Nausea is often a symptom of a M
Nausea is often a symptom of a Migraine attack. Some have theorized over the years that the nausea might be caused by gastric stasis, delayed emptying of the stomach. There have also been questions about how gastric stasis might affect treating Migraine attacks because it can slow the disintegration and absorption of medications in the stomach.
The results of studies have shed some light on gastric stasis as it relates to Migraine disease.
In a continuing medical education module, “Targeting Multiple Mechanisms in Migraine: New Advances in Acute Care,” the principle investigator in this study, Dr. Sheena K. Aurora, asks “Why Should Clinicians Who Treat Migraineurs Care About Gastric Stasis?” Her answer is:
“The emphasis is that although we have known for a long time that perhaps gastric stasis occurs in migraine, this has not been very well quantified. With all the oral treatment that is available… there is a lot of dissatisfaction out there with oral treatment. Perhaps it is the reason that drugs may not be getting absorbed as well in migraine. So it really behooves us to study the GI system in migraine to elucidate those results.”
2006 Study Methods: Ten Migraineurs were compared to 10 people without Migraine, matched by age and gender. After a standard meal, gastric scintigraphy was performed, both during a Migraine and between Migraine attacks. To facilitate the study, the Migraine attacks studied were induced by medication.
2006 Study Results:
- Among the Migraineurs, the time to the stomach emptying by half was delayed by 78% during a Migraine attack.
- Among the Migraineurs, the time to the stomach emptying by half was delayed by 80% not during a Migraine attack.
- The time to emptying by half among Migraineurs was significantly longer among the Migraineurs, 188.8 minutes, than the control subjects. 111.8 minutes.
2006 Study Conclusions:
Dr. Aurora and her colleagues concluded that, “nausea is caused by a central process as a part of changes occurring in the brainstem as a part of the acute migraine rather than due to gastric stasis, as the stasis is present even outside an attack and none of these patients were nauseous outside an attack.”
Implications of 2006 Study:
This study and Dr. Aurora’s section of the Medscape CME presentation show a clear need for more studies in this area. For acute Migraine treatment to be successful, we must either find a way to address gastric stasis or decrease our dependency on oral delivery of medications.
At this time, there are some Migraine abortives available in forms other than oral administration:
- DHE45 injections (dihydroergotamine)
- Migranal Nasal Spray (dihydroergotamine)
- Imitrex STATdose injections (sumatriptan)
- Imitex Nasal Spray (sumatriptan)
- Zomig Nasal Spray (zolmitriptan)
Even so, in the Medscape presentation, Dr. Aurora comments, “Patients were asked what their choices were for treatment. The injection was rated the lowest, and the tablet was rated the highest. So even though pain relief, as we’ve shown, is much better through the nonoral route – and particularly the injectable route – still the oral tablets seem to be what patients prefer the most.”
In 2007, another study was conducted to evaluate gastric motility and emptying during spontaneous Migraines (not induced) and compare the data to the 2006 study in which Migraines were induced.
2007 Study Methods:
Three Migraineurs were observed during three periods:
- during a spontaneous Migraine
- during an induced Migraine
- during the interictal period (between Migraines).
Gastric scintigraphy was performed following a standard meal.
2007 Study Results:
Similar gastric slowing was seen in all 3 groups.
2007 Study Results and Implications:
"These studies continue to provide evidence of a dysfunction in the autonomic system in a subset of migraineurs. Previous imaging studies have demonstrated a dysfunction in the periaqueductal gray (PAG). High field strength MRI testing determined that iron accumulation occurred in the PAG and that these changes correlate with duration of migraine frequency, are not independent of the presence of aura, and do not correlate with patient age. Recent imaging studies have demonstrated that the hypothalamus, the main area of the brain which controls the autonomic system and also the area of the brain which potentially triggers a migraine, had increased blood flow during migraine. An abnormality of this area inherited or otherwise may indeed be a key factor in causation of migraine.
Future studies are warranted to include establishing a relationship between gastric stasis and migraine disease burden; any correlation to disease phenotype; correlation to changes in the brain stem, hypothalamus, and other areas; and correlation to other autonomic changes in migraineurs. In conclusion, based on these data, it appears that some migraineurs have abnormal gastric emptying, both during and outside of an attack. Further exploration of the implications of this to therapeutic interventions is warranted."3
Summary and Comments:
These studies clearly demonstrated that gastric stasis occurs in Migraineurs, at all times, not just during a Migraine. This has significant implications regarding the use of oral medications. It explains to a great extent why many Migraineurs do not get timely and adequate relief from oral medications taken during a Migraine attack.
As stated in the study results, more studies are needed to fully understand the relationship between gastric stasis and it’s impact on Migraine and any clues it may offer regarding dysfunction in the periaqueductal gray area of the brain, iron accumulations in the PAG, the role of the hypothalmus, and more.
The practical “take-away” of this study is for Migraineurs to discuss Migraine abortives in the nonoral types listed above if oral abortives seem ineffective.
1 Richard B. Lipton, MD; Sheena K. Aurora, MD; Rami Burstein, PhD; Stephen D. Silberstein, MD, FACP. “Targeting Multiple Mechanisms in Migraine: New Advances in Acute Care.” Medscape CME Circle. 2005.
2 Aurora, Sheena K., Kori, Shashidhar H., Barrodale, Pat, McDonald, Susan A. & Haseley, David (2006) “Gastric Stasis in Migraine: More Than Just a Paroxysmal Abnormality During a Migraine Attack.” Headache: The Journal of Head and Face Pain 46 (1), 57-63. doi: 10.1111/j.1526-4610.2006.00311.x
3 Aurora, Sheena K., MD; Kori, Shashidhar, MD; Barrodale, Patricia, RN; Nelsen, Andrew; McDonald, Susan, MA. “Gastric Stasis Occurs in Spontaneous, Visually Induced, and Interictal Migraine.” Headache: The Journal of Head and Face Pain 2007;47:1443-1446. doi: 10.1111/j.1526-4610.2007.00922.x.
Teri Robert is a leading patient educator and advocate and the author of Living Well with Migraine Disease and Headaches. A co-founder of the Alliance for Headache Disorders Advocacy and the American Headache and Migraine Association, she received the National Headache Foundation’s Patient Partners Award and a Distinguished Service Award from the American Headache Society. Teri can be found on her website, and blog, Facebook, Twitter, StumbleUpon, Pinterest, LinkedIn, and Google+.