Category: Blogs

Researchers at the Headache Center of the University of Naples “Federico II” gave the glucagon-like peptide-1 (GLP-1) receptor agonist liraglutide to 26 adults with obesity and chronic migraine (defined as ≥15 headache days per month). Patients reported an average of 11 fewer headache days per month, while disability scores on the Migraine Disability Assessment Test dropped by 35 points, indicating a clinically meaningful improvement in work, study, and social functioning.

GLP-1 agonists have gained recent widespread attention, reshaping treatment approaches for several diseases, including diabetes and cardiovascular disease.² In the treatment of type 2 diabetes, liraglutide helps lower blood sugar levels and reduce body weight by suppressing appetite and reducing energy intake.^3,4,5

Importantly, while participants’ body-mass index declined slightly (from 34.01 to 33.65), this change was not statistically significant. An analysis of covariance confirmed that BMI reduction had no effect on headache frequency, strengthening the hypothesis that pressure modulation, not weight loss, drives the benefit.

“Most patients felt better within the first two weeks and reported quality of life improved significantly,” said lead researcher Dr Simone Braca. “The benefit lasted for the full three-month observation period, even though weight loss was modest and statistically non-significant.”

Patients were screened to exclude papilledema (optic disc swelling resulting from increased intracranial pressure) and sixth nerve palsy, ruling out idiopathic intracranial hypertension (IIH) as a confounding factor. Growing evidence closely links subtle increases in intracranial pressure to migraine attacks.⁶ GLP-1-receptor agonists such as liraglutide reduce cerebrospinal fluid secretion and have already proved effective in treating IIH.⁷ Therefore, building on these observations, Dr Braca and colleagues hypothesized that exploiting the same mechanism of action might ultimately dampen cortical and trigeminal sensitization that underlie migraine.

“We think that, by modulating cerebrospinal fluid pressure and reducing intracranial venous sinuses compression, these drugs produce a decrease in the release of calcitonin gene-related peptide (CGRP), a key migraine-promoting peptide,” Dr Braca explained. “That would pose intracranial pressure control as a brand-new, pharmacologically targetable pathway.”

Mild gastrointestinal side effects (mainly nausea and constipation) occurred in 38% of participants but did not lead to treatment discontinuation.

Following this exploratory 12-week pilot study, a randomized, double-blind trial with direct or indirect intracranial pressure measurement is now being planned by the same research team in Naples, led by Professor Roberto De Simone. “We also want to determine whether other GLP-1 drugs can deliver the same relief, possibly with even fewer gastrointestinal side effects,” Dr Braca noted.

If confirmed, GLP-1-receptor agonists could offer a new treatment option for the estimated one in seven people worldwide who live with migraine,⁸ particularly those who do not respond to current preventives. Given liraglutide’s established use in type 2 diabetes and obesity, it may represent a promising case of drug repurposing in neurology.

About the Expert:

Dr Simone Braca is a neurology resident and clinical research fellow at the Headache Centre of the University of Naples “Federico II,” Italy. His work focuses on the interplay between applied pharmacodynamics, intracranial-pressure regulation and primary headache disorders. Dr Braca has authored or co-authored several peer-reviewed papers on migraine therapeutics and serves as an early-career representative in the European Academy of Neurology (EAN) Headache Scientific Panel. He combines hands-on patient care with translational research, aiming to bring novel, mechanism-based treatments from bench to bedside.

References:

