Psychopathology Of Migraine And Personality Characteristics
The relationship between migraine and psychopathology has been discussed far more often than it has been systematically studied (Silberstein et al., 1995). Over the years, many studies have focused on particular personality traits of migraineurs. The basic assumptions are that (1) migraineurs share personality traits, (2) these traits are enduring and measurable, and (3) these traits differentiate migraineurs from control subjects (Schmidt et al., 1986). The notion of a “migraine personality” first grew out of clinical observations of highly selected patients seen in subspecialty clinics (Silberstein et al., 1995).
Touraine and Draper (1934) reported that migraineurs were deliberate, hesitant, insecure, detailed, perfectionistic, sensitive to criticism, and deeply frustrated emotionally. They were said to lack warmth and to have difficulty making social contacts. Wolff (1937) found migraineurs to be rigid, compulsive, perfectionistic, ambitious, competitive, chronically resentful, and unable to delegate responsibility.
Most investigations have used psychometric instruments such as the Minnesota Multiphasic Personality Inventory (MMPI) (Hathaway and McKinley, 1943) or the Eysenck Personality Questionnaire (EPQ) (Eysenck and Eysenck, 1975). The EPQ is a well standardized measure that includes four scales: (1) psychoticism (P), (2) extroversion (E), (3) neuroticism (N), and (4) lie (L).
Brandt et al. (1990) used the Washington County Migraine Prevalence Study to conduct the first population-based case-control study of personality in patients with migraine. More than 10,000 12- to 29-year-olds who were selected through random-digit dialing received a diagnostic telephone interview. Subjects who met the criteria for migraine with or without aura (n = 162) were compared with subjects without migraine. Each subject received the EPQ, the 28-item version of the General Health Questionnaire (Goldberg, 1975), and a question about headache laterality.
Subjects with migraine scored significantly higher than control subjects on the neuroticism scale of the EPQ, indicating that they were more tense, anxious, and depressed than the control group. In addition, women with migraine scored significantly higher than control subjects on the psychoticism scale of the EPQ, indicating that they were more hostile, less interpersonally sensitive, and out of step with their peers. Rasmussen (1992) screened a population-based sample to identify patients with migraine and those with tension-type headache (TTH). Tension-type headache occurring alone was associated with high neuroticism scores on the EPQ. Persons with pure migraine (i.e., without TTH) did not score above the norms on the neuroticism scale, although persons with migraine, with and without TTH, tended to score above the norms on the neuroticism scale.
Merikangas et al. (1993) investigated the cross-sectional association between personality, symptoms, and headache subtypes as part of a prospective longitudinal study of 19- and 20-year-olds in Zurich, Switzerland. Subjects with migraine scored higher on indicators of neuroticism than subjects without migraine.
In summary, studies that used the EPQ or similar personality measures and compared persons with migraine to control subjects without migraine have generally reported an association between migraine and neuroticism (Passchier et al., 1984; Passchier and Orlebeke, 1985; Phillips, 1976; Rasmussen, 1992; Silberstein et al., 1995).
Many investigators (Invernizzi et al., 1989; Kudrow and Sutkus, 1979; Sternbach, 1980; Weeks et al., 1983) have used the MMPI to investigate the personalities of migraineurs. These studies have been limited by several factors (Stewart et al., 1991). The MMPI studies have usually been clinic-based, limiting their generalizability and creating opportunities for selection bias. Most have not used control groups, relying instead on historical norms. Many have not used explicit diagnostic criteria for migraine. Despite these limitations, most studies have shown elevation of the neurotic triad, although this is not statistically significant (Silberstein et al., 1995).
Studies of migraine and personality have generally not controlled for drug use, headache frequency, and headache-related disability. Furthermore, they have not controlled for major psychiatric disorders (such as major depression or panic disorder), which occur more commonly in migraineurs. The association between major psychiatric disorders and personality disorders may confound the assessment of the relationships between these disorders and migraine. Neuroticism, in particular, is associated with depression and anxiety, which occur with increased prevalence in migraineurs. Differences in neuroticism across studies might reflect variations in the role of comorbid psychiatric disease. The available data suggest that subjects with migraine may be more neurotic than those without migraine. The stereotypical rigid, obsessional migraine personality might reflect the selection bias of a distinct subtype of migraine that is more likely to be seen in the clinic.
Breslau and Andreski (1995) examined the association between migraine and personality, taking into account a history of concurring psychiatric disorders. Data came from their epidemiologic study of young adults in Detroit, Michigan. Migraine was associated with neuroticism but not with extroversion or psychoticism, as measured by the EPQ. The association remained significant when the authors controlled for sex and history of major depression and anxiety disorders. More than 25% of persons with migraine alone, uncomplicated by psychiatric comorbidity, scored in the highest quartile of neuroticism. The results suggest that subjects with migraine are more likely to have psychopathology and to adjust poorly to their medical condition. The findings also suggest that the association between migraine and neuroticism is not attributable to comorbid depression or anxiety disorders.
Breslau et al. (1996) presented findings from prospective data on the migraine-neuroticism association from their epidemiologic study of young adults. In women, neuroticism measured at baseline predicted the first incidence of migraine during the 5-year follow-up. Specifically, controlling for major depression and anxiety disorders at baseline, women scoring in the highest quartile of the neuroticism scale were nearly three times more likely to develop migraine than those scoring in the lowest quartile. In men, neuroticism did not predict migraine, although the small number of cases in men precluded reliable estimates of the risk for migraine associated with neuroticism.
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Aaron L Shechter
Richard B Lipton
Stephen D Silberstein
Editors: Silberstein, Stephen D.; Lipton, Richard B.; Dalessio, Donald J.