34 | Migraine Management: Finding Relief with Food

Is there a migraine-friendly diet? Does sugar trigger migraines? Are there any vitamins that treat migraines? How much water should I be drinking? With at least 39 million Americans living with migraines, your patients are sure to seek your help finding relief.  Joining me today is The Migraine Dietitian Kelli Yates, to unpack the complex world of migraine management through the lens of nutrition. 

Key Takeaways:

• Hydration Goals: Encourage patients to consume 65-100 ounces of water daily.
• Caffeine and Migraines: Individual tolerance varies; limit caffeine intake to below 200 mg per day.
• Sugar Management: Balance sugar intake with protein and fiber to avoid blood sugar spikes.
• Supplements: Consider magnesium, riboflavin, and CoQ10 for migraine prevention; start with one and evaluate. Ensure vitamin is third-party tested.
• Consider environmental triggers: sleep, stress, smells, and bright lights

Connect with Kelli on Instagram: @the.migraine.dietitian

Transcript

Colleen: 0:00

Is there a migraine-friendly diet? Does sugar trigger migraines? Are there any vitamins that manage migraines? If you suffer from migraine or work with patients who do, you won't want to miss today's episode. I'm Colleen Sloan, a pediatric PA and registered dietitian, and this is the Exam Room Nutrition Podcast where each week, I'm giving you the nutrition education you never had in school to help you become a more confident, compassionate clinician. But migraine affects an estimated 10% of people worldwide, and the American Migraine Foundation estimates that at least 39 million Americans live with migraine.

Colleen: 0:40

Migraine occurs most often among people aged 20 to 50 years and is about three times more common in women than in men. So what role does nutrition play in migraine treatment and prevention? Today's episode will discuss the importance of having your patients keep a food symptom log which vitamins might provide symptom relief, what effect sugar and caffeine have on migraines and so much more. Gone are the days of just providing a handout with a list of foods your patient should avoid. Spoiler alert if you're still doing this, you might be causing more harm than good. But don't worry, friend. After today's episode, you will confidently be able to help your patient find relief from their migraine.

Colleen: 1:25

Joining me today is Kelly Yates. Kelly is a registered dietitian who specializes in helping people with migraine find relief using food supplements and lifestyle changes. You can find Kelly on Instagram at themigrainedietitian Kelly. I am so excited for our discussion today. Thank you so much for being here. Welcome to the show. Yeah, thank you so much for having me. I'm excited. I love this topic and, you know, in pediatrics I actually do get quite a lot of kids who complain more along the lines of headache, but I know migraine is a huge, huge concern for so many patients, so I can't wait to give our listeners some really good, helpful tools. So let's first start off by discussing if there are any specific foods that actually trigger migraines.

Kelli: 2:07

Yeah, so that's a really common question and a common approach to migraine, I think, is to look for any foods that could be causing a problem, and migraine patients can have food triggers that increase their likelihood of experiencing an attack. It's not necessarily going to cause an attack, but it can contribute to the onset of one. But there truly are no specific foods that, just because you have migraine, you should avoid, Like there's no universal migraine food triggers and some patients have no food triggers at all. This is actually more common than we might even think. So food triggers are very unique patient to patient. So if a patient is coming to you concerned about food triggers or you're concerned yourself, for a patient, a food and symptom journal would be a really good tool to attempt to uncover some food triggers that could be contributing to their symptoms.

Colleen: 3:01

Now, regarding the food symptom log how long do you recommend they keep a log for?

Kelli: 3:07

So it depends on the situation, I think, but for many patients even just a couple of weeks to a month can be helpful. Some patients will keep a food and symptom journal long term, but this oftentimes isn't necessary to figure out what food triggers are, or at least what the most prominent food triggers are for that patient. Oftentimes, if it's something that's really going to impact them, it's something that they're eating frequently or drinking frequently. So that can be found out relatively quickly and two to four weeks typically.

Colleen: 3:40

Perfect, thank you so much. So how about any nutritional deficiencies that might be linked as the cause of a migraine that, as clinicians, we need to be aware of?

