Vicky

Good evening, everyone, and thanks for joining us.

Okay, once again, good evening, and a very warm welcome to our webinar on treatments for migraine.

My name's Vicky, and I'm hosting the session this evening.

I'm delighted to be joined by our expert speaker, Dr Clinton Mitchell, Consultant Neurologist.

Tonight's session will begin with a presentation from Dr Mitchell, followed by a live Q&A.

If you have any questions at any point, please feel free to submit them using the Q&A icon at the bottom of your screen.

You are welcome to ask anonymously or include your name, but just a quick note that the session is being recorded, so any names shared may be visible in the recording.

To help us get through as many questions as possible, on this popular topic, please, keep your questions brief.

If you're interested in booking a consultation, we'll share all the relevant contact details at the end of the session.

So I'm now going to hand over to Dr Mitchell, to present this evening.

Thanks, Dr Mitchell.

Dr Clinton Mitchell

Thanks, Vicky, and thanks to all the Benenden members who are joining this evening.

It's always nice to talk about migraine, it's kind of what I do, my bread and butter with neurology, so it's something I enjoy talking about, and hopefully you can get something out of that as well this evening.

So a little bit of background about me.

I've obviously got a bit of a strange accent, so I, am from New Zealand originally, and did most of my specialist training in Wellington in New Zealand and then in 2014, I came over to the UK for, sort of, a year of finishing school at the National Hospital in London, and the idea was that I was going to come over for a year, and then head back to New Zealand, and then, you know, things got in the way, and now, sort of, 12 years later, here I still am.

During that time, I've held, sort of, consultant posts in different parts of the country, but I'm now based here in the southeast and as it says there, you know, my special interests certainly include headache, but also, sort of other aspects of neurology as well, that, I'm happy to see patients for as well.

I was fortunate when I moved down to the southeast to get in touch with Benenden, and so I've been delighted to work with them, since late last year.

So what we're going to talk about in this session is kind of debunking migraine, or sort of talking a little bit about, kind of, what migraine is, why maybe it's a bit under-recognized, why people think, you know, oh, it's just a headache, and sort of talk about, you know, what we can do to kind of increase their awareness of it for GPs, but also, you know, what treatments there are out there.

You know, a lot of people come and see me, and they say, the GP says they've tried everything and in fact, there's often, you know, a laundry list of things that haven't been tried yet and so what we can hopefully do is give people some hope that actually you're not at the end of the list or at the end of the road, there is still a lot of paving ahead to get into, and to manage your migraine.

Now, the thing about migraine is, you know, despite the fact that people kind of or, you know, GPs kind of almost have a bit of a, ugh, you know, when you come in and talk about migraine.

You know, it's exceedingly common, and this is something that they're seeing all the time.

You know, it's one in seven people worldwide have migraine, 10 million people in the UK.

If you look at A&E presentations, about one in four is due to headache.

So, you know, this is something that is coming across the hospital and the GP doors every day, and so you sort of think there'd be a lot more, kind of, excitement or awareness or, you know, want to get to the bottom of it out there, but it kind of there's a little bit of a heart sink that goes with migraine, I think, and you know, unfortunately, that kind of transference that kind of gets feedback to the patient.

The patient thinks, oh, no one's really interested in my headache or interested in my migraine, which, again, kind of has this feedback loop.

So what, you know, I want to do, and what I hope colleagues want to do, is try and really change people's lives and get to the bottom of this, and try and make things a little bit better for you.

It's the second highest disability cause of disability worldwide, and there's a lot of talk about, you know, what does that disability mean as well? It's not just things like not going to work, but it's also, you know, not making plans.

You know, the kids have got school recital, or, you know, friends have asked you if you want to go and see a movie next week, and people sort of go, well, I don't I can't make these plans, because I might have a migraine and one of the greatest things I love hearing from patients, is when we get them onto the right treatment, and they say to me.

I can make plans now and that, to me, is more important than the number of migraines you have a week, or the number of triptans you use a month, knowing that the patient can now go yes, I'll say yes to that in two weeks' time, because in all likelihood, I'll be fine, or I'll be able to manage that.

So that's a really nice thing to be able to do.

So there's not just that disability of not going to work, or it's that disability of missing out on life, and so I really, you know, that's one of the things that, you know, gets me up in the morning to try and turn that around for people.

Obviously, migraine is more common in women, and, you know, that's because there is this sort of hormonal influence that goes with migraine, but it does happen in men as well, so it's not just an aggressively female disorder.

And, you know, the reasons why people get migraine are very complex.

There's certainly, you know, genetic factors.

If you've got a family history of migraine, you're much more likely to have migraine yourself but also, migraine can vary over the course of a lifetime and so, you know, women who get it when you start menarche can then have changes in your migraine when you get pregnant.

You can have changes in your migraine when you give birth, when you're breastfeeding, when you're going through the menopause.

So, you know, for poor women, you know, across your lifetime, migraine can change to be more frequent, less frequent, split sides, change all the symptoms that go alongside it, so it can be a really difficult condition to get on top of.

And, you know, as I said, men get this as well, so we can't always blame hormones on this, so there are other sorts of reasons that people get migraine as well.

I think, you know, one of the main problems with migraine, and the main problems that people come across, is they say, you know, how many headaches do you have a week, or, what's the severity of your migraine from one to 10?

And what that doesn't take into account is a lot of the other symptoms that go alongside migraine, and if there's one thing I can say to people again and again is migraine is more than just headache, and I think you know, there'd be a lot of people out there that would agree with me that it's the brain fog, it's the lethargy, it's the kind of odd symptoms that go with it, the cravings, the yawning, the neckache, all the sorts of things that go alongside it.

So the headache might actually only be a very small part of what you go and see your GP for.

but actually, and so, you know, they get the impression that perhaps the migraine isn't as bad as they think.

You know, you're only talking about having five headaches a month, but in fact, there's all these other days that are lost because of the brain fog or the hangover feeling, and actually, when you count those up, and you have 15 days a month, you know, that should be something that people should be sitting up and taking into account on, because that's half your month is out because of this single condition.

So, you know, I always say to people, you know, it's more than just a headache and although we talk about, you know, how long does the headache last for, and that is important to look into, what we do need to think about is how long those other symptoms are lasting for as well, and is there something we can do about those?

Now when we talk about migraine, we talk about, kind of, the character of the headache itself, but it's also useful to think about what we talk about as the, kind of, stages of migraine and we talk about a prodromal phase first, and that's kind of where migraine is starting to come in, and people will often say, I have food cravings, I'm doing a lot of yawning, and I have a lot of neck ache.

