Many people with migraine have an adversarial relationship with their gut. During an attack, it can cause stomach and abdominal pain, nausea, an overly full sensation, and more. But why would a disorder that causes crippling headaches affect the gastrointestinal (GI) tract so severely?

Vince Martin, MD, AQH, Director of the Headache & Facial Pain Center at the University of Cincinnati Gardner Neuroscience Institute, spoke at the 2024 Migraine World Summit and explained some of the varied reasons people living with migraine also struggle with gut issues.

The association, he says, relates to the autonomic nervous system, especially the vagus nerve. It’s often called the gut-brain superhighway, since it extends all the way from the brain and down into the GI tract. That means many of the same neurochemicals involved in migraine are also found in the nerve cells of the gut.

Some of the main players are serotonin, which we know is important in migraine; glutamate, another neurotransmitter involved in attacks; and CGRP (calcitonin gene-related peptide, a key component of new preventive treatments). They’re all found in the gut in large quantities.

There are also neurologic connections between the trigeminal system,  the main nerve involved in migraine, and the center in the brain that controls nausea. When that center gets activated, nerves that go to the stomach cause the organ to stop contracting, and that gives you the feeling of nausea.

Gastroparesis, the loss of contraction, is a common side effect of a migraine attack. Normally, the stomach contracts to propel the food into the small intestine. But when someone has a migraine attack, those contractions may stop, and the stomach just kind of sits there. It can lead to issues with nausea, but it can also lead to problems with drug absorption. Some of the oral pills that migraine patients take may not actually be absorbed if the person has gastroparesis.

It’s also possible that these symptoms could manifest outside of a migraine attack. People with migraine may chronically feel full easily or lose their appetite, they may have some pain in their stomach region, and they become easily nauseous.

One lesser-known form of migraine is called abdominal migraine. People develop pain in their epigastrium, which lies just beneath the sternum in the abdomen; they can have recurrent bouts of abdominal pain with or without “classic” migraine symptoms.

This can occur repetitively and may even stump gastroenterologists trying to diagnose the problem. They look for other pathology like gallstones or liver problems, but they don’t find anything significant. And that’s because the diagnosis is really one of exclusion. Once they’ve done their full gastrointestinal evaluation, and particularly if the patient has a history of migraine, then the pain could be called abdominal migraine.

There’s another factor to consider, too, which is the microbiome; it’s basically the collection of all the bacteria that live in your gut. The microbiome changes on a daily basis, as it’s linked to your diet, whether you’ve had any recent antibiotics, and a number of other factors.

The bacteria are a mix of anti-inflammatory and pro-inflammatory types. So, it’s the ratio between the good and the bad bacteria and the substances they produce that may promote or inhibit gut inflammation. And since what happens in the gut can influence what happens in the brain, this balance between good and bad becomes very important.

A lot of healthy lifestyles — diets rich in fruit, vegetables, and fiber — promote the healthy bacteria in your gut. If you eat a poor diet with lots of carbohydrates, sugars, and unhealthy fats, though, it creates an unhealthy environment, and you may struggle with gut symptoms.

And if you’ve been on broad-spectrum antibiotics for a long period of time, they can wreak havoc on the GI tract and the ratio of bacteria in the microbiome. It can throw you into a bad pro-inflammatory state for a long period, and perpetuate the migraine attacks.

More research needs to be done to discover the intricacies of the gut-brain system and how it affects migraine attack symptoms and migraine as a whole.

 

If you think you have migraine (or any other type of ongoing headache), discuss your symptoms with your primary care physician (PCP) first. They may be able to diagnose the condition and start treatment, though most don’t have enough of the proper training to handle more than routine cases. As a result, your PCP will probably refer you to a general neurologist or a headache specialist for follow-up.

