What is the Relationship Between Migraine and Gastroparesis?

Written by: Kylie Petrarca, RN, BSN

Medically Reviewed by: Dr. Thomas Abell

Edited by: Leigh Serth

What is Gastroparesis?

Gastro = stomach paresis = partial paralysis/weakness

Gastroparesis is defined as delayed emptying of solids and liquids from the stomach into the small intestine without evidence of a blockage. However, some patients have the symptoms of gastroparesis without delayed gastric emptying. 

Although it is unknown why gastroparesis occurs, it is thought that it occurs from damage to the various branches of the nervous system in the body. 

There are three main parts of the nervous system thought to be involved with gastroparesis symptoms:

• The central nervous system (CNS) – Includes the brain and spinal cord
• The autonomic nervous system (ANS) – Controls involuntary functions (heart rate, breathing, etc)
• The enteric nervous system (ENS) – Controls the digestive system

The symptoms of gastroparesis include abdominal discomfort, heartburn, nausea, vomiting, bloating, feeling full quickly and/or excessively full after eating. Some patients, in addition to the symptoms above, may also experience urinary symptoms such as frequency, decreased bladder sensation and difficulty emptying.¹

When the symptoms of gastroparesis occur, either chronically or episodically, complications can arise. Some people may develop dehydration, electrolyte imbalances, bacteria overgrowth, blood sugar abnormalities, malnutrition and/or a mass called a bezoar.

Gastroparesis is associated with other conditions such as multiple sclerosis, diabetes mellitus and Parkinson’s disease. Diabetes, a metabolic disorder, can cause or exacerbate existing gastroparesis due to high blood sugar and/or nervous system(s) damage. Certain medications, such as tricyclic antidepressants or opioids and previous gastrointestinal surgery can lead to gastroparesis. 

How is Gastroparesis Diagnosed?

Gastroparesis is most often diagnosed by a gastric emptying study. For this test, a person will ingest a meal that contains radioactive material which is followed by a series of x-rays taken at 1 hour, 2 hours and 4 hours. The goal of the study is to see how long it takes food to move from the stomach into the intestine. A person is diagnosed with gastroparesis if 60% or more of the food remains in the stomach after 2 hours of eating or greater than 10% of the food remains in the stomach after 4 hours. Other tests such as breath tests, wireless capsule testing or measurement of gastric electrical activity can help diagnose patients with gastroparesis symptoms.

How Are Migraine and Gastroparesis Related?

Migraine and Gastric Emptying Times

A study of 10 people with migraine with aura were compared to a control group to determine if there were differences in gastric emptying. The study found those with migraine met the criteria for gastroparesis during (78%) and in between migraine attacks (80%). The study also found that those with migraine who were in-between attacks took over an hour longer to empty their stomach than controls (188.8 vs 111.8 minutes).²

Secondly, a study of 27 episodic migraine patients, 12 controls and 32 patients with functional dyspepsia were studied to determine if there were differences in gastric emptying.³ Migraine patients were excluded if they had dyspeptic symptoms (such as epigastric pain or discomfort, postprandial fullness, early satiety, nausea, vomiting and abdominal bloating, etc.) between attacks.³ They found no differences in gastric emptying between controls and those with migraine.³ 

A third study evaluated gastric emptying of liquids and found that it was delayed during a migraine attack but did not differ between attacks.⁴ These findings may be related in part to the interaction of branches of the nervous system (see CNS, ANS and ENS discussion above) in patients with migraine. Thus, gastroparesis may occur during an attack and possibly in-between attacks but larger studies are needed to confirm.

Migraine Symptoms and Comorbidities As They Relate to Gastroparesis

It is hypothesized that interaction of the CNS, ANS and ENS are the reason for the nausea that occurs during a migraine attack.⁵ It is well known that medication absorption is delayed among those experiencing a migraine attack. A study found that effervescent aspirin (aspirin that dissolves in water) absorption was delayed during a migraine attack but not in the symptom free-period.⁶ 

Another study reported on findings of 516 patients with gastroparesis and 195 patients with chronic unexplained nausea and vomiting.⁷ They found 36.6% of patients with gastroparesis also reported having migraine attacks.⁷ They were also more likely to have severe gastroparesis symptoms rated by the patient reported outcome (PRO) measure of the Gastroparesis Cardinal Symptom Index (GCSI) compared to those without migraine.⁷