So all of those are often signs that the migraine is kind of brewing and again, this might be something that you recognize in yourself.

Or actually, only now that I'm saying it, you think, oh gosh, you know, I do get that sweet foods two days before the migraine actually kicks in so that's the prodromal phase.

Then we talk about having the aura phase, which a lot of you will recognize as well, so that's the bright lights, the flashing lights, the buzz, the loss of vision, the kind of spreading scotoma but people can also get migraines that affect other parts of the body, so any part of the brain can be affected by an aura, so you can get numbness, tingling, word finding difficulties, all of those things can go along with that as well.

So, aura isn't just the visual stuff, it can often be other symptoms as well and then we talk about the headache, so that's only the third part of the migraine and then we can obviously think about what happens during that time.

So, is the migraine unilateral? Is it bilateral? Is it pulsating? Is it throbbing? Those sorts of words we like to hear, because that kind of reinforces that we're dealing with migraine here and typically, when we're thinking about migraine, versus perhaps one of the other headache conditions, is what I really want to hear is that people with migraine want to stay still.

You know, this is the lie under the bed with the covers over your head, because anything that aggravates a headache, like movement, coughing, sneezing, getting up to go to the bathroom, that's really kind of classic for migraine, whereas a lot of other headache disorders, people will often pace or they'll bang their head against the wall, or they'll do something to distract themselves, and so if I hear that in the story, I think, gosh, maybe we're not dealing with migraine, maybe this might be something else.

Then you also get those other symptoms that go alongside the headache, so often that nausea and vomiting is quite key and then the light and sound sensitivity, and people can also get smell sensitivity as well, so certain smells can, be set you off or make the headache feel worse as well.

Again, this is going over some of those symptoms with that prodromal phase, and then that aura phase as well, so these are symptoms that sort of you may recognize as sort of the beginning of your migraine, but certainly, again, you know, this now tells me that, you know, this is likely that we're dealing with migraine if we've got this recognizable pattern that is building up and then the last phase we talk about is the post-drome of the migraine, and that's kind of the day after the headache goes away and again, most of you would recognize that if you feel a bit You know, you're operating on 50%, or there's a bit of a hangover feeling, or you're just not quite there.

You can't quite cognitively grasp things as easily as you could have before, and then once that passes, then you're back into, kind of, your quote-unquote normal stop time until, kind of, the next prodromal phase.

So, you know, what we're looking for as well is sometimes, rather than saying how many migraines might you have in a month, or how many days are affected in a month, which can sometimes be quite a bit negative to focus on, kind of, those bad days.

The other way of looking at it is to flip the switch and sort of say, how many crystal clear days are you having a month? So, if you're saying to me that there are only four days a month where I feel completely normal, like a, you know go out sailing, I can go out with the kids, I can go grocery shopping, all of those things.

You know, if you're only having four days of those months, then you're telling me that there's 27 days a month that you're actually affected in some way.

So your migraine burden is really large, even if actually in that time you're only having seven headache days.

So that crystal clear day is a good way of thinking, what is the burden of my migraine here?

Oops, I'm sorry, I think I've gone backwards there.

You know, this is kind of going over some of those things we've already spoken about.

One of the diagnostic criteria for migraine is that it has to be a moderate or severe headache, and I think anyone here that suffers from migraine would know it's not just the headache you get from when you're being a bit dehydrated, or you've, you know, haven't slept well the night before, you know, it's a very different quality headache as well.

So I think that's, you know, patients as a whole are very self-selecting, and if you're coming to see a specialist for your headache, it's probably and then we talked about those sensitive delight smells, and kind of the vomiting as well and this is, again, looking at, kind of, what the difference is between migraine and perhaps just an ordinary tension headache.

There is a school of thought among urologists about you know, is tension headache just a milder form of migraine? And certainly that's something that, you know, you do recognize.

Sometimes people say they have that kind of squeezing quality to the head.

It feels on it is bilateral, and so people will start saying, well, that doesn't sound like migraine.

Migraine should be on one side, maybe it should it should be throbbing rather than squeezing but actually, if you kind of look at what else goes alongside it, then often sometimes the tension headache is just a milder version of what you're migraine is.

So, if you're saying, you know, I definitely know that I have seven migraines a month, but there are five or six kind of milder headaches that I have a month, I would actually also count those among your migraine burden, because actually they're probably part of the same problem, and if we can treat everything, we'll treat all the headache.

But, you know sometimes it's hard to sort of distinguish between those but I think probably the main thing for me that sort of makes me realize that when we're dealing with migraine is that kind of aggravated bike activity.

So if you're saying to me, when I'm bad, I just want to sit still and do nothing, then, you know, for that, I tend to think I think we're on the right track here.

And, you know, there are lots of reasons or triggers for people to have migraines, and I think the problem with looking for triggers is you end up finding things that aren't necessarily triggers.

If every time you have red wine, or every time you have cheese, you get a migraine the following day, fine, I would recognize that as a trigger but the problem with looking at food diaries, or looking at activity diaries and saying, what is the commonality here?

People start to recognize that on, you know, one day where I had caffeine, I had a migraine, and then another I had red wine, I had a migraine, and then another I had cheese, I had a migraine.

In fact, probably all of those are quite random, and aren't related to those foods at all and so people end up living like a monk, you've stopped taking everything that's enjoyable in life, and you're still having migraines.

So, I'm less, sort of worried about what triggers of your migraine are, unless there is something that's really consistent for it but some things we do know a lot of the time will lead to migraine is potentially, you know, changes in hormonal cycles, so with menses, or, you know, a change in your hormonal life, so going through the menopause, those sorts of things.

Then also tiredness, stress, they can obviously exacerbate migraine as well and increasingly, probably in the last, sort of, 20 years or so, we've started to realize, kind of, why migraine happens and there's a very, kind of interesting system going on in your head called the trigeminal vascular system.

So your trigeminal nerve is one of the nerves that kind of supplies kind of the skin, the lining of the brain, the inside of the skull, that sort of thing and there are a lot of blood vessels that go alongside that, and so these nerves run along the blood vessels as well and so this is something called the trigeminal vascular system.

We know that gets activated in people with migraine.

Now, why that activation occurs, we don't necessarily know that, but we know the reason why migraine happens and so because of that, we're starting to come up with a lot better, sort of, individualized treatments.

For dealing with that problem alone, rather than saying, well, now that you've got the pain, let's do something about it.