The specialist diagnoses migraine after taking a complete medical and family health history and asking you a lot about your symptoms, including:

• What symptoms do you experience during each phase of migraine?
  How severe are the symptoms?
  How long do symptoms last?
  Do you experience an aura preceding the pain?
  How does the pain feel (i.e., shooting, throbbing, aching), and where is it located?
  Does anything make your headache better or worse?
• How long does it take you to get back to normal?
• Do any of the symptoms affect your daily life?

In addition, the doctor performs a physical exam, a neurological exam, and may also order blood tests and imaging tests (e.g., a CT scan or an MRI) to make sure nothing else can account for your headache. An electroencephalogram (EEG) can also help rule out other conditions.

If the doctor can’t find any other condition to explain your symptoms and diagnoses you with either episodic or chronic migraine, the discussion moves to treatment.

There are two types of treatment: preventive and abortive. Preventive treatment is something you take or use every day to prevent a migraine attack from starting up. Abortive (or rescue) treatment is something you take or use at the first sign of an attack to, hopefully, prevent the attack from progressing.

Both the preventive and abortive treatments can be broken down further into two categories: medication and neuromodulators.

Medication

Until recently, most preventive and abortive medications used were drugs repurposed from other conditions that, by chance, also worked on one or more of the migraine pathways in the brain.

Some of the common preventive migraine medications include:

• Antiseizure medications (valproic acid, topiramate)
  Beta-blockers (atenolol, propranolol, nadolol)
  Calcium channel blockers (verapamil)
  Tricyclic antidepressants (amitriptyline, nortriptyline, doxepin)
  Serotonin and norepinephrine reuptake inhibitors (venlafaxine, duloxetine)

Some of the common abortive medications include:

• Triptans (5-hydroxytryptamine)
  Ditans (lasmiditan)
  Dihydroergotamine (DHE) (prochlorperazine)
  Antinausea medications (metoclopramide, promethazine)

Medications come in different forms:

• An injection under your skin (subcutaneous)
  An oral medication
  A nasal spray
  Through an IV (intravenously)
  Suppository

The doctor weighs the risks and benefits of each type of medication before choosing one or more to manage your symptoms. As with any medication, you need to carefully follow their instructions on how to use these safely.

It’s only been in the last few years that research into the mechanisms of migraine has turned up new, migraine-specific classes of drugs. For preventive use are the calcitonin gene-related peptide (CGRP) agonists. These are monoclonal antibodies that prevent the CGRP protein from triggering the cascade that leads to a migraine attack.

The first group of anti-CGRPs released were Aimovig®, AJOVY®, and Emgality®. They come as a subcutaneous injection self-administered once a month. Almost 60% of migraine patients treated with these drugs experienced a ≥ 50% reduction in monthly migraine days at 12 weeks compared to control subjects. Unfortunately, that means over 40% didn’t see that improvement.

For abortive use are a group of short-chain proteins called gepants and ditans, that dock with the CGRP receptor, preventing CGRP from initiating pain signals. Gepants and ditans come as oral pills or dissolvable tablets, not injectables like the monoclonal antibodies. They target very specific receptors on sensory nerves that can resolve migraine symptoms like sensory sensitivity and nausea. Because of their specificity, they come with fewer side effects than the older drugs.

Neuromodulators

The American Migraine Association explains the three noninvasive neuromodulation devices currently FDA-approved for both preventive and abortive treatment.

Transcutaneous supraorbital neurostimulator

Image from American Migraine Foundation

This device is known more commonly as the Cefaly, and it uses electrodes for stimulation. Patients place the electrodes on their forehead, connect the device, and turn it on. It stimulates the supraorbital nerves, which transmit the device’s signal to the brain.

Preventative treatment with the Cefaly lasts for 20 minutes daily. Acute treatment, which uses a different setting on the device, lasts one hour. It takes about three months to determine if the device is effective at preventing migraine attacks.

You buy the device outright, and it’s the only one available without a prescription.

Single Pulse Transcranial Magnetic Stimulator device (SpringTMS or sTMS)
This device simulates nerves using a magnet rather than electrical pulses. You place it on the back of your head, and the device delivers a magnetic charge in about one second. You can rent it in three-month increments.

