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Keywords:

  • migraine;
  • depression;
  • anxiety;
  • substance overuse and misuse;
  • behavioral medicine

Abstract

  1. Top of page
  2. Abstract
  3. RELATIONSHIP OF PSYCHIATRIC CONSIDERATIONS AND PRIMARY HEADACHE DISORDERS
  4. MAJOR DEPRESSION
  5. COMORBIDITY OF DEPRESSIVE DISORDERS WITH ANXIETY DISORDERS
  6. SUBSTANCE ABUSE, OVERUSE, AND MISUSE
  7. AXIS II DISORDERS
  8. BEHAVIORAL MEDICINE
  9. REFERENCES

Objective.—To review psychiatric issues that accompany migraine and means of addressing these issues.

Background.—Psychiatric factors and migraine may interact in three general ways, etiologically, psychophysiologically or biobehaviorally, and comorbidly (the two disorders coexist), which is the present focus. There are several possible mechanisms of comorbidity. The relation between two disorders may be a result of chance. One disorder can cause another disorder: Diabetes can cause diabetic neuropathy. There might be shared environmental risks: Head trauma can cause both posttraumatic epilepsy and posttraumatic headache. And there may be environmental or genetic risk factors that produce a brain state giving rise to both conditions, that is, there may be some common biology underlying both conditions. This last mechanism seems to be the most likely one underlying comorbidity of migraine and psychiatric disorders. We introduce a possible role for classical paradigms of learned helplessness in regard to psychiatric comorbid depressive and anxiety disorders and migraine.

Results.—There appears to be an association between migraine and affective disorders, particularly depression and anxiety. There are a number of formal tools for recognizing depression, but clinical evaluation should not be overlooked. Once diagnosed, depression and anxiety should be treated, both to improve the success of migraine treatment and to improve the patient's quality of life. Patients with recurring headaches are much more likely to overuse and misuse, rather than abuse, pain medications. It is important to be alert for signs that the patient may be misusing medication. Behavioral approaches can surround and support pharmacological therapy.

Conclusions.—Migraine is often comorbid with psychiatric disorders, particularly depression and anxiety. The relationship is likely based on shared mechanisms and successful treatment is possible.

Abbreviations:
DSM-IVPC

Diagnostic and Statistical Manual of Mental Disorders, Primary CareVersion

PRIME-MD

Primary Evaluation of Mental Disorders

HRQOL

health-related quality of life; 5-HT 5-hydroxytryptamine; SSRIs selective serotonin reuptake inhibitors

The symptoms and suffering of patients with migraine must be seen in the context of the human experience. Psychiatric issues are prominent among patients with more difficult headache problems, particularly chronic daily headache. Patients with chronic daily headache often present with a sense of emptiness, sadness, and pain that may be visible even in their facial expressions. We review psychiatric issues that accompany migraine and how to address them.

The “difficult” headache patient, often one with chronic daily headache (Table 1), can usually be identified as refractory to the “usual” pharmacological and nonpharmacological approaches. He or she presents with intractable pain and often overuses, misuses, or is dependent on medication. This person has frequent emergency room visits and generally has ongoing compliance issues. One can note a decreased ability to function and multiple referrals, providers, and tests. When treating a difficult patient, one must consider psychiatric issues and how they relate to primary headache disorders.

Table 1.—.  Clinical Features of Chronic Daily Headache
  • *

    Symptoms common to depressive disorders.

Daily or near daily mild to moderate headache
Superimposed episodes of migraine defined by the International Headache Society criteria
Sleep disorder*
Decreased energy*
Anhedonia*
Decreased concentration*
Decreased libido*
Daily or near daily comsumption of symptomatic medications in most cases

RELATIONSHIP OF PSYCHIATRIC CONSIDERATIONS AND PRIMARY HEADACHE DISORDERS

  1. Top of page
  2. Abstract
  3. RELATIONSHIP OF PSYCHIATRIC CONSIDERATIONS AND PRIMARY HEADACHE DISORDERS
  4. MAJOR DEPRESSION
  5. COMORBIDITY OF DEPRESSIVE DISORDERS WITH ANXIETY DISORDERS
  6. SUBSTANCE ABUSE, OVERUSE, AND MISUSE
  7. AXIS II DISORDERS
  8. BEHAVIORAL MEDICINE
  9. REFERENCES

Psychiatric factors and migraine may interact in three general ways. Psychiatric factors may be etiological, but this is extremely rare. The second possibility is psychophysiological or biobehavioral. In this case there is a real physiological disorder that can be influenced by psychological factors (which is true of virtually any medical disorder). The last interaction is psychiatric comorbidity, in which two disorders coexist, and that is the focus here.1

Etiological Considerations.