It's actually getting to that root cause and trying to address that in the first instance.

Again, sorry, we've already spoken a little bit about triggers there, but these are things that certainly, you know, we would recognize are pretty clear triggers, rather than saying, you know, cheese is going to cause everyone a migraine, or chocolate's going to cause everyone a migraine and when we talk about treating migraines, and again, I'm probably preaching to the choir here, I'm sure a lot of you have gone through some of these steps already, but we always talk about the acute treatment, the migraine you have at the moment, and then the preventative treatment, which is the migraine that's going to come, kind of, next week and so the difference between those two are really based on kind of the numbers, and this is where, unfortunately, we do sort of tend to focus on the amount of headaches per month, or at least the sort of days of migraine per month that you're having.

Because so there's a magic number of about four migraines per month, where the need for a preventative treatment is there.

So if you're having less than that, we would tend to say that let's focus on dealing with the migraine when and where it comes on, getting on top of that as quickly as possible, moving you on from that.

Rather than giving you a treatment every day to prevent migraine and the reason for that is, if you can imagine you're having two migraine days a month, that's, you know, 28 other days when you're not having anything.

So if you're taking a tablet every day, or sometimes twice a day, the burden of kind of tablet taking isn't quite justified.

You know, some people will say to me, look, having one migraine a month is too many, so, you know, certainly there's a bit of variability there.

Or other people say, look, I'm not really a pill person, I'd rather have, you know, give me at least a week of migraine before I consider taking something to prevent it.

So, you know, there is some variability there, but generally we talk about saying four migraines a month is when we'd start to think about preventative treatment, and less than that.

We're just sort of focused on the acute treatments.

Now, that's not to say during the kind of people with more than four that we wouldn't do acute treatments as well, but certainly, kind of, adding in that preventative, that's when that comes along.

So, for acute treatment, so focusing just on the migraine you have at the moment, that's generally some form of painkiller.

A lot of GPs will talk about naproxen, ibuprofen, paracetamol, codeine even.

I would tend to not go with those.

My, kind of, migraine cocktail will usually include aspirin, and quite high-dose aspirin at that.

If you're having a stroke or a heart attack in the hospital, we'll give you 300mg of aspirin, whereas when I'm giving someone a treatment for their migraine with aspirin, I'm giving them 900 milligrams.

So, you know, really kind of big doses and the idea behind that is that you're really getting on top of the migraine as quickly as possible, hitting it hard, getting it done, getting it gone and I always include in with my aspirin, an anti-nausea tablet.

And, you know, we know that nausea is a common feature that people experience with their migraine, but one of the other things that happens with migraine is your tummy just tends to sit there and so it doesn't empty, it just sits there and does nothing, and that's why you often feel, oh, I just don't feel like eating, I feel a bit bloated and so what happens with that is all those tablets just sit in the stomach and don't do anything and by giving you an anti-nausea tablet, it kind of turns the conveyor belt on of your GI system, and so those tablets are getting into your small intestine, getting absorbed, getting into the system a lot quicker.

So even if you're not having nausea, I would often include that as well, just to get that stomach moving and then the other one I often add to that is the triptan, and that's something those these are drugs that have been around for a long time, and they work on, kind of, that trigeminal vascular system a little bit, and we'll talk about a little bit more about the design of drugs that do that these days, but what they do is indirectly influence, kind of, one of the markers that are released by that system, and try and reduce it.

So, they're quite good about turning around migraine, and most people will would have tried a form of triptan before, and kind of the commonest one that GPs will prescribe is something called Sumatriptan.

There are six other triptans out there, and the difference with triptans is that each one behaves slightly differently.

They've got different onsets of action, they last for different lengths of time, and so sometimes, actually, all it takes is to change around the triptan that people are taking, and I even if you have a bad reaction to one triptan, potentially the other six will still work for you.

So, you know, there is some thought that actually what we should be doing is kind of tailoring the triptan to your symptoms, and what I would generally do in any consultation is try and get an idea, is there a better triptan for you if you haven't tried, kind of, more than one triptan before, or if, you know, if there's something that's a little bit more appropriate for you.

Now, unfortunately, there are some people that can't take triptans, so certainly if you're getting a little bit older in age, if you've had a history of heart attacks or strokes, you should be on triptans and if you have hemiplegic migraines, that's when you have a migraine, and perhaps half your body gets paralyzed, or you get a bit of weakness in your arm or your leg, we probably should avoid triptans in those situations.

So, sometimes we say, oh, you know, about a year or two ago, we would have said, well, we can't give you anything, so we'll just stick with the aspirin and the anti-nausea tablet but actually, more recently, there's been this newer drug come out called Rimegepant, which specifically targets that trigeminal vascular system even more so than triptans, and that's something that's very safe in patients that can't otherwise take triptans.

So that's something to look at as well.

So, aspirin, anti-nausea, and now this Rimegepant rather than the triptan, if that's appropriate for you and Rimegepant, as a drug is very available in primary care on the NHS, so GPs can prescribe this in situations where people have failed to improve with two triptans, so if you've tried Sumatriptan and Naratriptan by a GP that hasn't worked, then Rimegepant might be an option for you.

For people who haven't had, sorry, aren't able to take triptans, or if, you know, there's sort of a profile that tells me that perhaps the Rimegepant might be better for you.

For instance, sumatriptan lasts in the system for about 4 hours, so if you're having a migraine that lasts for 24 hours, that 4 hours at the beginning you know, you're not doing really much for the 20 other hours of the migraine that's coming along, whereas Rimegepant lasts for about 48 hours.

You can see that if you take one tablet of Rimegepant, that actually you're going to have, sort of, coverage for the next two days to prevent that migraine kind of bouncing back, coming back, or recurring and the advantage of Rimegepant as a drug is that it's a dissolvable tablet.

It tastes like peppermint, so if that's a bit helpful for your nausea but also, it does mean that if you do vomit, it's probably got into the system already because it is dissolvable and gets absorbed under the tongue rather than kind of through the gut.

So, you know, there are lots of different reasons why, kind of these newer drugs might be more helpful for you, than drugs that you've potentially tried in the past.

So that's kind of acute treatment in a nutshell.

When we talk about preventative treatment, we talk about, kind of, the drugs, again, that I'm sure some of you have tried before.

So these are usually either anti-seizure medications, so topiramate, pregabalin, Valproate has probably gone off the boil now, but that used to be another one.

Antidepressant medications, so amitriptyline, venlafaxine, duloxetine, or blood pressure drugs like propranolol, candesartan, pizotifen.

