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Josh Turknett transcript

Written by Christopher Kelly

June 15, 2017


Christopher:    Hello and welcome to the Nourish Balance Thrive Podcast. My name is Christopher Kelly and today I'm joined by Dr. Josh Turknett. Hi, Josh.

Josh:    Hello.

Christopher:    Josh is a neurologist and I first became aware of his work in 2014 when I attended the Ancestral Health Symposium in Berkeley where was Josh was presenting on the migraine as a hypothalamic distress signal. I was there in that lecture hall with my wife Julie and we both can believe it because she had suffered from migraines in the past and then she switched to a Paleo diet and can you guess what happened to her migraine, Josh?

Josh:    Let me guess. They got better.

Christopher:    They got better. They went away completely. Absolutely brilliant. So, maybe we could start this conversation by me asking you why is it you care about migraine so much? Tell me about your personal experience with migraines.

Josh:    My experience with them is pretty much lifelong. Both my parents actually have them but my mom had it even worse growing. So, for as long as I can remember, I can remember her dealing with them. It takes a lot to get her down and I knew that whatever it was that would sort of take her out for days on end had to be something significant. So, from an early age, I kind of despised whatever this thing was. I knew she referred to them as migraines. Probably, I've declared war on them from an early age.

    When I was probably 10 or 11, mine first started, I have some early memories of some particularly bad ones but they were pretty infrequent early on in my life and as a teenager and then steadily worsened the older I got, probably partly related to the lifestyle and diet I was leading as I was doing my medical training and residency and so on, ironically enough, in the field of neurology where migraines are--

Christopher:    Oh my goodness.

Josh:    -- primary areas of expertise. So, mine steadily worsened over the years to the point where I had multiple per month. It was basically a struggle for me to try to not miss days of work. I did well in that regard but it was a constant everyday kind of battle trying to keep the headaches at bay with the available tools that I had which was what neurologist traditionally treat migraines with, the drugs that we have and so on. And for a long period of time even though they were pretty bad they've gotten to several times a month, they were pretty severe enough to take a prescription medication and then sort of layered on top of that more lower level chronic headaches.

    But I thought I was doing the best I could do because here I was applying everything that I knew and that I would give to my patients to myself. It felt like I was -- This was kind of as good as it would get. And then made a switch probably, I think, around 2010, changed my diet and lifestyle with zero expectation on it having any impact on my migraines and, lo and behold, like Julie's, they vanished, which I thought was miraculous, which is why I decided to title my book the Migraine Miracle, even though I'd be instantly skeptical of that title.

Christopher:    It really is a miracle.

Josh:    And most people who go through the experience, they're like, "Oh, I get it now." It's like I went through this whole thing all my life and now they're gone and it didn't seem like this should be possible.

Christopher:    Can you describe a migraine headache to someone that's never had one? So, I've had a headache but I've never had a migraine, I believe. Can you describe the symptoms?

Josh:    Migraines are kind of like a many armed beast. So, there are all these different pathophysiologic pathways that can be activated during the course of a migraine and sort of we consider something that's called a classical migraine as when all of those pathways are kind of turned on. There are actually four phases. One of those phases is the pain phase which is what gets the most attention. And, I think, the most helpful analogy is to compare it to sort of drugs of abuse, with something like heroin or opiates.

    They're basically going straight to your pleasure centers and turning them on in a way that nothing sort of in ordinary life is capable of doing. You're just going straight to the source and turning on those circuits and that's why it's sort of such a great experience that people want to do it again because there is nothing else in their life that replicates it and that's kind of the big downside to it as well.

    The same thing is true of migraine. You have the pain part of the brain being turned on in a way that sort of nothing in the course of everyday life would do. The migraine process itself directly turning on the pain centers. It's a mixture of every possible type of cranial pain, sensation all at one time. So, you've got throbbing pain that's super intense, you can have stabbing pain, you have this sort of diffuse achiness all over the skull combined with sort of these other disturbances in sort of autonomic function and sensory processing where you're exquisitely sensitive to lights or sounds. Nausea and vomiting is usually a big part. Oftentimes, any type of movement will provoke vomiting and so on. It's basically this sort of situation that you wouldn't ever encounter in real life where the whole pain system has gone awry and everything is kind of being switched on.