A study of individuals with gastroparesis and abdominal pain found that those who reported severe abdominal pain were more likely to have migraine than those with mild symptoms. Many people with migraine have a history of abdominal migraine and it is often comorbid with other GI conditions such as IBS and cyclic vomiting syndrome. In addition, a study of subjects with a cyclical vomiting pattern (having recurrent episodes of nausea and vomiting with symptom-free intervals) and diabetic gastroparesis (gastroparesis due to diabetes) found 47.4% of subjects had migraine compared to 20.7% of controls.⁸

Commonalities Between Migraine and Gastroparesis

• Both conditions have a higher prevalence in women
• Nausea and vomiting are two main symptoms of both conditions
• Symptoms can occur periodically or can be constant 
• Symptoms may occur during attacks or between attacks
• Botulinum toxin and metoclopramide are medications used to treat both conditions
• Non-invasive vagus nerve stimulation is FDA cleared for the acute and preventive treatment of migraine and is undergoing clinical trials for gastroparesis.^9,10
• Both conditions are comorbid with cyclic vomiting syndrome, fibromyalgia, interstitial cystitis, endometriosis, Parkinson’s disease, systemic lupus erythematosus and depression.^11,12

What Treatments are Used for Migraine and Gastroparesis? 

Treating Gastroparesis

Lifestyle Modifications

• Eating small, frequent meals (4-5), avoiding fats and insoluble fibers (ex. raw vegetables) and participating in regular exercise. 
• Consuming liquids like soup, stews and protein shakes.
• Avoiding alcohol, carbonated beverages and smoking. 
• Taking a daily multivitamin.
• Psychological interventions such as cognitive behavioral therapy or mindfulness.

Medications

• Medications that may be used to speed up gastric emptying include metoclopramide (use less than 12 weeks), erythromycin (use less than 4 weeks) and domperidone.

Procedural Based Interventions

• If medication is ineffective, a provider can inject botulinum toxin into the pyloric sphincter during an endoscopy. This is the valve that allows food to pass from the stomach to the small intestine. 
• Gastric electrical stimulation is also used to stimulate the nerves related to the stomach. It helps decrease nausea and vomiting associated with gastroparesis. 
• A feeding tube known as a jejunostomy tube may be necessary in severe cases to ensure proper nutrition.
• A gastrostomy tube may be placed to drain air and fluid from the stomach. This relieves nausea and abdominal distention.

Treating Gastroparesis AND Migraine 

There are a few treatments that may be beneficial for both migraine and gastroparesis such as metoclopramide. This medication helps speed up gastric emptying, treats nausea and vomiting but has been found to be effective as a pain reliever. For someone with gastroparesis and migraine, it might be beneficial to use this medication over other options for nausea. However, metoclopramide is not recommended to be taken for more than 12 weeks and some patients can not tolerate its CNS effects. Domperidone was also shown to prevent migraine attacks and is used to treat gastroparesis.⁵ Neuromodulation devices such as non-invasive vagus nerve stimulation, have not been studied for both migraine and gastroparesis. However, it has been cleared by the FDA for the acute and preventive treatment of migraine and is undergoing clinical trials for gastroparesis. Lastly, a provider will likely opt for treatments that are administered intravenously, rectally, subcutaneously or intranasally versus orally. For a full list of migraine treatments, click here.

What Type of Doctor Should I See for Migraine and Gastroparesis? 

A clinician with a headache specialty is recommended to diagnose and treat migraine. For gastroparesis diagnosis, treatment and management, a gastroenterologist is highly recommended. 

A Note To Patients and Providers

It is important for patients to report the symptoms of gastroparesis to their headache specialist or primary care doctor. A provider will likely change the route of the medication they prescribe from oral to subcutaneous, intravenous, intramuscular, intranasal or rectal. Neurologists and headache specialists should be aware about gastroparesis as it is a common comorbidity of migraine. Many patients living with migraine who are not aware about gastroparesis are likely consuming medications orally and are not absorbing all of the medication. A provider may opt for treatments that are beneficial for both conditions such as metoclopramide, domperidone and non-invasive vagus nerve stimulation. More clinical trials are in progress for gastroparesis, therefore we encourage readers to routinely check clinicaltrials.gov.