Kelli: 3:49

Yes, so there are some relatively common nutritional deficiencies that are linked with worsening migraine. So the ones I see most often are going to be magnesium, iron, b12, vitamin C, and then even, like, omega 3, fatty acids can be something that we want to think about as well, because we know that that ratio of omega 3 to omega 6 fatty acids can be really important for migraine patients. Now, they, of course, don't cause migraine, but they can contribute to it. They can lower a patient's threshold for experiencing an attack. So if we can uncover and address these deficiencies, it can really help them see a big improvement in their ability to control migraine and, of course, in their health overall and other symptoms that they may be experiencing and it's interesting that you said that it doesn't necessarily cause it, because I think as patients who are so desperate to find the answer to their migraines and relief for their migraines.

Colleen: 4:48

but I love that you pointed out that it's just an important aspect of the overall total health of the patient.

Kelli: 4:53

Exactly, and I think that can be a really useful tool to help educate patients and how migraine works. We're really looking for things that are worsening it, looking for triggers, but we don't know really what the cause of migraine is at this point other than genetic factors and things like that. So it can be a helpful tool.

Colleen: 5:13

All right. So let's kind of go over this, and I think you alluded to it in the beginning but is there a migraine-friendly diet?

Kelli: 5:22

Yes. So I do think there is, in general, a migraine-friendly diet, and this can be another really big tool when used thoughtfully and appropriately for patients. However, I don't think that the basis of a migraine-friendly diet should be about restricting foods or removing any specific foods in general, right Like oftentimes you might hear we need to remove chocolate, or we need to remove aged cheeses, or there are a bunch of different foods out there that are flagged as problematic. However, when we're looking to construct a migraine-friendly diet for a patient, there are some things that I think about, and that's going to be supporting blood sugar balance, which is nice for everyone, but particularly helpful for people who have migraines. So eating regularly, not skipping meals, having balanced meals, protein, carbs, fat, nutrient density is going to be another really helpful one. So helping prevent those deficiencies that we talked about, making sure we're getting plenty of antioxidants from fruits and veggies and different plant foods.

Kelli: 6:31

And then we also want to think about some other things like supporting gut health, because this is a newer area of research for migraine and we know that supporting a healthy gut environment and a healthy microbiome can be really beneficial for that gut brain connection and, in turn, for migraine itself. So fermented foods, prebiotic foods so foods that support the microbiome those can be really helpful. Viber can make a huge difference. And then we also want to be practical and search for ways that we can make eating easy for someone with migraine, because oftentimes migraine can be debilitating and some people deal with attacks every single day. So we really want to look for ways to make putting together balanced meals easy and doable. We want to look for ways to help them eat despite nausea or high pain or vertigo. So that's another really important strategy that we can help patients with to actually incorporate all of the other things I just talked about.

Colleen: 7:37

Oh my gosh, that was talk full of so much information and that was just so helpful. I think the basis, though it sounds like really we should be recommending just an overall well balanced diet, and if it is full of fruits and vegetables, then hopefully they are getting their fiber. But I mean, I probably talk about fiber on every episode, and it is just so important for every disease and symptom, and more and more research is coming out on like how amazing fermented foods are and how awesome probiotics and fiber is, so I love that it's helpful in migraine as well too, because it's kind of like this beautiful miracle food that it can help symptoms and so many things. So you mentioned about kind of helping the patient navigate when they're having like a really bad attack and alleviating those symptoms and making sure that they are eating during those symptoms of vertigo and nausea and when the pain is just debilitating. Are there any specific foods that can actually help alleviate migraine symptoms when they are currently in an attack?

Kelli: 8:33

So there, are some foods that have been looked at a little bit for their ability to help alleviate some of the symptoms that we might experience during a migraine attack. Now we also again have to be practical in this situation, because there are some attacks where a patient won't be able to eat. So in that situation, you know sipping on electrolyte solutions or you know broths or something like that can be helpful. But if they can continue eating every three to four hours or whatever works for that patient, then we can love to incorporate some foods like ginger, which can be helpful for some patients with a little bit of pain. Support, nausea, support even like a ginger tea can be really soothing for a patient dealing with nausea. And same thing with peppermint teas or adding peppermint to smoothies. That can be really helpful for some nausea. So there are some foods that may have a therapeutic benefit for some patients, but with migraine one thing isn't going to work for everyone. So it's really helpful to help the patient experiment to figure out what's going to work for them.

Colleen: 9:42

Good point, kind of lingering here, where you had said you know what the balanced meals is super important but can be really challenging when they are just in so much pain. What would you suggest that the clinician suggests to their patient who might say my head hurts so bad, I just feel like I can't eat? You kind of mentioned some electrolytes and some broth. What other things would be helpful that the clinician to suggest?

