Migraine has many comorbidities. When we speak about comorbidities and associated conditions of migraine, we are talking about 3 situations:
- When one condition makes it more likely to have another condition at the same time; e.g. migraine and depression. These are comorbid conditions.
- When one condition may be a risk factor for other conditions; e.g. migraine may be a risk for stroke.
- A condition that may contribute to the severity or frequency of migraine attacks; e.g. obesity may increase the risk of developing chronic migraine.
Mental Health
Depression is one of the most common comorbidities of migraine, occurring up to 2.5 times more than in the general population. It occurs more frequently among those with chronic migraine and migraine with aura. Anxiety can occur along with both depression and migraine. Anxiety disorders (especially generalised anxiety disorder (GAD), obsessive compulsive disorder (OCD) and panic disorder (PD)), are 2-5 times more common in people with migraine than in the general population. The rate increases for chronic migraine.
People with anxiety disorders (especially panic attacks) and migraine tend to have increased migraine frequency, increased disability, higher risk of chronification and higher risk of medication overuse. The two conditions can have similar manifestations such as functional impairment, gastrointestinal (nausea), autonomic (dizziness), affective (fear) symptoms during attacks, plus the worry about further attacks.
PTSD is more common among people living with migraine than those who do not. In specialist headache clinic studies, between 22-30% of headache patients fulfilled PTSD criteria and in veteran (i.e. people who have served in the military) groups, the prevalence of PTSD was even greater.
ASTHMA AND ALLERGIES
Asthma, hay fever, chronic bronchitis and allergy were all found to be comorbid with migraine. The relationship works both ways - asthma and allergy make migraine worse, and migraine makes asthma and allergies worse.
These chronic conditions share inflammatory, genetic and immune dysfunction aspects; and both conditions may be triggered by anything from seasonal weather changes to stress. They also act on various systems within the body. Although a direct relationship is difficult to establish, people living with migraine and diagnosed with asthma are more at risk of developing chronic migraine. Since worsening of one condition is likely to cause a worsening of the other, the primary aim of treatment is to prevent attacks and provide effective rescue treatment when attacks do occur.
While some people find that eliminating or avoiding certain foods (or chemicals in foods) and drinks reduces their migraine frequency, the most definitive way to be sure if someone has a food allergy or intolerance would be to have an allergy skin test or to go through an exclusion diet and slowly introduce potential food triggers one by one, observing the body’s reaction. The most solid evidence for food triggers and intolerance is for tyramine found in foods such as aged cheeses, cured or smoked meat, pickled food (e.g. sauerkraut), some beans, over-ripe fruit and some beers.
IRRITABLE BOWEL SYNDROME (IBS) AND OTHER GUT DISORDERS
Gastrointestinal (GI) disorders in patients with migraine are more common than in the general population. On the other hand, chronic headache has been reported in 34%-50% of all IBS patients. Helicobacter pylori infection, irritable bowel syndrome (IBS), gastroparesis, coeliac disease (CD) and alterations in the microbiota are all linked to migraine. A number of mechanisms involving the gut-brain axis, such as a chronic inflammatory response and dysfunction of the autonomic and enteric nervous system, among others, are thought to explain these associations.
When seeking treatment, it is worthwhile to consider both conditions as some GI disorders may affect how you respond to migraine treatments; e.g. gastroparesis may affect how well your body absorbs oral medications and an alternative route may be more suitable. Additionally, it is important to ensure that your IBS is not just misdiagnosed abdominal migraine. For some patients, diet modifications might be beneficial, not only for their GI disorder, but also for migraine.
Obesity is also linked to migraine but the relationship is complex.
INSOMNIA AND OTHER SLEEP DISORDERS
Sleep disorders are three times more common among people living with migraine than among the general population. Over a third of migraine patients report frequent sleep difficulties, chronic short sleep and sleep disorders (including obstructive sleep apnoea (OSA), periodic limb movement disorder (including restless leg syndrome), bruxism (teeth grinding), circadian rhythm disorder, insomnia, and hypersomnia).
The relationship between sleep and migraine works both ways – migraine makes sleep more difficult and sleep disorders make migraine worse. Treating the sleep disturbance can have a beneficial effect on migraine; at times even a reversal from chronic to episodic. On the other hand, for those living with migraine, who also engage in shift work or have regularly broken or poor-quality sleep, there is a possibility that episodic migraine may develop into the chronic form.
BALANCE DISORDERS
There is some difficulty in distinguishing many balance disorders that may be comorbid with migraine, from vestibular migraine — which may result in balance-related symptoms such as dizziness or vertigo. However, there is evidence to suggest that balance disorders and migraine are comorbid conditions. For example, motion sickness has been found to be more prevalent in patients with migraine.
