Molly O’Brien: Have you ever noticed you get a headache or a migraine attack at the end of the week or right when you get on vacation? Maybe you notice how well you can power through a really stressful event or a difficult time, but as soon as you calm down, boom, a migraine attack strikes.

Welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. And if you can relate to any of what I just said, then this episode is for you. Today, we’re going to talk about the let-down effect. You may have heard the terms let-down migraine or let-down headache.

And to help us understand the let-down effect, I’d like to introduce our guest, Dr. Hope O’Brien. Dr. O’Brien is a neurologist and headache medicine specialist recognized nationally and internationally for her expertise in migraine care. She’s the founder of a comprehensive headache program, integrating advanced therapies and multidisciplinary approaches. Dr. O’Brien has led pivotal clinical trials, authored numerous publications, and she’s the founder and CEO of Headache Center of Hope.

Dr. O’Brien, thanks for joining us today.

Hope O’Brien, MD, MBA, FAH, FAAN: Hi. Thank you so much, Molly, for having me.

M. O’Brien: Let’s start off with a note to our audience that let-down migraine isn’t a migraine type. It’s not like chronic migraine, migraine with aura, vestibular migraine. When we use the term let-down migraine, it’s a colloquial term. We’re referring to the timing of an attack. So now that we have that note, can you explain to us what is the let-down effect or a let-down headache/let-down migraine?

Dr. O’Brien: So, great question, Molly. And I will tell you that as headache specialists, we don’t talk about this enough, but I hear patients mention it quite frequently. And so a let-down headache refers to a headache, and most commonly migraine, that occurs following stress or maybe a period of heightened stress or tension. It can occur either before or after a vacation. But it describes a phenomenon where a headache onset is temporally associated with a transition from a stressful period to a relaxation or relief period.

M. O’Brien: I want to back up just a moment there because I said let-down headache, and people will kind of hear us chatting. We might say let-down headache, let-down effect, let-down migraine. Can people who have different types of migraine, maybe vestibular migraine or silent migraine, those who don’t actually have the headache portion, can they still have let-down attacks?

Dr. O’Brien: What I would say is migraine or having headaches…first of all, it’s important to get the diagnosis, right? So headache is just a symptom. It doesn’t tell us what the cause is. So just like having a bellyache or, you know, having a toe ache, we want to figure out what that underlying cause is. And for patients I see, the most common reason why they present to me is because they have a condition called migraine. And as you know, migraine can be pretty severe and debilitating and can really interfere with somebody’s quality of life. So getting that diagnosis is really important.

Now, there’s other types of migraine or other types of headache. And so, in reality, if there are recurrent symptoms with different types of associated features like light sensitivity, sound sensitivity, imbalance, those are phenomena that could potentially be triggered by, let’s say, stress or changes in what’s going on with the environment. So it’s not always just migraine, but it’s any type of headache phenomenon that a patient’s been diagnosed with.

M. O’Brien: Can you give us some other examples of when people might experience this across the age spectrum?

Dr. O’Brien: You know, when I think about somebody who has recurrent migraine attacks, I think about somebody who’s inherited a sensitive nervous system. And that nervous system is sensitive to changes. It could be changes in hormones, not just stress, what you’re eating, drinking, the timing of your exercise or changes in pattern of sleep.
And so, you know, migraine can begin in childhood. And so, let’s say, for a child, they may experience a let-down headache if they are staying up on Friday nights or Saturday nights. And then, now they have to wake up and go to school on a Monday. They may experience a let-down headache that will occur either on Monday or a Tuesday. Now, as you are progressing towards young adulthood, you may be, let’s say, cramming for that exam. And then, all of a sudden, you know, the exam is over and, oh, you know, now I’ve got this migraine because you’ve got this stressful situation.

As you progress into, you know, further and late adulthood, it may be that you’re trying to meet a deadline for a particular project that you’re doing. And after that deadline hits, you now have this let-down headache. And it can last, you know, anywhere between hours to days for that particular individual. You know, when you’re getting ready to go on vacation, you’re excited about it. You’re anticipating what it’s going to be like. You’re anticipating that relaxation. You’re already kind of in that vacation mode. And so already, you know, you’re actually incorporating those parasympathetics in relaxation mode. And then you get to the travel part, which may or may not be stressful, right? And so, oftentimes, I’ll have patients say, I got to vacation, and I had a really bad migraine. You know, well, that can happen. And so, you know, sort of preparing for that, there are some tricks and some things that I recommend to patients that they can do to prevent that from happening.

