Comorbidities of Migraine: Implication for Treatment

By Egilius L.H. Spierings, M.D., Ph.D.

The treatment of migraine and chronic pain is the focus of MedVadis’s research activities. Regarding migraine, across the board people are not adequately or optimally treated. Knowledge is key! Here we discuss the implications for treatment of the comorbidities of migraine. Comorbidities are associated medical or psychiatric conditions that are generally considered unrelated to the condition with which they are associated. However, this may not be true and addressing them may, in fact, be of great benefit to the condition they are associated with, in this case, migraine.When it comes to migraine, most of the comorbidities are associated with the migraine condition known as chronic migraine. Migraine is divided into episodic and chronic based on the total number of headache days per month, including migraine and other headaches. When this total number of headache days is less than 14, we refer to the condition as episodic migraine; when it is 15 or more, we talk about chronic migraine.

The list of comorbidities that tend to be associated with chronic migraine is long. Among others, it includes anxiety, depression, insomnia, fatigue, tight neck and shoulder muscles, tight jaw muscles, also referred to as temporomandibular disorder (TMD), chronic low-back pain, restless legs syndrome, not an uncommon cause of insomnia, chronic nausea, generally due to inflammation of the stomach referred to as gastritis, heart burn or acid reflux, constipation, and irritable bowel syndrome.

Almost invariably, people with chronic migraine have tight neck, shoulder, upper-back, and sometimes also jaw muscles. Treatment with Botox® illustrates the importance of treating a comorbidity assumed to be unrelated. Botox® has been demonstrated to be effective in the preventive treatment of chronic migraine and is approved by the FDA for this particular migraine condition. It is not approved for episodic migraine, which is too a much lesser extent than chronic migraine associated with the muscular symptoms mentioned above.

In the treatment of chronic migraine, Botox® is injected into the muscles of the forehead, back of the head, back of the neck, and shoulders. Sometimes it is good to treat the jaw muscles as well although that is not part of the FDA-approved treatment for chronic migraine. Botox® is essentially a long-acting muscle relaxant: it blocks the nerve fibers in the muscles from making the muscles contract and, hence, be tight. It is a treatment that has been shown to decrease the frequency and intensity of the migraine headaches.

At MedVadis Research, we recently compared Botox® treatment of chronic migraine with treatment of the condition with Topamax®. While 40% of the patients treated with Botox® experienced a reduction in headache days of 50% or more, only 12% of the patients treated with Topamax® had this kind of benefit. The CGRP antibodies currently in development for the treatment of episodic and chronic migraine provide this particular benefit in about 60% of patients. MedVadis has been involved in the development of the CGRP antibodies for migraine prevention since 2012 and studies are ongoing. We encourage you to call us at 617-744-1310 or contact us by e-mail ( regarding those studies. We appreciate your interest and look forward to hearing from you!