The preventive dose is four pulses twice daily, with as-needed extra pulses for acute treatment up to 17 pulses per day. Like the Cephaly, it takes about three months of daily use to determine if it has a preventative effect.

Non-Invasive Vagus Nerve Stimulator (nVNS)(aka gammaCore)

Image from electroCore®

This device uses electrodes to treat attacks of episodic cluster headache, but it’s also been FDA-approved for the acute treatment of migraine-related pain in adults. You put gel on the electrodes and then press the device to the side of your neck and turn it on.

It stimulates the vagus nerve in two-minute increments. Two cycles twice a day is the dose for preventive treatment; you can add additional cycles, as needed, for acute treatment.

You do need a prescription for the device, which you rent in three-month installments. Again, it takes about three months to determine effectiveness.

Neuromodulators are a viable alternative for those who either don’t respond to the medications or have unwanted side effects.

 

Migraine is a common neurological disorder, whose attacks contains four distinct phases, one of which is a ghastly headache. Interestingly, though, it’s possible to have migraine attacks without the pain phase, a state called a silent migraine.

In children, it’s more common to see abdominal migraine, where they develop pain in their stomach and abdomen that lasts 1-72 hours and is usually not accompanied by head pain. Adults can have abdominal migraine, too, but it’s much less common.

Researchers estimate some 12% of the population live with some form of migraine, though the experience varies from one person to the next.

Unlike tension-type headaches, migraine attacks come with a bevy of neurological symptoms in addition to the pain.

Types of migraine

There are several types of migraine. The most common migraine categories are:

• Migraine with aura (classic migraine)
  Migraine without aura (common migraine)

Other types of migraine include:

• Abdominal migraine
  Chronic migraine (more than 15 headache days a month)
  Hemiplegic migraine (muscle weakness on one side)
  Menstrual migraine (hormonally induced attack)
  Migraine without headache (silent migraine)
  Retinal migraine (ocular migraine)
  Status migrainosus (aka a transformed migraine; lasts longer than a week)

You can have more than one type of migraine attack at the same time or different types at different periods in your life.

The four phases of a migraine attack

A “typical” migraine attack includes four phases, though the specific symptoms in each phase may differ between people. It’s also possible to have only two or three phases.

1. Prodrome

The first phase begins anywhere up to 24-36 hours before you experience the headache, and it’s a “warning” that an attack is coming. Symptoms include:

• Mood changes
  Excessive yawning
  Difficulty concentrating
  Difficulty sleeping
  Fatigue
  Nausea
  Increased hunger and thirst
  Frequent urination

You may also experience symptoms that are unique to you, as well as have specific triggers (e.g., processed meats, chocolate, caffeine) that set off an attack.

2. Aura

An aura is a collection of sensory, motor, and/or speech symptoms that usually precedes the headache but may appear at the same time. It lasts anywhere up to 60 minutes. You may see zigzag lines or starbursts across your vision, experience muscle weakness, tinnitus, numbness and/or tingling, and/or have difficulty speaking or understanding others.

Aura is a warning that the migraine attack is progressing and the pain phase is imminent.

Most people either have migraine with aura or migraine without aura; it’s relatively rare to have a mix of the two.

3. The pain phase

This is the phase that most people think of when you say “migraine.” It consists of a blinding, one-sided, throbbing headache that may come up from the neck region and stab you through the eyeball. It worsens with any type of activity, and you may be extremely sensitive to light, sounds, and smells.

The headache is often accompanied by a slowing of gut motility, nausea, and repeated bouts of vomiting, as well as a great deal of brain fog and difficulty concentrating on anything other than the pain, which can last from 4-72 hours. You may have difficulty falling asleep or staying asleep because of the pain.

4. Postdrome

The postdrome stage usually lasts for a few hours up to 48 hours. Symptoms feel similar to an alcohol-induced hangover, which is why it’s sometimes called a migraine hangover. Some people also say it feels like a post-adrenaline crash.