M. O’Brien: Yeah, like we think we’re going on vacation so we’re going to be able to relax, but all that build-up, it’s important to acknowledge that. Like, maybe you have deadlines for work or maybe you have to finish final exams at school, and then packing for your trip, and making sure you don’t forget everything, and getting to the airport on time. All of these things, even though they don’t seem huge in the grand scheme, if you’re stressed, and worked up, and it’s out of your normal routine, then yeah, of course, when you get to finally relax, boom, you get hit with it. So it’s almost like recognizing the pattern can help us, hopefully.

Dr. O’Brien: Absolutely, you’re 100% correct, Molly. And just sort of being a little bit more preactive as, you know, in what could potentially happen and what are you going to do to help, not negate that or navigate that, can be really, really helpful.

M. O’Brien: Do we know why this is a thing? Because when you think about it, it’s, like, oh, I’m super stressed, and now I’m not stressed. So you would think that would be good that you’re no longer stressed. So it’s a little bit hard to understand, but it also makes a lot of sense. Can you just kind of help us understand why this happens?

Dr. O’Brien: So, you know, when we are stressed, we don’t realize what’s really going on from a biochemical standpoint, what’s going on in the biology. And so what’s happening is that you are increasing the cortisol levels. You know, you may be pushing through and trying to finish deadlines. You’re probably staying awake. You probably aren’t drinking enough, as well. If you’re really pushing through, you may be drinking more caffeine than you’re used to. And then all of a sudden, all of that goes away. And then you’re left with, oh, the after effects with that.

And so what the body of somebody who has a genetic predisposition to getting these recurrent headaches, when they experience these changes, the brain doesn’t like it. The brain likes everything to be even keel. And when things change, that change is enough to trigger that onset of a headache or migraine.

I think about hormonal changes. So, you know, when individuals, let’s say, you know, right before menses, may experience that worsening of a headache prior to menstruation. Part of that is due to the change in estrogen levels. Estrogen actually drops significantly and that change is what can trigger that migraine attack. So similar to the let-down, you may feel more relaxed. But in the end, the brain and the underlying pathophysiology feel that change that your body was experiencing prior to that relaxation.

M. O’Brien: From what you’re saying, it all kind of goes back to that basic understanding that we have that the migraine brain likes routine. It likes predictability. It likes that normal. It craves just that regular, like, everything.

Dr. O’Brien: It does. And honestly, that is part of the treatment plan when I talk to patients is that, you know, if you can’t identify or recognize what your triggers are, it’s important to just incorporate in your daily life that you need to get enough rest, okay? Make sure that the rest is consistent. So not staying up too late or sleeping in, especially on the weekends. So those sorts of things to try to, you know, to be more proactive in preventing a migraine attack.

M. O’Brien: Do we know anything about timing of these attacks? Is it boom, we’re stressed and then we’re not stressed and then we get the attack? Or does there seem to be a pattern for most people? What do we kind of know about timing so that we can use that down the road to talk about prevention?

Dr. O’Brien: There’s not a lot of studies on this. And so what we can gather is that this can happen sort of hours after a person experiences, you know, that stressful moment and into relaxation. So it sort of depends on a lot of different things. The climate is one thing. So kind of where you are, if you’re in a hotter climate or colder climate, the weather changes. And so, you know, for the patient, if you find that consistently there tends to be a time period between, you know, you finishing that stressful period and when the headache starts, I think that could be an opportunity to intervene.

Now, for many patients, unfortunately, and with migraine, it can come at any moment. And that’s what’s really, really frustrating about having the condition is that if they could plan, then, you know, they would be in a better place. But, you know, what I find is that for most patients, it’s unpredictable. And it’s really challenging to try to pinpoint that timeframe of when it will; or if it even happens at all.

M. O’Brien: If we find ourselves in one of these stressful situations, like a big life event or final exams, going on vacation, do we know if there are any options for potentially pre-treating an attack?

Dr. O’Brien: That’s a really interesting question. Because in the past, we really didn’t have a treatment that patients could take to prevent a migraine attack from happening.
And so recently, one of the gepants actually did a study that looked at pre-treating prior to having a migraine attack. And these individuals who pre-treated were those who could identify certain warning signs prior to the migraine occurrence. For instance, fatigue, neck pain, yawning. If those are the things that occur prior to the migraine attack starting, then you could potentially pre-treat with this medication and either minimize or lessen the likelihood of that headache becoming severe.

M. O’Brien: Let’s talk about preventing these attacks or reducing risk. Is it all about stress reduction, stress management? And what are some things or techniques that people can do to reduce the risk of having a let-down headache?

Dr. O’Brien: You know, here in the US, we are stressed. I mean, unfortunately, we’re a stressed-out nation. And part of that is because we’ve got so much that we are balancing.
If you are an individual who, say, has kids and then are still having to manage, you know, or take care of a parent, that can be pretty stressful. Our jobs can be pretty stressful. What we’re looking at on social media can be pretty stressful.

