Migraine and Mood: Linked Conditions
Abstract & Commentary
By Dara G. Jamieson, MD, Associate Professor of Clinical Neurology, Department of Neurology and Neuroscience, Weill Medical College, Cornell University Dr. Jamieson reports that she is a retained consultant for Boehringer Ingelheim, Merck, and Ortho-McNeil and is on the speaker's bureau for Boehringer Ingelheim and Merck.
Synopsis: Migraine is associated with multiple psychiatric disorders, including major depressive disorder and post-traumatic stress disorder.
Sources: Jette N, et al. Comorbidity of migraine and psychiatric disordersa national population-based study. Headache 2008;48:501-516; Peterlin BL, et al. Post-traumatic stress disorder in episodic and chronic migraine. Headache 2008;48:517-522.
Up to 30 million americans suffer from migraine headaches that compromise quality of life and inhibit productivity. The disability of migraine may be further compounded by co-morbid psychiatric conditions that complicate disease management and lead to worsening health outcomes. These two papers evaluate the prevalence of multiple psychiatric disorders that were found to predict poor outcome in patients with migraine headaches.
The population-based study by Jette and colleagues evaluated the prevalence of various psychiatric conditions in patients with migraine and described the association of these co-morbidities with a variety of health-related outcomes. The study used data from the 2002 Canadian Community Health Survey, a national health survey that included administration of the World Mental Health Composite International Diagnostic Interview. In the population interviewed (n=36,984) the prevalence of physician-diagnosed migraine was 15.2% for females and 6.1% for males. The diagnosis of migraine was most common in patients between the ages of 25 and 44 years and was associated with lower income levels. Major depressive disorder, bipolar disorder, panic disorder, and social phobia occurred more than twice as often in those with migraines, as compared with those without migraines. The lifetime prevalence of major depressive disorder in migraineurs was 18.8%, as compared to 9.8% in nonmigraineurs. The higher prevalence of psychiatric disorders in migraineurs was not related to gender, although there was a trend for females to have a higher prevalence. Psychiatric disorders were not associated with drug, alcohol, or substance dependence and they were less common in older, married, and wealthier migraineurs. Health-related outcomes were worst in those with both migraines and a psychiatric disorder and intermediate in those with either condition alone. Antidepressant and antiepileptic drug use was highest in those with both migraine and a mental health disorder.
Post-traumatic stress disorder (PTSD) is an anxiety disorder that develops as a result of exposure to a traumatic event. Symptoms of PTSD include a sense of reliving the experience, avoidance of situations reminiscent of the event, emotional blunting, or hyperarousal. Peterlin and co-workers assessed the relative frequency of self-reported PTSD in patients with episodic migraine and chronic or transformed migraine that was linked with risk factors for chronification of headache disorders, such as childhood abuse. A prospective pilot study of adults with episodic, chronic, or transformed migraine was conducted at a headache center. Demographic information, depression history, body mass index, and headache characteristics were obtained. PTSD was assessed using the life events and PTSD checklists. Of the 60 migraine patients, 91.7% were female, with a mean age of 41.4 +/- 12.5 years. Episodic migraine was diagnosed in 53.3% and chronic migraine in 46.7%. The relative frequency of depression was significantly greater in subjects with chronic migraine (55.2%) than in those with episodic migraine (21.9%, p=0.016). The relative frequency of PTSD reported in chronic migraine (42.9%) was significantly greater as compared to episodic migraine (9.4%, p=0.0059) even after adjusting for depression and other potential confounders.
Commentary
Multiple mental health disorders contribute to the suffering of many migraine patients, complicating their treatment and resulting in poorer health-related outcomes. Co-morbid psychiatric conditions, including depression, phobias, and PTSD, increase the risk of developing chronic headaches. The success of cognitive behavioral therapy in patients with chronic headaches reflects the psychological component triggering and perpetuating their disorder. Physicians treating patients with chronic headaches should screen their patients for mood disorders and offer both pharmacological and behavioral therapy to relieve the pain, both physical and emotional, suffered by migraineurs.
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