Migraine and headache and pain conditions

Ever notice that your patients with migraine and headache often have other medical issues? Well, there are a number of common coexisting medical conditions which are often associated with migraine and headache. Frequently these issues are associated with pain, and are referred to as overlapping pain conditions. Examples of these types of overlapping pain conditions include fibromyalgia (or small fiber neuralgia), endometriosis and dysmenorrhea, musculoskeletal pain (possibly associated with Ehlers Danlos Syndrome), and gastrointestinal disorders. 

In your practice, you might have a teen girl with migraine and dysmenorrhea, a teen boy with migraine and chronic knee pain post-injury, a teen with migraine and IBS, or a tween chronic neck pain and tension-type headache (TTH).  These are all medical comorbidities that are associated with migraine, some with TTH.

Chronic pain disorders and migraine often coexist. The most common comorbidities seen with migraine in pediatrics are dysmenorrhea/endometriosis, interstitial cystitis/painful bladder syndrome (IC/PBS) and/or fibromyalgia. For dysmenorrhea, IC/PBS, and fibromyalgia, a likely mechanism is central sensitization, which is a generalized increase in pain sensitivity both in painful and non-painful areas. For endometriosis and migraine, research notes there is between 30-60% overlap between these conditions, with also a hormonal and genetic predisposition.

Connective tissue/musculoskeletal disorders, such as Ehlers Danlos syndrome (EDS), all types, are often comorbid with migraine. EDS is a mixed group of connective tissue disorders, varying in severity, which are characterized by hypermobility and instability in many joints, possibly leading to dislocations and chronic pain. EDS is more common in females, like migraine. With EDS, there can be neck and upper back pain related to hypermobility associated with atlantoaxial instability, craniocervical instability, and/or Chiari I Malformation. This often leads to chronic TTH and neck pain, related to muscular tension in the neck and upper back.

Gastrointestinal conditions are often comorbid with migraine/tension-type headaches, and are strongly connected via neural, endocrine, and immune pathways. These GI disorders are possibly related to increased intestinal permeability. Functional abdominal pain and/or IBS are related to central sensitization. Gastroparesis is present during migraine episodes, leading to nausea/vomiting as a common symptom. Colic is present more often in babies of mothers with migraine, and children with migraine often have a history of infantile colic. Patients with functional abdominal pain or irritable bowel syndrome (IBS) often have more migraine, and effective IBS treatment can lower migraine frequency. Patients with Celiac disease have more migraine and migraine patients have more Celiac disease.  Migraine frequency can often be reduced by adopting a gluten-free diet. Patients with inflammatory bowel disease (IBD) have a higher prevalence of migraine.  

So what does this mean for you in your clinical practice? Your patients with migraine in particular may present more often with pain complaints in other bodily systems. They are not just ’complainers’.  They have much more predisposition for pain or discomfort that your other patients.  Just like headache pain, their other pain complaints are real and can cause significant distress.  For most of these kids, their nervous system is overly sensitive and reacts to a higher degree to all possible pain-inducing situations.  

Comorbidities that travel with migraine and headache are common, and your awareness can make a huge difference in ameliorating their pain experiences. This means early intervention for the teen girl with terrible menstrual cramping- either with an oral contraceptive or referral to a gynecologist. This means sensitivity to complaints of abdominal pain, working with the family on elimination diets or referral to a gastroenterologist. This means close observation of your teen male with an ankle sprain to make sure he does not develop chronic pain in that ankle, ensuring they do physical therapy and referring to a pain specialist early if you are suspicious.

Knowing these kids over time, PCP’s are in a prime position to help them recognize and cope with their pain conditions, which is good for everyone involved.