Is Your Migraine All In Your Head?: Co-Morbidity of Intractable Headache and Mood Disorders
There is a significant amount of research and anecdotal information about the frequency with which adults with intractable headaches or migraines also experience mood disorders. The two most common mood disorders reported by patients are depression and anxiety. In fact, an article published in 2010 suggests that there may be a genetic link between depression and migraine. In her discussion of this research, Teri Robert indicates that 47% of migraineurs also experience depression. (See _ Migraine and Depression May Be Linked Genetically_.) Other research indicates a strong relationship between anxiety disorder, bipolar disorder, and major depressive disorder. (See Migraine Associated with Mental Health Disorders.)
This is hardly news to those of us who deal with intractable headaches and chronic migraines. Discussion forums are full of comments from men and women with intractable headaches and chronic migraines who struggle with either depression or anxiety. While we may assume the same is true of adolescents and young adults, there has been little research exploring this assumption.
"To determine the prevalence of comorbid mood disorders in adolescents and young adults with intractable headache presenting to an outpatient clinic for specialty headache treatment."
"Identifying the prevalence of comorbid mood disorders in the young adult population may help explain the difference in mood comorbidities between pediatric and adult headache patients and inform treatment options for this understudied developmental group."
Definition of Terms:*
- Comorbid: the presence of two diseases appearing simultaneously. The diseases occur independently of each other but may interact so that they impact the presentation and treatment of both diseases.
- Intractable: difficult to manage or cure.
- Retrospective Study: one that looks back in order to draw conclusions; for example, a review of patient records.
- Mean: Mathematical average of values; i.e. all values are added and then divided by the number of included values.
- Retrospective study conducted of 353 patients
- Patients ranged in age from 15-26 years of age.
- Patients presented to a headache specialty clinic.
- Patients given multidisciplinary evaluation consisting of a semi-structured interview and a neurological and headache exam.
- Standardized questionnaires were completed by each patient and contained information about headache and health history
- Each patient was given a treatment plan and a headache diagnosis based on the International Criteria for Headache Disorders, 3rd Edition (ICHD-3)
- Multi-disciplinary team consisted of board certified Neurologist and Headache Medicine specialist, pain psychologist, nurse practitioner and registered nurse.
- Female to male ration was 3:1.
- 88% were Caucasian and 7% were African American.
- The mean age at the evaluation was 16.9 +/- 2.5 years old.
- 96% met ICHD-3 criteria for migraine without aura.
- 31.2% had episodic migraine.
- 68% had chronic migraine.
- Upon initial visit, 18% presented with a comorbid diagnosis of depression.
- Upon initial visit, 17% presented with a comorbid diagnosis of anxiety.
- Self-report during the interview indicated 47% had sleep difficulty; 47% had feelings of worrying; 29% reported feeling anxious; 26% reported feeling depressed and 19% reported having low self-esteem.
- "Mood disorders and symptoms are common in adolescents and young adults with intractable headaches.
- "Comorbid mood disorders are diagnosed in only 1/6 of patients, but symptoms are present in nearly 1/2 of patients."
- "These symptoms may be the result of the current state of their headaches, especially when chronic."
- "Recognition of these characteristics should prompt further investigation and early treatment of headaches and co-morbid mood symptoms."
From My Perspective
It's clear from this research and other research of its nature that many of us with migraines and headache disorders, particularly those who are chronic or intractable, also experience accompanying mood disorders such as depression and anxiety. I want to be absolutely clear in saying that this does** not** mean that our headaches or migraines are caused or triggered by psychological disorders, such as depression or anxiety. How many of you, like I, have been told by a doctor, a family member or a friend that if we just relaxed more, worried less or saw a therapist that we would significantly decrease, or even be rid of, our migraines? I don't know about you but those kinds of questions make me crazy (pardon the pun). If only it were that easy; don't they think we would have tried it? This is a part of the stigma of migraines, and the sad thing is that many of us live in fear that others think our migraines are "just in our heads." It's difficult enough to live with a chronic illness without blamed or somehow responsible for our own pain. Luckily, research shows that this is absolutely not true. Yes, it does show that those of us with intractable headaches or chronic migraines also frequently have depression or anxiety, BUT it does NOT mean that we have migraines because we are depressed or anxious! To suggest that is ludicrous and, frankly, demoralizing. So why is it even important that we look at the relationship between mood disorders and intractable headaches/migraines? Why spend the time evaluating this when getting a headache work-up?
