Evidence-Based Reviews

How to control migraines in patients with psychiatric disorders

Current Psychiatry. 2002 November;1(11):39-44

Migraines often coexist with psychiatric disorders, including anxiety and major depression. Managing the headaches can improve psychiatric symptoms, too.

PDF Download

References

1. Lipton RB, Stewart WF, Diamond S, Diamond M, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache 2001;41(7):646-57.

2. Breslau N, Davis GC. Migraine, major depression and panic disorder: A prospective epidemiologic study of young adults. Cephalalgia 1992;12(2):85-90.

3. Stewart WF, Linet MS, Celentano DD. Migraine headaches and panic attacks. Psychosom Med 1989;51(5):559-69.

4. Mersky H, Peatfield RC. Headache in the psychiatrically ill. In: Olesen J, Tfelt-Hensen P, Welch KMA (eds). The headaches (2nd ed). Baltimore: Lippincott, Williams and Wilkins, 1999;962-3.

5. Davidoff RA. Comorbidity. In: Davidoff RA (ed). Migraine manifestations, pathogenesis, and management (2nd ed). Oxford, UK: Oxford University Press, 2002;21-2.

6. Chang CL, Donaghy M, Poulter N. Migraine and stroke in young women: case-control study. BMJ 1999;318(7175):13-8.

7. Migraine-epilepsy relationships: epidemiological and genetic aspects. In: Andermann FA, Lugaresi E (eds). Migraine and epilepsy. Boston: Butterworths, 1987.

8. Smith R. Impact of migraine on the family. Headache 1998;38(6):423-6.

9. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society. Cephalalgia 1988;8(suppl 7):1-96.

10. Smith R, Hasse LA, Ritchey PN, et al. Extent of migraine and migrainous headache in headache NOS patients in family practice. Cephalalgia 2001;21:291-2.

11. Olesen J, Friberg L, et al. Basic mechanisms in vascular headache. Neurol Clin 1990;8:801-15.

12. Sumatriptan—an oral dose-defining study. The Oral Sumatriptan Dose-Defining Study Group. Eur Neurol 1991;31(5):300-5.

13. Diener HC. Positron emission tomography studies in headache. Headache 1997;37(10):622-5.

14. Joutel A, Bousser MG, V Biousse, et al. A gene for familial hemiplegic migraine maps to chromosome 19. Nat Genet 1993;5(1):40-5.

15. Iadecola C, Pelligrino DA, Moskowitz MA, Lassen NA. Nitric oxide synthase inhibition and cerebrovascular regulation. J Cereb Blood Flow Metab 1994;14(2):175-92.

16. Holroyd KA, Penzien DB, Lipchik GL. Efficacy of Behavioral Treatments. In: Silberstein SD, Lipton RB, Dalessio DJ (eds). Wolf’s headache and other head pain (7th ed). New York: Oxford University Press, 2001;563-6.

17. Robinson LA, Berman JS, Neimeyer RA. Psychotherapy for the treatment of depression: A comprehensive review of controlled outcome research. Psychol Bull 1990;108:30-49.

18. Gould RA, Otto MW, et al. Cognitive behavioral and pharmacological treatment of generalized anxiety disorder. Behav Ther 1997;28:285-305.

19. Breslau N, Andreski P. Migraine, personality and psychiatric comorbidity. Headache 1995;35(7):382-6.

20. Breslau N. Migraine, suicidal ideation, and suicide attempts. Neurology 1992;42(2):392-5.

21. Breslau N, Schultz LR, Stewart WF, et al. Headache and major depression: is the association specific to migraine? Neurology 2000;54(2):308-13.

Many of the 28 million people who suffer from migraine headaches each year¹ need psychiatric care in addition to headache relief. Migraine headaches often coexist with depression,² anxiety/panic disorders,^2,3 bipolar disorder,⁴ and phobias,⁵ as well as with stroke⁶ and epilepsy.⁷ A study of 995 young adults found that anxiety disorders, phobias, major depression, panic disorder, and obsessive-compulsive disorder were two to five times more prevalent among migraine sufferers than among a control group (Table 1 ).²

Migraine sufferers know that at any time an attack could hamper their ability to work, care for their families, or engage in social activities. A nationwide study of migraineurs found that attacks often impaired their relationships with family and friends.⁸

Psychiatrists should screen patients for a history of migraine or other headaches and carefully consider the relationship between migraines and psychiatric disorders when prescribing treatment. In this article, we outline acute and preventive headache treatments and present two cases to help you treat these patients appropriately.

