Associations Between Migraine and Psychiatric Comorbidities, Implications for Treatment

Migraine, woman with headache
Migraine, woman with headache
There may be a bidirectional association between migraine and some comorbid psychiatric disorders.

There may be a bidirectional association between migraine and some comorbid psychiatric disorders, according to a systematic review published in the Journal of Headache and Pain.

Researchers systematically reviewed several scientific databases and selected 178 studies in which the presence of psychiatric comorbidities in individuals with migraine was examined.

Twice as many individuals with migraine were found to have comorbid depression compared with people in the general population. Studies reviewed indicate the presence of a bidirectional relationship between the occurrence of migraine and major depression, an association thought to involve the serotonin and dopaminergic systems. Treatment with onabotulinumtoxin A or cognitive behavioral therapy may be effective both on migraine and psychiatric comorbidities, according to the review authors, as these disorders have common mechanisms.

Individuals with bipolar disorder were found to have a higher prevalence of migraine compared with the general population (55.3% vs 15.7%, respectively), and the occurrence of migraine was found to often precede the onset of bipolar disorder Several studies indicated that dysfunction in the serotonergic, dopaminergic, and glutamatergic systems may underlie comorbid migraine and bipolar disorder. Some of the treatments that have shown to stabilize bipolar disorder (eg, valproate and topiramate) may also be effective on comorbid migraine. Social rhythm therapy, which seeks to stabilize an individual’s circadian rhythms was found to be effective for migraine and bipolar disorder.

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Other common migraine psychiatric comorbidities included anxiety disorders (eg, panic, phobic, and generalized anxiety disorders). The prevalence of these disorders was found to increase with the frequency of migraine, suggesting, according to the review authors, a dose-response effect. Anticonvulsant medications (eg, pregabalin, topiramate) may be effective for the treatment of migraine and some comorbid anxiety disorders.

Review limitations include the cross-sectional design of most studies, which prevented full assessment of causal relationships.

“Clarifying the comorbidity between psychiatric disorders and migraine is essential not only at the clinical diagnostic level but above all for the complex therapeutic implications of such comorbidity,” noted the review authors. “Many biological and neural aspects related to the comorbidity still need to be clearly elucidated to better approach the real complexity of this issue.”

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Dresler T, Caratozzolo S, Guldolf K, Huhn JI, Loiacono C, Niiberg-Pikksööt T, et al. Understanding the nature of psychiatric comorbidity in migraine: a systematic review focused on interactions and treatment implications. J Headache Pain. 2019;20:51.