- What does the thyroid do? 1:20-2:20
- Explanation of hyper and hypothyroidism 2:35-6:40
- The relationship between migraine and thyroid disorders 7:05-10:40
- Testing and treating thyroid disorders 11:15 – 18:50
- Questions from followers 19:00-24:45
Voice-over: Welcome to Spotlight on Migraine, hosted by the Association of Migraine Disorders. Join us for fresh perspectives by medical experts and advocates as we explore the spectrum of migraine and dig deeper into this complex disease.
Headache specialist Dr. Deena Kuruvilla describes the role of the thyroid in our bodies as well as the effects of hypo- and hyperthyroidism. She reports on research findings that explain the overlap of these conditions with migraine and how treating thyroid conditions can impact migraine.
This episode is brought to you in part by our generous sponsors Amgen and Novartis.
Molly O’Brien: Hello and welcome to Spotlight on Migraine. I’m your host, Molly O’Brien. Today we’re talking all about the relationship between migraine and thyroid. Our guest today is Dr. Deena Kuruvilla. She’s the medical director at the Westport Headache Institute, and she’s an assistant adjunct at Yale University.
Dr. Kuruvilla, thanks so much for joining us.
Dr. Deena Kuruvilla: Thank you for having me, Molly.
Molly: Oh, I’m so excited to talk to you, just in general but also on this topic. We’ve had a ton of interest by our followers, so really hoping to get some good information out there, and obviously no pressure to you.
All right, so I always like to start pretty basic, start out at the basic level. So can you explain what the thyroid is and what it does in our body?
Dr. Kuruvilla: Yeah, so it’s really interesting. The thyroid is a very important gland. It comes from the Greek word shield, and it is a butterfly-shaped gland that’s located right in the neck. It’s responsible for making hormones that regulate so many important functions in the body. It has a role with the heart. It has a role with the gastrointestinal tract, the way that our stomach and our intestines work. It has a role with the brain. It has a role with the mood side of the brain, so it has an impact on how your mood is doing, what anxiety levels are like. And then it also has a role in many neurological functions of the brain, like your everyday thinking, remembering things, and what we’re going to be focusing on today, of course, migraine.
Molly: Well, it’s fascinating to learn, because just when you think you understand what the thyroid does, it’s almost like, Nope, it does more than that.
Dr. Kuruvilla: Absolutely.
Molly: Fascinating. So sometimes people’s thyroid doesn’t work properly, so they can have either hypo- or hyperthyroidism. Can you explain what those are?
Dr. Kuruvilla: Yeah, absolutely. So it’s really interesting. Hypothyroidism comes in two flavors. One flavor is subclinical hypothyroidism, where the thyroid levels may be normal, but the hormone that’s supposed to be stimulating those thyroid levels is actually — it comes out high. Subclinical hypothyroidism may not manifest. You may not have symptoms of it, and that is the most common type of hypothyroidism. So it’s kind of a down-function of the thyroid.
The other type of hypothyroidism is clinical hypothyroidism, where there is a clear decrease in the thyroid hormones and an increase in the hormone that’s supposed to be stimulating those specific thyroid hormones, called TSH. So in clinical hypothyroidism, folks may end up having many of the symptoms that go along with the diagnosis. Many of the common symptoms are sluggishness and fatigue, brain fog, constipation. There’s so many different ones. Low heart rate, high blood pressure. There’s just so many different symptoms that go along with every organ symptom with hypothyroidism.
Hyperthyroidism is when the thyroid is overactive, so those thyroid hormones are actually elevated. And the most common cause for hyperthyroidism in the US is called Graves’ disease, which is an autoimmune process that attacks the thyroid. So that’s just a little flavor on hypo- and hyperthyroidism.
Molly: Now, can you tell us how common hyper- or hypothyroidism are, and is anyone more likely to have these conditions?
Dr. Kuruvilla: Absolutely. So hypothyroidism has been found to be more common in women, folks who are of older age, so the elderly are certainly more likely to have hypothyroidism. People with diabetes or other autoimmune conditions are more likely to have hypothyroidism, and then folks with Caucasian ancestry may be more likely to have hypothyroidism. I will say a lot of the studies out there are specifically on Caucasian folks with hypothyroidism, so we do need more data on specific ethic groups and how hypothyroidism affects those groups.
Subclinical hypothyroidism is more common than clinical hypothyroidism. So there may be tons of folks out there who are walking around with no symptoms of hypothyroidism, those low thyroid levels, and they may have no idea that they have it. That’s much more common, and the statistics show that occurs in around 4 to 10 percent of the US population.
