Migraine, major depression and panic disorder: a prospective epidemiologic study of young adults

Migraine Frequency and Intensity: Relationship With Disability and Psychological Factors

BACKGROUND

Migraine can be disabling, but it varies greatly in frequency and intensity between individuals. It is not clear which clinical features have the greatest impact on a migraineur's quality of life.

OBJECTIVE

To determine the influence of headache intensity and frequency on headache-related disability.

METHODS

Patients who were referred to a headache clinic and given a diagnosis of migraine with or without aura or transformed migraine (n = 115) were divided into different groups based on headache frequency and mean headache intensity. Headache frequency was determined from patient diaries. Headache intensity also was assessed from patient diaries and from scores on the pain severity scale of the Multidimensional Pain Inventory (MPI). Headache-related disability was assessed with the Headache Disability Inventory and by scores on the activity interference scale of the MPI. The degree of depression present was assessed with the Beck Depression Inventory, and emotional distress was measured by scores on the affective distress scale of the MPI.

RESULTS

In our patient population, higher mean headache intensity levels were associated with higher levels of headache-related disability. Our results also suggested that increased headache intensity is associated with higher levels of depression and emotional distress, although this correlation was statistically significant in only 1 of 4 comparisons. Headache frequency did not correlate with disability, depression, or emotional distress.

CONCLUSIONS

For a headache referral population, headache intensity appears to be a major determinant of headache-related disability, and it also correlates, to some extent, with the degree of depression and emotional distress present. Headache frequency was not clearly related to disability or psychological factors.

Headache complaints associated with psychiatric comorbidity in a population-based sample

The objective of the present study was to determine the frequency at which people complain of any type of headache, and its relationship with sociodemographic characteristics and psychiatric comorbidity in S o Paulo, Brazil. A three-step cluster sampling method was used to select 1,464 subjects aged 18 years or older. They were mainly from families of middle and upper socioeconomic levels living in the catchment area of Instituto de Psiquiatria. However, this area also contains some slums and shantytowns. The subjects were interviewed using the Brazilian version of the Composite International Diagnostic Interview version 1.1. (CIDI 1.1) by a lay trained interviewer. Answers to CIDI 1.1 questions allowed us to classify people according to their psychiatric condition and their headaches based on their own ideas about the nature of their illness. The lifetime prevalence of "a lot of problems with" headache was 37.4% (76.2% of which were attributed to use of medicines, drugs/alcohol, physical illness or trauma, and 23.8% attributed to nervousness, tension or mental illness). The odds ratio (OR) for headache among participants with "nervousness, tension or mental illness" was elevated for depressive episodes (OR, 2.1; 95%CI, 1.4-3.4), dysthymia (OR, 3.4; 95%CI, 1.6-7.4) and generalized anxiety disorder (OR, 4.3; 95%CI, 2.1-8.6), when compared with patients without headache. For "a lot of problems with" headaches attributed to medicines, drugs/alcohol, physical illness or trauma, the risk was also increased for dysthymia but not for generalized anxiety disorder. These data show a high association between headache and chronic psychiatric disorders in this Brazilian population sample.

Factors associated with the onset of an episode of depressive symptoms in the general population

OBJECTIVES

To determined the association between spinal pain, headache, health, demographic and socio-economic characteristics, and development of depressive symptomatology.

METHODS

A population-based, random sample of adults was surveyed and followed at 6 and 12 months. Individuals at risk of depression at baseline are the subjects of this article (n=845). We used Cox proportional hazards models to measure the time-varying effects of demographic, socio-economic, and health status; comorbid medical conditions; spinal pain; and headaches on the development of depression.

RESULTS

After adjusting for baseline depressive symptoms and factors associated with nonresponse to follow-up, we found that spinal pain severity, younger age, marital status (separated/divorced/widowed), self-perceived poor health status, and comorbid neurologic and gastro-intestinal disease were associated with onset of a new episode of depression.

CONCLUSIONS

Important predictors of depressive symptomatology include demographic characteristics, health problems, and pain problems.

