Unraveling the Link Between Multiple Sclerosis and Migraine
A high proportion of people with MS have migraine, but doctors don’t know why this is the case.
Migraine is one of the most common chronic diseases in the United States and around the world. About 15 percent of Americans have migraine, and about 14 percent of people worldwide have it.
But among people with multiple sclerosis (MS), the prevalence of migraine is about 30 percent overall, with a higher prevalence in American and African countries and a lower prevalence in Asian and European countries.
“The emerging science suggests a higher morbidity of migraine in patients with other inflammatory or immunological conditions such as multiple sclerosis,” says Ana Felix, MBBCh, assistant professor in the division of general medicine and clinical epidemiology at the University of North Carolina School of Medicine in Chapel Hill.
This suggests (with an emphasis on “suggests”) that there may be some link, although there is no data available to support the hypothesis to date, says Dr. Felix.
Both MS and Migraine Are Relapsing-Remitting Conditions
From a distance, MS and migraine can look similar, says Anne Damian Yacoub, MD, co-director of the Johns Hopkins Headache Center in Baltimore who specializes in both multiple sclerosis and headache.
“Both are relapsing-remitting conditions, and they both tend to preferentially affect young women,” she says.
In a relapsing-remitting condition, relapsing is when symptoms are worse for a period of time, and remitting is a period of remission when the symptoms get better or even go away completely.
About 85 percent of people diagnosed with MS have relapsing-remitting MS, according to the National MS Society, with a smaller number diagnosed with primary-progressive MS, in which symptoms steadily worsen, with no periods of relapse or remission.
MS and Migraine Don’t Appear to Have the Same Underlying Causes
Both MS and migraine are neurological disorders, meaning they affect the central or peripheral nervous system, but scientists don’t know the specific cause of either.
“Multiple sclerosis is an autoimmune condition, and there are both genetic and environmental risk factors for the development of MS,” says Dr. Yacoub. When a person has MS, the body’s own immune system attacks protective tissue in the central nervous system of the brain and spinal cord and causes inflammation and damage.
For migraine, “There are clear genetic predispositions. It’s very commonly seen in families,” Yacoub says. “However, it’s not a genetic condition where there is only one gene involved and you can test for it and know if you’re going to get it or not. It’s polygenic, so there’s lots of different genes involved.”
That’s what is currently known about MS and migraine, Yacoub says. “There are different theories, but right now there isn’t a known underlying shared pathology between migraine and MS.” Underlying pathology means any disease process or what is happening in the body to cause a particular condition.
Does having one of the conditions increase the risk of developing the other? Right now, there is no known link to suggest that, says Felix. “For practical purposes of patient care, MS and migraine are treated as separate entities,” she says.
Headache Isn’t Typically a Symptom of an MS Relapse
Headache is not typically a sign of MS. It can happen, depending on the area of the brain that’s affected, but it’s not very common, says Yacoub.
“There’s not a known association between worsening MS disease activity and worsened headaches, except in individuals where the specific parts of the brain stem that are involved with their MS are part of the systems that are involved in migraine pain. In that case, there can be a worsened headache,” she says.
Pain behind the eye that can mimic migraine symptoms may be caused by a condition called optic neuritis, which can occur with an MS relapse, says Yacoub. Optic neuritis is swelling of the eye’s optic nerve, which carries light signals from the retina to the brain.
Because this is a possibility, if you have both conditions and develop a lot of pain behind your eyes, don’t automatically assume that this is related to migraine or headache, she says: “Make sure you discuss it with your neurologist to make sure it’s not optic neuritis.”
MS Relapses and Migraine Attacks Can Both Have Visual Symptoms
Both an MS relapse and migraine with aura can come with changes in vision, but there typically are key differences, says Yacoub. About 25 to 30 percent of people with migraine experience aura, which is described as a series of sensory changes that that occur shortly before an attack, according to the American Migraine Foundation.
