MS and Migraine: More than Meets the Eye

Multiple sclerosis and migraine share a lot more than the first letter of their names.

While many people reading this article have MS, many more people worldwide have migraines and other types of headache. There is a perception that migraine is more common in people with MS, and there is some reason to think that this may be true. However, there are a few issues surrounding migraines and MS that need to be further explored.

Migraines are common (approximately 40 million Americans have migraines), while more than 99 percent of the U.S. population has “ever had a headache.” MS, while not common, is also not rare – it is estimated that 400,000 people in the United States have MS. Many people with MS may have migraines simply because they have one uncommon diagnosis (MS) and one common one (migraine).

So, everyone with a migraine has a headache, but not everyone with a headache has a migraine. There are many other types of headaches. Some people with migraines also happen to have MS and some people with MS have migraines. Sometimes this is simply coincidental, but sometimes the MS itself may be to blame for the migraines.

What is a migraine?

Migraines are a type of primary headache disorder (meaning that they are not generally thought to be caused by something else, like a mass) where a person has headaches that are usually on one side of the head, although the side may change and they may be on both simultaneously. They are usually moderate to severe in intensity, last for longer than four hours if not treated, get worse with activity, feel throbbing and pulsating or are duller or more stabbing. The migraine headache is also accompanied by nausea and/or difficulty with light and loud noises.

While some people have warning signs (often sparkling lights or other visual symptoms) for migraines, called “auras,” this is less common. Migraines without auras are called “common migraines,” while migraines with auras are called “classic migraines.”

Chicken or egg? Which came first?

For most people who have MS and migraines, the migraines came first and are not caused by the MS itself. Some people, however, had no history of migraines prior to their first MS symptoms. In fact, in some cases, a bad headache led to a first brain MRI (magnetic resonance image) which eventually led to a MS diagnosis. Sometimes, however, migraine may be a symptom of MS or even a sign of a MS relapse.

MS is generally thought to be an autoimmune disease with an inflammatory attack on the myelin covering the nerves and the axons themselves within the central nervous system. Migraines are believed to be triggered in a part of the CNS called the brainstem. After the spinal cord and optic nerves, the brainstem is one of the three most common sites for the demyelination seen in MS. This means that a MS lesion in the periaqueductal grey matter may cause a migraine.

MS lesions in the optic nerve, which is called optic neuritis, may be very painful and can make someone feel like they are having the explosive eye pain seen in some migraines. In reality this is a MS lesion causing swelling of the optic nerve (the nerve that transmits signals from the eye), which causes this searing pain. 

People with MS may also have migraines because of various medications they are taking, such as migraines triggered by MS disease-modifying treatments, more specifically the beta interferons and fingolimod. While people without a migraine history who take beta interferons may develop headaches as a potential side effect (which also usually improves as the medication is brought up slowly and your body gets used to it), it seems that only people with a personal or family history of migraines actually develop migraines triggered by the MS medications. So, just like many people with migraines know if they have a food or weather trigger for their migraines, MS medications may sometimes be triggers for migraines as well.

Okay, so I have MS and migraines. What do I do about it?

Talk to your neurologist who is treating your MS and let them know that you are having migraines.

This advice is crucial because sometimes neurologists, nurse practitioners and physician assistants may become so focused on your immunological status, relapses, walking, and multitude of other symptoms associated with MS.

In one research trial, we looked at how often different practitioners were diagnosing their MS patients with migraines. At the first analysis, there were surprisingly less people with MS who had migraines than in the rest of the population. When the researchers looked more carefully, however, they found that it made a difference who was seeing the MS patients: the MS specialist reported just as many people with MS had migraines as people without MS have migraines, but the general neurologist and nurse practitioner in this study only had two people with migraines (out of more than 200 MS patients)! It seems unlikely that completely different types of patients were coming to see these different practitioners, and instead it seems that when your health care practitioner is less comfortable with your MS, then they may not take the extra steps to deal with all of your symptoms and other neurologic conditions affecting your life.

The job of physician educators is to help improve the knowledge of doctors and other healthcare practitioners about both MS and migraine, but your help is needed also. Come to your office visits with a list of issues that are troubling you – and if migraines are on that list, then please make sure to bring the topic up.

General approaches to migraines

Once you have informed your neurologist that you have both MS and migraines, your neurologist will try to determine:

A.) Are the MS and migraines related?

B.) Is there an MS lesion that is causing the migraines?

C.) Are the migraines a side effect of a medication?

D.) Treatment options for the migraines.  

We have a three-way approach to migraines, similarly to how we approach MS:

1. Prevention

2. Handling symptoms

3. Rescue therapy when things get out of hand 

For MS that means:

1. Disease modifying drugs/agents/ treatments (DMDs/DMAs/DMTs)

2. Symptomatic treatments, including Neuro-functional Enhancers (NFEs)

3. Medicines to hasten recovery during a relapse (e.g. intravenous methylprednislonose and injectable ACTH) 

For migraines that means:

1. Prophylactic medications – such as antiepileptic medications, blood pressure medications, etc.

2. Abortive medications – such as triptans, NSAIDs, etc.

3. Rescue with occipital nerve blocks and muscle trigger point injections, as well intravenous   infusions of medications in and out of the hospital. 

Migraine doctors, just like MS doctors, often use complementary therapies, including herbal remedies that have good evidence to support their use.

Although there may not necessarily be a direct link between migraine and MS, with one causing the other, we do know that both MS and migraine should be treated.

As we learn more about MS and migraines, we are finding similarities not just in our approaches to them but also in some of the underlying pathophysiology. In fact sometimes people with migraines but without MS have white spots on their brain MRIs; we are still trying to figure out the exact cause of these spots and to understand what they mean.

Next time you hear about a disease that affects women more than men, the young more than the old, is increased with a family history, where “normal appearing” white matter of the brain may not be completely “normal,” there is an inflammatory soup on the covering of the brain (meninges) and in a quarter of some series patients have white spots on brain MRIs, think migraine.

Daniel Kantor, M.D. is the President of the Florida Society of Neurology, Secretary of the Duval County Medical Society and the Medical Director of Neurologique, an organization dedicated to patient-centered care, research and education. He is board-certified in both Neurology and Headache Medicine and he is the chair of the Education Committee and a board member of the Southern Headache Society. Dr. Kantor focuses on patient-centered MS care and the interactions between MS and migraine. He is a member of the MS Views and News Medical Advisory Committee. Dr. Kantor is an investigator in many clinical trials, including those having to do with MS, pain, and headaches.