Clinical characteristics of patients with major affective disorders and comorbid migraine

The present study was undertaken to examine the clinical characteristics of patients with major affective disorders and comorbid migraine. Patients (n = 102) with an index episode of either major depression or mania were interviewed with a semi-structured interview based partly on DSM-IV criteria and partly on Akiskal's criteria for affective temperaments. Compared to the patients without migraine (n = 49), the patients with comorbid migraine (n = 53) had a higher frequency of bipolar II disorder (43% vs. 10%), a lower frequency of bipolar I disorder (11% vs. 33%), an approximately equal frequency of unipolar depressive disorder (45% vs. 57%) and a higher frequency of affective temperaments (45% vs. 22%). The migraine patients also had a greater number of anxiety disorders (3.0 vs. 1.9) and a higher frequency of panic disorder and agoraphobia. Gender distribution, age, age at onset of first affective episode, number of previous episodes and symptoms during depressive episodes were similar in both groups. Based on these findings it is suggested that the presence of migraine may be used to delineate a distinct subgroup of the major affective disorders.

Depression scores following migraine treatment in patients attending a specialized center for headache and neurology

OBJECTIVE

To determine the changes in clinical characteristics and depression levels among patients following treatment for migraine.

BACKGROUND

Epidemiologic studies have provided consistent evidence regarding an association between migraine and depression. In Puerto Rico, however, migraine has not yet been systematically investigated.

METHODS

A chart review of 144 Puerto Rican patients who presented with migraine, diagnosed according to the International Headache Society criteria, and depression over a 2-year period was performed. The level of depression, before and after migraine treatment, was evaluated using the Zung Self-rating Depression Scale.

RESULTS

The mean age of patients was 37.0 +/- 14.4 years; 77.1% were women. More than half (52.8%) reported severe headache and 56.9% reported a monthly frequency of five attacks or more. Nearly 9% were using antidepressant therapy and 8% were under psychiatric treatment. The mean Zung index score at baseline was 50.6 +/- 10.9. Following treatment with triptans, the intensity and frequency of migraine and the Zung index score decreased significantly (P<.00001). A trend for a greater reduction in Zung index scores among patients receiving triptan medications for more than a year was demonstrated (P =.07).

CONCLUSIONS

These results indicate that migraine treatment with triptans appears to be effective in decreasing the headache frequency and intensity, and depression levels, independent of antidepressant medication use or psychiatric treatment.

Epidemiology of migraine

Migraine is a highly prevalent headache disorder that has a substantial impact on the individual and society. Over the past decade, substantial advances in research have increased understanding of the pathophysiology, diagnosis, epidemiology, and treatment of the disorder. This article reviews data on the epidemiology and impact of migraine. It also highlights the increased awareness of migraine, citing examples from the popular media and the Internet.

Personality traits in childhood and adolescent headache

We evaluate personality traits, anxiety and depression in a population of paediatric and adolescent patients, correlating personality characteristics with headache and sociodemographic variables. The clinical features of headache include specific personality traits. We report a clinical study of 57 patients (age 8-18 years), divided up as follows: 12 migraine with aura, 29 migraine without aura and 16 tension-type headache. One of Cattel's tests was administered to every patient; the Children's Depression Inventory test was administered to 53 patients and the Test Anxiety Inventory test to 43 subjects. The scores obtained by every patient in each test were correlated with the characteristics of headache and with sociodemographic data. We found that patients affected by idiopathic headache share some personality traits, mainly emotional rigidity and tendency to repress anger and aggression. These traits do not seem to be correlated with sociodemographic data and the duration of headache: we considered these as characteristic of migrainous patients.

