Comorbidity of major depression and migraine--a Canadian population-based study

Understanding the Biological Relationship between Migraine and Depression

Migraine is a highly prevalent neurological disorder. Among the risk factors identified, psychiatric comorbidities, such as depression, seem to play an important role in its onset and clinical course. Patients with migraine are 2.5 times more likely to develop a depressive disorder; this risk becomes even higher in patients suffering from chronic migraine or migraine with aura. This relationship is bidirectional, since depression also predicts an earlier/worse onset of migraine, increasing the risk of migraine chronicity and, consequently, requiring a higher healthcare expenditure compared to migraine alone. All these data suggest that migraine and depression may share overlapping biological mechanisms. Herein, this review explores this topic in further detail: firstly, by introducing the common epidemiological and risk factors for this comorbidity; secondly, by focusing on providing the cumulative evidence of common biological aspects, with a particular emphasis on the serotoninergic system, neuropeptides such as calcitonin-gene-related peptide (CGRP), pituitary adenylate cyclase-activating polypeptide (PACAP), substance P, neuropeptide Y and orexins, sexual hormones, and the immune system; lastly, by remarking on the future challenges required to elucidate the etiopathological mechanisms of migraine and depression and providing updated information regarding new key targets for the pharmacological treatment of these clinical entities.

Using digital phenotyping to capture depression symptom variability: detecting naturalistic variability in depression symptoms across one year using passively collected wearable movement and sleep data

Major Depressive Disorder (MDD) presents considerable challenges to diagnosis and management due to symptom variability across time. Only recent work has highlighted the clinical implications for interrogating depression symptom variability. Thus, the present work investigates how sociodemographic, comorbidity, movement, and sleep data is associated with long-term depression symptom variability. Participant information included (N = 939) baseline sociodemographic and comorbidity data, longitudinal, passively collected wearable data, and Patient Health Questionnaire-9 (PHQ-9) scores collected over 12 months. An ensemble machine learning approach was used to detect long-term depression symptom variability via: (i) a domain-driven feature selection approach and (ii) an exhaustive feature-inclusion approach. SHapley Additive exPlanations (SHAP) were used to interrogate variable importance and directionality. The composite domain-driven and exhaustive inclusion models were both capable of moderately detecting long-term depression symptom variability (r = 0.33 and r = 0.39, respectively). Our results indicate the incremental predictive validity of sociodemographic, comorbidity, and passively collected wearable movement and sleep data in detecting long-term depression symptom variability.

The role of metacognition, negative automatic thoughts and emotions in migraine-related disability among adult migraine patients

This cross-sectional study investigates the relationship between problematic metacognitions, negative cognitive content and emotional distress, and migraine-related disability among adult migraine patients. The migraine group consisted of 74 patients. Forty-seven healthy volunteers with similar sociodemographic characteristics were selected as the comparison group. Sociodemographic form, Migraine Disability Assessment Scale, Depression Anxiety Stress Scale, Automatic Thought Questionnaire, and Metacognition Questionnaire-30 were administered. Our results showed that higher depression, anxiety, stress levels, and negative automatic thoughts are significantly associated with more significant migraine disability. Our data also showed that high levels of depression and increased headache frequency predict migraine-related severe disability. We found that the frequency of headaches over three months and positive beliefs about worry significantly predicted the presence of chronicity in migraine. Our findings may help determine different approaches such as cognitive behavioral therapy and relaxation techniques in treating migraine.

Prevalence and Associated Factors of Depression among Adults Suffering from Migraine in Spain

Considering the significance of migraine and the limited amount of research conducted on its association with depression in population-based studies in Spain, this study aimed to determine the prevalence and change of depression from 2017 to 2020 among adults with migraine in Spain and to analyze the sociodemographic and health-related variables linked to depression in migraine sufferers. A cross-sectional study on 5329 adults with migraine from the Spanish National Health Survey 2017 and the European Health Survey in Spain 2020 was performed. Binary logistic regression was used to examine the factors related to depression. A total of 26.32% of people with migraine suffered from depression. No significant changes in that prevalence between 2017 and 2020 were observed. The risk factors associated with depression included being between the ages of 25 and 44 (p = 0.018), being separated or divorced (p = 0.033), being unemployed (p < 0.001), not engaging in recreational physical activity (p = 0.016), perceiving one's health as average, poor, or very poor (p < 0.001), experiencing moderate to severe pain in daily activities (p = 0.011, p = 0.004, p < 0.001, respectively), and having 1-2 or ≥3 chronic conditions (p = 0.003, p < 0.001, respectively). Conversely, being married (p = 0.001) and alcohol consumption (p = 0.007) were identified as protective factors.

Diseases of the musculoskeletal system and connective tissue in relation to temporomandibular disorders-A SWEREG-TMD nationwide case-control study

INTRODUCTION

Temporomandibular disorders (TMD) are comprised by a heterogenous group of diagnoses with multifaceted and complex etiologies. Although diseases of the musculoskeletal system and connective tissue (MSD) have been reported as risk factors for developing TMD, no nationwide population-based registry studies have been conducted to investigate this possible link. The aim of this study was to investigate the association between MSD and TMD in a population-based sample using Swedish registry data, and to further investigate the difference in such association between patients diagnosed with TMD in a hospital setting and patients surgically treated for the condition.

MATERIALS AND METHODS

Population based case-control study using Swedish nationwide registry data. Data was collected between 1998 and 2016 from 33 315 incident cases and 333 122 controls aged ≥18, matched for sex, age, and living area. Cases were stratified into non-surgical (NS), surgically treated once (ST1) and surgically treated twice or more (ST2). Information on MSD exposure (ICD-10 M00-M99) was collected between 1964 and 2016. Odds ratios were calculated using conditional logistic regression, adjusted for country of birth, educational level, living area, and mental health comorbidity.

RESULTS

A significant association between MSD and the development of TMD was found for all diagnostic categories: arthropathies (OR 2.0, CI 1.9-2.0); systemic connective tissue disorders (OR 2.3, CI 2.1-2.4); dorsopathies (OR 2.2, CI 2.1-2.2); soft tissue disorders (OR 2.2, CI 2.2-2.3); osteopathies and chondropathies (OR 1.7, CI 1.6-1.8); and other disorders of the musculoskeletal system and connective tissue (OR 1.9, CI 1.8-2.1). The associations were generally much stronger for TMD requiring surgical treatment. The diagnostic group with the strongest association was inflammatory polyarthropathies, M05-M14 (OR 11.7, CI 8.6-15.9), which was seen in the ST2 group.

