Chapter 30 - Psychiatric comorbidities of migraine

Abstract

Migraine is commonly comorbid with psychiatric conditions, particularly major depressive disorder, anxiety disorders, and sleep disorders. The presence of psychiatric disorders can make diagnosis and treatment more challenging. Existing studies suggest that the relationship between migraine and psychiatric disorders is bidirectional, such that each disorder confers increased risk for onset of the other. Mechanisms underlying this comorbidity are largely speculative but include serotonergic dysfunction, medication overuse, allostatic load, and behavioral factors such as pain-related appraisals and unwarranted avoidance behaviors. Psychiatric comorbidities present unique clinical considerations for assessment and treatment, foremost among which is a need to routinely screen migraine patients for depression, anxiety, and insomnia. Common screening considerations and measures validated on headache patients are reviewed. Comprehensive treatment of migraine requires interventional attention also to any psychiatric comorbidities, though few randomized trials have rigorously evaluated the efficacy of pharmacologic or behavioral migraine interventions for comorbid psychiatric symptoms. Most modern antidepressants lack strong efficacy for migraine, and providers often utilize separate agents to treat migraine and any psychiatric comorbidities. Recent research on adjunctive behavioral interventions such as cognitive-behavioral therapy and acceptance-based approaches suggests they hold value in reducing psychiatric symptoms, though larger trials are needed.