Epidemiology and economic impact of migraine

Migraine is a very common disorder, affecting about 11% of adult populations in Western countries. Prevalence is highest during the peak productive years--between the ages of 25 and 55. The prevalence is higher in females than males at all post-pubertal ages, but the sex ratio varies with age. In the United States, migraine prevalence is higher in those with low income or education, perhaps because migraine interferes with work and school. Most migraineurs mane their headaches without conventional medical advice and generally treat their attacks with over-the-counter medication. The indirect costs of migraine greatly outweigh the cost of treatment, creating opportunities for cost-effective intervention. The public health burden of migraine is substantial due to its high prevalence and prominent temporary disability. The widespread disability produced by migraine is an important target for treatment.

Personality traits and psychological reactions to mental stress of female migraine patients

The purpose of this study was (i) to compare a range of stress-related personality traits, including defense and coping mechanisms, of migraine patients (n = 23) with those of tension headache patients (n = 18) and dermatologically afflicted, but otherwise healthy, controls (n = 22), and (ii) to compare their state anxiety and other moods before, during, and after the presentation of a psychological stressor (mental arithmetic). For all three groups, mental arithmetic induced a significant increase in state anxiety and mood disturbance, followed by a subsequent decrease during recovery. Migraine patients were not found to have a higher disposition for anxiety, depression, or rigidity than tension headache patients or controls. Between the headache groups no differences in the use of defense and coping mechanisms were found. Compared to the control group, however, both migraine patients and tension headache patients were more inclined to use internally focused defense mechanisms and less inclined to seek social support when confronted with a problem. The psychological reaction of migraine patients to mental stress hardly differed from tension headache and control subjects. Compared to the control subjects, however, both groups of headache patients exhibited a diminished recovery from feelings of vigour, depression, and fatigue due to the stress induced. It is suggested that this distinct psychological reaction to stress of headache patients versus healthy control subjects is related to the more internally focused defense style of the headache sufferers. Thus, in contrast to previous results, this study does not present evidence of a migraine personality. It suggests the development of specific personality characteristics as a consequence of suffering from episodic headache.

Comorbidity of headache and depressive disorders

The goal of the present study was to investigate the clinical profile of patients with primary headache syndromes who also suffer from mood disorders. Four-hundred-and-seventy headache outpatients (170M, 300F) and 150 age- and sex-matched healthy subjects were screened using a specific questionnaire that included the Hamilton rating scales for anxiety and depression. The average scores of the Hamilton rating scales for anxiety and depression were significantly higher in headache sufferers (17.4 and 14.2, respectively) than in healthy people (6.8 and 5.7, respectively). The frequency of headache attacks, the history of headaches, and gender (women more than men) were correlated with the score of the Hamilton rating scale for both anxiety and depression. Sixteen headache patients (3.4%) achieved the DSM-IV criteria for major depression or dysthymia versus one among headache-free subjects (0.6%; OR 5.2). Patients suffering from drug-overuse and migraine with aura showed the higher odds ratios (35 and 17, respectively). These results suggest that those headache patients with long history and high frequency of headaches, or patients suffering from migraine with aura and drug-overuse might benefit from psychiatric evaluation.

A psychiatric study of nonorganic chronic headache patients

Nonorganic chronic headache is a common, challenging presentation in clinical practice. The aim of this study was to investigate the frequency of associated psychiatric psychopathology, personality disorders, or traits. In addition, the study attempted to investigate possible relationships of nonorganic chronic headache with alexithymia, locus of control, and pain perception. Psychiatric pathology, personality traits, and pain profiles were examined in 100 randomized patients with chronic headache lacking an obvious organic basis, and they were compared with 100 subjects, 50 with headache of a known organic cause and 50 seemingly healthy persons, by using structured clinical interviews. Somatoform pain disorder was diagnosed in 43% of the nonorganic and 20% of the organic headache group. Nine percent of the former group had major depression, 16% had dysthymia, and 8% had both. In the organic group, 56% had no psychiatric disorder and 20% had somatoform pain disorder. Seventy-seven percent of the patients in the nonorganic pain group had personality disorders, mostly of the mixed and multiple types, compared with 24% of the organic headache patients. The study sample was more alexithymic than the other groups (in 65% of subjects) and had a culturally influenced locus of control and a pain profile characterized by dramatization, vagueness, lower pain threshold, and lower pain tolerance. The nonorganic chronic headache patients showed a high prevalence of somatoform, depressive, and other forms of psychiatric disorders. The high frequency of personality disorders, mostly the mixed and multiple types, the high alexithymic pattern, and low pain threshold and tolerance in the study group should be taken into consideration in the evaluation and management of nonorganic headache patients.

