Psychiatric Comorbidity of Migraine
Migraine affects nearly 12% of the adult population in the United States and causes significant lost productivity and decrements in health-related quality of life. The burden of migraine and the challenge in managing it are increased by the comorbid psychiatric conditions that occur in association with it. Studies in both clinical and community-based settings have demonstrated an association between migraine and a number of specific psychiatric disorders. This review will focus on the relationships between migraine and depression, generalized anxiety disorder, panic disorder, and bipolar disorder. In large scale population-based studies, persons with migraine are from 2.2 to 4.0 times more likely to have depression. In longitudinal studies, the evidence supports a bidirectional relationship between migraine and depression, with each disorder increasing the risk of the other disorder. Migraine is also comorbid with generalized anxiety disorder (Odds Ratio [OR] 3.5 to 5.3), panic disorder (OR 3.7), and bipolar disorder (OR 2.9 to 7.3). A diagnosis of migraine should lead to a heightened level of diagnostic suspicion for these comorbid psychiatric disorders. Similarly, a diagnosis of one of these psychiatric disorders should increase vigilance for migraine. Treatment plans for migraine should be mindful of the comorbid conditions.
Introduction
Migraine affects nearly 12% of the adult population in the United States, and causes significant lost productivity and decrements in quality of life. Part of the burden of migraine is produced by the psychiatric conditions that occur in association with it. When one disorder occurs with another with greater than chance frequency the disorders are said to be comorbid.
Studies in both clinical and community-based settings have demonstrated an association between migraine and a number of specific psychiatric disorders. While the association between migraine and depression is most widely reported, there are also strong associations with other psychiatric disorders. Understanding the nature of the association between migraine and these psychiatric disorders has implications for diagnosis and treatment. The occurrence of comorbidity may also provide clues to the etiology of each disorder. This review will focus on the relationships between migraine and depression, generalized anxiety disorder, panic disorder, and bipolar disorder.
Methodological Issues
Studying comorbidity presents a series of methodological challenges. First, clinic-based studies are prone to overestimating comorbidity due to a phenomenon called Berkson bias. This bias arises when conditions may occur together in the clinic at increased frequency because of patterns of consultation and referral. For example, primary care doctors who tend to treat migraine with β-blockers may preferentially refer asthmatic migraineurs to neurologists, because β-blockers are contraindicated. As a consequence, a study in the neurologic offices might overestimate the association between migraine and asthma. Clinic-based studies should be viewed as hypothesis generating; studies of comorbidity are best conducted in representative samples of the general population. Second, studies of comorbidity must apply systematic methods for ascertaining both migraine and the other conditions under study. Comorbidity studies that rely on medical records review or medical claims data may overestimate comorbidity due to clinical detection and coding bias. For example, clinicians who code migraine may be more likely to code other pain disorders, potentially leading to overestimation of comorbidity. Third, studies of comorbidity can assess the cross-sectional or longitudinal association between migraine and another disorder. While cross-sectional studies demonstrate associations, they do not indicate directionality. Longitudinal studies make it possible to determine if one condition predisposes to the other (unidirectional relationship) or if each disorder predisposes to the other. Understanding directionality has implications for clinical practice and for exploration of disease mechanisms.
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.
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