1. Braca S., Russo C. et al.GLP-1R Agonists for the Treatment of Migraine: A Pilot Prospective Observational Study. Abstract A-25-13975. Presented at the 11^th EAN Congress (Helsinki, Finland).
2. Zheng, Z., Zong, Y., Ma, Y. et al. Glucagon-like peptide-1 receptor: mechanisms and advances in therapy. Sig Transduct Target Ther 9, 234 (2024).
3. Lin, C. H. et al. An evaluation of liraglutide including its efficacy and safety for the treatment of obesity. Expert Opin. Pharmacother. 21, 275-285 (2020).
4. Moon, S. et al. Efficacy and safety of the new appetite suppressant, liraglutide: A meta-analysis of randomized controlled trials. Endocrinol. Metab. (Seoul.) 36, 647-660 (2021).
5. Jacobsen, L. V., Flint, A., Olsen, A. K. & Ingwersen, S. H. Liraglutide in type 2 diabetes mellitus: clinical pharmacokinetics and pharmacodynamics. Clin. Pharmacokinet. 55, 657-672 (2016).
6. De Simone R, Sansone M, Russo C, Miele A, Stornaiuolo A, Braca S. The putative role of trigemino-vascular system in brain perfusion homeostasis and the significance of the migraine attack. Neurol Sci. 2022 Sep;43(9):5665-5672. doi: 10.1007/s10072-022-06200-x. Epub 2022 Jul 8. PMID: 35802218; PMCID: PMC9385793.
7. Mitchell J.L., Lyons H.S., Walker J.K. et al. (2023). The effect of GLP-1RA exenatide on idiopathic intracranial hypertension: a randomised clinical trial. Brain. 146(5):1821-1830.
8. Steiner T.J., Stovner L.J., Jensen, R. et al. (2020). Migraine remains second among the world’s causes of disability. The Journal of Headache and Pain. 21:137.

By MARC-DAVID MUNK

In our palliative medicine clinic in the working suburbs of Boston, my colleagues and I tend to some of the sickest patients in the city. Through the window, I can see the afflicted pull up to our squat building in family sedans, wheelchair vans, and subsidized municipal ride cars. Few drive themselves: most bear terrible illnesses that make them too frail or sedated. I watch as patients who are barely able to dress themselves, somehow arrive in their Sunday best for clinic.

Our job, as their doctors, is to manage their pain and provide moral support and practical help with things such as rent and transportation, sometimes spiritual support too. It’s important work, among the highest callings in medicine. Yet, as noble as this work might be, our clinic doesn’t begin to support itself financially. If there was ever a reason to spend graciously on patients and their needs, these visits, with their sick and vulnerable patients, would be exemplars. In fact, we don’t receive enough payment from insurers to cover the costs of the complicated work that’s needed. Practically, this translates to few staff to help with appointments, not enough follow-up calls, nobody to help with insurance headaches or pharmacy shortages, nobody answering the phone. Our facilities are tired. The simplest niceties—coffee in the waiting room, magazines, a comfortable chair—are long gone.

There is a feeling of “meagerness” in the air. It’s the feeling of being rationed. It’s an absence of all but the truly essential; no plenitude, a lack of graciousness. I see meagerness when my friend, an emergency physician at a major trauma center, shares pictures of his decomposing ER: desk chairs held together with medical tape, rooms without functioning equipment. Medical supplies that are so scarce that doctors keep stashes in their desks and coat pockets.

The administrators will say that these barren conditions are a consequence of financial scarcity. There isn’t enough money to pay for more than skeleton support and upkeep. Hospitals are running deficits and downsizing. Keeping the lights on is apparently a question of saving pennies at every opportunity. And, with every cut, meagerness grows. This all sounds, on its surface, understandable till you take a step back and realize it isn’t. We know that American healthcare consumes more money than any other country, per capita. Money is pouring, truly flooding, into our healthcare system. Family health insurance premiums rose 7% from 2023, after another 7% increase the year before. The average family policy now costs around $25,000 per year.

Which leaves me wanting to reconcile how there can be so much money entering the system, with so little left for essential front-line care. I know that this isn’t a complicated answer.

My fifteen years spent as a healthcare administrator, negotiating with payers and suppliers, has taught me that our societal healthcare money has, simply, been diverted, tapped out. Intermediary costs, across a broad healthcare landscape, have become so extreme, so unregulated, so usurious, that there is only a trickle left to deliver anything but the most miserly front-line care.

Here in America, we specialize in allowing thousands of organizations, many found nowhere else in the world, to pass on unheard-of costs to, well, ourselves. We have group purchasing organizations (GPOs) and accountable care organizations (ACOs). There are medical service organizations (MSOs) and physician organizations (POs). Also managed care organizations (MCOs) and health maintenance organizations (HMOs). Physician-hospital organizations (PHOs) need to be paid for, too. There are contracting offices, coding offices, compliance offices, credentialing offices, case management offices and claims processing offices. Many organizations exist to provide push for one outcome; others exist to push for the opposite. All are costs.