Somatoform pain disorders are one type of etiological consideration. This is a disorder in which there is a persistent complaint of pain without a physical cause or the pain and impairment is greater than would be expected from the physical findings. Hypochondriasis, somatization disorder, and pain disorder comprise subgroups of somatoform disorders. Hypochondriasis is noted when patients have a preoccupation with physical symptoms, so that any change from the norm is interpreted as pathology. These patients constantly seek reassurance from their doctors that they are not ill. This is not quite delusional. Somatization disorder patients have complaints on many different medical axes.2

Malingering is rarely seen, even in posttraumatic headache disorders involving litigation. Cases of factitious disorder and Munchausen by proxy, in which people pretend to suffer from migraine to gain sympathy and support, can occur but are rare.3 In delusional disorder, somatic type, the patient may interpret real pain caused by structural problems in some delusional way (snakes are in his head or the radio tower is beaming things at her). It is important to note that though the pain may be ascribed to a delusional system, the origin of the pain may indeed be real and requires a thorough evaluation.

Psychophysiological or Biobehavioral.

Adler4 was the first to use the term psychobiology, linking psychological and biological factors. Selye,5 Cannon,6 Bernard,7 and Pavlov8 did the early work linking the external and internal milieu and describing how external stress can impact physiology. Alexander and Benedek9 were among the first to talk about psychological and somatic factors in a model of psychosomatic disorders, now termed psychophysiological.

The “migraine personality” has been written about extensively. Harold Wolff, who reviewed his charts and found that many migraine patients tended to be rigid obsessional people with high expectations of themselves, coined the term.10 Recently, “psychological factors affecting medical conditions” has replaced “psychosomatic conditions” in the Diagnostic and Statistical Manual of Mental Disorders, Primary Care Version (DSM-IVPC).2 The DSM-IVPC emphasizes the use of nine diagnostic algorithms for the most prevalent psychiatric disorders in primary care.

Headache and Psychiatric Comorbidity.

Before discussing headache and psychiatric comorbidity, it is important to understand the possible mechanisms of comorbidity, of which there are several.1 The relation between two disorders may be a result of chance. One disorder can cause another disorder: Diabetes can cause diabetic neuropathy. There might be shared environmental risks: Head trauma can cause both posttraumatic epilepsy and posttraumatic headache. Environmental or genetic risk factors may produce a brain state that gives rise to both conditions, that is, there may be some common biology underlying both conditions. This last mechanism seems to be the most likely one underlying comorbidity of migraine and psychiatric disorders. A simple way of looking at the relationship between pain and depression would be to say that pain causes depression or that pain is a form of somatic depression. However, the relationship is probably more complex than that and most likely based on common biological mechanisms.

Table 2 depicts possibilities for headache and psychiatric comorbidity, depending on presence of disorders in Axis I to Axis III of the DSM-IVPC.2 Axis I is the acute presenting problem such as mood or affective disorders (dysthymia, major depression, bipolar disorder), anxiety disorders, substance-related disorders, and “psychological factors affecting medical conditions” (formerly known as psychosomatic disorders). Axis II is the underlying character disorder, if any, and Axis III is the physical symptom (headache). It has been said that Axis I disorders are within the patient and Axis II disorders are between the patient and others. On the left side of the table, headache is accompanied by no Axis I or Axis II disorders. Treatment is very straightforward. In the middle of the table, headache is accompanied by major depression but no Axis II disorder. And in the right column there are disorders in all three axes. As one moves from left to right, patient treatment becomes more complex and more challenging.

