Association Between Empty Sella Syndrome and Migraine
Empty sella syndrome is not causally associated with migraine, and headache in patients with empty sella is nonspecific in character and does not represent a distinct headache syndrome. While headache is frequently reported in patients with empty sella (particularly in middle-aged overweight women), no specific headache type has been proven to be caused by this anatomical finding 1.
Understanding the Relationship
The evidence demonstrates that empty sella is primarily a radiological finding rather than a true syndrome in most cases. When headache occurs in patients with empty sella:
The headache characteristics are nonspecific - Studies show that while the majority of patients with primary empty sella (PES) complain of daily headache (mostly localized anteriorly), these headaches do not follow a consistent pattern that would suggest a causal relationship 2
Empty sella syndrome is a misnomer - The term "syndrome" is misleading, as PES represents a radiological finding that may coincidentally occur with various headache types, including migraine 1
Headache is a common associated symptom but not causally linked - Among the clinical manifestations that can occur with empty sella (including obesity, visual disturbances, CSF rhinorrhea, and pituitary insufficiency), headache is frequently reported but represents a nonspecific association 3
Clinical Implications
When evaluating a patient with both empty sella and migraine:
Treat the migraine according to standard guidelines - Follow evidence-based migraine management as outlined in current consensus statements, using NSAIDs as first-line acute treatment, triptans as second-line, and considering preventive therapy if quality of life remains impaired 4
Screen for endocrine dysfunction - The most clinically relevant aspect of empty sella is potential pituitary hormone deficiency. The 2025 Pituitary Society guidelines indicate that 29% of incidentally diagnosed empty sella patients have at least one hormone axis deficiency 5. Endocrine screening should be considered even in asymptomatic patients 1
Look for specific risk factors - Empty sella should be suspected particularly in middle-aged overweight women with daily headache, even without endocrine symptoms 2. However, this represents a clinical association rather than causation
Important Caveats
Do not attribute migraine to empty sella - The presence of empty sella on imaging does not explain migraine symptoms and should not alter standard migraine management
Recognize when empty sella becomes clinically significant - Empty sella syndrome (as opposed to isolated empty sella) is defined by the presence of pituitary hormonal dysfunction and/or neurological symptoms from coexisting idiopathic intracranial hypertension 6
Distinguish primary from secondary causes - If empty sella is found, determine whether it is primary (idiopathic) or secondary to previous pituitary pathology, surgery, radiation, or trauma 6
The key clinical message: Empty sella and migraine commonly coexist but are not causally related. Manage each condition independently according to established guidelines, with particular attention to screening for pituitary dysfunction in patients with empty sella.