Are migraines a common symptom of fibromyalgia for you?
The Relationship Between Migraine and Fibromyalgia
Written by: Kylie Gagan, RN, BSN
Medically Reviewed by: Dr. Jessica Ailani
Edited by: Melissa Calise and Leigh Serth
What is Fibromyalgia?
Fibromyalgia (FM) is a chronic condition that causes widespread pain, primarily affecting the muscles, bones, and joints. People with this disease experience a hypersensitivity to both painful and non-painful stimuli. People may experience other associated symptoms, such as sleep disturbances, brain fog, memory impairment, headache, fatigue, and numbness and tingling in the extremities. It is often comorbid with anxiety and/or depression. It is unknown why fibromyalgia occurs, but it is believed to be a disorder of abnormal pain regulation and central sensitization. The central nervous system, which includes the brain and the spinal cord, may be hyperactive or overly sensitive to stimuli.
FIBRO = fiber, MYALGIA = muscle pain
How are Fibromyalgia and Migraine Related?
A large epidemiological study found, “a 55.8% prevalence of migraine among fibromyalgia patients, while other studies showed the prevalence of fibromyalgia in migraine patients to be over 30%.”1
It is unclear if migraine triggers fibromyalgia or fibromyalgia triggers migraine, but some cases have been made for both.
Migraine triggering fibromyalgia: One belief is that repeated headaches in patients with migraine may change the way neurons respond to painful stimuli and cause spontaneous neural activity in the central nervous system, therefore increasing the chances of developing fibromyalgia.2
Fibromyalgia triggering migraine: In the beginning stages of fibromyalgia, musculoskeletal pain appears in the neck and shoulder region which may activate painful sensory stimuli and transmit pain impulses through the upper cervical spinal nerves and into the trigeminal nucleus caudalis thereby triggering a migraine attack.2
Commonalities Between Migraine and Fibromyalgia
Both conditions are associated with abnormal levels of serotonin and norepinephrine. The underlying pathophysiology may be similar among those with migraine and fibromyalgia, as both conditions respond to medications that increase serotonin and norepinephrine levels, such as SNRIs. Also, both conditions are commonly comorbid with anxiety and depression, which are also associated with lower neurotransmitter levels.
Central sensitization is a state where the central nervous system (brain and spinal cord) is hypersensitive to stimuli. This manifests in migraine disease, where many people experience light and sound sensitivity, and in fibromyalgia, where people experience widespread pain and sensitivity to touch. Additionally, allodynia or pain caused by a stimulus that wouldn’t usually cause pain is a characteristic of both fibromyalgia and migraine.
Fibromyalgia and Tension-Type Headache
Tension-type headache typically presents as a pressure or squeezing pain across the forehead, on the sides of the head, and/or in the back of the head to the neck. The pain is usually bilateral, occurring on both sides. Some people describe the feeling as a tight band around their head. “Tension-type headache was the most common primary headache associated with FM, with a 59.01% prevalence.”3 It is unclear why tension headaches occur so commonly with fibromyalgia, but two common triggers are stress and stiff neck muscles.
Diagnosis and Treatment of Fibromyalgia and Migraine
Neither migraine nor fibromyalgia has tests that allow for a definitive diagnosis. They are both diagnosed by a health care provider through physical examination, history-taking, laboratory tests, and exclusion of other diseases. Diagnosis of fibromyalgia is likely if the person is sensitive in at least 11 of the 18 tender points in the body and experiences widespread pain in all four quadrants of the body. The four quadrants include the right and left sides of the body above the waist and the right and left sides below the waist. When a physician presses on these 18 tender points, a person with fibromyalgia may feel pain, while a person without the condition would feel pressure.
Tricyclic antidepressants like amitriptyline are commonly used as the first-line treatment for fibromyalgia and are used as second-line medications for migraine. Muscle relaxers such as cyclobenzaprine are also commonly used for fibromyalgia. If one therapy alone is not effective, then combination therapy is explored with SSRIs, SNRIs, nerve pain medications, tricyclic antidepressants, and/or anticonvulsants. A health care provider will determine which combination of medications is most effective for the patient. Interestingly, SNRIs, tricyclic antidepressants, and anticonvulsants are all used as preventive medications for migraine as well. Magnesium is also commonly used as a preventive medication for migraine and is also used for fibromyalgia. It’s been found that low levels of magnesium can exacerbate fibromyalgia symptoms.2 An interesting discovery by researchers is that “people who do not respond to standard migraine treatments often also have FM.”2
Other therapies for fibromyalgia and migraine may include trigger point injections with anesthetics, onabotulinumtoxinA, and/or steroids. A person with fibromyalgia may require a referral to a dietician due to numerous food intolerances that often occur in those with this condition. It is important that those with fibromyalgia and migraine have a regular sleep routine, meaning they go to bed and wake up at the same times each day. Patients should abstain from using their phones and watching TV before bed, and avoid caffeine, exercise, and alcohol after 5 p.m. Regular, mild-to-moderate intensity exercise is beneficial. Consulting a physical therapist can help develop a customized exercise plan that is beneficial for fibromyalgia patients who have increased pain with activity. Routine exercise is also recommended for migraine, although for some it may cause increased head pain, so it may take trial and error to find the right types and intensity of exercise.
What Type of Doctor Should I See for Migraine and Fibromyalgia?
Migraine is best treated by a clinician who specializes in headache medicine. A rheumatologist is the preferred specialist for the diagnosis and treatment of fibromyalgia. As with migraine, many primary care physicians and neurologists can diagnose and treat FM. Also, a psychiatrist or psychologist may be useful to help combat the anxiety and depression commonly seen in both conditions. A physical therapist may be involved to help with creating an exercise plan for those with fibromyalgia and/or migraine.
Overlapping Comorbid Conditions
In addition to depression and anxiety, fibromyalgia and migraine are also commonly comorbid with chronic fatigue syndrome, rheumatoid arthritis, systemic lupus erythematosus, irritable bowel syndrome, Raynaud’s phenomenon, interstitial cystitis, vulvodynia, obesity, and endometriosis.
A Note to Patients and Providers
It is important for physicians to screen those living with migraine disease for fibromyalgia and vice versa. It may be helpful for physicians to use a symptom-based screening tool to assess for overlapping conditions. Signs and symptoms of migraine should be reported to a provider if they occur. More research is needed for fibromyalgia; therefore, those with the condition are encouraged to enroll in clinical trials by routinely checking clinicaltrials.gov.
References
Giamberardino, M.A., Affaitati, G., Martelletti, P. et al. Impact of migraine on fibromyalgia symptoms. J Headache Pain 17, 28 (2016). https://doi.org/10.1186/s10194-016-0619-8
Penn, I. W., Chuang, E., Chuang, T. Y., Lin, C. L., & Kao, C. H. (2019). Bidirectional association between migraine and fibromyalgia: retrospective cohort analyses of two populations. BMJ open, 9(4), e026581. https://doi.org/10.1136/bmjopen-2018-026581