Table 2.—.  Headache and Psychiatric Comorbidity (Multiaxial Examples)
Axis IAxis IAxis I
No disorderMajor depressionMajor depression
  Somatization
  Substance abuse
Axis IIAxis IIAxis II
No disorderNo disorderBorderline personality
Axis IIIAxis IIIAxis III
“Migraine without aura” (MO)“MO”“MO”
Chronic tension-type headacheChronic tension-type headacheChronic tension-type headache
Analgesic rebound/medication induced headacheAnalgesic rebound/medication induced headacheAnalgesic rebound/medication induced headache
Increasing Complexity and Difficulty [RIGHTWARDS ARROW]

Affective Disorder Comorbidity with Migraine.

Breslau et al11 found that, compared with control subjects, patients with migraine are four to five times more likely to have affective disorders, including dysthymia, major depression, and bipolar disorder (Table 3). In other studies, Breslau et al12 found that patients with migraine were three times more likely to develop depression and patients with depression were three times as likely to develop migraine than control subjects. Panic disorder was similar, but patients with severe nonmigraine headache did not show the same correlation: Nonmigraine headache was predictive of psychiatric disorder, but the reverse was not true.12

Table 3.—.  Comorbidity of Migraine and Affective Disorder from Breslau et al11
 Odds Ratios
Dysthymia4.4
Major depression3.7
Manic episode5.4
Bipolar disorder5.1

MAJOR DEPRESSION

  1. Top of page
  2. Abstract
  3. RELATIONSHIP OF PSYCHIATRIC CONSIDERATIONS AND PRIMARY HEADACHE DISORDERS
  4. MAJOR DEPRESSION
  5. COMORBIDITY OF DEPRESSIVE DISORDERS WITH ANXIETY DISORDERS
  6. SUBSTANCE ABUSE, OVERUSE, AND MISUSE
  7. AXIS II DISORDERS
  8. BEHAVIORAL MEDICINE
  9. REFERENCES

Overview of Depression.

The lifetime prevalence for major depression is up to 17.1% and is approximately twice as great in women as men.13,14 Depression is generally underdiagnosed and undertreated.14,15 Untreated depression has a high impact on mortality and morbidity, with an economic burden estimated to be $44 billion per year.16,17 However, with appropriate therapy, most patients can be treated successfully, even though depression may be a life-long disorder.17,18

Major clinical depression is a common psychiatric disorder in which patients present with a constellation of symptoms. Both medical and psychiatric illnesses may be associated with depression, with headache being the most frequent somatic complaint. Successful outcomes in regard to headache management are severely compromised if depression is not recognized and properly treated. Effective treatments for depression are available, but depression is still often under- or misdiagnosed. The costs associated with not treating or undertreating depression can be extremely high.

Tools for Recognizing Depression.

Formal tools for recognizing depression include the Hamilton,19 Zung,20 or Beck21 Inventories or Scales and PRIME-MD (PRIMary Evaluation of Mental Disorders).22 There is also the Minnesota Multiple Personality Inventory, but this requires some skill and time to administer.23 In the clinical evaluation, migraine should be sought if depression is the chief complaint or, conversely, depression should be sought if migraine is found.

PRIME-MD is a system for diagnosis of mental disorders in primary care. It consists of a self-administered 26-item patient questionnaire (positive in 40%) to screen for the 5 most common DSM disorders seen in the primary care setting: mood disorders, anxiety disorders, eating disorders, alcohol abuse or dependence, and somatoform disorders. The Clinician Evaluation Guide is then used to evaluate the patient questionnaire. With practice, the PRIME-MD takes about 12 minutes to administer.

Depression and Medical Illness.

Krishnan24 studied a group of patients with stroke and found that the longer the medical problem existed, the greater the chances that a patient became depressed. “One of the biggest factors for the development of depression in this [cohort] was their perception of the lack of social support they were given during illness.”24 Reducing the symptoms of depression in chronically ill patients may play a large role in improving their physical health.

Although not necessarily viewed as a chronic illness, migraine should probably be treated as if it were. Just as we would not consider the depression associated with Parkinson disease, multiple sclerosis, or stroke to be causative, we should give patients with migraine the same view and understanding. Depressed patients present with a constellation of symptoms (Figure 1).

image

Figure 1.—. Depressed patients present with a constellation of symptoms.