CONCLUSIONS

Patients with MSD diagnoses have a higher probability of being diagnosed with TMD, in comparison to individuals without MSD. This association is even stronger for TMD that requires surgery. The results are in line with earlier findings, but present new population-based evidence of a possible causal relationship between MSD and TMD, even after adjusting for known confounders. Both dentists and physicians should be aware of this association and be wary of early signs of painful TMD among patients with MSD, to make early referral and timely conservative treatment possible.

Clinical features of migraine with onset prior to or during start of combined hormonal contraception: a prospective cohort study

Many studies have described the features of menstrually related migraines but there is a lack of knowledge regarding the features of migraine in combined hormonal contraceptive users (CHC). Hormone-withdrawal migraines in the pill-free period could differ from those in the natural cycle. Gynaecologic comorbidities, like dysmenorrhea and endometriosis, but also depression or a family history might modify the course of migraine. A better understanding of migraine features linked to special hormonal situations could improve treatment. For this prospective cohort study, we conducted telephone interviews with women using a CHC and reporting withdrawal migraine to collect information on migraine frequency, intensity, triggers, symptoms, pain medication, gynaecologic history and comorbidities (n = 48). A subset of women agreed to also document their migraines in prospective diaries. The mean number of migraine days per cycle was 4.2 (± 2.7). Around 50% of these migraines occurred during the hormone-free interval. Migraine frequency was significantly higher in women who suffered from migraine before CHC start (5.0 ± 3.1) (n = 22) in comparison to those with migraine onset after CHC start (3.5 ± 2.1) (n = 26). Menstrually related attacks were described as more painful (57.5%), especially in women with migraine onset before CHC use (72%) (p < 0.02). Comorbidities were rare, except dysmenorrhea. The majority of migraine attacks in CHC users occur during the hormone-free interval. Similar as in the natural cycle, hormone-withdrawal migraines in CHC users are very intense and the response to acute medication is less good, especially in those women, who developed migraine before CHC use.

What is the link between migraine and psychiatric disorders? From epidemiology to therapeutics

The association between migraine and psychiatric disorders is well documented through numerous population-based studies. The results of these studies are coherent and show an increased risk of suffering from depression, bipolar disorders, numerous anxiety disorders, especially post-traumatic stress disorder. This raises the question of stress as a precipitating factor for migraine illness. Psychiatric comorbidity is even more frequent in chronic migraine than in episodic migraine patients. Many prospective studies have shown that psychiatric comorbidity could be considered as a risk factor for migraine chronicization. Psychiatric comorbidity is also responsible for an increase of the frequency of anti-migraine drug intake, a worsening of quality of life and a worsening of functional impairment. It is also responsible for an increase in the direct and indirect costs of migraine. The reason why psychiatric comorbidity is so high in migraineurs is not unambiguous. Multiple causal relationships and common etiological factors are linked. Recently, genome-wide association studies gave leads to a genetic common heritability between major depressive disorder and migraine. For clinicians, an important topic remains how to treat migraineurs with psychiatric comorbidity. These patients suffer frequently from severe migraine or refractory migraine. Antidepressant and anti-convulsive drugs can be useful, as well as psychological therapies. But moreover, it is of utmost importance to propose an integrated multidisciplinary approach to these difficult patients.

Hypoechogenicity of the midbrain raphe detected by transcranial sonography: an imaging biomarker for depression in migraine patients

Background

The high comorbidity of migraine and depression is suggestive of shared risk factors or common mechanisms between the two diseases. In individuals with a depressive disorder, there is a high prevalence of altered midbrain raphe (MBR) echogenicity, detectable via transcranial sonography (TCS), that is suggested to be linked with a dysfunction of the serotoninergic system. In patients with migraine, this alteration has seldom been explored in earlier studies, and conclusions are often lacking. Our study aimed to elucidate whether this alteration is specific to migraine and to determine whether it is related with depression.

Methods

This study enrolled patients with migraine (n = 100, 72% female) and patients with tension-type headache disorders (TTH) (n = 62, 78.5% female) from a headache clinic. In addition, 79 healthy subjects (79.7% female) were recruited as controls. All participants underwent a standard interview to evaluate headache information and an interview with psychiatrists for depression evaluation. TCS examinations were performed on all participants.

Results

Patients with migraine had a higher rate of MBR hypoechogenicity (28%) compared with that of healthy controls (15.2%) and that of patients with TTH (12.9%). In patients with migraine, reduced MBR echogenicity was associated with depressive symptoms assessed using the Hamilton Depression Rating Scale (HAM-D). No association between migraine self-medication and MBR echogenicity was found.

Conclusion

Reduced-echoic MBR detected by TCS is prevalent in migraine patients and is associated with depressive symptoms. TCS-detected hypoechogenic MBR abnormality could be an imaging biomarker of depressive symptoms in patients with migraine.

Clinical Profile of Migraine in a Rural Population Presenting to Tertiary Care Hospital in North India

Background and Objective:

Migraine is one of the most common types of headache leading to significant disability; still people do not seek early help in developing countries. Therefore, we planned to conduct a study to assess the clinical profile of migraine, its triggers, comorbidities, and related disability in rural India.

Design:

An observational study in which 1,245 men and women suffering from migraine were recruited at a tertiary care hospital and were asked to complete a questionnaire related to migraine, its triggers, comorbidities, and disability.

Results:

Out of 1245 patients, females constituted 75% (937) of the patient pool and rest 25% were males (308). Fatigability (52.7%), nausea/vomiting (42.7%), phonophobia (33.57%), numbness (28.2%), and vertiginous sensation (20.8%) were accompanying features. Stress was the most common trigger impacting 44.9% of the patient population, followed by noise in 44.3% of cases. Exertion and sleep disturbance acted as triggers in 36.1%, smells in 20.5%, hormonal factors in 11.5%, and visual stimuli in 5.1% of patients. Anxiety was identified as the most common comorbidity affecting 542 patients (43.5%), followed by depression in 25.7%of patients. Around 103 patients (8.2%) had other psychiatric illnesses such as panic disorder and bipolar mood disorder.

Conclusion:

The migraine-related disability is high; therefore we conducted a study to understand its triggers and clinical profile. This was the first observational study conducted in a tertiary care hospital on migraine in north India catering to a sizeable rural population however, larger population studies are required to understand migraine more exhaustively.