    And on a physiological level, you have these feedback loops that are sort of self perpetuating and amplifying over time so that the whole thing is getting worse until something comes along to kind of burn it out or it ends. So, yeah, it's one of those things that's incredibly hard to imagine unless you've been through it particularly the worst of it. And it's actually hard, fortunately hard to remember after the fact. So, it's sort of like child birth, I think, in that regard. It's hard to imagine just how bad it was until you're in the midst of it and then you do tend to forget. But, yeah, it's miserable.

Christopher:    I'm sure it's one of those things I noticed in myself and then we've heard clients say too is that once the problem is resolved you just don't think about it anymore. You don't walk around thinking, "Oh, I'm so glad that I don't have a migraine," or, "I'm so glad that I don't have something stuck in my eye right now." It's just not the way you think.

Josh:    Exactly. It's a double-edged sword too because it's like you forget so then you're less likely to avoid the behaviors that led to it. There are times when I'm in the midst of it and I say, "Remember this moment."

Christopher:    And so, would you have warning signs? Would you know it's coming before pain would set in?

Josh:    It's interesting because there are definitely warning signs. Oftentimes, they're not appreciated until and unless in retrospect. But you oftentimes say, "Oh, that's what that was about." There's something known as a prodrome where you'll experience certain symptoms and these actually can be viewed as symptoms of hypothalamic dysfunctions but sort of overwhelming fatigue or burst of energy or feeling excessively hungry or excessively thirsty. These are sorts of things that can perceive the migraine oftentimes up to a day or so.

    But you don't necessarily put it together. A few time you're like, "I wonder if this is migraine," and then it comes on. After that, there's what's known as an aura phenomenon where you can have these temporary disturbances in neurological function. They're usually visual in nature, is the most common. I've had a few of those but most of my headaches aren't preceded by auras.

Christopher:    Okay. That's interesting what you said about maybe feeling hot or cold or thirsty because that's what the hypothalamus controls, am I right in thinking that?

Josh:    Exactly. Yeah. So, that's one of the pieces of evidence that sort of we long wondered. We know sort of a lot about the pathophysiology but less so about kind of how it all starts or what kicks it off. And that's one of the lines of evidence that would indicate that the hypothalamus is kind of the primary generator of the mechanism, is that the very first signs of it in people who experience the prodrome are these times when the hypothalamus is kind of malfunctioning, when you're thirsty but you don't need water or when you're tired when you shouldn't be and so on and so forth, kicking in these regulatory mechanisms at the inappropriate time.

Christopher:    Do you know how common migraines are in people overall?

Josh:    Extremely. I mean, it's about one -- The estimates are one in a five women. This tends to be more common in women. And probably one in ten men. Those are probably underestimates in my view. It probably depends on sort of how restrictive a criteria you use to define migraine. In some sense, I think that we should simply characterize headaches as either head pain in the absence of cranial pathology or head pain with cranial pathology.

    Because the first one is sort of the pain system going awry and there's a lot of commonalities between those things. So, migraine is kind of the fullest expression of that but, I think, any type of headache that's experienced without there being any insult to the head should be kind of treated the same way.

Christopher:    Okay. And so you're a neurologist. What if I was to show up at your office and say, "Hey, I've got migraine headache," what would the standard of care be?

Josh:    The standard of care would be, first, to pick the prescription for you to get rid of your migraine. There's a host of options there, most of which have ended up causing more harm than good. That's the first step. And then there's kind of two ways that are traditionally treated. That's the first way, which is to choose a medicine for migraine relief when a migraine comes. And then the other thing is there's several classes for medications that are used for migraine prevention. So, these are things that are taken every day with the idea being to try to lessen the likelihood that a migraine will come on. They're kind of standards that are given for how often someone needs to be having them to take one of those medications.

    But that's the main thing. And then the next step is what some people do is to try to identify the sort of dietary triggers and there's kind of a list of foods and so forth that have been linked to triggering migraine attacks that people can maintain a diary and see if they can find those sorts of connections. And that's pretty much the standard of treatment these days in the conventional sense.

Christopher:    Okay. And then how effective are these medicines?

Josh:    The preventative medicines aren't very effective at all despite the fact that we're, as physicians, encouraged to use them. So, the studies on them, the sort of best available ones that we have, have been shown to reduce the number of headache days per month in a migrainer who's experiencing typically multiple in the teens reduce the number of headache days by one.


    So, that's taking something every day to get that type of gain. Risk reduction percentage wise is fairly minimal. Not insignificant to reduce migraine but the question being is that worth the cost and the risks of being on long term medication? And then as far as the other class that are used to abort migraines to get rid of one that's ongoing, for a long time there wasn't hardly anything that was effective particularly that would get rid of a migraine that had been going on for any length of time.