In clinical hypothyroidism, in folks who are actually having the symptoms of hypothyroidism and the lab work to match that, the statistics vary a little bit more. I’ve seen numbers at .1 percent of the US population all the way to 7 percent of the US population. So there was a much larger range there. But subclinical hypothyroidism is certainly much more common.
Hyperthyroidism really appears to be less common than hypothyroidism, and I saw statistics ranging anywhere from .5 percent of the US population to 3 percent of the US population. So those numbers — we certainly need more studies to look at how common these really are.
Molly: And just those numbers that you gave us, it’s more common than I might have imagined, so that’s pretty interesting. And affecting women more so, well, that sounds familiar, like migraine.
Dr. Kuruvilla: Right, absolutely.
Molly: So can you talk to us a little bit about what thyroid disorders are related to what type of headache disorders?
Dr. Kuruvilla: Sure. So doing extensive searches on this, it appears that there are many more studies looking at hypothyroidism related to migraine than hyperthyroidism related to migraine, which is really interesting. It’s been found in several studies that having hypothyroidism may be a risk factor more for folks to have migraine. They found that even children with hypothyroidism or subclinical hypothyroidism are more likely to develop migraine over their lifetime. So there’s certainly stronger connections in the studies between hypothyroidism and migraine than with hyperthyroidism or other disorders of the thyroid.
Molly: That is absolutely fascinating. Do we know what the relationship is between hypothyroidism and migraine?
Dr. Kuruvilla: We don’t know the direct relationship, but what’s interesting is this headache group out of Cincinnati did a 12-year study and found that new-onset hypothyroidism was present in 21 percent of folks with headache disorders in general and in over 40 percent of folks with migraine.
Molly: Wow, those numbers are alarming, but I feel like having these kinds of conversations that you and I are having, getting that information out there, can help people who might not know that there is a relationship, but they might have both disorders.
Dr. Kuruvilla: Right, absolutely.
Molly: So can you talk to us a little bit about — continue on talking about that relationship between migraine and thyroid? Can your thyroid disorder actually impact migraine attacks?
Dr. Kuruvilla: There’s no specific evidence that fluctuations in the actual thyroid levels, the hormone levels, result in specific attacks. But the only thing I could find that there have been associations between plasma TSH, or thyroid stimulating hormone, and migraine. But over time those relationships between those blood levels and migraine have been very controversial. So there’s no specific evidence that the blood levels contribute to specific attacks.
Molly: Okay, and then going back to those numbers that you said just a moment ago, can hypothyroidism directly impact someone’s migraine disorder, or do we just see them coexisting together?
Dr. Kuruvilla: It’s so interesting. You see both. In my clinic, personally, I am seeing many folks who have episodic migraine and chronic migraine and also having hypothyroidism or a thyroid disorder. I have seen in the research that’s been done that people who have subclinical hypothyroidism or clinical hypothyroidism and are treated for the condition had a significant drop in their headache, in their migraine frequency specifically. So hypothyroidism, thyroid disorders can certainly cause or worsen baseline migraine frequency and severity, based on the research that’s out there.
Molly: This is just fascinating to me. I don’t know if it’s because it’s not talked about a ton among general migraine patients or what, but I just think this is absolutely fascinating and probably gives some answers to folks out there with the two conditions.
So you just mentioned that we’ve seen migraine frequency go down in people [who have an?] underlying thyroid disorder. Have you seen this yourself? Can treating thyroid disorder actually impact and possibly reduce frequency of migraine or help out folks who also have migraine?
Dr. Kuruvilla: Absolutely. I think it’s so important that when I see patients — I think the vast majority of my colleagues do this too — we get a really detailed report from patients about how every organ system is doing. So we ask specifically — starting off with the brain, specifically about pain, any trouble with thinking, memory loss, any trouble functioning in their everyday life. Then we move on to the heart and ask specific questions about low heart rate, lightheadedness, palpitations. We move on to every organ system.
If we’re seeing that when we ask about each of these different systems within the body that there are a lot of complaints coming up, it really behooves us to check those thyroid levels to see if there’s a direct association with thyroid dysfunction and that manifestation of migraine. Because studies have shown that levothyroxine, that thyroid replacement, could — if we’re treating that underlying thyroid disorder, hypothyroidism especially, we can see a significant drop in headache frequency and severity.
So absolutely. If I am seeing that someone is telling me that they have many complaints in different systems, I am telling them to please follow up. I order the lab work, and I have them follow up with their primary care doctor or their endocrinology doctor to get treated for the condition if something is there.
