Questions About Migraines

Shift Work Sleep DO FMX II

  • What is your process for stopping medications like Ambein in patients with long term use and helping with the transition?
  • Answer: 
     
  • Is long term melatonin use problematic? Does it cause the brain to have less naturally occurring melatonin?
     
  • Any advise on sleep during insomnia related to menopause?
     
  • What is the actual solution for our night shift or third shift workers? Can you give a sample schedule/suggested routine?
     
  • If you have to work 9 night shifts a month, what is the best way to organize that schedule? Shifts are 10hrs long.
     
  • Do blue light reducing settings on devices help reduce impact on alertness at all?
     
  • Is it fair to say that a person with delayed or advanced phase circadian rhythm lives a “shift work” every day if trying to work “banker’s hours” jobs?
     
  • Are you aware of whether insurance covers light therapy, purchase of light box?
     
  • Best recommendation for night float: 1 week increments vs 2 weeks vs 4 week (if you need to do 4 weeks in a year, for example)
     
  • When you say shift workers keep same sleep schedule. Does this mean that on days off they stay awake during the night and sleep during the day as if working?
     
  • What do you think about the anchor sleep theory?
     
  • If accelerated biologic aging affects young people more, why should they bear the burden of shift work more than the old?
     
  • Your website in “under construction” and your letter template is not available. How do we get a copy?
     
  • How does this system work? Just asking for a friend.
     
  • With low rates of success in treating delayed phase circadian rhythm, is it healthier for the brain to abandon failing attempts at realigning rhythms and make the rest of life work around innate sleep rhythms?
     
  • as we age is there more ASPD?
     
  • There’s a good evolutionary case for group survival if individuals with different sleep schedules persist in the population, that way there is always someone awake to guard the group pretty much 24/7
     
  • Is it true that screen time can lower melatonin release throughout the night?
     
  • If perturbations in sleep are bad for a 40yo brain, wouldn’t they also be for a 20yo brain? Maybe the reason it’s hard as a 40yo is all the time spent doing it as a 20yo
     
  • More details about how cooler temperatures help sleep? Some people have a spouse who wants at least 74 F 
     
  • Does it follow that a person who is unusually sensitive to melatonin necessarily has a melatonin deficiency? Or are some people just sensitive regardless?
     
  • How do we justify physician and resident 24 or 28 hour call given what you just presented?
     
  • Did you define “insomnia”? Is it “insomnia” for pt with DPSD who can’t fall asleep easily at 10pm if it’s not their biology? If they can’t fall asleep at 1am after their sleep gate is open, that makes more sense to call that “insomnia,” no?
     
  • How about those that work night shift every day, like factory’s? Is there a strategy?
     
  • Is seroquel for delayed sleep a good choice for patients with bipolar disorder
     
  • Was there outreach to the religious leaders to see if they could be convinced?
     
  • Found this just a few hours after the lecture: Iyer, S., Monk, V., Slater, R. and Baxter, L. (2025), Exogenous Melatonin and Sleep Quality: A Scoping Review of Systematic Reviews. J Clin Pharm. https://doi.org/10.1002/jcph.70115

Questions About Migraines

Migraine FMX 2 1 Questions

  • Please discuss safety of use of estrogen-containing contraceptives in migraines with aura.
     
  • Are gepants fine to take trying to conceive or should still be stopped ahead of trying to? Right now I’m using propranolol for patients trying to conceive and it’s mildly helpful at best
     
  • If cost was not a factor and you had no other “me-too” diagnoses to treat - what med would you choose for episodic therapy? Preventive therapy?
     
  • Ideas of how to get Gepants covered Insurance prefer Neurologist prescribe but cannot get patients in to them.
     
  • For a patient on chronic long term butalbital- how to wean/ taper?
     
  • How do you determine when to start triptan vs gepants in patient that is new headache treatments, maybe just tried NSAIDs?
     
  • Can migraine sunglasses be made with prescription lenses?
     
  • Can you use gepants and triptan together
     
  • Abdominal migraine treatment?
     
  • Can you discuss if there is any contraindications of using triptans in hemiplegic migraines or brainstem migraines?
     
