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The Fibromyalgia and Migraine Comorbidity

The Fibromyalgia and Migraine Comorbidity

When the serpentine grip of a migraine begins to tighten around her head, Carol Harrison reacts swiftly.

The 52-year-old outdoor and motorcycling enthusiast tosses back a cup of coffee, takes medication for the pain and crawls back into bed, hopeful a four-hour retreat into darkness will leave her with nothing more than a migraine hangover. Every now and again one sneaks up on her, but she can usually stave them off with her coping strategies—strategies she has honed since the onset of her tension- and allergy-triggered migraines in puberty.

But the migraines are hardly the worst of it, she says. In December 2010, Harrison was also diagnosed with fibromyalgia—the full-body pain condition—after a bout of shingles left her with lingering hip pain that spread to other parts her body. Now, the muscle tension that her fibromyalgia brings has a direct impact on her propensity for migraines.

“I’m just day-to-day,” she says. “I’m just maintaining, but not getting any real relief.”

Harrison is among an unlucky subgroup of migraineurs who suffer from fibromyalgia, a painful one-two punch that can lead to excruciating discomfort and a compromised quality of life. Harrison has curbed her once-active lifestyle. She can no longer work a 40-hour week at her job with a telecommunications company.

“It has really restricted my activity,” says the Kansas City, Mo., native. “It totally debilitates you in every way.”

Fibromyalgia affects roughly 5 million American adults. Women suffer in disproportionate numbers—as many as 90 percent of those diagnosed are female—and most are in middle age. The cause is murky, but studies indicate that about half of those with fibromyalgia reported its onset after an illness or trauma. Those with a close relative with fibromyalgia have an increased chance of being diagnosed, as do those with pre-existing conditions such as rheumatoid arthritis or lupus.

While symptoms of fibromyalgia can number in the hundreds, the most commonly reported are muscle and joint aches and pains, fatigue, sleep disturbances, irritable bowel syndrome and sensitivity to noise, light and sound.

Fibromyalgia-Migraine Coincidence or Connection?

Some studies show that as many as 75 percent of treatment-seeking fibromyalgia sufferers, like Harrison, also experience migraines, myofascial headaches or tension headaches. While the link between the conditions is tenuous, it may be more than a coincidence.

“The ‘migraine brain’ is just more sensitive to various stimuli,” says Morris Levin, MD, a pain management specialist and co-director of the Head- ache Center at Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H. A dog barking? A strong odor? A change in weather? “They are the first ones to notice it,” he says.

The pain of a migraine arises from the inflammation of arteries on the surface of the brain, a process known as cortical spreading depression, marked by surges of ionic activity followed by lulls.

“It is something that happens to all brains,” Dr. Levin says, “but people with migraines have a much higher propensity for this electrical phenomenon.” Dr. Levin sees patients from all over New England reporting a wide array of headaches, but migraines are the most common. Dr. Levin declined to estimate how many of his migraine patients also reported having fibromyalgia, but he did acknowledge that co-occurrences were an unfortunate reality for some.

“A lot of us believe that any pain condition lowers the threshold for another pain condition,” Dr. Levin says. Pain, he explains, is essentially a signal telling us to do something, such as pulling a hand out of a fire. It’s meant to signal impending damage. It starts in the skin, the organs, the nerves—the signals are received, travel up the spinal cord, and ultimately to the brain, and then? Ouch.

“It’s a good system,” he says, “until it acts with no real reason.”

And therein lies the confusion for patients and researchers: They know something is wrong, but the precise “how” and “why” are elusive. It’s not clear one way or the other whether there is a connection, despite all the evidence. “It’s a tough issue,” says Brian Walitt, MD, a rheumatologist at the Washington Hospital Center and director of the Fibromyalgia Evaluation and Research Center at Georgetown University Medical Center in Washington, D.C.

Evidence of a Link Between Fibromyalgia and Migraine?

Dawn Marcus, MD, a professor at the University of Pittsburgh Medical Center specializing in fibromyalgia and migraines, conducted a study that shows strong evidence of a link between the two maladies. Published in the journal Clinical Rheumatology in 2005, the study examined 100 treatment-seeking fibromyalgia patients at the university’s Pain Evaluation and Treatment Institute.