Our six largest health insurers together have revenue that would make them the 14th largest GDP in the world if they were a country, smaller than Spain but bigger than Australia. They typically spend around eighty-five percent of what they collect on medical care… the rest is their overhead and profit. The United States spent almost twice as much as other high-income countries on care, driven by labor, pharmaceuticals and devices, and administrative costs. Drug manufacturers charge Americans multiples more than other countries for identical medicines. Prices for cardiac implant devices are multiples higher in the US than in Germany. Hip implants in the US are multiples more than those in Canada. Malpractice insurance is crushing, with some doctors paying hundreds of thousands annually for liability coverage. Electronic medical records cost hospitals up to hundreds of millions of dollars to install.

Here, regulatory agencies have made themselves both expensive and indispensable. The American Board of Internal Medicine brought in $90 million in fees in 2023 (and there are 23 other specialty boards). The Joint Commission pulled in $208 million last year. Press Ganey, which owns a large part of the mandatory patient survey business, reportedly had revenues in the hundreds of millions of dollars (before they stopped reporting revenue figures after being bought by private equity). The medical journal business is especially galling: doctors write, edit, and review articles for free, yet those journals are locked behind paywalls. Elsevier’s parent company, with over 2,500 journals, generated £3.06 billion in revenue in 2023 with a 38% profit margin.

Good luck saying no to all this. We’re stuck. Doctors have no choice but to be board certified. Hospitals must be surveyed. Expensive licenses and permits are non-negotiable. We pay what they ask, with increases year after year. On these cocooned organizations, we impose few demands, few hard bargains and few consequences for poor value. In my early years in medicine it felt like there was at least a veneer of plentitude. These days, I look at our worn clinic and our patients who respond with dignity as I explain that their insurer has rejected their fifteen-dollar pain medication prescription, again.

I wonder when we will admit that we are at a point where–through regulation and administrative gaming, policy contortions and oligopolist behavior—the opportunists have finally killed the golden goose. I wonder when, in an environment of clinician fortitude and heroic commitment to patients, we will know that we have reached a tipping point where it’s no longer an environment of meagerness but one of privation, where balls are dropped and people truly suffer.

With so many entrenched interests, it’s hard to imagine how this gets resolved. For thousands of years, when it has mattered most, there has been no substitute for the work of a doctor caring for a patient, one-on-one. There still isn’t. But, around the best parts of American medicine we have settled for a Rube Goldberg-like apparatus that functions mostly to perpetuate itself. It extracts real tolls from real people. It’s uniquely repugnant, uniquely absurd, uniquely American.

Marc-David Munk is an academic palliative medicine physician, and a former healthcare executive at several private and VC-backed value-based healthcare delivery organizations. 

Cortisol, often referred to as the “stress hormone,” is one of the most powerful hormones in the body. While cortisol’s primary function is to help manage stress, it also plays a crucial role in a wide range of bodily processes, from metabolism to immune function, and even brain activity. When cortisol levels are out of balance, they can cause a variety of health problems, including chronic stress, fatigue, weight gain, and poor sleep.

It’s gotten a lot of attention lately and has been trending on social media, with many people claiming that just “fixing” their cortisol drastically improved their health and helped them lose weight. This points to just how important cortisol is, but before we jump into believing that a stack of herbs is a miracle cure, it’s important to understand some background context. 

The Low Down on Balancing Cortisol

Specifically, “cortisol cocktails” including ingredients like orange juice, coconut water, and salt are trending as miracle cures. Personally, I’ve found some other (no-cost) factors to be more effective. Even though I did create my own version of the cortisol cocktail drink!

In this article, I’ll break down my understanding of cortisol and what’s worked for me. As always, this is my opinion, shared only for inspiration and general information and is never for comparison or advice!

So, how can we manage and optimize our cortisol levels to feel our best? The answer lies in understanding how cortisol works and supporting its natural rhythm with simple lifestyle habits. These habits include things like light exposure, supplements, and sleep practices. 

In this post, we’ll take a deep dive into the science of cortisol, explain how light impacts cortisol levels, explore the top supplements for supporting healthy cortisol patterns, and show you how sleep can be a game-changer for hormone balance. Plus, I’ll share what I do to keep my cortisol levels in check.

