Migraine and Gastroparesis

PURPOSEOF REVIEW

Migraine is a chronic and disabling disease affecting a significant proportion of the world's population. There is evidence that gastroparesis, a gastrointestinal (GI) dysmotility disorder in which transit of gastric contents is delayed, can occur in the setting of migraine. This article aims to review recent literature on overlap in the pathophysiology and clinical manifestations of migraine and gastroparesis and highlight management considerations when these disorders coexist.

RECENT FINDINGS

There has been increasing recognition of the importance of the connection between the GI tract and the brain, and mounting evidence for the overlap in the pathophysiology of migraine and gastroparesis specifically. There exists a complex interplay between the central, autonomic, and enteric nervous systems. Studies show that gastroparesis may be present during and between acute migraine attacks necessitating modification of management to optimize outcomes. Gastric dysmotility in the setting of migraine can impact absorption of oral migraine medications and alternate formulations should be considered for some patients. Noninvasive vagus nerve stimulation has been FDA cleared for migraine treatment and is also being studied in gastroparesis. Dysfunction of the autonomic nervous system is a significant feature in the pathophysiology of gut motility and migraine, making treatments that modulate the vagus nerve attractive for future research.

A link between gastrointestinal disorders and migraine: Insights into the gut-brain connection

Background

Migraine is a complex, multifaceted, and disabling headache disease that is often complicated by gastrointestinal (GI) conditions, such as gastroparesis, functional dyspepsia, and cyclic vomiting syndrome (CVS). Functional dyspepsia and CVS are part of a spectrum of disorders newly classified as disorders of gut–brain interaction (DGBI). Gastroparesis and functional dyspepsia are both associated with delayed gastric emptying, while nausea and vomiting are prominent in CVS, which are also symptoms that commonly occur with migraine attacks. Furthermore, these gastric disorders are comorbidities frequently reported by patients with migraine. While very few studies assessing GI disorders in patients with migraine have been performed, they do demonstrate a physiological link between these conditions.

Objective

To summarize the available studies supporting a link between GI comorbidities and migraine, including historical and current scientific evidence, as well as provide evidence that symptoms of GI disorders are also observed outside of migraine attacks during the interictal period. Additionally, the importance of route of administration and formulation of migraine therapies for patients with GI symptoms will be discussed.

Methods

A literature search of PubMed for articles relating to the relationship between the gut and the brain with no restriction on the publication year was performed. Studies providing scientific support for associations of gastroparesis, functional dyspepsia, and CVS with migraine and the impact these associations may have on migraine treatment were the primary focus. This is a narrative review of identified studies.

Results

Although the association between migraine and GI disorders has received very little attention in the literature, the existing evidence suggests that they may share a common etiology. In particular, the relationship between migraine, gastric motility, and vomiting has important clinical implications in the treatment of migraine, as delayed gastric emptying and vomiting may affect oral dosing compliance, and thus, the absorption and efficacy of oral migraine treatments.

Conclusions

There is evidence of a link between migraine and GI comorbidities, including those under the DGBI classification. Many patients do not find adequate relief with oral migraine therapies, which further necessitates increased recognition of GI disorders in patients with migraine by the headache community.

No Gastrointestinal Dysmotility in Transgenic Mouse Models of Migraine

OBJECTIVE

To determine whether transgenic mouse models of migraine exhibit upper gastrointestinal dysmotility comparable to those observed in migraine patients.

BACKGROUND

There is considerable evidence supporting the comorbidity of gastrointestinal dysmotility and migraine. Gastrointestinal motility, however, has never been investigated in transgenic mouse models of migraine.

METHODS

Three transgenic mouse strains that express pathogenic gene mutations linked to monogenic migraine-relevant phenotypes were studied: CADASIL (Notch3-Tg88), FASP (CSNK1D-T44A), and FHM1 (CACNA1A-S218L). Upper gastrointestinal motility was quantified by measuring gastric emptying and small intestinal transit in mutant and control animals. Gastrointestinal motility was measured at baseline and after pretreatment with 10 mg/kg nitroglycerin (NTG).

RESULTS

No significant differences were observed for gastric emptying or small intestinal transit at baseline for any of the 3 transgenic strains when compared to appropriate controls or after pretreatment with NTG when compared to vehicle.

CONCLUSIONS

We detected no evidence of upper gastrointestinal dysmotility in mice that express mutations in genes linked to monogenic migraine-relevant phenotypes. Future studies seeking to understand why humans with migraine experience delayed gastric emptying may benefit from pursuing other modifiers of gastrointestinal motility, such as epigenetic or microbiome-related factors.

