The American Headache Society (AHS) is a professional society of health care providers dedicated to the study and treatment of headache and face pain. 

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Twice a year, members of the American Headache Society meet to discuss scientific and clinical updates related to headache disorders. Here are a few key highlights from the recent June 2021 meeting.

Triggers or Premonitory Symptoms?

Do bright lights trigger your migraine? What about strong smells or loud noises?  It may not be as simple as you might think.

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Migraine attacks occur in different phases:

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1. Premonitory symptoms such as yawning, food cravings, light sensitivity prior to the headache (this can be days or even hours before the migraine pain starts)
2. Aura - neurological symptoms such as visual disturbances, vertigo, numbness or tingling lasting minutes up to an hour before the headache pain
3. Headache pain - the actual migraine attack
4. Postdromal symptoms such as fatigue and cognitive difficulties (these can last hours to days after the migraine)

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Dr. Peter Goadsby, one of the winners of the prestigious 2021 Brain Prize, and his colleagues studied both what people report as triggers to their migraine attacks and what constitute people’s premonitory symptoms. They found that often, what people attribute to migraine triggers are instead migraine attack premonitory symptoms.

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For example, some people have extreme sensitivity to light or sound the day before their headache as premonitory symptoms. People might think that light or sound triggers their headache because their headache follows exposure to bright light or annoying sound. However, the migraine attack process started way before the headache and made them more sensitive to light or sound. 

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Another example would be people who notice they get headaches after physical exercise. Instead of physical exertion being a trigger, it may be that sensitivity to motion is part of their migraine premonitory symptoms. Some people might think that chocolate triggered their headache, but instead they were craving chocolate as part of their migraine premonitory symptoms. In that case, staying away from chocolate would not improve the frequency of their migraine attacks. 

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It is important to differentiate between triggers and premonitory symptoms because 1) trying to avoid triggers is already hard enough, it would be very frustrating to avoid triggers that are not actually triggers, 2) premonitory symptoms are an alert that the headache is coming, which helps getting ready to take acute treatment early. We don’t have great data on whether taking an acute treatment for migraine early in the premonitory phase stops a migraine from occurring, but most doctors recommend taking some non-medical steps in this situation.  This includes hydrating, going into a darker, quieter environment, and taking the time to do relaxation exercises such as deep breathing, progressive muscle relaxation or meditation.

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Keeping track of your headaches on the Neura app will help better understand the unique patterns of your migraine attacks.

Genes, Stress, and Resilience

Dr. Huda Akil, a neuroscientist famous for her work on the neurobiology of emotions, presented on the genetic predisposition to pain, anxiety, and depression. 

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Stress is a key component of migraine and stressful life events worsen migraine. Stress management and exercise help with migraine. Up to a certain level, a healthy amount of stress is helpful to the brain. It stimulates learning and brain function. However, when too much, stress becomes toxic and causes damage to the brain. As humans, we all have different stress thresholds - the “levels” at which stress becomes toxic. Some of us are more comfortable with risks and more resilient to stressful events than others. 

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The differences in the amount of stress one can handle correlate with one’s brain biology. For example, depression is associated with differences in the expression of both the cells that support neurons in the brain and certain genes called clock genes. Our genes dictate the building of proteins that help regulate our bodies. By definition, the function of clock genes is intrinsically related to our circadian rhythm, i.e. the recurring body changes that follow the 24-hour periodicity of our days. The function of clock genes is tightly regulated based on the time of the day. However, in depression, those genes lose their strict schedule and look jet lagged. Based on our unique biology and genes, we are more or less sensitive to the stressors of our surrounding environment. 

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However, our resilience to stress is more complicated than a direct relationship between genetic predisposition and the environmental stressors we are exposed to. Social support helps mitigate this relationship. With a good amount of social support, there might not be any difference in the likelihood of developing anxiety or depression between those with a high genetic risk score and those with a low genetic risk. Sometimes environmental stressors can be so strong that even people with very low genetic risk develop anxiety or depression, as seen during the COVID-19 pandemic. 

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In summary, we are all different in our response to stress, which is based on our genes. Some stressors are so strong they may impact everyone regardless of the genetic predisposition to anxiety or depression. Social support can significantly mitigate the negative impact of stressors. 

COVID-19 Vaccines

Dr. Amy Gelfand, the Editor in Chief of the journal “Headache”, explained that there are no interactions between Botox injections or CGRP antibodies medications (such as Aimovig, Ajovy, Emgality, Vyepti) and any of the COVID-19 vaccines. There is no need to change the timing of migraine preventive injections based on the COVID-19 vaccine injection. There is also no reason to think that taking Tylenol or NSAIDs for headache after a COVID-19 vaccine would decrease the immune response to the COVID-19 and hence making it less effective. There is also no evidence that the immune response to the COVID-19 vaccine will create neutralizing antibodies to Botox or the injectable CGRP medications. 

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The COVID-19 vaccines with adenovirus vector (Johnson & Johnson and AstraZeneca) have been associated with a rare coagulation disorder called thrombosis with thrombocytopenia syndrome (TTS). That disorder tends to present with headache within 1 to 2 weeks after the vaccine. It is most common in young women. There are 0.9 TTS cases per million doses for women of 50 years and above. There are about 12 TTS cases per million doses for women between 30 and 39 years old. Please contact your doctor if you develop a headache within 1 to 2 weeks after receiving the Johnson & Johnson vaccine. Other signs of TTS include shortness of breath, leg pain, or other neurological signs such as seizures. More data is coming in about COVID and how COVID vaccines are affecting migraine patience. Stay updated and always consult with your doctor on what your strategy for COVID treatment should be.

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However, it is reassuring to keep in mind that post-vaccination headaches are very common and most of the time self-limited. About 50% of people who get vaccinated (including the COVID-19 vaccines) develop a headache within 1 to 3 days of the injection. However, if you feel that you are getting a new or different headache, it is always good to call your doctor to check or schedule a virtual appointment using Neura Health app.

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