The Relationship Between Migraine and Irritable Bowel Syndrome - Comorbidity (1)

The Relationship Between Migraine and Irritable Bowel Syndrome

Written by: Kylie Petrarca, RN, BSN

Medically Reviewed by: Andrea D. Murphy, MSN, APRN, ANP-BC, NEA-BC, AQH

Edited by: Melissa Calise and Leigh Serth

What is Irritable Bowel Syndrome?

Irritable Bowel Syndrome (IBS) is a disorder of gut-brain interaction (DGBI), previously called “functional gastrointestinal disease” that primarily affects the lower gastrointestinal tract. Common symptoms include: stomach pain, constipation, diarrhea, and bloating. There are subtypes of IBS which include constipation, diarrhea, mixed, alternating and unsubtyped. In different patients receiving a diagnosis of IBS, there may be distinct factors causing or associated with the disorder, including problems with the gut-brain axis, or even overgrowth of bacteria and hormonal changes. Other plausible explanations of the pathophysiology include: altered GI motility, an abnormal heightened response to pain known as visceral hyperalgesia, and abnormal central nervous system processing.1 Stress can be associated with IBS, and while experts think it can certainly impact IBS symptom severity, it is less likely that stress alone causes IBS. 

How is Irritable Bowel Syndrome Diagnosed?

IBS is diagnosed by the ROME IV criteria which is defined as:2

“Recurrent abdominal pain on average at least 1 day per week in the last 3 months, associated with two or more of the following criteria:

  1. Related to defecation
  2. Associated with a change in frequency of stool
  3. Associated with a change in form (appearance) of stool

* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis”

Other diagnostic tests that may be ordered include: colonoscopy, endoscopy, stool samples, blood tests, hydrogen breath test, lactose intolerance test, barium enema, colonic transit, anorectal manometry and more.

A provider will decide which tests are right for you based on your presenting symptoms and other conditions.

The Relationship Between Migraine and Irritable Bowel Syndrome

Migraine and IBS frequently coexist, but the underlying reason is unknown. However, there are theories and the relationship seems to be complex. Interestingly, migraine and IBS have a bidirectional relationship, meaning those who live with migraine have an increased risk of developing IBS and vice versa. A study found that people with migraine were 4.13 times more likely to have IBS than those without migraine.3 Another study found that people with IBS had a 60% higher risk or were 1.6 times more likely to have migraine than people without IBS.4 In addition to having a bidirectional relationship, a study found that those living with migraine and IBS had more severe migraine symptoms.3 Another study found that “migraine patients with higher headache frequency, longer length of headache history, and anxiety disorders were more likely to also suffer from IBS.”5

The gut-brain-axis appears to be at the center of the relationship between migraine and IBS. The gut brain axis allows for communication between the gastrointestinal system and the central nervous system (brain and spinal cord). This complicated relationship between migraine and IBS likely involves neurotransmitters such as serotonin and glutamate, the hypothalamic-pituitary-adrenal axis (HPA axis), central sensitization, an altered gut microbiome, hormones and more.

  • Serotonin: Serotonin is an important neurotransmitter in the central nervous system. Defective serotonin has been linked to IBS and migraine. It has many functions including regulating how food moves through the stomach and intestines (peristalsis).3 Serotonin is also one of the most prominent neurotransmitters in the gut. A study found that serotonin levels in the colon were 10 times higher in those with IBS compared to controls.6
  • Glutamate: Glutamate is a neurotransmitter that is involved in migraine pathophysiology including cortical spreading depression, central sensitization and trigeminovascular system stimulation. Disturbances in this neurotransmitter pathway are also involved in gastrointestinal disorders such as IBS.7
  • Hypothalamic-pituitary-adrenal axis: The pathophysiology of IBS is thought to involve an overactive HPA axis.8 The HPA axis is linked to the gut-brain-axis and is activated by psychological or physical stressors which increase the release of stress hormones. Abnormal levels of stress hormones by the HPA axis have been linked to migraine disease.7 
  • Central sensitization: Central sensitization is when the central nervous system is hypersensitive to stimuli and can cause many people with migraine to experience allodynia or light and sound sensitivity. People with IBS may experience visceral hypersensitivity, where they experience pain from their internal organs which is believed to be a result of central sensitization.9
  • Altered gut microbiome: A study found that those who had migraine and IBS had more severe gut dysbiosis or an imbalance in the gut compared to those without migraine.10 
  • Inflammation: We know neuroinflammation occurs in migraine but it likely also occurs in IBS via the gut-brain axis.11
  • Hormones: Hormones are believed to be involved due to high prevalence of both conditions affecting women. Estrogen can increase serotonin levels in the brain which increases pain sensitivity.7 

