Migraine: psychiatric comorbidities

Historical note and nomenclature
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By Chaichana Nimnuan MD PhD and Anan Srikiatkhachorn MD

The co-occurrence of various psychiatric symptoms and migraine has long been observed. Such observation led to a hypothesis of certain psychological traits; namely depression, anxiety, and social phobia, that predisposed patients to migraine. In 1937 Wolff initiated the concept of the purported “migraine personality” (Wolff 1937). This personality is characterized by a constellation of obsessive-compulsive traits including perfectionism, orderliness, moralistic preoccupation, and rigidity. These entrenched, often interpersonally successful surface qualities may be understood as reaction formations against a considerable amount of anger. The other traits, such as unexpressed dependency, shyness, sensitivity to criticism, sexual inadequacy, and exploitive interpersonal relationships were also mentioned. These clinical studies concluded that unexpressed anger is what is represented in migraine (Harrison 1975). This concept of migraine personality has not been supported by more recent studies with better methodology. Accumulating evidence revealed that the psychiatric symptoms observed in persons with migraine are the result of coexisting disorders rather than underlying personality abnormalities.

The term “comorbidity,” introduced by Feinstein in 1970, refers to the presence of any additional coexisting ailment with a particular index disorder (Feinstein 1970). Comorbidity of migraine is a rule rather than exception. It usually coincides with medical symptoms, medically unexplained physical symptoms, and mental conditions. Angina, hypertension, colitis ulcer, stroke, asthma, epilepsy, essential tremor, and allergies are among the physically explained conditions (Merikangas and Fenton 1994; Silberstein 2001; Low and Merikangas 2003). For medically unexplained physical symptoms, fibromyalgia and irritable bowel syndrome were reported as associated with the presence of migraine (Hudson and Pope 1989; Peres et al 2001; Cole et al 2006). Overlapping symptoms with psychiatric disorders are sleep disorders, decrease energy, anhedonia, decreased concentration, and decreased libido (Sheftell and Atlas 2002). Comorbidity of migraine has also been supported statistically by multivariate technique, ie, cluster analysis. Two constellations are evident, 1 with medical conditions, and the other with medically unexplained syndrome and psychiatric disorders (Tietjen et al 2007).

Comorbidity of migraine with mental disorders has long been noted in literature. Consistent reports on this comorbidity appear far too often to be coincidental. A population survey in the U.S. found prevalence of any mental disorder in migraineurs was 1.5 and 3.1 times as high compared to nonmigraine headache and nonheadache groups respectively (Saunders et al 2008). These psychiatric comorbidities have strong impact on an individual suffering from migraine as well as on the society. Comorbidity can alter the clinical course of migraine, its prognosis, and quality of life of the sufferers. Persons with migraine with comorbid depression or anxiety also have significantly higher medical costs than those with episodic migraine (Pesa and Lage 2004).