Kelli: 10:03

right so broth, electrolyte drinks you can also look for, like a meal replacement shake or protein shake that the patient might tolerate Well, that can help them get some calories and some protein. Even a homemade smoothie can be really beneficial. And then, honestly, for some of my clients I'll recommend a Greek yogurt ice cream kind of product, because that can be really soothing, even on, you know, some head pain. That cold food can be really helpful. And Then some patients can tolerate a soup really well, like a pureed vegetable soup that they can keep in the freezer. That's another tool that I'll use.

Kelli: 10:42

But, honestly, if it's a patient who is, you know, dealing with attacks that don't happen every single day, if the attacks don't last more than a couple of hours, then not eating during that attack is not the end of the world. We don't need to push it, especially if they're dealing with a lot of nausea and maybe vomiting. But if it's a patient who's dealing with, you know, intractable migraine that can go on for 72 plus hours, then of course we need to use these strategies to help them get some nourishment.

Colleen: 11:11

That is so helpful. So before we jump into kind of some supplements and vitamins that can help to prevent and treat migraines, I want to talk about some big three things that can be kind of triggers or that maybe I've heard that are triggers. So let's first jump into the association between hydration and water intake and if there is any impact on migraine occurrences and how important is water for those who suffer from migraines.

Kelli: 11:36

Yes, water is a big one, dehydration is a big one.

Kelli: 11:40

Even Mild dehydration can act as a migraine trigger and, you know, even those of us or people who don't have migraine Know if you get dehydrated you're likely going to experience a headache, maybe some lightheadedness.

Kelli: 11:53

So we know that lower water intake is associated with significant increases in migraine disability, as well as attack severity, frequency, duration. So it is a big deal and, honestly, most migraine patients do know that. But I think a big part of Helping them get the amount of water that they need each day is actually figuring out where they're starting from. I think a lot of people think they're drinking more water than they may actually be. So the first thing I like to do with clients is doing a water intake log, figuring out where we're starting from, and then help them gradually get to a goal of 65 to 100 ounces a day, depending on the person, and then looking for, you know, electrolytes that we can maybe add to increase hydration, really educating the patient on what counts as a hydrating fluid. Those are all some things that we can look into to help prevent that dehydration that is such a prominent trigger for migraine.

Colleen: 12:53

So what is the best way? Number one, to ask if they're getting enough water, because it's so easy to be like do you drink water during the day? Yes, okay, then they're good right, but, like you said, most people underestimate how much water they're actually drinking. So what are some really good ways to actually find out how much they're drinking and how do we determine how much they need? Yes, so honestly.

Kelli: 13:13

I will like to ask if you're doing especially a telehealth session like this, I'll ask my client what do you typically drink your water out of? We figure out how many ounces is in their typical Water bottle or their water glass, and then that's a really easy way to figure out how much they're drinking, because they can probably more easily say I'm drinking like one and a half of these a day, rather than I'm drinking 35 ounces of water a day. Most people don't know how many ounces they're drinking a day, so we can use that as a good tool and then For most people, at least for adults, that two liter or, you know, 65 ounces is a good end goal. So we can just work up gradually to that. Rather than going from 35 ounces to 65 overnight. We can just gradually increase that for them and then using tools like adding Citrus fruits or other flavorings to water if they really hate water can be another good way to get that up too, and what else counts for, like total fluid intake.

Colleen: 14:14

So, yes, we've got our water. Hopefully they're eating plenty of fruits, because I know that has a lot of water in it as well but what are the things that we can suggest to help them increase their total fluid intake?

Kelli: 14:25

Yes, so of course water, but we can also be thinking about if they're making smoothies. The fluid that they're putting in there absolutely counts. Any decaffeinated or herbal teas that they're drinking will count. Any suits that have broth in them, we can count that. So there are a lot of sources that I think people are forgetting about and not giving themselves credit for. Even like a seltzer water or something like that can also count, and oftentimes people will enjoy that more as in plain water. So these are all things we can be adding to the tally to help them get to that.

