FIGURE 2: Sex-specific odds ratio of PTSD in episodic migraine
Source: Adapted with permission from Peterlin BL, et al. Post-traumatic distress disorder and migraine:
Epidemiology, sex differences, and potential mechanisms. Headache. 2011;51(6)860-868.
The neurobiological mechanism linking PTSD to migraine is not known. Although a variety of theories exist—including low serotonin levels, dysfunctions of the autonomic system and hypothalamic-pituitary-adrenal axis (HPA) in both migraine and PTSD, and elevated baseline cortisol levels in migraineurs—it remains unclear why the association is stronger in men than in women.34 Some studies suggest that sex-related differences of the HPA axis may play a role.36,37 Others consider fMRI findings of sex differences in cerebral blood flow to pain centers in response to psychological distress.37 Further research into the sex-related differences of migraineurs with PTSD will likely reveal insights into new therapeutic directions for men and women with these disorders.
Implications for clinicians
The preceding data add to the understanding that numerous comorbidities exist in individuals with migraine. If a patient is a migraineur, screen for PTSD as well as depression and anxiety. Treatment with cognitive behavioral therapy—alone or in combination with pharmacological therapy—should be considered, since treatment of PTSD alone has been shown to have a beneficial effect on both pain and disability in chronic pain patients.38
Given that obesity is a modifiable risk factor, educate all migraine patients about the association with obesity in general, the increasing risk of migraine associated with increasing obesity, and the potential effect of weight gain/loss on headache frequency.26,27 Also inform patients about the potential effects migraine medications may have on their weight, and encourage them to eat a healthy diet, exercise, and avoid gaining excessive weight. If other comorbidities are involved, tailor the therapeutic regimen based on that combination. If a migraine patient is obese and has high blood pressure, look for an antihypertensive agent that is relatively weight-neutral.
Eliminating menstrual migraine should be an important treatment goal for patients in whom it is the most disabling migraine of the month. Hormonal preventives may be the best approach for women whose menstrual attacks are resistant to acute treatment.21
Disclosures
B. Lee Peterlin, DO, has received grant/research support from GlaxoSmithKline, has served as a consultant to Nautilus, and has served on the speaker’s bureau of Zogenix. She holds a provisional patent for use of adiponectin-modulating drugs for migraine.
Anne H. Calhoun, MD, has no conflicts of interest to report.
Fred Balzac has no conflicts of interest to report.
