Dear Doctor: Lauren Natbony
The headache medicine specialist and assistant professor of neurology at Mount Sinai on the interventional and integrative modalities she uses to treat pain, headaches, and migraine — and how her blended approach fits into the future of wellness.
As someone who suffers from migraine, Dr. Natbony knows firsthand how debilitating and misunderstood the chronic condition can be. Leveraging integrative and comprehensive treatments with traditional medications enables her to offer specialized care to each one of her patients. Though often underdiagnosed, Dr. Natbony believes that people with migraine headaches do not need to suffer alone. Read on to learn more about her integrative modalities and how she hopes the future of healthcare will shed light on the importance of accessibility to headache care.
How did you get started in medicine and what inspired you to choose your specialty?
I’ve always wanted to be in medicine. I used to spend a lot of time shadowing my mom, who is also a doctor, and watching how she cultivated strong relationships with her patients was incredibly inspiring. Early on, I thought I wanted to be a veterinarian because I loved animals. But as I grew up, I realized that I too wanted to talk to my patients, hear about what was affecting them, and use my knowledge to help.
In medical school, I gravitated toward neurology and psychiatry because of my fascination with the brain. Ultimately, I decided to go into neurology because I wanted to learn more about the brain and its complex relationship with other parts of the body. But during my residency, it became clear that I also wanted to work with conditions that could be helped and that better integrated the whole person approach that had originally attracted me to medicine.
And then, I fell in love with headache medicine. I have a personal experience with it: I have migraine, my mom has migraine, and I believe it runs in our family. Remembering what it was like to watch my mom suffer and cry in the bathroom with pain while I did whatever I could to help her really solidified my passion for helping others with this chronic disease.
Finally, I loved the patients that I met in residency. Even though headache medicine is not something tangible that we can see on a scan or an image, it is a real, chronic, and debilitating condition. Given my interest and personal experience with migraine and other associated headache disorders, I believed I could help these patients and hopefully change their lives for the better.
What makes your treatment of pain, migraine, and headaches different?
I like to look at the whole person. These days, it’s easy to focus on symptoms and simply “band-aid” them with medication. I’m all for medication, but it’s only one tool in my toolbox.
When I see a patient, I look at more than just their symptoms. For example, a patient with chronic migraine might also suffer from insomnia, anxiety, and back pain. All of these come together to form a complete picture of this person’s health. But without identifying each symptom, a provider could overlook the possible genetic, environmental, and lifestyle influences of the condition.
My style of treatment focuses on all of these categories, as well as on alternative treatments. I’m a licensed acupuncturist who is also trained in nutrition counseling. I talk about nutrition, behavior modification, meditation, and mood with my patients. There’s a big misconception that mood is a cause of migraine. Though it’s not a cause, it can be an exacerbating factor.
I address all of the different aspects of life that can impact migraine and that — along with medication — can be modified to make real sustainable change. I often tell my patients that medication is like having someone holding your hand as you cross the street. Once you cross the street and let go of that hand, you need to have the foundation to do well on your own. If we’re not building that foundation of healthy lifestyle habits, then we’re not going to make true progress on halting the disease course.
Can you tell us more about the interventional procedures you use?
I use a lot of interventional procedures, but the most common is Botox. Botox is FDA-approved for the treatment of chronic migraine — which is identified as 15 or more headache days a month for more than three months — and it is still probably the most effective migraine treatment available.
I also do a lot of nerve block treatments, which involve small injections of numbing medication around the regions of the nerves that supply pain to the head. Some of my patients come every two-to-three weeks for nerve blocks because it can help to significantly diminish pain, plus it’s safe to do during pregnancy.
Additionally, I do trigger point injections, which are injections into tight bands of muscle that can refer pain to certain areas. For example, there are trigger points in the back of the head that might refer to pain behind the eye. Injecting into the trigger points can reduce that pain referral pattern, release tension in the muscle, and decrease head and neck pain.
Finally, I also do sphenopalatine ganglion (SPG) blocks, which is another very effective tool in the treatment of headache disorders. The sphenopalatine ganglion is a group of nerve cells in the back of the nose that also are responsible for transmitting pain. These procedures involve putting a catheter or a device into the back of the nose to spray numbing medication for pain relief.
Are there any innovations in the field you’re particularly excited about?
The CGRP realm has opened a new array of medications for us. Specifically, I’m excited to see the combination effect of Botox with the CGRP monoclonal antibodies. I have a few patients on these combination therapies who are already doing better, and I am hopeful that they will see added success by continuing both treatments in the long term.
In that realm, I’m also very excited about Vypeti, an IV CGRP treatment that recently became available. Though my center has had limited experience with Vypeti thus far, I believe that for my patients who are really suffering and need something that’s fast acting, this will be a very good option.