The results were stark: Only 24 percent of the patients evaluated said they did not have troublesome headaches. Among 100 transformed migraine patients evaluated, 36 percent had fibromyalgia. Of 70 migraineurs tested, about 40 percent of those reported a significant number of the physical tender points consistent with that of fibromyalgia. “It was really surprising that most of them did have headaches. Most of those were migraines,” Dr. Marcus says. “There really seemed to be a link between a migraine and fibromyalgia.”

Numerous studies have indicated that fibromyalgia patients have an elevated level of what is known as “substance P,” a neuropeptide thought to be a major player in pain transmission. It has also been studied as a possible source of pain associated with migraines.

Fibromyalgia, migraines, depression, anxiety and other conditions have been linked to low levels of serotonin, a neurotransmitter often associated with mood regulation. Yet Dr. Walitt cautions against pinning the cause on one thing—substance P, serotonin or other deficiencies—in patients with fibromyalgia as well as migraines, as the root causes are more complex than one trigger. “I would shy away from over-emphasizing those types of results,” he says. In other words, substance P and serotonin theories are inconclusive, and pinning the conditions on one or the other could be shortsighted.

While Dr. Walitt says he did not know of a universally accepted study on a possible connection, he contends that the headaches fibromyalgia patients experience tend to be worse than the headaches among those without fibromyalgia. “The way they talk about their headaches, it seems to be more distressing,” he says.

Living in Uncertainty

Migraines are tricky to diagnose in fibromyalgia patients, especially those who are not in treatment. The patients might have a battery of symptoms labeled as migrainous, but they don’t do well with migraine medication, Dr. Walitt says.

Many of his patients have symptoms consistent with migraines, such as light sensitivity, but the pain “doesn’t have the same migrainous course,” he says. Experiencing one or several triggers that might set a migraine in motion doesn’t necessarily follow a similar pattern in those with fibromyalgia. “They are adding to the misery,” Dr. Walitt says, “but they are not the overriding misery.”

Fibromyalgia patients “tend to have this nervous system that is more sensitive to pain stimuli,” says Dr. Marcus. Like migraineurs, “they tend to identify pain earlier and perceive things as painful quicker.” And for those who suffer from both migraines and fibromyalgia, the former tends to have an earlier onset.

Another link between headaches and fibromyalgia is a common comorbidity: depression. In addition to her full-body pain, Harrison has battled depression since her 20s. “A very large percentage of the patients have depression or anxiety and receive treatment for them,” Dr. Levin says of migraineurs in his practice.

Dr. Marcus’s fibromyalgia and headache study showed that among treatment-seeking headache patients, depression was found in 46 percent, and anxiety in 39 percent. About one-third of fibromyalgia patients studied had major symptoms of both depression and anxiety.

Tricyclic antidepressants have been used in treating both fibromyalgia and headaches, specifically migraines, but they are not a cure-all. Other approaches include physical therapy, massage, acupuncture and aerobic exercise. “The therapies are not wonderfully effective,” Dr. Wallit says. “The headaches that are treated in these fibromyalgia approaches are just a symptom of the fibromyalgia patient.” Headaches, he says, are not treated as a separate diagnosis, but as just one symptom on the laundry list, not any more or less significant than the others.

In Harrison’s case, some of the non-pharmacological treatments, such as exercise, aren’t a viable option because they could also exacerbate pain. And her yearlong, twice-a-day regimen of taking 50 milligrams of the antidepressant Sabella, a selective serotonin reuptake inhibitor, hasn’t helped much either.

Harrison has been receiving treatment from her general practitioner since her fibromyalgia diagnosis, but she thinks it’s time to enlist the help of a specialist. As for whether her fibromyalgia is in some way connected to her migraines? “I’m not certain it’s not,” she says. “Your nerves are just hypersensitive.”

The cause is uncertain. The treatment is elusive. And life with both conditions is unmanageable for so many. “I’m depressed, frankly, and I don’t see any way out of it,” she says. But if there is any good news to come from this possible connection, it is that the research for a cure to both conditions continues.

Symptoms in Common

Fibromyalgia and migraines share a number of symptoms and triggers, including:

  • Feeling as though you are in a fog
  • Numbness in extremities
  • Sensitivity to light, sound and touch
  • Pain instigated or exacerbated by and during menstrual periods
  • Average onset in adulthood
  • More common in women
  • Stress-triggered
  • Comorbidity with depression

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