    And then in the early '90s, a drug called sumatriptan came out and it was a first in the class of medications called triptans and they're now multiple. It was the first thing that could actually relieve an existing migraine and its success rate is around 50%. I can actually still remember the first time my mom took it because it was the first thing that had really helped her and it was in the form of an injection. So, she pulled over on the side of the road and injected herself and got relief within a matter of minutes. It was a pretty incredible thing.

    The downside, and something that we've only increasingly recognized in recent years and sort of I've only fully appreciated the full extent of recently, is that the medications, while they work on a short term, seem to worsen the condition over the long term. So, it makes you more likely to experience migraines later on. And that's a function of the frequency at which they're taken. So, there's a phenomenon known as rebound headaches which are when the medication taken for the headaches predisposes you to further headaches and you get stuck in this endless cycle of medication and headache. And that's actually extremely common.

    Recently, I did a chart audit just to see like when I'm seeing someone for the first time how often they were in that situation. It was about 80%. There's not good statistics on this but at least in my clinical experience, I think, that's going up. The downside, as much as I love those medications that were the first thing that would ever help, we may have traded the short term improvement for these sort of turning into a lot more chronic migraine conditions.

Christopher:    Okay. Tell me what you know about the causes of migraines?

Josh:    I have my own ideas about causes of migraine. The most conventional view that you would hear is that migraines are a genetic condition. That, for a lot of people, ends up being misleading because genetics alone, as it is with almost every other disease, genetics alone aren't enough. They still require some kind of environmental condition that releases that phenomenon. But that's been kind of the way it's typically treated.

    These are genetic, i.e. there's not a whole lot you can do about them. But I certainly beg to differ in my experience with what's happened since I adopted an ancestral diet, has certainly changed my view about that as well, and having worked with so many people who've been able to reverse their migraines using that approach. I would argue that the evidence is that sort of, as I presented in that talk that you refer to, that migraines are the distress signal of an overwhelmed hypothalamus.

    The evidence for that comes from a few different areas. Number one, as I mentioned before, there's several lines of evidence that would indicate that that's where migraines arise. The hypothalamus is kind of the generator. So, the next question is what's triggering that to happen? And the two kind of really important observations in my mind that came after, in my experience, with applying an ancestral diet was, number one, that seem to be a incredibly effective approach at relieving migraines and, number two, as much as I can look, I can't find any evidence that wild humans or hunter-gatherers experienced either migraines or other forms of headaches in the absence of any type of cranial trauma.

    So, those two things would indicate that there's something about our modern diet and lifestyle that is the environmental trigger that releases whatever genetic predisposition exists for them. And if you then look to see where in the brain, what part of the brain would carry the greatest burden or would be most stressed by the way we eat and the way we live now, the hypothalamus is a pretty good candidate. Its job is to maintain homeostasis or keep the internal state of the body, keep those conditions stable. It evolved under a very different environment than the ones we're living in now.

    The greater the gap between our ancestral conditions and our current ones the greater the homeostatic burden on the hypothalamus. You can conceive of migraines as a reaction when the hypothalamus homeostatic capacity has kind of been exceeded or is being strained. And that fits with what we know of as the biggest triggers for migraine. We've long known that not getting enough sleep is a huge trigger or any type of disruption in circadian rhythms. If we know that there are certain range of foods, then I would argue that probably the biggest dietary issue is metabolic inflexibility or kind of the energy rollercoaster that most people are on all the time as a consistent kind of homeostatic stress.


Christopher:    Okay. That's very interesting. So, you're saying that people that are getting squeezed from both ends unable to use glucose and fat or is it just one end they're being squeezed at?

Josh:    Well, I mean, I think most everybody who's experienced being on a, at least a standard diet, carb heavy, knows what that's like from an energy standpoint. You experience those fluctuations day in and day out. One of the most consistent things people say after switching their diet is, "I can't believe how much energy I feel. I can't believe I'm not getting sleepy after lunch. I can't believe I'm not wiped out after I get home." All those variations in energy levels are kind of evened out, which I think the physiologic we'll relate to that is the ability to mobilize fats when glucose is low and so that alleviates the energy issue.

    And when that's not the case, the hypothalamus is constantly sensing this sort of energy crisis. The reason that those feelings of feeling fatigue, that's coming from your hypothalamus. That's its way of saying, "Hey, we don't have enough energy to do anything. You settle down." That's a clear signal that day in and day out it's being strained and that it's telling us that.