Affective temperaments and lifetime major depression in female migraine patients

The relationship between affective temperaments and migraine is not well studied to date. It is also uncertain whether some affective temperaments may predispose the migraine patients to major depression (MD). We hypothesized that migraine patients had more affective temperament traits than HCs, and certain affective temperament traits in migraine patients are associated with lifetime MD. The sample included fifty-eight female migraine patients and age-matched 55 healthy women. The migraine was diagnosed according to the third edition of International Classification of Headache Disorders (ICHD-III). Lifetime MD was determined by means of Structured Clinical Interview I for DSM-IV. Migraine Disability Assessment (MIDAS) Questionnaire was applied to participants to determine the impact of migraine on daily life. Affective temperamental traits were assessed through Temperament Evaluation of Memphis, Pisa, Paris and San Diego Auto-questionnaire. All affective temperament traits (p < .0001) and the rate of MD (p = .002) were significantly higher in migraine patients compared to HCs. Non-depressive migraine patients (n = 36) had significantly more hyperthymic temperament traits compared to depressive patients (n = 22) (p = .04). Specifically, depressive temperament traits were significantly associated with higher lifetime MD in female migraine patients (B = 0.196, Exp(B) = 1.216, p = .01). Our findings suggest that affective temperaments may predispose some women to migraine, and depressive temperament may have a casual role in the development of lifetime depression in migraine patients.

My Migraine Voice survey: disease impact on healthcare resource utilization, personal and working life in Finland

BACKGROUND

A global My Migraine Voice survey was conducted in 31 countries among 11,266 adults who suffered from ≥4 monthly migraine days (MMD). The aim of this retrospective observational survey-based study was to analyse the country specific results in Finland in order to understand the impact of migraine based on disease severity.

METHODS

The included participants (3%, n = 338/11,266) were stratified by mean MMDs into 4 ≤ MMD < 8 (n = 133), 8 ≤ MMD < 15 (n = 139) and MMD ≥ 15 (n = 66) subgroups. Comorbidities, migraine-related emotional burden and impact on daily living and work productivity and activity impairment (WPAI) were assessed. Subgroup analysis on healthcare resource utilization (HCRU) due to migraine was assessed by visits to healthcare practitioners (HCPs) during the past 6 months and by hospitalizations and emergency room (ER) visits during the past 12 months. The group difference was tested using the one-way ANOVA and for categorical variables using the Chi-squared test. The association between HCRU and MMD and number of comorbidities was assessed using negative binomial regression analysis.

RESULTS

Mean age was 44 years, 93% were women and 67% (n = 227) were employed. Chronic migraine (CM, MMD ≥ 15) was reported in 19.5% of the respondents. The negative impact on daily functioning and emotional burden increased significantly by migraine frequency. Mean number of comorbidities was 2.4, and mean number of HCP visits during the previous 6 months was 5.9. Increase in migraine frequency and comorbidities was associated with higher HCRU. Eighty-eight percent of the respondents reported negative impact on working life and 52% experienced overall work productivity impairment. Over previous month, the mean number of missed working days for all respondents was 2.8 days of which 54% were paid sick leave days, and in CM up to 6.0 days and 30%, respectively. Both absenteeism and presenteeism were higher in the CM group.

CONCLUSIONS

The emotional and functional burden was high, and the societal burden increased by frequency and severity of migraine, as shown by higher HCRU and reduced work productivity. There is a need to improve quality of care in migraine and improve migraine management related issues in both healthcare and society in Finland.

Evidence of new-onset depression among persons with migraine after discontinuing antidepressants

Antidepressants have been hypothesized to cause tardive dysphoria-the delayed development of negative emotional symptoms. We assessed the risk of tardive dysphoria in a cohort of persons with migraine taking anti-migraine antidepressants with no known diagnosis of any mood or anxiety disorder. We included all outpatient encounters in a university hospital system for migraine from January 2008 through October 2018, excluding subjects with prior psychiatric diagnoses. Kaplan-Meier survival curves and multivariable Cox proportional hazards analyses were conducted. 13,048 subjects were included; 1191 took an antidepressant; 402 discontinued an antidepressant. In multivariable analyses examining the first year after exposure, antidepressant use was not significantly associated with risk of a depression, any mood disorder (including depression, mania, and other mood disorders), or anxiety. Antidepressant discontinuation was significantly associated with increased risk of depression, but not any mood disorder or anxiety. Among persons with migraine with no known psychiatric diagnosis, antidepressants did not appear to be associated with indicators of tardive dysphoria. Antidepressant discontinuation, however, was associated with increased risk of a depression diagnosis.

The exploration of mechanisms of comorbidity between migraine and depression

Migraine comorbid with depression is common and is often encountered in clinical practice. The comorbidity may lead to more serious conditions with other symptoms and a longer duration of treatment and it may impose heavy economic and social burdens, directly or indirectly, on patients and their families. Numerous studies have been published on the association of migraine with depression. Numerous literature have showed that the comorbidity may have a common complicated pathogenic mechanism involving biopsychosocial characteristics, including abnormal brain development and shared genetic basis, as well as neurotransmitters, sex hormones and stress. In addition, some studies have identified the multiple, bidirectional relationship between migraine and depressive disorder. We searched the literature for the possible common mechanisms between migraine and depression and classified the research results.

Understanding the nature of psychiatric comorbidity in migraine: a systematic review focused on interactions and treatment implications

BACKGROUND

Migraine is a highly prevalent and disabling neurological disorder which is commonly linked with a broad range of psychiatric comorbidities, especially among subjects with migraine with aura or chronic migraine. Defining the exact nature of the association between migraine and psychiatric disorders and bringing out the pathophysiological mechanisms underlying the comorbidity with psychiatric conditions are relevant issues in the clinical practice.

METHODS

A systematic review of the most relevant studies about migraine and psychiatric comorbidity was performed using "PubMed", "Scopus", and "ScienceDirect" electronic databases from 1 January 1998 to 15 July 2018. Overall, 178 studies met our inclusion criteria and were included in the current review.

RESULTS

According to the most relevant findings of our overview, the associations with psychiatric comorbidities are complex, with a bidirectional association of major depression and panic disorder with migraine. Importantly, optimizing the pharmacological and non-pharmacological treatment of either migraine or its psychiatric comorbidities might help clinicians to attenuate the burden of both these conditions.

