Performing an MRI scan is unnecessary in the vast majority of migraine sufferers. However, many migraineurs end up having this test because they are concerned about having a brain tumor or another serious condition and because many doctors order MRIs to avoid a possible malpractice suit, however remote the possibility. MRI scan does not involve any radiation, so it is not harmful, but it can cause other problems, besides wasting healthcare dollars. The harm often comes from finding an abnormality on the MRI which is benign, but nevertheless can be very anxiety provoking.

Lesions seen on MRI scans which are benign but very upsetting to patients are arachnoid cysts and venous malformations.

The most common finding though is white matter lesions (WMLs), which doctors sometimes jokingly refer to as UBOs – unidentified bright objects. The origin and the meaning of these spots remains unclear, although the most likely explanation is that these spots are due to ischemia or lack of blood flow. A Dutch study of 295 men and women published in 2004 showed that people who have migraine with aura had a higher risk for silent strokes. As far as WMLs, surprisingly, control subjects, that is people without migraines, had the same high chance of having WMLs as those with migraines – about 38%. However, women with migraine were more likely to have these lesions, regardless whether they had auras or not. A follow-up study published in 2012 reported on 203 of the original 295 patients who underwent another MRI scan 9 years later. This study showed that 3 out of 4 women had progression of these lesions, but they did not have any more strokes. They also did not find an increased risk of dementia in these women.

Another important finding from this long-term study is that migraine sufferers who tend to have syncope attacks (fainting) or near-fainting or feeling lightheaded on standing up or when having blood drawn are more likely to have these WMLs. This suggests that lack of blood flow to the brain may be responsible for WMLs. These findings were presented in a separate article in Neurology.

So, while we still don’t know the cause of WMLs they do appear to be benign and do not lead to other serious problems.

If WMLs are related to strokes as suggested by the fact that drop in blood flow to the brain may predispose one to having WMLs and in a severe form drop of blood flow causes strokes, then possibly approaches that prevent strokes may also prevent WMLs. Even if they are benign, having WMLs is concerning because we may not yet know some of their negative consequences. We know that the risk of strokes can be reduced by avoiding smoking, controlling blood pressure in people with hypertension and blood glucose in diabetics, maintaining normal cholesterol levels, maintaining normal weight, and exercising regularly.

A recent study published in Neurology showed that WMLs are strongly correlated with the frequency of exercise – the more people exercised the less likely they were to have WMLs.

Art credit: JulieMauskop.com

Migraine aura seems to indicate a different underlying brain condition than that of migraine without aura. We know that the risk of strokes is higher in patients who suffer from migraines with aura. The increase in this risk is very slight, although it is three times higher in women than in men and in women it is magnified by oral contraceptives. The risk is also increased in both men and women by the known risk factors, such as high blood pressure, diabetes, high cholesterol, smoking, and other.

A recent study by Stephanie Nahas and other neurologists at Thomas Jefferson University in Philadelphia discovered that aura carries another risk. A study of 139 patients admitted for stroke evaluation showed that those who had a history of migraine aura had a much larger stroke than those without. This is another reason for people who suffer from migraines with aura (or auras without a migraine) to take all possible measures to reduce their risk of strokes. These might include regular exercise, healthy diet, controlling blood pressure, blood glucose, and cholesterol. Some people could also benefit from a daily dose of aspirin (make sure to check with your doctor first), omega-3 fatty acids, and in people with high homocysteine levels, vitamin B12 and other B vitamins.

Bipolar disorder and other psychiatric problems are 2-3 times more common in those who suffer from migraine headaches and migraines are 2-3 times more common in patients with mental illness. Those who suffer from migraines are very familiar with the attitude of doctors, family members and employers who consider migraine to be just another headache, meaning that it is not something that should stop you from doing any activities. Some doctors still blame migraine sufferers for their condition and think that this is a problem of neurotic women. People with mental illness face even more severe discrimination from doctors and everyone else. A very good article on this topic, “When Doctors Discriminate” has appeared in the New York Times this Sunday.

Dr. Robert Shapiro of the University of Vermont recently presented a study which looked at attitudes toward patients with migraine, epilepsy and other conditions. It was an internet-based survey of 705 individuals that examined the levels of stigma by asking following questions:
How comfortable would you be with Jane as a colleague at work?
How likely do you think it is that this would damage Jane’s career?
How comfortable would you be with the idea of inviting Jane to a dinner party?
How likely to you think it would be for Jane’s husband to leave her?
How likely do you think it would be for Jane to get in trouble with the law?

Scoring ranged from 0 to 100. The mean scores were very similar for migraine, panic disorder, and epilepsy and were all significantly greater than for asthma. He concluded that migraine carries as much stigma as epilepsy or panic disorder, although he noted limitations.

Another group of researchers from Philadelphia led by Dr. William Young interviewed 123 patients with episodic migraine, 123 with chronic migraine, and 62 with epilepsy for levels of stigma as perceived by these patients.

Chronic migraine patients had much higher scores on the Stigma Scale for Chronic Illness (SSCI) than the other two groups, but that seemed to be due to chronic migraine patients’ reduced ability to work.

Dr. Young reported that migraine patients reported more “internalized” stigma, that is negative attitudes in themselves or anticipation that others would think negatively of them, and less actual discrimination on the basis of their illness, compared with the epilepsy patients.

