29 Apr Ask the Expert: Seasonal Changes and Migraine
Question: I dread the springtime because my migraine attacks get more frequent and much worse in intensity. What do you recommend? Is there something I can do to lessen the severity? Thanks, Susan
Answer: Unfortunately allergic rhinitis and asthma are very common comorbidities of migraine. One study revealed that 34% of migraine sufferers also have seasonal allergies (i.e., hay fever). That same study also found that people with allergic rhinitis (the medical term for seasonal allergies) are 14 times more likely to also have migraine headaches.
Migraine is a neurovascular disorder that primarily affects the trigeminal nerve in the face. Both migraine and allergic rhinitis cause an inflammatory reaction of the trigeminal nerves surrounding the nasal and ocular (i.e, eye) areas of the face. In fact, approximately 45% of patients with migraine report at least 1 ocular or nasal symptom with their migraine headaches. In another study, 67% of migraine patients reported rhinitis symptoms. These cranial autonomic symptoms may include nasal congestion, clear rhinorrhea (i.e., nasal drainage), itchy nose, red or watery eyes, or sinus pain and pressure. Thus activation of the inflammatory response triggered by seasonal allergies could also activate the migraine generator.
Therefore, Susan, it is very common to have an increase in frequency, severity, and duration of migraine attacks during spring when pollen counts are high. This is why migraine is commonly misdiagnosed as ‘sinus’ headache. Multiple studies have shown that people diagnosed with ‘sinus’ headache are actually suffering from the neurologic condition called migraine. Yet, they never receive migraine treatment without the correct diagnosis.
We have several recommendations for your dreaded springtime migraine attacks. First, make sure your headache specialist is aware of your increase in frequency and severity of migraine attacks. A headache diary is the best way to track your migraine attacks, record your symptoms and treatments, and your response to attack medications. Your provider needs this information so he/she can optimize your treatment plan.
You need a migraine prevention medication with proven efficacy (Level A evidence is best). This would include antiepileptic medications, like sodium valproate and topiramate, or beta-blockers, like propranolol, metoprolol, or timolol. Onabotulinum toxin A is an injectable medication that is approved for prevention in chronic migraine. Calcitonin gene-related peptide antagonists are the only migraine-specific medications that have been FDA-approved for the prevention of migraine. These include erenumab, galcanezumab, fremanezumab, and eptinezumab.These are monthly or quarterly injections that can be administered at home or in the clinic.
Additionally, if you suffer from allergies and/or asthma, it is important that you are being treated for these conditions as well. You can monitor the pollen in your area on an app on your phone. Nasal corticosteroids, montelukast, and antihistamines have been shown to be useful in treating allergic rhinitis. Many of these can be found over-the-counter. Immunotherapy with allergy shots or sublingual immunotherapy can be obtained by referral to an asthma and allergy specialist. There have been some uncontrolled studies suggesting that in patients with both allergic rhinitis and migraine, treatment with immunotherapy may decrease the frequency of migraine attacks by as much as 52%.
Another key in migraine treatment is the attack plan. If your headaches are more frequent or severe, they may be less responsive to treatment even with good prevention on board. Migraine affects the gastrointestinal system causing gastroparesis. This leads to delayed absorption and response to oral medications used at the onset of a migraine headache. Headache specialists have many options now for treatment that either enhance the GI absorption of oral medications or completely bypass the GI system altogether, leading to a more rapid relief of migraine symptoms. This means you can be restored to normal functioning much sooner. Non-oral therapies include neuromodulation devices that have been FDA-cleared for the acute treatment of migraine, as well as injectable and nasal preparations of migraine-specific abortive medications. Many headache specialists will prescribe an evidence-based toolbox approach which includes a combination of medications that work synergistically to abort a migraine attack for a more consistent and sustained pain-freedom response. However, frequent use of attack medications may lead to Medication Overuse Headache which increases the risk of transforming from episodic migraine to chronic migraine, causing more disability. Thus, prevention therapies are the cornerstone of optimal migraine treatment.
In conclusion, I would recommend keeping a good headache diary recording the pollen count in your area, along with any nasal or ocular rhinitis symptoms. Make an appointment with your headache specialist immediately to review your headache diary, your prevention plan, and your attack medications. All patients with frequent monthly migraine attacks should be offered both prevention and acute medications to control this very common neurologic condition. Without optimal treatment, disability rates are very high. Migraine is the number one cause of years lived with disability under the age of 50.
For a list of headache specialists in your area, click on our Find a Provider tab.
– Christina Treppendahl, FNP-BC, AQH, MHD
Christina Treppendahl, FNP-BC, AQH, MHD
National Headache Foundation’s Healthcare Leadership Council
Founder and Director of The Headache Center, Ridgeland, MS