Resources 

Common Questions About Gastroparesis

Causes of Gastroparesis

Diagnosis and Tests

Gastroparesis Clinical Research Consortium

Pediatric Gastroparesis Registry

Adult Gastroparesis Registry

Recruiting Clinical Trial for Gastroparesis

Access Cards

Thank you to our sponsor electroCore!

References 

1. Goldman HB, Dmochowski RR. Lower urinary tract dysfunction in patients with gastroparesis. J Urol. 1997 May;157(5):1823-5. PMID: 9112531.
2. Aurora, S.K., Kori, S.H., Barrodale, P., McDonald, S.A. and Haseley, D. (2006), Gastric Stasis in Migraine: More Than Just a Paroxysmal Abnormality During a Migraine Attack. Headache: The Journal of Head and Face Pain, 46: 57-63. https://doi.org/10.1111/j.1526-4610.2006.00311.x
3. Yu YH, Jo Y, Jung JY, Kim BK, Seok JW. Gastric emptying in migraine: a comparison with functional dyspepsia. J Neurogastroenterol Motil. 2012 Oct;18(4):412-8. doi: 10.5056/jnm.2012.18.4.412. Epub 2012 Oct 9. Erratum in: J Neurogastroenterol Motil. 2013;19(2):274. PMID: 23106002; PMCID: PMC3479255.
4. Yalcin H, Okuyucu EE, Ucar E, Duman T, Yilmazer S. Changes in liquid emptying in migraine patients: diagnosed with liquid phase gastric emptying scintigraphy. Intern Med J. 2012 Apr;42(4):455-9. doi: 10.1111/j.1445-5994.2012.02741.x. PMID: 22498119.
5. Parkman, H.P. (2013), Migraine and Gastroparesis From a Gastroenterologist’s Perspective. Headache: The Journal of Head and Face Pain, 53: 4-10. https://doi.org/10.1111/head.12112
6. Volans GN. Migraine and drug absorption. Clin Pharmacokinet. 1978 Jul-Aug;3(4):313-8. doi: 10.2165/00003088-197803040-00004. PMID: 354637.
7. Aurora, S.K., Shrewsbury, S.B., Ray, S., Hindiyeh, N. and Nguyen, L. (2021), A link between gastrointestinal disorders and migraine: Insights into the gut–brain connection. Headache: The Journal of Head and Face Pain, 61: 576-589. https://doi.org/10.1111/head.14099
8. Christensen CJ, Johnson WD, Abell TL. Patients with cyclic vomiting pattern and diabetic gastropathy have more migraines, abnormal electrogastrograms, and gastric emptying. Scand J Gastroenterol. 2008;43(9):1076-81. doi: 10.1080/00365520802085411. PMID: 18609160.
9. Paulon E, Nastou D, Jaboli F, Marin J, Liebler E, Epstein O. Proof of concept: short-term non-invasive cervical vagus nerve stimulation in patients with drug-refractory gastroparesis. Frontline Gastroenterol. 2017 Oct;8(4):325-330. doi: 10.1136/flgastro-2017-100809. Epub 2017 May 24. PMID: 29067158; PMCID: PMC5641854.
10. Gottfried-Blackmore A, Adler EP, Fernandez-Becker N, Clarke J, Habtezion A, Nguyen L. Open-label pilot study: Non-invasive vagal nerve stimulation improves symptoms and gastric emptying in patients with idiopathic gastroparesis. Neurogastroenterol Motil. 2020 Apr;32(4):e13769. doi: 10.1111/nmo.13769. Epub 2019 Dec 5. PMID: 31802596; PMCID: PMC8054632.
11. Burlen J, Runnels M, Mehta M, Andersson S, Ducrotte P, Gourcerol G, Lindberg G, Fullarton G, Abrahamsson H, Al-Juburi A, Lahr C, Rashed H, Abell T. Efficacy of Gastric Electrical Stimulation for Gastroparesis: US/European Comparison. Gastroenterology Res. 2018 Oct;11(5):349-354. doi: 10.14740/gr1061w. Epub 2018 Oct 1. PMID: 30344806; PMCID: PMC6188037.
12. Paulon E, Nastou D, Jaboli F, Marin J, Liebler E, Epstein O. Proof of concept: short-term non-invasive cervical vagus nerve stimulation in patients with drug-refractory gastroparesis. Frontline Gastroenterol. 2017 Oct;8(4):325-330. doi: 10.1136/flgastro-2017-100809. Epub 2017 May 24. PMID: 29067158; PMCID: PMC5641854.

*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.