For quite a bit of time, an underappreciated pain complaint in patients with FMS was headache. After studying 89 fibromyalgia patients, a well-known neurologist diagnosed 84 people suffering from migraine headaches and 5 from tension type headaches (TTH).  He then published the statement in 1995, that “fibromyalgia suffers are headache suffers.” Unbeknownst to him, he actually diagnosed the two most common headaches to be found in FMS – migraines and tension-type headaches.

One of the first reports on headache and FMS was that in 1992 by a FMS researcher who noted that 45% of the FMS patients he examined currently suffered from migraine headaches and 55% of the patients had migraines at least one in their lifetime. Subsequent studies around the world have found that migraine headaches were present with FMS anywhere from approximately 17% to 36% in countries that included Israel, Italy, and Brazil. In 2005, a group of researchers did a careful epidemiologic study or a study of migraine headaches looking at FMS patients from the population level, and its relation to FMS and concluded that “headache, especially migraine, appears to be part of the fibromyalgia syndrome,” and “warrants inclusion of a headache assessment as part of the routine evaluation of fibromyalgia patients.” Meaning, physicians should include in their examination of FMS patients an examination for headaches. This is another reason you need a physician skilled in the treatment of FMS, as most physicians are not aware of the association between headaches and FMS.

The opposite holds for other physicians when they see patients primarily for headaches. In a paper written in 2010 for neurologists, the physicians who usually see patients for headache, the authors wrote, “In our opinion, fibromyalgia should be always considered, especially in women between 20 and 40 years, in the differential diagnosis of headache.” The term, “differential diagnosis” is a medical phrase that means all the possible causes for particular symptoms.

Of the medical specialties first managing FMS patients, other than rheumatologists, neurologists have been keenly aware of the presence of headache pain. FMS patients suffer the most from recurrent migraines and tension type headaches, consequently these have received the most attention. The first studies that the neurologists published have shown that 35% to 48% of FMS patients had either of these two disorders. One of the first studies that associated headache pain in FMS patients did so in 1995 by first noting that headaches occurred in patients with the sleep disorder that has been found in FMS patients – alpha intrusion on delta wave sleep. When the researchers found this sleep disorder they had a rheumatologist examine the patients and he diagnosed the patients with FMS – they previously had never been given that diagnosis! You can read about this sleep disorder in the short report on FMS and sleep.

Now that physicians are more aware of patients with FMS having “legitimate” headache pain, it is being diagnosed more frequently. A 2005 study suggests that up to 53% - 82% of FMS patients report some type of headache pain. In another epidemiologic study a group of rheumatologists found recurrent headaches in 76% of 100 FMS patients being treated at a university pain clinic with 63% suffering from migraine.  Of these patients, 80% of patients rated the impact of their headache as severe.  In this study, on average, headaches developed approximately seven years prior to FMS symptoms. The onset of headache symptoms prior to FMS had been noted in a previous study where 45% of FMS patients were found to have migraine headaches.

Three features were unique to this population – migraine with aura occurred in 44% of the FMS patients, compared to the usual average of 20-30% of migraine sufferers, headaches occurred more frequently, 2 or more times weekly in 53% and 5 or more in 53%, and pain lasted 12 or more hours in 47%. The characteristics of headaches in this population may not reflect community FMS patients as this was a university clinic and the FMS patients at universities are usually those who have more severe symptoms.

Studies have shown FMS patients with migraines to have higher levels of depression and anxiety, or mental distress 75% in one report. FMS patients with depression tend to have headaches that are more incapacitating. The consensus among the neurologists, however, is that these factors are more a “reflection of the burden of the disease rather than a hallmark of a specific headache category.” In other words, the headaches are what make someone depressed, rather than depression causing a specific type of headache.  Another confounding factor is the overlap between poor sleep, headaches, and FMS, as sleep disorders are a frequent finding in headache conditions. Overall, as you would expect, the severity of headaches tends to be more severe and incapacitating in FMS patients.