Christopher:    Right.

Josh:    And I've kind of have developed what I say the three pillars or the three cornerstones of achieving migraine freedom and metabolic flexibility is one of them because that seems to be one of the most critical pieces. Because once people reach that point, things change dramatically.

Christopher:    So, I don't know migraines but I certainly know that reactive hypoglycemia, that feeling of being ready to get the guy that's next to you on a bike ride.

Josh:    Exactly.

Christopher:    It's interesting. When I was at Bryan Walsh's training, he was saying that he didn't think that reactive hypoglycemia existed. And I asked Tommy about that at the conference and he explained it, I think, quite nicely. I think this is right. So, what Bryan meant by that was if you were to measure your blood glucose during one of these episodes you would never see a low number. So, what's going on is your brain is far smarter than that and it's like imagine a pilot is doing some aerobatics and the pilot pulls up and it makes you feel like terrible, like you're going to barf, but you don't actually hit the ground. Nothing bad really happens. Your brain saved the day before there was really a crash in blood glucose. So, it's not really hypoglycemia but you still feel like shit.

Josh:    Exactly. And it's more a global assessment of energy availability than just glucose. So, yeah.

Christopher:    Right. Of course, of course.

Josh:    If you're burning multiple fuel sources then that's changing -- And it's using that as its input. That's changing kind of its overall assessment of energy availability.

Christopher:    In your AHS talk, you presented this really nice chart and I wonder if I could get a copy of it for the show notes.

Josh:    Sure.

Christopher:    Because it really illustrated your point quite perfectly. Do you remember that XY chart where you're showing the amount of stress on the X axis? They're almost like bars that close in and close in and close in. And then once your amount of stress goes over one of those bars that's when you might see migraine triggered. You talked about some other things which may lower the threshold for a migraine to occur. I remember one of those was inflammation. Can you talk about inflammation, how that might be a trigger?

Josh:    Sure. We know there's linkages between inflammatory disorders and migraines. And there's also evidence that the hypothalamus' function is compromised when itself is inflamed. So, the other potential mechanism by which you could implicate the hypothalamus as a generator beyond just straining its homeostatic capacity is that its function is further compromised in situations where it's inflamed.

    And so we know that so many of things that are part of the impact of our modern diet and lifestyle, the root of that is systemic inflammation and that's -- We have studies showing that that affects the brain as well and the hypothalamus. And so that's another possible linkage or another possible vulnerability that's occurring because of our modern diets and particularly its impact on migraines.

    I think that graph you're referring to, it was showing kind of the typical homeostatic excursions that a hunter-gatherer might face in the course of their day and then the ones that we would face nowadays which are much greater. There's probably a threshold. A lot of people think that migraines can be provoked in anybody, myself included. A lot of the physiology seems to come from very old parts of our neurobiology. So, the genetics there probably just reflect how sensitive you are to those homeostatic disruptions.

    So, your particular genetics confer a particular sensitivity so once you get to a certain homeostatic excursion that's when it's triggered. Whereas for someone else without the genetic predisposition, it takes a lot more but it still can be released in anyone.

Christopher:    This, I think, is where the ancestral health lens becomes so powerful because surely, or either that or the model is just completely wrong, because surely our ancestors had lots more stress. They had huge excursions in temperature compared to what we have today.


    They may have gone for long periods of time with and without food, I mean, surely there must have been ways they were stressed out a lot more than we are now.

Josh:    Sure.

Christopher:    Maybe it's really what's the problem is that it's stresses that we're not very well adapted to.

Josh:    Exactly, right. Whatever environment, if you're thrown into a completely novel environment, no matter how stable or unstable it is, it's not one that you've been adapted to, then the hypothalamic functions that are in all those systems that have been precisely calibrated for the old environment won't work. It's a good framework for understanding obesity as well.

Christopher:    Talk about the connection between obesity and migraines.

Josh:    There's an increased risk of migraines the more obese you are and conversely losing weight definitely has an impact in lowering migraine frequency. Now, the correlation, causation, all that is unclear. One of the interesting things and one thing that kind of led me down the line initially thinking about metabolic flexibility was the literature showing that gastric bypass surgery initially seemed to be very effective for a lot of people in decreasing migraine frequency.

    So, one of the possible reasons there is, obviously, if you're losing weight after gastric bypass or increasing the amount of energy being burned from the fat mass, that phenomenon potentially being protective overall, probably the connections between obesity and migraine are probably best explained by disruptions in energy metabolism that are happening to cause the obesity. So that probably would be the common pathway. At least that would be my hunch.