So there are lots of different drugs out there, and again, that's 9 that I've just sort of rattled off, whereas GPs will often try two or three and say, there's nothing else to try for you and I guess, you know, the problem with those drugs is psychologically, I think it's a little it's hard for patients to say, I've got migraine, why am I being given an antidepressant, or why am I being given an anti-seizure medication? Now, we do know that these drugs are effective, so we're not giving you kind of stuff just for the hell of it.

We do know they're effective, but I think there is that leap of faith, or, you know, that, why am I being given this drug where, you know, it doesn't say migraine on the box and fortunately, we have now some newer treatments out there that do allow, that are migraine on the box.

They are developed specifically to deal with migraine, and I think just seeing that is sometimes a little bit easier, to kind of swallow, literally, that, you know, I've been given a treatment here that is being designed, it's been tested at its full migraine rather than kind of full blood pressure, but it just happens to do something for your migraine.

The only problem with, kind of, these newer drugs is, unfortunately, just because of funding and what have you, patients do usually need to try some of those other ones first but again, fortunately, most of the time that I'm seeing patients in Benenden or in other situations, you know, you've often tried a lot of things from your GP that haven't worked, and so usually we can go back with these medications relatively quickly to try and get things working for you.

the, sort of guidelines around these preventative medications is that they need to be trailed for a sufficient length of time, and a sufficient dose to prove that they haven't worked.

So if you take amitriptyline, for instance, and you took it for 3 days, and you've got some bad side effects, you stopped taking it, that doesn't usually count as a trial, so these have got to be drugs that have been taken for, you know, a good length of time, and you've said, I've tried propranolol for 10 weeks, and I had no difference in my headache, then we can say, okay, you've tried one.

tick, let's move on to the next and sometimes, as I said, you have to go through two or three of those before we can kind of get on to the other stuff but sometimes along that way, one of those two or three might actually be helpful for the migraine.

So, you know, there is a rationale for trying those ones first.

Now, the kind of specialist treatments that are out there for migraine, and kind of that we wouldn't muck around with if you'd tried, kind of, two of those three of those preventative drugs before, is Botox for migraine.

We also can do something called a GON block and then there are these newer, kind of, designer drugs, the CGRP injectable drugs, and now kind of the newest player on the stage is these gepant drugs as well.

So, a lot of those, you know, these are the drugs that we should be looking at for managing migraine, rather kind of try another antidepressant, or another anti-seizure medication, or another blood pressure medication and if we go through those kind of sequentially, a gong block is, probably The easiest one to talk about, so if, you know, if everyone on the screen at the moment, if you feel at the back of your head, in the very middle, you've got a knobbly bit there, that's called your occipital protuberance, and if you run along the base of your skull, about a third along away along, kind of about here, it'll feel a little bit tender.

If you press hard enough, that's where your greater occipital nerve comes out at the back of the skull, and that nerve kind of wraps over the top of your head and meets up with one that comes up above the eye here, and that kind of almost forms a pain network.

Now, if we give you a local anaesthetic and a steroid injection over that area, what that can do is interrupt the network and allow the sort of the headache to stop, or not be propagated.

As a treatment, a GON block is more of a temporizing measure, so I will often use this if, for instance, you know, you've had migraine consistently for a month and it hasn't gone away, there hasn't been any break introduced, and it's very hard to kind of bring a drug into that situation and try and stop things when it's already kind of in the throes of it.

So sometimes a GON block can be quite helpful there about sort of introducing a break in your migraine to allow us to try some of those other medications.

It certainly is something that can be used, kind of, in that situation to give us a bit of breathing room to bring something else in.

Sometimes people can actually find that GON blocks periodically can actually prevent their migraine and so, if that is effective for the management of your migraine, this is something that can be given every, sort of, 10 to 12 weeks, you know, periodically to kind of manage things there.

In terms of side effects, this is a medication that's given as a small injection just under the skin there.

It's a bit unpleasant when you have it done the first time, but generally speaking, there aren't a lot of problems associated with it.

If we inject you in the same place again and again and again and again, there is a risk of getting a small bald spot in that area.

Now, women, obviously, with longer hair, it doesn't usually make a difference, but, you know, that's probably the one risk of it.

The other risk is that sometimes medication just doesn't work, and so the risk would be that you try something and it actually doesn't make any difference to your migraine but other than that, not usually a lot in the way of side effects.

The CGRP drugs, so as I said, these are kind of these designer drugs here, and there's a very kind of interesting cartoon on the slide here and this, CGRP is this, kind of protein that is made in this trigeminal vascular system, and what we know is that when people are having migraines, the amount of CGRP in their spinal fluid and in their bloodstream increases, so we certainly know it's causative for why people are having migraine and when we were kind of investigating does CGRP, you know, is this the smoking gun? Patients in the trials who were willing to be given this, were given infusions of CGRP, and that set off a migraine.

So, you know, we certainly knew that this was causative, it wasn't just sort of a red herring and as a drug, these drugs are available as injectable drugs, and so you may have seen ads for these, or seen read about these online and these are drugs that you can give yourself once a month.

They're an injection just in the tummy, they're a bit like a, you know, if you've ever tried Sumatriptan, it's an injectable thing.

It's a, you know, an auto-loaded pen device, you stick it against the skin, you push a button, it goes in, you know, the needle's retracted, it goes into a sharps, and you know, it's a very easy thing to give yourself and one of the advantages of this drug is it's a once a month, so sometimes for people that, you know, this is effective for, this is a sort of a one and done, you can always forget about it until the next month when you need to do it again.

So it's quite nice for, again, people who are a little bit pill-phobic, you know, you don't want to be taking the medication every day.

This is something that's been quite helpful for that.

If we think of CGRP like a lock that goes into a key sorry, a key that goes into a lock, so when that happens, the migraine is propagated, or, you know begins and so what these drugs do is aim to either gunk up the lock so the key no longer fits, or they bind to the key itself and change the shape so it no longer fits in the lock.

So the idea is that lock and key system doesn't work anymore and these medications are licensed for, you know, either episodic or chronic migraine.

They're usually very well tolerated, because this is a designer drug, this is designed to do kind of one thing and one thing alone.

There's CGRP, In the brain, in this trigeminal vascular system, and it's also in the gut as well, so it can cause a little bit of constipation to people that are taking this, but generally speaking, this is a drug that's well tolerated, and again, when people have started on this, they're usually quite happy to continue on this it doesn't cause a lot of problems.