“Patients who have migraine with aura can sometimes have visual symptoms like flashes of light in the central area in their vision where it looks like there are bright shiny lights or bright zigzags,” she says.
Visual symptoms in migraine are characterized mostly by positive visual phenomenon, says Yacoub. “That means things appearing in their vision rather than a loss of vision, which is less common.”
In an MS relapse in which there are visual problems, those symptoms can include things like double vision, blurry vision in one eye, loss of color vision in one eye, or loss of vision in one eye, says Yacoub. “Those symptoms would not be common in migraine,” she says.
Another key difference is that in a migraine attack, the visual symptoms tend to be intermittent, unlike an MS flare, which is likely to last longer, says Yacoub. Auras typically last 20 to 60 minutes, according to the American Migraine Foundation. MS relapses tend to develop over several days and then last for days to weeks.
Numbness and Tingling Can Be Symptoms of Both Migraine and MS
Although visual aura is more common in migraine, sensory changes are another type of aura symptom, according to the American Headache Society. Sensory aura can feel like tingling or numbness in the face, body, hands, and fingers.
As with visual symptoms that come with aura, these sensory symptoms tend to be intermittent and of short duration.
Depression Is More Common in People With MS or Migraine
Depression seems to be more prevalent both in people with MS and in people with migraine than in the general population, says Yacoub. Studies show that people with migraine are 2 to 4 times more likely to develop major depressive disorder in their lifetime. It’s estimated that up to half of all people with MS will report developing depression at some point in their life.
If you are diagnosed with depression, it may impact how your provider treats your migraine or MS, so it’s important to have that discussion, says Yacoub. “Some antidepressants have been shown to reduce the frequency of migraine attacks, and so your provider may choose one of those medications if you have migraine,” she says.
What to Know if You’re Being Treated for Both MS and Migraine
From a practical perspective, there are many options for treating both conditions, says Felix. “It is not uncommon to be on complex treatment regimens for both migraine and MS,” she adds.
None of the traditional migraine medicines are known to worsen MS or cause MS to relapse, and most MS medicines don’t seem to increase the burden of migraine or cause worsened headaches, says Yacoub. That being said, there are a few potential issues to be aware of when a person is being treated for both conditions, she notes.
Interferon-Beta Therapy People with MS who take the treatment interferon should be aware that the medication is associated with an increased risk of headaches, she says. “Patients who already have migraine should discuss that with their doctor before starting on interferon treatment,” she suggests. A study published in 2020 in the Journal of Pain Research found that interferon-beta therapy aggravated preexisting headaches and caused primary headaches in people with MS.
“Typically, patients who have headaches from interferon have them within the first few days of their injection and not at other times. That’s one way we distinguish if the patient is having one of their usual underlying migraines or if it’s related to the interferon treatments,” says Yacoub.
Topiramate People who have both MS and migraine who take the medication topiramate to prevent migraine attacks should be aware that it can sometimes cause cognitive symptoms, says Yacoub. Studies show that about 10 percent of people who take the medication report problems with cognition.
“That can include issues with thinking and with memory, which can also be symptoms of MS as well. It’s important for people with MS to be vigilant about noticing any cognitive symptoms while on topiramate and discuss those with their neurologist, because they could be related to the MS or the medication,” says Yacoub.
Lifestyle Recommendations for People With Both MS And Migraine
Yacoub’s top recommendation for lifestyle approaches in people with both conditions is exercise. “Exercise has been shown to reduce the frequency and severity of MS relapses as well as the frequency and intensity of migraine attacks. Regular exercise is really helpful for both conditions,” she says.
It’s also recommended that people with MS follow a heart-healthy diet, she says. “This isn’t particularly because that will impact the disease course in MS but because we don’t want any additional insults to the brain when it’s already vulnerable due to the MS,” says Yacoub. A heart-healthy diet can reduce the risk of having any heart-related impact on the brain, she adds.
Regular bedtimes and wake times and getting enough sleep is good for brain health in general — something that’s relevant to both migraine and MS, says Yacoub.