Christopher:    Was this ever a problem for you? So, seeing Josh in person, he's very, very lean. And it's hard to imagine that you were ever metabolically deranged. But maybe you were. I guess, I'm one of these people too, that basically developed insulin resistant type II diabetes without ever getting fat. Some people would say that diabetes is the price that you pay for not being able to get any fatter and that may happen at 3% body fat or it may happen when you're obese, you don't really know. Did you ever check your blood glucose and see if anything was going on for you? Maybe you wouldn't see it in your blood glucose but some other marker that you'd need to look at.

Josh:    I know. I wish I had. I definitely never did but it's interesting. Just the other day, I was going back and looking at a picture of myself probably about ten years ago and I've never been overweight. I definitely lost weight when I switched to my diet, probably about 15 pounds, and then it stabilized. But I looked unhealthy. It was kind of this bloating around my face.

    And I remember, I mean, I had developed a little spare tire around my abdomen. I would not at all be surprised if I was tending towards insulin resistance at that time and that's all gone away. It was just we were looking at that. It didn't even look like me. Even though nobody looking was saying, "Oh, he's overweight," or unhealthy, but comparing the now to then it was a pretty dramatic difference. So, yeah, I would be surprised if I didn't have some issues with glucose metabolism at that point.

Christopher:    Interesting. Well, we got to talk about some of the solutions then. I wanted you to start by talking about your Angry Bird story that Tommy and I have been telling all over the internet. I hope we've been crediting every time. I'm sure we have. But especially as a computer programmer, this one really, really resonated with me. You first told this story at the Physicians for Ancestral Health. I think I can link that video in the show notes for this episode. Tell us about the angry birds.

Josh:    This came out of sort of first thinking about one of the things that's been the biggest issue in my career as a physician is that I graduated from medical school in 2001. And really since that time, especially in the field that I'm in of neurology, there haven't been any therapeutic breakthroughs. And if you just look at sort of what breakthroughs we have had in the various domains of medicine, most of the drugs came out many decades ago and we still don't really have anything that's significantly better.

    So, most of the things that are the sort of the state of the art for most conditions are medications that were discovered a long time and there hasn't been any major breakthroughs in most spheres in a long time in the world of neurology. The last big one was sumatriptan, which I mentioned before, in 1991. I think anybody who takes a sober look at that thinks there's something really wrong there especially when you contrast that with how much technology has changed in other domains and how much we've learned about pathophysiology of disease over that course of time.

    So, it's not for a lack of furthering of our understanding of disease mechanisms but yet we still haven't been able to translate that into more effective therapies. There's few ways you could explain that but then my view suggests there's something fundamentally wrong with the underlying paradigm of trying to find a drug to treat the conditions that we now face. So, the talk that I gave there was that we've been kind of seduced by our powers with reductionism. So, we've learned a ton about the world around us including how our bodies work by applying reductionist methods, right?


    So, finding out how things work on different levels of organization down to the molecular biology. And it seems reasonable to think that if we can -- Once we get to that level, if we can intervene at the microscopic level then that's where the greatest power is. And that's kind of what the approach has been, is to find molecular targets for drugs to improve or reverse disease processes. But the analogy there would be to -- playing a video game.

    So, I gave the hypothetical scenario of an alien civilization suddenly finding an iPhone on their planet loaded up with a game Angry Birds and you have two different groups of aliens deciding they're going to compete against each other to see who can be the best at Angry Birds. So, they each go away and train. One group just plays the game over and over again getting better and better at playing the game. And the other groups says, "Oh, we're going to be clever. We're going to take it apart. We're going to figure out how it works. That's going to be our edge to victory."

    So they do so and they get down to realizing that it's built on this coding language which ultimately is specifying the moment to moment state of transistors and understanding machine language. And so they say, "Well, we've cracked the code. We're going to play the game not by playing at the game level but we're going to sort of try to manipulate the source code in real time." Of course, we know that there's not a computer scientist alive who could do anything like that.

Christopher:    Yeah. Actually, I can remember trying to do this when I was a kid with some of my first home computers, the Sinclair ZX Spectrum. You take a game and the technical term is you disassemble into the machine code. It's complete noise. There's nothing you can do with that at that stage. Even the most talented of programmers would struggle to do anything useful with that.

Josh:    Exactly. But it seems like a plausible idea to do that, right?

