Expert opinion: migraine, psychiatric comorbidities, and treatment

Menopause hormone therapy, migraines, and thromboembolism

Migraine, a common form of headache, is a highly prevalent and disabling condition with a predilection for females. Migraines are neurovascular diseases. The two main types of migraines are migraines with and without aura, and several subtypes exist. There is a strong link between sex steroids and migraines. In women, migraine remissions are associated with stable and critical oestrogen levels. The literature reveals an association between migraine with aura and stroke, with a higher incidence in the young compared with that in the old. The absolute risk of stroke is low; tobacco use and a high dose of oral oestrogens may increase the risk. Early diagnosis, follow-up, and nonhormonal symptomatic and preventive treatments address the neglected area of migraines. Judicious use of hormones throughout the lifespan as needed would improve the quality of life.

Traditional and alternative treatments for depression: implications for migraine management

BACKGROUND

Migraine is frequently comorbid with major depressive disorder, the presence of which confers increased disability and various clinical challenges.

METHODS/RESULTS

The present article reviews empirically supported pharmacologic and cognitive-behavioral interventions for depression, as well as the emerging yet generally mixed efficacy for various complementary and alternative medicine depression treatments.

DISCUSSION AND CONCLUSION

Clinical implications and treatment strategies for migraine patients with comorbid depression are discussed. The literature reviewed here draws together clinical practice options for clinicians.

One-day behavioral intervention in depressed migraine patients: effects on headache

OBJECTIVE

To determine whether a 1-day behavioral intervention, aimed at enhancing psychological flexibility, improves headache outcomes of migraine patients with comorbid depression.

BACKGROUND

Migraine is often comorbid with depression, with each disorder increasing the risk for onset and exacerbation of the other. Managing psychological triggers, such as stress and depression, may result in greater success of headache management.

METHOD

Sixty patients with comorbid migraine and depression were assigned to a 1-day Acceptance and Commitment Training plus Migraine Education workshop (ACT-ED; N = 38) or to treatment as usual (TAU; N = 22). Patients completed a daily headache diary prior to, and for 3 months following, the intervention. Clinical variables examined included headache frequency/severity, medication use, disability, and visit to a health care professional. Comparisons were made between baseline findings and findings at the 3-month follow up.

RESULTS

Participants assigned to the ACT-ED condition exhibited significant improvements in headache frequency, headache severity, medication use, and headache-related disability. In contrast, the TAU group did not exhibit improvements. The difference in headache outcomes between ACT-ED and TAU was not statistically significant over time (ie, the treatment by time interaction was nonsignificant). These results complement those of a previous report showing effects of ACT-ED vs TAU on depression and disability.

CONCLUSION

A 1-day ACT-ED workshop targeting psychological flexibility may convey benefit for patients with comorbid migraine and depression.These pilot study findings merit further investigation using a more rigorously designed large-scale trial.

Physical co-morbidity among treatment resistant vs. treatment responsive patients with major depressive disorder

Co-morbid physical illness has been suggested to play an important role among the factors contributing to treatment resistance in patients with major depressive disorder. In the current study we compared the rate of physical co-morbidity, defined by ICD-10, among a large multicenter sample of 702 patients with major depressive disorder. A total of 356 of the participants were defined as treatment resistant depression (TRD) patients-having failed two or more adequate antidepressant trials. No significant difference was found between TRD and non-TRD participants in the prevalence of any ICD-10 category. This finding suggests that although physical conditions such as diabetes, thyroid dysfunction, hypertension, ischemic heart disease, and peptic diseases are often accompanied by co-morbid MDD, they do not necessarily have an impact on the course of MDD or the likelihood to respond to treatment. Marginally higher rates of co-morbid breast cancer, migraine and glaucoma were found among TRD participants. Possible explanations for these findings and their possible relation to TRD are discussed.

Prevalence of migraine and co-morbid psychiatric disorders among students of Cumhuriyet University

Backround

The aim of this study was to investigate the prevalence of migraine and associated psychiatric disorders among university students at Cumhuriyet University of Sivas in Turkey.