So one of the things that I recommend to patients is, first of all, identifying that stress is inevitable. It’s inevitable. So everyone’s going to experience it. You know, what are you doing to help mitigate that? And so what I tell patients is, you know, first and foremost, number one, ensuring that you have a regular routine. It’s making sure that you have a bedtime regimen, and you’re waking up around the same time every day, not sleeping in too late or staying up too late. Adequate sleep is going to be very important. Especially if you’ve noticed that traveling, let’s say, from the West Coast to the East Coast will trigger a migraine, making sure that you get that regular sleep is going to be important.

Number two, making sure you stay well hydrated. That hydration can be really important in soothing the blood vessels and the nerves that are involved in migraine. Number three, making sure that you’re not drinking too much caffeine. That’s a hard one because many of my patients rely on that caffeine to keep them up and active in the morning. And so making sure that you minimize that because caffeine can actually do the opposite. It can make you more anxious and less likely for you to handle stress.

Not skipping meals. Making sure that you’re eating breakfast, lunch, and dinner every day. Watching out for those high-sugary foods that could potentially, you know, lead to situations where it’s difficult for you to deal with stress. The changes in sugars can also potentially trigger a migraine.

Last but not least, what I tell my patients is getting regular exercise. Exercise can increase endorphins. It can be very protective, neuroprotective, because not only does it increase endorphins, but it helps in activating that parasympathetic nervous system and help you remain calm and deal with stress in a better way. So really, those environmental and behavioral lifestyle modifications can really be protective for patients.

M. O’Brien: So I think it’s so helpful to kind of go back to those basics and remember what our body needs, how we can protect our bodies. And again, like you said, just understanding that stress is a natural part of life. So learning how to protect ourselves and manage that stress can really be helpful.

Dr. O’Brien: As somebody who has had migraine, I have to remind myself as well. Because I get very busy and I’m, like, oh, I haven’t exercised in a few days, or I didn’t really drink enough. So I think it’s not to point the finger at anybody. And obviously, migraine is not something that, you know, we have caused, the patient has caused. But it’s just a reminder that we just need to sort of take a break in our lives and really take care of ourselves.

M. O’Brien: If people notice a trend or they keep experiencing the timing of these attacks, when might be a good time to consider preventive treatment? Oftentimes, what ends up happening is patients are trying to figure out what to do. This is happening so frequently. And so they start taking maybe, let’s say an over-the-counter medication, more and more so, not recognizing that sometimes those over-the-counter medications can actually contribute to the headache occurring.

So first and foremost is really having a conversation with your healthcare provider, so your primary care physician or maybe the nurse practitioner that you’re seeing, and letting them know that, hey, this is happening, and this is really impacting my day-to-day life and what do I need to do to help minimize that?

And then a discussion about preventive medication should be done. And when I think about prevention and who would qualify, it’s based on the American Headache Society when we think about the guidelines and who would qualify. And so that’s any individual who’s having three or more headache or migraine-days per month that are pretty disabling would probably benefit from starting a preventive medication. And if you think about it, how many of us can afford to miss one day of work or their daily lives in a month because of migraine, right? If you end up in the emergency room, probably a good sign that you need to probably start a preventive medication. And there’s many different options that are out there. And that’s the, you know, beauty of medicine is that now we have more tools in our toolbox that we can actually customize based on the patient’s needs and their preference.

M. O’Brien: Dr. O’Brien, this has been so insightful, really interesting to talk to you about, and I really appreciate your time.

Before we go, is there anything else that you might want to share with our listeners and our viewers?

Dr. O’Brien: So I want to just let viewers know that you’re not alone, that migraine is very common, and don’t be afraid to talk about it. I think we tend to, you know, stay silent about this condition because of perceived judgment. But it’s interesting that more people have migraine than you think. If you’re in a room, you know, one in four. So it’s pretty common. So don’t be afraid to talk about it. Don’t be afraid to get help. Help is out there. And obviously, reach out to the AMD websites for resources on how they can help.

M. O’Brien: Dr. O’Brien, thank you so much for joining us today. We really appreciate your expertise and your time in talking about the let-down effect and chatting with us about migraine. So thank you again for joining us.

Dr. O’Brien: It’s my pleasure. Thank you, Molly. I appreciate it.

M. O’Brien: And that wraps up this episode of Spotlight on Migraine. Don’t forget to hit like and subscribe. To our followers, thank you for listening. This podcast is made possible by supporters like you. You can make a tax-deductible donation today at migrainedisorders.org.

I’m Molly O’Brien. We’ll see you next time.

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*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. AMD and the speaker do 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.