Table 1

PSYCHIATRIC COMORBIDITIES IN PATIENTS WITH VS. WITHOUT MIGRAINES*

	Migraineurs (%) (n = 128)	Controls (%) (n = 879)
Any anxiety	54	27
Generalized anxiety disorder	10	2
Phobia	40	21
Major depression	35	10
Panic disorder	11	2
Obsessive-compulsive disorder	9	2
* Prevalence Source: Breslau N, Davis GC. Cephalalgia 1992;12(2):85-90.

Table 2

THREE TYPES OF PRIMARY HEADACHE: DIAGNOSTIC CRITERIA

Headache type	Age of onset (years)	Location	Duration	Frequency/timing	Severity	Quality	Features
Migraine	10 to 40	Hemicranial	4 to 72 hr	Variable	Moderate to severe	Throbbing, steady ache	Nausea; vomiting; photo/phono/osmophobia; neurologic deficits; aura
Tension-type	20 to 50	Bilateral/generalized	30 min to 7 days+	Variable	Dull ache, may wax and wane	Tight, band-like pressure	Generally none
Cluster	15 to 40	Unilateral, periorbital or retro-orbital	15 to 180 min	1 to 8 times per day or night	Excruciating	Boring, piercing	Ipsilateral, conjunctival injection, nasal congestion, rhinorrhea, miosis, facial seating
Source: Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society. Cephalalgia 1988;8(suppl 7):1-96.

Headache definitions and diagnosis

Primary or secondary. Under the International Headache Society’s (IHS) 1988 headache classification and diagnostic criteria,⁹ headaches are primary or secondary:

Primary headaches are benign recurrent headaches that commonly present in practice.
Secondary headaches occur much less frequently and are caused by underlying pathology.

The possibility of secondary headache should be ruled out before a primary headache can be diagnosed. The following headache features should cause concern:

Severe headache with abrupt onset
Subacute or progressive headache over days or months
Headache, nausea, vomiting, and fever not explained by systemic illness
New-onset headache late in life
Headache with neurologic signs or symptoms such as confusion, decreased level of consciousness, meningismus, or papilledema
Headache following head trauma
Patient history of sickle cell disease, malignancy, or HIV.

Headache types. The three major types of primary headache are migraine, tension-type, and cluster (Table 2 ). Tension-type is the most common, is often mild, and is either self-treated with over-the-counter medications or ignored. Migraine is the most troublesome headache in everyday practice. Cluster is the most severe and fortunately is rare.

Migraine with aura and migraine without aura are separate diagnoses. IHS criteria for diagnosing migraines without aura are listed in Table 3. According to the IHS, migraine with aura (or “classic migraine”) fulfills all the criteria for migraine without aura, with fully reversible neurologic symptoms indicating focal cerebral cortical and/or brain stem dysfunction.

Auras. About 15% of migraineurs experience auras. Symptoms develop within 5 to 20 minutes, usually last less than 1 hour, and fade before the headache’s onset. Gradual onset and history of previous attacks helps to distinguish aura from transient ischemic attacks. Auras may manifest as visual, sensory, motor, or brain-stem symptoms, or as combinations of these:

Visual auras are most common, presenting as localized visual loss (scotoma), with flashing lights (scintillation) at margins or jagged edges (fortification).
Sensory auras present as facial or limb paresthesias.
Motor auras manifest as weakness or lack of coordination.
Brain stem auras manifest as vertigo or double vision.

Migraine aura is considered part of the headache’s prodrome, which may occur days or hours before the headache’s onset. The aura may bring about:

an altered mental state (e.g., depression, hyperactivity, euphoria, difficulty concentrating, dysphasia)
neurologic symptoms (e.g., photophobia, phonophobia, hyperosmia, yawning)
general bodily discomforts (e.g., anorexia, food craving, diarrhea, thirst, urination, fluid retention, cold feeling).

Despite their sometimes severe effects, migraines often remain undiagnosed.¹⁰ Migraine should be suspected in patients with recurrent moderate to severe disabling headaches (Box).^11-15

Case 1: “Bad, sick headaches”

Ms. A, 23, a single parent with a 2-year-old child, has had trouble staying employed because of repeated illnesses. She made 17 visits to her primary care physician within 26 months. While her main complaint was headache, she also complained of other aches and pains, a lack of energy, and insomnia. Numerous examinations revealed no physical abnormalities.