Co-Occurrence of Depression and Anxiety in People With Migraine
Two studies have reported on the co-occurrence of depression and anxiety in people with migraine. Merikangas et al examined this relationship in a prospective study by categorizing subjects into mutually exclusive categories of anxiety and depression. Based on this analysis, they found that there was a 2-fold increased risk of migraine among subjects with both major depression and an anxiety disorder. In contrast, subjects with depression only were 2 times less likely to have migraine. In a similar, but somewhat different analysis, Breslau et al found that the combined effects of anxiety disorder and migraine increased the odds for major depression far more than might be expected. While the OR for migraine and major depression was 2.7 (95% CI 1.1 to 6.3), the statistic for major depression in people with migraine and any anxiety disorder versus people with neither disorder was 22.8 (95% CI 12.7 to 41.2).
Merikangas et al also reported the results of a logistic regression analysis conducted to examine the diagnostic overlap among those psychiatric disorders most strongly associated with migraine. The model controlled for sex and risk group while assessing the effects of major depression, bipolar spectrum, general anxiety disorder, and social phobia. The best fitting model included only general anxiety disorder.
Conclusions
Migraine and anxiety disorders are comorbid, and in some studies, the relationship is even stronger than that between migraine and depression. In the studies reported herein, the OR for migraine and generalized anxiety disorder ranged from 3.5 to 5.3. In addition, most people with depression also have anxiety disorders, but many people with anxiety disorders do not have depression. For this reason, it is important to screen for both depression and anxiety in persons with migraine. Migraine and other severe headaches are also comorbid with panic disorder, and the data suggest that the temporal relationship is in the headache-to-panic disorder direction, rather than the reverse.
The co-existing relationship between migraine, depression, and anxiety disorders can have important clinical implications, depending on the chronology of these conditions. Treatment of one condition could help prevent progression to one or both of the other two.
Migraine and Bipolar Disorder
The relationship between migraine and bipolar disorder is less well studied than the inter-relationships between migraine and depression or migraine and anxiety disorders. The relationship between migraine and bipolar disorders has been studied in both clinic and community-based populations, but this review will emphasize the population-based studies.
Merikangas et al. reported that 8.8% of the 61 migraineurs, compared with only 3.3% of the 396 individuals without migraine had bipolar spectrum disorder (defined by a manic or hypomanic episode) (OR 2.9, 95% CI 1.1 to 8.8). Breslau reported similar results in their study of a Detroit sample of young adults. In this study, the OR for Bipolar I was 7.3 (95% CI 2.2 to 24.6) and Bipolar II was 5.2 (95% CI 1.4 to 19.9).
Overall Conclusions
Migraine is consistently associated with several psychiatric disorders, including depression, anxiety, and bipolar disorders. It is important to maintain diagnostic vigilance for comorbid conditions. When migraine and a comorbid psychiatric disorder are present, it is important to take both disorders into account in formulating a treatment plan.
Sandra W. Hamelsky, PhD, MPH, The Bradstreet Group, 1588 Route 130 North, North Brunswick, NJ 08902, USA
Department of Neurology, Albert Einstein College of Medicine, Bronx, NY, USA (Drs. Hamelsky and Lipton); Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY, USA (Dr. Hamelsky); and Montefiore Headache Center, New York, NY, USA (Dr. Lipton).
Headache. 2006;46(9):1327-1333.
References
- Stewart WF, Lipton RB, Celentano DD, Reed M. Prevalence of migraine headache in the United States: Relation to age, income, race, and other sociodemographic factors. JAMA. 1992;267:64-69
- Lipton RB, Hamelsky SW, Stewart WF. Epidemiology and impact of headache. In: Silberstein SD, Lipton RB, Dalessio DJ, eds. Wolff’s Headaches and Other Head Pain, 7th ed. Oxford: Oxford University Press, 2001:85-107
- VonKorff M, Stewart WF, Simon DJ, Lipton RB. Migraine and reduced work performance: A population-based diary study. Neurology. 1998;50:1741-1745
- Hu HX, Markson LE, Lipton RB, Stewart WF, Berger ML. Burden of migraine in the United States: Disability and economic costs. Arch Intern Med. 1999;159:813-818
- Lipton RB, Hamelsky SW, Kolodner KB, Steiner TJ, Stewart WF. Migraine, quality of life, and depression: A population-based case-control study. Neurology. 2000;55:629-635
- Berkson J. Limitation of the application of the 4-fold table analysis to hospital data. Biometrics. 1946;2:47-53
- Dworkin SF, VonKorff M, LeResche L. Multiple pains and psychiatric disturbance: An epidemiologic investigation. Arch Gen Psychiatry. 1990;47:239-244
- VonKorff M, Resche LL, Dworkin SF. First onset of common pain symptoms: A prospective study of depression as a risk factor. Pain. 1993;55:251-258
- Haythornthwaite JA. Migraine headaches and psychopathology: Future directions. J Psychiatr Res. 1993;27:183-186
