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MS Today


The MS and Migraine Connection

Headache is a common problem for people living with multiple sclerosis (MS) - many report suffering from migraine and/or tension type headache. A survey focusing on migraine in people with MS noted that 41% met the study criteria for migraine, compared with about 10% of Canadians in the general population.

MS patients with headache tend to have developed MS at an earlier age, and to have significantly higher rates of relapses and pain-related complaints compared to those who don't have headache. Migraine seems to occur more often in younger people with relapsing-remitting MS, while a smaller proportion of tension-type headache tends to affect individuals who are older, male, and have secondary progressive MS.

Despite the link between MS and migraine, it is not clear if headaches exacerbate MS, or if MS contributes to migraine-like headaches. To date, studies comparing MRI scans of MS patients with headache to those with no headache have observed a non-significant association between a greater number of mid-brain plaques and an increased likelihood of headaches, especially headaches with migraine characteristics. Research continues.

What type is your headache?

Primary headache, which includes the following three types, do not have an identifiable other cause. (Secondary headaches are due to identifiable causes, such as head injury or brain tumor, or medications.)

  • Tension type headache: These may be intermittent attacks (episodic tension type headaches) or be very frequent or even continuous. The pain is usually less severe than in migraine, and nausea and light sensitivity (common features of migraine) are unusual.
  • Cluster headache and related headaches: Cluster headaches are less common. They occur mainly in men, are always one-sided, and headache attacks are short (under three hours in duration). They may occur several times a day, and often occur at night during sleep.
  • Migraine: There are several types of migraine, but the most common are migraine with aura and migraine without aura, and migraine related to the menstrual cycle (a subtype of migraine with- out aura).

This article will focus on migraine because of its relatively greater impact on the lives of those affected. Regardless of the type of headache you have, see your doctor if it is interfering with your daily activities and is not responding to regular pain medications. There is a lot you can do to manage your headache.

Know your migraine

Migraine without aura

Migraine without aura, which used to be referred to as “common migraine", is diagnosed based on having at least five headache attacks with at least two of the following characteristics:

  • One-sided head pain
  • Throbbing or pulsating pain
  • Pain that is of at least moderate or severe intensity
  • During an attack, the pain is made worse by slight motion or exertion

During a headache attack, one of the following must be present:

  • Nausea and/or vomiting
  • Light and sound sensitivity

Untreated or unsuccessfully treated headache attacks generally last between four and 72 hours.

Migraine with aura

These migraines have the same characteristics as those without aura. Less than a third of people with migraine will have an aura with at least some of their headache attacks, and only a small minority, perhaps one in nine migraine patients, will have an aura with most or all of their headaches.

What's an aura?

The most common aura consists of visual symptoms, which may take a variety of forms, such as bright lines in their vision, which expand over minutes, reduced vision, and blind spots. Some people will experience numbness or tingling which usually spreads slowly over a part of the body. It commonly involves the hand and the face on the same side. (Similar symptoms can also occur due to increased MS activity. If they last more than 24 hours, consult your physician.) Other people experience speech disturbances as part of their aura.

These symptoms typically last less than an hour, and often only 15 or 20 minutes. The headache usually follows right after the aura, or within an hour after it stops. Although aura symptoms may be frightening at first, they are generally harmless.

Menstrual migraine

A true menstrual migraine occurs with a five-day period that starts two days before the menstrual period and ends on the third day of the period. Menstrually-related migraine (MRM) usually occurs during those five days, as well as at other times of the month, such as when estrogen levels drop mid-month, during ovulation.

Migraines associated with menstruation tend to be of long duration and more likely to recur after initial treatment.

Impact of migraine

In general, approximately 90% of individuals who get migraine headaches (migraineurs) have moderate or severe pain. During a migraine attack, many individuals (three in four) experience a reduced ability to function, and one in three require bed rest. And about 63% of all migraineurs suffer from migraines that last more than 24 hours. Stress-related migraines of long duration can be very disruptive to working life, as well as daily activities. Despite the significant impact of migraine, many individuals fail to seek treatment, or give up on treatment because the medications they try are not providing relief. It takes persistence, but migraine headaches can be controlled, or even prevented, once you find the right combination of medications and non-drug approaches like stress management.

Who is most likely to have migraine?

Like MS, migraine affects many young adults during their most pro- ductive years. Women are about three times as likely as men to have migraines; about 18% of women and 6% of men are affected. This increased prevalence in women does not emerge until after puberty, and is thought to be due to the effects of changes (i.e. a decrease) in estrogen levels on headache. About 50% of women with migraine link their headaches with menstruation, while migraines tend to improve during pregnancy and after menopause.