  • Do gepants lead to medication overuse headaches and can switching to another class be helpful vs just stopping all meds?
     
  • In your practice Do you use acupuncture for migraines?
     
  • How many doses of reglan per month do you allow before having concerns for EPS?
     
  • How do you discuss triggers with patients?
     
  • What's the role of naproxen taken concurrently with triptan for abortive treatment?
     
  • Any difference in treatment if patient has dysarthria or a vertigo prodrome?
     
  • Overlap of migraine and muscle tension HA? Please also comment on under treatment of migraine being did as chronic sinus infection
     
  • How do I practically order these tens devices for veterans or non-Va patients?
     
  • Is there a head to head trial of monoclonal AB vs gepant?
     
  • How soon do you think gepants will be approved for<18yo
     
  • Any recommendations weaning from something like butalbital to a gepant?
     
  • Who is the most appropriate patient for use of lasmitidan?
     
  • Thoughts on Avulux glasses?
     
  • How/where does one purchase the FL-41 glasses?
     
  • On social media, some patients are "curing" migraines by putting their feet in warm/hot water and placing a cold pack over their neck at the same time. Are there other things patients can do at home without medications or any equipment ?
     
  • How many doses of reglan per month do you prescribe? When worry about EPS?
     
  • Can you combine TENS/REN with pen Gepants
     
  • Discussing the nonpharmaceuticals is helpful-interesting but I have to question these as “gimmicky”
     
  • In an ideal world where cost/coverage are not an issue: what are your top 2 neuromodulators?
     
  • Issues with carotid atherosclerosis and the vagal nerve stimulator
     
  • What app do you recommend to patients to use to track their headaches??
     
  • What do you do for pregnant people with migraines
     
  • SPG Blocks where do those come into play
     
  • You mentioned a lot of drugs and devices but what about supplements like riboflavin, coq10, feverfew, and +/- magnesium. How do you use them with all the other things you recommend?
     
  • Ever prescribe OMT for migraines?
     
  • Just a FYI for those patients with Tricare insurance. Emgality is covered without a prior authorization.
     
  • Any thoughts about magnesium and riboflavin for migraine prevention?
     
  • Are these also treatments for SUNCT syndrome and those related headaches?

Migraine Questions

SWSD DO FMX1 

  • Is there an ideal schedule that you would propose for people that go back and forth between nights and days?
     
  • Is food a stronger influence on circadian cycle than light?
     
  • Patient has ADD/ADHD ….AND….. shift work fatigue. Can i treat both with two different drugs? Like Nuvigil …and… a stimulant???
     
  • Melatonin vs melatonin ER? And how long before bed to take?[cite: 3]
     
  • In patients with SWSD should we be checking circadian related labs at different time based on their typical sleep wake cycle? Like salivary cortisol and testosterone?
     
  • I don’t believe I have a sleep disorder, but would using bright light therapy in the mornings make me even more alert?
     
  • Is sleep the most significant factor affecting health in the US?
     
  • If someone has been doing night shift for 40 years. Would switching to a morning shift now be helpful?
     
  • Is there good research supporting the benefit of bright light exposure (light boxes, lamps, etc) to better align C and S for night shift workers?
     
  • What do you think about light glasses like AYO?
     
  • What is the optimal time between switching from nights to days?
     
  • So much variation. Is there an app or similar to input all a patient’s information and come up with a plan?
     
  • What is your opinion on sleep mats or mattresses that seek to influence body temp? (8 sleep, chilli pod)?
     
  • has light therapy been shown effective for other mood disorders or anxiety?

Migraine Questions

Insomnia FMX Questions 2025

  • Our elderly patients that say it's the only thing that works, when they try to taper they dont sleep for days?
     
  • How do you feel about trazodone? What is your go to medication for sleep?
     
  • Patients that have been on benzodiazepines/sedatives for DECADES… is it possible to get them off?
     
  • Due to high stress issue (ICE deportations and fear, family death) issues with sleep what is the recommendation?
     
  • For tapering a patient who is taking zolpidem 5 mg every night. How do you taper 25% every 2 weeks? Take 3/4 tab? Or 3/4 of 14 tabs for 14 days?
     