CONCLUSIONS

The available data highlight the need for a comprehensive evaluation of psychiatric disorders in migraine in order to promote an integrated model of care and carefully address the burden and psychosocial impairment related to psychiatric comorbidities in migraine.

Migraine headache and depression in adults: a systematic Review and Meta-analysis

BACKGROUND

Migraines have adverse psychological consequences, one of which is the tendency towards depression. This study aimed to investigate the effects of migraine on adults' depression in the form of a systematic review and meta-analysis METHODS: Several scientific databases were searched using relevant keywords until the end of January 2018. After reviewing the titles and abstracts and the full texts, the researchers eventually included 16 eligible articles. Major and sub-group analyses were carried out using random effects. Publication bias was also measured.

RESULTS

Pooled Odd Ratio (PR) = 1.95; and 95% confidence interval (CI) = CI = 1.61-2.35 were obtained in studying the effects of migraine on depression. This effect was equal to OR = 1.81 (95% CI = 1.20-2.72) in cohort studies, and OR = 2.00; 95% CI = 1.64-2.43 in cross sectional studies. The heterogeneity was high, and no publication bias was found.

CONCLUSIONS

Migraine can play an important role in increasing the incidence of depression in affected patients. Therefore, identifying and ultimately treating the disease can be beneficial in reducing the negative psychological effects of this disease.

Depression screening by physical therapists: Practices, beliefs, barriers

BACKGROUND

Depression, a common comorbidity encountered in physical therapy (PT) practice, negatively impacts outcomes. There is limited knowledge of PT practice patterns relative to screening for depression.

OBJECTIVE

Objectives were to describe beliefs regarding depression, and identify practice patterns and perceived barriers regarding screening for depression among APTA Board Certified Orthopedic Clinical Specialist (OCS) PTs.

METHODS

Surveys were distributed to all PT OCSs in the US; 416 responses were analyzed. Descriptive, univariate and multiple regression analyses were performed.

RESULTS

Ninety-five percent of respondents believed that depression has a moderate to high influence on PT outcomes, whereas 68% believed a pre-existing diagnosis of depression influences the plan of care. Most believed that 20% or more of their current patients presented with symptoms of depression. Nevertheless, only 18% formally screen for depression during the initial evaluation. Those with formal depression screening education were 2.3 times more likely to screen at initial examination. Common barriers to screening included lack of department policy, limited knowledge and lack of follow-up resources.

CONCLUSIONS

Formal screening did not occur as frequently as expected, given the belief regarding depression's impact on plan of care and outcomes. Addressing barriers may assist in greater compliance with recommended screening guidelines.

Depression comorbidity in migraine

Migraine and Major Depressive Disorder (MDD) are highly prevalent conditions that can lead to significant disability. These conditions are often comorbid, and several studies shed light on the underlying reasons for this comorbidity. The purpose of this review article is to have a closer look at the epidemiology, pathophysiology, genetic and environmental factors, temporal association, treatment options, and prognosis of patients suffering from both conditions, to allow a better understanding of what factors underlie this comorbidity. Studies show that patients with migraine are 2-4-times more likely to develop lifetime MDD, predominantly due to similar underlying pathophysiologic and genetic mechanisms. There appears to be a bidirectional temporal association between the two conditions, although longitudinal studies are needed to determine this more definitively. Quality-of-life and health-related outcomes are worse for patients that suffer from both conditions. Thus, a careful assessment of the patient with access to appropriate resources and follow-up is paramount. Future studies in genetics and brain imaging will be helpful in further elucidating the underlying mechanisms in these comorbid conditions, which will hopefully lead to better treatment options.

Tear osmolarity and subjective dry eye symptoms in migraine sufferers

OBJECTIVE

Previous studies have suggested an association between dry eye and migraine. In a busy ophthalmologist clinic, quick identification of dry eye in migraine sufferers may improve their quality of life. Tear osmolarity is an objective and reliable tool for diagnosing dry eye. It has not been investigated in any population with migraine. Using tear osmolarity and questionnaires, we aimed to explore the relationship between dry eye and clinical symptoms in patients with migraine.

DESIGN

Prospective cross-sectional study.

PARTICIPANTS

Thirty-four adults with migraine sequentially recruited from a single neurologist's practice.

METHODS

Patients were assessed for subjective and objective signs of migraine and dry eye by using the Migraine Disability Assessment Score, the Ocular Surface Disease Index, and tear osmolarity (TearLab). Headache characteristics were compared by using χ², Fisher's exact, and Mann-Whitney U tests. Osmolarity scores were compared with scores for headache features.

RESULTS

Median age of patients was 38 years, and 76.5% were females. Severe migraine disability was reported in 75.6%, and 34.5% reported moderate to severe dry eye symptoms. Objectively, 49.5% had evidence of dry eye, significantly higher than the 20% recognized in the general population (p < 0.0001). Aura was found to occur more frequently with dry eye (43.8% vs 5.9%; p = 0.02). Those with daily headaches were also more likely to have higher tear osmolarity with marginal significance (median osmolarity 310 mOsm/L vs 299 mOsm/L; p = 0.08).

CONCLUSIONS

Patients with migraine, especially those with aura, appear more likely to have dry eye, as indicated by tear osmolarity. Tear osmolarity may also be greater in those who suffer from daily headaches.

Depression in epilepsy, migraine, and multiple sclerosis: Epidemiology and how to screen for it

Purpose of review

To provide an overview of the epidemiology of depression in chronic neurologic conditions that can affect individuals throughout the lifespan (epilepsy, migraine, multiple sclerosis [MS]) and examine depression screening tools for adults with these conditions.

Recent findings

Depression is common in neurologic conditions and can be associated with lower quality of life, higher health resource utilization, and poor adherence to treatment. It affects around 20%-30% of those with epilepsy, migraine, and MS, and evidence for a bidirectional association exists for each of these conditions. Depression screening tools generally perform well in neurologic conditions, but are not without limitations.

Summary

Depression is a major contributor to poor outcomes in epilepsy, migraine, and MS. Although psychiatric resources are scarce globally, this is no reason to ignore depression in neurologic conditions. Depression screening tools are available in neurology and should be considered in clinical practice.

Familial Aggregation of Migraine and Depression: Insights From a Large Australian Twin Sample

OBJECTIVES

This research examined the familial aggregation of migraine, depression, and their co-occurrence.

