Migraine and the Brain-Gut Connection: Learn More, Expect More!

(This blog is part of an educational project sponsored by Tonix Medicines. Tonix Medicines did not contribute to the content below.)

Have you ever wondered about the gut-brain connection in migraine? Why do attacks often cause nausea or even vomiting? What does it mean to have “gastroparesis” during an attack? Does this impact finding out the best way(s) to get my migraine attacks under control? And… is it even possible to do that?! In this blog, we will answer some of these crucial questions, explain a little bit about the gut-brain connection, why that matters, and why people with migraine disease should expect more from their acute treatments. We will also give tips to help you talk to your doctor about adding non-oral treatments to your migraine toolbox.

What is the Brain-Gut Connection in Migraine?

As mentioned above, migraine disease often impacts gastrointestinal issues due to the Brain-Gut Connection. The gut is frequently called the second brain, or the enteric nervous system (ENS). The brain and gut communicate through the brain-gut axis. Recent studies show the brain-gut connection is highly complex, creating a broad range of symptoms associated with migraine and gastrointestinal (GI) disorders. Additionally, emerging evidence shows an association between altered gut microbiota and migraine, fibromyalgia, and IBS.

Protecting our gut microbiome can help reduce migraine and GI symptoms, and improve our overall health and mood. This includes using non-oral medications to treat acute migraine symptoms. Keep reading to learn more!

Which Brain-Gut Symptoms Occur During Migraine Attacks?

Nausea & Vomiting: Both nausea and vomiting are common migraine attack symptoms. An extensive survey in the United States, completed by 29,727 participants, reported that 73% of patients with migraine experienced nausea during attacks and 29% experienced vomiting. Surprisingly, these symptoms were often reported to be worse than the head pain itself. If you are nauseous, your stomach is unlikely to absorb oral medications as efficiently and effectively as needed to stop an attack. If you are vomiting, it can be hard, or even impossible, to know whether an oral medication had a chance to be absorbed before you threw up. The ramifications of this are potentially huge, including the safety of taking another medication on top of one you have already used, which may or may not have been absorbed. Knowing how long to wait before trying something else can be impossible. During this time your attack escalates, making it harder to treat.

Gastroparesis: Gastroparesis, sometimes called GP, is a disorder that delays stomach emptying. GP is also known as “stomach paralysis.” Gastroparesis keeps your stomach from working correctly. The condition slows down the digestion of food, making it harder for the food to move from the stomach to the small intestine. Symptoms of gastroparesis include feeling full quickly while eating, loss of appetite, indigestion, upper abdominal pain, nausea, and vomiting. You may also have constipation, a bloated stomach, and for some people, it can impact their blood sugar levels. Unfortunately, some migraine medicines can worsen this, as well as other medications often used by people with migraine, such as GLP-1 medications, such as semaglutide. The GLP-1 medications are often used as treatments for diabetes and obesity, both of which are comorbid conditions of migraine disease. Most important to know is that gastroparesis can slow down the rate of absorption of oral medications. Instead of getting symptom relief within 1-2 hours, you may not experience relief at all as your attack continues to escalate unabated.

Your Choice Of Migraine Treatment Matters

Migraine disease is unique to each person. Although we may share common symptoms and triggers, our individual experience of attacks and responses to medication may greatly differ from others’ experiences. In addition, each person’s experience can vary from attack to attack in terms of severity, symptoms, and length. Identifying the type of attack you are having, when to start treatment, and how to manage an escalating attack are crucial to migraine management.

Option 1: Oral Medications

It’s common for people with migraine to take oral medications. Here are a few reasons why your migraine pill may not work as well as it should:

• Pills work slowly: They are absorbed in your stomach and travel through your bloodstream to get to your brain. This takes time.
• Some can cause or worsen GI side effects: Oral medications can cause stomach upset and increase migraine nausea, and they can worsen gastroparesis.
• Attack symptoms can impact their absorption: Gastroparesis and nausea can slow the absorption of oral migraine medications, and vomiting can expel the medication from your body before absorption can occur.

If oral medications are not relieving your acute symptoms within 1-2 hours of taking them, talk with your doctor about non-oral medications.