Colleen: 14:58

you know, 65 to 100 ounces a day, I think that number is so helpful because, again, as clinicians sometimes it's hard for us to remember. You know there's formulas and you register dieticians. You're so great at all your formulas, but in a quick clinic visit, so if you guys can just remember 65 to 100 ounces a day, that would be a really good goal, especially on the lower end. And then if they are eating soups and fruits, then they can add those in. So thank you so much for that, kelly. That is such a good, helpful number. I hope you guys store that in your pocket for later today. So I wanna move on to my favorite beverage, and this is coffee or caffeine. And so this is another big one. And is there a connection between caffeine and migraines? Should it be limited? Does this trigger migraines or treat migraines? So give us the facts on coffee and please don't tell me that I need to stop drinking my coffee.

Kelli: 15:49

Well, I definitely won't do that, because I'm also a daily coffee drinker and the role of caffeine in migraine is very confusing, honestly, for everyone for patients and providers alike because it does depend on the person with like so much with migraine. It depends on the person, and caffeine can help, it can hurt. So let's talk a little bit about how to figure that out for the patient and kind of what we know about caffeine. Each patient's tolerance and sensitivity is gonna be a little bit different, so I think it's really helpful to have a conversation with the patient to figure out, one, if they're even consuming caffeine and if that's something they care about, and two, how they feel when they're drinking caffeine, which they may not know just right off the top of their head might be something you need to revisit. But figuring out if they feel jittery or anxious or even headache-y after having a cup of coffee in the morning, that they may just be kind of pushing through for that energy, that's some really helpful information to tell us. Okay, this may be an issue for them. We might wanna dial that back.

Kelli: 16:57

Caffeine can act as a trigger for some patients, so assessing that response can help you figure that out, as can that food and symptom journal that we talked about earlier. But in general, if someone is drinking caffeine daily and they want to continue doing that which, like I said, I'm a coffee drinker, so it's fine. If that's something that they wanna work into their life, then keeping it below 200 milligrams of caffeine per day is where we wanna be. And then, to make sure that we're considering sleep quality, we wanna cut that caffeine intake off at 3 pm, max 12 noon if they have trouble with sleep already is gonna be where we wanna cut it off.

Kelli: 17:40

Drinking too much caffeine every day can be an issue, as can variations in caffeine intake. So if they're gonna be a caffeine drinker, they need to drink it every day or just save it for acute management. Otherwise they can start to have some withdrawal symptoms and that can be a trigger as well. So avoiding variability and intake and keeping it below 200 milligrams is what we wanna tell our coffee drinkers. And then for people who have episodic migraine so like less than 15 migraine days a month and they don't drink caffeine every single day we can use a cup of coffee as an acute migraine management tool, and that can actually be pretty effective for helping cut down the severity of a migraine attack. So that's where the helpfulness of caffeine can come in.

Colleen: 18:30

That was so helpful. So again, you're just giving us these little golden nuggets of numbers that we can keep in our pockets and suggest to patients. So 200 milligrams? I want you to educate us a little bit on that, because all I know is I like my cup of coffee. So how many cups of coffee is 200 milligrams?

Kelli: 18:48

Yes, so that is where it gets a little bit tricky because it's gonna depend on how it's brewed, the strength of the coffee, all kinds of stuff. But in general I typically tell people that a cup of coffee in the morning not a big, huge cup, but like eight-ish ounces of coffee you can call that 100 milligrams. That's gonna be a good average. So two cups of coffee max a day is gonna be where you wanna sit. Awesome, very, very helpful.

Colleen: 19:16

What about espresso? Does that have more about the same?

Kelli: 19:20

Espresso and Belive is about 70 milligrams per little shot.

Colleen: 19:25

Okay, so it's actually a little bit less. So we're going to move nicely into my next question, and that's about the role of sugar in migraines, because as we talk about coffee, unfortunately so many people are putting so much sugar in there and sweetened creamer in there. So I'm curious what role does sugar in all forms play in triggering migraines?

Kelli: 19:49

Yes, and this is a really common question you'll hear from patients too because sugar is kind of the new fat. Right, we were all afraid of fat for a while. Now we're all afraid of sugar and, just like fat, sugar is not evil, but it is something we want to be thoughtful around because if we're consuming it in excess or on its own, then it can act as a migraine trigger for a lot of people. So the biggest issue when we're thinking about sugar is the potential for it to cause those blood sugar spikes and then blood sugar dips, and that, like blood sugar roller coaster, is what can act as a trigger for a lot of people with migraine. So that's what we're looking to avoid.