Personally, I think that there are a couple of good reasons. First of all, any thorough migraine and headache specialist is going to assess to see if we have any other comorbid conditions maybe fibromyalgia or hypothyroidism that may affect our treatment plan. Certainly, other disorders increase our pain and our degree of disability. They also impact our treatment plan. For example, I have a bleeding disorder and bradycardia. Because of these two things, there are a number of medications and treatments that just aren't appropriate or even safe for me. I also have fibromyalgia that significantly effects my perception of pain and my ability to function on a day to day basis. If my doctor ignores these things, then I'm not getting the help I need, and I may even get treatment that can cause me more harm than good. The same is true with mood disorders. They are physiological disorders just like the others mentioned. They have nothing to do with my character or my will; however, they do affect my life as a migraineur. I personally deal with depression which is hard enough without adding the isolation, stigma and pain of migraines. It's important for my doctor to know that and to plan my treatment accordingly. He certainly does not need to give me meds that can increase depression or that interfere with my depression medication. I need a doctor who treats me as a whole person - not just a chronic migraine. I need a doctor who understands the relationship among all my other medical issues. I want a doctor who helps me to balance all these issues and to interact with my other healthcare providers as needed. He can only do this if he has the complete picture of me physically and psychologically.
It's kind of funny that we're quick to take a list of all our "physical" problems to our migraine and headache specialist and to think nothing of it when we are asked about those kinds of issues, but God forbid that the doc ask us about our mood. I remember a time this happened to me. I went to a comprehensive migraine and headache clinic and, as a part of the evaluation; I completed a questionnaire about depression and anxiety. Boy, I was ticked. How dare he assume that my migraines were psychological in nature? Why would he waste my time and money with this when I was in serious pain and distress with daily chronic migraines? Everything in me was on the defensive and with some good reasons. After all, I had in the past encountered some doctors who treated me like a "hysterical female" who just needed to chill and learn to take better care of myself. But, this wasn't the case with this doctor. He explained the frequent co-morbidity between headaches/migraines and mood disorders. He pointed out that if I had the very real physiological disorder of depression or anxiety that the pain, isolation, and stigma of chronic migraines could increase my depressive or anxious symptoms. He also pointed that the reverse was true. He helped me to understand that there is an additive or cumulative effect which may make the experience of either disease more pronounced. This made sense to me and has drastically changed my perception. In fact, I now expect any "good" doctor to ask me questions about other medical and psychological issues. To me, it is now a sign of their competence, their thoroughness, and their caring.
Secondly, by knowing about my mood and treating any comorbid mood disorders, my doctor can help me balance my life with chronic migraines. Let's face it; it's hard to live with chronic migraines. It's also hard to live with a sense of sadness, grief, lack of purpose, isolation or anxiety. It's hard to live in a society still sometimes equates migraines with psychological weakness and equate psychological disorders with personality, spiritual or character flaws that we should be able to change.
It's really tough to have people make assumptions about the cause and nature of our headaches and migraines. As we all know too well, all of those feelings can sometimes lead to thoughts of hopelessness. And sometimes thoughts of hopelessness lead to thoughts of suicide. If I don't have a doctor who understands the very real inter-connectedness of my migraines and my depression then I may not get the help I need, and I may become of the number of those who attempt to take their lives out of despair.
Doctors who understand the comorbidity of mood disorders and intractable headaches and migraines do not point fingers at the patient. They don't suggest our migraines or headaches are psychological in nature. They know the facts. They know that mood disorders such as depression and anxiety are very real medical problems that frequently co-exist with intractable migraines and headaches.
As the authors of this study concluded, studies like this "prompt early treatment of headaches and comorbid mood symptoms." Frankly, I think they have understated it. Studies like this show the urgent need for headache specialists to ask questions about mood in a caring and compassionate way and for patients to be honest and up front with their answers.
In my opinion, it is only in this collaboration that my headache doctor has any real chance of helping me manage life with chronic migraines. Now when a doctor asks me about my mood, I am thankful to have found someone who cares about me as a whole person and who recognizes the very real toll living with chronic migraines can have on me.
As this study shows, mood disorders are no respecters of persons. They don't discriminate on the basis of age, gender or race. An adolescent or young adult may experience mood disorders just as often as an older population, and it is critical that this be identified so that everyone get the treatment they need and deserve.
O'Brien,H.; Vaughan, P.; Kabbouche,M.; Kacperski, J.; Hershey, A.D.; Slater,S. "Co-Morbid Mood Disorders Identified in Adolescent and Young Adult Patients Presenting to a Headache Specialty Clinic" Poster Presentation. 56th Annual Scientific Meeting; American Headache Society. Los Angeles. June, 2014.