- Merikangas KR, Risch NJ, Merikangas JR, Weissman MM, Kidd KK. Migraine and depression: Association and familial transmission. Psychiatry Res. 1988;22:119-129
- Merikangas KR, Angst J, Isler H. Migraine and psychopathology: Results of the Zurich Cohort Study of Young Adults. Arch Gen Psychiatry. 1990;47:849-853
- Breslau N, Davis GC, Andreski P. Migraine, psychiatric disorders and suicide attempts: An epidemiologic study of young adults. Psychiatry Res. 1991;37:11-23
- Breslau N, Davis GC. Migraine, physical health, and psychiatric disorders: A prospective epidemiologic study of young adults. Psychiatry Res. 1993;27:211-221
- Breslau N, Davis GC, Schultz LR, Peterson EL. Migraine and major depression: A longitudinal study. Headache. 1994;34:387-393
- Merikangas KR. Psychopathology and headache syndromes in the community. Headache. 1994;34:17-26
- Breslau N, Merikangas K, Bowden CL. Comorbidity of migraine with major affective disorders. Neurology. 1994;44(suppl 7):S17-S22
- Breslau N, Schultz LR, Stewart WF, Lipton RB, Lucia VC, Welch KMA. Headache and major depression: Is the association specific to migraine? Neurology. 2000;54:308-313
- International Headache Society. Classification and diagnostic criteria of headache disorders, cranial neuralgia, and facial pain. Cephalalgia. 1988;8(suppl 7):1-96
- Cox DR. Regression models and life tables. J R Stat Soc Ser B. 1972;34:187-220
- Cox DR. Partial likelihood. Biometrika. 1975;62:269-276
- Swartz KL, Pratt LA, Armenian HK, Lee LC, Eaton WW. Mental disorders and the incidence of migraine headaches in a community sample. Arch Gen Psychiatry. 2000;57:945-950
- Zwart JA, Dyb G, Hagen K, et al Depression and anxiety disorders associated with headache frequency. The Nord-Trondelag Study. Eur J Neurol. 2003;10:147-152
- McWilliams LA, Goodwin RD, Cox BJ. Depression and anxiety associated with three pain conditions: Results from a nationally representative sample. Pain. 2004;111:77-83
- Patel NV, Bigal ME, Kolodner KB, et al Prevalence and impact of migraine and probable migraine in a health plan. Neurology. 2004;63:1432-1438
- Breslau N, Lipton RB, Stewart WF, Schultz LR, Welch KMA. Comorbidity of migraine and depression: Investigating potential etiology and prognosis. Neurology. 2003;60:1308-1312
- Breslau N. Psychiatric comorbidity in migraine. Cephalalgia. 1998;18(suppl 22):56-61
- Merikangas KR, Merikangas JR, Angst J. Headache syndromes and psychiatric disorders: Association and familial transmission. J Psychiatr Res. 1993;27:197-210
- Antilla P, et al Psychiatic symptoms in children with primary headache. J Am Acad Adolesc Psychiatry. 2004;43:412-419
- Oedegaard K, Neckelmann D, Mykletun A, et al Migraine with and without aura: Association with depression and anxiety disorder in a population-based study. The Hunt Study. Cephalalgia. 2006;26:1-6
- Devlen J. Anxiety and depression in migraine. J R Soc Med. 1994;87:338-341
- Hung C, Wang SJ, Hsu KH, Juang YY, Liu CY, et al Risk factors associated with migraine or chronic daily headache in out-patients with major depressive disorder. Acta Psychiatr Scand. 2005;111:310-315
- Garvey MJ, Tollefson GD, Schaffer CB. Migraine headaches and depression. Am J Psychiatry. 1984;8:986-988
- Harper M, Roth M. Temporal lobe epilepsy and the phobic anxiety-depersonalization syndrome. I. A comparative study. Compr Psychiatry. 1962;3:129-151
- Merikangas KM. Sources of genetic complexity of migraine. In: Sandler, M, Ferrari MD, Harnett S, eds. Migraine: Pharmacology and Genetics. New York: Cambridge University Press, 1996:254-281
- Stewart W, Breslau N, Keck PE. Comorbidity of migraine and panic disorder. Neurology. 1994;44:S23-S27
- Smoller J, Pollack MH, Wassertheil-Smoller S, et al Prevalence and correlates of panic attacks in postmenopausal women: Results from an ancillary study to the Women’s Health Initiative. Arch Intern Med. 2003;163:2041-2050
- Stewart WF, Linet MS, Celentano DD. Migraine headaches and panic attacks. Psychosom Med. 1989;51:559-569
- Stewart WF, Breslau N, Keck PE Jr. Comorbidity of migraine and panic disorder. Neurology. 1994;44:23-27
- Marazziti D, Toni C, Pedri S, et al Prevalence of headache syndromes in panic disorder. Clin Psychopharmacol. 1999;14:247-251
- Breslau N, Schultz LR, Stewart WF, Lipton RB, Welch KMA. Headache types and panic disorder. Neurology. 2001;56:350-354
- Marchesi C, De Ferri A, Petrolini N, et al Prevalence of migraine and muscle tension headache in depressive disorders. J Affect Disord. 1989;16:33-36
- Blehar MC, De Paulo JR Jr, Gershon ES, Reich T, Simpson SG, Numberger JI Jr. Women with bipolar disorder: Findings from the NIMH genetics initiative sample. Psychopharmacol Bull. 1998;34:239-243
- Cassidy WL, Flanagan NB. Clinical observations in manic-depressive disease. J Am Med Assoc. 1957;164:1535-1546
- Low NC, DuFort GG, Cervantes P. Prevalence, clinical correlates, and treatment of migraine in bipolar disorder. Headache. 2003;43:940-949
- Mahmood T, Romans S, Silverstone T. Prevalence of migraine in bipolar disorder. J Affect Disord. 1999;52:239-241
- Younes RP, De Long GR, Neiman G, Rosner B. Manic-depressive illness in children: Treatment with lithium carbonate. J Child Neurol. 1986;1:364-368