Psychiatric comorbidity and psychosocial stress in patients with tension-type headache from headache centers in Italy. The Italian Collaborative Group for the Study of Psychopathological Factors in Primary Headaches

A multicenter study was carried out in 10 Italian Headache Centers to investigate the prevalence of psychosocial stress and psychiatric disorders listed by the IHS classification as the "most likely causative factors" of tension-type headache (TTH). Two hundred and seventeen TTH adult outpatients consecutively recruited underwent a structured psychiatric interview (CIDI-c). The assessment of psychosocial stress events was carried out using an ad hoc questionnaire. The psychiatric disorders that we included in the three psychiatric items of the fourth digit of the IHS classification were depressive disorders for the item depression, anxiety disorders for the item anxiety, and somatoform disorders for the item headache as a delusion or an idea. Diagnoses were made according to DSM-III-R criteria. At least one psychosocial stress event or a psychiatric disorder was detected in 84.8% of the patients. Prevalence of psychiatric comorbidity was 52.5% for anxiety, 36.4% for depression, and 21.7% for headache as a delusion or an idea. Psychosocial stress was found in 29.5% of the patients and did not differ between patients with and without psychiatric comorbidity. Generalized anxiety disorder (83.3%) and dysthymia (45.6%) were the most frequent disorders within their respective psychiatric group. The high prevalence of psychiatric disorders observed in this wide sample of patients emphasizes the need for a systematic investigation of psychiatric comorbidity aimed at a more comprehensive and appropriate clinical management of TTH patients.

Headaches and psychopathology in children and adolescents

OBJECTIVE

To examine the association between chronic headaches and DSM-III-R-defined psychiatric disorders, including depression, anxiety disorders, conduct disorder, oppositional defiant disorder and attention-deficit hyperactivity disorder, in a population-based sample of children and adolescents.

METHOD

1,013 children aged 9 to 15 years in the Great Smoky Mountains Study were evaluated annually over a 3-year period using the Child and Adolescent Psychiatric Assessment, a child and parent diagnostic psychiatric interview. Headaches that lasted at least 1 hour and occurred at least once a week during the 3 months prior to the interview were studied.

RESULTS

Girls with depression and anxiety disorders had a significantly greater prevalence of headaches than girls without an internalizing disorder. This association was not found for boys. Conduct disorder was significantly associated with headaches in boys. Each of these associations was constant with age.

CONCLUSIONS

This study suggests that a distinct gender difference exists between boys and girls in the associations between headaches and psychopathology. Carroll's theory of dysfunction in central pain regulation as an underlying cause of depression is discussed in relation to the proposed serotonergic dysregulation common to headaches, depression, anxiety, aggression, and pain.

MIG ACCESS: a population-based, nationwide, comparative survey of access to care in migraine in France

A national control-matched survey was conducted in France to evaluate the access of migraineurs to health care. A validated IHS criteria-based diagnostic procedure for screening was conducted in adults drawn from a sample of 6,000 households. A group of 650 subjects fulfilling the IHS criteria for migraine were matched by sex, age and activity status with a group of non-headache, non-migraine controls. Response rates were 87% and 82% for the migraineurs and the controls, respectively. The comparability of the groups was demonstrated by the absence of statistical differences between either respondents versus non-respondents or migraineurs versus controls for sex, age and occupation. The 3-month prevalence of migraine was estimated at 13% (95% CI: 12-14). The health care consumption of migraineurs was not higher than that of the controls. Migraineurs rarely consult for headaches and seem to content themselves with their routine analgesic treatment. They believe, however, that improvement in their condition is possible and discuss this with their physicians. This ambivalent attitude mainly reflects a fatalistic outlet which may constitute the major obstacle of an improved management of migraine.