METHODS

Diagnoses of migraine and depression were determined in a sample of 5,319 Australian twins. Migraine was diagnosed by either self-report, the ID migraine™ Screener, or International Headache Society (IHS) criteria. Depression was defined by fulfilling either major depressive disorder (MDD) or minor depressive disorder (MiDD) based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria. The relative risks (RR) for migraine and depression were estimated in co-twins of twin probands reporting migraine or depression to evaluate their familial aggregation and co-occurrence.

RESULTS

An increased RR of both migraine and depression in co-twins of probands with the same trait was observed, with significantly higher estimates within monozygotic (MZ) twin pairs compared to dizygotic (DZ) twin pairs. For cross-trait analysis, the RR for migraine in co-twins of probands reporting depression was 1.36 (95% CI: 1.24-1.48) in MZ pairs and 1.04 (95% CI: 0.95-1.14) in DZ pairs; and the RR for depression in co-twins of probands reporting migraine was 1.26 (95% CI: 1.14-1.38) in MZ pairs and 1.02 (95% CI: 0.94-1.11) in DZ pairs. The RR for strict IHS migraine in co-twins of probands reporting MDD was 2.23 (95% CI: 1.81-2.75) in MZ pairs and 1.55 (95% CI: 1.34-1.79) in DZ pairs; and the RR for MDD in co-twins of probands reporting IHS migraine was 1.35 (95% CI: 1.13-1.62) in MZ pairs and 1.06 (95% CI: 0.93-1.22) in DZ pairs.

CONCLUSIONS

We observed significant evidence for a genetic contribution to familial aggregation of migraine and depression. Our findings suggest a bi-directional association between migraine and depression, with an increased risk for depression in relatives of probands reporting migraine, and vice versa. However, the observed risk for migraine in relatives of probands reporting depression was considerably higher than the reverse. These results add further support to previous studies suggesting that patients with comorbid migraine and depression are genetically more similar to patients with only depression than patients with only migraine.

Genetic epidemiology of migraine and depression

Background

Migraine and major depressive disorder (commonly referred to as depression) are both common disorders with a significant impact on society. Studies in both clinical and community-based settings have demonstrated a strong relationship between migraine and depression. In addition to complicating the diagnosis, depression that is comorbid with migraine may lower treatment adherence, increase risk of medication overuse and is associated with migraine chronification, thus leading to higher direct and indirect costs and poorer health-related outcomes with increased disability.

Aim

The aim of this review is to summarise the current knowledge on the genetic epidemiology of migraine and depression and the possible biological mechanisms underlying their comorbidity.

Methods

We present a narrative review reporting on the current literature.

Results and conclusions

Epidemiological findings indicate that there is a bidirectional relationship between migraine and depression, with one disorder increasing the risk for the other and vice versa, suggesting shared biological mechanisms. Twin and family studies indicate that this bidirectional relationship can be explained, at least partly, by shared underlying genetically determined disease mechanisms. Although no genes have been robustly associated with the aetiology of both migraine and depression, genes from serotonergic, dopaminergic and GABAergic systems together with variants in the MTHFR and BDNF genes remain strong candidates.

Association between somatic amplification, anxiety, depression, stress and migraine

BACKGROUND

The aim of this study is to investigate the associations between migraine related disability and somatosensory amplification, depression, anxiety, and stress.

METHOD

Fifty-five migraine patients who applied to the outpatient unit of the Neurology Department of Acibadem University School of Medicine, Maslak Hospital in Istanbul, Turkey, and twenty-eight subjects without migraine were recruited for the study. The participants were asked to complete a sociodemographic form, Migraine Disability Assessment Scale (MIDAS), Depression Anxiety Stress Scale, Somatosensory Amplification Scale (SSAS).

RESULTS

Somatosensory amplification scores were significantly higher in the migraineurs than in the control group (29.85+/-6.63 vs 26.07+/-7.1; p=0.027). Somatosensory amplification scores and depression scores were significantly higher in migraineurs with moderate and severe disability than in patients with minimal and mild disability (31.7+/-6.4 vs 27.71+/-5.49; p=0.01, 11.27+/-8.7 vs 7.38+/-8.11; p=0.04, respectively). A significant positive correlation was found between the frequency of migraine attacks for at least three consecutive months (MIDAS A scores) and the SSAS scores (r=0.363, p=0.007) in migraineurs. The MIDAS total scores were also significantly correlated with the DASS depression subcale scores (r=0.267, p=0.04), and the DASS stress subscale scores (r=0.268, p=0.05).

CONCLUSION

Psychological factors, and vulnerability to bodily sensations may incease the burden of migraine. We point out that the timely assessing of somatic amplification and the evaluation of mental status would help improve the quality of life of in migraineurs.

The contribution of stress to the comorbidity of migraine and major depression: results from a prospective cohort study

OBJECTIVES

To assess how much the association between migraine and depression may be explained by various measures of stress.

DESIGN

National Population Health Survey is a prospective cohort study representative of the Canadian population. Eight years of follow-up time were used in the present analyses.

SETTING

Canadian adult population ages 18-64.

PARTICIPANTS

9288 participants.

OUTCOME

Incident migraine and major depression.

RESULTS

Adjusting for sex and age, depression was predictive of incident migraine (HR: 1.62; 95% CI 1.03 to 2.53) and migraine was predictive of incident depression (HR: 1.55; 95% CI 1.15 to 2.08). However, adjusting for each assessed stressor (childhood trauma, recent marital problems, recent unemployment, recent household financial problems, work stress, chronic stress and change in social support) decreased this association, with chronic stress being a particularly strong predictor of outcomes. When adjusting for all stressors simultaneously, both associations were largely attenuated (depression-migraine HR: 1.30; 95% CI 0.80 to 2.10; migraine-depression HR: 1.19; 95% CI 0.86 to 1.66).

CONCLUSIONS

Much of the apparent association between migraine and depression may be explained by stress.