Christopher:    You wouldn't do it. I'm sure there's lots of other computer programmers who are listening to this who have also done this. It does seem like something you should try.

Josh:    Right, right. So, the team that took apart the Angry Birds and figured that out, they understand a lot more about how the game is made. But the flaw there was in trying to think that intervening at the microscopic level would be the best approach achieving the results at the macroscopic, that it would achieve the better game play than someone playing at the game level.

    So, the source code there, the analogy being the machine language is basically us at the level of molecular biology and we're far more complex than any computer game and we understand far less about ourselves at that level. So, to think that we can sort of do things by intervening at that level and predicting any way what's going to happen and do it in a way that's going to influence our biology in the direction we want is a pretty foolish notion just to begin with.

    And the most effective things that we do, and we know this, are what I would call game level interventions. There's a good reason why things like sleeping better, eating better and removing stress are the most effective remedies we still have that far surpass drugs because they're all game level interventions. They're all operating upstream and influencing all these pathways in ways we don't fully understand but we don't have to.

    Because if you just try game level interventions and then assess their impact on health you can use sort of the body's wisdom at healing and adapting rather than trying to sort of hack into it yourself which we're a long way from being able to do. So, this to me is why we've been stuck for so long in medicine at trying to find new therapeutic breakthroughs is because our paradigm is just completely wrong and we have to go back to figuring out the most effective game level interventions and then using the tools at reductionism to refine those and also for diagnostic purposes but not believing that we have the capacity at this point in time to go in and monkey with the code.

Christopher:    You can sort of do both, right? You could monkey with the codes and play the game but it's really important that you play the game. Like if you're going to do one thing, play the game.

Josh:    Right. Exactly. And, I think, what probably the most important lesson there is to realize how much harm you can do by monkeying at that level. "First, do no harm." It's part of the Hippocratic Oath for a reason and we ignore it way too often. But there's a lot more potential for unintended consequences when you operate at the source code. The more benign your intervention the better, the less likely it is to lead to an unintended consequences, the safer you are at going after something on that level. But you got to be really, really sure ahead of time that you're not causing more problems with those types of interventions.

Christopher:    So, how do we play the game? I hope that everybody listening to this podcast is already playing the game. But how do we play the game? Can you describe in more detail the type of diet that -- Obviously, you can't recommend anything over the internet that's why this is for educational purposes. What type of diet would you recommend?

Josh:    The basic diet that I recommend for migraineurs is pretty much what I recommend for anyone who's trying to achieve optimum health and longevity.


    And the mainstay of that is removing from the diet the things that have been added since the industrial and agricultural revolution first, retaining those things if we have good evidence to believe that they are not harmful. And for migraineurs, I tend to, at least on the early phase, recommend that they go on a lower carbohydrate side of things. That seems to have additional therapeutic benefit at least for a while, and then some people are able to increase that over time.

    That seems to be sort of a common thing in multiple areas where taking someone sort of using an ancestral framework for their diet and then using sort of low carb on top of that, or at least a while, seems to be a good kick start and then kind of become more flexible over time. That's been the experience with them as well but maybe it has to do with sort of getting all that metabolic machinery [0:30:56] [Indiscernible] towards metabolic flexibility bringing that online faster or immediate results.


    And then once it's on board you kind of have a lot of little more room to play with. But that's the thing that's worked the best. I think, probably, the next phase -- That tends to work for a lot of our people particularly when we address the medication issue as well. So, that's kind of one of the things that came since the book was -- I realized that the medications, the ones that are taken to relieve headaches and that rebound phenomenon I mentioned were exerting even more of an effect than I thought and removing that effect was really pivotal for people. So, that was a really important piece.

    And then the other one being to establish metabolic flexibility. The other thing that we do, in some cases, we do is ketogenic diets. So, your listeners probably are aware that there's some pretty special things that happen inside the brain with ketones and the evidence we've had the longest is their effect on epilepsy and seizures and there are lots of parallel between seizure and migraines. And so, for some folks, adding a ketogenic diet for a period of time can add even additional benefit for migraines.

Christopher:    Do you have any idea what the mechanism is there? Do you know if it's ketones as an energy source or is it a signaling molecule or something else?

Josh:    I don't know for sure. One really interesting study that I'd found which I was surprised never been reported was that in animal models -- So, there's a phenomenon called spreading cortical depression that happens in the aura phase of a migraine. So, it's this wave of sort of reduced activity in the cortex that happens before the pain phase occurs. And it's actually a phenomenon that can be adduced in any vertebrae animal by just poking around on their brain.