Prevalence and pathophysiology of post-prandial migraine in patients with functional dyspepsia

Background

Migraine is a condition frequently associated with gastrointestinal disorders. Previous reports have shown the relationship between irritable bowel syndrome and migraine, but no data are yet available in patients with functional dyspepsia. We therefore evaluated whether alteration of gastric sensorimotor activity may be related to migraine.

Methods

Sixty patients affected by functional dyspepsia, 38 with postprandial distress syndrome and 22 with epigastric pain syndrome were enrolled in a cohort study. Presence and severity of dyspeptic symptoms, migraine presence and severity, gastric sensitivity thresholds during fasting and postprandial period, gastric accommodation and gastric emptying time were evaluated.

Results

In epigastric pain syndrome, 12/22 (54%) patients suffered from migraine and this condition was never correlated with meal ingestion. In postprandial distress syndrome patients, 29/38 (76%) suffered from migraine, in 26/29 (89%) its onset was considered as meal-related, and migraine severity was significantly correlated with postprandial modification of the gastric discomfort threshold (r = −0.73; p < 0.001). In patients with postprandial distress syndrome, in the subgroup with moderate to severe migraine, the severity of fullness and early satiation was significantly higher than in patients with mild or absent migraine. In patients with moderate to severe migraine, gastric accommodation, sensitivity thresholds and gastric emptying time were similar to patients with mild or no migraine.

Conclusions

In patients with functional dyspepsia and postprandial symptoms, migraine is a very frequent comorbidity. On clinical grounds, it is associated with an increased severity of fullness and early satiation and, on pathophysiological grounds, it seems correlated with postprandial hypersensitivity.

Infrequent or Non-Response to Oral Sumatriptan does not Predict Response to Other Triptans—Review of Four Trials

A migraineur can claim to be an infrequent responder (‘non-responder’) to an oral triptan independent of which triptan he or she is presently using. Four trials of an alternative triptan (zolmitriptan/rizatriptan; eletriptan; naratriptan; almotriptan) in patients with a history of infrequent response to oral sumatriptan were compared and contrasted in terms of study design, patient characteristics, and efficacy and tolerability of the triptan under investigation. Unfortunately, none of the reported studies used an appropriate parallel design, which would have had the non-responding triptan (oral sumatriptan) in one arm and without encapsulation. While the four trials differed in terms of study design (open-label vs. placebo-controlled), definition of sumatriptan ‘non-responder’ (retrospective vs. prospective) and pain intensity at baseline (30% severe to 70% severe), all four demonstrated that lack of response to sumatriptan did not predict lack of response to an alternative triptan. Changing triptans resulted in 2-h pain-relief rates of 25–81% in patients with a history of poor response to sumatriptan. It can be concluded that migraine patients who respond infrequently to sumatriptan should be switched to a different triptan, as lack of response to one triptan does not predict likelihood of responsiveness to another. A review of the available evidence suggests that almotriptan may be one of the most appropriate choices for an alternative triptan.

Subcutaneous Sumatriptan Provides Symptomatic Relief at any Pain Intensity or Time During the Migraine Attack

Over the years the paradigm of treating early during the migraine attack has become well established in clinical practice. It is also recommended that the 5-HT1B/1D agonists be administered early during the migraine attack for efficacy. This is because it has been proposed that most migraineurs are less responsive to delayed treatment, owing to the development of central sensitization of the pain transmission. The main objective of this prospective, cross-over study at a specialist clinic was to evaluate if these recommendations should also apply to the subcutaneous formulation of sumatriptan. Results are based on 20 adult International Headache Society migraineurs. Two attacks ( n = 40) were treated with 6 mg subcutaneous sumatriptan as early as possible after the onset of migraine headache and two attacks ( n = 40) as late as the patients could bear. The median intra-individual difference between the two strategies in time from first occurrence of pain to injection was 5.7 h and the median intra-individual difference in pain intensity at the time of injection was 29 visual analogue units. No significant differences were found in time to freedom from pain, pain severity at 1 and 2 h, area under the curves from injection to pain free or in headache recurrence after injection. At the end of the study, most of the patients claimed that their medication was as effective when given early as when given late in the course of the attack. The discrepancy between our present findings and retrospective analyses of trials on oral triptans probably has more to do with the less disturbed pharmacokinetics early during the migraine attack than with central sensitization. Consequently, we recommend nonoral formulations of triptans, which do not necessarily have to be administered early during the migraine attack to provide efficacy. In conclusion, it is reassuring for migraineurs that it is worthwhile taking their medication in an appropriate formulation even if they have not been able to do so early in the course of the attack.

