It occasions unseemly and dreadful symptoms: nausea, bilious vomiting, collapse, gas in the stomach, eructations, vomiting, palpitations of the heart, vertigo, depression, despair. Sick headache is very common, there is much torpor, heaviness of the head, anxiety and life becomes a burden. For they flee the light. Darkness soothes their disease, nor can they bear readily to look upon or hear anything pleasant. The patients are weary of life and wish to die.
Aretaeus the Cappadocian
Last week, I listened to the writer and stand-up comedian, A.L. Kennedy, talk about her migraines on Radio 4 and was struck by the similarities with IBS. You might wonder how that can be, yet as Aretaeus observed in the first century AD, migraine (hemicrania) encompasses a variety of bodily symptoms. So does IBS. It is little wonder, therefore, that many people diagnosed with chronic fatigue syndrome, fibromyalgia, chronic back ache, functional dyspepsia and many other unexplained illnesses also suffer from migraine and IBS. Moreover, both illnesses share a similar variety of predisposing factors and triggers, have strong associations with stress and psychological disturbance and even exhibit similarities in brain physiology. Like migraine, IBS is more a individual state of being than a stereotypical disease. Bearing all of that in mind, it is not surprising that there is considerable overlap between the two conditions. One recent study showed that IBS occurs in over half the number of patients with migraine, while migraine occurs in little more than a third of the patients with IBS. So maybe we can learn something about IBS by studying migraine.
Like IBS, our understanding of migraine depends on how it is defined. Many clinicians will only diagnose migraine when it conforms to the classical description of a severe headache, that usually affects one side of the head and face, is accompanied by nausea, and preceded by a typical aura; often flashes of light or jagged lines (fortification spectra) across the visual field. Similarly, the medical diagnosis of IBS has to conform to official Rome criteria of frequent abdominal discomfort with a disturbance of defaecation, which might be diarrhoea or constipation, and ignores the multiplicity of other symptoms.
Like IBS, most patients with migraine don’t present as a ‘text book case’. Auras only occur in about 20% of migraineurs, and they are not just visual disturbances but can include sounds, smells, tingling of the skin, slurred speech, paralysis, anaesthesia, and even gut symptoms, emotional feelings and disturbances in fluid balance. You can even get migraine without headache, but with a range of paroxysmal or ‘autonomic’ disturbances which include bilious attacks, cyclic vomiting, abdominal pain, periodic diarrhoea, chest pain, breathlessness, peri-menstrual symptoms, fainting, travel sickness, hangovers, torpor and trance like states. Oliver Sacks regarded those as ‘migraine equivalents’ if they occurred as discrete attacks with a duration, periodicity and clinical format similar to classic attacks of migraine and were precipitated by similar emotional and physical antecedents. Patients with IBS often report a history of migraine or asthma in childhood.
The pattern and sequence of such paroxysmal symptoms is reminiscent of post traumatic reactions where specific contextual factors may trigger tension via activity in the sympathetic nervous system, which then gives way to collapse or dissociation, brought about by activity in the dorsal vagus. IBS has a similar biphasic response: constipation may be related to a relative sympathetic dominance and diarrhoea to an increase in parasympathetic tone.
Both migraineurs and patients with IBS are remarkable for the diversity of their presentation, which render statistic analysis somewhat meaningless and encourages the conjecture that IBS and Migraine are more ‘individual’ expressions of the personality than characteristics of the ‘disease’.
Oliver Sacks has written ‘Compact and clearly defined at its centre, migraine diffuses outwards until it merges with an immense surrounding field of allied phenomena. The only boundaries which exist are those which we are forced to adopt for nosological clarity and clinical action. We construct those boundaries and limits for there are none in the subject itself.’ I have written about the Rome Criteria for IBS in similar terms though not so eloquently.
Alison Kennedy reports that, ‘when a migraine is coming on, I feel cut off from the world. Nothing makes any sense; it’s like a ghost following me around. Then the headache starts and the sickness and all I want to do is to escape the world and find somewhere dark to rest’. This suggests a bodily reaction to severe threat, which originates in a region where emotional experience and its physiological reactions are contiguous and co-extensive.
William James once said that, ‘emotion is nothing but the feeling of a bodily state’. I have also wondered whether emotions are essentially bodily responses, brought to mind, where they can be thought about, acted upon and resolved, but under conditions of trauma, when the frontal cortex goes off-line, they remain as bodily symptoms, which may represent what has happened. In such circumstances, an attack of migraine or IBS might therefore perform the task of emotional equilibration, binding painful feelings that might otherwise subject the individual to confusion and distintegration. Sacks has compared migraine attacks to city walls, conferring protection while preventing freedom of thought and action. This might explain why curing a person of migraine, IBS or any other disabling ‘unexplained’ symptom may be followed by intolerable anxiety or the substitution of another symptom.
An illness that starts as a ‘response’ to life situations or events may, if those are not resolved, be incorporated into the personality as a no-go area. Sacks compares this process to ‘walking’, which is basically a spinal reflex, but becomes elaborated at higher and higher levels by life experience until, finally, we can recognise a man by the way he walks, by his walk. We are ‘what has happened to us’.
Both migraine and IBS tend to run in families, but that does not necessarily imply that either is inherited. Such ‘illness’ may be readily learned and emulated within the family environment. Moreover, family members may share the stressful environment, the same foods and the similar populations of colonic bacteria. Nevertheless, disturbances in genes encoding for serotonin receptors have been postulated for both IBS and migraine.