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Depression and Migraine.

A recent population- based study captured the experience of patients with migraine who never consulted a physician about their headaches and those who did. Lipton et al25 compared health-related quality of life (HRQOL) and depression in a group with migraine with a group without migraine in the United States and the United Kingdom. Results were similar in both countries—migraineurs had significantly decreased HRQOL and significantly higher prevalence of depression than nonmigraineurs, and those with a higher frequency of attacks had a poorer HRQOL. Migraine and depression were highly comorbid, and each exerts a significant and independent influence on HRQOL.

Neurotransmitters and Migraine.

There is evidence for involvement of both monoamine (serotonin and dopamine) and peptide (endorphin and encephalin) neurotransmitters in depression. Endorphins and encephalins are involved in both mood control and pain control.

Serotonin (5-hydroxytryptamine [5-HT]) in particular has been implicated in mood disorders, anxiety disorders, sleep disorders, eating disorders, obsessive-compulsive disorder, migraine, and tension-type headache.26,27 A number of different classes of 5-HT receptors have been identified and named 5-HT1 through 5-HT7. There is good evidence for the involvement of 5-HT1 receptors in migraine, because the effective triptan medications are 5-HT1 agonists.28

Evidence is accumulating that dopamine is also intimately involved in migraine. Migraine prodrome is often characterized by dopaminergic symptoms (yawning, mood changes, nausea, vomiting),29 and antidopaminergic compounds can often be helpful in treating them.30 Patients with migraine have an increased density of dopamine receptors on peripheral lymphocytes compared with control subjects, perhaps reflecting that the dopaminergic system is under functioning.31 There is also evidence that migraine is associated with a particular dopamine β-hydroxylase allele.32

Role of Learned Helplessness in the Comorbidity of Depression and Migraine

The classic work of Seligman33 reviewed the role of learned helplessness as a factor in the genesis of depression. Helplessness is defined as “the psychological state that frequently results when events are uncontrollable.” Furthermore, depression and anxiety are related to uncontrollability and unpredictability. In this model, depression is caused by the belief that action is futile. One can see how responses to recurrent disabling migraine attacks might be viewed as learned helplessness, because migraine attacks are generally unpredictable and, if poorly treated, also uncontrollable. We believe this paradigm may be another mechanism of psychiatric comorbidity, which has not been addressed in the headache literature. By recognizing migraine and following the treatment paradigms of the U.S. Headache Consortium and Primary Care Network, we can prevent learned helplessness and depression from developing.34,35 For moderate to severe episodes, evidence strongly suggests triptans are appropriate. Preventive strategies can reduce attack frequency and intensity, and appropriate acute agents can mitigate helplessness by giving sufferers tools to control the episodes.34 The model of learned helplessness further supports the need for cognitive behavioral interventions, modification of lifestyles, and trigger reduction.

Pharmacological Treatment for Depression and Migraine.

After making a diagnosis it is necessary to monitor treatment every few weeks (Figure 2). Response to treatment should be assessed at week 6, and if the patient shows clear improvement the treatment should be continued for an additional 6 weeks. If there is a complete remission, medication is continued for 4 to 9 months and maintenance treatment is considered. After 1 episode of major depression, the chance of recurrence is 50%.36,37 If the patient is only somewhat better, the dose can be increased. Treatment should be continued, monitoring every 2 weeks, and assessed at week 12 for treatment response. If there is not complete response at that point, a referral to a psychiatrist or psychopharmacologist or change in medications might be considered. It may be faster and easier to augment medication rather than switching it. One of the more common augmenting strategies for selective serotonin reuptake inhibitors (SSRIs) is bupropion.38 Goals of therapy for depression are remission of all signs and symptoms, restore occupational and social function, reduce acute risk of suicide, reduce the likelihood of relapse and recurrence, and improve long-term outcome.18

image

Figure 2.—. Agency for Health Care Policy and Research guidelines for treating major depression.18