These studies and the New York Times article indicate a great need for educating both doctors and the general public about the nature of chronic migraines and mental diseases and for combating the stigma associated with these conditions.

Auditory hallucinations can be associated with chronic headaches, according to a report by our own Dr. Sara Crystal and three other neurologists from the Bronx.

These four doctors reported on 7 of their own patients and also described 8 patients previously reported in the medical literature. Half of the patients had migraine with aura. Regarding hallucination content, the most common sound was distinct human voices in 8 patients, followed by hearing crickets in 2, and ringing bells in another 2, general white noise, also in 2, and repetitive beeping in 1. Regarding timing, 12 experienced hallucinations along with the headache while 3 heard sounds prior to attacks. The duration of the auditory hallucinations was less than one hour but occasionally lasted 4-5 hours or for the duration of the headache. Ten patients had either a current or previous psychiatric disorder, mostly depression. Improvement in both headaches and auditory hallucinations occurred both spontaneously and when prophylactic medications were used, which included propranolol, topiramate, and amitriptyline.

In conclusion, auditory hallucinations are uncommon, but do occur before or during migraine attacks. They usually feature the sound of human voices. Because these are unusual manifestations of migraine, doctors should consider other possible causes, such as a brain tumor, epilepsy, or schizophrenia.

The vascular theory of migraine suggested that changes in the blood vessel size and blood flow were responsible for the development of migraine attacks. This theory went out of fashion and for the past 20 years most headache experts thought that the process of migraine begins in the brain and not blood vessels. A new study by researchers at the University of Pennsylvania seems to again implicate blood vessels as the culprit.

Brain is supplied by four blood vessels that come up from the neck into the brain – two carotid and two vertebral arteries. At the base of the brain they connect with each other making a circle of Willis. Thomas Willis was a 17th century English physician who first described this circle. This circle ensures good blood flow to the brain even if one or even two of the four blood vessels become occluded. Only a third of the population actually has a complete circle connecting all four arteries, while in the rest the circle is incomplete.

This is not a new finding – a group of French physicians reported this discovery in 2009. However, the current study showed that having incomplete circle affected cerebral blood flow and this may be contributing to the process of triggering migraines.

This abnormality appears to be particularly common in those who have migraine with aura. The study looked at 170 people from three groups – a control group with no headaches, a group that had migraine with aura, and a group that had migraine without aura. An incomplete circle of Willis was more common in people with migraine with aura (73 percent) and migraine without aura (67 percent), compared to a headache-free control group (51 percent).

One of the authors commented that “People with migraine actually have differences in the structure of their blood vessels — this is something you are born with” and, “These differences seem to be associated with changes in blood flow in the brain, and it’s possible that these changes may trigger migraine, which may explain why some people, for instance, notice that dehydration triggers their headaches.” A very interesting observation was that “Abnormalities in both the circle of Willis and blood flow were most prominent in the back of the brain, where the visual cortex is located. This may help explain why the most common migraine auras consist of visual symptoms such as seeing distortions, spots, or wavy lines”. It is also possible that the increased risk of strokes in patients with migraine with aura is due to this anatomical defect.

It is most likely that having an incomplete circle of Willis is only one of many predisposing factors. Unfortunately, we cannot do much about this congenital abnormality, but we do have many ways to prevent migraine headaches even without fixing this problem directly.

Art credit: JulieMauskop.com

It is a well established fact that migraine sufferers are 2-3 times more likely to develop anxiety and depression. The reverse is also true: if you suffer from anxiety and depression, you are 2-3 times more likely to develop migraine headaches. These associations are called comorbidities. Anxiety and depression are also comorbid with other pain syndromes. A group of Dutch researchers examined records of almost 3,000 patients with anxiety and depression to look for the presence of comorbid migraines and pain in the back, neck, face, abdomen, joints, and chest. All patients were interviewed twice, with a two year interval, and were asked if they had any of those pains in the preceding 6 months. Their results, published in The Journal of Pain, clearly show that having anxiety and depression increases the risk of developing migraines and other pain syndromes equally. So, this association is not specific to migraines, but applies to all pain syndromes. This means that anxiety and depression do not cause headaches and pain and the other way around. Most likely, one condition predisposes the sufferer to develop the other. It is also likely that shared genetic predisposition or the involvement of certain brain chemicals that are involved in both pain and depression, such as serotonin, adrenalin, and other, may be responsible for these associations.

Tension and migraine headaches are the 2nd and 3rd most common medical problem in the world after dental caries (cavities), according to a new study conducted by the World Health Organization (The Global Burden of Disease Survey 2010) and reported in the journal Headache. Tension-type headaches affects 20.1% of the world’s population and migraine, 14.7%. Migraine is the 7th most disabling of all medical conditions. Migraine sufferers spend more than 5% of all of their time having pain and other symptoms of this condition. Migraine is by far the most disabling of all neurological condition. Hundreds of millions of people in the world suffer unnecessarily from headaches. This is in part due to lack of awareness of the extent, the severity, and the impact of headaches, but also due to limited resources. The National Institutes of Health in the US allocates very little money to researching headache disorders and a disproportionally large amounts on neurological conditions such as epilepsy, MS, Parkinsons, and other. I am not suggesting that these other condition do not deserve to be studied, but suffering by many more people would be relieved by investing more money in headache research.

Art credit: JulieMauskop.com