Primary care update Current p SYCHIATRY How to control migraines in patients with psychiatric disorders Robert Smith, MD Lora A. Hasse, PhD Professor and director emeritus Research assistant professor of family medicine Department of family medicine Headache Research Unit Founder, Cincinnati Headache Center Department of family medicine University of Cincinnati University of Cincinnati Migraines often coexist with psychiatric disorders, including anxiety and major depression. Managing the headaches can improve psychiatric symptoms, too. any of the 28 million people who suffer from migraine headaches each year1 need psychiatric care M in addition to headache relief. Migraine headaches often coexist with depression,2 anxiety/panic disorders,2,3 bipo- lar disorder,4 and phobias,5 as well as with stroke6 and epilepsy.7 Table 1 A study of 995 young adults found that anxiety disorders, PSYCHIATRIC COMORBIDITIES IN phobias, major depression, panic disorder, and obsessive- PATIENTS WITH VS. WITHOUT MIGRAINES* compulsive disorder were two to five times more prevalent Migraineurs (%) Controls (%) among migraine sufferers than among a control group 2 (n = 128) (n = 879) (Table 1). Migraine sufferers know that at any time an attack Any anxiety 54 27 could hamper their ability to work, care for their families, Generalized anxiety disorder 10 2 or engage in social activities. A nationwide study of migraineurs found that attacks often impaired their rela- Phobia 40 21 tionships with family and friends.8 Major depression 35 10 Psychiatrists should screen patients for a history of Panic disorder 11 2 migraine or other headaches and carefully consider the Obsessive-compulsive disorder 92relationship between migraines and psychiatric disorders when prescribing treatment. In this article, we outline * Prevalence Source: Breslau N, Davis GC. Cephalalgia 1992;12(2):85-90. acute and preventive headache treatments and present two cases to help you treat these patients appropriately. VOL. 1, NO. 11 / NOVEMBER 2002 39 Migraine headaches Table 2 THREE TYPES OF PRIMARY HEADACHE: DIAGNOSTIC CRITERIA Headache type Age of onset Location Duration Frequency/ Severity Quality Features (years) timing Migraine 10 to 40 Hemicranial 4 to 72 hr Variable Moderate Throbbing, Nausea; to severe steady vomiting; ache photo/ phono/ osmophobia; neurologic deficits; aura Tension-type 20 to 50 Bilateral/ 30 min Variable Dull ache, Tight, Generally generalized to 7 days+ may wax band-like none and wane pressure Cluster 15 to 40 Unilateral, 15 to 180 1 to 8 times Excruciating Boring, Ipsilateral, periorbital or min per day or piercing conjunctival retro-orbital night 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 • New-onset headache late in life Primary or secondary. Under the International Headache • Headache with neurologic signs or symptoms such as Society’s (IHS) 1988 headache classification and diagnostic confusion, decreased level of consciousness, meningis- criteria,9 headaches are primary or secondary: mus, or papilledema • Primary headaches are benign recurrent headaches that • Headache following head trauma commonly present in practice. • Patient history of sickle cell disease, malignancy, or • Secondary headaches occur much less frequently and are HIV. caused by underlying pathology. Headache types. The three major types of primary headache The possibility of secondary headache should be ruled are migraine, tension-type, and cluster (Table 2). Tension-type out before a primary headache can be diagnosed. The follow- is the most common, is often mild, and is either self-treated ing headache features should cause concern: with over-the-counter medications or ignored. Migraine is the • Severe headache with abrupt onset most troublesome headache in everyday practice. Cluster is • Subacute or progressive headache over days or months the most severe and fortunately is rare. • Headache, nausea, vomiting, and fever not explained by Migraine with aura and migraine without aura are sepa- systemic illness rate diagnoses. IHS criteria for diagnosing migraines without 40 Current VOL. 1, NO. 11 / NOVEMBER 2002 p SYCHIATRY Current p SYCHIATRY aura are listed in Table 3. According to the IHS, Table 3 migraine with aura (or “classic migraine”) fulfills all DIAGNOSTIC REQUIREMENTS the criteria for migraine without aura, with fully FOR MIGRAINE WITHOUT AURA reversible neurologic symptoms indicating focal cere- bral cortical and/or brain stem dysfunction. Mandatory Auras. About 15% of migraineurs experience auras. 1. Secondary headache excluded Symptoms develop within 5 to 20 minutes, usually last 2. Duration 4 to 72 hours less than 1 hour, and fade before the headache’s onset. 