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Tricyclic and related cyclic antidepressants work well in treating headache, although they are no longer used much in treating depression, because therapeutic doses for depression are high and side effects become problematic. Although SSRIs are extremely useful in treating depression and certain anxiety disorders, they are less useful in treating headache. For comorbid migraine and depression it is possible to combine a tricyclic antidepressant with an SSRI, but the interactions should be carefully considered.38

Monoamine oxidase inhibitors are excellent antidepressants, but they are not used as much as the other agents because of the dietary restrictions needed when they are taken. There are some anecdotal data for the utility of the newer medications, including bupropion,39 nefazadone,40 trazadone,41 and venlafaxine42 in migraine, and they have been shown to be useful in depression. The efficacy of all antidepressants is essentially identical, so choice is a matter of side effect profiles and treatment target.

Although the efficacy of antidepressants in sufficient doses is comparable, Slaby and Tancredi43 recently reviewed evidence for choosing an agent based on presenting symptoms and behaviors mediated by specific neurotransmitters. Serotonin influences mood, sleep, cognition, nociception, appetite, and sexual behavior. Dopamine modulates mood, cognition, drive, aggression, pleasure seeking, motivation, and aggression. And norepinephrine impacts mood, learning, memory, sleep-wake cycles, functions of the hypothalamic-pituitary axis, and the sympathetic system. By carefully evaluating the constellation of symptoms in the patient with depression, one may be better able to select an agent that may influence specific behaviors. For example, a patient with addictive behaviors may be best treated with dopaminergic agents such as bupropion. Sertraline combines serotonergic and dopaminergic actions, paroxetine affects both noradrenergic and serotonergic activity, and monoamine oxidase inhibitors modulate all the monoamines.

COMORBIDITY OF DEPRESSIVE DISORDERS WITH ANXIETY DISORDERS

  1. Top of page
  2. Abstract
  3. RELATIONSHIP OF PSYCHIATRIC CONSIDERATIONS AND PRIMARY HEADACHE DISORDERS
  4. MAJOR DEPRESSION
  5. COMORBIDITY OF DEPRESSIVE DISORDERS WITH ANXIETY DISORDERS
  6. SUBSTANCE ABUSE, OVERUSE, AND MISUSE
  7. AXIS II DISORDERS
  8. BEHAVIORAL MEDICINE
  9. REFERENCES

There is a fairly high comorbidity of depression and anxiety (Table 4),13 and the same issue arises in considering the relationship between anxiety and depression as between migraine and tension-type headache: Are they part of the same spectrum or are they totally separate disorders? Anxiety and depressive disorders can often be treated with similar medication.

Table 4.—.  Comorbidity of Depressive Disorders with Anxiety Disorders13
Major Depression Comorbid WithComorbid (%)
Panic disorder9.9
Simple phobia24.3
Social phobia27.1
Generalized anxiety disorder17.2
Any anxiety disorder58.0

Anxiety disorders are much more prevalent among people with migraine than among the general population (Table 5),11 so physicians should be looking for these disorders in their migraine patients. Although the lifetime prevalence of panic phenomenology is not extremely high (Figure 3), morbidity is (Figure 4).44,45

Table 5.—.  Lifetime Prevalence of Anxiety Disorders in Migraine11
 Migraine GroupControl Group
Panic disorder11%2%
Anxiety disorder10%2%
Obsessive-compulsive disorder9%2%
image

Figure 3.—. Lifetime prevalence of panic.44

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image

Figure 4.—. Panic disorder morbidity.45

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Drugs used to treat panic disorders are similar to those used to treat depression: SSRIs, tricyclic antidepressants, monoamine oxidase inhibitors, and newer agents.46 In addition, high-potency benzodiazepines may be useful. In the beginning, short-acting benzodiazepines are useful while preventive strategies are being put in place, but on an ongoing basis the longer acting ones, such as clonazepam, are preferable. Other approaches that may be useful include combined treatments, the antiepileptic drugs, and β-blockers, which decrease sympathetic outflow.

Role of Learned Helplessness in the Comorbidity of Anxiety and Migraine.