What Does Cortisol Do?

Cortisol is a steroid hormone produced by the adrenal glands, which are found on top of your kidneys. It’s primarily known for its role in the “fight or flight” response, helping the body respond to stress by increasing blood sugar, enhancing brain function, and suppressing non-essential functions like digestion and reproduction. While cortisol is essential for survival in stressful situations, chronic cortisol imbalance (too high or too low) can lead to serious health problems.

Our cortisol levels follow a natural circadian rhythm, peaking in the morning shortly after waking and gradually declining throughout the day. This daily pattern is essential for maintaining energy levels, sleep quality, and emotional balance. When cortisol levels are chronically elevated or suppressed, this rhythm is disrupted, leading to feelings of fatigue, difficulty focusing, and mood swings. 

In the past, there was a point when my cortisol patterns were exactly opposite of the ideal natural pattern. My deep dive into helping my body find balance taught me a lot about cortisol, light, sleep, and other factors that can help. 

The Impact of Light on Cortisol

One of the most powerful and often overlooked influences on cortisol patterns is light exposure. In fact, I’d dare say this was the most important factor for me in finding balance, and the good news is that it’s free. Light has a direct effect on cortisol production, helping regulate the body’s internal clock or circadian rhythm. Exposure to natural light, especially in the morning, plays a crucial role in maintaining healthy cortisol patterns.

1. Morning Light to Balance Cortisol

Getting natural sunlight in the morning is critical for resetting your circadian rhythm and ensuring cortisol levels peak at the right time. When you wake up and are exposed to sunlight, it triggers the release of cortisol to help you feel alert and energized. This cortisol surge is designed to support your wakefulness and focus throughout the day.

Research shows that morning light exposure, preferably within the first 30 minutes of waking, has a significant impact on the timing and intensity of your cortisol release. Studies suggest that people who receive adequate morning light exposure tend to have better sleep quality, improved mood, and a more stable cortisol rhythm.

A study published in The Journal of Clinical Endocrinology & Metabolism found that morning light exposure increases cortisol production. This in turn improves alertness and reduces sleep inertia (the grogginess many people experience after waking). The timing of light exposure matters though. Blue light exposure at night can interfere with your ability to fall asleep and disrupt cortisol patterns.

2. Natural Light Throughout the Day

Not just the morning light, but consistent exposure to natural light throughout the day helps to maintain healthy cortisol rhythms. When you’re indoors all day, especially under artificial lighting, your body doesn’t receive the necessary signals to effectively regulate its circadian rhythm. This can result in disrupted cortisol patterns, leading to fatigue and increased stress.

Spending time outdoors during daylight hours helps synchronize your body’s internal clock. This can improve sleep, reduce stress, and enhance overall well-being. If you’re working from home or spend most of your day indoors, try to step outside every few hours for a short walk or simply sit by a window with natural light.

I love Dr. Courtney Hunt’s recommendation of: sunrise, sunlight, sunset, repeat. 

3. The Effect of Artificial Light

Artificial lighting (especially blue light from screens) can throw off your cortisol patterns. Exposure to blue light late at night suppresses melatonin (the sleep hormone). It also delays the natural decline of cortisol in the evening, making it harder for you to unwind and get restful sleep. To minimize the negative effects of artificial light, consider using blue light filters on your devices in the evening. You can also limit screen time at least an hour before bed.

In my house, we try to avoid screens after the sun goes down and I have red and amber bulbs in lamps that we use after dark. I don’t go as far as just using candles, though some people have tried this as well. If I’m going to be in a car, airport or store after dark, I’ll often wear blue light blocking glasses. 

Top Supplements to Support Healthy Cortisol Levels

While light exposure and sleep play foundational roles in managing cortisol, certain supplements also help. They support healthy cortisol levels and alleviate the negative effects of chronic stress. Here are some of the most effective, evidence-backed supplements to consider.

1. Ashwagandha

Ashwagandha, an adaptogenic herb, helps the body adapt to stress and regulate cortisol levels. Several studies show ashwagandha supplementation can reduce cortisol levels and improve the body’s stress response. Cherry rose moon milk is a great way to get some ashwagandha before bed!

