Relationships between epistaxis, migraines, and triggers in hereditary hemorrhagic telangiectasia

Objectives/hypothesis: To identify whether relationships exist between epistaxis and migraines in hereditary hemorrhagic telangiectasia (HHT), to potentially provide further preventative and therapeutic options for the debilitating nosebleeds that are often very difficult to manage in clinical practice.

Study design: Study participants were recruited from a UK specialist service, and online following advertisement by the HHT Foundation International. They completed a nonbiased questionnaire in which paired questions on nosebleeds and migraines were separated by at least 17 other questions.

Methods: Migraines were defined as headaches with associated autonomic and/or neurological features. The reported frequencies and precipitants of epistaxis and migraines were compared using numerical scales applied equally for each condition.

Results: The 220 HHT-affected respondents reported frequent nosebleeds, 153 (69.5%) used iron tablets, and 39 (17.7%) had received at least 10 blood transfusions. Migraines displaying typical features were reported by 51 (23.2%), and were more common with pulmonary or cerebral arteriovenous malformations. Thirty of 51 (58.8%) migraine sufferers reported that nosebleeds occurred at the same time as their migraines. More frequent migraines were reported by patients with more frequent nosebleeds (r2=15%, P=.007), or transfusions (r2=16.9%, P=.004). In menstrual, lifestyle, and dietary analyses, consistency was observed between factors having no effect, and those provoking both nosebleeds and migraines in multiple patients (premenses; activity; lack of sleep; stress; caffeine, cheese, alcohol, and chocolate).

Conclusions: We demonstrate an unexpected and provocative association between nosebleeds and migraines in HHT patients. Evaluation of whether antimigraine approaches limit HHT nosebleeds may be appropriate.

Level of evidence: 4.