Commonalities Between Migraine and Irritable Bowel Syndrome

  • Both conditions are highly prevalent in the population. Globally, IBS is estimated to affect 1 in 10 people and migraine is estimated to affect 1 in 7 people.12,13
  • Comorbid with fibromyalgia, anxiety, chronic pelvic pain, interstitial cystitis, insomnia, depression and chronic fatigue syndrome14 
  • Female predominant
  • Stress and anxiety are triggers for flares/attacks
  • Chocolate, dairy products, fruits high in fructose, and legumes are all found to be triggers of migraine and IBS
  • A family history is common 
  • Fluctuating periods of increased symptoms (IBS refers to it as flares whereas migraine refers to it as attacks)
  • Migraine and IBS are often diagnosed in people who have a history of trauma. A history of childhood sex abuse is often found in people with IBS whereas a history of emotional, sexual and/or physical abuse is often found in people with migraine.15,16
  • Neither disease has a cure

What are the Recommended Treatments for Irritable Bowel Syndrome and Migraine?

  1. Food diary to avoid triggers
  2. Elimination diets including FODMAP diet – with dietitian guidance, and, if no improvement after 4-weeks the regular diet is often resumed. It is typically avoided if there is a history of an eating disorder.
  3. Neuromodulators or nerve-moderating agents that are used to treat IBS can also be used to treat migraine. This includes tricyclic antidepressants.
  4. Biofeedback/cognitive behavioral therapy

Other Options

Serotonin receptor agonists such as sumatriptan and rizatriptan as well as antagonists such as trazodone were found to be beneficial in managing migraine and IBS.3 Cannabinoids have also been considered as another treatment that may be beneficial for both IBS and migraine due to its ability to block dopamine, improve GI function and reduce inflammation.3 

Non-pharmacological management modalities that may help symptoms for both conditions include:

  • Peppermint oil
  • Yoga
  • Acupuncture 

What Type of Doctor Should I See For Irritable Bowel Syndrome and Migraine?

A primary care physician may treat IBS. However, they may refer to a gastroenterologist for further evaluation and to rule out secondary causes. Migraine is best treated by a clinician that specializes in headache medicine. Due to the common overlap between both conditions, an interdisciplinary approach among neurology and gastroenterology is recommended to best treat both diseases. 

A Note to Patients and Providers

Physicians should be aware of the bidirectional relationship between IBS and migraine. These complex conditions have an unknown origin and are diagnosed based on subjective symptoms. Patients should inform their health care providers if they are experiencing any symptoms of IBS or migraine. Some common medicinal treatments of migraine may be beneficial in treating comorbid IBS however there are some medicines that have the potential to exacerbate symptoms (ie. worsen diarrhea or constipation). Due to the high prevalence of both conditions, primary care providers should be aware of the diagnostic criteria of migraine and IBS. 

Resources 

  1. What is IBS?
  2. IBS Self-Care Program
  3. IBS Treatments
  4. IBS Awareness Month
  5. IBS Patient Forum

References

  1. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC5741982/
  2. https://theromefoundation.org/rome-iv/rome-iv-criteria/
  3. https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC8789428&blobtype=pdf
  4. https://bmcgastroenterol.biomedcentral.com/articles/10.1186/1471-230X-6-26
  5. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC5510134/
  6. https://www.cureus.com/articles/34925-how-serotonin-level-fluctuation-affects-the-effectiveness-of-treatment-in-irritable-bowel-syndrome#references
  7. https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-020-1078-9
  8. https://www.gastrojournal.org/article/S0016-5085(05)02394-2/fulltext?referrer=https%3A%2F%2Fpubmed.ncbi.nlm.nih.gov%2F
  9. https://www.degruyter.com/document/doi/10.1016/j.sjpain.2014.02.005/html?lang=en
  10. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC5741982/
  11. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC6159811/
  12. https://www.nature.com/articles/s41575-020-0286-8
  13. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8904749/#:~:text=The%20global%20age%2Dstandardized%20prevalence,per%20100%2C000%20population%20(7)
  14. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC5741982/
  15. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC4479362/
  16. https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.12994

*The contents of this blog 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 writer 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.

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