of a dosage or an amount of CBD that can help with migraine?

Dr. Goldstein: Right, and that is a great question. But the answer is no, we have no idea. There are people that are highly sensitive to low doses and other people need much higher doses. We all absorb cannabis differently. We call it in the medical world a large amount of interindividual variation. I mean, it’s just — right? 

So, for CBD, just so people understand, CBD has a very what we call wide therapeutic range of dosing. There are people that do respond at very low dose, 10 to 25 milligrams, and then there’s people that need 100, 200, 300, even more. I’ve got pediatric patients with epilepsy taking 800 milligrams to help minimize seizures. So there is a very wide therapeutic range.

But the one tip that I think can be very helpful to people is if you are taking CBD and you don’t feel an effect, it probably means you are not taking enough. Even if your best friend says, “Oh, it works great at 25 milligrams a day,” that may not be you. You might be 150 milligrams a day. 

So if you don’t try a higher dose — and I’ll share with you. Like 99 percent of people that come into my office and say that CBD didn’t help them, when I suss out what they were taking and the dose they were taking, they were underdosing. 

And part of it is that too, for instance, you said drink a whole bottle, and I kind of laugh at that. If you buy a bottle of 250 milligrams total CBD in the whole bottle and your dose is 100 milligrams, you just bought two and a half doses. That’s not really the right one. There are companies that sell 3,000 milligrams or 5,000 milligrams in a bottle. That might be what you might have to do. 

And so I know cost is an issue because this is an out-of-pocket. But there are some companies out there that have good-quality CBD in bigger doses to allow people to be able to explore. 

We have the saying in the cannabis industry “Start low and go slow.” With CBD, you don’t have to go so slow, but I have a colleague who says, “But don’t be afraid to go higher.” So I always tell people, “Push the dose.” If you don’t find relief, go ahead and try a higher dose. You’re very unlikely to harm yourself with that.

Molly: OK, and that’s good to know. And you just kind of mentioned that: a reputable company, finding the right dose. And we have been bombarded with CBD products all over. You can find stuff at the gas station. You can find stuff at the grocery store. So if someone’s interested in trying CBD for migraine, what can they look for? I mean, there is a huge market out there, and not everything is legitimate, so it can be overwhelming.

Dr. Goldstein: A hundred percent. It is truly buyer beware. OK, so the online “hemp market” that has CBD, there can be very good products in that market. But, again, it’s unregulated, so you have to do your due diligence. So what I recommend is if you found something online that you’re interested in, you look to see if the company provides you with what’s called a COA, certificate of analysis. That is the testing. 

Now, if you walked into a cannabis dispensary in a state that has dispensaries, those products are regulated by the state, for the most part, and aren’t actually in the shop without a good COA, because it has to meet a certain criteria. So that is likely the best place to buy CBD if you just want to go pick something up that you don’t have to do a huge amount of research on. 

But if you’re going to buy it online, you want to double-check the COA. You want to make sure it comes from a third-party, independent lab that’s checking. And what the COA tells you is how much CBD is in the product, if there’s THC in the product or not or other cannabinoids. It tells you whether or not there’s pesticides. It tells you whether or not there’s heavy metals, because the hemp plant can pull heavy metals out of the ground. You want to make sure you don’t have arsenic or zinc or lead in your product. And also other contaminants like solvents and mold and that kind of thing. 

So, again, you have to do your due diligence. The reality is, is that there are some companies that are just kind of slapping it in a bottle and putting it out there. So it really does have to be buyer beware. And also, whenever you’re looking at a bottle, look to see if the label is clear. Does it say how many total milligrams are in that bottle, OK, so you know how much you’re getting for what price? 

And also what I recommend, too, is to make sure that it’s labeled somewhere how many milligrams are per either one eyedropper or per 1 ml so you actually know, when you take the oil, how much you’re taking.

Molly: OK, that is very useful information, and I’m sure people are going to find that very helpful, things to look for, because it can be overwhelming, especially if you’re just getting started looking into this option to help with migraine. 