Expect your brain to still be foggy and to feel wiped out from the experience.

If you’re someone who lives with chronic migraine, you may start the prodrome for the next attack while still in the postdrome from the previous attack. As a result, you may find it difficult to concentrate on school or work, and it may be difficult to hold a job without accommodations for the attacks.

 

NEXT: Primary Headache: Migraine Diagnosis and Treatment

 

Tension-type headaches (TTHs) are the most common type of primary headache. Researchers estimate that over 70% of people have episodic TTHs. They generally affect women and people assigned female at birth more than men and people assigned male at birth.

The most common description of how the headache feels is like a tight band or vise wrapped around the head that exerts pressure on the forehead and temples.

Many factors can trigger a TTH, and you may be unable to avoid all of them. Fortunately, however, you can do a number of things to prevent TTHs from occurring, and if home-based treatments don’t work, healthcare providers have medications and other therapies to ease the pressure and pain.

Types of tension headaches

Doctors classify TTHs based on how often they occur. They include:

• Infrequent episodic: occur one day a month or less frequently
  Frequent episodic: one to 14 headaches every month for at least three months
  Chronic: more than 15 headaches every month for at least three months

As we’ve mentioned, episodic headaches are the more common form.

Symptoms of tension headaches

Symptoms vary from person to person, but most describe a TTH attack as including:

• Constant mild-to-moderate pressure and pain
  Feeling like a vise is squeezing both sides of the head
  Aching or tight neck and shoulder muscles
  Sensitivity to light and sound

These symptoms tend to emerge slowly, and they can last anywhere from 30 minutes to as long as a week. Some people with chronic TTHs feel like they’re always struggling with headache pain and pressure.

What causes a TTH?

Researchers are still trying to pin down a single cause for tension headaches. Some believe they start when the muscles between your head and neck knot up, sending the pain up into the head, and eventually tightening your scalp muscles. This muscular ripple effect often occurs when you’re stressed or dealing with emotional conflict. Other causes may include:

• Neck strain from looking down to read, look at your phone, or work on a tablet (colloquially called tech neck)
• Eye strain from staring at a screen or documents for a long time without taking breaks
  Temporomandibular jaw disorder (TMJ): damaged or misaligned muscles lead to pain and stiffness
  Degenerative arthritis in your neck
  Sleep disorders: e.g., sleep apnea and insomnia
  Anxiety
  Depression

Complications of TTHs

Chronic tension headaches that don’t let up for weeks and months can easily affect your quality of life, making it hard to focus on your work or family responsibilities because you’re always in pain.

Treating TTHs

Treatments vary depending on what type of tension headache you have. For example, for episodic headaches, the doctor may recommend you start with over-the-counter pain relievers like:

• Acetaminophen (Tylenol®)
  Aspirin
  Ibuprofen (Advil®, Motrin®)
  Naproxen sodium (Aleve®)

If you have chronic tension headaches, your provider may prescribe:

Antiseizure medications like gabapentin (Neurontin®) or topiramate (Topamax®, Topiragen ®)
Antidepressants like amitriptyline that also relieve pain
Alternative therapies like biofeedback, meditation, or cognitive-behavioral therapy to help manage stress
Physical therapy for sleep apnea or TMJ problems

Treatment side effects or complications

Side effects or any complications you might develop vary depending on the specific treatment, but one of the most common potential side effects are what used to be called rebound headaches and are now called medication overuse headaches. This can happen no matter if the medication is over-the-counter or a prescription pain reliever.

These headaches happen if you use the medication too often. Most doctors recommend limiting your dose 10 days in any given month.

Preventing a TTH

Managing your stress level may be the most effective way to prevent a TTH from forming. The most effective stress management tools  fit into your daily routine and make you feel good, like massage therapy, regular exercise (150 minutes a week), and getting enough good-quality sleep (7-9 hours a night).