In one study published in The Indian Journal of Psychological Medicine, participants who took ashwagandha showed a significant reduction in cortisol levels and reported less stress and anxiety. Ashwagandha has also been shown to support improved sleep and better physical performance.

2. Rhodiola Rosea

Rhodiola rosea is another adaptogen that can help the body manage stress and balance cortisol rhythms. Studies suggest rhodiola can reduce fatigue, improve mood, and decrease cortisol levels during times of stress.

A review published in Phytomedicine found that rhodiola supplementation helped reduce cortisol secretion and improved mental performance in individuals exposed to stress. This herb is particularly helpful for people who experience energy crashes during the day, as it helps maintain balanced cortisol levels throughout the day.

3. Phosphatidylserine

Phosphatidylserine is a phospholipid found in the brain that plays a critical role in cognitive function and cell signaling. Research has shown that phosphatidylserine supplementation can help reduce cortisol levels in response to exercise and stress.

A study published in The Journal of the International Society of Sports Nutrition showed that participants who took phosphatidylserine experienced lower cortisol levels after intense physical activity. This supplement is beneficial for managing cortisol spikes after exercise or stressful events.

Taking choline supplements in the morning was also helpful for my energy and focus. I rotate between this choline supplement, this one, and this one. I did this while also taking these cortisol supplements. 

4. Magnesium

Magnesium is a vital mineral that plays a crucial role in over 600 biochemical reactions in the body. It’s also known for its ability to help regulate the stress response. Studies have shown that magnesium supplementation can help reduce cortisol levels, especially in people experiencing chronic stress.

A study in The Journal of Research in Medical Sciences found that magnesium supplementation helped lower cortisol levels in individuals under stress, improving both mood and relaxation. Magnesium-rich foods like leafy greens, nuts, and seeds can also support healthy cortisol rhythms. I also like to supplement with Magnesium Breakthrough which has 7 different types of magnesium 

5. Omega-3s

Omega-3 fatty acids are essential fats that play a crucial role in supporting overall health, and they’ve been shown to help regulate cortisol levels. Research indicates that omega-3s, found in fatty fish like sardines, can reduce inflammation and lower cortisol levels in response to stress. They also help improve brain function and mood, further supporting your body’s ability to manage stress effectively. 

There are Omega-3 supplements and I occasionally take these but some people worry about oxidation in these supplements. Whenever possible I try to get Omega’s from food sources like seafood. 

Adding sardines to your diet a few times a week is an excellent way to boost your omega-3 intake. Sardines are not only rich in omega-3s, but they’re also an affordable and sustainable option for enhancing your overall nutrition, helping to maintain balanced cortisol levels and improve your stress resilience.

6. Magnolia Bark

Magnolia bark is an ancient herb that has gained attention for its potential to support cortisol balance and promote relaxation. The active compounds in magnolia bark, particularly honokiol and magnolol, have been shown to help reduce cortisol levels by interacting with the body’s stress response systems. Studies suggest magnolia bark can help manage anxiety and promote a sense of calm, which is essential for keeping cortisol levels in check during stressful situations. 

Additionally, magnolia bark may help improve sleep quality by supporting the natural decline of cortisol in the evening. Incorporating magnolia bark as a supplement or in a calming tea can be a beneficial addition to your routine for managing stress and promoting balanced cortisol levels.

A supplement blend like this one has magnolia bark along with other supporting herbs for balanced cortisol. 

How to Use Sleep to Improve Cortisol Levels

Sleep is one of the most effective ways to balance cortisol levels and support overall hormone health. The relationship between sleep and cortisol is complex, but it’s essential for keeping your body’s stress response in check.

1. Prioritize Sleep Quality

Chronic sleep deprivation can elevate cortisol levels and disrupt your body’s natural rhythm. To optimize cortisol levels, focus on improving your sleep quality. Aim for 7-9 hours of sleep per night, and ensure that your sleep environment is conducive to rest. This means a dark, quiet, and cool room.

Avoid caffeine and heavy meals close to bedtime, and incorporate relaxing activities like reading or meditation to wind down. Here’s how to create an ideal sleep environment.

