Tension-type headache found to have significant association with white matter hyperintensities
by Deena Kuruvilla, MD
One of the most common questions posed to me in my headache practice is “why do I have white spots on my brain?” I often obtain magnetic resonance imaging (MRI) of the brain in my patients with a worrisome story to make sure there is not an underlying cause for the headaches. I then end up with an MRI report that shows white matter hyperintensities (WMH). WMH are lesions in the brain that show up as areas of increased brightness on specific MRI sequences. They may be caused by wear and tear of the cerebral vessels which can result in strokes or in inflammatory disorders such as multiple sclerosis. Migraine patients, especially those with migraine with aura have a higher risk of stroke and cardiovascular disease than the general population. While these associations exist, WMH are usually benign depending on the location and how extensive the lesions are. Benign WMH are found in >90% of people over the age of 60. Larger or more extensive WMH can be seen in cerebrovascular disease, infection, neurodegenerative conditions or multiple sclerosis. Previous studies showed that WMH are more common in patients who experience migraine compared to those who are headache free. In the most recent study about WMH and headache disorders, Honningsvag et al, found that having tension-type headache (TTH) or new onset headache in adulthood is associated with significant WMH. The WMH were specifically found in the deep white matter. Interestingly they did not find an association between WMH and migraine. The finding that WMH are more prominent in TTH suggests that there may be a vascular or inflammatory component to the underlying cause.
In January, the British Medical journal published an article by Adelborg and colleagues which showed that patients with migraine are more likely to have cardiovascular disease, venous thromboembolism, atrial fibrillation and atrial flutter. This finding is relevant for providers and patients because previous research has shown that managing cardiovascular risk factors such as blood pressure, can slow the progression of WMH. While we do not routinely obtain imaging in every person with headache, advanced age or other red flags such as a complicated medical history should certainly prompt providers to consider it.
This study certainly has some pitfalls. It is unclear which definitions were used for tension-type headache and migraine in this study. The authors state that subjects were given a questionnaire to fill out with the details of the headache but the defining points of the headache disorder are unclear. In many cases, we find that what is classified as TTH is truly migraine. We most commonly see this in our Chronic migraine patients who suffer from 15 or more headache days monthly for at least 3 months. Some of these 15 headache days may be mild headache days and incorrectly labeled as TTH.