Option 2: Non-Oral Medications

There are many benefits to using a non-oral medication to manage sudden migraine attacks. Instead of a pill, these medications are administered through a nasal spray or injection. The positive outcomes of this medication delivery are:

• They work fast: Since non-oral medications bypass your gut, the medicine can reach your brain faster. This is essential when an attack escalates quickly, or when you wake up in the night with a full-blown attack.
• They don’t affect your stomach: Injections and nasal sprays do not rely on the gut for absorption and are less likely to cause stomach upset or worsen nausea.
• Vomiting does not impact the dose: If you vomit shortly after taking a pill, you have no way of knowing how much of the medication was already absorbed and how much was lost due to vomiting. Non-oral medications are not “lost” if you vomit.

In a recent Q&A, Christopher Gottschalk, MD, FHS from Yale School of Medicine, stated: “I recommend all migraine patients have non-oral migraine treatments available.”

Migraine Treatment Goals

It is surprising how many patients leave their doctor’s office with a prescription without knowing realistically what they can expect from the acute treatment they’ve been given. The other side of that knowledge is knowing when a medication is NOT working appropriately and needs to be re-evaluated in dose, combination with other treatments, or replaced. Migraine treatment goals should ideally focus on the mTOQ-4 questionnaire, which was created by Richard B. Lipton, MD, Director of the Montefiore Headache Center in New York. This is a validated, self-administered questionnaire that assesses the efficacy of current acute treatment, and it asks the following 4 questions with the answer options each time being: Never or Rarely, Less Than Half the Time, or Half the Time or Greater.

1. After taking your migraine medication, are you pain-free within 2 hours for most attacks?
2. Does 1 dose of your migraine medication usually relieve your headache and keep it away for at least 24 hours?
3. Are you comfortable enough with your migraine medication to be able to plan your daily activities?
4. After taking your migraine medication, do you feel in control of your migraines enough so that you feel you can return to normal function?

Some versions include  an additional two questions, making it the mTOQ-6:

5. Is your migraine medication well-tolerated?
6. Are you able to quickly return to your normal activities (i.e., work, family, leisure, social activities) after taking your migraine medication?

This questionnaire is an ideal starting point for a conversation with your doctor about managing your migraine attacks effectively. It can also be the groundwork of a personalized migraine action plan (MAP). A fillable version of the MAP can be downloaded and printed out for free on our website here: https://migrainemeanderings.com/migraine-toolbox.

Preventing Migraine Progression

One of the least known facts about migraine is that it is a progressive disease, which means that it can chronify – get worse. One of the risk factors for this is appropriate, timely, and effective acute treatment. When migraine is not treated appropriately, attacks can become more frequent, more severe, last longer, and be harder to treat. Attacks that only happen 3 times a month can increase to 6 times a month or more. Treating migraine attacks effectively is not only preferable in the short term, but it is crucial for disease management in the long term!

During a live Q&A, Christopher Gottschalk MD, FHS, shared, “The people who say their migraine treatment is not working well are more than 3 times as likely to progress to chronic migraine a year from now.”  You can watch the recording of this information Q&A on our YouTube channel here.

The “toolbox approach” is often the most effective treatment of migraine, and this can be easily personalized using a written Migraine Action Plan. The toolbox approach means you have a variety of treatment “tools” to choose from:  at-home therapies, FDA-cleared devices, supplements, and integrative therapies. It is essential to talk with your doctor about what you should include in your Migraine Action Plan so that you know which treatment to start and when, how to manage escalating symptoms, and when you need a medical intervention. Visit and download our free, printable Migraine Treatment Toolbox and MAP.

NOTE: Preventing, reducing, and stopping migraine attack symptoms is key to disrupting migraine progression and improving your quality of life. Shoshana Lipson, Founder and Executive Director of Migraine Meanderings, states:

“During my migraine attacks, I rarely get relief from pain and other symptoms when using just oral medications. Until my doctor started prescribing nasal sprays and injections, I frequently had to go to the ER for relief. My migraine attacks can be debilitating, but treating them at home is so much easier than going to the emergency room.”

Time to Take Action for Migraine!

If you take the mTOQ questionnaire, how do your answers score? When you look at your migraine “toolbox,” is it more of a “one pill and done” approach to stopping attacks, or does it realistically cover your migraine attack experience? If your answers are “Never, Rarely, or Less Than Half the Time,” then it’s time to talk with your doctor about creating a personalized Migraine Action Plan that includes a non-oral medication for acute treatment. In short, it’s time to take action… because YOU are worth it!

Let Us Know!

Do you experience stomach pain, nausea, and vomiting during an attack? Do you have gastroparesis during attacks, or even outside of your attacks? Is your acute migraine treatment plan working well for you, or is it time to Take Action because you deserve more when it comes to managing your migraine and reclaiming your quality of life?!