    So, there was a study that was done where they put animals in ketosis and they weren't able to elicit the spreading depression. So, there's this sort of very fundamental piece of migraine physiology that wasn't able to occur in the presence of ketones. Now, we don't know in terms of -- I assume that the mechanisms are probably similar to why they suppress epileptic seizures. There's a range of possible explanations there but nobody's certain.

    They do appear to enhance sort of inhibitory transmission so [0:33:14] [Indiscernible] transmission in the brain. That potentially is one mechanism by which they work because a lot of the medicines that are used for aborting a seizure work in the same way. But, I think, that there may be something to do with the energy availability that in my personal experience and in working with patients glucose and sugar seems to be the best migraine fuel that anything that's not that, the brain is running on something besides that, it seems to help break the migraine cycle. But why, the mechanisms at the cellular level are still not clear.

Christopher:    Okay. So, you talked about diet, you talked about sleep, you talked about stress. You mentioned three pillars. Did I miss some of the pillars? I want to know what the pillars are.

Josh:    The three pillars are elimination of mismatched foods and behavior. So, basically, eliminating evolutionary discordant parts of the diet and lifestyle. So, that encompasses a lot of sleep and stress and foods. The second one is the establishment of metabolic flexibility. And those two are interrelated but that's where sometimes deliberately restricting carbohydrates to achieve that at least initially can be helpful. And then the third is the elimination of rebound headaches which is the phenomenon where the medications themselves are contributing to a continued vulnerability to migraines.

    And I used to think that it was -- You had to consume them fairly frequently for that to occur. I think that probably the vulnerability lasts for a lot longer than we realize even after just one dose. And the downside is that the more effective the drug is for migraines, the worse it seems to be about doing that. That's one of the three pillars because I realized that ignoring that was one of the things that would frustrate progress the most. So, those are the three. Mismatched foods, yeah.

Christopher:    Okay. And what would you do with someone who's doing all of those things and they're still having migraines? Does that ever happen?


Josh:    It's always hard to say. I think, yes and no. it's not been the case where people don't make progress. A lot of it is figuring out what the time course is going to be, which is going to be individual for one person to the next. And there's so many factors that contribute there that it's always difficult to tell and you kind of have to take the birds eye perspective to know is someone continuing to make progress?

    I haven't had situation where it doesn't work. The main variation is in how long it takes. But I do suspect that there is a subset of people for whom, who don't reach the level that we would like for them to reach and that the mechanism there is in the gut and that if we could be a little smarter about gut health and healing and customizing that to the individual, I suspect that that's sort of the last piece of the puzzle in those people.

Christopher:    And do you get lots of patients that report gut symptoms as well as their migraines?

Josh:    We do. There's definitely an increase in gut symptoms and people with primary headache disorders including migraines. So, there seems to be a link whether what direction it's occurring but, yeah, there's definitely overlap there. And I think there's also some fairly compelling reasons for people with migraines to be particularly mindful of their gut health. I wrote something about the connection between the gut and celiac disease and migraines on the blog recently about that topic.

Christopher:    That was a really good article. I'll link to that in the show notes. So, along with your website, mymigrainemiracle.com, which has some fantastic resources. Is that the best place? Where would you send people now as your best resource? Would you have them read the book, the Migraine Miracle, or would you come to the website and have them sign up to something else?

Josh:    On the website, yeah. Probably the best place to start nowadays is a place in the website which is The Ultimate Guide to Migraine Freedom. I think it's mymigrainemiracle.com/migrainefreedom. So, they can download that there. That's kind of a big level view of what I talk about in the book, kind of with the modifications that I've added on since then particularly the piece about the medications and the importance of metabolic flexibility. They can start there and then dive in with the book if they want, sort of more of the back story as to why this came to pass and why this works.

Christopher:    Okay. And talk about what other support you provide? So, if someone needs a bit more help, you do some plans and technical support, right?

Josh:    Yeah. Right, so, yeah, one of the things, one of the sort of overarching missions I've had since this happened was how to figure out a way to reach more people with this because they weren't going to be getting it in the conventional system, and just being able to align myself with people who were receptive to what I had to offer. We have a Facebook group, which you can join when you go on the website and we have several resources that folks can sign up for. One of those is we've done a meal plan.

