A Study of Headaches and Migraine in Sjogren's Syndrome and other Auto-Immune Disorders

From the paper by Dr B Pal which appeared in The Annals of the Rheumatic Diseases, as reported in The Bulletin number 131, June 2004
 

My interest in Sjogren's Syndrome ( SS ) goes back to my time as a Senior Registrar in the North-East where we studied a large number of patients with SS in different categories. One of these aspects we looked into was the question of headaches and specifically migraine in our patients.

For the benefit of the non-medical readership, it might be helpful to describe some of the conditions that I will be mentioning. One is systemic lupus erythematosus, a rheumatic condition with disturbances in immunity characterised by various manifestations such as joint pain which is non-destructive in contrast to, say, in rheumatoid arthritis. There is a presence of skin rashes, sensitivity to the sunlight, kidney involvement and other features, as in a number of other rheumatic disorders. Lupus commonly affects women and the peak age on onset around 20.

Another disorder is scleroderma or systemic sclerosis of which there are various subtypes. It is an uncommon condition characterised by tightness of the skin in general and particularly noticeable on the face and the peripheral parts of the limbs and contracture of the fingers. It may also cause problems in various organs of the body such as dilatation of the oesophagus ( gullet ) or the lower part of the bowels, compromise of the lungs, kidneys and other disturbances.

Headaches may occur in patients with rheumatoid arthritis from the upper cervical spine ( neck ) involvement and more characteristically is seen in patients with a condition called temporal arteritis which affects mainly the large arteries in the body in elderly subjects. A specific type of headache ie. migraine, has been reported more frequently in patients with lupus compared to control subjects ( Isenberg et al, 1982 ).

Another study by Zahevi et al in 1984, reported an increased prevalence of Raynaud's phenomenon in subjects with migraine. Raynaud's phenomenon is subjects with migraine. Raynaud's phenomenon characterised by episodic blanching of the distal parts of the limbs followed by dusky discolouration and return of colour to redness with some discomfort, numbness or throbbing. It is typically seen in a few rheumatic conditions especially scleroderma where about 90% of the patients are affected and also in the overlap rheumatic condition called mixed connective tissue disease found in about 85% but much less frequently in lupus and polymyositis.

In our experience with primary SS we found that Raynaud's occurs more frequently than has previously been documented and we have seen this feature in about 50 of our patients.

Because of the above observations we wondered whether migraine occurred with undue frequency in primary SS and system sclerosis and, therefore, we devised this study the aims being

  1. to assess the prevalence of migraine in primary SS and systemic sclerosis;
  2. to explore and temporal relationship between migraine and Raynaud's phenomenon.

191 patients with various rheumatic conditions were studied including 35 with primary SS and 97 with Scleroderma. We administered a questionnaire on migraine devised by Taylor et al 1972 which included 17 items about the frequency, severity and nature of headaches, and three special questions about common accompaniments of migraine such as
  1. warning before headaches;
  2. associated nausea/vomiting;
  3. pain on one side of the head only.

The word "migraine" was not mentioned in this questionnaire. Migraine was considered present if there was frequently unilateral throbbing headache usually with nausea, vomiting and photophobia, and preceded or accompanied by and aura of the visual, motor or sensory type.
Other information we sought was use of drugs, timing of episodes of headache and Raynaud's phenomenon and any temporal relationship between them. Headaches were complained about by nearly 75% of patients with primary SS, a third of patients with rheumatoid arthritis ( RA ), approximately 45% of normal subjects. However, when specifically looking at the question of migraine, we found it was present in 45% of patients with primary SS and a third of scleroderma patients compared to just about 12% in the RA and control groups. From the questionnaire survey, it appeared that the more severe attacks tended to occur in the primary SS and scleroderma subjects rather then other groups.

The presence of Raynaud's phenomenon was studied again by questionnaire designed by Miller et al in 1981. This complaint was found in just over 50% of patients with primary SS and nearly 90% of scleroderma patients as compared to 30% in the RA and 10 in the normal groups. Temporal relationship between Raynaud's and migraine was not seen in the latter two groups but was present in just about 5% in the SS and scleroderma patients.
On analysis of these findings, it was clear that migraine occurred in the patient groups with Raynaud's phenomenon more by chance than in those without Raynaud's phenomenon.

It therefore does appear that there is a high prevalence of migraine in primary SS and scleroderma. This may not have previously been documented in view of the comparatively minor nature of the problem in contract to the more pressing problems seen in these rheumatic conditions, particularly in scleroderma. There is also a high prevalence of Raynaud's phenomenon in these two patient groups that in primary SS having not been previously recognised to occur so frequently. Finally there does appear to be an association between migraine and Raynaud's phenomenon, but no temporal relationship of the attacks of these two complaints.

In view of the findings from this study, I would suggest that patients should always be asked about these symptoms so that the diagnosis is made clearly and appropriate treatment can be offered. One may wonder why migraine is so commonly associated with the rheumatic conditions discussed here. The speculation is that small vessel pathology may account for symptoms in lupus including the central nervous system disturbances. Similar disturbances may occur in these patients. A clear association of migraine with these rheumatic conditions may indicate a link with common pathogenic mechanisms. On the other hand, migraine may simply be a result of stress related to these disorders.

QUESTIONS and ANSWERS by Dr. Pal

What is the treatment for Raynaud's associated with Migraine?
Where Raynaud's is concerned avoid exposure to the cold, thermal gloves and battery-operated gloves are available. There are drugs to be tried eg, thymoaxamime, nifedipine etc These should be started off in small doses to avoid headaches. Research is going on to see if saturated fatty acids would be beneficial. Smoking is to be avoided.
What is the cause of painful areas in the head?
These can occur in Temporal Arteritis, but this generally affects people in the over 60 age group as a result of inflammation of the bigger arteries.
Is there any medication which can help Migraine in SS?
It is important to take preventative medicines in an effort to avoid Migraine attacks in frequent enough; occasional attacks should respond to pain killers.
Are there any inhalants available for Migraine attacks?
Suppositories are useful if you cannot take tablets by mouth, prophylactic medicines are better tolerated by mouth, and inhalants are not widely used. (One called Medihaler is available).
What can help the flashing lights in Migraine?
Tinted glasses are a great help in this condition and for those who suffer from light sensitivity: many patients with SS find such glasses helpful even in the absence of "flashing lights".
Can loss of concentration be attributed to SS?
Reading, watching TV, using VDUs increases your concentration and due to this fact you blink less often and eyes dry more quickly and thus you may feel tired more easily. .

 

Disclaimer :
The Lupus Group of W.A. (Inc.) does not recommend or endorse any products, drugs, treatments, procedures, medical or health professional in this article. We suggest you discuss this information with your doctor or specialist.