In my last post, I discussed common pain conditions that are often comorbid with migraine and headache. But there are many other common medical conditions that are found within the population of those with migraine in particular. Some of these conditions are neurologic, some are metabolic or other systems. Examples of these types of medical conditions include epilepsy, sleep disturbance, Tourette’s syndrome, attention deficit hyperactivity disorder (ADHD), patent foramen ovale (PFO), atopic disorders (asthma, allergy, eczema), obesity, and polycystic ovary syndrome (PCOS).
In your practice, you might have a teen girl with migraine, obesity and PCOS, a teen boy with migraine and asthma, a teen with migraine and insomnia or a tween with migraine and epilepsy (absence seizures). These are all medical comorbidities that are associated with migraine.
Most commonly associated with migraine are neurologic disorders:
Epilepsy: Migraine and seizures are well known comorbid conditions, most frequent in childhood and adolescence. These conditions share common mechanisms related to the dysfunction of ion channels, and these channelopathies may be the link between epilepsy and migraine, especially when comorbid. The overall prevalence of migraine in children with epilepsy varies from 8 to 15%. The prevalence is increased in children with central-temporal EEG spikes and absence seizures. Headache and vomiting may occur before, during or after an epileptic seizure. In idiopathic occipital epilepsy, episodes are characterized by vomiting associated with visual symptoms, focal seizures and headache.
Sleep: The relationship between sleep and headache is well known, both sleep deprivation and prolonged sleep, particularly in triggering migraine. Sleep is also an important factor in the resolution of migraine. Headaches and migraine are known to occur during sleep, after sleep, and in relationship with various sleep stages, and cause sleep disruption. Children with migraine often have sleep difficulties, including difficulty falling asleep and staying asleep, restless sleep, anxiety around sleep, nightmares, bedwetting, and sleepwalking. Periodic limb movement disorder (PLMd or restless leg syndrome) is quite disruptive to sleep. PLMd is a common sensorimotor disorder, and related to dopaminergic system dysfunction. There is a higher prevalence of PLMd in patients with migraine than other headache types. Migraine patients who also had PLMd were more likely to have associated symptoms, and to report disability, depression, and poor sleep quality.
Attention deficit hyperactivity disorder (ADHD): Both children and adults with ADHD seem more likely to have migraine headaches. There may be genetic factors, related to anxiety and mood disorders, connected to both ADHD and migraine, with stress and other stimuli affecting neurotransmitters, including dopamine.
Tourette’s syndrome: TS is one of the most common childhood movement disorders, associated with neurotransmitter dysregulation in the serotonin system, also implicated in migraine headache. It has been reported that in people with Tourette’s may have as many as 4 times more migraine headaches.
Other medical comorbidities:
Patent foramen ovale: PFO is the result of incomplete fusion of the heart atrial septum, which normally occurs shortly after birth. There is a clear comorbidity between migraine with aura and PFO. The mechanism underlying the relationship is not clear, possibly as a result of common genetic factors or in a causal relationship with migraine attacks. The mechanism may be the passage of microemboli and vasoactive chemicals through the PFO, triggering migraine. Spreading cortical depression, (mechanism behind the migraine aura) could be more likely in the presence of a PFO.
Atopic disorders: Asthma, allergic rhinitis, and eczema are frequently found in comorbidity with migraine. The prevalence of migraine is significantly higher in children and adults with asthma than those without. The specific relationship underlying the association between asthma and migraine is unknown. Studies have suggested that asthma and migraine have a shared pathophysiology, related to several channelopathies.
Obesity: The relationship between migraine and obesity remains uncertain but recent research suggests that obesity )as indicated by increased body mass index) was significantly correlated with migraine frequency and disability in children and adults. There are multiple areas of overlap between migraine pathophysiology and the central and peripheral pathways regulating feeding, involving neurotransmitters (serotonin), peptides (orexin), and adipocytokines (adiponectin and leptin). Interventions to modify/reduce BMI have shown to be a useful treatment model for reducing frequency and severity in obese migraineurs.
Polycystic ovary syndrome: PCOS has its etiology in hormonal imbalance and insulin resistance, with a strong genetic predisposition. There has been little research done about the connection between PCOS and migraine, but anecdotally, there are many women who suffer from both conditions. There is a hormonal component for many women with migraine (menstrual migraine), and also insulin resistance. PCOS often is diagnosed in adolescence.
These are patients you will see often in your clinical practice in pediatric primary care. One condition does not necessarily lead to another, but they are commonly seen together. Medical comorbidities that travel with migraine are common, and your awareness can guide your care.
Perhaps your 8 year-old patient with ‘staring spells’ and severe abdominal pain really has absence seizures comorbid with abdominal migraine. Perhaps your teen with terrible insomnia develops migraine with onset of menses. Perhaps when you have diagnosed a tween with asthma and eczema, and there is a family history of migraine, you mention to the family that she might develop migraine as well.
Knowing these kids over time, PCP’s are in a prime position to help recognize these conditions earlier rather than later, leading to a better outcome.
HeadFirst PNP 