This is an excellent question, though we don’t yet have a definitive explanation, and the underlying relationship is likely multifactorial. One established observation is that certain lesion locations are associated with a higher risk of migraine, several of which involve pain-processing networks. In addition, there appears to be some genetic overlap between the two conditions. There is also a notable demographic overlap. Both multiple sclerosis and migraine demonstrate a female-to-male ratio of approximately 3:1. Although later-onset MS has historically been underrecognized, the typical age of onset is between 20 and 40 years, which closely aligns with the peak incidence of migraine. Importantly, this association has persisted in studies—including this one-that controlled for these factors, suggesting that additional mechanisms are involved. There are a number of indirect mechanisms such as musculoskeletal changes and increased incidence of other comorbidities including sleep disorders and depression, which is why we believe it’s important to screen for these conditions as well.
The tendency is to treat them as completely separate conditions, which isn’t inherently wrong, but it’s always important to consider the entire patient, which is true even for conditions that don’t have the correlation previously mentioned. When selecting migraine therapies for people with MS, medication tolerability is a critical consideration. Many of the older migraine treatments can lead to increased sedation and cognitive side effects, which are already common symptoms in the MS population, so it’s essential to prioritize non-sedating medications. Additionally, many people with MS already manage complex medication regimens that can be burdensome, so the thought of adding another daily pill can sometimes sound worse than the migraines themselves. For these patients, it’s important to offer medications that can instead be offered monthly, every 3 months, or as needed. While we have the expertise to offer daily medications, we also offer monthly injectables, every 3 month infusions, procedures including botulinum toxin, and even non-pharmacological treatments like physical therapy to address musculoskeletal concerns through our new therapy center. I’m proud to be part of a center that can offer every possible option to best tailor the treatment to the individual.
To put it simply, our primary goal as neurologists is to improve your quality of life, and effective migraine management is one of the many ways that we can help accomplish that. While a significant portion of our visits appropriately focus on disease-modifying therapies and MRI findings, we also want to know about any bothersome symptoms that you’re experiencing. If you have had even one headache this past year that affected your quality of life, we want to know about it, as we can easily help.
I feel fortunate to have benefited from a training path that offered the best of both worlds. I completed my neurology residency at Temple University in Philadelphia, one of the nation’s more rigorous programs, which provides a strong foundation in general neurologic care. I then pursued a fellowship at Johns Hopkins, where I received highly specialized training in neuroimmunology. This combination has prepared me to care for patients with complex MS and neuroimmunologic conditions, while also having the general neurology background to address the full spectrum of neurologic issues they may face, including migraine, stroke, seizures, and cognitive concerns. Over the course of my lifetime, the progress in MS research and treatment has been truly remarkable, leading to meaningful improvements in quality of life. At the same time, significant challenges remain for many individuals living with MS. I am eager to contribute to ongoing research efforts aimed at addressing these unmet needs and further advancing patient care.
Most studies looking at MS and headache disorders are retrospective, meaning researchers look at data that was already collected (such as in medical records, surveys, databases etc). This is a prospective study. Prospective studies are created to collect specific data with a question in mind. Prospective studies are thought to be stronger as there is more control over what information is collected. This study utilized a headache diary in 96 people with MS and 96 people without MS to make a comparison of headache characteristics over two years.
They looked at two different types of primary headache disorders: tension-type headaches and migraine. Tension-type headaches are the most common type of headache, affecting anywhere from 30-70% of the population. Tension-type headache presents as mild to moderate both-sided pressure-like pain lasting anywhere from 30 minutes to 7 days. Migraine is less common, but still common in the general population, affecting about 15% of individuals. Migraine presents as moderate to severe one-sided throbbing or pounding lasting 4 to 72 hours with associated nausea, vomiting, loss of appetite, worsening with routine physical activity, and/or light and sound sensitivity. This study demonstrated that individuals with MS have a higher risk of having headaches and are more likely to have migraine headaches. Based on headache diary reports, individuals with MS had more frequent headaches that lasted longer and were more intense than people without MS. They were also utilizing more medications as rescue therapy for severe attacks. This study underscores that in patients with pre-existing neurologic disease, migraine is common. Migraine is also one of the leading causes of disability in young people. Fortunately, migraine is also very treatable.
As mentioned before, primary headache disorders such as tension-type headaches and migraine headaches are common across populations, including individuals with MS! There are several causes of headache that we see unique to MS, including head pain related to active inflammation during a flare, lesion-related headaches (especially if the MS attack involves pain-producing parts of the brain or involvement of both trigeminal nerves), and we can see headache as a common side effect with some of the older medications for MS.
