Abstract
Two patients with migraine are described who also suffered from gastric reflux. The reflux triggered headaches that originated from the upper gum/teeth and responded to specific reflux treatment.
Introduction
Migraine headaches can be triggered by a great variety of stimuli. A very potent trigger of often severe and prolonged headaches is the oestrogen cycle in women. Other common triggers of migraine headache are stress/tension, not eating on time, fatigue and lack of sleep (1). Also, the gastrointestinal tract can provide a trigger for migraine headache (2) and here I describe two patients whose migraine headaches were triggered by gastric reflux. The reflux-triggered headaches were different from their usual migraine headaches in that they originated from the upper gum/teeth. Treatment was simple and consisted of increasing the dose of the proton-pump inhibitor the patients were taking for their gastric reflux.
Case studies
A 43-year-old man had experienced migraine headaches since age 19 years. The headaches occurred four to eight times per month and usually lasted for 1 day but sometimes for 2–4 days. About half of the headaches were present on awakening in the morning. They were almost always located on the right, in the temple and the eye. The headaches were moderate in intensity on awakening and became severe if not treated effectively. They were always accompanied by nausea and, when severe, also by vomiting. Sumatriptan, 50 mg orally, generally provided full relief of the headache within 1 h.
When coming on during the day, the headaches tended to be on the left. These left-sided headaches originated from the upper gum and extended via the cheek into the eye. They were more resistant to treatment with sumatriptan than the right-sided headaches. The left upper gum was sore and sensitive to temperature changes; it was sore to touch on the inside above the second molar. He had experienced reflux for years with severe retrosternal pain but controlled it effectively with omeprazole, 20 mg daily. Increasing the dose of the medication to 20 mg twice daily relieved the left gum soreness and reduced the left-sided headaches to sporadic occurrence.
A 64-year-old woman had experienced migraine headaches since age 42 years. Initially the headaches occurred once every 2 weeks, usually on the weekends. They woke her up out of sleep at 03.00 to 04.00, built to their maximum intensity in 3 h, and lasted for 14 h. They were severe in intensity and associated with nausea, vomiting, photophobia, phonophobia and osmophobia. The headaches were located in the right forehead and eye. For no apparent reason, they became more frequent a year prior to consultation, ultimately occurring daily. The headaches were present on awakening in the morning when she slept beyond 06.00 to 07.00. They were moderate in intensity and relieved by half to one 50-mg indomethacin suppository. The headaches were still located on the right but now originated from the upper teeth, extending via the cheek into the eye. She had experienced reflux for several years, causing a burning pain high retrosternally. The reflux was initially controlled with ranitidine, 150 mg twice daily, but more recently required omeprazole, 20 mg daily. However, when she forgot to take it for 3–4 days, she again experienced the burning pain. Increasing the dose of the medication to 20 mg twice daily rapidly improved the headaches to once per week. Also the reflux became much less bothersome, allowing her to gradually decrease the use of the omeprazole.
Discussion
Gastric reflux occurs in particular at night when, due to the horizontal position, acid runs back into the oesophagus, causing complaints ranging from retrosternal burning to hoarseness or cough. However, also sensitive gum/teeth can be a manifestation of reflux and in the patients described above, the sensitivity was sufficient to trigger migraine headaches. It caused pain to radiate from the upper gum/teeth into the cheek and from there, into the eye, a common location of migraine headache.
The origin of the pain in the upper gum/teeth suggested reflux as the trigger, which was confirmed by the dramatic improvement of the headaches following the increase in anti-reflux treatment. It is, of course, also possible that proton-pump inhibitors have a specific preventive effect on migraine headaches, so far not described. However, I consider this possibility remote on the basis of extensive experience with the medications to treat gastritis in my headache patients.