The sort of newest drug, as I was saying, on the line, is a gepant, and that's an oral version of those injectable drugs and there are two ones that are out at the moment, so there's Rimegepant, which we spoke about as that kind of acute treatment.

So, Rimegepant can also be used as a preventative treatment as well, but only for people with episodic migraine and so that's a drug that's taken every other day, so it's that dissolvable drug.

You take it every second day, so you're only taking, sort of, 15 tablets a month and that can be effective at sort of turning off those migraines as well and there's Atogepant, which is kind of the newest, that's been around about 12 months now.

Again, that's a daily drug, so you take that every single day, and that's for, episodic or chronic migraine as well, so people can take it for both indications and I think the advantage of these two drugs, at least, is unlike amitriptyline or propranolol, or any of those drugs where we start off at a low dose and we build it up over time, and we wait for that 10 weeks to see if there's been a difference, these drugs have a single dose.

So you start on one dose, you stay on that dose, and that's a little bit easier as well, you don't have to think on increasing this, I'm getting more side effects because I'm increasing this and they also kick in a lot quicker, so usually with the Atogepant, you should be noticing changes in your migraine within that first week of taking it.

So again, you're getting that feedback very early on that things are helpful here.

Also, the great thing about these drugs is when we do a migraine trial, one of the measures that we look at are how many people had a 50% reduction in their migraine.

So, of this 1,000 people, you know, 250 people had reduction in their migraines.

25% of people had a 50% reduction in their migraines, so we pat ourselves on the back and say, what a good drug this is and when we get that sort of level, with the Atogepant trials, we were getting sort of 60, 70% of people were having that 50% reduction, so it's much more effective than any of those drugs that we've tried in the past.

So, you know, this is where we should be aiming to get patients on, but unfortunately, you know, it's a new drug, it's expensive, these sorts of things, so it is taking a little bit of time to get out there but this, I keep saying to GPs when I talk to GPs about migraine, this is the future, and this is what you know, GPs will be managing going forward, so I think when we're giving this talk in five years' time, you know, we'll be talking a lot more about Atogepant that can be available directly from your GP.

At the moment, it's a little bit of a postcode lottery.

In the NHS trust I was working in, just until recently, this was something that was available from GP, so you could ask the GP to start prescribing this, but a lot of the other trusts have this as a specialist-initiated drug, so a specialist has to start it before the GP will continue it, so sometimes that's a little bit of a stumbling block there.

The other thing that we're wanting to talk about today is kind of Botox migraine and, you know, why does that work? And, you know, people say, oh, is it because you're, you know, paralyzing the face? Are you paralyzing the muscles, they can't get tense, but it's not anything like that at all.

The doses that we're using are so small that it's not actually paralyzing any of the muscles on the face, so you still have facial expression and what have you but what this drug does is, if we were talking about that CGRP business before, when we give people Botox for their migraine, the amount of CGRP is reduced in the bloodstream during a migraine.

So we're not exactly sure why it works, but it was something that kind of was developed by the drug company that first created Botox, and they kind of developed this very rigorous protocol of saying, why does this happen? And found that there was a very particular kind of set of injections that led to people having a reduction in their migraine and so that's something that we call the pre-empt protocol.

So, if you're ever talking to a specialist about having this done, we talk usually about 31 injections, and over the next couple of slides, we're going to see where these are.

So, as you can see in this first slide here, this patient will get seven injections over the forehead.

The main kind of complication of Botox are these injections just above the eyebrows here, so if they're not done correctly, what can happen is that muscle, because it is so small, can be a little bit paralyzed, or the wrong muscle can be paralyzed, and it causes your eyebrows to sort of look a bit asymmetric, and you can look a little bit like, Spock from Star Trek, if this is done incorrectly, and you'll have sort of a quizzical eyebrow for three months.

But fortunately, with Botox, at least, it does wear off, so if there's any cosmetic side effects from it, we know they will go away once the Botox wears off.

Unfortunately, Botox wears off, and so if it is effective in your migraine, it does need to be given kind of every three months as a repeated dose to maintain that.

What Botox actually is, is if you think of botulism, so it's the protein that is made by the bacteria that's responsible for botulism, but we're not going and getting rusty cans and drawing needles up off that.

What we get this from is that toxin sort of made In a laboratory, it's grown, you know, we're dealing with it very safely, so there's no risk of any kind of getting any nasty conditions from that.

We've just seen in that first slide, so that the woman in the top left there is getting those seven injections.

We do four injections into the temple on each side and then the back of the head with E, there are six injections across the base of the head, and then we'll do the G injections, down sorry, the F and the G injections, which are at the base of the neck and along the top of the shoulders as well.

So that makes up sort of the 31 injections that we would give people to manage their migraine.

It seems like a lot, but, you know, most of the time when people have it done with me.

They do say afterwards, oh, that wasn't as bad as I thought.

You know, you sort of think you're going in and you're going to be come out looking a bit like a pincushion.

It's a very small needle, it's very small amounts, it's done very quickly, and often, you know, people don't mind it so much when they come and see me.

They all they all say, who would choose to have this done, in terms of for cosmetic reasons, but most of them say that, you know, that it's kind of worth it for the effectiveness they get from the management of their migraine.

There's something called follow the pain that goes along with Botox as well.

So, although we talk about having 31 injections, there is the potential for people to have about eight more injections as well.

So if people say to me, look, the Botox was effective, but when my migraine comes back, I really feel it around my left temple, what we can actually do is do a couple more injections around that area, so we can kind of target these areas that are sort of more problematic for people.

Unfortunately, if things are going across the forehead, or you're getting things behind the eye, there's not any extra injections there but if we can do extra injections, we can do that in the temples, at the back of the neck, or over the top of the shoulders as well.

So there is a, you know, way of kind of tailoring it to people there this is kind of the rationale for, are people suitable to have Botox injections?

And really, the only reason not to have Botox would be if you've had a bad reaction to it in the past, or that there's some infective problem going on around the time of the injection, so if you've got You know, pimples across the top of the forehead are things we might not want to inject at that time, just to sort of prevent any spread of infection.

And, you know, pregnancy and breastfeeding, we tend to say avoid it during those, times as well.

but otherwise, most people are sort of eligible for Botox if, following a consultation, you know, it's deemed to be appropriate for you.

The main thing about Botox is that patients need to have a particular number of migraines to justify it, so what we're looking at is people having at least eight migraines a month, and sort of 15 headache days a month, so we're looking kind of at half, half a month as a as by migraine to sort of get you over the line to have Botox there.

