A billion people suffer from migraine headaches, the third most disabling neurological condition worldwide. The burden may be even greater among individuals with autism.
One study reports a lifetime migraine prevalence of approximately 42% among people with autism compared with roughly 20% in a control population.
Even these numbers likely underestimate the true rate due to lack of recognition and underreporting of migraine in general. In a recent UCLA study, migraine rates were elevated in cohorts of individuals with autism, despite conservative estimates in the datasets reviewed from the National Survey of Children's Health and the University of California Los Angeles hospital system electronic health.
The cohort study suggests that migraines are not merely incidental in this population. Rather, they are both more common and more severe, warranting greater diagnostic vigilance.
“The data trended toward higher severity and more frequent, chronic migraine,” says Sinifunanya Nwaobi, MD, PhD, pediatric neurologist and headache medicine specialist, assistant professor of neurology at UCLA, and lead author of the recently published UCLA study.
Dr. Nwaobi adds that the odds of severe headache were markedly increased by 4-fold. While migraine characteristics such as duration, nausea, light and sound sensitivity, and premonitory symptoms have not yet been exhaustively studied in relation to autism, these now form the next frontier of continuing investigation for the UCLA team.
“Do people with autism experience more or less of certain features? What is the ‘migraine experience in those with autism’ – from symptomatology to barriers to diagnosis? Hopefully, we will soon be able to provide more answers,” Dr. Nwaobi says.
Diagnostic blind spot
Clinical underrecognition is a central concern. During a typical office visit, migraine symptoms may be eclipsed by competing priorities. Behavioral concerns, epilepsy and gastrointestinal issues often take precedence when headache pain remains unvoiced or expressed differently by patients with autism.
“Communication barriers, particularly among nonverbal or minimally verbal patients who cannot describe sensory phenomena such as light sensitivity or nausea, further complicate the detection process,” explains Dr. Nwaobi.
This diagnostic blind spot is especially troubling given the functional impact caused by migraines. In pediatric populations, migraines are associated with increased school absenteeism, poorer academic performance, higher rates of grade retention and missed extracurricular activities.
“They rate their overall quality of life as poor, the same as children with cancer or chronic rheumatologic disease,” Dr. Nwaobi adds. “When layered onto autism, migraine’s cumulative burden is likely substantial, even if not yet fully quantified.”
The cause of migraines being more prevalent in autism remains something of a question mark, Dr. Nwaobi says. However, she believes one conceptual bridge lies in how the brain interprets and responds to sensory input.
“Migraine is a sensory processing disorder at its core, characterized not only by head pain but by sensory disruptions around light, sound, smell, balance, etc.,” she explains. “Autism, likewise, is defined in part by atypical sensory responses, ranging from sensory sensitivity to profound aversion to certain stimuli. There is overlap in abnormal sensory processing occurring in both autism and migraine, raising the possibility of a shared neurobiological vulnerability.”
Additionally, research shows that people with autism experience higher rates of central sensitization disorders. Conditions such as fibromyalgia, irritable bowel syndrome and chronic pain syndromes, all characterized by heightened central nervous system responsiveness, are overrepresented in patients with migraines and patients with autism. Whether this reflects shared mechanisms or parallel susceptibility remains unknown.
Diagnosis and treatment
For clinicians, the implications of the migraine/autism connection are practical and immediate. Dr. Nwaobi urges providers to maintain a lower threshold for considering migraines when autistic patients show changes in behavior, sleep, mood or concentration.
“Migraines should be part of physicians’ differential diagnosis,” she stresses, particularly when patients present with agitation or functional decline without an obvious cause. Family history of migraine is also an important diagnostic clue, as are behavioral cues such as retreating to dark rooms, aversion to lighted screens or increased distress in noisy environments.
Treatment principles remain largely the same for people with and without autism. Triptans, CGRP-inhibitors and other standard preventive strategies appear to be effective in autistic patients, though formal comparative trials are lacking.
“Clinicians should, however, be mindful that people with autism can be very sensitive to medications. Consider starting with a lower dose, titrating slowly, with frequent monitoring,” Dr. Nwaobi advises.
Additionally, she says alternative delivery systems and nonpharmacologic options, including neuromodulation devices, may be valuable for patients with sensory aversions or needle phobia.
Ultimately, the greatest gap in the migraines/autism conundrum is perceptual. Migraine remains underrecognized, underdiagnosed and undertreated even in the general population. In autism, where barriers to care are already substantial, that gap widens further.
“The first step is recognizing it,” Dr. Nwaobi says. “For physicians across disciplines, keeping migraine on the diagnostic radar may meaningfully improve quality of life for a population whose pain too often goes unseen.”
