OJAI, CA—Patients with difficult-to-manage migraine have headache that is refractory to the usual pharmacologic and nonpharmacologic treatment approaches and pain that is typically deemed intractable. These patients are often overusing or misusing acute medication or are dependent on it. They may have ongoing compliance issues, have a diminished ability to function, and present with a history of multiple providers, referrals, and tests. Perhaps chief among all defining characteristics, these patients usually have several comorbid conditions, including psychiatric disorders.
“It’s very rare that you see a patient with chronic daily headache who doesn’t have other comorbid conditions,” said Fred Sheftell, MD, in a talk focused on the shared pathophysiologic traits of migraine and psychiatric disorders, presented at the First Annual Headache Cooperative of the Pacific Winter Meeting.
Patients with difficult-to-treat chronic migraine typically fall into a category of headache and psychiatric comorbidity sometimes seen in Minnesota Multiphasic Personality Inventory profiles with seizure and movement disorders. “These are patients who do have migraine but also have something else that’s going on,” emphasized Dr. Sheftell, who is the Director of the New England Center for Headache in Stamford, Connecticut. “These patients probably have a biologic/genetic predilection for some of these disorders. A variety of factors become superimposed on that—sensitization, personality issues—and that may set the clinical picture on fire.
“Just as one would not ascribe the cause of stroke, Parkinson’s disease, or multiple sclerosis to comorbid depression or anxiety, the same understanding and view should be given to patients with migraine and comorbid psychiatric disorders. As in any other neurologic disorder, comorbid psychiatric issues must be recognized and treated to improve quality of life and outcomes.”
The “Migraine Personality”
The question of whether migraine and psychiatric disorders have a common pathophysiology can be traced back to the debate regarding psychiatry versus neurology and which disorders are appropriately treated by each field. As disciplines, psychiatry and neurology started out together, Dr. Sheftell explained. “Then over time, neurology laid claim to those disorders which you can see, touch, and feel, and psychiatry staked a claim to the mind,” he said. “That’s completely changed nowadays because of molecular biology, functional imaging, and the kinds of things we have available for neuropsychiatry, and neurology is slowly changing.”
He cited the work of Harold G. Wolff, MD, who wrote in 1948 that it was “unprofitable to establish a separate category of illness to be defined as psychosomatic. Rather, man’s nervous system is implicated in all categories of disease.”
Dr. Wolff coined the term “migraine personality,” based in part on a chart review of 46 migraineurs. He found that in childhood half the subjects were “delicate, shy, well mannered, stubborn, inflexible, often with undue attachment to the mother” and that in adolescence subjects generally had been “preoccupied with moralistic and ethical problems, particularly concerning sex.” In adulthood, nine of 10 subjects were “unusually ambitious … driving individuals, unable to relax, conscientious, perfectionist, meticulous, fastidious, poor at delegation, overanxious and tense at work, prone to let-down headache [on] weekends … and unable to cope with criticism.” Dr. Wolff also noted “lack of plasticity” and “fear of not being able to finish tasks on time.”
Dr. Sheftell juxtaposed this description with a contemporary list of clinical features of chronic daily headache, including daily or near-daily mild to moderate headache; sleep disorder; decreased energy, concentration, libido, and ability to enjoy oneself; and, in most cases, daily or near-daily consumption of “symptomatic” medications. “So where else do you find that?” he asked. “You find it in anxiety disorders, and you find it in depression.”
In noting some of the neurotransmitters involved in migraine—from such monoamines as serotonin and dopamine to GABA and glutamate—Dr. Sheftell pointed out that they are also implicated in depression. “I want to remind you while talking about GABA and glutamate … [of] the FDA alert on the antiseizure drugs and their ability to cause profound personality changes and suicidal ideation,” he said. “What I’m saying to you is, as physicians, these drugs are perfectly good. They have tremendous efficacy, and they have been studied very carefully….
“The point is, you’ve got to warn the patients about changes in personality, onset of depressive symptoms, etc…. You do that and tell the patient to be in contact with you if he or she sees any of these problems. I think some of these patients who develop suicidal ideation are patients who may have unrecognized bipolar disorder … and may require aggressive therapies [for it] as well.”
Dr. Sheftell believes that serotonin may be one of the most important neurotransmitters in terms of clinical relevance. “You can’t get away from serotonin in terms of its importance, not only in migraine, centrally and peripherally, but also in terms of its relevance in mood and anxiety disorders,” he said, adding such conditions as sleep and eating disorders, obsessive-compulsive disorder, and tension-type headache.