Delayed absorption of many (paracetamol, aspirin, other NSAIDs and zolmitriptan) but not all (sumatriptan, rizatriptan) drugs during migraine attacks and most likely normal gastric emptying outside attacks. A review

Background In most pharmacokinetic studies, the oral absorption of drugs is impaired during migraine attacks but exceptions occur. A study on gastric emptying using gastric scintigraphy indicated that gastric stasis also occurs interictally in migraine. These studies were reviewed critically. Results In seven studies, mainly investigating NSAIDs and analgesics, the early absorption of the drugs during 112 migraine attacks was delayed. The absorption of sumatriptan is usual in therapeutic doses, and rizatriptan was normal during 131 migraine attacks. The interictal gastric stasis observed using gastric emptying scintigraphy (GES) with solids ( n = 13) could not be confirmed in a larger study ( n = 27) using the same method. Also gastric emptying measured with GES with liquids ( n = 7) and epigastric impedance ( n = 64) was normal outside migraine attacks. Conclusions and possible clinical implications Drug absorption is not generally impaired during migraine attacks. Gastric emptying is most likely normal in the majority of migraine patients outside attacks. Prokinetic and antiemetic drugs such as metoclopramide and domperidone should not be routinely combined with oral analgesics or oral triptans. If, however, nausea is severe or vomiting occurs, treatment with an antiemetic with proven efficacy on the nausea of migraine can be indicated.

The influence of thiethylperazine on the absorption of effervescent aspirin in migraine

The absorption of effervescent aspirin was studied in three groups of patients during attacks of migraine. The first group received intramuscular thiethylperazine 10 min before effervescent aspirin; the second group received intramuscular metoclopramide 10 min before effervescent aspirin; and the third group received effervescent aspirin alone. Where possible each patient was retested when headache-free but under conditions which were otherwise as similar as possible to those during the acute attack. Intramuscular metoclopramide corrected the impairment of drug absorption that occurred during a migraine attack, whereas thiethylperazine did not. In the group of patients treated with thiethylperazine and aspirin, the impairment of absorption did not correlate with the duration of the symptoms, nor with the severity of the headache and nausea. Patients treated with thiethylperazine and aspirin tended to take longer to recover than those patients treated with metoclopramide and aspirin. However, in the thiethylperazine treated group, the time to recover did not correlate with the salicylate level achieved.

Cutaneous allodynia and migraine: another view

The paradigm of early treatment of the migraine attack at mild pain intensity has become one alternative to circumventing the problem of compromised oral absorption of symptomatic drugs due to migraine-induced gastrointestinal dysmotility. Early treatment also has been proposed to be advantageous because most migraineurs could be less responsive to delayed treatment, owing to the development of central sensitization of the trigeminal pain transmission. Ranking the underlying principles, it seems that the improved response to an oral triptan formulation at mild migraine symptom intensity has more to do with less impaired gastrointestinal absorption in the early stage of the attack than decreasing the time and preventing chances for central sensitization and development of cutaneous allodynia. Furthermore, parenteral administration of a triptan is always more likely to provide relief of symptoms than conventional tablets, even when it is used later in the course of the migraine attack. Individually tailored use of the available triptan formulations will increase, without any doubt, the within-migraineur consistency of response. It also will reduce the overall proportion of migraine attacks or migraineurs not responding to triptan treatment. Notwithstanding, the recommendation of early treatment during the migraine attack when the pain is mild remains valid.

Non-oral formulations of triptans and their use in acute migraine

The introduction of triptans (5-HT (1B/1D) agonists) into clinical practice has expanded the therapeutic options for doctors treating migraine sufferers. The triptans are available in several different formulations such as conventional oral tablets, orally disintegrating wafers, subcutaneous injections, nasal sprays, and suppositories, which provide an excellent opportunity to tailor therapy to individual patients' needs. Although the oral formulations are the most popular with patients, they are not the most appropriate route of administration for drug delivery during the migraine attack. Due to gastrointestinal dysmotility, the intestinal absorption of any triptan administered orally may be impaired and treatment effects become inconsistent. For this reason, triptans preferably should be prescribed in a non-oral formulation (injection, nasal spray, or suppository). Parenteral administration of a triptan is more likely to provide relief of symptoms, even when it is used later in the course of the migraine attack.