And I’m kind of curious on that. You touched base on what to look for. You touched base on dosage; we don’t really know. What’s the best way to — if you need advice or if you want to have a conversation with your doctor about implementing CBD in your treatment program or into your toolbox, what’s the best way to get the conversation started? Some people might think it’s taboo because it’s related to cannabis. Hopefully, we’re getting out of that. But what’s the best way to have a conversation with a provider if you want to try CBD?

Dr. Goldstein: The first question is “Doctor, how do you feel about CBD or cannabis?” Because if they’re negative about it right out of the gate, they’re not going to be able to advise you. That doesn’t mean you shouldn’t take it, but that means that you should probably seek out somebody who has some expertise in treating patients with cannabinoid medicine. It doesn’t help if your doctor says, “Sure you can use it, but I don’t know anything.” That’s not going to be very helpful. It would be nice to have support, but at the same time, not very helpful.

There’s a ton of people out there that are what we call cannabis coaches, and nurse practitioners, nurses that are working in this field where you can do a one-time “Hey, can you give me some advice?” And it’s important, too, to make sure that whatever medication you’re on, you run by somebody who knows about drug interactions so that you’re not set up for some possible issues down the line. 

For the most part, CBD is a pretty safe medicine, but there can be drug interactions. In very, very high doses, it can be a little sedating. It can also cause some diarrhea. But we’re talking really high doses that the vast majority of people are not using. So, in general, there’s not a lot of side effects. I think I run into more “Oh, it didn’t help me” more than I’ve run into “Oh, I was harmed by it.” I just don’t see that. 

But getting expertise, advice can be very helpful. And luckily, Molly, there’s a lot of doctors who are starting to become interested in this. And so we are seeing lots of healthcare professionals open up to helping patients because, look — the way I look at it — if patients are going to use it, it behooves us to know about it, to understand, and to help direct treatment to try to minimize any harm that could happen.

Molly: I think those are all really good answers, and, yeah, having a conversation. If your doctor kind of has a stone wall up about CBD use, then you’re probably not going to get a lot of help in there. So, again, very helpful information. 

And you talked a little bit about research earlier on in our conversation. There’s not a ton out there. So where do we stand on CBD research for migraine? Can we look forward to new stuff coming up? Are we seeing more research happening and the flood gates starting to open now that we are starting to learn a little bit more? What’s the latest in migraine research with CBD?

Dr. Goldstein: Sure. Well, I wouldn’t say it’s flood gates. It takes is a lot of effort, right? 

Molly: It was a [inaudible].

Dr. Goldstein: Right, a [inaudible], yeah. It takes a lot of effort to get the United States government to agree to approve — again, Schedule 1 status still. Even though CBD is sold all over the place in gas stations, like you mentioned, it is still considered a Schedule 1 drug, and thereby professionals who are either researchers, scientists, doctors, we’re still prohibited from investigating and doing research on it, which is crazy because it’s in everybody’s hands.

So, I mean, my goodness, take all cannabis off the Schedule 1 status, what I call deschedule it. It doesn’t need to be there. It’s not dangerous, especially under medical supervision. Let us study it. Let us figure out the ways that — like the dosing. I would love to be able to tell you what dosing is required for migraines, right? But that’s the whole point of clinical trials, right? 

Now, the reality is, is that I can still help patients under state law and help them find. But, boy, research is so important because it helps direct that. It helps kind of a little more straight-line effect. Right now, I saw that there is a study that’s recruiting patients at University of California in San Diego for an inhaled-cannabis migraine study, and they’re looking at four arms; placebo, THC alone, CBD alone, and then combination THC CBD. 

And what I really like is not only are they looking at the pain relief that the people will experience, but also does it help with light and sound sensitivity? Does it help with nausea? Does it help with vomiting? So you can really dial in “What can I expect from my medicine?” Right? And that would be so helpful. So I’m really encouraged by the fact that they’re doing that study.

It says that people who want to look, clinicaltrials.gov shows you. And you type in “migraine.” You can put in CBD or cannabidiol or cannabis or cannabinoids, whatever terminology, and you’ll see the studies coming up. And it’s very exciting that at least this is on the horizon. I can’t wait to see the results from it.

