A group of American and Chinese researchers reported an objective way to diagnose migraine headaches using functional magnetic resonance imaging (fMRI). The paper just published in Neurology used machine learning to examine differences between the brains of migraine sufferers, patients with chronic pain, and healthy controls.

MRI scans of migraine patients typically show normal brain structure. fMRI scans can visualize connections between different parts of the brain, or so-called connectome. The researchers discovered abnormal functional connectivity within the visual, default mode, sensorimotor, and frontal-parietal networks that allowed them to distinguish migraineurs from healthy controls with 93% sensitivity and 89% specificity. They verified the specificity of this diagnostic marker with new groups of migraineurs and patients with other chronic pain disorders (chronic low back pain and fibromyalgia) and demonstrated 78% sensitivity and 76% specificity for discriminating migraineurs from nonmigraineurs. They also found that the changes in the marker correlated with the changes in headache frequency in response to real acupuncture.

If confirmed, these findings could offer a very accurate way to diagnose migraine, rather than relying on subjective clinical description. This test could also allow for an objective way to test various new treatments. Because of the cost of fMRIs, it will be a long time before it becomes a routine clinical test. It is also possible that genetic testing and testing of blood samples for biochemical markers will lead to other accurate diagnostic tests and tests to predict responses to various therapies.

If you suffer from migraines you are at a higher risk of having certain other medical problems, or comorbidities. They are not the result of having migraines, nor do those condition cause migraines. Most likely, they may have common underlying genetic, environmental, or behavioral factors. You should be aware of this link because treatment choice may be affected by the presence of these comorbidities.

Here is the list of conditions more common in migraines: anxiety, asthma, bipolar disorder, chronic pain, depression, fibromyalgia, reflux (GERD, or heartburn), irritable bowel syndrome (IBS), high cholesterol, hypertension, obesity, sleep apnea, TMJ syndrome. Having these coexisting diseases increases the risk of worsening (chronification) of migraines.

Migraine often coexists with another one or more painful conditions listed above – chronic pain (low back and other), fibromyalgia, irritable bowel syndrome, and TMJ. One plausible explanation is that chronic pain of one type leads to an increased sensitivity of brain cells. This increased sensitivity is well documented and is called wind-up phenomenon. Fortunately, many treatments can address several pain syndromes at once. These include antidepressant drugs (amitriptyline, duloxetine, and other), cognitive-behavioral therapy, exercise, and other.

One possible explanation for the coexistence of psychiatric disorders is that 40-60% of people with chronic pain have a history of physical, emotional, or sexual abuse and may suffer from posttraumatic stress disorder (PTSD).  Another cause could be that they share serotonin and other neurochemical disturbances in the brain. Here too, antidepressants or certain epilepsy drugs may address both migraines and mood disorders.

Reflux (GERD) often seen in migraine sufferers could be the result of taking too many anti-inflammatory drugs such as ibuprofen, aspirin, and naproxen. Many patients will treat their heartburn with drugs such as omeprazole (Prilosec), which after prolonged use can cause multiple vitamin deficiencies, which in turn can worsen migraines and cause other symptoms.

Migraine has an inflammatory component and obesity is known to be pro-inflammatory, which could explain this connection. Diabetes drug, metformin could be a useful drug for patients who have difficulty losing weight with diet and exercise alone.

A typical migraine aura consists of a visual disturbance (partial loss of vision, flickering lights, zigzags, etc) which lasts 15 to 60 minutes and precedes the headache. Auras can also occur without a headache. Auras occurs in 15 to 20% of migraine sufferers and those who experience them have a slightly higher risk of strokes. The reason for this increased risk has remained unclear.

A study just published in Neurology suggests a possible explanation. The study followed 11,939 participants, of whom 426 reported migraines with visual aura, 1,090 migraine without visual aura, 1,018 non-migraine headache, and 9,405 had no headache. Over a 20-year follow-up period, 232 (15%) of 1,516 with migraine developed atrial fibrillation, a type of cardiac arrhythmia (irregular heart beat). Migraine with visual aura was associated with 1.3 times higher risk of atrial fibrillation compared to no headache as well as 1.4 times higher when compared to migraine without visual aura.

Atrial fibrillation is very common and carries a fivefold increase in the risk of stroke compared to those with normal heart rhythm. This risk is even higher in those who are older than 65 years, in women, those who have congestive heart failure, had a prior stroke or transient ischemic attack, hypertension, diabetes and vascular disease. You can’t do anything about your age or being a woman, but good control of hypertension and diabetes (and exercise, weight control, and not smoking) can lower this risk. Patients with atrial fibrillation are usually treated with an anticoagulant (blood thinner), such as apixaban (Eliquis), which can prevent strokes.

Estrogen-based oral contraceptives are usually contraindicated for women who have migraines with aura. In the latest issue of the journal Headache, Dr. Anne Calhoun of the Carolina Headache Institute argues that this contraindication is no longer valid.

She analyzes research studies that consistently show that stroke risk is not increased with today’s very low dose combined hormonal contraceptives containing 20-25 µg ethinyl estradiol and that continuous ultra low-dose formulations (10-15 µg) may even reduce the frequency of migraine auras. The past prohibitions were mostly based on the risk associated with contraceptives containing over 30 µg and often 50 µg of estradiol.

We often use continuous contraception (not having a period for 3 to 12 months) in women with menstrually-related migraines, which usually are not accompanied by aura.

There is no doubt that the risk of strokes in women with migraines with aura who take oral contraceptives is significantly increased by smoking and other stroke risk factors, such as hypertension, diabetes, high cholesterol, and other. So, women who have migraine with aura and take estrogen-based contraceptives should not smoke, should exercise regularly, have a healthy diet and have regular check-ups to detect conditions that may augment the risk of strokes. If such risk factors are present, progesterone-only or non-hormonal contraceptives should be used.

Dr. Calhoun also points out other benefits of oral contraceptives, besides the reduction of the chance of undesired pregnancy, relief of painful periods, excessive bleeding, acne, and PMS. These include reduction in death rate from any cause, 80% reduction in the risk of ovarian and endometrial cancers and reduced risk of colorectal cancer. On the other hand, oral contraceptives do increase the risk of breast cancer.