Is there a message that has stuck out to you?

Well, there's sort of like a general theme, I think, that's been really neat this time.

And it's this idea of kind of sharing stories.

And what I'm seeing in our show this season and what I see even in my clinic where we've started doing group learning meetings where we're bringing multiple chronic migraine patients together and they share sit with a provider and discuss particular topics and they're sharing stories.

And then here on the show, we have our wonderful guests coming in and sharing stories.

And it makes me think about Qasim, who we've had previously.

And then again, this season is someone who has continuously stood out to me, mostly because he doesn't just experience chronic migraine.

What kind of questions are you asking?

How common is it for you to integrate Botox into a treatment plan for chronic migraine?

Nora, it's super common.

It's one of the tools that I will reach for in chronic migraine as soon as we have the opportunity.

Botox has been FDA approved for the preventive treatment of chronic migraine for 15 years now since its approval in 2010.

So yes, it may not be what you initially think of when you hear Botox, but it's been part of our arsenal as a preventive treatment for a long time.

Botox is a prescription medicine injected into muscles and used to prevent headaches in adults with chronic migraine, which is 15 or more headache days per month, each lasting for four or more hours.

Botox is not approved for adults with migraine who have 14 or fewer headache days per month.

What is the usual response when you first bring it up as a possible treatment?

Yeah.

Um, yeah, I'm not sure where I, where I fall on that, 'cause I do feel like, you know, you've got a limited amount of time, and so spend as little of it as possible doing something you don't wanna be doing.

But on the other hand, I do think it pays...

I mean, I don't know.

The...

You and I talked about Scott Galloway last night, I think, and I, I think he's a very interesting, admirable guy in a lot of ways, but I'm disappointed to [laughs] in the extent to which it feels like he recognizes, uh, some of his insecurities that drive his behavior, but he hasn't changed his behavior.

Mm.

It's, it's really bec- it's so touching because it...

How long does it take someone to identify their personal triggers once they begin tracking patterns?

It's such an important question, and I think the patients that come to see me, they describe the headaches they associate with their menstrual cycle, their seasonal allergies, and stress.

And really what they're telling me is what they're explaining as each one of their particular triggers.

And what it points to is the idea that a lot of chronic migraine patients, because they're dealing with symptoms so frequently, will sort of rationalize these situations away to make them less of a problem.

So when you come to them and you say, "Hey, I want you to spend some time actually putting all of this puzzle together," usually what you'll see is somewhere on the order of 30 to 90 days.

But if they're really committed to it, they'll see the opportunity to really understand what tends to set them off, but they really need some time to do that, and I think 30 to 90 days is the way to go.

So after hearing Kasim talk about his own more intentional advocacy work, I'm curious, from your perspective, Dr. Ryan, what changes have you seen in the way patients advocate for themselves, whether that's asking questions, tracking symptoms, or just staying more engaged in their care?

So I think the biggest changes that I see really in the room on the day-to-day basis based on the kind of work that Kasim's doing is that patients are saying out loud that there is a problem that needs to be addressed.