Adolescents with chronic migraine commonly exhibit depressive symptoms

Psychiatric comorbidity in patients with headache contributes to poorer prognosis, chronification of disease, poor response to treatment, increased cost of treatment, and decreased quality of life. The purpose of the present study was to evaluate the depressive symptoms in adolescents with chronic and episodic migraines and healthy adolescents. The study was performed between November 2010 and November 2011. All patients completed a detailed headache questionnaire comprising of demographical and clinical data and were instructed to fill out a headache diary over a 2-month period. The subjects ranged in age from 13 to 19 years. To evaluate depression symptoms, all of the subjects were asked to fill out the Beck Depression Inventory (BDI). A total of 137 participants were evaluated; 44 had episodic migraine (EM), 46 had chronic migraine (CM) and 47 were control subjects. Patients with a history of chronic migraine had significantly higher scores on the BDI than the other participants. Patients with chronic migraine had BDI scores that were 8.8 points higher than controls [95 % CI (β) = 5.0, 12.6] and 5.8 points higher than patients with EM [95 % CI (β) = 2.2, 9.4]. The main finding of this study was that chronic migraine is strongly associated with depression symptoms, regardless of demographic data. Comorbid depression may increase the total burden of migraine and diagnosis and treatment of depression in adolescents with migraine is likely to result in a better prognosis.

Comorbidity of migraine and mood episodes in a nationally representative population-based sample

OBJECTIVE

To examine the lifetime comorbidity of migraine with different combinations of mood episodes: (1) manic episodes alone; (2) depressive episodes alone; (3) manic and depressive episodes; (4) controls with no lifetime history of mood episodes, as well as sociodemographic and clinical correlates of migraine for each migraine-mood episode combination.

BACKGROUND

Migraine has been found to be comorbid with bipolar disorder and major depressive disorder in clinical and population-based samples. However, variability in findings across studies suggests that examining mood episodes separately may be fruitful in determining which of these mood episodes are specifically associated with migraine.

METHODS

Using a cross-sectional, population-based sample from the Canadian Community Health Survey 1.2 (n = 36,984), sociodemographic and clinical correlates of migraine were examined in each combination of mood episodes as well as controls. Logistic regression analyses controlling for age, sex, and education level compared the lifetime prevalence of migraine (1) between controls and each combination of mood episodes, and then (2) among the different combinations of mood episodes.

RESULTS

Migraine comorbidity in all combinations of mood episodes was associated with lower socioeconomic status, earlier onset of affective illness, more anxiety, suicidality and use of mental health resources. Compared with controls, the adjusted odds ratio of having migraine was 2.0 (95% confidence interval [CI] 1.4-2.8) for manic episodes alone, 1.9 (95% CI 1.6-2.1) for depressive episodes alone, and 3.0 (95% CI 2.3-3.9) for subjects with both manic and depressive episodes. Compared with those with manic episodes alone and depressive episodes alone, the odds of having migraine were significantly increased in subjects with both manic and depressive episodes (odds ratio 1.5 vs. manic episodes alone; 1.8 vs. depressive episodes alone). In addition, migraine comorbidity was associated with different correlates depending on the specific combination of mood episodes; in subjects with both manic and depressive episodes, migraine comorbidity was associated with an earlier onset of mental illness, while in subjects with either manic or depressive episodes alone, migraine comorbidity was associated with increased suicidality and anxiety.

CONCLUSIONS

Migraine comorbidity appears to delineate a subset of individuals with earlier onset of affective illness and more psychiatric complications, suggesting that migraine assessment in mood disorder patients may be useful as an indicator of potential clinical severity. Differences in the prevalence of migraine as well as sociodemographic and clinical correlates associated with specific combinations of mood episodes underscore the importance of examining this comorbidity by specific type of mood episode.

Prevalence and risk factors for depression and anxiety among outpatient migraineurs in mainland China

This study aimed to investigate the prevalence and risk factors for anxiety and depression symptoms in outpatient migraineurs in mainland China. In addition, we evaluated whether the Hospital Anxiety and Depression Scale (HADS) provided sufficient validity to screen depression and anxiety. A cross-sectional study was conducted consecutively at our headache clinic. Migraine was diagnosed according to International Classification of Headache Disorders, 2nd edition (ICHD-II). Demographic characteristics and clinical features were collected by headache questionnaire. Anxiety and depression symptoms about migraineurs were assessed using HADS. Several questionnaires were simultaneously used to evaluate patients with depressive disorder including the Hamilton Depression Rating Scale-17 (HAMD), Hamilton Anxiety Rating Scale (HAMA) and HADS. Pearson correlation analysis was applied to test the validity of HADS. 176 outpatients with migraine (81.8 % female) were included. Overall, 17.6 and 38.1 % participants had depression and anxiety, respectively. Possible risk factors for depression in migraineurs included headache intensity of first onset of migraine, migraine with presymptom, migraine with family history and migraine disability. The possible risk factors for anxiety included fixed attack time of headache in one day and poor sleeping, and age represented a protective factor for anxiety. The correlation coefficient of HADS-A and HADS-D with HAMA and HAMD was 0.666 and 0.508, respectively (P < 0.01). This study demonstrates that depression and anxiety comorbidity in our mainland Chinese migraineurs are also common, and several risk factors were identified that may provide predictive value. These findings can help clinicians to identify and treat anxiety and depression in order to improve migraine management.

Migraine headaches and suicide attempt

BACKGROUND

Previous cross-sectional studies reported an increased risk of suicide attempt in persons with migraine headache, which was sustained when psychiatric comorbidity was statistically controlled.

OBJECTIVE

To estimate the risk of suicide attempt in persons with migraine vs controls with no history of severe headache, using prospective data and validated diagnostic assessment. To examine the specificity of the migraine-suicide attempt risk by comparing it to the risk associated with non-migraine headache of comparable severity and disability.

METHODS

A cohort of persons with migraine (n = 496), non-migraine severe headaches (n = 151), and controls with no history of severe headache (n = 539) was randomly selected from the general community, assessed in 1997 and reassessed 2 years later.

RESULTS

Persons with migraine had an increased risk of suicide attempt during the 2-year follow-up period, compared with controls. Odds ratio, adjusted for sex, psychiatric disorder, and previous history of suicide attempt at baseline was 4.43 (95% confidence interval [CI] 1.93, 10.2). Persons with non-migraine headache of comparable intensity and disability also had an increased risk of suicide attempt, compared to controls: odds ratio, adjusted for the same covariates, was 6.20 (95% CI 2.40, 16.0). The difference between the 2 estimates was not significant. In the entire sample, headache severity at baseline predicted suicide attempt: a difference of 1 standard deviation (SD) in pain score increased the risk of suicide attempt by 79%, adjusting for sex and psychiatric disorders.

CONCLUSIONS

The results suggest the possibility that pain severity might account in part for the increased risk of suicide attempt associated with migraine.

