Related Conditions

by | Jul 11, 2021 | Comorbidity

Comorbid Conditions and Migraine

Related conditions are also known as comorbid conditions.  Sounds scary!  But what does it really mean?

The term comorbidity can be used in two ways.  The older and most proper definition is this:  a medical condition existing simultaneously with but independently from another condition, and in a higher rate than expected by coincidence.  Comorbidity can also be used to mean a situation in which one condition is caused by or closely related to another condition.  This is a newer and non-standard definition, and is sometimes used to describe situations in which we are learning more about a disease state such as migraine.

There are a number of conditions which are comorbid with migraine.  Some of them associate as true comorbidities in the first and more classic sense.  Others we are finding group together as “comorbidity clusters”, and this new information is leading us to further avenues of research.  Some comorbid conditions may exist because of shared genetic factors that increase the risk of both the comorbid condition and migraine.

Cardiac Patients with Migraine

by | Aug 17, 2020 | Comorbidity

If you have heart disease, your options for migraine treatment used to be limited.  Triptan medications should be avoided.  This is because triptans can decrease the diameter of blood vessels which, if already narrowed by heart disease, can potentially restrict blood flow further and result in heart attack.  A recent study of over 120,000 people with migraine from 10 health plans revealed that 22% of people with a heart condition prohibiting the use of triptans were nevertheless given a triptan prescription.

Are these migraine-specific drugs unsafe for migraine sufferers without heart disease?  Triptans are not known to cause heart disease, and can be safely taken as long as you do not have heart disease.  Safety of these medications in migraineurs who have several risk factors for heart disease is not certain, but often alternatives are recommended.

NSAID Risk in Cardiac Patients

Often, nonsteroidal anti-inflammatory medications are offered for migraine pain instead of or in addition to triptan medications.  However, you may not know that nonsteroidal anti-inflammatory drugs (NSAIDs) can be even more dangerous.  Non-steroidal anti-inflammatory medications can be a cause of risk, even amongst those without heart disease or its risk factors, but is especially risky in cardiovascular conditions.  Conditions at particular risk are stroke, unstable angina, recent bypass surgery, or myocardial infarction.  NSAIDs tend to elevate blood pressure, and this accounts for some of the cardiovascular risk.  In those who already have atherosclerosis, the COX-2 NSAIDs also affect the balance of chemical factors affecting clot formation, tilting things toward clotting.

Using NSIADs increases the risk of recurring myocardial infarctions.  Even short term use–as little as seven days–can increase the risk of another myocardial infarction of death by about 50%.  (Drugs used most commonly in this study were ibuprofen, naproxen, rofecoxib, and celecoxib.)

For those with known cardiovascular disease or risk factors for ischemic heart disease, aspirin, tramadol, or acetaminophen (paracetamol) have previously been the safest choices for the treatment of pain.  Naproxen, although not risk-free, was the safest choice in those who have not responded to those medications. There are now newer options (discussed below.)  Narcotic analgesics may be used as rescue medication.  These are not, however, the best options for migraine attacks. 

NSAIDs should be avoided in those who have heart disease or heart failure.  But what about migraine patients who do not have heart disease?  Current recommendations are to weigh the benefits of these medications against their risks. If over-the-counter nonsteroidal anti-inflammatory medication is required for more than ten days, you should see a doctor.  Also, be aware that ibuprofen can interfere with the ability of aspirin to provide protection against clotting, and should be taken either 30 minutes before or twelve hours after taking low-dose aspirin.

New Options for Migraine Patients with Cardiac Disease

Newer medications for migraine are available that have proven safe in cardiac patients.  These include lasmiditan (Reyvow), rimegepant (Nurtec), and ubrogepant (Ubrelvy).  All three of these can be used for the acute management of migraine, and have been found to be safe for cardiac patients.

References:

1. American Neurological Association (ANA) 136th Annual Meeting:  Poster T1614.  Presented September 27, 2011.

2. Antman, EM, Bennett, JS, Daugherty, A, Furberg, C, Roberts, H, Taubert, KA.  Use of nonsteroidal antiinflammatory drugs:  an update for clinicians:  a scientific statement from the American Heart Association.  Circulation. 2007; 115:1634-1642.

3. Hammad, TA, Graham, DJ, Staffa, JA, Komegay, CJ, Dal Pan, GJ.  Onset of acute myocardial infarction after use of non-steroidal anti-inflammatory drugs.  pharmacoepidemiol Drug Sof. 2008; 17:315-321.

4. Fosbol, EL, Gistason, GH, Jacobsen, S, Folke, F, Hansen, ML, Schramm, TK, Sorensen, R, Rasmussen, JN, Andersen, SS, Abildstrom, SZ, Traerup, J, Poulsen, HE, Rasmussen, S, Kober, L, Torp-Pesersen, C.  Risk of myocardial infraction and death associated with the use of nonsteroidal anti-inflammatory drugs (NSAIDS) among healthy individuals:  a nationwide cohort study.  Clin Pharmacol Ther. 2009; 85:190-197.