Methods

A total of 1601 university students participated in this study and answered the questionnaires. The study was conducted in three stages: the self-questionnaire, the neurological evaluation, and the psychiatric evaluation. In the first stage, the subjects completed a questionnaire to assess migraine symptoms. In the second stage, the subjects who reported having migraines underwent a detailed neurological evaluation conducted by a neurologist to confirm the diagnosis. In the final stage, the subjects with migraines completed a psychiatric examination using the structured clinical interview for DSM IV-R Axis I.

Results

The self-reported migraine prevalence rate was 13.7%, and the actual prevalence rate of migraine among the university students was calculated to be 10.6% (n = 169). When the results obtained with the SCID-I were examined, a current SCID-I psychiatric diagnosis was found in 39 (23.1%) of the 169 subjects with migraines. A total of 73 (43.2%) students with migraines had a lifetime SCID-I psychiatric diagnosis.

Conclusions

The results of this study indicate that migraines were highly prevalent among university students in Turkey with comorbid psychiatric disorders. Treatment strategies must be developed to manage these comorbidities.

One-day behavioral treatment for patients with comorbid depression and migraine: a pilot study

BACKGROUND

Migraine is a common and disabling disorder that is highly comorbid with depression. The comorbidity of depression and migraine is a major health concern as it results in poorer prognosis and quality of life. Yet, effective treatments have rarely been investigated.

METHOD

45 patients with comorbid migraine and depression were assigned to a 1-day Acceptance and Commitment Training plus Migraine Education workshop (ACT-ED; N = 31) or to Wait List/Treatment as Usual (WL/TAU; N = 14). Assessment of depressive symptoms, general functioning, and migraine related disability were completed at baseline and 2-, 6-, and 12 weeks after the workshop.

RESULTS

At the 3-month follow up, participants in the ACT-ED condition exhibited significantly greater improvements in depressive symptoms, general functioning, and migraine-related disability than patients in the WL/TAU group.

CONCLUSION

A 1-day ACT-ED workshop is a promising approach to the treatment for depression and disability in migraineurs that merits further investigation.

Concomitant use of triptan, and SSRI or SNRI after the US Food and Drug Administration alert on serotonin syndrome

OBJECTIVE

The present study was designed to discern the prevalence of concomitant use of a 5-hydroxytryptamine receptor agonist (triptan), and a selective serotonin reuptake inhibitor (SSRI) or a selective serotonin/norepinephrine reuptake inhibitor (SNRI) after the US Food and Drug Administration issued an alert regarding serotonin syndrome in 2006 and to contrast findings with data published prior to the federal warning.

BACKGROUND

In July 2006, the US Food and Drug Administration warned patients and health-care professionals to be aware that use of a triptan in combination with an SSRI or SNRI may result in a potentially life-threatening problem known as serotonin syndrome. In 2010, the American Headache Society published a position paper noting that there existed conflicting and insufficient information to discern the risk of serotonin syndrome with the use of triptan, and SSRI or SNRI, and that said Class IV data were not to be used as the basis for limiting the prescribing of triptan with SSRI or SNRI (Level U). Clinicians were cautioned as to the seriousness of serotonin toxicity and that monitoring was warranted.

METHODS

We used weighted data from the US National Ambulatory Medical Care Survey for years 2007 and 2008 to derive national estimates of the number of office-based physician-patient encounters (visits), documenting the concomitant use of triptan, and SSRI or SNRI. Results are compared with previously published findings for the years 2003 and 2004.

RESULTS

During the time-frame 2007-2008, an annualized mean of 5,256,958 patients were prescribed a triptan (vs 3,874,367 in 2003-2004, a 35.7% increase), and 68,603,600 patients were prescribed an SSRI or SNRI (vs 50,402,149 in 2003-2004, a 36.1% increase). An annualized mean of 1,319,763 patients were simultaneously prescribed or continued use of triptan, along with SSRI or SNRI (vs 694,276 in 2003-2004, a 90.1% increase).

CONCLUSION

Our study documents that 1.8% (1,319,763/73,860,558) of patients in 2007-2008 were prescribed triptan, and SSRI or SNRI (vs 1.3% in 2003-04, an increase of 38.5%). While this is a small fraction overall, the actual number of patients on a nationwide basis is substantial. What remains missing from the literature is documentation as to the number of cases of serotonin syndrome and resulting consequences (clinical and economic) because of the concomitant use of triptan, and SSRI or SNRI in the time-frame 2007-2008. Absent in these data, it remains difficult to assess the risk benefit associated with the use of triptan, and SSRI or SNRI.

