Migraine, the gut and diverticular disease


What has migraine got to do with diverticular disease?”

That was the occasional response when DD sufferers were asked in a survey if they or any blood relative have/did have migraine. However, 42% of females and 29% of males had migraine themselves or a blood relative did. Some noted that they ‘used to have’ migraine. These figures are far higher than the 10% or so incidence of migraine expected at retirement ages. A survey of migraine sufferers in Ireland found that 51% had also been diagnosed with IBS. A survey of people with IBS found a 60% greater prevalence of migraine than in non-IBS controls (1). There was a frequent association between headache, including migraine, and gastrointestinal symptoms (acid reflux, diarrhoea, constipation and nausea) in a Norwegian report (2).

Patients who did not respond to a high fibre diet, who had a single, intermittent abdominal pain were investigated in Leeds (3). Symptoms and family history suggested that 49% of them might have abdominal migraine and 32% of these had typical migraine symptoms during the attack. Mulak (4) noted that migraine and IBS often coexist.

Abdominal migraine (AM) is recognised in children and often is followed by the typical head pain as they get older. In adults, functional abdominal pain is classified as IBS or dyspepsia but AM should be considered if other symptoms or a family history of migraine are present (5). AM in adults is sometimes controversial, but the older diagnosis if ‘bilious attack’ did not have age limits. Other non-headache effects of migraine are recognised in both adults and children e.g. dizziness and vertigo (6), brief fainting (7), cyclic vomiting (8, 9), diuresis (10) and light-headedness (11).


Migraine is not just a head pain, although intense research and drug treatments concentrate on that particular symptom. There is evidence that the metabolism of amines (body and food chemicals) and their changing levels in blood, urine and the brain are behind a range of effects on the body (12, 13, 14, 15  ).  Osipenko (16) noted high levels of amino acids in the urine of DD patients which suggested a metabolic factor in DD.

EFFECTS OF MIGRAINE ON THE BODY The duration of the stages is variable, between 20min. and 3days is possible – = normal
Level of serotonin in blood plasma High, can be up to 300% of normal Low, can be down to 40% of normal Back to normal level
Brain Visual disturbances“ AURA”
Mood Raised, restless, hyperactive Low, tired, depressed
Headache Headache begins Sleep often restores normality
Senses Heightened, dizziness, tingling Aversion to light and sound, sensitive to temperature ditto
Blood vessels Become constricted Begin to open up at end of stage. Pale, black round eyes.
Fluid balance Fluid retention, thirst Bloated Extra urination
Stomach Hunger, food craving Indigestion, no appetite, nausea, vomiting Appetite returns
Guts Sometimes looseness or diarrhoea Nothing moving, constipation, abdominal pain Clearing of faeces backlog, diarrhoea

Symptoms roughly follow changes in the serum level of serotonin (5HT). This is illustrated in the table. Different symptoms predominate during an attack in individuals and can change with age and gender. Older people can suffer from various forms of migraine (17), head pain can decrease or change in frequency and the prevalence of aura can increase (18). Migraine can be a life long disorder. Having a diagnosed bowel disease such as DD does not exclude the effects of migraine. People with DD are often told they also have IBS when their symptoms cannot be explained by infected and inflamed diverticula.

Abdominal migraine occurs in distinct episodes. It is characterised by a dull/sore type of pain in the middle, upper abdomen, perhaps with nausea, vomiting or loss of appetite. The digestive system slows down or stops. If the attack lasts for 2-3 days, then the pain and discomfort of constipation starts. This is a particular problem with DD. When the migraine resolves, the backlog of faeces can be evacuated suddenly or by several toilet visits – what might be called diarrhoea. There may or may not be a headache or other migraine effects. It is easy to see that such symptoms might be considered as part of a bowel disease such as IBS or DD. Varying constipation and diarrhoea were reported by nearly 60% of DD patients in the survey.


The link between migraine and bowel symptoms is the neurotransmitter serotonin (5HT).Constriction of blood vessels due to low levels of 5HT and their subsequent opening are considered to be the cause of migraine head pain. The same mechanism would apply to blood vessels supplying the gut. 5HT also plays a major role in the movement, secretions and pain perception of the intestines. Raised 5HT gives diarrhoea and low 5HT results in constipation (19). One 5HT receptor (5HT7) in the colon is involved in the exaggerated accommodation of the gut wall related to distension and bloating (20). This is a common problem with DD. Successful drugs for aborting the head pain, the tryptans, mimic the effects of 5HT. Drugs which block or imitate the effects of 5HT for treatment of IBS, have had less success because of side effects. Perhaps the difference has been the episodic use in migraine compared with continuous use in trials of the gut drugs which assumes 5HT levels are permanently high or low.

Large amounts of 5HT are stored in cells within the gut walls. The amount of active 5HT depends on stimulants which cause its release and also the transporter system which causes reuptake and deactivation (19). The number of cells which contain 5HT can also vary. In DD there were more 5HT cells in diseased areas of the colon than in unaffected parts of the same organ (21). Patients with a history of diverticulitis had a decrease in the 5HT uptake function (22). A genetic abnormality in this mechanism was found in children with abdominal migraine and also with migraine aura (23). There is currently much interest into 5HT levels and the effect on gut function in bowel diseases. Migraine affects about 10% of males and 20% of females and should be considered as a potential factor in 5HT bowel research.