5. Gislason, GH, Rasmussen, JN, Abildstorm, SZ, Schramm, TK, Hansen, ML, Fosbol, EL, Sorensen, R, Folke, F, Burch, P, Gadsboll, N, Rasmussen, S, Poulsen, HE, Kober, L, Madsen, M, Torp-Pedersen, C. Increased mortality and cardiovascular morbidity associated with use of nonsteroidal anti-inflammatory drugs in chronic heart failure.  Arch Intern Med. 2009; 169:141-149.

6. Young, WB, Mannix, L, Adelman, JU, and Schechter, AL. Cardiac Risk Factors and the Use of Triptans:  A Survey Study.  Headache:  The Journal of Head and Face Pain. 2000; 40:587-591. 

7. Berman, G, Croop, R, Kudrow, D, Halverson, P, Lovegren, M, Thiry, AC, Conway, CM, Coric, V, Lipton, RB.  Safety of Rimegepant, an Oral CGRP Receptor Antagonist, Plus CGRP Monoclonal Antibodies for Migraine.  Headache:  The Journal of Head and Face Pain. 2020. 60 (8):1734-1742.

8. Shapiro, RE, Hochstetler, HM, Dennehy, EB, Khanna, R, Gautier Doty, E, Berg, PH, Starling, AJ. Lasmiditan for Acute Treatment of Migraine in Patients with Cardiovascular Risk Factors:  Post-hoc Analysis of Pooled Results from 2 Randomized, Double-Blind, Placebo-Controlled, Phase 3 Trials.  j. Headache Pain.  2019. 29; 20(1):90.

 

 

 

Raynaud’s Disease

by | Mar 24, 2018 | Comorbidity

Raynaud’s Disease and Migraine

Raynaud’s disease affects 4-15% of the general population.  The female to male predominance is 7:1.  As association has been found between Raynaud’s and migraine.  The symptoms are color changes in the fingers and toes in response to cold exposure.  The digits sometimes turn first white, then blue, and finally red as a reactive phase.  Tingling and numbness can also occur  This happens because of vasospasm, and it is important for your doctor to know about this, because it may affect the choice of medication used to treat your migraines.

Beta-blockers, clonidine, and ergots are contra-indicated as they are vasoconstrictors and can make the condition worse.  Smoking also makes it worse.  However, calcium channel blockers can be used to treat Raynaud’s disease, and this is also a migraine preventive agent.  Biofeedback has also been used for Raynaud’s, and is also useful in migraine.

This is a helpful ink about Raynaud’s

Mental Health

by | Feb 9, 2018 | Comorbidity

Mental Health and Headaches

Depression, anxiety and panic disorder, and bipolar disorder all occur more commonly in migraine sufferers than in the general population. In fact, a constellation of depression, anxiety and migraine has been found in a subset of migraineurs. Some studies suggest that bipolar disorder may be even more strongly associated with migraine than with depression.

There is emerging evidence that early childhood abuse or neglect can affect migraine sufferers as well, and there may be an association between PTSD and migraine or chronic headache. In women with chronic migraine, 42% were found to have had some form of childhood abuse, neglect, or abandonment.

Correlations have also been found between PTSD and migraine in returning Iraq and Afghanistan Veterans, even in the absence of head injury. (Naturally PTSD and blast injury only further compound the resultant headaches.)

References:

1. Afari N, Harder LH, Madra NJ, et al. PTSD, combat injury, and headache in Veterans Returning from Iraq/Afghanistan. Headache. 2009;49(9):1267-1276. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19788469
2. Peterlin BL, Tietjen GE, Brandes JL, et al. Posttraumatic stress disorder in migraine. Headache. 2009;49(4):541-551. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19245387
3. Peterlin BL. Post-traumatic stress disorder in migraine: further comments. Headache. 2009;49(5):787. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19456892
4. Peterlin BL, Tietjen G, Meng S, Lidicker J, Bigal M. Post-traumatic stress disorder in episodic and chronic migraine. Headache. 2008;48(4):517-522. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18377377
5. Ruff RL, Ruff SS, Wang X. Headaches among Operation Iraqi Freedom/Operation Enduring Freedom veterans with mild traumatic brain injury associated with exposures to explosions. J Rehabil Res Dev. 2008;45(7):941-952. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19165684
by Christina Peterson, MD
updated Feb 7, 2010

Gluten and Migraine

by | Nov 15, 2016 | Comorbidity

Gluten Intolerance and Migraine

Did you know that gluten intolerance, also known as celiac disease, is more common in migraine sufferers?  Celiac disease was once thought to be due to an allergy to the gluten protein found in wheat and other grains.  It is now known to be an autoimmune disorder, with an inherited tendency.