Molly: Again, fascinating. So I guess we kind of want to look at the flip side of that. Say you are taking thyroid medication or you have a treatment in place, can that actually impact migraine in a negative way? Can it increase your headache? Can it increase migraine attacks?
Dr. Kuruvilla: Yeah. It’s interesting. The short answer is absolutely. So thyroid hormone replacement therapy, a huge percentage of my practice is on it or will be on it at some point, so. And they do say that the thyroid medication, on the actual label, that one of the lesser common side effects is headache. And so when I see folks in my clinic, I do monitor for headache as a side effect of the medication.
In many cases, folks might have a too-high dose of the thyroid medication or a too-low dose of the thyroid medication, which may be contributing to migraine. For example, if someone is underdosed with the thyroid medication replacement therapy, they might continue to have symptoms of hypothyroidism such as depression, feelings of being in a brain fog, headaches, those migraine symptoms, constipation. It hits every organ system. So migraine can get worse that way.
The flip side of the coin, if someone is overdosed or on a too-high dose of that levothyroxine, that thyroid hormone medication, they can have manifestations of hyperthyroidism, of which anxiety is one of the symptoms of that. And so we know there is this really strong relationship between anxiety and migraine, so on that side of the coin, the medication could cause those side effects as well.
Molly: Hoo, that sounds like a tricky situation to find that right balance, but it sounds like doctors have an idea of which way it could go, so that dosing can be super important and especially important to talk to your doctor about.
Dr. Kuruvilla: Yes, absolutely.
Molly: So can you tell us a little bit about testing for thyroid disorders? Say someone out there has migraine. They’re not sure if their thyroid is off or not working properly. Could it be valuable for those people to get tested or get a workup on their thyroid? And if so, what are some of the tests that doctors and labs run?
Dr. Kuruvilla: Absolutely. So if there’s suspicion for an underlying thyroid disorder, the first thing to do is speak with your doctor about the symptoms, of course, and then get blood work. Blood work is the easiest way to start diagnosing and evaluation a thyroid disorder. Specifically, we look at TSH, the thyroid stimulating hormone, which is released from the pituitary gland, which stimulates the thyroid to release T3 and T4, the hormones that come directly from the thyroid. And so those three things are preliminarily checked in the blood to look for an underlying thyroid disorder.
If these thyroid levels are off kilter and they’re either high or low — the balance of TSH and T3 and T4 has to be in perfect balance to have the thyroid functioning appropriately. If there’s an off-balance of these and you have hypo- or hyperthyroidism, the doctor might pursue further workup with a sonogram of the thyroid to see if there’s a goiter or another underlying mass to see if something is directly causing this. And they may recommend specific medications to treat it.
Molly: Again, this is so fascinating. Now, I kind of want to continue that. Say people think that they have one of these type disorders, a genetic predisposition, but their levels aren’t off, and they also have migraine. Could it be valuable to get tested every so often? Say they get tested and everything seems fine. I mean, should they get tested a year down the road, two years down the road, or just say, “Hey, I’m okay”?
Dr. Kuruvilla: Yeah. That’s a great question. The general rule of thumb that I follow and I know a lot of my colleagues follow is if there are no new symptom. If there are no new symptoms of hypothyroidism, hyperthyroidism, there’s really no need to regularly check thyroid levels. But it’s an interesting conversation. It also depends on how frequently are you following up with your doctor and really going through these symptoms, a symptom checklist. How frequently are you seeing them? Because if you’re seeing someone once a year and you’re having symptoms in between that, then it really is a phone call in to the doctor to review those symptoms and see if new blood work is indicated. But if there are generally no symptoms, then there’s probably not a role to regularly repeat levels.
Molly: OK, I think that’s really valuable for folks out there. It also sounds like if you’re going to your primary care doctor once a year or whatever, it could be valuable to track your symptoms. [If you?] have migraine disorder, sometimes it gets to be overwhelming, writing all that stuff down. But it sounds like it really could be valuable down the road, especially if you are genetically disposed to thyroid disorders.
Dr. Kuruvilla: One scenario where we as providers, physicians, could really consider checking thyroid levels is if we have someone who has chronic migraine, we have tried treatments, we’ve already ruled out other dangerous things with imaging studies like MRI, and we have used several medications to treat, and it’s just not getting better. That may be another reason to check blood work and double-check those thyroid levels to make sure that we’re not missing something.
Molly: Now, like I said earlier, that this was sort of a hot topic with our followers. People had a ton of questions, so hopefully we answered some of those for you watching or listening. But we also had a couple question that I wanted to take directly from our follows. Any information you can provide would be great.