3. At least 5 attacks Gradual onset and history of previous attacks helps to At least 2 of the following: distinguish aura from transient ischemic attacks. Auras 1. Location unilateral may manifest as visual, sensory, motor, or brain-stem 2. Pulsating/throbbing symptoms, or as combinations of these: 3. Moderate or severe headache (inhibits or prohibits • Visual auras are most common, presenting as routine activities) localized visual loss (scotoma), with flashing 4. Aggravated by walking stairs or similar activities lights (scintillation) at margins or jagged edges (fortification). During headache • Sensory auras present as facial or limb paresthesias. At least one of the following: • Motor auras manifest as weakness or lack of coordi- 1. Nausea and/or vomiting nation. 2. Photophobia and phonophobia • Brain stem auras manifest as vertigo or double vision. Additional features Migraine aura is considered part of the headache’s Migraine prodrome—A range of general, neurologic, and prodrome, which may occur days or hours before the mental changes may occur hours or days before the headache’s onset. The aura may bring about: headache’s onset • an altered mental state (e.g., depression, hyperactiv- General—Anorexia, food craving, diarrhea or constipation, ity, euphoria, difficulty concentrating, dysphasia) thirst, urination, fluid retention, cold feeling • neurologic symptoms (e.g., photophobia, phonopho- bia, hyperosmia, yawning) Mental—Depression, hyperactivity, euphoria, difficulty • general bodily discomforts (e.g., anorexia, food crav- concentrating, dysphasia ing, diarrhea, thirst, urination, fluid retention, cold Neurologic—Photophobia, phonophobia, hyperosmia, feeling). yawning Despite their sometimes severe effects, migraines SOURCE: Classification and diagnostic criteria for headache disorders, cranial neuralgias 10 often remain undiagnosed. Migraine should be suspect- and facial pain. Headache Classification Committee of the International Headache Society. ed in patients with recurrent moderate to severe disabling Cephalalgia 1988;8(suppl 7):1-96. headaches (Box).11-15 Case 1: “Bad, sick headaches” times lasted 2 to 3 days. Bed rest helped but this was not Ms. A, 23, a single parent with a 2-year-old child, has had always possible. The headache was throbbing and usually trouble staying employed because of repeated illnesses. She one-sided. She had no aura, and ibuprofen gave partial relief. made 17 visits to her primary care physician within 26 She noted that her mother gets similar headaches. months. While her main complaint was headache, she also Ms. A was diagnosed with migraine without aura, and complained of other aches and pains, a lack of energy, and she was treated with sumatriptan, 100 mg (1 or 2 doses, as insomnia. Numerous examinations revealed no physical needed). Her headaches responded well to this treatment, but abnormalities. the frequency of attacks remained unchanged. She requested She reported having “bad, sick headaches” that some- a change in her medicine. continued VOL. 1, NO. 11 / NOVEMBER 2002 41 Migraine headaches Box Treating the psychiatric comorbidity WHAT CAUSES MIGRAINE HEADACHES? Behavioral therapy is used as an adjunct to pharmacologic headache treatment. This he underlying mechanisms of migraine headaches are not approach is usually considered after a poor or Tcompletely understood. adverse response to treatment, or when phar- Vascular causes. A recently described neurovascular macologic treatment is contraindicated (e.g., mechanism11 suggests that perivascular neurogenic inflammation during pregnancy). involving meningeal vessels causes migraine. The triptan drugs have Relaxation training, biofeedback, and been found to reverse this process and relieve the headache.12 cognitive-behavioral stress management are Positron emission tomography has demonstrated increased blood the most commonly used forms of behavioral flow during acute migraine in midline brain stem structures. This therapy. Thirty-five to 55% improvement in suggests the presence of a central migraine generator in that migraine has been reported following such 16 location.13 treatments. Heredity. A rare form of migraine, familial hemiplegic migraine, Cognitive-behavioral intervention has 17 is associated with a genetic abnormality on chromosome 19.14 been shown to be effective in depression 18 Nitric oxide. Nitroglycerine-induced migraine headache, caused and anxiety disorders. When either psychi- by the release of nitric oxide in cerebral vessels, can be reversed by atric problem is comorbid with migraine, nitrous oxide synthase inhibitors,