I encourage an individualized approach to managing head pain. There is no “one-size fits all” treatment plan: what works for one person may not work for another. I like to explore lifestyle factors, offer preventive options for those with more than 4 headache days per month, and determine a rescue plan to lessen pain or time spent in a moderate or severe attack. For prevention and rescue, each headache type is managed somewhat differently. For example, for shooting electric shock-like pain, I would utilize an agent that targets nerve pain rather than a medication for migraine. There are many different options for migraine prevention, ranging from natural supplements, to older prescription medications that we’ve “borrowed” from other diseases that we’ve found to be helpful (such as blood pressure medications, anti-seizure medications, anti- depressant medications), the newer “migraine specific” therapies, botulinum toxin injections, and devices. There are a number of options and combinations of therapies that we use for migraine rescue. With my patients, I explore the pros and cons of each therapy and consider additional health problems they may have before we decide where to start. I want to find therapies that are effective and well-tolerated.
Like Dr. Lindgren alluded to previously, not that long ago, we did not have the knowledge about these diseases and therapies that we have today. While challenges still remain, I anticipate that we will continue learning more about these diseases and our field will continue to move forward. As someone who grew up in Colorado Springs and whose family resides here, I’ve really enjoyed my return to the community – I anticipate being here to stay! Over the past twenty years, I’ve watched our city grow exponentially. We need more healthcare providers! Across the nation, there is a known shortage of neurologists, not to mention headache subspecialists. I’m happy to help fill that need. I’ve enjoyed collaborating with primary care providers and different specialties across not just Colorado Springs, but across the region. Within my community at CSNA, I’ve seen how a multi- disciplinary team can benefit our patients. I can walk several steps to run cases by my colleagues in neurology, neuropsychology, physical therapy, and occupational therapy. For my neurology and neuro-optometry colleagues at our other location, a phone call isn’t too far away. Working Together for Better Care
Dr. Lindgren: While I specialize in MS and immune-mediated conditions, it’s really important for all of us at CSNA that we meet the needs of the community, so I see every neurologic condition. Headache is one of the most common things I see, so I feel extremely comfortable treating it, though I certainly can’t match Dr Moore’s expertise. I’m typically able to get significant relief for my headache patients, but the handful of times I haven’t, Dr Moore has always been eager to help and quickly troubleshoot. I’ve had patients who had seen five to ten different neurologists and had essentially given up on gaining control of their migraines, but after seeing her, they experienced quality-of-life improvements they hadn’t thought possible.
Dr. Moore: I also manage a variety of neurological diseases and do see individuals with both conditions. Headaches are one of the most common reasons to see a neurologist. Because MS is less common, I less frequently treat these conditions that fall into Dr. Lindgren’s expertise! I have a very low threshold to reach out to Dr. Lindgren. He has an incredible knowledge base, and I’ve learned so much from him regarding these challenging diseases. He’s always willing to be a second set of eyes and ears for my patients, and I certainly appreciate this.
Dr. Moore: Being a subspecialist who also practices general neurology is a win-win for patients. It means you have access to deep, focused expertise when a condition needs it, while still benefiting from a broad, whole-person approach to neurologic care. Working collaboratively allows each patient’s plan to be thoughtful, coordinated, and tailored to their individual goals. My goal is that within our community, our shared expertise and strong communication will lead to more support for our patients, leading to better experiences and outcomes overall.
Dr. Lindgren: When I was a teenager, my father was diagnosed with a neurodegenerative disorder. At the time, there were no specialists in Oklahoma with expertise in his condition, which meant our family had to travel most of a day for his out-of-state appointment. That experience left a lasting impression on me and shaped my commitment to improving access to specialized neurologic care. During my training at Johns Hopkins, I had the privilege of working closely with 14 neuroimmunologists and receiving world-class training. While I deeply valued that academic environment and continue to rely on those mentors for collaboration and guidance, my long-term goal was always to bring that level of expertise to a community where it was needed most. I strongly believe that patients should not have to leave their home communities to access specialized neurologic care. That philosophy, combined with CNSA’s commitment to building a truly comprehensive multiple sclerosis center, is what led me to choose Colorado Springs as my professional home. The scope of resources we offer—including infusion services, MRI, research, neuro-optometry, physical therapy, and neuropsychology—allows us to provide fully integrated MS care in a way that is rarely available in a single community.