Kelli: 20:33

And for patients who are sensitive to sugar, which is going to be a lot of them, then combining sugar with that protein fiber can help slow that blood sugar response, slow the absorption of sugar and prevent those spikes and dips that are going to be so problematic. So that's one really helpful education piece for patients when it comes to sugar. Strict avoidance of sugar is honestly not something I recommend for anyone. Unless there's a special circumstance, it can lead to cravings, you know, binging, disordered eating, just stress and anxiety around food so we can really help our patients learn how to have not only healthy blood sugar responses but also how to have an easier and healthy relationship with food at the same time. Because of that, you know, kind of imbalanced conversation that's happening around sugar right now. We can help kind of correct some of that, but moderation and balance is definitely key, as with most things, when we're talking about sugar for migraine.

Colleen: 21:39

What an excellent point, because unfortunately, I hear way too many clinicians tell patients you need to cut out all sugar. I think that's a horrible recommendation. Because number one well, what is all sugar Like? What does that mean? I mean, sugar isn't everything that's baked, cooked, you know, like it's in sauces, it's in everything. I think that's just a terrible recommendation.

Colleen: 21:59

And so, like what you had said, helping our patients have that healthy relationship with food is so important just for their life and vitality in general. And I want to linger here a little bit because I love that you said hey, you could still have, you know, a cookie at the end of the day or a cake because it's your birthday. I love that. All the dieticians I have on talk about that. Add in approach rather than making it district avoidance. So let's say, if a patient does you know want to have some sweets you had mentioned pairing it with a protein or a fat what would that look like? Can you give us just an example of how they can include some sugar foods in their diet but still managing their blood sugar and preventing those spikes?

Kelli: 22:38

Oh, absolutely. This is a conversation I have all the time, so let's use the cake example. So it's someone's birthday. They want to have a piece of cake. Awesome, sounds amazing.

Kelli: 22:49

So what we can do to make that a easier experience when it comes to migraine is to try and have that piece of cake after a balanced meal. So if we're having it as dessert and we've just had a nice, you know, protein rich, fiber rich meal, then we're probably going to have a pretty easy time tolerating that cake because we've already got that good foundation hanging out in our stomach. So that's one thing that we can be thinking about. I think also, helping your patients get in tune with those hunger and fullness cues can be another really powerful tool, because that can help them manage their intake of those sweets more easily. So they can have maybe a few bites of that cake and then realize, actually, I'm satisfied, I'm full, I'm good, I don't need any more cake. Or, of course, if they want more, they can have it. But that's another way that they can use their own body's cues to manage sugar intake, along with those, you know, balancing blood sugar reactions.

Colleen: 23:50

So helpful and I love that you're not just saying that you have to avoid all sugar, because it's part of life, it's part of enjoying food and it can be done so healthfully. And I talk about this with my pediatric population all the time, because when you do restrict it, what do you want more of? You know you really want more of the sweets and of the sugar and of those things. So if you learn early on how to just incorporate it into your regular meals, then you really don't have any of those binge restriction issues at all. So that was such a helpful piece of advice. So I want to round out this conversation with if there are any supplements or vitamins that are effective in preventing or treating migraines that we can suggest our patients try.

Kelli: 24:30

Yes, so there are kind of the migraine prevention supplement trifecta that we talk about. So that's going to be magnesium, riboflavin and CoQ10. Those are probably the most recommended supplements for managing migraine and there are recommended dosages for these. Of course you want to make sure it makes sense for your individual patients, but with magnesium we're usually looking around 400 to even 1200 milligrams per day, depending on the person. Riboflavin is 400 milligrams a day and then CoQ10, between 100 and 300 milligrams is what we're looking at. So these can be pretty helpful. Again, depending on the patient. They're not going to work for everyone, but trialing these one at a time, I think can be really helpful. Just to make sure that they're going to tolerate it in the first place and then seeing if it's worth keeping in their routine can also be good to evaluate.

Colleen: 25:29

You read my mind because I was going to ask you do you just kind of throw all these at them, three at a time or one at a time? So we try them one at a time. Let's just say we do magnesium first and it's working really well. Do you recommend adding on any of the other ones? Is there any benefit to? More is better, or just kind of sticking with one of them?