If you're having kind of just those, you know, two, three, four a month, probably wouldn't look at using Botox in that setting.

We do have a very calm outpatient department at Benenden, and, you know, this is something that could be done in the consultation room.

You don't need to come into a theatre, this doesn't need any special preparation at all.

There's usually an alcohol wipe just to clean the skin, but otherwise, you can go swimming, driving, you can go and have your hair cut afterwards, you know, there's no special restrictions that need to happen following the Botox injection.

When people, come out, you will have some spots over the forehead there, that's just the, area that we've injected.

There's a half a mil that goes into, sorry, 0.05 of a mil, so, you know, a 20th of a mil goes into each injection, and so there will be a little bit of a bump where that has gone in, but that's absorbed over a couple of hours or so, so by the afternoon, you won't have any Noticeable effects of the injections and then, of course, why coming to Benenden Hospital? Well, hopefully to see me but also because, you know, I, you know, working there, as I have for the last couple of months, it's been a great place to work.

I find everyone very helpful there, staff are all lovely, you know, this is not just me saying this, this is, you know, a genuine feeling, and I really appreciate being given the opportunity to speak with you today, and being invited by Vicky and the team.

To come across and talk about this and so, Vicky, should I hand over to you now?

Vicky

Thank you, Dr Mitchell.

So, it's now time for the Q&A session, and we're really pleased to have so many of you joining us tonight and while we won't be able to answer every question, we'll do our best to cover as many as we can.

So on this slide, you'll find information about arranging treatments.

Please note that you will need a GP referral for a consultation, and our private GP service is available if you don't have this already.

Okay, so on to the questions.

Thanks for your patience.

The first one is from, Gioti.

I hope I've pronounced that correctly.

I have chronic severe migraines that usually last 48 to 72 hours.

I've also started experiencing menstrual migraines, which feel somewhat different from my regular migraines, with the same treatment applied to both types.

Dr Clinton Mitchell

Thanks, for the question.

So It's always difficult with a menstrual migraine to say, you know, do you treat that alone, or do you sort of treat the whole migraine burden across the entire month?

There are some specific treatments that are quite helpful for menstrual migraines, so if people have only got that alone, sometimes we can give you a particular triptan to take around the time of your menses, or there are those injectable drugs, one of them, the Fremanezumab, is particularly helpful for preventing menstrual migraine as well.

If it's menstrual migraine alone, sometimes we can do specific treatments, but if you've got this extra menstrual stuff as well, so if stuff is going on at other times of the month, I would tend to give you a broad strokes approach, and try and manage, kind of, everything in one go, unless we needed to really, kind of, tailor things along the way, but usually speaking, probably one approach would be safer for you if you're having stuff at other times as well.

Vicky

Lovely, thank you, that was helpful.

Next question, can you have a migraine without the headache?

Dr Clinton Mitchell

Yes, so there's something called, acephalgic migraine, which is just means no pain migraine, and a lot of the time, that's kind of all of that you get the prodrome, you get the aura, and then you get the post-drome afterwards, so you recognize, kind of, everything else that goes along with it, that brain fog, you know, moving through treacle, without actually having the headache as well, so we would look at treating that.

Excuse me, in a similar fashion, so even though you're not having the pain, we're probably still look at giving a triptan and potentially the anti-nausea, maybe not the aspirin, but we could look at giving you those things to try and turn that off and try and attenuate that procedure and we'd also look at, depending on, again, the amount of times this is happening per month, look at giving you that preventative treatment as well to prevent any of those things happening.

So, the absence of headache wouldn't necessarily put me off.

Vicky

Lovely, thank you.

Next question is from David, and David says, I was interested to hear about the trigeminal nerve, as I've had trigeminal neuralgia and had an MVD operation last year.

He says, I also contracted Steve's-Johnson syndrome as a result of a reaction to carbamazepine.

Dr Clinton Mitchell

Gosh so that is a lot, so I'm sorry that you've gone through all of that.

So, trigeminal neuralgia, as you've mentioned, is related to the trigeminal nerve.

There's also the trigeminal autonomic cephalgia, so these are things like cluster headache, which people might have heard of, but there are other ones there as well and then there's migraine, which is related to the trigeminal vascular system.

So, although they've all they all share that kind of trigeminal part, a lot of they are quite different disorders, and so You'd be you are unlucky if you're having you've had trigeminal neuralgia, and now you're having migraine as well but certainly these would be sort of individual disorders that we would look at managing, kind of, specifically there, rather than saying they're all part of a bigger picture.

Vicky

Lovely, thank you.

I hope that was helpful for you, David.

Next question is from Jessica, and Jessica asks, is there a way a patient can get to the potential root cause of their migraine?

Dr Clinton Mitchell

Thanks, Jessica.

So, yeah, that's a tricky one.

As we said, we know, kind of, the pathophysiology that underlines it, we know, kind of, why people develop migraines, or what's happening in your brain when it is, but the exact reason of why you get migraine versus your neighbour not, that's a little bit harder to pin down, and again, that can be genetic factors, that can be hormonal problems, and so it's, you know, getting to that root cause and saying, well, if I just change one thing, will my migraine go away completely? It's a lot harder.

If migraine is very, very hormonally dependent, so I think, you know, it's just with the menses, as we spoke about, Jyoti, what you can look at doing is giving a treatment that specifically targets menstrual migraine, or we can, you know, look at, you know, contraceptive devices and hormonal devices that can change your hormonal cycle.

Ultimately, as I said, getting to the that, you know, eliminating the reason people develop migraine is a lot harder, and not something that we can sort of look at doing in this day and age.

Vicky

Okay, thank you.

I hope that was helpful, Jessica.

Next question is from Juliet, and Juliet says, does vagus nerve treatment help with migraines? I'm currently getting help from a chiropractor for this.

Dr Clinton Mitchell

Yeah, so the vagus nerve stimulation, so we're talking about, kind of, either the Gamma core devices, or people can get the carefully devices across the head as well, so those can be helpful for migraine.

They're not ones that are recognized, sort of, in a randomized controlled trial, so when we talk about, kind of, evidence for treatments, what we want to see is that they've been proven to be better in this, you know, a trial where you've had one group get it and one group don't, and see, has there been a difference between two?

So it hasn't been proven in, kind of, that robust away, but we do know that there is a lot of anecdotal evidence out there that people find that those devices are helpful, so that is something that people can look at doing, but it's not necessarily something that, on, kind of, the NHS, for instance, that you would necessarily be able to access because it hasn't had, sort of, that level of, kind of, rigor put to it.

