Author: Vincent T. Martin, MD, Co-director of the Headache & Facial Pain Center at the University of Cincinnati
Spring is a welcomed change in seasons, especially for people who endure frigid winters and copious snowfall. But for the percentage of people living with migraine who also experience allergies, asthma or hay fever, it’s a time of year when headaches tend to increase and are accompanied by the symptoms of seasonal allergies.
Here’s what we know about the connection between migraine, hay fever, asthma, allergies, and the treatment options currently being used to manage them.
What is hay fever and how is it diagnosed?
The medical term for hay fever is allergic rhinitis. Allergic rhinitis occurs when a patient develops symptoms of runny nose, post nasal drip and nasal congestion upon exposure to an allergen. An allergen is something in the environment to which you are allergic such as tree pollen, mold, cat hair, dog hair or dust. To firmly establish the diagnosis of allergic rhinitis, one must have the above mentioned symptoms upon exposure to the allergen and also have a positive allergy test to that allergen. Allergy testing can take one of two forms: skin prick testing and blood tests. With skin prick testing, an allergist puts minute quantities of allergen on the tip of a needle and then he/she pricks your skin with the needle. A positive response requires that a certain degree of redness and swelling of the skin occurs in the region of the skin prick. In addition, blood tests can be performed to identify an allergen.
What is asthma and how is it diagnosed?
Asthma is a disease in which your airways constrict intermittently and you become short of breath. Its diagnosis can be established by pulmonary function testing, a specialized lung test in which you blow into a tube and a technician will record the volume of air that is exhaled before and after receiving inhaled asthma medications that dilate a person’s airways. Persons with asthma will have a reduced volume of exhaled air before the asthma medication, and normal amounts of exhaled air after the asthma medication. The “reversibility” of airway constriction before and after administration of asthma medications is necessary to firmly establish a diagnosis of asthma.
How are allergies related to asthma?
Approximately 70% of persons with asthma have one or more allergies found in allergy testing. Allergies do not cause asthma, but represent an important trigger factor for attacks of asthma. Exposure to allergens creates inflammation in your lungs that can increase constriction of the airways.
What causes allergies and asthma?
The cause of allergies and asthma is “in part” genetic and “in part” environmental. A genetic predisposition to allergies and asthma is often passed from one generation to another. However, environmental factors are also important. In the past it was thought that “over exposure” to allergens might predispose to development of these disorders, but recent studies have demonstrated that “under exposure” to allergens during childhood might lead to more allergies. This is called the “hygiene” theory of allergies.
Are hay fever and asthma related to migraine?
Numerous studies have found that migraine is more common in those with hay fever and asthma. One study found that migraine occurred in 34% of persons with hay fever (allergic rhinitis) as compared to 4% of those without this disorder.1 Asthma is 1.2-1.6 times more prevalent in those with migraine than in those without it.2-5
If one has migraines and hay fever or asthma, then the frequency of migraine attacks are increased. Headache attacks were 14-28% more frequent in those with migraine and hay fever than in those with migraine alone.6 Persons with episodic migraine (less than 15 days per month with headache) and asthma are 2.1 times more likely to develop chronic migraine (greater than 15 days per month with headache) one year later than those with episodic migraine alone.7
Where is the location of headaches that are related to hay fever or sinus disease?
We don’t know the specific location of headaches related to hay fever, but one study did describe the location of headaches in those with chronic rhinosinusitis, which is a long standing infection of the sinuses.8 The headaches were located in the regions of the sinuses including the forehead, between and around the eyes and cheekbones. The headaches had a mild to moderate intensity, were generally located on both sides of the head and resembled tension-type headaches.
How might hay fever and asthma predispose to migraine?
There are numerous ways that these disorders could increase the frequency of migraine attacks. First, increased inflammation caused by these disorders might increase migraine. Second, nasal congestion caused by hay fever could directly activate the trigeminal nerve in the nose and trigger migraine. Also, it might cause snoring that could lead to sleep apnea that could precipitate headaches. Third, use of asthma medications such as albuterol might trigger attacks of migraine. Fourth, both hay fever and asthma activate nerves in the parasympathetic nervous system. It is possible that activation of these nerves increases migraine frequency.
Can hay fever medications help your migraine?
We really don’t know the answer to this question because there have been no studies of these therapies in persons with migraine. However, there have been studies in persons with rhinitis to determine if sinus pain and/or headache improve with these therapies. One study found that steroid nasal sprays decrease the severity of sinus pain in persons with hay fever.9 Another found that capsaicin nasal spray (a substance found in hot chili peppers) decreased the severity of headache in those with non-allergic rhinitis, which is a form of rhinitis triggered by non- allergic triggers (perfumes, cigarette smoke).10
Montelukast is an oral therapy used to treat asthma and allergic rhinitis. Uncontrolled studies suggested that it was effective in the treatment of migraine.11,12 However, a randomized controlled trial found it to be ineffective as a preventative therapy for migraine.13 This study was conducted in migraine patients irrespective of whether they had allergies or not. It is unknown if the results would have differed if it had been conducted in those with migraine and allergies.
