Clinic speak: headache in MS

Headache in MS: is it a bigger problem than expected? #MSBlog #MSResearch #ClinicSpeak

“In this study more than half of MSers reported headache. Wow! This is a much higher self-reported prevalence of headache than I would have expected from my own clinical experience. What is your experience?”

“In the introduction the investigators suggest that headache may be due to inflammation, in particular B cell follicles, in the meninges (membranes covering the brain) of MSers. Why? Interestingly, the actual brain substance is devoid of pain fibres or pain receptors. The pain sensitive structures in the brain that cause headache or the blood vessels (arteries, veins and venous sinuses), meninges (membranous coverings of the brain), cranial nerves, paranasal air sinuses, skull and scalp. These investigators suggest that inflammation in the meninges and around blood vessels is causing headaches in MSers. However, they provide no evidence that this is the case. If this was the case then treatment with anti-inflammatory agents to reduce inflammation should reduce headaches. This data may be available in trial databases, but as it hasn’t been collected systematically it won’t be very useful.”

“The MS inflammation-headache hypothesis may be a subject to study in more detail using questionnaires given pre and post DMTs and using MRI and CSF analysis to quantify inflammation and to see if it correlates with headache. if this was  the case then headaches could be another sign of MS disease activity. In other words if you develop headache, or your headaches get worse, this may indicate that your MS is active.”

“Migraine in MSers is very common as I have previously commented on. I usually treat migraine in MSers as I would treat it in people without MS. You have to maintain a headache diary to ascertain how frequent and disabling the headaches are. Don’t rely on your memories to provide you with the information; you will simply forget and over- or under-report your headache frequency and severity. The treatment strategy for migraine is based on three principles; prophylaxis, abortive and symptomatic treatments. Prophylactic treatments for migraine include drugs such as propanolol (beta-blockers), anti-convulsants (topiramate, valproic acid), anti-depressants (amitriptyline) and calcium channel blockers that reduce the frequency or prevent migraine. Abortive therapies are taken at the onset of the headache to stop the migraine getting worse; licensed abortive therapies are essentially the class of drugs called triptans. Finally, there are symptomatic treatments that are given to treat the pain, nausea and vomiting that are common in migraine sufferers. One of the problem in acute migraine is that migraine also affects the function of the gut with delayed gastric emptying; therefore oral tablets may not work or their effects are unpredictable. If oral drugs don’t work we have to use other routes of administration; i.e. intranasal, sublingual (under the tongue), rectal suppositories or even subcutaneous or intramuscular injections. In addition to medication there are large number of lifestyle interventions that have been shown to reduce the frequency and severity of migraines, one of these includes exercise. More recently botox injections and greater occipital nerve block have been shown to work in some people with chronic migraine. If you have severe intermittent headaches that have not been diagnosed or treated you should speak to your neurologist. Migraine, and other headaches, are another unpleasant MS co-morbidity that may need treating to improve your quality of life. This is why MS needs an holistic approach.”

Background: Recent studies on MS pathology mention the involvement of “tertiary B cell follicles” in MS pathogenesis. This inflammatory process, which occurs with interindividually great variance, might be a link between MS pathology and headaches.

Aim: The aim of this study was to detect the prevalence of headaches and of subtypes of headaches (migraine, cluster, tension-type headache [TTH]) in an unselected MS collective and to compile possibly influencing factors. 

Methods: Unselected MSers (n = 180) with and without headache were examined by a semi-structured interview using a questionnaire about headache, depression and the health status. Additionally clinical MS data (expanded disability state score [EDSS], MS course, medication, disease duration) were gathered. 

Results: N = 98 MSers (55.4%) reported headaches in the previous 4 weeks. They subsequently grouped MSers with headache according to the IHS criteria and detected 16 (16.3%) MSers suffering from migraine (migraine with aura: 2 [2%]; migraine without aura: 14 [14.3%]), 23 (23.5%) suffering from TTH and none with a cluster headache. Thus, headaches of 59 (60.2%) MSers remained unclassified. When comparing MSers with and without headaches significant differences in age, gender, MS course, physical functioning, pain and social functioning occurred. MSers with headaches were significantly younger of age (p = 0.001), female (p = 0.001) and reported more often of a clinically isolated syndrome (CIS) and relapsing/remitting MS (RRMS) instead of secondary chronic progressive MS (SCP). EDSS was significantly lower in MSers suffering from headaches compared to the MSers without headaches (p = 0.001). 

Conclusion: In conclusion headache in MSers is a relevant symptom, especially in early stages of the MS disease. Especially unclassified headache seems to represent an important symptom in MS course and requires increased attention.

“To try and replicate this studies findings I would appreciate it if you could complete this short survey. Thank you.”

Other posts of interest:

29 Sep 2011
Objective: To determine the frequency and risk factors of post-LP headache (PLPH) in research volunteers. Background: Despite increasing interest in measuring cerebrospinal fluid (CSF) biomarkers to investigate disease 
07 Aug 2013
Yes, it is one of the most disabling conditions to afflict man; those of you who have migraine headaches know what I mean.” “Neuropathic pain is another form of pain and is typically due to damage of central sensory pathways.
18 Jan 2013
They quantified prevalence of headache (43%; 95% CI 33-52%), neuropathic extremity pain (26%; 95% CI 7-53%), back pain (20%; 95% CI 13-28%), painful spasms (15%; 95% CI 8.5-23%), Lhermitte’s sign (16%; 95% CI 

About the author

Prof G

Professor of Neurology, Barts & The London. MS & Preventive Neurology thinker, blogger, runner, vegetable gardener, husband, father, cook and wine & food lover.


  • Always believed that my migraines were in some way connected to my MS. First migraine came the same time as my MS symptoms. They always became worse and more frequent before a relapse. Was attending the Migraine Clinic and the National and suffered for years before I had SPMS. Now I just have bad headaches not Migraines. Thanks for this post.

  • I wonder what % of headaches in MS patients are caused by optic nerve issues, even if the patient doesnt notice vision problems.

  • My migraine changed character when closer to diagnosis:
    I had migraine-attacks before diagnosis – they were very seldom and mostly with aura. But closer to diagnosis I experienced two short attacks with speech-problems and one with temporary numbness on my cheek. All three attacks lasted only 5 minutes or so. All attacks came when drinking coffee, two of them I was taking estrogen pills in addition. Nowadays I experience just “normal” headache (?) and then only on the right side of my forehead. It might be on the same spot as one of my last lesion.
    My strange migraine-attacks might sound like very, very short MS-relapses. Maybe the were? My relapses have been many and mild. I have read that migraine attacks can also involve both speech- and skin-feeling disturbances.

    • Anonymous I am SPMS when I was finally diagnosed by these inept neurologists in BC. Lesion load now > 35. Had MS Migraines since 13, Also I suffered from precclampsia at 21 years. Parent heavy smoker. Family history of MS on both sides. Note there is some correlation! Migraines have gotten worse and are stranger………loud bangs and static associated with beautiful colour of cobalt blue in shape of large boulder! Also am very sensitive to noise particularly traffic and equipment.
      Brief attacks can be triggered by wind,eating or touching of my right side of face associated with right pain. Believe your body……research.

By Prof G



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