2. Maintain a Consistent Sleep Schedule

Going to bed and waking up at the same time every day helps regulate your cortisol patterns. Irregular sleep schedules can confuse your body’s internal clock, leading to fluctuations in cortisol levels. Try to get up at the same time each morning, regardless of whether it’s a workday or weekend, and avoid sleeping in excessively.

3. Use Sleep to Lower Cortisol at Night

The body naturally releases cortisol in the morning to help you wake up, but cortisol should be at its lowest point at night to prepare your body for restful sleep. A consistent sleep routine, combined with reducing stress during the day, will help promote this natural decline. 

Avoid stimulating activities in the evening, like intense exercise or stressful work tasks. These can raise cortisol levels and disrupt sleep. Here’s a peek into my nighttime routine.

What I Do to Support Healthy Cortisol Patterns

For me, balancing cortisol is about creating a routine that respects my body’s natural rhythms. In my opinion, supplements alone won’t work without these other lifestyle factors as well. Here’s what I do:

• Morning sunlight: I aim to get outside within 30 minutes of waking up to soak up some natural sunlight. This helps reset my circadian rhythm and supports a natural cortisol surge to get my day started. I also try to eat breakfast and all meals outside when I can. 
• Light exposure throughout the day: I make a point of staying active during the day, taking short breaks to step outside or sit near a window with natural light. This keeps my cortisol levels balanced throughout the day. I feel best when I get enough bright light 
• Supplements: I take ashwagandha and magnesium in the evenings to support relaxation and help lower cortisol levels before bed.
• Sleep routine: I stick to a consistent bedtime, avoiding screens for at least an hour before bed, and make sure my bedroom is cool, dark, and quiet.

Action Steps

• Get outside for 20-30 minutes in the morning to get natural light.
• Consider adding supplements like ashwagandha or magnesium.
• Establish a consistent sleep schedule and create a relaxing bedtime routine.

By supporting your body’s natural rhythms with light, supplements, and sleep, you can help maintain balanced cortisol levels. This can lead to improved energy, mood, and overall health. 

What do you do to support your cortisol levels? Leave a comment and let us know!

Some nights you just need a win and that’s where this Sloppy Joe recipe comes in. This is a 20 minute meal that is easy to make, inexpensive and kid-friendly. For me sloppy joes will always remind me of summer camp as it’s the type of meal that would be served in a cafeteria style setting. This is total comfort food mixed with nostalgia for me.

If you aren’t familiar a sloppy joe is a type of sandwich made with ground beef and tomato sauce. It’s sort of cross between spaghetti sauce and chili but served like a hamburger.

Related: If you like the classic next try our baked vegetarian sloppy joe recipe.

Ingredients

• Ground beef
• Onion
• Bell pepper
• Garlic
• Olive oil
• Tomato sauce
• Ketchup
• Worcestershire sauce
• Brown sugar

You will also want hamburger buns or slider buns to serve with. Or you could serve this sloppy joe filling over chips or noddles like chili.

How to make Sloppy Joes

Finely chop the onion and bell pepper. Mince the garlic. In a large sauce pan or skillet heat the oil over medium heat and cook the onion and bell pepper until softened, 2-3 minutes. Then add the garlic and cook for another minute. Remove the cooked veg to a bowl.

In the same pan cook the ground beef until no pink remains, until it’s cooked through.

In a medium bowl stir together the sauce ingredients: tomato sauce, ketchup, Worcestershire sauce and brown sugar.

To the pan of cooked meat add the sauce and cooked vegetables. Continue to cook for a few minutes until everything is hot.

Toast the buns before adding the sloppy joe filling. Enjoy!

Tips and Notes

• You can substitute the ground beef or any ground meat including turkey or chicken.
• I used two shallots in this recipe but 1/2 a yellow or red onion would work well too.
• I use green bell pepper but any color works. You can also omit the bell pepper although I like the slight crunch it adds to the filling.
• Sometimes I will add a little hot sauce, like Frank’s, to the sauce.
• I don’t drain the pan of the fat / juices from the cooked ground beef before adding the sauce and veg. But if you want your sloppy joe filling to be a little lighter and thicker (less liquid) then drain it before adding.

More Easy Ground Beef Recipes