 

NEXT: Primary Headache: Introduction to Migraine

 

The 150+ types of headaches can be divided into two large categories: primary and secondary.

Primary headaches are caused by dysfunction or overactivity of pain-sensitive structures in your head and are not a symptom of an underlying medical condition. Primary headaches generally aren’t dangerous, but they can be very painful and disrupt your daily life.

Some primary headaches can be triggered by lifestyle factors or situations, including:

• Alcohol, especially red wine
  Processed meats containing nitrates or foods with added MSG (food-triggered headaches)
  Using nicotine (nicotine headache)
  Change in sleep habits or lack of sleep
  Poor posture
  Physical exercise (exertion headaches)
  Skipped meals (hunger headache)
  Coughing, sneezing, blowing your nose, or straining during a bowel movement

The best-known of the primary headaches are:

• Tension-type headaches (most common type of headache)
  Migraine (a neurological disorder)
  Cluster headaches
  New daily persistent headaches (NDPH)

We’ll discuss each one of these in its own post.

Secondary headaches are caused by an underlying medical condition and are considered a symptom or sign of that condition.

Some common and non-dangerous types of secondary headaches that resolve once the underlying condition is treated include:

• Dehydration headache
  Sinus headaches (results from underlying infection)
  Medication overuse headaches (overtreating a headache with medication)

There are, however, types of secondary headaches that may indicate a serious or potentially life-threatening condition:

Spinal headaches

Spinal headaches occur when spinal fluid leaks out of the membrane surrounding your spinal cord, usually after a spinal tap. While you can treat most spinal headaches at home, prolonged, untreated spinal headaches may cause life-threatening complications like a subdural hematoma and seizures.

Thunderclap headaches

A thunderclap headache is a violently painful headache that appears suddenly, like a peal of thunder. It reaches its most intense pain within one minute and lasts at least five minutes. While these headaches may sometimes be harmless, you should seek immediate medical attention because they can be a sign of a head injury, brain bleed, or a sudden, severe rise in blood pressure that could set off a stroke.

 

NEXT: Primary Headache: Tension-Type Headache (TTH)

 

 

When you get a headache, you probably just pop some acetaminophen or ibuprofen, and it goes away a short time later. If that describes you, you’re one of the lucky ones.

Not only are there about 150 different types of headaches, but the World Health Organization (WHO) indicates that headache disorders — characterized by recurrent headaches — have been underestimated, under-recognized and under-treated worldwide.

This is true even though headaches are among the most common nervous system disorders, ranking third (after stroke and dementia) for neurological disease burden measured by age-standardized disability-adjusted life years, effective in 2019.

Globally, WHO found that headache disorders affected some 40% of the population, or 3.1 billion people in 2021, and they occurred in females more than in males, perhaps due to shifting hormones. Despite small regional variations, headache disorders affected people of all races, income levels, and geographical areas.

Headache disorders impose a burden on the people living with the condition that can include substantial personal suffering, impaired quality of life, and financial hardship. And repeated headache attacks, as well as the constant fear of when the next one will occur, can damage family life, social life, and the ability to remain employed.

In the long term, living with a chronic headache disorder may also predispose the person to other illnesses. WHO also notes that anxiety and depression are significantly more common in those who experience migraine attacks than in healthy individuals.

The primary clinical problem for getting effective treatment for headaches is the lack of knowledge among healthcare providers about the subject; most receive only scant training. And, in many countries, medications like the triptans that have been used for migraine treatment for decades simply aren’t available.

Poor awareness of the burden of headache disorders extends to the general public. They don’t perceive the disorders as serious since they’re mostly episodic, don’t cause death, and aren’t contagious. The low rate of provider consultations in developed countries may indicate that many people aren’t even aware that effective treatments for most types of headaches exist.

Outreach and advocacy for headache diagnosis and treatment need to be ramped up to decrease the toll on the individuals living with headache disorders and the society of which they’re a part. Clearly there’s much work that needs to be done.

 

NEXT: Introduction to Primary and Secondary Headaches