I have written in previous posts of how an attack of gastroenteritis, a traumatic experience, or depletion of the micro-biome might all predispose to IBS by making the gut more sensitive, while other factors, essentially ‘foods and moods’, trigger IBS symptoms in a sensitive gut.
A similar biphasic response occurs in migraine. Sacks and others have reported how a conscientious, perfectionist and defensive personality, head injury, illness or emotional trauma might predispose to migraine attacks, which are triggered by a range of factors that include atmospheric states, perfumes, car journeys, alcohol, dietary components, lack of sleep, injury, sexual orgasm or violent passions. 90% of migraine attacks are brought on by emotional stress, which may cause intense emotions of anxiety, guilt, shame, anger or despair. Migraineurs are often highly conscientious and work too hard, but the migraine doesn’t always come on during the period of intense work, but may inconveniently occur at the weekend forcing the individual to hide away instead of relaxing and enjoying themselves.
The relationship between certain foods and migraine is often attributed to allergy, but remains unproven. In many cases it is the expectation or fear that a certain food may induce the attack that brings it on. A few cases of migraine may be related to specific components in the food, such as monosodium glutamate in the Chinese Restaurant Syndrome or tyramine in strong cheeses, cured meats, beers, broad beans, soy products and Marmite. Food allergy and intolerance are more established in IBS, though expectation and the nocebo response also plays a prominent role in that condition.
Some people have periodic migraine, related to anniversaries, menstrual cycles or weekends, but the nature of these attacks suggests ‘nerve storms’ set off in a charged and waiting nervous system by association and expectation. The same applies to some people with IBS.
Other patients with migraine or IBS may suffer from a combination of an ambitious, perfectionist, and cautious personality and entrapment either within a relationship or occupation, or by financial constraints or family obligations. Once the predisposing factors are no longer there, the attacks tend to disappear. Such illnesses represent what Jorges Luis Borges termed ‘apparent desperations and secret assuagements’.
Just as the early theories of IBS focussed on the motility of the gut, so the physiology of migraine was originally ascribed to the reactivity of the blood vessels in the head and neck. The vasoconstriction of the prodromal aura changes to vasodilation when the headache occurs. The temporal artery may be swollen and tender on affected side associated with increased sensitivity, pallor or redness of the skin around the head and the neck. Pain may occasionally be relieved by occulting the artery or pressing on eyeball on affected side. These vasomotor theories of migraine cannot be said to be causative. Excise one temporal artery, treat with serotonin inhibitors, and attacks may recur in a different form. This suggests the central organisation of migraine can use different effectors and helps to explain the changing nature of unexplained illness.
Although brain scans have failed to reveal any definitive results, neurosurgeons found than when they implanted electrodes in the raphe nucleus in the brain stem to relieve back pain, many of these patients started to develop migraines while similar studies in animals showed typical vascular changes. The Australian neurologist, Dr James Lance (1982) has envisaged that attacks may be initiated in the hypothalamus and then descend through the brain stem to the periaqueductal grey and the raphe nuclei, causing a spreading depression in the blood supply to the cortex followed by rebound hyperaemia. The raphe nuclei are a major component of the brain body serotonergic system, which is involved in mediating arousal, sensation and pain perception and implicated in IBS and other central sensitivity syndromes.
Drugs acting on the serotonergic system have been shown to be effective for both IBS and migraine, though side effects have precluded their widespread use. Ondansetron, Alosetron (5HT3 antagonists) have been used to reduce pain and diarrhoea in IBS. Tegaserod (a 5HT4 agonist) has been used to treat constipation. The serotonin agonist, Sumatriptan (5HT1B/D agonist) can abort an attack of migraine in some people. The antidepressant, amitriptyline, which is serotonin/noradrenaline re-uptake inhibitor with additional effects on the serotonin transporter, can help to prevent attacks of both IBS and migraine.
Nevertheless, drugs are not always the answer. Migraine is often so severe and incapacitating that all a patient can do is to find somewhere dark to lie down and rest, cutting out all sensory input. An attack will often disappear after a good night’s sleep. Relaxation and hypnotherapy can also be very effective for attacks of IBS. Complementary therapies can help to provide the space and relaxation to build bodily confidence and prevent attacks, while biofeedback can be very effective in understanding and controlling the effect of triggers.
As with all illness, it is important not only to treat the disease but also the afflicted individual. Both migraine and IBS can be thought of as personal reactions to what has happened. Therapy cannot always be reduced to specific treatments, it is dependent on innumerable variables and above all on an effective doctor patient relationship. This is as important as anything the doctor says or does. The most common complaint of patients with migraine and with IBS is that ‘my doctor never listens to me’. A trusting connection with an empathic doctor can relax tension, promote insight and instil confidence. It is unfortunate that with increasing time pressure, too few clinicians have patience for people with IBS or migraine. Attitudes to unexplained illnesses have changed little over the last half century. I’ll leave the last word to Oliver Sacks.
The common attitude is that migraine is merely a form of mainly disabling headache which occupies far more of a busy doctors time that its importance warrants. Tablets and advice to learn to live with it may be proferred by the doctor who hopes he will not be on duty the next time the patient comes in for advice. Because of the lack of full comprehension of the complexities of migraine, many doctors are only too pleased when a patient, in desperation, takes himself off to the practitioners of fringe medicine.
Oliver Sacks, 1977