Kelli: 25:49

So it depends on what type of response you get. So usually I will start with magnesium and that one I find tends to be the most helpful for the most amount of people. So if we add that in, let's say, three months later they're doing pretty well, but they're still dealing with some major fatigue or maybe some brain fog, migraine symptoms. Of course, then we might try something like CoQ10, which is going to help with mitochondrial support, energy production. We might add that in and see if we can get any further improvements. So that's kind of how I would evaluate whether we need to use all three of these or not with somebody.

Colleen: 26:27

And now, where should people buy these? Because I know that's not a prescription. What should they look for specifically on a label when they are kind of in the madness of a vitamin store, because there's probably like 30 different kinds that they can look at? So can you give us a little bit of guidance on selecting a high quality vitamin?

Kelli: 26:44

So if you are buying a supplement, then buying it from a store or from if your provider has a formulary that they use, those are going to be your best options, rather than Amazon, because, believe it or not, there are counterfeit supplements out there which is hard to believe, but it happens all the time. So you want to make sure you're buying from somewhere reputable, that's number one. And then if you can find a product that is third party tested, that means that a separate you know, third party, a separate company that isn't the supplement brand itself, has evaluated that product for purity, for potency. Basically it says you know, this product has what it's supposed to have in it and it doesn't have anything that it's not supposed to have in it. So that third party testing, if I can find it, that's going to be my gold standard.

Kelli: 27:37

And it will specifically say that on the label that this was third party tested or something like that Ideally sometimes you'll need to find that information on the website, and you can even email or call the company I have done that many times to check and then you can even request results.

Colleen: 27:52

That's awesome. So good to know. Oh, Kelly, this has been so wonderful. So I love to finish with what is the worst piece of advice a clinician could tell a patient who suffers with migraine.

Kelli: 28:03

Okay, so I may get a little bit of a flag for this one, but honestly, I think the worst piece of advice you can just hand someone on the way out the door is to give them a list of foods to eliminate. This is a very common practice and honestly, it can leave the patients very confused and very anxious around foods. So I think if that's something that's part of your practice, that might be something to reevaluate and see if it's actually helping people and if not, maybe we can start to play around with some of the stuff we've talked about today, because I think that can be a lot more helpful for the patients and an easier intervention for them to play around with.

Colleen: 28:45

So good and you honestly looped it right back around to where we started, whereas it's not a full migraine-friendly diet and keeping that food symptom log is so important. So I think it's better to just give them a piece of paper that says what are you eating, what are your symptoms, Rather than an elimination diet. So I think that would be a really, really good way to change kind of how you practice. Kelly, thank you so much for being with us. You were so helpful. I learned so much from you. I would love to have you back on again.

Colleen: 29:15

Yeah absolutely, and thank you so much for having me. This was fun, awesome. So if you guys want to learn more about migraine management, you can follow Kelly at the Migraine Dietitian on Instagram. If you have any questions for me or any other topics that you would like me to cover, go ahead and find me on Instagram as well, at exam room nutrition. Thank you so much, kelly. We'll see you soon. Hi, thanks, all right guys. Now it's time for my nutrition notes In this section. I leave you with a nutrition tip and encouraging quote or an interesting case that I think might add value to your day. So I wanted to give you a few questions that you can ask your patients to really help direct your nutrition education.

Colleen: 29:52

Triggers are so important, but it's really important to remember that migraines are not always triggered by a food. Sometimes it is, but sometimes it's not, and it could be multiple triggers at once. So you can easily just ask your patient hey, do you know what triggers you? Sometimes they already know this and sometimes they don't, because it might be a few things. A couple of things that patients might think about is smells, so very strong perfumes or cleaning supplies can trigger them to have a migraine. Light, such as bright sunlight or really bright fluorescent lights in a room and lack of sleep. So it's very important to be asking about your patient's sleep quality. We do know that poor sleep is associated with increased migraine burden, so make sure you're asking about how long they're sleeping and how well rest they feel when they wake up.

Colleen: 30:36

So I hope this served as a reminder to not only consider food triggers, but to treat your patient holistically to help them get the relief they deserve. Thank you so much for spending time with me today. If you know of any friends or colleagues who would benefit from this information, feel free to grab the link and share this episode with them. Well, that's it for today. So, as always, let's continue to make our patients healthier, One exam room at a time. I'll see you next time, weilinus.