Ménière’s disease is a chronic condition of the inner ear, which occurs with a set of symptoms including: dizziness or vertigo, at times with nausea and imbalance; and muffled hearing, tinnitus (ringing in ears) and/or hearing loss. It usually occurs in people aged between 40 and 60 years old. Like some forms of migraine, it can be preceded by an aura phase and like migraine, it can be associated with other conditions such as anxiety. Aas much as 45% of people with Ménière’s may also have migraine, but this number is changing as many Ménière’s patients are being rediagnosed with vestibular migraine.
Benign Paroxysmal Positional Vertigo (BPPV) is the most common balance disorder. People may experience a sense of dizziness and/or spinning; light-headedness, unsteadiness, loss of balance and nausea which occur with movements of the head; e.g. getting out of bed or rolling over, or raising the head to look up at the ceiling. There is an established relationship between BPPV and migraine, with as many as 55% of BPPV patients having migraine.
Postural orthostatic tachycardia syndrome (PoTS), also known as Postural tachycardia syndrome, is a disorder of that part of the nervous system which manages things that we don’t consciously control (e.g. heart rate, blood pressure and body temperature); i.e. the autonomic nervous system. PoTS presents with a number of symptoms (some of which overlap with migraine), but the defining feature is that symptoms such as significant heart rate increase and dizziness, are present within the first 10 minutes of standing up. In medical practices, up to 90% of PoTS patients report a history of migraine.
ME/CFS and Fibromyalgia
There is a significant overlap of symptoms between ME/CFS, Fibromyalgia and migraine.
Chronic fatigue syndrome (CFS) or myalgic encephalomyelitis (ME) - commonly shortened to ME/CFS, affects many body systems and presents with: extreme fatigue (lasting more than 6 months) worsening with activity; difficulty with memory and concentration, "brain fog"; sleep disturbances, and dizziness worsening on standing. Headache, most often fulfilling migraine criteria, is also often reported by people with ME/CFS.
Fibromyalgia is a chronic pain condition that presents with widespread musculoskeletal pain, fatigue, “brain fog”, sleep, memory and mood issues; all symptoms which overlap with migraine. Studies have found that between 18% - 36% of people with migraine, also experience fibromyalgia or another chronic pain condition. Factors that may be part of the cause of both migraine and fibromyalgia are genetic predisposition, neurophysiological changes, and abnormal stress response.
CARDIOVASCULAR DISORDERS
Cardiovascular disease is an umbrella term for all diseases which affect the heart, or blood vessels in any part of the body.
A large study found that migraine increases the risk of a range of cardiovascular diseases including stroke, myocardial infarction (heart attack) and angina. An unexpected and important result was that associations between migraine and cardiovascular disease were similar across subgroups of women: age (<50/≥50); smoking status (current/past/never); hypertension (yes/no); postmenopausal hormone therapy (current/not current); and oral contraceptive use (current/not current). This means that migraine is a greater risk factor for cardiovascular disease than all of these commonly-known risk factors.
Migraine with aura roughly doubles the risk of heart or coronary artery disease, increases the risk of stroke, and men with migraine are at a significantly greater risk of heart attack.
Patent foramen ovale (PFO) is a congenital (about 15-25% of people can be born with it) heart defect, where there is a passageway between the right and left upper chambers (atria) of the heart. Clots can form or move between the 2 parts of the heart eventually causing stroke, TIA, or aura-like episodes. Results from studies vary considerably about the numbers of people with migraine along with PFO. Although it is possible that migraine is a risk factor for stroke because of a PFO, and some people may benefit from PFO closure, clinical trials of PFO closure have not proven that this is an effective way to prevent migraine.
Other Neurological Disorders
Migraine and epilepsy are comorbid conditions, with epilepsy usually presenting first. Migraine (mostly migraine with aura) has been found to occur in 8-24% of people with epilepsy, and epilepsy has been found among 5-9% of migraine patients. Rates of both conditions increase when they are the result of head trauma. The two conditions do not cause one another; rather migraine and epilepsy share some common mechanisms.
Multiple sclerosis (MS) is a chronic disease of the central nervous system where the covering of nerve fibres is are damaged, so nerve signals from the brain and spinal cord to other parts of the body are affected. Some of the symptoms of MS overlap with the symptoms of migraine; e.g. tiredness, dizziness, problems with concentration, and changes in mood. MS and migraine are comorbid neurologic conditions in the sense that migraine is three times higher in the MS population compared to the general population. Patients with MS and migraine have more severe symptoms (cognitive, psychiatric, brainstem and visual symptoms, depression, anxiety and fatigue) than patients with MS but without migraine.