    So, we have a lot of people who would say, "I want to do this but can you just tell me what to eat?" So, we've created a meal plan people can sign up for which is a weekly set of recipes with grocery list and so on and actually has these three different options. So, if people kind of just want to kind of a primary ancestral approach there's that. There is also a ketogenic plan. And there's some basic plan for people who don't like to use a lot of ingredients. So, there's recipes with five ingredients or less. So, we have that. We also have a paid support community we call Migrai-Neverland.

Christopher:    You're really good at coming up with names.

Josh:    So, there's that. And we do kind of a weekly group coaching session inside of that. We post the transcript of that every week. That's called The Chatter. That's another thing people can sign up for if they're interested in reading that. It's kind of sort of highly tailored information for migraineurs. So, those things. And the meal plan is called Primal Provisions. So, there's those two resources plus the Facebook group where it's pretty active group of people who are kind of all following the plan and so it's a resource for people who wants support along those lines.

Christopher:    Right. I'll link to all these things in the show notes. And I'll also link to the wall of inspiration which you have to come and see. It's unbelievable. Josh has taken a group of Facebook testimonials and also Amazon.com reviews and you've created like this huge montage. I'm looking at this webpage now. The scroll bar on the right hand side is about three pixels high because this page is so long.

    I wouldn't just urge you to come and have a look at this. I would urge you to share it with somebody who's currently suffering from migraines. I know that lots of people listening to this podcast will already be doing many of the things that Josh has talked about but I'm sure you know somebody in the office who's suffering from these same problems, because it's ridiculously common. And this would really move me. Like if I was having this problem and I saw this page, I'm in. It's absolutely incredible you've managed to collate all these testimonials.

Josh:    Yeah. That's the idea. And it's far more powerful than me sitting here saying it. So, yeah, seeing someone who's been there and has gone through the same thing is, yeah, like you say, it's really powerful stuff.


Christopher:    Right. Yeah, definitely. Well, Josh, we're going to have to do a separate podcast, I think. Josh also teaches people how to play the banjo but I feel like that might be a different podcast.

Josh:    Yeah. Maybe so. I'm happy to do it again. Yeah, that's another interest of mine which is also tied into -- I had a long standing interest in the world of learning and neuroplasticity and so developed a methodology for learning music that's currently for banjo players because I play a few instruments but I consider myself a banjo player first and foremost. So, developed a teaching method that's called Brainjo, [0:40:38] [Indiscernible] of brain and banjo. And, so, yeah, and I'm actually devoting even more energies to that these days. I'm happy to do another podcast talking about that and learning and brains and all that kind of stuff.

Christopher:    Okay. Yeah, we should definitely do that. Can you sound me on the banjo? If I've never played a musical instrument, do you think that the banjo is an instrument that I should start with?

Josh:    The banjo is without a doubt the best instrument. I'm trying to convince the world of this. But absolutely it's not only -- So, there's no like pretension around it. That's one of the good things. You get to play it however you want to play it. There's many different styles and ways of playing it, so almost anybody can find something that suits them. It's set up so that you get early rewards unlike something like the violin, which takes forever to make something pleasing. You can start making pleasing music on a banjo pretty quickly. If you want to learn how to play the banjo, go to clawhammerbanjo.net and start today.

Christopher:    Awesome. Can you give us a little sample of banjo music that I can play on the end of this podcast?

Josh:    Absolutely. I'm going to play on a gourd banjo. So, one of the things that I like about the banjo is it's often misunderstood. There are a lot of different types of banjos and a lot of different sounds that the banjos can make. This particular banjo is kind of related to the instruments that were brought to the US from Africa. A lot of people don't know that the banjo is an African instrument that was then modified here in the US. But those early instruments were just a hollowed gourd like similar to a pumpkin that were dried with an animal skin stretched over them and then a neck sticking out with strings.

    This banjo that I'm going to play is something known as a gourd banjo. I think you'll find that the sound that you get from it is very different than sort of what people may commonly associate with the banjo. It's really great. It's one of my most favorite possessions.


Christopher:    Well, this has been awesome, Josh. Thank you so much for your banjo music. I'm very excited about learning more about the banjo and I'm very excited about all of the fantastic resources that you're creating. So, yeah, thank you very much. I'm hoping to connect with you again and have you back on the podcast very soon because you're, obviously, a wealth of knowledge and there's so much I want to talk to you about, but thank you.

Josh:    I would love to do it and talk about learning and brains and optimizing brain health.

Christopher:    Yeah, of course, everyone cares about that. That's something that everyone really cares about, is like how can I make my brain work better? You wouldn't care about that? That's amazing stuff. Thank you.

[0:46:00]    End of Audio

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