Seligman33 reviewed the relationship between learned helplessness and anxiety, stating that “anxiety results from unpredictable shocks” and anxiety is greater with unpredictable versus predictable “trauma.” Anxiety may be chronic during unpredictable events and intermittent with predictable events. His work suggests that the ability to control an aversive event (ie, migraine) reduces anxiety. Again, we suggest a possible further relationship between migraine and psychiatric comorbidity, in this case anxiety disorders, and the need for early recognition and appropriate interventions.

SUBSTANCE ABUSE, OVERUSE, AND MISUSE

  1. Top of page
  2. Abstract
  3. RELATIONSHIP OF PSYCHIATRIC CONSIDERATIONS AND PRIMARY HEADACHE DISORDERS
  4. MAJOR DEPRESSION
  5. COMORBIDITY OF DEPRESSIVE DISORDERS WITH ANXIETY DISORDERS
  6. SUBSTANCE ABUSE, OVERUSE, AND MISUSE
  7. AXIS II DISORDERS
  8. BEHAVIORAL MEDICINE
  9. REFERENCES

Substance abuse is defined as recurrent adverse consequences related to repeated substance use. Most patients with recurrent headache are not substance abusers, rather they are substance “overusers” and “misusers.” Substance overuse is a nonpejorative term to reflect the use of medication beyond appropriate use solely in the pursuit of pain relief and in the absence of behavioral issues. Substance misuse is similar except that there are added destructive patterns of use such as manipulative behavior, multisourcing, and so on. For a more detailed discussion, see Saper and Sheftell.47

Many medications can be used excessively, but certain ones, including mixed analgesics, benzodiazepines, ergotamine tartrate, meperidine, and butorphanol nasal spray, are more likely to be overused by patients with headache pain.47 Signs that the patient may be misusing medication include new patients asking for narcotics before their first visit, nighttime calls when another doctor is covering, eliciting sympathy with less than credible stories, and specific requests for a particular opiate.

Patients whose families have a history of alcoholism or drug abuse are more vulnerable to drug overuse. To manage a patient identified as a medication overuser or misuser, suspicion may be warranted: Corroborate the story as soon as possible, prescribe small amounts of medications with no refills, use one prescriber and one pharmacy, do not replace lost bottles, and suggest alternate means of pain control. Also consider a formal signed pain medication agreement capturing the above guidelines. Patients deserve appropriate and effective pain treatment, which can actually reduce the likelihood of medication overuse and misuse.

AXIS II DISORDERS

  1. Top of page
  2. Abstract
  3. RELATIONSHIP OF PSYCHIATRIC CONSIDERATIONS AND PRIMARY HEADACHE DISORDERS
  4. MAJOR DEPRESSION
  5. COMORBIDITY OF DEPRESSIVE DISORDERS WITH ANXIETY DISORDERS
  6. SUBSTANCE ABUSE, OVERUSE, AND MISUSE
  7. AXIS II DISORDERS
  8. BEHAVIORAL MEDICINE
  9. REFERENCES

Axis II disorders, particularly borderline personality disorder, are extremely difficult to deal with even in the context of a psychiatric setting, let alone the office practice of primary or specialty care.

Borderline Personality Disorder.

The essential feature of borderline personality disorder is a pervasive pattern of unstable interpersonal relationships, mood, and self-image accompanied by five of the following2:

• Unstable relationships alternating between overidealization and devaluation

• Impulsive and self-destructive behavior

• Affective instability, mood shifts

• Inappropriate intense anger

• Recurrent suicidal threats or gestures

• Persistent identity disturbance (eg, uncertainty regarding self-image, goals, career choice, friends, values, etc.)

• Chronic emptiness or boredom

• Concerns regarding real or imagined abandonment

A typical patient with borderline personality may present in the following way: “Thank god I found you!” or “Those other doctors never listened to me and they didn't say very nice things about you!” After some time has passed, these patients become disgruntled: “You're just like all the rest,”“You're never there when I need you,”“I knew you'd do this to me.”

When dealing with patients with borderline personality, it is best to be very clear about expectations and patient responsibility and to set limits early regarding missed appointments, lost medications, and so on. It is extremely important to set appropriate boundaries, avoiding familiarity and first names. Engagement in psychotherapy should be a prerequisite in dealing with active borderline patients, and treatment contracts regarding appointments and terms of engagement should be considered.

