Symptom Management

MS and Headaches

By Daniel Kantor, M.D.

Do headaches cause MS, does MS cause headaches, or is there another link (or none at all)? These are questions that clinicians and researchers interested in the intersection between headache and MS are trying to answer, but they are also questions that many people with MS face on a regular basis.
 A recent article by German researchers and neurologists in Brain and Behavior reinvigorated the debate by reporting that 78 percent of 50 patients seen for early MS had a recent headache at the time of evaluation. The relatively small number of people with early MS and clinically isolated syndrome in this study, the unclear lag from first MS symptom to onset of headache, and the lack of information on each person’s prior headache history, raise questions about whether this study can be used to argue that headaches are an early MS symptom or not.
Why does it matter if headache is an MS symptom?
It isn’t purely an academic exercise of whether MS causes headaches (after all, MS can cause lots of different symptoms). But if headaches can be counted as an initial (and later) MS symptom, then there are a number of important consequences:
  1. People who are currently labeled as having radiologically isolated syndrome (people who have MRIs that look like MS, but experience no symptoms) who have a certain type of headache, could then be diagnosed as MS or clinically isolated syndrome.
  2. MS disease-modifying therapies may be offered to people earlier. An overwhelming amount of data has shown that while treating MS later is good, treating it as early as possible is even better.
  3. If someone with MS has a certain type of headache then this could be interpreted as breakthrough disease activity, which could have implications for switching MS DMTs.
Is there an MS-specific headache?
It remains unclear whether headache is a symptom of MS – it appears that for some people, headaches can be an MS symptom. The problem is that it is hard to know whether an individual headache is an MS symptom for an individual person with MS.
It did appear that a lot of the people in the study had headaches that had migraine features. Migraines are common (approximately 40 million Americans have migraines), while more than 99 percent of the U.S. population has “ever had a headache.” MS, while not common, is also not rare – research presented at the European Committee for Treatment and Research in MS annual meeting in Paris in October 2017, increases the estimate to close to a million people in the United States who have MS. Many people with MS may have migraines simply because they have one uncommon diagnosis – MS – and one common one – migraine.
 So, everyone with a migraine has a headache, but not everyone with a headache has a migraine. There are many other types of headaches. Some people with migraines also happen to have MS and some people with MS have migraines. Sometimes this is simply coincidental, but sometimes the MS itself may be to blame for the migraines.
What is a migraine?
Migraines are a type of primary headache disorder (meaning that they are not generally thought to be caused by something else, like a mass) where a person has headaches that are usually on one side of the head, although the side may change and they may be on both simultaneously. They are usually moderate to severe in intensity, last for longer than four hours if not treated, get worse with activity, feel throbbing and pulsating or are duller or more stabbing. The migraine headache is also accompanied by nausea and/or difficulty with light and loud noises.
 While some people have warning signs  for migraines – often sparkling lights or other visual symptoms, called “auras” – this is less common. Migraines without auras are called “common migraines,” while migraines with auras are called “classic migraines.”
Recent research suggests the role of calcitonin gene related peptide (CGRP) as a chemical messenger that is elevated in migraines, and medications that bind to CGRP or its receptors are being evaluated by the Food and Drug Administration as migraine specific treatments.
Does the recent article answer the question about whether headache is an MS symptom?
Unfortunately, the recent article by Gebhardt and colleagues does not offer a definitive answer to the question of whether there is an MS-specific headache that can be counted as an MS symptom. The article does make a compelling case for the need for more research so that people with MS and their doctors have more information in the future.