Migraine mechanism and management

Migraine affects an estimated 10% to 15% of the population with greater or lesser regularity and throughout much of their lifetime. It causes disability, be it often temporary, and strains personal relationships and professional development. Little is known about it scientifically, and its treatment remains mostly empirical. This article describes the pathogenesis of migraine, as well as its management in terms of abortive and preventive treatment.

Mechanism and management of migraine

Migraine is a condition that affects 10%-15% of the population. Abortive treatment is always indicated because the intense headaches interfere with normal functioning. Preventive treatment is indicated when the headaches exceed 3-4 per month.

Mechanism of migraine and action of antimigraine medications

Dilation and inflammation of cephalic arteries and intracranial extra cerebral arteries cause the migraine headache. The migraine-associated symptoms result from the activation of the sympathetic nervous system caused by the pain. The migraine aura is caused by the neurophysiological phenomenon of spreading excitation/depression. The various mechanisms are tied together in the so-called "parallel theory" of the pathogenesis of the migraine attack. The abortive antimigraine medications act by constricting the dilated arteries through stimulation of the serotonin 1B receptor. The preventive antimigraine medications act by increasing the tone of the extacranial arteries, inhibiting the mechanism of neurogenic inflammation, or inhibiting pain transmission within the central nervous system.

An overview of the diagnosis and pharmacologic treatment of migraine

Migraine, an episodic headache disorder, is one of the most common complaints encountered by primary-care physicians and neurologists. Nevertheless, it remains underdiagnosed and undertreated. Rational migraine treatment necessitates an accurate diagnosis, identification and removal of potential triggering factors, and, frequently, pharmacologic intervention. Effective management also includes establishing realistic expectations, patient reassurance, and education. The choice of medication (abortive, symptomatic) for an acute attack depends on such factors as the severity of the attack, presence or absence of vomiting, time of onset to peak pain, rate of bioavailability of the drug, comorbid medical conditions, and side-effect profile. Effective agents for acute attacks include simple or combination analgesics, nonsteroidal anti-inflammatory drugs, ergot derivatives, selective serotonin agonists, and antiemetics. Opioid analgesics are unnecessary for most patients. The choice of preventive (prophylactic, interval) medication depends primarily on comorbid medical conditions and side-effect profile. Useful preventive agents include beta-adrenergic blockers, calcium channel blockers, tricyclic antidepressants, anticonvulsant medications, and serotonin antagonists.

A correlation between severity of migraine and delayed gastric emptying measured by an epigastric impedance method

1. This study examined the ability of a bioimpedance method to detect the delay in gastric emptying which occurs during attacks of migraine. 2. In 64 non-migraineur control patients and 46 migraine patients outside an attack, gastric emptying rates were within the predicted normal range. 3. In contrast, rates in 14 migraineurs during 20 attacks were delayed during severe or moderate attacks and were significantly correlated with the intensity of headache, nausea and photophobia. 4. The epigastric impedance method was generally well tolerated by patients and appears to merit further investigation as a clinical method of monitoring gastric emptying of liquids.

Effect of migraine attacks on paracetamol absorption

The absorption of effervescent paracetamol (1000 mg) was investigated in nine female patients during a migraine attack and in the same patients when headache free. Migraine attack decreased (P less than 0.05) the areas under the serum paracetamol concentration-time curves (AUC) of 0-2 h, 0-4 h and 0-6 h and the peak serum concentration. The severity of nausea correlated significantly with the decrease in the AUC values. Our results support findings of delayed gastric emptying in migraine attacks. Both a delay and an impairment of drug absorption may follow.

The effect of metoclopramide on the absorption of effervescent aspirin in migraine

1 The absorption of effervescent aspirin was studied in two groups of patients during attacks of migraine. The first group received effervescent aspirin alone whilst the second group received intramuscular metoclopramide before effervescent aspirin. 2 After effervescent aspirin alone there was significant impairment in the rate of aspirin absorption during migraine attacks compared with the rate of aspirin absorption in normal volunteers and in the same patients when headache-free. 3 When metoclopramide was given before effervescent aspirin the rate of aspirin absorption during migraine attacks was not significantly different from that obtained in normal volunteers given effervescent aspirin alone or from that obtained in the patients themselves when given both metoclopramide and effervescent aspirin when headache-free. 4 It is concluded that the impairment of absorption of effervescent aspirin during migraine attacks is related to impaired gastro-intestinal motility with delayed gastric emptying and that this impaired motility can be overcome by parenteral metoclopramide.