Since we’ve mentioned migraine and tension headaches, you should know something about them. Migraines are commonly mentioned in the press and sometimes people will even use the term jokingly. However, if you suffer from migraines, you know they are no joke as they can make your life miserable for several days. About 30 million people in the US suffer from migraines, women about 3 times more frequently than men. Migraine headaches may occur after visual disturbances such as blurriness, stars, sensations of tunnel vision, or eye pain. This is termed a migraine with aura; there is both migraine with aura and migraine without aura. Anywhere from a few minutes to up to a day, but usually about 15 minutes after the visual disturbances, migraine sufferers will develop a pounding, pulsating, or pounding pain that is almost always worse on one side of the head and usually behind the eye or in the back of the head. It may start out as a dull pain and then increase over minutes or hours and can last over a day. As if this isn’t bad enough, there is usually nausea and vomiting, tingling sensations, extreme sensitivity to light and sounds, chills, and extreme fatigue that accompany the headache.

Tension headaches usually feel like someone has tightened a belt around your neck or head. People will try to move their neck and shoulders as only certain positions provide some type of relief. Unlike a migraine headache, the pain is usually not throbbing but is more like a dull, continuous ache. A common source of tension headaches is myofascial trigger points. You can read more about these in the short report on the tender points and the trigger points of FMS – which also describes how these can be treated.

This is another reason a pain physician is an appropriate physician for FMS. Headaches are pain disorders and pain physicians treat pain. Headaches are also treated by neurologists, but many headaches are caused by structures outside of the head, pain physicians term these structures, “pain generators.” You will hear more about pain generators in future short reports. Pain generators can send pain to areas outside of where they are located, a phenomenon termed, “referred pain.” Again, you will hear more about referred pain in future short reports. For example, irritation from the upper parts of the bones of the spine, the cervical spine, can refer pain to the base of the neck and the back of the skull. Irritation of the neck and shoulder muscles can send pain to the same region. The area where the skull meets the spine, termed the atlanto-occipital junction, is guilty of the same “crime.”

In fact, the atlanto-occipital junction is a major player in terms of tension-type headaches.  This is the first joint in the spine and actually is quite complex. The atlas bone is the first bone in the spine and is shaped like a ring. It’s named after Atlas, the figure in Greek mythology who supported the heavens.  The occiput is the bony ridge you can feel when you bring your hand up along the back of your neck toward the top of your skull – this is where the two meet, the spine and the skull. This is the joint that allows you to nod your head. Only pain physicians trained in interventional joint injections can treat this joint if it is the source of headache pain. The method of treatment is by an injection of an anesthetic and steroid mixture into the joint itself. Although this is a safe procedure and capable of providing tremendous relief, only pain physicians have the training to provide this type of injection.

Other sources of pain may be the joints on the outside of the cervical spine, termed the cervical facet joints. These are joints that allow the spine to move – in the cervical spine, the motion is primarily one of rotation, allowing you to turn your head from side to side. About 50% of rotating your head comes from the second joint in the spine, the atlanto-axial joint, and the remaining 50% from the rest of the cervical spine. The cervical spine stops moving when it becomes fixed in the thoracic spine where the ribs start to become attached. The fancy name for the facet joints are the zygapophyseal joints. They are actual joints, just like the joints of your hands or knees and can develop wear and tear. If you think about how much you rotate your head during the course of your life you can appreciate just how much they are used. Again, if they are determined to be the “pain generators,” they can be treated with an injection of anesthetic and steroid. Like the atlanto-occipital injection, facet joint injections are part of the training of pain physicians and are done under a fluoroscope so that there is no question that the injection is correctly placed. We’ll talk more about facet joints in a future short report.

Sorting out pain generators, referred pain, and headache pain in FMS is a complex issue. Pain is a complex issue and an area in which pain physicians are quite familiar.