Having a family history of migraine increases your risk of migraine. About 60% of migraineurs have a family history of migraine. As discussed, MS increases headache risk. A recent survey suggested that individuals with migraine were more than twice as likely to have a family history of migraine as were those with no headache (42% versus 18%).

Know your migraine triggers

  • Migraine may be triggered by a wide range of factors, and the headache may not occur for 24 hours or longer after exposure to the trigger.
  • Triggers vary from person to person - most people affected by migraine have more than one trig- ger, and it may take several factors to add up to trigger an attack.
  • Drops in estrogen, stress, and changes in weather are common triggers.
  • Food triggers affect only about 20% of migraineurs. Common food triggers include aged cheeses, processed meats like hotdogs and ham, and especially red wine.
  • Not keeping to a regular lifestyle, for instance by skipping meals, sleeping too little or too long can be a migraine trigger for some individuals.

Track your symptoms

As with MS, keeping a record of your symptoms and the treatments you use each day can help you better understand your migraines. A migraine diary is a simple way to identify the pattern of your migraines, and their triggers. It will also help you and your doctor determine whether your treatment is effective. Monthly headache diaries are available from many organizations, such as the Canadian Headache Network. Or you may wish to track your headaches along with MS symptoms, in the MS daily planner. Take your diary when you visit your doctor to help assess the effectiveness of your treatments.

MS medications and headache

It is not clear as to whether or not the class of interferon beta (IFNB) medications increase the frequency and duration of headache. Some studies have noted newly devel- oped headaches or an increase in existing headaches in individuals when they begin taking an IFNB for MS, while other studies have seen no difference in headache between patients taking and not taking IFNBs. Studies of headache in patients taking COPAXONE® (glatiramer acetate) or an INFB have suggested that the increase in headache seen with IFNBs compared with COPAXONE® may be due to the different brain pathways used by these drugs.

If you have headaches, tell your doctor before starting immuno-modulatory treatment, so you can be monitored and your MS treatment can be adjusted if your headaches increase. If you develop headaches after starting an MS treatment, scheduling an appointment with your doctor specifically to discuss your headaches may help you minimize the impact of future headaches - as in MS, early treatment is ideal.

Migraine can be treated

Migraine is under-diagnosed in Canada, and when identified, it is often under-treated. Each person with migraine, as well as each migraine, must be treated individually. You may need to try several types of medication before you find what works for you, and be prepared to switch if treatment loses its effectiveness over time. Although triptans are acknowledged as an ideal treatment for migraine, med- ications from the following six classes may also be helpful:

  1. Simple analgesics
  2. Non-steroidal anti-inflammatory drugs (NSAIDs)
  3. Combination analgesics without opiates
  4. Triptans
  5. Ergot alkaloids and derivatives
  6. Opiates

Triptans: Meant for migraine

For treatment of migraine that's severe enough to interfere with your usual activities, experts consider triptans the optimal choice, and note that they are not used by many people who could benefit from them.

All of the triptan medications were designed and developed specifically to treat migraine; they are not used for tension type headaches or as general-purpose painkillers.

There now are several different triptans available in Canada, which come in various formulations (injections, tablets to swallow, tablets that dissolve in the mouth, and nasal sprays).

The triptans (and brand names) include:

  • Axert® (almotriptan)
  • Relpax® (eletriptan)
  • Frova® (frovatriptan)
  • Amerge® (naratriptan)
  • Maxalt® (rizatriptan)
  • Imitrex® (sumatriptan)
  • Zomig® (zolmitriptan)

Despite being in one class, the triptans are not identical. It is well known that an individual may respond to one and not another. New triptan medications continue to be developed. Experts advise people taking a triptan who are not getting relief after a reasonable trial to try another triptan.

Treat your MS and headache - ASAP!

With education and planning, and often, lifestyle changes, you can reduce your headache frequency and cope better with migraine attacks. Learn to identify your triggers and where possible, avoid them. Maintaining a healthy lifestyle and using stress manage- ment and relaxation techniques can help relieve migraine.

Being informed on appropriate medication use for both migraine and MS will help you get the best results from treatment. Given the link between MS and headache, it is important to treat your MS effectively as early and effectively as possible. Your quality of life is important, now and over the long term - maximize it by treating your headaches and keeping your MS well-controlled.