Health-related quality of life under six months' treatment of migraine--an open clinic-based longitudinal study

Health-related quality of life (HQL) assessment in the clinical setting have distinguished subjective perceptions (e.g., well-being), signs/symptoms of the disease and functional capacity as three major components. The impact of short-term treatment for migraine attacks on these variables was evaluated in an open prospective 6-month study at the Gothenburg Migraine Clinic. Socio-economic factors, subjective symptoms, and general well-being/quality of life were evaluated by self-administered questionnaires in 99 patients with migraine with or without aura in accordance with the classification of the International Headache Society. Short-term treatment comprising conventional therapy or subcutaneous sumatriptan reduced number of days per month with migraine and absenteeism from work, migraine-associated symptoms, but did not significantly improve general well-being between attacks. Future assessment of the patients' HQL in accordance with this approach would enable us to consider all the advantages and disadvantages of current therapies of particular interest in the field of migraine.

Increasing identification and referral of panic disorder over the past decade

The study's objective was to contrast the prevalence, phenomenology, and medical care utilization for panic disorder from 1980 to 1990. All psychiatric consultations from a university consultation service from the years 1980, 1985, and 1990 were located (N = 2,400). Patients meeting DSM-III-R panic disorder criteria were selected for chart review. Variations in demographics, comorbidity, prior medical evaluations, and referral patterns were analyzed. The prevalence rate for consultations meeting panic disorder criteria has increased (2.5% in 1980, 4.2% in 1985, and 5.1% in 1990; chi 2 = 7.5, P = 0.024). Referring physicians more frequently noted panic attacks in 1990 (5% in 1980, 21% in 1985, and 59% in 1990; chi 2 = 21.2, P = 0.0001). A summary measure of medical care utilization revealed no significant interval change. Panic disorder is being recognized and referred more frequently by medical physicians since the publication of DSM-III and DSM-III-R. However, delay of diagnosis and high medical care utilization remain significant problems.

Migraine patients experience poorer subjective well-being/quality of life even between attacks

The aim of the present study was to compare the general well-being of migraine patients between attacks with that of an age- and sex-matched control group. One hundred and forty-five consecutive and eligible patients at the Gothenburg Migraine Clinic were asked about their well-being and their complaints. Using three self-administered standardized questionnaires, the Minor Symptoms Evaluation Profile (MSEP), Subjective Symptoms Assessment Profile (SSAP) and the Psychological General Well-Being (PGWB) Index, evaluable responses were obtained from 138 migraine patients. Compared with control subjects, migraineurs perceived more symptoms and greater emotional distress as well as disturbed contentment, vitality and sleep. It is concluded that the general well-being of the migraine patient is impaired, even between the attacks.

Migraine, physical health and psychiatric disorder: a prospective epidemiologic study in young adults

In a prospective study of a random sample of 1,007 young adults, we examined the association between migraine and psychiatric disorder, physical complaints, indicators of functional impairment, and use of mental health services. A history of migraine was associated with increased lifetime rates of major depression, anxiety disorders, illicit drug use disorders, nicotine dependence, and suicide attempts. Compared with subjects without a history of migraine, those with such a history had significantly more physical symptoms and were more likely to report job absenteeism, assess their general health as fair or poor, and use mental health services. Follow-up data, gathered 14 months after the baseline interview, revealed that subjects with a history of migraine at the baseline had significantly increased rates of first incidence major depression and panic disorder during the interval period (odds ratio (OR) for major depression = 4.2, 95% confidence interval (CI) 2.0-9.2; and OR for panic disorder = 12.8, 95% CI 4.1-39.8). The risk for these psychiatric disorders in persons with prior history of migraine was unrelated to the recentness of their migraine attacks. These findings suggest that the link between migraine, major depression and anxiety might reflect a common predisposition.