BEHAVIORAL MEDICINE

  1. Top of page
  2. Abstract
  3. RELATIONSHIP OF PSYCHIATRIC CONSIDERATIONS AND PRIMARY HEADACHE DISORDERS
  4. MAJOR DEPRESSION
  5. COMORBIDITY OF DEPRESSIVE DISORDERS WITH ANXIETY DISORDERS
  6. SUBSTANCE ABUSE, OVERUSE, AND MISUSE
  7. AXIS II DISORDERS
  8. BEHAVIORAL MEDICINE
  9. REFERENCES

Behavioral medicine asserts that a person's behavior can influence the course of medical illness and treatment outcome. It is important to incorporate behavioral medicine into our approach to treating patients with migraine, because a variety of behavioral approaches surrounds and supports pharmacological therapies. Behavioral approaches include cognitive behavioral therapy; stress management; time management; diet and proper exercise; monitoring possible triggers, medication intake and effect, and headache frequency, intensity, and duration (calendars); biofeedback; and type A modification.

Stress and Lifestyle Modification.

To modify type A behavior, the adage “learn to play more at work and work less at play” can be a place to start. Also, intensity levels should be evaluated and stressors identified (eg, family, work, interpersonal) to make life changes and to evaluate their impact.

Locus of Control.

Locus of control refers to whether one views the outcomes of their actions as dependent on what they do (internal control) or on events outside their personal control (external control). Patients with an external locus of control are characterized by a “Cure me!” approach, whereas patients with an internal locus of control are characterized by a more collaborative “How can we work together?” position. A headache-specific locus of control scale has shown that an external locus of control is associated with higher levels of depression, poor pain coping strategies, and greater disability.48 By learning pain management techniques and other means of controlling migraines, patients can see themselves as more able to affect their own lives. Patients who are more confident that they can prevent and manage their headaches have less headache-related disability.49

Patient Education.

The goals of patients education are as follows:

• To manage headache episodes in the situations they occur (home, work, etc)

• To become their own “primary caregivers” and manage attacks in the absence of the health care provider

• To initiate headache management activities

• To make effective use of medical therapies

• To alter daily routines to support headache management

The “stick of dynamite” model (Figure 5) can be useful in educating patients. The aim is to contain the explosion made possible by the underlying biology. To this end, preventive medication can be used to come between outside “triggers” and the underlying biology. Also, it is possible to decrease the triggers and thus avoid stimulating the explosion.

image

Figure 5.—. Educational model: “stick of dynamite.”

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Support groups can be a useful adjunct. They provide the patient with the sense that they are not alone. They may also provide education, an opportunity for patients to share experiences and gain mutual support, and an appropriate forum for family involvement.

In conclusion, migraine is often comorbid with psychiatric disorders, particularly depression and anxiety, and their relationship is likely based on shared mechanisms. Learned helplessness may be a further avenue of explanation of psychiatric comorbidity. Comorbid psychiatric disorders on both Axis I and II must be recognized and addressed to improve outcomes. The most complex problems with disorders on both Axis I and II, and particularly the borderline patient, often require more intensive multidisciplinary approaches. Successful treatment is possible, but migraine for many is a lifelong disorder characterized by remissions and exacerbations.

Psychiatric comorbidity is certainly one of the more confounding factors in patients with chronic headache syndromes. As health care providers, we can deal with it to the extent that we are comfortable. However, competent and interested psychiatric and psychological colleagues are needed who understand the fundamental biology of headache and do not just view these patients as people psychodynamically troubled or full of repressed anger.

Acknowledgment:  Supported by an unrestricted educational grant from Merck & Co.

REFERENCES

  1. Top of page
  2. Abstract
  3. RELATIONSHIP OF PSYCHIATRIC CONSIDERATIONS AND PRIMARY HEADACHE DISORDERS
  4. MAJOR DEPRESSION
  5. COMORBIDITY OF DEPRESSIVE DISORDERS WITH ANXIETY DISORDERS
  6. SUBSTANCE ABUSE, OVERUSE, AND MISUSE
  7. AXIS II DISORDERS
  8. BEHAVIORAL MEDICINE
  9. REFERENCES
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