There are also some promising oral prevention medications in the class of Gepants. Rimegepant (brand name Nurtec), for example, was found to be effective for migraine prevention in March 2020 studies. If FDA approved, it will be the first oral preventive medication made specifically for migraine.
Finally, I’m a big fan of neuromodulation. I know that devices have had trouble in the marketplace because they’re expensive, but I do think that if we can overcome that barrier, these kinds of devices can be great tools for patients in addition to medication or when medications are contraindicated.
What role does integrative health play in your approach to care?
I always try to incorporate integrative therapies, depending on how a patient feels about it. In headache medicine, integrative, or complementary therapies are evidence-based. Therapies like acupuncture and biofeedback have high levels of evidence for migraine prevention.
For acupuncture specifically, there is evidence for reduction in frequency for episodic migraine, but it takes commitment. Notable benefits take shape when a patient gets acupuncture treatments consistently — say once a week for six weeks — and even then, the benefits take shape over time. There’s also some evidence for acute treatment if you’re having a migraine attack. As with many complementary therapies, the biggest obstacles are access and coverage.
Biofeedback is another example of an effective complementary therapy. In my opinion, it’s one of the greatest tools in headache medicine and very underutilized, especially in the pediatric population. Learning biofeedback is essentially learning how to regulate your body’s responses to pain through breathing, skin temperature, and other techniques. Ultimately, biofeedback shows us that we have the ability to decrease our bodies’ response to pain on our own, we just have to learn it.
Also, anyone who knows me knows that I’m also a huge fan of exercise. Exercise helped heal me and is what I do to make myself feel better, especially when I have headaches. Looking at the studies, regular cardiovascular exercise is just as beneficial as oral medication in episodic migraine.
Too often, we don’t put enough weight into the benefit of producing our own endorphins through exercise. So, I write prescriptions for exercise. I tell patients to start with a few minutes and build up over time. It can be difficult to start, and is by no means a cure-all, but all of these modalities can only add more benefit.
You’ve shed an important light on how migraine is an “invisibility illness” for outlets like ABC News. What steps can the medical community take to better acknowledge and care for people with this chronic and disabling disease?
First, it’s important to realize and acknowledge that it’s a chronic disease. I have a lot of patients who come to me and say: “My friend recommended that I take some Tylenol and that I’ll be fine.” But you wouldn’t recommend someone with longstanding diabetes to simply take something over-the-counter and leave it at that. Both are chronic illnesses and should be treated as such.
Secondly, we have to realize that migraine requires specialized treatments. Using the diabetes analogy, if you have type two diabetes, you’d go on medication to bring down your blood sugar. But that’s not the only thing you’d do. You’d also work on diet, exercise, and losing weight. And if you do all of those things, you might not need to be on your diabetes medication forever. I wish the medical community would recognize that migraine merits specialized care just like diabetes and other chronic illnesses.
I also believe that the way we refer to the condition matters. Language is powerful and can either help promote stigma or awareness of a condition. A popular phrase that bothers me is: “I have migraines,” or, “You’re having your migraines right now.” These sentences don’t hold water because migraines don’t exist. Migraine is a chronic disease of which headache is only one symptom. Instead of saying: “You’re having your migraines right now,” we should be saying: “You’re having your migraine headache with debilitating pain.” It’s a small change, but it would make a big difference.
It’s safe to say that more attention has been placed on pain and health since the outbreak of Covid-19. How do you see your work impacting the future of wellness?
I hope that this pandemic has helped people take their health seriously. We need to focus more on whole body, preventive health and not just on health management.
The pandemic has also brought telemedicine to the forefront, which has been a true gift in terms of accessibility. As a headache specialist, I strongly benefit from seeing a patient’s living environment. For the first time, I can have an intimate view of a patient’s medicine cabinet, light and sound conditions, and whether or not they have the space for at-home exercise. It’s the perfect platform to talk about integrative health and about implementing sustainable lifestyle modifications.
In the future, I’d love to be able to reach a broader range of patients who don’t currently have access to headache care with telemedicine. Of course, the problem right now is licensing, since you have to be licensed in every state you want to see patients in, and that’s a huge process. But I’d love for this pandemic to prioritize accessibility in healthcare and enable me to help more and more people seek specialized treatment down the road.
Do you have a new go-to at-home snack? Trader Joe’s just released a new chocolate hummus that is absolutely delicious. I wasn’t sure what to expect, but it’s the perfect combination of chocolate and protein.
What’s your favorite place in NYC for a walk or midday break? The reservoir at Central Park. I find blue very calming, and love places where I can look at water and sky at the same time.
What’s one healthful habit you’d love to see patients adopt? Exercise! It’s the hardest thing to incorporate into your routine, but you get so much bang for your buck. It can help reduce anxiety, stress, dementia, and improve cardiovascular and headache health.