A population-based longitudinal community study of major depression and migraine

OBJECTIVE

To examine whether major depressive episodes (MDEs) are associated with an increased risk of migraine in the general population and to examine whether migraine is associated with an increase risk of MDE.

BACKGROUND

Population-based cross-sectional studies have consistently reported an association between migraine and depression. However, longitudinal studies about this potentially bidirectional association are inconsistent.

METHODS

This retrospective cohort study used 12 years of follow-up data from the Canadian National Population Health Survey (15,254 respondents, age >12). Stratified analysis, logistic regression, and proportional hazard modeling were used to quantify the effect of migraine on subsequent MDE status and vice versa.

RESULTS

After adjusting for sex, age, and other chronic health conditions, respondents with migraine were 60% more likely (HR 1.6, 95% confidence interval 1.3-1.9) to develop MDE compared with those without migraine. Similarly adjusting for sex and age, respondents with MDE were 40% more likely (HR 1.4, 95% confidence interval 1.0-1.9) to develop migraine compared with those without MDE. However, the latter association disappeared after adjustment for stress and childhood trauma.

CONCLUSIONS

The current study provides substantial evidence that migraine is associated with the later development of MDEs, but does not provide strong causal evidence of an association in the other direction. Environmental factors such as childhood trauma and stress may shape the expression of this bidirectional relationship; however, the precise underlying mechanisms are not yet known.

A diffusion tensor magnetic resonance imaging study of corpus callosum from adult patients with migraine complicated with depressive/anxious disorder

OBJECTIVE

The aim of this study was to investigate the possible microstructural abnormalities of the corpus callosum (CC) in adult patients with migraine without aura complicated with depressive/anxious disorder.

BACKGROUND

Emotional disorders, especially depression and anxiety, are with relatively higher incidence in migraine population. However, the mechanism of migraine complicated with depressive/anxious disorder remains unclear.

METHODS

Diffusion tensor magnetic resonance imaging was carried out in 12 adult patients with simple migraine (without aura and without depressive/anxious disorder) (S-M group), 12 adult patients with complicated migraine (without aura but complicated with depressive/anxious disorder) (Co-M group), and 12 age- and sex-matched healthy subjects (Control group). Fractional anisotropy (FA) and apparent diffusion coefficient were measured at genu, body, and splenium of the CC, respectively.

RESULTS

There were significant differences in FA values at all locations of the CC among the 3 groups. The FA values from both the SM and Co-M groups were significantly lower than the control (P < .05 and P < .01, respectively). The FA values from Co-M group were significantly lower than the SM group (P < .01). The apparent diffusion coefficient values of the above regions had no significant differences among these groups (P > .05). There were negative correlations between FA value of genu of the CC and disease course as well as FA value of genu and body of the CC and headache frequency (P < .05). Negative correlations were also found between FA values at all locations of the CC and Hamilton anxiety and Hamilton depression scores (both P < .05).

CONCLUSIONS

There might be an integrity change of neurofibrotic microstructures existing as a possible neuroanatomical basis in the CC of migraine patients complicated with depressive/anxious disorder.

Management considerations in the treatment of migraine in adolescents

Migraine is common in adolescents. It can significantly reduce quality of life, may contribute to significant school absences, and disrupt social activities. This article will address the clinical presentation, natural history, types, evaluation, diagnosis and prognosis of migraine. Common adolescent lifestyle factors such as stress, irregular mealtimes, and sleep deprivation may exacerbate migraines. Management options are discussed including lifestyle modifications, acute and preventative therapies. Features of chronic daily headache including comorbid conditions, management, and outcome are also addressed.

The associations between migraine, unipolar psychiatric comorbidities, and stress-related disorders and the role of estrogen

Migraine is a common and often disabling neurovascular disorder. It has been linked with several psychiatric disorders, such as depression and anxiety, and to stress-related disorders, such as abuse and posttraumatic stress disorder (PTSD). Epidemiological data have consistently shown a higher prevalence of migraine, depression, anxiety, abuse, and PTSD in women as compared with men. The increased vulnerability of women to migraine and psychiatric disorders often occurs during periods of marked hormonal fluctuations of ovarian hormones. One consequence of these associations is the hypothesis that estrogens have a role in the pathophysiology of both disorders. This article offers an in-depth review of several studies linking psychiatric disorders and stress-related disorders with migraine. We also discuss the role of estrogen in the pathophysiologic overlap between these disorders. Finally, we briefly touch on where future research may be headed, in light of these data.

Association between migraine, anxiety and depression

Logistic regression was used to evaluate the relationship between self-reported medical diagnosis of migraine, self-reported depressive symptomology (RDS) and self-reported anxious symptomology (RAS) in the National Health Interview Survey ( n = 30 852). Semipartial squared correlations evaluated the population-level variability between RDS, RAS and migraine impairment. Migraine prevalence was 15.2% (overall), 20.5% (women) and 9.4% (men). Migraine risk was higher in participants with RAS [odds ratio (OR) 2.30, 95% confidence interval (CI) 2.09, 2.52), with RDS (OR 2.23, 95% CI 1.93, 2.58), who smoked (OR 1.19, 95% CI 1.09, 1.30), or who consulted a mental health provider (OR 1.45, 95% CI 1.27, 1.65). Although migraine risk was increased in both women (OR 1.93) and men (OR 2.42) with RAS ( P < 0.001), men with RAS had a higher migraine risk than did women with RAS ( P < 0.001). Only 7% of the variability in migraine impairment (population level) was predicted by variability in RDS and/or RAS.

Psychiatric disorders and headache familial recurrence: a study on 200 children and their parents

The main aim of the study was to examine the relationship between headache and familial recurrence of psychiatric disorders in parents and their children. Headache history and symptomatology have been collected in a clinical sample of 200 patients and their families, using a semi-structured interview (ICHD-II criteria). Psychiatric comorbidity was assessed by DSM-IV criteria. Chi squares and a loglinear analysis were computed in order to evaluate the main effects and interactions between the following factors: frequency and headache subtypes (migraine/not-migraine) in children, headache (migraine/not-migraine-absent/present) in parents, headache (absent/present) in grandparents, and psychiatric comorbidity (absent/present) have been analyzed: 94 mothers (47%) and 51 fathers (25.5%) had at least one psychiatric disorder, mainly mood and anxiety disorders. Considering the significant prevalence of Psi-co in children (P < 0.0001), we compared it with the presence of familiarity to headache: a significant interaction has been found (P < 0.05) showing that migraineurs with high familial recurrence of headache had a higher percentage (74.65%) of psychiatric disorders, than no-migraineurs (52.17%). Absence of headache familial loading seems to be related to psi-co only in no-migraine headache (87.5 vs. 45.5%). The occurrence of psychiatric disorders is high in children with headache, but a very different pattern seems to characterize migraine (familial co-transmission of migraine and Psi-Co?) if compared with non-migraine headache.

