Migraine

Source: Migraine by Tudor Barker

Migraines commonly occur in people with ME/CFS. In a 2011 study by Ravindran, et al, migraine headaches were found in 84%, and tension-type headaches in 81% of a cohort of chronic fatigue syndrome patients. This compared to 5% and 45%, respectively, in a cohort of healthy controls.

Phases

Migraine phases:

Prodromal (pre-headache) stage

changes in mood, energy levels, behaviour and appetite that can occur several hours or days before an attack

Aura phase (if present)

visual problems are very common, e.g. flashes of light (scintillations) or blind spots (scotoma), aura symptoms last for 5 to 60 minutes

Headache phase

usually a moderate or severe pulsating or throbbing pain on one side of the head, often accompanied by nausea, vomiting or extreme light sensitivity and extreme sensitivity to loud sounds, which last from 4 hours to 3 days

Postdromal or resolution stage

the severe headache and other symptoms gradually fade, but there may be tiredness for few days after

Migraine phases.
Source: Khan et. al. (2021). Biomedicine & Pharmacotherapy, 139, 111557.

Types

Migraine without aura

Migraine without aura is defined by the following diagnostic criteria outlined in The International Classification Of Headache Disorders, 3rd edition:

Migraine without aura diagnostic criteria

1. At least five headache attacks that
2. Last 4–72 hours without successful treatment
3. Headaches have at least two of the following four characteristics:
1. unilateral location;
2. pulsating quality;
3. moderate to severe pain intensity; and
4. aggravation by or causing avoidance of routine physical activity.
4. During the headaches at least one of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia (avoidance of loud noises)
5. Not better accounted for by another ICHD-3 diagnosis.

Migraines without aura may also be called common migraine or hemicrania simplex'.

Migraine with aura

Migraine with aura diagnostic criteria

Visual, sensory and central nervous system symptom in beginning shortly before a migraine headache are known as an aura, although migraine with aura without migraine headaches are also recognized.

1. At least two migraine attacks fulfilling criteria B and C
2. One or more of the following fully reversible aura symptoms
1. visual
2. sensory
3. speech and/or language
4. motor
5. brainstem
6. retinal
3. At least three of the following characteristics:
1. at least one aura symptom spreads gradually over five minutes or longer
2. two or more aura symptoms occur in succession
3. each individual aura symptom lasts 5 to 60 minutes
4. at least one aura symptom is unilateral (one sided)
5. at least one aura symptom is positive
6. the aura is accompanied, or followed within 60 minutes, by headache
4. Not better accounted for by another ICHD-3 diagnosis.

The recognized types of migraine with aura are:

• Typical aura with headache
• Typical aura without headache
• Migraine with brainstem aura
• Hemiplegic migraine, including familial hemiplegic migraine (FHM) type 1, type 2, type 3 and with other loci
• Sporadic hemiplegic migraine (SHM)
• Retinal migraine

Migraines without aura may also be called Classic or classical migraine, ophthalmic, hemiparaesthetic, hemiplegic or aphasic migraine, or complicated migraine.

Silent migraine

Migraine symptoms that do not result in a headache are known as silent migraines, e.g. migraine aura symptoms without head pain.migraine aura without headache, also known as silent migraine – where an aura or other migraine symptoms are experienced, but a headache does not develop.

Triggers

Common migraine triggers include:

• Food and drinks, e.g., chocolate, alcohol, aged cheese, gluten, high histamine foods
• Lifestyle patterns, e.g. stress, weather changes, or fasting
• Genetics
• Physiological and biochemical factors, e.g. insulin or oestrogen hormone levels, increased oxidative stress

Migraines in ME/CFS

Migraines is one of several illnesses or conditions common in people with ME/CFS.

The Canadian Consensus Criteria recognizes migraines in the possible neurological symptoms of ME/CFS, and the International Consensus Criteria recognizes headache conditions including migraine and tension-type headache in the diagnostic criteria for myalgic encephalomyelitis.

Potential treatments

Migraine treatment consists of:

• Abortive treatments, that aim to stop a migraine attack or reduce the symptoms

• Prevention, which aims to reduce how often migraines occur and their intensity

Migraine attack treatments

• General pain medications, including acetaminophen and nonsteroidal anti-inflammatories (NSAID), for mild to moderate migraines. Different types of medications are sometimes combined, for example acetaminophen and naproxen.
• Triptans for moderate or severe migraine e.g. sumatriptan (Imitrex): 13 out of 14 newly diagnosed migraine subjects responded to sumatriptan in one CFS patient cohort or zomitriptan (Zomig)
• Small molecule CGRP antagonists, known as gepants, which are the newest group of migraine drugs
• There is some limited evidence for transcranial magnetic stimulation (TMS) in migraines with aura, this is a non-invasive brain based treatment

Migraine prevention

• Migraine elimination diets, which rely on identifying particular foods, drinks or additives that trigger migraines, for example avoiding food or drinks containing nitrates or tyramine
• CGRP antagonists, particularly CGRP monoclonal antibodies but possibly some gepants
• Drugs developed for other uses that are known to reduce migraines, including propranolol, amitriptyline (Elavil), topiramate (Topamax) or botulinum toxin type A (Botox injections)
• Acupuncture
• Daith piercing, a type of ear piercings not routinely recommended
• Natural or alternative dietary supplements including magnesium, feverfew, the B vitamin riboflavin, CoQ10, and others. Butterbur is not recommended due to liver toxicity. Some neurologists still recommend supplements with Butterbur as long as they are free of pyrrolizidine alkaloids.
• Migraines with aura may be reduce with transcranial magnetic stimulation, although evidence for this is limited
• Neuromodulation Devices

Notable studies

• 2011, Migraine headaches in chronic fatigue syndrome (CFS): comparison of two prospective cross-sectional studies.
• 2013, Migraine in gulf war illness and chronic fatigue syndrome: Prevalence, potential mechanisms, and evaluation. (Full Text)
• 2016, Migraines Are Correlated with Higher Levels of Nitrate-, Nitrite-, and Nitric Oxide-Reducing Oral Microbes in the American Gut Project Cohort (Full Text)

News and articles

• Oct 18, 2016, Migraines could be caused by gut bacteria, study suggests
• May 19, 2018, The Migraine Drug Explosion Begins: Could Fibromyalgia and ME/CFS Benefit?

Learn more

• Migraine treatment - National Health Service
• Dietary Supplements for Headaches: What the Science Says - National Center for Complementary and Integrative Health

See also

• Headache
• Magnesium
• Analgesic (pain killer)