DD symptoms which are not related to infection and inflammation of diverticula, but are ‘functional’ in nature, are frequently called IBS. IBS has been defined as a medical invention to create a name for bowel symptoms that were otherwise unexplained (24). IBS has variable symptoms and variable causes and it appears that abdominal migraine is included in this fashionable, charismatic disease. If symptoms and family history suggest migraine might be involved, a diary is often recommended to try and pin point the triggers which lead to the episodes. DD people would have to look beyond fibre levels, probiotics and anticholinergic antispasmodic drugs. The triggers may be found to occur some time before the diarrhoea effect (see table). Some DD survey participants recognised and reported pork, citrus fruits, wine, cheese and chocolate as causes of their bowel symptoms. In general, cured and fermented foods containing particular amines or ingredients such as monosodium glutamate or aspartamate might be questioned. Irregular sleeping and eating habits, stress and dehydration can contribute to the trigger level. Migraine triggers vary between individuals and can add up until a tipping point is reached. Symptom diaries are also useful for finding the cause of problems with DD. Do not dismiss as irrelevant, triggers described above, because they are not related to dietary fibre levels or gut irritants.

Some people are sure that drinking plenty of water helps with both migraine and IBS. The body makes 5HT from the amino acid tryptophan and low levels of this in the diet appear to induce some symptoms in migraine sufferers (25). Foods containing tryptophan which may increase 5HT levels include turkey, eggs, almonds, chicken, soya, bananas, milk products and red meat.

© Mary Griffiths 2009

Note This article appeared in the Winter 2010 issue of The Journal of the Bladder and Bowel Foundation and is available in the professional resources section of their website. The article was a development of two previous contributions to charity magazines.

1 “Is you IBS another pain in the head” was included in Gut Reaction, the Journal of the IBS Network, issue No 38, July 2000

2 “Abdominal Migraine-underestimated and misunderstood?” appeared in the Jan.2002 Migraine Action News. For many years it was the basis of patient leaflets on abdominal migraine.

3 Migraine. Link with irritable bowel syndrome. Dr M Griffiths, Pharm J,  2000, 264, 693


1 Cole JA et al. Migraine, fibromyalgia and depression among people with IBS: a prevalence  study. BMC Gastroenterol. 2006,6,26.

2 Aamodt AH et al. Comorbidity of headache and gastrointestinal complaints. The Head-HUNT study. Cephalalgia, 2008,28,144.

3 Long DE et al. Abdominal migraine: a cause of abdominal pain in adults? J Gastroenterol Hepatol. 1992, 7, 210.

4 Mulak A et al. Migraine and irritable bowel syndrome. Neurol Neurochir Pol  2005, 39S1, S55.

5 Axon AT et al. Abdominal migraine: does it exist? J Clin Gastroenterol. 1991, 13, 615.

6 Lempert T et al. Epidemiology of vertigo, migraine and vestibular migraine. J Neurol. 2009, 256, 333.

7 Dass A et al. Familial vasovagal syncope associated with migraine. Pediatr Neurol. 2009, 40, 27.

8 Fleisher DR et al. Cyclic vomiting syndrome in 41 adults: the illness, the patients, and problems of management. BMC Med. 2005, 3, 20.

9 Pareek N et al. Cyclic vomiting syndrome: what a gastroenterologist needs to know. Am J Gastroenterol. 2007,102, 2832.

10 Poole CJ et al. Inhibition of vasopressin secretion during migraine. J Neurol Neurosurg Psychiatry, 1988, 51, 1441.

11 Honaker J et al. Migraine-associated vestibulopathy. Curr Opin Otolaryngol Head Neck Surg. 2008, 16, 412.

12 D’Andrea G et al. Biochemistry of neuromodulation in primary headaches: focus on anomalies of tyrosine metabolism. Neuro Sci. 2007,28S2, S94.

13 D’Andrea G et al. Abnormal platelet trace amine profiles in migraine with and without auras. Cephalalgia, 2006, 26, 968.

14 Anthony M et al. Amine turnover in migraine. Proc Aust Assoc Neurol. 1975, 12, 43.

15 D’Andrea et al. Platelet levels of dopamine are increased in migraine and cluster headache. Headache 2006, 46, 585.

16 Osipenko MF et al. Colon diverticula; origin, prevalence, clinical manifestations. Ter Arkh. 2007, 79, 26.

17 Rankin LM et al. Migraine in older patients: a case report and management strategies. Geriatrics 2000, 55, 70.

18 Bigal ME et al. Age-dependent  prevalence and clinical features of migraine. Neurology. 2006, 67, 246.

19 Spiller R. Recent advances in understanding the role of serotonin in gastrointestinal motility in functional bowel disorders: alterations in 5-HT signalling and metabolism in human disease. Neurogastroenterol Motil. 2007, 19S2, 25.

20 Cervio E et al. Recent insights into the pathogenesis of abdominal symptoms in functional bowel disorders. Recenti Prog Med. 2007, 98, 69.

21 Banerjee S et al. Increased presence of serotonin-producing cells in colons with diverticular disease may indicate involvement in the pathophysiology of the condition. Int J Colorect Dis. 2007, 22, 643.

22 Costedio MM et al. Seratonin signalling in diverticular disease. J Gastrointest Surg 2008, 12, 1439.

23 Szilagyi A et al. Contribution of serotonin transporter gene polymorphisms to pediatric migraine. Headache, 2006, 46, 478.

24 Read N. The Gut Trust. Gut Reaction journal. Issue 72, Winter 2008.

25 Drummond PD. Tryptophan depletion increases nausea, headache and photobia in migraine sufferers. Cephalalgia. 2006, 26, 1225.

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