Migraine and Psychiatric Comorbidity

Migraine is not a psychiatric disorder, although behavioral factors can critically influence the onset and course of headache episodes. Beginning in the 1950s, the conceptualization of migraine as a psychophysiological disorder by Wolff¹ and others ultimately supplanted the earlier and purely psychogenic or psychopathological view of migraine based on psychoanalytic principles of psychosomatic medicine. Just the same, migraine disproportionately presents comorbidly with a variety of psychiatric illnesses. Identifying and managing comorbid illness is essential and can prove challenging in the treatment of migraineurs.

Epidemiology

Migraine affects approximately 12% of Americans each year. It is 3 times more common among women than men (17.1% vs 5.6%, respectively) and peaks in prevalence between ages 25 and 55.² Whereas migraine often manifests as an episodic disorder, migraine is now recognized as a chronic disease that persists or progresses over time as a function of biological and psychosocial risk factors.³ Depressive and anxiety disorders are recognized as modifiable risk factors for transformation of episodic (fewer than 15 d/mo) into chronic (at least 15 d/mo) migraine and for development of frequent and refractory headache resulting from overuse of acute medications (medication overuse headache [MOH]).

Individuals with migraine are 2 to 4 times more likely to suffer from MDD than are those without migraine. Lifetime rates of MDD range from 22% to 32% among those with episodic migraine and are as high as 57% among those with chronic migraine.^4,5 Migraineurs also have a 3- to 4-fold increase in risk for bipolar disorder and for suicide attempts, even after controlling for psychiatric history.⁶

Among migraine sufferers, anxiety disorders are twice as common as depression, and migraineurs have a 3- to 5-fold increase in risk for various anxiety disorders compared with controls.^4,7 Panic disorder, phobias, and generalized anxiety disorder (GAD) are most common among migraineurs, although there is growing interest among researchers and clinicians in comorbidity with PTSD.⁷ Rates of depression, sui-cide attempts, and anxiety are most common among those who have greater headache frequency, those with aura symptoms, and those who seek treatment.

The temporal relationship between migraine and depression is bidirectional—either disorder increases the subsequent risk of developing the other. This bidirectional relationship appears unique to migraine, because depression typically occurs subsequent to onset of other severe headache diagnoses.⁸ Some evidence suggests that panic disorder and migraine also occur bidirectionally.⁹ However, depression is rarely present without anxiety among migraineurs, and among those with both diagnoses, the anxiety disorder typically predates depression.¹⁰ The patterning of these relationships indicates that depression and anxiety observed among migraineurs are not merely reactions to living with this chronic pain condition.

What new information does this article provide?

■ This article presents recent research highlighting increased rates of comorbid psychiatric disorders among migraine patients and reviews the impact of these comorbidities on migraine management and mechanistic hypotheses.

What are the implications for psychiatric practice?

■ All migraine patients should be screened for depression and anxiety at a minimum. Management of both migraine and the psychiatric condition often requires separate agents to target each individually or supplementation with behavioral therapies.