  • No forced tapers recommended, but how do you handle prescribing for someone who never agrees with you that tapering down or stopping is something that they agree on?
     
  • Do you like Rozerem (ramelteon)?
     
  • What if patient declines any type of CBT/changes in lifestyle to assist with sleep and only wants medication therapy?
     
  • Just putting a plug here for the new American Society of Addiction Medicine guideline for BZD tapering.
     
  • Are the risks of z drugs and BZDs regarding sleep architecture the same for meds like trazodone, mirtazapine, gabapentin, etc ?
     
  • How do you feel about the DORA class of sleep meds which apparently do not affect the glymphatic system?
     
  • What do we do for shift workers?
     
  • Does melatonin have negative effects on sleep architecture?
     
  • How do you do small reductions in dose when smaller pills not made, such as zolpidem that only has a 5mg and 10mg dose?
     
  • In a past talk, you discussed caution of melatonin use. Any guidance on Unisom?
     
  • We used these to shift sleep cycles for USAF pilots esp deployed fighter pilots and long haul pilots crossing multiple time zones . Any other suggestions for this population? They sometimes have very limited time to transition and no control over their flight schedules
     
  • Why switch to long acting BZD instead of just keep short acting during taper?
     
  • Is there any programs or studies about teaching younger patients calming exercises so they don't look to these drugs in the first place?
     
  • How can you reduces a LA med by 10 or 20%? Pill strength is not usually negotiable for small changes in dose.
     
  • Do you use TRANSDERMAL buprenorphine to transition patients off hydrocodone?
     
  • SLEEP STUDY crucial to identify other reasons for early onset or middle insomnia. Comments?
     
  • What's your take on acupuncture (or other CAM therapies) for insomnia? Since there is no money in it for Big Pharma, there is no funding for research...
     
  • My state health authority suggests switching to diazepam because of the 2,5,10 mg dose and it can be cut into half. And it’s longer acting than sleep sedatives. Agree or are there better alternatives?
     
  • Would the process for deprescribing be similar for non benzodiazepine sedative/hypnotics?
     
  • I had a patient recently who seemed to be getting benzos in the mail from the u k is that a thing? Can they order these strips from the netherlands without a prescription?
     
  • Sometimes we inherit patients on benzodiazepines and opioids. Do you push for benzodiazepines taper?[cite: 4]
  • And Z drugs? Do we wean similar to bad?
     
  • Do you recommend any medication for insomnia? Or no meds are good?
     
  • Do you know why tolerance can develop so quickly but withdrawal can be so prolonged? Why is upregulation so fast and downregulation so slow?
     
  • What is y opinion on holding off deprescribing if patient is in palliative care or hospice. Would you increase the dosage?
     
  • How about mindfulness to assist tapering and then replace benzo?
     
  • What do you prescribe patients with panic attacks that are on SSRI/SNRI and done CBT? Hydroxyzine has issues as well especially in elderly.
     
  • Algorithms for tapering off zolpidem. How to cut doses?
     
  • Being pressured to do involuntary tapering for everyone. Please discuss.
     
  • Is unisom (doxylamine) bad too?
     
  • For older patients with mild cognitive impairment who struggle to learn new things? what strategies can help them with sleep while tapering off these meds?
     
  • Should I even attempt to wean my 88 yo who’s been on Ativan for 30 years?
     
  • Bzd-dementia connection is not clearly defined: J Pers Med. 2023 Oct 12;13(10):1485. doi: 10.3390/jpm13101485
     
  • Do you perform urine drug screens regularly?
     
  • What is the exact indication for the DORA drugs?
     
  • For zolpidem taper is it more effective to try to tell patients to skip nights vs lowering nightly dose?
     
  • I use doxepin for patients with sleep maintenance insomnia and/or comorbid depression/anxiety. Any recommendations for/ against?
     
  • Do people Still prescribe trazodone? Is it still safer than some of the hypnotics?
     
Information icon

We need your consent to load the translations

We use a third-party service to translate the website content that may collect data about your activity. Please review the details in the privacy policy and accept the service to view the translations.