Migraine: Clinical pattern and psychiatric comorbidity

BACKGROUND

Migraine is a common disorder which has psychiatric sequelae.

OBJECTIVE

The objective of this study was to determine the clinical pattern and psychiatric comorbidity of migraine.

MATERIALS AND METHODS

100 cases of migraine seen over a period of one year were analysed to know the sociodemographic characteristics, clinical pattern and psychiatric morbidity.

RESULTS

Maximum patients were between 31-40 years of age group (40%), females (78.0%), married (76%) and housewives (56.0%). Family history of migraine was present in 12% cases. Average age of onset was 22 years. Unilateral and throbbing type of headache was most common. The commonest frequency was one to two per week. Migraine without aura was commonest sub-type (80%). Generalized anxiety disorder (F41.1) was the most common psychiatric disorder (34%), followed by mixed anxiety and depressive disorder (F41.2) (18%) and depressive episode (F32) (14%). In 22% cases, no psychiatric disorder could be elicited.

CONCLUSION

The present study confirms that majority patients with migraine had psychiatric disorders. This needs timely detection and appropriate intervention to treat and control the migraine effectively.

The FDA alert on serotonin syndrome with use of triptans combined with selective serotonin reuptake inhibitors or selective serotonin-norepinephrine reuptake inhibitors: American Headache Society position paper

BACKGROUND

In 2006, a US Food and Drug Administration (FDA) alert warned about the potential life-threatening risk of serotonin syndrome when triptans are used in combination with selective serotonin reuptake inhibitors (SSRIs) or selective serotonin/norepinephrine reuptake inhibitors (SNRIs). This American Headache Society Position Paper further reviews the available evidence of the potential risk of combining triptans with other serotonergic agents.

METHODS

Using the Sternbach Criteria or the Hunter Serotonin Toxicity Criteria, the 29 cases used as the basis for the FDA alert were assessed in addition to a more recently published clinical review of 11 case reports of serotonin syndrome resulting from monotherapy, and one report of combination serotonergic agents. Evidence was evaluated according to the American Academy of Neurology Clinical Practice Guideline Process Manual.

RESULTS

Collectively, 40 case reports are available in the literature for subjects receiving either combination or monotherapy of serotonin agonists, all of which are limited to Class IV level of evidence. Of the 29 cases used as the basis for the FDA alert, 10 cases actually met the Sternbach Criteria for diagnosing serotonin syndrome. No cases fulfilled the Hunter Criteria for serotonin toxicity. One case published since the original report does not meet either criteria, and subsequently reported cases involving triptan monotherapy include insufficient details to confirm a diagnosis of serotonin syndrome.

RECOMMENDATIONS

With only Class IV evidence available in the literature and available through the FDA registration of adverse events, inadequate data are available to determine the risk of serotonin syndrome with the addition of a triptan to SSRIs/SNRIs or with triptan monotherapy. The currently available evidence does not support limiting the use of triptans with SSRIs or SNRIs, or the use of triptan monotherapy, due to concerns for serotonin syndrome (Level U). However, given the seriousness of serotonin syndrome, caution is certainly warranted and clinicians should be vigilant to serotonin toxicity symptoms and signs to insure prompt treatment. Health care providers should report potential cases to MedWatch and consider submitting them for publication.

Migraine and psychiatric disorders: comorbidities, mechanisms, and clinical applications

Migraine is often comorbid with psychiatric disorders such as major depression, bipolar disorder, and anxiety disorders. Although most of the research on psychiatric comorbidities and migraine is of an epidemiologic nature, a growing body of literature has investigated possible mechanisms underlying this relationship, such as medication overuse, serotonergic dysfunction, ovarian hormone fluctuations, and central sensitization. The present article overviews this growing literature and notes strategies for the clinical management of migraine patients with psychiatric comorbidities.

Migraine: a question and answer review

Internists commonly treat migraine, which affects more than 29 million Americans yearly. This article reviews epidemiology, pathophysiology, comorbidity, clinical features, diagnostic testing, acute and preventive treatment, and women's issues. Physicians and migraineurs would like to see more effective and more tolerable medications.