An Expert Explains Why Migraine Attacks Make You Nauseous

8 Out of 10 People Experience a Stomach Ache with Migraine Attacks

Not just a headache” has become a rallying cry for the millions of us living with Migraine. Even though Migraine creeps into almost all areas of our bodies and our lives, the general public still thinks of it as a “headache,” which is ironic when nausea and vomiting are among the most common symptoms.

Dr. Amaal Starling, headache specialist and Assistant Professor of Neurology at the Mayo Clinic, is just one of many valuable people in the Migraine community working hard to educate doctors, patients, and the public. Her education, clinical expertise, and personal experience provide her with a valuable perspective on Migraine disease.

We sat down with Dr. Starling to find out why so many of us experience a stomach ache with Migraine attacks.

1-on-1 Interview with Mayo Clinic Headache Specialist, Dr. Amaal Starling

Paula Dumas: In my personal experience, and most people in our community, a stomach ache with a Migraine attack can be very disabling. How common are nausea and vomiting among people with Migraine?

Dr. Starling: It’s very common. The majority of my patients that have Migraine experience nausea as well as vomiting. In general, from the studies, we know that approximately eight out of every ten Migraine patients will experience nausea, and about 50% of patients that have Migraine will also experience vomiting. So it’s very common.

Paula Dumas: What is actually going on in the digestive system when that happens?

Amaal Starling, MD, headache specialist at Mayo Clinic

Dr. Starling: I tell my patients that when they’re having a migraine, even though they’re having pain in their head, their entire body is going through the Migraine process. So your stomach is also having a migraine, and what happens is the nervous system that is within the stomach sends the signals for the stomach to stop functioning well.

This causes something called slowed gastric emptying, meaning the stomach is slow to dump the material from inside the stomach into the intestines. The other word for this gastric stasis.

Paula: So during gastric stasis, the food is not going anywhere, and this makes you vomit or makes you feel queasy. Is constipation also a part of this?

Dr. Starling: Yes, that can definitely happen. Again, just like there’s a nervous system that controls the stomach, that same nervous system also controls the intestines.

The intestines can get slowed down, and that can cause some constipation or even diarrhea for some patients. A Migraine attack basically causes dysfunction of your entire GI tract, from your stomach all the way down into your intestines.

Many kids with Migraine with experience stomach issues without head pain. Image: Pixabay

Kids Experience Unique Stomach issues with Migraine

Paula: Can you explain cyclical vomiting and abdominal migraines?

Dr. Starling: Cyclic vomiting syndrome and abdominal migraine are variants of Migraine, and they’re actually more common in our pediatric population. With abdominal migraine, individuals will have episodes of abdominal pain that is usually poorly localized somewhere in the stomach area.

These episodes will come and go, similar to migraine attacks that will come and go. There are patients for whom abdominal Migraine develops into a more chronic problem similar to Chronic Migraine.

Cyclic vomiting syndrome is another Migraine variant where they’ll have episodes where they’re unable to stop vomiting, and then episodes where they’re doing okay in between – similar to having episodic Migraine. Both of these things, as I mentioned, are more common in the pediatric population, but they can be treated effectively with the same types of medications that we use for Migraine, whether they have a headache or not.

That is another important concept: Migraine should not be synonymous to head pain. Migraine is a sensory processing disorder, and so some people have Migraine without any head pain at all, and they may only have nausea, the abdominal pain, all of these other symptoms that talk about.

The Link Between Irritable Bowel Syndrome and Migraine

Paula: A lot of people with Migraine will report that they also deal with IBS. Is that truly IBS or is that just a form of Migraine?

Dr. Starling: Irritable bowel syndrome is something that is comorbid with patients that have Migraine, meaning a lot of individuals with Migraine will also have symptoms of irritable bowel syndrome. In irritable bowel syndrome, individuals will have alternating episodes of diarrhea and constipation.

It’s definitely possible that someone who has irritable bowel syndrome with those alternating episodes of diarrhea and constipation may be more prone to some of the GI symptoms, or gastrointestinal symptoms, in Migraine, but I do think that they’re recognized as two separate disorders. I could imagine, though, that individuals that have irritable bowel syndrome are more susceptible to having those symptoms when they have a migraine attack.

Best Options for Treating Migraine when You Have GI Symptoms

Paula: Let’s say we have somebody who is dealing with a lot of nausea and vomiting, and they’re losing time from work and family. And because of this nausea and vomiting, they can’t swallow their oral medication. What are their best treatment options?

Dr. Starling: First, it’s not just that individuals that have significant nausea and vomiting are unable to sometimes keep their medication down, but even if they keep it down, it may actually not be working very well. They’re unable to absorb that medication effectively. Or it may take too long, and so someone doesn’t have benefit from their triptan medication for two hours or more when they should have had benefit within one hour.

We need to treat the symptoms, but we also need to get the medications into the bloodstream more effectively. To treat the symptoms, there are a lot of anti-nausea medications that can be used, and some are actually effective not only for nausea but also for the head pain itself. We call these neuroleptic medications, and they include things like prochlorperazine, promethazine, and metoclopramide.

In addition, the triptan medications, which are the gold standard for as-needed treatment of Migraine headaches, usually come in oral tablets, but those are useless if we’re throwing up or it’s not well-absorbed.

Fortunately, the triptans also have non-oral formulations that we can use. The various non-oral formulations include nasal sprays as well as injections, and there are also some additional formulations that are coming down the pipeline, which include inhalations, transdermal patches.

Those are all different formulations that can more effectively get into the bloodstream and completely bypass the gastrointestinal tract.

Paula: And these act more quickly than oral medications?

Dr. Starling: Exactly, because they’re able to access the bloodstream much quicker. The sumatriptan injection, the subcutaneous injection, is actually the most potent and the fastest triptan that we have, and that’s because it’s able to get into the bloodstream very, very quickly.

The injection formulation is ideal for individuals who have significant nausea and vomiting, and also for individuals who have a rapid onset of their migraine attack.

Don’t miss interviews with Dr. Amaal Starling + more experts on the 2019 Migraine World Summit – Watch here

Paula: Are there any other non-oral treatments, like some of the neuromodulation devices, that would be appropriate for somebody who’s got nausea and vomiting with their attacks?

Dr. Starling: Yes, so the other concept is that if we can treat early, then we may be able to prevent nausea and vomiting from occurring. Some of the neuromodulation devices, like the single-pulse transcranial magnetic stimulation device, are recommended for early treatment.

Studies have shown that if we treat early with that device, we’re able to prevent nausea and vomiting from even occurring.

Paula: Are there any options that might work for a stomach ache with a Migraine attack, like ginger?

There are several different ways to use fresh ginger for Migraine relief. Image: Pixabay

Dr. Starling: I’m a proponent of anything that is not a medication that can be added onto medication treatments or non-oral treatments for pain as well as for nausea and vomiting. Ginger can be helpful.

Some patients have used B6 which can be helpful as well for nausea. Other patients have used the Sea-Bands that activate acupressure points. Other individuals will simply use acupressure points and acupuncture to help with nausea and vomiting.

Paula: Anything else you would like to add about overcoming nausea and vomiting?

Dr. Starling: The one thing that I really would like to emphasize is how debilitating nausea and vomiting is. I want to emphasize this to empower patients to make sure that when you meet with your doctor, that you talk to them about your treatment options for your GI symptoms.

You should always have a medication that you can use symptomatically.