Does Migraine Cause Progressive Brain Damage? “UBOs” and you: what’s up with those white dots on your MRI?
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Aside from the unpleasant symptoms migraine intermittently may cause and the adverse effect those symptoms have on quality of life, is migraine also a progressive disorder that produces irreversible brain injury with consequent impairment of brain function? Does migraine belong in the same chapter of the textbook as the primary dementing disorders such as Alzheimer’s, amyotrophic lateral sclerosis (ALS), Parkinson’s disease and the other less common degenerative brain diseases for which we currently possess mostly treatments that may alleviate symptoms but precious few that modify the otherwise inevitably progressive course of the illness? To pose the question in its starkest terms, is migraine a disease, or is it a disorder?
Even those patients who have episodic migraine often find it difficult to accept that the disabling paroxysmal headaches and associated symptoms they experience do not result from a structural abnormality within the nervous system and are not inflicting further harm on the nervous system. If I have headaches this bad, they are thinking, there must be something wrong with my brain.
The concern that migraine is causing progressive brain injury is even more common in the chronic migraine patient population. Specifically, these patients often are convinced that their headache disorder is causing progressive dementia. Citing problems with impaired concentration, easy distractibility, and embarrassing lapses of short-term memory, and despite continuing to function adequately at a cognitively demanding job, a highly educated 35-year-old woman with frequent and at times disabling migraine headaches will confide to her doctor, “I think I have Alzheimer’s.” A study authored by Sotero et al and published in the January 2025 of the journal Headache examined migraine burden during the intervals between acute migraine headache episodes, and the migraine population surveyed (the majority of whom had chronic migraine) rated impaired memory function as the greatest contributor to their burden.
Such concern is understandable, but at this point in the evolution of migraine theory this is what we know to be true:
Despite considerable research, there is no convincing evidence to suggest that migraine results from a structural abnormality within the brain or produces progressive and irreversible structural injury to the brain that correlates with an unfavorable long-term outcome.
Although “mimickers” of migraine definitely do exist, for patients whose headache histories are consistent with a diagnosis of migraine, whose histories contain no “red flags” to suggest that they may have a superimposed pathologic process as well as migraine and whose examinations are normal, the accurate diagnosis typically will be migraine.
As a corollary to #2, brain imaging and other diagnostic evaluation of patients with clinical presentations consistent with migraine are highly unlikely to yield findings that will alter diagnosis, management or outcome. What extensive testing will do is drive up the direct costs of a prevalent disorder whose price tag already is staggeringly high and, paradoxically (see below) often fuel patient anxiety.
Again, justified or not, the concern regarding short and long-term “brain health” expressed by migraineurs is understandable. And so, despite the high expense/low yield involved, vast truckloads of brain MRI are ordered and performed. While the brain MRI scan of a migraineur typically is normal, the high frequency with which imaging is performed is such that the scans often detect abnormalities and variations that are “incidentalomas”: findings that are unrelated to the patient’s headache disorder and in most cases have no clinical or prognostic significance.
The most common and vexing MRI incidentaloma encountered in a headache clinic is the “UBO” (or, as they usually are multiple, “UBOs”). The acronym stands for “unidentified bright objects,” and in MRI parlance the UBOs are small areas of increased signal intensity found in the white matter (ie, the wiring) of the brain.
When MRI began to be used clinically in the early 1980s, these small punctate areas that many scans demonstrated initially created quite a stir. Did these UBOs indicate we were experiencing an epidemic of asymptomatic and unsuspected multiple sclerosis? As similar white matter changes occur more commonly in patients with stroke risk factors such as hypertension, did they represent small areas of similarly asymptomatic stroke injury? If not MS or stroke, then what?
Bottom line: we still do not know the precise origin of these UBOs, and chances are good that they result from a variety of different causes.
Interestingly, UBOs are seen more commonly on the brain MRI scans of individuals with migraine. The results of the CAMERA-1 study performed in the Netherlands and published in the medical literature in 2004 indicated that UBOs were present more commonly in females with migraine when compared to age-matched females without migraine, and in the migraine female migraineur they were most commonly observed in those individuals who had a history of aura. There also appeared to be an association between migraine frequency and the presence of UBOs, with more frequent migraine episodes correlating with an increased likelihood of UBOs being present.
So what? What is the clinical and prognostic significance of UBOs present on the MRI scans of so many females with migraine? This Dutch research population was studied nine years later, and while the number of UBOs present on MRI had increased in a high percentage of those with UBOs demonstrated by baseline MRI, the likelihood of developing more UBOs was no greater in individuals with more clinically severe migraine than in those with clinically mild migraine. More comforting to individuals with UBOs, there was no correlation between the presence of UBOs and evidence of early dementia or stroke risk when the migraine UBO/migraine population was compared to age and gender-matched individuals without MRI evidence of UBOs.
From what we know to date, then, in this clinical setting UBOs appear to be no more than an MRI marker of migraine and to have no more clinical significance than the presence of freckles on one’s face. There is no evidence that these MRI findings indicate an increased risk of developing stroke, dementia, multiple sclerosis or any other significant neurologic disorder. They do not even appear to predict a more negative clinical course as regards the headache disorder itself.
What we do know is that when UBOs are detected by MRI, much unnecessary concern, commotion and cost can result. if you have migraine, and if you undergo brain MRI that demonstrates these white matter findings, consider consultation with someone skilled in the practice of headache medicine before you embark upon a long, inconvenient, expensive and ultimately pointless journey to rule out another neurologic disease that you thankfully do not have.