Parental psychopathology and migraine headaches among adolescent girls

Migraine headaches and depression often co-occur within individuals, and both syndromes run in families. However, knowledge about how these disorders relate across generations, as well as how migraine relates to other forms of psychopathology, is sparse. This study examined risk for migraine among female adolescent offspring of parents with different types of psychopathology. The sample was drawn from the Minnesota Twin Family Study, a community-based study of adolescents and their families (n = 674, 17-year-old female adolescents and their biological parents). Diagnoses of maternal, paternal and offspring major depression, antisocial behaviour, alcohol dependence and drug dependence were based on structured interviews. Migraine headaches in each family member were assessed via interviews with the mother. Parental depression, antisocial behaviour and drug dependence were associated with offspring migraine. These associations mostly remained significant even when parental migraine and the corresponding type of psychopathology in offspring were adjusted for. In contrast, there were no significant associations between parental psychopathology and offspring stomach problems, indicating that these associations did not extend to all offspring somatic symptoms. These results emphasize the need to look at antisocial behaviour and substance-related problems when examining associations between migraine and psychopathology, and indicate that more research on inter-generational links between migraine and psychopathology is needed.

Major depression as a risk factor for chronic disease incidence: longitudinal analyses in a general population cohort

OBJECTIVE

Cross-sectional studies have consistently reported associations between major depression (MD) and chronic medical conditions. Such studies cannot clarify whether medical conditions increase the risk for MD or vice versa. The latter possibility has received relatively little attention in the literature. In this study, we evaluate the incidence of several important chronic medical conditions in people with and without MD.

METHOD

The data source was the Canadian National Population Health Survey (NPHS). The NPHS included the Composite International Diagnostic Interview Short Form to assess past-year major depressive episodes. The NPHS also collected self-report data about professionally diagnosed long-term medical conditions. A longitudinal cohort was interviewed every 2 years between 1994 and 2002. Proportional hazards models were used to compare the incidence of chronic conditions in respondents with and without MD and to produce age-, sex- and covariate-adjusted estimates of the hazard ratios.

RESULTS

The adjusted hazard ratios associated with MD at baseline interview were elevated for several long-term medical conditions: heart disease (1.7), arthritis (1.9), asthma (2.1), back pain (1.4), chronic bronchitis or emphysema (2.2), hypertension (1.7) and migraines (1.9). The incidences of cataracts and glaucoma, peptic ulcers and thyroid disease were not higher in respondents with MD.

CONCLUSION

A set of conditions characterized particularly by pain, inflammation and/or autonomic reactivity has a higher incidence in people with MD.

Pharmacogenetics of migraine: genetic variants and their potential role in migraine therapy

Migraine is a paroxysmal neurological disorder affecting up to 6% of males and 18% of females in the general population, and has been demonstrated to have a strong, but complex, genetic component. Genetic investigation of migraine provides hope that new targets for medications and individual specific therapy will be developed. The identification of polymorphisms or genetic biomarkers for disease susceptibility and treatment should aid in providing a better understanding of migraine pathology and, consequently, more appropriate and efficient treatment for migraineurs. In this review, we will discuss results investigating genetic biomarkers for migraine and their potential role in future therapy planning.

Comorbidity of migraine and psychiatric disorders--a national population-based study

BACKGROUND

Migraine is common, with an estimated lifetime prevalence of 7-17%. Population-based studies have reported an association between various psychiatric conditions and migraine. This is a population-based study exploring the association between migraine and psychiatric disorders in a large cohort and assessing various health-related outcomes.

OBJECTIVE

(1) Determine the prevalence of various psychiatric conditions in association with migraine; (2) describe the patterns of association of these comorbidities with a variety of health-related outcomes.

METHODS

Data from the 2002 Canadian Community Health Survey were used. This is a national health survey which included administration of the World Mental Health Composite International Diagnostic Interview to a sample of 36,984 subjects. Health-related outcomes included 2-week disability, restriction of activities, quality-of-life, and mental health care utilization.

RESULTS

The prevalence of physician-diagnosed migraine (n=36,984) was 15.2% for females and 6.1% for males. Migraine was most common in those between ages 25 and 44 years and in those of lower income. Migraine was associated with major depressive disorder, bipolar disorder, panic disorder, and social phobia, all occurring more than twice as often in those with migraines compared with those without. Migraine was not associated with drug, alcohol, or substance dependence. The higher prevalence of psychiatric disorders in migraineurs was not related to sociodemographic variables. Psychiatric disorders were less common in those over 65 years, in those who were in a relationship, and in those of higher income whether migraine was present or not. Health-related outcomes were worst in those with both migraines and a psychiatric disorder and intermediate in those with either condition alone.

CONCLUSION

Migraine is associated with major depressive disorder, bipolar disorder, panic disorder, and social phobia. Migraine in association with various mental health disorders results in poorer health-related outcomes compared with migraine or a psychiatric condition alone. Understanding the psychiatric correlates of migraine is important in order to adequately manage this patient population and to guide public health policies regarding health services utilization and health-care costs.

Unexpected reduction in migraine and psychogenic headaches following rTMS treatment for major depression: a report of two cases

Our objective is to report a coincident reduction in headache pain in patients treated with repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder (MDD). Two patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of MDD, non-responsive to prior antidepressant treatment who were enrolled in a sham-controlled, double-blind study of rTMS for MDD. After the study, it was revealed that both were in the active-treatment arm. Both patients suffered from near daily headaches and kept logs of headache frequency and severity before, during, and after the study. Headache pain was significantly reduced under double-blind conditions with rTMS treatment, but returned to baseline following cessation of rTMS treatment. Ultimately, when receiving rTMS post-study as a maintenance intervention for MDD (approximately 2 rTMS sessions/week), the positive effects on headache amelioration were sustained. Headache pain is frequently comorbid with mood disorders and has been reported as the most common side effect with rTMS. In these subjects, rTMS was, in fact, associated with relief of depressive symptoms and preexisting headache pain. This indicates that rTMS may be beneficial for both disorders in some patients.