Most people with migraine attacks are careful to avoid their triggers. Common triggers can include stress, hunger, caffeine, hormones, bright lights, and—gasp! Even chocolate! Recent research has added low back pain to the list.
Both conditions can start out as dull, throbbing pain and quickly progress to an intensity that is unbearable. If you’ve ever experienced a migraine or low back pain, you know that the pain can reach a point where the only thing you can do is lie down in a dark room and hope relief comes quickly.
The potential causes of migraine attacks and low back pain are plentiful. Knowing how foods, environmental factors, and stress affect your body can help keep them at bay.
[Further exploration: Does Ehlers-Danlos Syndrome Cause a Migraine Attack?]
What causes migraine and back pain together?
The link between migraine and back pain is well established in the literature. Several robust studies that include a large number of participants, in several countries, across the lifespan have examined the connection between the conditions.
A study on chronic migraine in the journal Pain reported that people with a history of migraine or tension-type headache were more likely to have frequent low back pain. Researchers noted that these findings were in line with other study findings.
Both population and clinic-based studies have reported that general headache, and particularly migraine, often occurs with low back pain. They also found that these headaches were associated with other pain conditions, such as fibromyalgia, TMJ disorders, and facial pain.
A Danish study in the Journal of Neurology Research looked at the risk factors for developing migraine and identified low back pain to be a potential cause. A 2019 systematic review in the Journal of Headache and Pain found an association between chronic headaches and low back pain. The main implication of linking these conditions is in the treatment.
While no one really knows exactly what the mechanisms are behind the link between migraine and low back pain, it’s likely associated with a decrease of grey matter in the brain that are often found among people with chronic pain. The location of where they lose the grey matter varies among each person, but some research shows an overlap in the anterior cingulate cortex, insula, and dorsolateral prefrontal cortex. Gray matter, which makes up most of the outer layer of the brain, is associated with memory, emotions and its regulation, and various cognitive functions like reasoning and learning.
See image of a comparison of where grey matter is decreased.
Typically, migraine and back pain would be treated by clinicians in different specialities where it would likely benefit the patient to have the conditions managed together.
Some causes of headache and back pain include:
- Premenstrual syndrome
- Infection
- Arthritis in the neck or upper back
- Fibromyalgia
- Injury
- Stress
- Temporomandibular Joint (TMJ)
- Back spasms
- Cerebrospinal fluid (CSF) leakage
When should you see a doctor?
In most conditions, it’s time to see a physician when your normal routine is interrupted by pain or dysfunction. Migraine attacks or back pain that keeps you from caring for yourself or others, going to work or school, or maintaining your normal social habits are cause for concern. Your physician may recommend prescription medications or changes to your daily routine that can help reduce migraine attacks by eliminating triggers.
When meeting with your physician, it may be helpful to attend your appointment with a list of questions ready. Some things you may wany to ask include:
- What are some foods that might be triggering my migraine attacks?
- Are any of my current medications known to cause migraine symptoms?
- How does stress affect the condition?
- What conservative (non-pharmacological) treatments are available?
- What are the side effects of the pharmocological interventions?
- Are there any lifestyle changes I can make that could be helpful?
What works for treating migraines?
Treatment for migraine attacks can be pharmacological or non-pharmacological. The non-drug options generally involvemaking immediate environmental changes to reduce triggers. This could mean turning out lights, eliminating foods, or performing bio-feedback exercises. Over-the-counter medications have also been found to be helpful, particularly if they are taken at the first sign of an attack.
- Symptom-relieving medications: over-the-counter pain relievers such as aspirin or ibuprofen may help but their long-term effects (gastrointestinal upset, ulcers, etc.) may preclude them from being a true solution. Prescription drugs can be used for several reasons.
- Triptans are used to block pain pathways in the brain but may not be appropriate if you are at risk of a heart attack or stroke.
- Dihydroergotamine can be helpful for migraine-related nausea and vomiting but should not be used if you have high blood pressure, kidney or liver disease, or coronary artery disease.
- Calcitonin gene-related peptide (CGRP) antagonists have been found to improve both pain and other migraine-related symptoms; the downside is they are known to cause excessive sleepiness.
- Preventative medication: medication for migraine can take two forms: pain-relieving or prophylactic (preventative). Prophylactic medications include beta blockers to lower blood pressure, antidepressants, anti-seizure drugs, Botox, and CGRP monocolonal antibodies. Antidepressants and anti-seizure medications can cause side effects such as sleepiness or dizziness. Anti-seizure drugs should not be used if you are pregnant or trying to get pregnant.
- Exercise: exercise is an excellent tool to treat migraine attacks because it decreases stress and inflammation while increasing the release of endorphins. Both aerobic and anaerobic exercises appear to release endorphins and, as such, both may have a role in the treatment of migraine.
Exercise also has psychological benefits such as improved self-efficacy and reduced migraine burden. Research has shown higher intensity exercise tends to be more beneficial, but patients who cannot tolerate high-impact activities can still benefit from low-impact exercise, such as walking and yoga.
- Physical therapy: physical therapy for patients with migraine attacks focuses on the musculoskeletal symptoms as well as vestibular symptoms in the ear. Treatment may include manual therapy to the neck and upper back, exercises that focus on positional/postural awareness, and education that empowers the patient to continue to participate in their activities of daily living.
