Evidence-Based Reviews

How to control migraines in patients with psychiatric disorders

Current Psychiatry. 2002 November;1(11):39-44

References

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She reported having “bad, sick headaches” that sometimes lasted 2 to 3 days. Bed rest helped but this was not always possible. The headache was throbbing and usually one-sided. She had no aura, and ibuprofen gave partial relief. She noted that her mother gets similar headaches.

Table 3

DIAGNOSTIC REQUIREMENTS FOR MIGRAINE WITHOUT AURA

Mandatory Secondary headache excluded Duration 4 to 72 hours At least 5 attacks
At least 2 of the following: Location unilateral Pulsating/throbbing Moderate or severe headache (inhibits or prohibits routine activities) Aggravated by walking stairs or similar activities
During headache At least one of the following: Nausea and/or vomiting Photophobia and phonophobia
Additional features Migraine prodrome—A range of general, neurologic, and mental changes may occur hours or days before the headache’s onset General—Anorexia, food craving, diarrhea or constipation, thirst, urination, fluid retention, cold feeling Mental—Depression, hyperactivity, euphoria, difficulty concentrating, dysphasia Neurologic—Photophobia, phonophobia, hyperosmia, yawning
SOURCE: Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. Headache Classification Committee of the International Headache Society. Cephalalgia 1988;8(suppl 7):1-96.

Ms. A was diagnosed with migraine without aura, and she was treated with sumatriptan, 100 mg (1 or 2 doses, as needed). Her headaches responded well to this treatment, but the frequency of attacks remained unchanged. She requested a change in her medicine.

Box

WHAT CAUSES MIGRAINE HEADACHES?

The underlying mechanisms of migraine headaches are not completely understood.

Vascular causes. A recently described neurovascular mechanism¹¹ suggests that perivascular neurogenic inflammation involving meningeal vessels causes migraine. The triptan drugs have been found to reverse this process and relieve the headache.¹²

Positron emission tomography has demonstrated increased blood flow during acute migraine in midline brain stem structures. This suggests the presence of a central migraine generator in that location.¹³

Heredity. A rare form of migraine, familial hemiplegic migraine, is associated with a genetic abnormality on chromosome 19.¹⁴

Nitric oxide. Nitroglycerine-induced migraine headache, caused by the release of nitric oxide in cerebral vessels, can be reversed by nitrous oxide synthase inhibitors, thus opening up intriguing possibilities of new therapeutic agents and increased understanding of underlying migraine mechanisms.¹⁵

Treating migraines

Acute treatment. Migraineurs whose attacks are infrequent and mild may find OTC analgesics or NSAIDs adequate. Most patients, however, require specific migraine treatment, usually with triptans. Acute oral treatment options include sumatriptan, 50 to 100 mg; rizatriptan, 10 mg; zolmitriptan, 2.5 to 5 mg; and eletriptan, 40 mg.

In case of vomiting or nausea, options include sumatriptan, 20 mg nasal spray or 6 mg SC; rizatriptan, 10 mg on a dissolving wafer; or dihydroergotamine, 2 mg nasal spray or 1 mg IM or SC. For severe nausea or vomiting, an anti-nauseant (e.g., prochlorperazine suppositories, 25 mg) may be of value.

Preventive treatment. Preventive treatment may be warranted, depending on attack frequency, severity, and the extent of disability caused. One prolonged, severe attack per month that responds poorly to acute treatment may indicate the need for preventive treatment. A range of preventative treatments is available (Table 4).

In Ms. A’s case, oral sumatriptan lessened the severity of the migraine attacks, and the addition of nortriptyline, 50 mg/d, reduced frequency by about 50%. She felt more energetic overall and was sleeping better.

Treating the psychiatric comorbidity

Behavioral therapy is used as an adjunct to pharmacologic headache treatment. This approach is usually considered after a poor or adverse response to treatment, or when pharmacologic treatment is contraindicated (e.g., during pregnancy).

Relaxation training, biofeedback, and cognitive-behavioral stress management are the most commonly used forms of behavioral therapy. Thirty-five to 55% improvement in migraine has been reported following such treatments.¹⁶

Cognitive-behavioral intervention has been shown to be effective in depression¹⁷ and anxiety disorders.¹⁸ When either psychiatric problem is comorbid with migraine, cognitive therapy can improve both the migraine and the psychiatric comorbidity.

Pharmacologic therapy. Depression is commonly associated with migraine and may be caused by living with chronic disabling headaches over time. In such cases, the depression will improve as the migraine responds to treatment. However, in cases where comorbid depression or anxiety trigger or exacerbate acute migraine attacks, neither the migraine nor the psychiatric problem responds until the underlying psychopathology is treated. In such cases, simultaneous psychiatric and migraine pharmacologic treatment is required.

We recommend that you treat the psychiatric comorbidity as it would be treated without a co-existing migraine. Be advised, however, that monoamine oxidase inhibitors are contraindicated in depression during the 2 weeks before treating the comorbid migraine with a triptan. If the patient does not respond or if there is concern regarding possible underlying pathology, consult with a clinician who specializes in headache treatment.

Precipitating and aggravating factors