Vicky

Lovely, thank you very much.

Next question.

When you speak of treatment for migraine, is a drug considered effective if it reduces the severity of attack, but not the frequency?

Dr Clinton Mitchell

Yeah, that's a you've picked up on one of my bug bears as well, so most of the time, when we look at the reasons that people have to when you get started on a drug, there is a does this make a difference? If not, we need to stop it.

You know, this seems like a fair question for, you know, the country to ask us, you know, in terms of spending health dollars.

With a lot of these drugs, people come back and say, my migraine frequency hasn't changed, but the severity of it is much better.

I can now go to the shops, you know, I can manage through my migraine.

And when I'm looking at people's response to migraine, I take that into account and say, for that reason, I would continue the treatment for you but by the strict letter of the law, that wouldn't necessarily be allowed, but I think, you know, there's an increasing recognition that quality isn't the same as quantity and I remember, you know, one time, I had a patient come back, you know, she had a headache diary, and she used to it was always coloured in, so every day was black and then when we started on her on Botox, and she came in and every day was black, and I, you know, my heart was like, oh, it hasn't worked and she said, oh, no, it's great.

I can now go out and ride the horses, I can go to work, I can do all these sorts of things.

So, you know, even though her headache diary still looked appalling, there was definitely a, you know, an improvement there and so, you know, that would be a reason for me, at least, to say, look, let's continue with this medication.

So, yeah, I think you've hit the nail on the head.

There's a really difficult conversation to be had there but again, this is something that I when I talk to GPs and colleagues and things, you know, we're always harping on that sometimes we need to be looking at quality rather than saying, has there been a 50% or a 25% reduction in your migraine? Because I think when we focus on numbers like that, we end up missing kind of the bigger picture of what people are experiencing.

Vicky

Yeah, lovely, thank you.

Next question is, can you have a Atogepant with Botox?

Dr Clinton Mitchell

Yeah, so, that's probably a very new, question, so Previously, the answer would have been no, but now what we're looking at doing is something called layering, so when people have a Atogepant to perhaps have kind of a substandard response to it, so again, thinking back to Stephen's question about having what we want to see as necessarily a sort of a 50% reduction in migraine, so if we're not getting that, what we can but you're saying, oh, look, you know, 40% better or 30% better, then maybe what we can look at doing is layering Botox on top of that, and again hoping that actually the combination of the two gives you a better outcome than one alone.

So, that is something that can happen nowadays.

Vicky

Lovely, thank you.

Next question is from Jackie.

It's quite a long one, so bear with me.

I'm waiting to go back on Botox after having it some years ago with some effect.

We'll possibly go back on for Fremanezumab, as it was very effective until it was paused, and then ineffective after this.

I've literally been on everything, gippantz, Viepti, many, many other meds.

Had a steroid rescue.

Next option after this is possible neuromodulation surgery.

How effective is this? I'm currently under GST.

Dr Clinton Mitchell

So yeah, gosh, that does sound like you've been through everything there.

So, there's always a patient that you can think of that has, reached the end of the road and has tried everything, so it sounds like you're certainly in that camp.

Neuromodulation is something that, you know, is a very, kind of last stab, and, you know, we were talking about, kind of, the device and the Gamma Core device for the vagus nerve simulator, so that's in a similar effect as looking at that, you know.

Without kind of second-guessing your specialist, that's obviously recommending the neuromodulation, you know, that is something that is on the cards for you.

Of course, when you've tried so many things and had so many things not work for you, it's hard to know exactly what your response would be to neuromodulation, but I think that is certainly, you know, an option that is out there and would be worth pursuing because of your refractory nature of your migraine, so I'm sorry to hear that you're going through that.

Vicky

Okay, thank you.

I hope that was helpful.

Next question is from Karen, and they ask, why is it important to maintain a routine and hydration to prevent migraines?

Dr Clinton Mitchell

So as we talked about triggers, certainly being dehydrated, having poor sleep.

not getting enough exercise, all of these things seem like I'm just being a health guru, you know, eat regularly, all of these sorts of things, but, you know, we do know that when people deviate from that pattern, migraine is more likely to occur.

So, it's more about, sort of, maintaining a healthy lifestyle, and so that the substrate, that the migraine is coming from is as healthy, you know, is as, small as possible.

So, if you're junk food, staying up to 3 o'clock in the morning, odd sleeping pattern, you know, stressed at work, those things are just right for a migraine to come out.

So if we minimize anything that can arise or trigger a migraine, then we would recommend then we would see that hopefully the migraine frequency would reduce.

Above and beyond any drug we can give you, exercise is helpful for your brain health, not just migraine health, but your brain health, so anytime you can exercise, that will improve your migraine.

Now, of course, some people do find that exercise makes your migraine worse, or makes it more likely that they get a migraine, so there's sometimes a double-edged sword there but if you are able to exercise, or if we can get into a situation where we can reduce the frequency of migraines so that you can exercise.

You will often find that that does make a difference as well.

Vicky

Okay, lovely, thank you.

Next question is from a Jill.

Jill asks, I have a long list of food triggers.

The migraine starts within an hour of eating the food, usually something that contains tyramine or histamine.

Is there anything I can do about this, or do I simply have to avoid the triggers? My diet is becoming quite narrow and boring.

Dr Clinton Mitchell

Yeah, so unfortunately, it sounds like, Jill, you're one of those people that I, you know, we talked about living like a monk.

This sounds like you, you know, very much have food triggers.

If it was only once that you'd had it and it caused a migraine, I'd say probably try it again, but it sounds like you're very consistent for that, and unfortunately, there's not a lot that can be done to, sort of manage that trigger.

What we could look at doing, or what I would look at doing, is trying to get on top of the migraines, try and manage them as best as possible, get them reduced down, and then once we're at that situation where the migraine burden is less, then say, can we start to introduce foods that previously were triggering?

Because we've already we've now suppressed your migraine, and then we might allow you to introduce cheese or other tyramine-containing foods, maybe, you know, and they won't necessarily trigger the migraine because we've got everything else under control.

That would probably be the only sort of recommendation I would have in that situation, aside from, unfortunately, avoiding all of those foods.

Vicky

Okay, thanks very much.

Next question, people have suggested electrolytes.

Is this something that you would recommend?

Dr Clinton Mitchell

Yeah, it, it would only be if there was a reason for the electrolytes.

So, you know, if you'd gone for a run, you came home, and you were dehydrated, and that caused a migraine, then perhaps the electrolytes would be helpful there but if you're drinking plenty, eating well, sleeping well, there wouldn't necessarily be a reason to take a Powerade if you had a migraine there, so it would only be if there was potentially a reason for that.