Molly: I did see that they were taking applicants for that clinical trial — very exciting as well — so I’m looking forward to that. 

As we kind of wrap up, I do want to mention that Dr. Goldstein does have a book, Cannabis Is Medicine: How Medical Cannabis and CBD Are Healing Everything from Anxiety to Chronic Pain. This is your latest book. I feel like there’s a lot to offer with CBD, and your book touches on this. Can you just give us a brief overview of what people could expect? Say, a migraine patient wants to pick this up?

Dr. Goldstein: So I spend a lot of time talking about what’s in the plant and the importance of the various compounds, because, remember, cannabis is different than a pharmaceutical, which is usually single compound. Cannabis is multiple compounds, so it makes it a little more complex. 

I talk also a lot about the endocannabinoid system and how a deficiency or just regulation of the endocannabinoid system can contribute to certain conditions. And it’s interesting: migraine, irritable bowel syndrome, and fibromyalgia are kind of linked in a way that we do think that they are all endocannabinoid-deficiency-type syndromes. And people may have overlap there, and I’ve certainly met in my practice people who have three family members with migraines, three with fibro, and two with irritable bowel syndrome, and it kind of all runs in — this certainly could be a genetic imbalance, right? 

And then I talk about — in the book, there’s one particular chapter that’s very science-y, so I apologize to those who get glazed over from science. But I take each cannabinoid and I summarize the research that we have so far into what receptors it targets and what that means, what that converts to in terms of what you can expect, like anti-inflammatory, antibacterial, pain relief, or anti-seizure. So it’s important to see that there’s more than just THC and CBD in the plant. 

Then I break down ailments and summarize all of the latest research that we have. There’s some advice as to what’s the ratio, what concentration, which method works better for which condition, and that kind of thing.

Molly: So that sounds like an excellent starting ground for people who are interested. Maybe you piqued their interest in this podcast. They can go out and check out your book and learn a little bit more and then hopefully start to have some conversations with their medical provider and try it out — hopefully, something that can work for them. 

And so many people with migraine have coexisting conditions, comorbidities, like you said, the link with IBS and fibromyalgia. We know these things, so, hopefully, that can help. So if you’re interested, you can go out and check out Dr. Goldstein’s latest book, Cannabis Is Medicine: How Medical Cannabis and CBD Are Healing Everything from Anxiety to Chronic Pain.

And before we let you go and totally wrap things up, I’m just wondering — we covered a lot of ground here. I’m wondering if there’s any last parting thoughts or anything that we didn’t touch on that you want people living with migraine to know about using CBD?

Dr. Goldstein: Yes. So what I’ll share is that cannabis comes — even CBD comes with all this baggage from all the propaganda. I am a very conservative physician. I’m not this out-there fringe doctor. I trained as a pediatrician. I worked as a pediatric ER doctor. I am overly neurotic with my patients, OK, and with “do no harm” and to make sure that we’re doing the best we can for our patients in my practice and to try to get the word out there. 

The fears that have been implanted in us are unfounded. Medical patients do not end up as potheads or addicted or any of that, and I want people to realize that medical use of cannabis is a completely different thing than kind of what we see when they show someone smoking a joint. I mean, that can be medical, but the reality is it doesn’t mean you have to do it that way. People who overdo, overuse, or abuse are going to end up with issues. But, for the most part, medical patients do really well, and there’s no risk. So if you’re suffering, it’s a good thing to consider.

Molly: And I appreciate that. A little bit of a disclaimer for folks out there to remember that there’s more than what has been forced down our throats for a while. 

Well, that wraps up this conversation with Dr. Bonni Goldstein. We’ve been talking all about CBD and migraine. I really hope it was beneficial to all of you watching and listening at home. And I’d like to thank Dr. Goldstein so much for taking the time to fill us in on all this today. Thanks for joining us.

Dr. Goldstein: Thanks so much, Molly. It was a pleasure.

Molly: Again, thanks, everyone, for watching and listening. With the Association of Migraine Disorders. I’m Molly O’Brien.

[music]

Voice-over: Thank you for tuning in to Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.

*The contents of this podcast are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The speaker does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.