Dr. Kuruvilla: Yeah, sure.
Molly: Cool. OK, so one question is, “Can a migraine attack inhibit thyroid function?”
Dr. Kuruvilla: Not that I know of. Not that I know of. So I looked into this specifically about the relationship, can migraine really be an offender directly to the thyroid? And there’s no evidence out there that specific migraine attacks or uncontrolled migraine attacks over time are going to affect specifically thyroid function.
Molly: OK. Thank you for that.
Our next question is, “Are there any synthetic hormone replacements that could be better for migraine patients?”
Dr. Kuruvilla: No. Actually, it’s interesting. The first line — for example, for hypothyroidism, levothyroxine, is really one of the go-to medications for endocrinologists and primary care doctors to fix those thyroid levels, but there’s no specific treatment that’s been studied for migraine. I believe from everything I’ve read, the previous studies that looked specifically at hypothyroidism, levothyroxine was used. And that’s pretty much the standard of care even now with or without migraine.
Molly: Awesome. Thank you for that.
Our next question is, “Are there any relevant links to migraines and a total thyroidectomy?”
Dr. Kuruvilla: There are not. So there is no evidence out there that removing the thyroid is in any way a treatment for migraine. A thyroidectomy may be indicated by your endocrinologist if you have an underlying thyroid cancer, a mass, a goiter, for one of those indications. But there is no indication for a total thyroidectomy for migraine.
Molly: OK, OK. That’s a great question, I think.
Our next follower wanted to know if the — we’re continuing with the thyroidectomy here. Our next follower wanted to know, “Can the neck position during a thyroidectomy or poor neck mobility after that surgery affect migraine?”
Dr. Kuruvilla: That’s a really interesting question. So positioning during surgery is tricky. We know that over 80 percent of people with migraine also have neck pain, and we know that there is so much going on in the neck when it comes to migraine. The main generator for migraine is in the neck. The trigeminal nucleus caudalis of the brain stem is located in the neck. And we know this area is overactive in folks with migraine.
There’s a really complicated pathway that gets activated when this area becomes overactive. I call it the TNC, the trigeminal nucleus caudalis. So when this are becomes active, there’s a complicated cascade of events, inflammation. The superficial nerves that are connected — the neck nerve roots that are connected to the trigeminal nucleus caudalis and the brain stem become irritated, and those have direct connections with the nerves that run through the neck and through the superficial parts of the head: the occipital nerves at the back of the head, the nerves on the sides of the head, the forehead. All of those superficial nerves can become activated in migraine.
In the same token, the neck and the trapezius muscle, specifically, is also involved in this entire circuit. It can become inflamed. That’s the muscle that runs right behind — it starts at the neck, yeah, goes into the shoulders and down into the back, a very large muscle. That area becomes inflamed and irritated also with migraine, and it’s been found that injections specifically in that area may be helpful for folks with migraine.
So the short answer is positioning during surgery, if you’re positioned in a specific way, can irritate the trapezius muscle and it can irritate the nerves that come out of the neck and run superficially within the neck and throughout the head. So when those nerves and muscles get irritated, certainly that could result in a migraine.
Molly: Wow, the short and long answer there, but my goodness. It makes me want to sit up straighter and use a better pillow at night, knowing all of that.
Dr. Kuruvilla: Me too.
Molly: [As we?] wrap up here, I’m wondering if there’s anything else you think would be valuable for people to know about the relationship between thyroid and migraine.
Dr. Kuruvilla: I think that — we covered a lot today, but I think it’s important to be very in tune with one’s own body and to see if there’s anything different from your regular life. Are there any symptoms of constipation, for example, that can point you towards hypothyroidism or diarrhea that may point towards hyperthyroidism? Are you feeling sluggish or depressed or anxious, overall just feeling like your skin may be changing? I think it’s nice to be in tune with the entire body and see if there is something that’s out of whack at one time or another and discuss it with your doctor so that these levels can be checked if needed.
Molly: Great. Well, thank you for all of this information. I’ve learned so much. And that wraps up this episode of Spotlight on Migraine. A big thank you to our guest, Dr. Deena Kuruvilla, for joining us.
Dr. Kuruvilla: Thank you so much for having me, Molly.
Voice-over: Thank you for tuning in to Spotlight on Migraine. For more information on migraine disease, please visit MigraineDisorders.org.
This podcast is sponsored in part by Amgen and Novartis.
*The contents of this podcast are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The speaker does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.