Vicky

I've got time for a couple more questions.

Next one is from Louise.

She says, I've had a hemiplegic migraine last July.

A constant headache on the left side since.

I'm awaiting a neurology appointment.

Would any of these treatments work for me? I'm still experiencing hemiplegic migraines at least monthly.

Dr Clinton Mitchell

Goodness, so that's very rough.

If the migraine is continuous, if we're talking about, sort of, having a, you know, a constant migraine for more than, sort of, five to seven days, so it certainly sounds like you're in that camp, what we can look at doing, I think one of the earlier questions talked about using steroid rescue, so sometimes steroids can be helpful about, sort of, again, kind of breaking that cycle to allow, kind of, other treatments to come in, but certainly everything we've discussed thus far would be helpful for hemiplegic migraine as well.

What I would say is that, you know, when people talk about migraine, we talk about hemiplegic migraine, migraine with aura, migraine with brain stem, aura, vestibular migraine.

All of these different types of migraine are essentially all treated the same.

So one treatment that will work for hemiplegic migraine will also work for migraine with aura, which will also work for vestibular.

So there is some slight variations, and some things are slightly more effective than others in particular subtypes, but for as a general rule.

I would approach migraine exactly the same regardless of what your symptoms are, so hopefully some of these treatments we've discussed would be suitable for you.

Vicky

Thank you, I hope that was helpful, Louise.

Next question is from Claire.

Claire has daily headaches, she says, which I have to take ibuprofen, as I have paracetamol rebound.

I've tried to perimate with no change.

I was prescribed propranolol, but reluctant to take due to beta blocker side effects.

What would you recommend? I see an osteopath For work on neck trapezium area.

Dr Clinton Mitchell

Sure.

So, you've mentioned, kind of, the paracetamol causing the rebound headache.

Unfortunately, ibuprofen can as well.

So what would be helpful would be to try and, kind of, reduce the frequency of the ibuprofen, because unfortunately, when people take paracetamol, ibuprofen, triptans.

Codeine, any of those drugs for more than about 10 days a month, so only once every three days.

It almost forms a bit of a force field around your migraine, so any of the treatments that we'd use like to permit, although I'm less enamoured by that, will often not do anything because of that kind of force field that's in place.

So the first thing we need to do is lower that, and then get some other treatments in there but there's certainly other ones out there that, you know, would be suitable for you.

I don't know if your GP has spoken about amitriptyline would be one, Pizotifen would be potentially another, or even Candesartan, which is another blood pressure drug, but potentially doesn't have kind of those side effects that beta blockers have as well.

I think there would be other options out there for you.

Vicky

Yeah, thank you.

Next question is from Judy.

Judy's 78 years old, and she's asking, should I expect migraines to be less frequent? She is still having migraines at 78.

Dr Clinton Mitchell

Oh, that's rough.

Unfortunately, you know, we talked about changes in migraine and people's hormonal lifestyle, and people say, oh, I was hanging out for the menopause because I was told it's going to get better after, you know, that, and sometimes it just doesn't, and so sometimes people can have migraine later in life, but there's no reason that any of these drugs that we've talked about, apart from perhaps the triptans, but any of these other drugs that we've spoken about, and all the trials that have been done, these have all been used in older adults as well, so there's no reason we can't use any of these drugs for you as well.

So, you know, push for them.

Vicky

Okay, thank you.

On a similar topic, Rebecca said, is migraine connected to HRT patches? She uses Evorel following a hysterectomy at age 62.

She's not sure if she needs HRT, and her migraines have got really worse in the last six months.

Dr Clinton Mitchell

So, yes, they can be related to HRT or, you know, any hormonal manipulation.

So, you know, the question is, if you feel you don't need the HRT, then potentially that would be something to speak with your GP about reducing those and seeing what happens.

You know, if the menopausal symptoms are so awful that you need to take the HRT, which are then causing migraine, then I would always say, well, let's work with you to manage the migraine.

You know, what I don't want you to be is, you know, migraine-free, but being miserable from postmenopausal symptoms.

So, if you need the HRT, then we'll just work with the problems that it gives you, but if perhaps you don't need the HRT, it might be helpful to see, you know, is that responsible for the increase in the migraine?

Vicky

Thank you.

Next question, my migraines are linked to trauma and stress.

Can urology prescribe EMDR or any other mental health therapy?

Dr Clinton Mitchell

So, not specifically from neurology, but those would be good, sort of areas to speak with your GP about getting specifically referred to, kind of, psychological therapies for that, but that would be helpful for you, I imagine.

Vicky

Lovely, thank you.

I've got time for a couple more.

What migraine treatment is used in psoriatic arthritis when on immune suppressants? Lisa asks, she's had a pineal cyst removed five years ago.

Dr Clinton Mitchell

Sure, so the fortunate thing about these kind of newer designer drugs is, you know, there are newer designer drugs for arthritis and irritable inflammatory bowel disease and all these other ones, but they're all safe to be used together, so because they target different parts of the body.

You can take any of the MABs that you take for the psoriatic arthritis, you can take it the same a different MAB.

For your migraine as well, so it's very safe for those to be taken alongside each other.

Vicky

Okay, lovely.

I think that's all we've got time for.

We've got a few questions left.

If we haven't covered them, and you provided your name, we'll follow up with you via email after the session.

I wonder if, Dr Mitchell, you could move on to the last slide, please?

Dr Clinton Mitchell

Sure thing.

Vicky

Okay, so as a thank you for attending, we are pleased to offer 50% off the value of your initial consultation, a callback from your dedicated private patient advisor, an email with a recording of this session, treatment information, and loyalty reward points.

And, updates on future events and health news.

We'd also appreciate it if you could take a moment to complete the short survey at the end of this session, because it helps us really to improve and tailor future sessions and webinars to your needs.

If you'd like to speak to somebody, to book your consultation or private GP appointment, our private patient team is available until 8pm this evening, and from 8am to 6pm Monday to Friday and you'll find the contact number on the screen just there.

We also have upcoming webinars on a range of topics, including hip and knee replacement surgery, varicose vein treatment, and gynaecology, and you can sign up for these on our website.

So, on behalf of Dr Mitchell and the team here at Benenden Hospital, I'd like to thank you all for joining us this evening, and we hope to hear from you very soon.

Thank you very much.

Goodbye.

Dr Clinton Mitchell

Thanks, Vicky.