We performed a study in younger persons with migraine and found that the administration of allergy shots were associated with 52% reduction in the frequency of migraines as compared to those that did not receive allergy shots.14 However, this study did not randomize patients to allergy shots or placebo, and therefore these results will need to be confirmed in future studies before definitive conclusions can be reached about this therapy.
What is our clinical approach to the migraine patient with allergies, hay fever or asthma?
It is extremely common for patients to have both migraine and symptoms of rhinitis. In fact, one study found that 67% of all persons with migraine had symptoms of rhinitis (nasal congestion, runny nose, post nasal drip, itchy nose).6 If patients with migraine also have rhinitis symptoms, we treat them with medications to treat this disorder, which include nasal steroids and oral/nasal antihistamines. This may help the rhinitis symptoms as well as any sinus pain/pressure they may be experiencing, but it is unknown if these therapies will decrease the frequency of migraine headache.
Allergy shots are an important therapy to reduce the frequency of allergy symptoms. We do not specifically recommend allergy shots for persons with migraine who have allergies, but we do tell our patients that uncontrolled studies suggest that allergy shots may be associated with a reduced frequency of migraine in individuals less than 45 years of age. Ultimately, the decision to start allergy shots is made between the allergist and patient weighing the risks, benefits and costs of this therapy.
If you have questions about your migraine or migraine symptoms, contact the American Migraine Foundation so we can help connect you with a doctor in your area.
- Ku M, Silverman B, Prifti N, Ying W, Persaud Y and Schneider A. Prevalence of migraine headaches in patients with allergic rhinitis. Ann Allergy Asthma Immunol. 2006; 97: 226-30.
- Davey G, Sedgwick P, Maier W, Visick G, Strachan DP and Anderson HR. Association between migraine and asthma: matched case-control study. Br J Gen Pract. 2002; 52: 723-7.
- Fernandez-de-Las-Penas C, Hernandez-Barrera V, Carrasco-Garrido P, et al. Population-based study of migraine in Spanish adults: relation to socio-demographic factors, lifestyle and co-morbidity with other conditions. J Headache Pain. 2010; 11: 97-104.
- Lateef T, Swanson S, Cui L, Nelson K, Nakamura E and Merikangas K. Headaches and sleep problems among adults in the United States: findings from the National Comorbidity Survey-Replication study. Cephalalgia. 2011; 31: 648-53.
- Aamodt AH, Stovner LJ, Langhammer A, Hagen K and Zwart JA. Is headache related to asthma, hay fever, and chronic bronchitis? The Head-HUNT Study. Headache. 2007; 47: 204-12.
- Martin VT, Fanning KM, Serrano D, et al. Chronic rhinitis and its association with headache frequency and disability in persons with migraine: results of the American Migraine Prevalence and Prevention (AMPP) Study. Cephalalgia. 2014; 34: 336-48.
- Martin VT, Fanning KM, Serrano D, Buse DC, Reed ML and Lipton RB. Asthma is a risk factor for new onset chronic migraine: Results from the American migraine prevalence and prevention study. Headache. 2016; 56: 118-31.
- Aaseth K, Grande RB, Kvaerner K, Lundqvist C and Russell MB. Chronic rhinosinusitis gives a ninefold increased risk of chronic headache. The Akershus study of chronic headache. Cephalalgia. 2010; 30: 152-60.
- Ratner PH, Howland WC, 3rd, Jacobs RL, et al. Relief of sinus pain and pressure with fluticasone propionate aqueous nasal spray: a placebo-controlled trial in patients with allergic rhinitis. Allergy Asthma Proc. 2002; 23: 259-63.
- Bernstein JA, Davis BP, Picard JK, Cooper JP, Zheng S and Levin LS. A randomized, double-blind, parallel trial comparing capsaicin nasal spray with placebo in subjects with a significant component of nonallergic rhinitis. Ann Allergy Asthma Immunol. 2011; 107: 171-8.
- Sheftell F, Rapoport A, Weeks R, Walker B, Gammerman I and Baskin S. Montelukast in the prophylaxis of migraine: a potential role for leukotriene modifiers. Headache. 2000; 40: 158-63.
- de Souza Carvalho D, Fragoso YD, Coelho FM and Pereira MM. Asthma plus migraine in childhood and adolescence: prophylactic benefits with leukotriene receptor antagonist. Headache. 2002; 42: 1044-7.
- Brandes JL, Visser WH, Farmer MV, et al. Montelukast for migraine prophylaxis: a randomized, double-blind, placebo-controlled study. Headache. 2004; 44: 581-6.
- Martin VT, Taylor F, Gebhardt B, et al. Allergy and immunotherapy: are they related to migraine headache? Headache. 2011; 51: 8-20.