Therapists who work with patients who are experiencing migraine and low back pain should be aware of the additional burden these patients feel from the combination of the conditions. Either condition can be overwhelming for the patient in isolation but the stress of both at the same time should not be ignored by their treating clinicians. - Massage: massage therapy can be helpful in addressing pain intensity in patients with migraine. Patients who had regular massage found that while the intensity of their attacks was unchanged, the frequency of them was decreased. These patients also reported improved sleep quality compared to the control group. Migraine seems to be related to central sensitization, which is a heightened sensitivity of the central nervous system that makes certain stimuli feel more painful. Massage therapists who work with patients experiencing back pain and migraine may need to be extra thoughtful when it comes to patient position, pressure, room lighting, and even background music.
- Psychotherapy: several psychological methods have been used to treat migraine, including cognitive behavioral therapy (CBT), relaxation training (RT), and biofeedback (BF). CBT, sometimes called mindfulness training, did not seem to reduce the number of attacks but rather the impact of the attacks on the patient’s daily tasks.
Biofeedback and progressive relaxation training can be used to help patients self-manage their condition without medications. These treatments teach patients to focus on the responses in their bodies (e.g. muscle tension, skin temperature) when they feel a migraine attack coming on. Learning to modulate these responses can substantially decrease frequency and severity of migraine, according to the American Migraine Foundation.
Studies have been unable to conclude that one type of therapy is better than another. CBT combined with RT, the most common approach, seems to create a decent reduction in symptoms.
What causes a migraine?
There are several types of migraine. The most common types are:
- Migraine with aura: This common type of migraine is characterized by a warning sign that typically involves sight (blind spots or flashing lights). The cause of migraine with aura is unknown, but research suggests it may be related to altered brain activity called cortical spreading depression (CSD). CSD describes a slow wave of activity in the brain that involves dramatic changes in the neural and vascular function.
- Migraine without aura: This type usually affects one side of your head and involves throbbing pain that gets worse with movement. Nausea and vomiting and sensitivity to light and sound may also be symptoms of this type of migraine.
- Chronic migraine: migraine condition defined by having a headache on at least 15 days of the month, with more than half of the days having migraine symptoms, for at least three months. Chronic migraine symptoms are headache, photophobia, phonophobia, nausea and/or vomiting.
The exact cause of chronic migraine is unknown but conditions thought to increase the tendency to develop migraine include: depression, anxiety, fibromyalgia, sleep apnea, and postural orthostatic tachycardia syndrome.
- Episodic migraine: similar to chronic migraine but with fewer than half of the 15 days of headaches having migraine symptoms. In those with episodic migraine, 2.5 out of 100 will develop chronic migraine.
- Migraine with brainstem aura: this rare migraine presents with at least two of these symptoms: slurred speech, vertigo, tinnitus, double vision, difficulty walking, loss of consciousness, numbness of the arms and/or legs, and impaired vision. This type is also thought to be caused by CSD.
- Vestibular migraine: combines vertigo, dizziness, and balance difficulties with other typical symptoms of migraine (nausea, vomiting, sensitivity to light and sound, etc.)
- Menstrual migraine: these migraine attacks seem to be related to the hormonal changes that occur with menstruation.
- Abdominal migraine: occurs in children and stops at adulthood, However, these people tend to have more traditional migraine headaches as adults. Abdominal migraine is characterized by severe stomach pain that can last up to three days. Those with abdominal migraine may feel sick and even vomit during attacks, but they do not typically have a headache. This cause of abdominal migraine is unknown.
- Hemiplegic migraine: This type is similar to a stroke. A person with this type of migraine will have weakness on one side of the body during the attack. Other symptoms such as visual disturbance, difficulty speaking or communication, vertigo, ringing in the ears, and confusion may accompany the temporary weakness. The familial version of hemiplegic migraine is inherited.
Resources for migraines and low back pain
What is emerging from the research on migraine and back pain is that treating these conditions separately may not be the best approach. Finding a healthcare provider who explores the link between the two conditions can get patients on the path to relief sooner than treating the conditions separately.
Both migraine and back pain can be debilitating conditions that make it difficult to perform normal daily tasks or engage with your social circle or environment. Establishing a health care team that makes you feel heard and finding support from in-person or online groups can make living with these conditions easier.
Check out the resources below to explore information related to migraine and back pain.
Association for Behavioral and Cognitive Therapies
Association of Migraine Disorders
Coalition for Headache and Migraine Patients (CHAMP)
Penny Goldberg, DPT, ATC
Penny Goldberg, DPT, ATC earned her doctorate in Physical Therapy from the University of Saint Augustine and completed a credentialed sports residency at the University of Florida. She is a Board Certified Clinical Specialist in Sports Physical Therapy.
Penny holds a B.S. in Kinesiology and a M.A. in Physical Education from San Diego State University. She has served as an Athletic Trainer at USD, CSUN, and Butler University.
She has presented on Kinesiophobia and differential diagnosis in complicated cases. Penny has published on returning to sports after ACL reconstruction and fear of movement and re-injury.
Outside of the clinic, Penny enjoys traveling, good cooking with great wine, concerts, working out and playing with her dogs.