Symptoms of Celiac Disease

These are the symptoms of full-blown celiac disease, but you could experience only some, or even almost none except migraine.  (Almost no one has all of them.)

  • Abdominal pain or bloating
  • Gas
  • Diarrhea
  • Constipation
  • Joint pains
  • Fatigue
  • Mood change or depression
  • Weight loss or weight gain
  • Muscle cramps
  • Anemia
  • Osteoporosis
  • Tingling due to neuropathy (nerve damage)
  • Missed menstrual periods
  • Infertility or miscarriages
  • Behavioral changes
  • Delayed growth in children and failure to thrive in infants
  • Itchy skin rash
  • Tooth discoloration and loss of enamel

As if that list wasn’t scary enough, researchers are finding that untreated celiac disease is found more commonly in conjunction with other autoimmune disorders such as Hashimoto’s thyroiditis, type I diabetes, and Addison’s disease. 

Lactose intolerance is also more common in people who have gluten intolerance or sensitivity.

Gluten Intolerance and Gluten Sensitivity

There is a difference between being gluten intolerant and being gluten sensitive.  Gluten intolerant individuals have had an autoimmune process triggered early in life, and over time, the continued exposure to the gluten protein results in flattening of the normal hills and valleys in the intestine (villi) .  The symptoms are due, in part, to a degree of malnutrition due to malabsorption of nutrients.

Gluten intolerance affects between 1 in 133 and 1 in 250 individuals, depending on which study one wishes to read.  Gluten sensitivity affects about 5% of the population. Why might this be?  There are some interesting theories about the probable origins of gluten intolerance historically.

Gluten sensitivity is less severe, and results in fewer symptoms. There is some evidence to suggest that the symptoms that have been attributed to gluten sensitivity might not be due to gluten at all, but may be due to fructan exposure, and may actually be better approached via the FODMAP diet than a gluten-free diet.

If you suspect you might have gluten intolerance, there are blood tests to look for antibodies.  If present, these are pretty reliable.  But it doesn’t mean nothing is wrong if the blood test is negative.  Sometimes, it’s necessary to get a biopsy of the small bowel. If you are concerned about possible gluten sensitivity, see a gastroenterologist, who can help pin down the nature of your problem.

While avoiding wheat, barley, and rye is an obvious strategy, it may be more difficult to avoid gluten when it hides in unusual places like vitamins, medications, communion wafers, cosmetics, and the glue on older envelopes.  Be aware that beer contains gluten as well.

If you are concerned that you might have a gluten sensitivity or intolerance, talk to your doctor about getting tested or referred to a gastroenterologist.

Concerned About Gluten in Medications?

How can you know if your medication contains gluten or not?  Here are some phone numbers for pharmaceutical companies:

Abbott products – 1-800-441-4987, option 1

GlaxoSmithKline products – 1-888-825-5249

Pfizer products- 1-800-438-1985

Teva generic drug products 1-800-545-8800

Or ask your pharmacist. 

Nutritional supplements should list the company phone number and/or website on the label-contact them and ask.  Since gluten is not an active ingredient, it is not required to be listed on the label, and may simply be referred to as an “inert ingredient”, or the technical term for this is, which is “excipient.”

Irritable Bowel Syndrome

Irritable Bowel Syndrome is also comorbid with migraine, and affects about 15% of the general population.  The symptoms of IBS can be very similar to the GI tract symptoms of gluten sensitivity and intolerance—the two disorders can be confused. And for those sensitive to fructans, avoiding them with the FODMAP diet may alleviate symptoms. A gastroenterologist can help.

Resources for gluten sensitivity and celiac disease:

http://celiac.nih.gov/

http://www.celiac.com/

http://www.glutenfreely.com/glutenfreely/nonceliacglutenintolerance.aspx

http://well.blogs.nytimes.com/2014/10/06/when-gluten-sensitivity-isnt-celiac-disease/

by Christina Peterson, M.D.

updated 11/15/2016

Metabolic

by | Nov 9, 2016 | Comorbidity

Endocrine and Metabolic Disorders and Headache

What are metabolic disorders?  A metabolic disorder occurs when there is any disruption in the normal chemical processes of one or more organs in your body.  Most metabolic disorders are inherited, but not all are.  There are also metabolic conditions that affect the functioning of the body that are not a permanent condition, such as vitamin D deficiency or alcohol overuse, which is self-inflicted, but which does adversely affect the functioning of your body’s organs.

While the list of endocrine and metabolic disorders is quite long, there are a few that can affect the risk of headache or migraine, such as thyroid disorders or Ehlers-Danlos syndrome.

This raises the issue of whether or not obesity should be included here, or whether it is a genetic issue.  Obesity does involve metabolic processes.  Whether or not it is genetic, and to what extent, remains controversial.  It is increasingly clear, however, that increasing obesity is correlated with an increased risk of chronic daily headache and with increased migraine frequency and severity.

by Christina Peterson, MD

updated Nov 9, 2016