Views and Perspectives

Migraine and Psychiatric Comorbidity:

From Theory and Hypotheses to Clinical Application
Fred D. Sheftell, MD; Susan J. Atlas, PhD

Objective.—To review psychiatric issues that accompany migraine and means of addressing these issues.
Background.—Psychiatric factors and migraine may interact in three general ways, etiologically, psychophys-
iologically or biobehaviorally, and comorbidly (the two disorders coexist), which is the present focus. There are
several possible mechanisms of comorbidity. The relation between two disorders may be a result of chance. One
disorder can cause another disorder: Diabetes can cause diabetic neuropathy. There might be shared environmen-
tal risks: Head trauma can cause both posttraumatic epilepsy and posttraumatic headache. And there may be en-
vironmental or genetic risk factors that produce a brain state giving rise to both conditions, that is, there may be
some common biology underlying both conditions. This last mechanism seems to be the most likely one underly-
ing comorbidity of migraine and psychiatric disorders. We introduce a possible role for classical paradigms of
learned helplessness in regard to psychiatric comorbid depressive and anxiety disorders and migraine.
Results.—There appears to be an association between migraine and affective disorders, particularly depres-
sion and anxiety. There are a number of formal tools for recognizing depression, but clinical evaluation should not
be overlooked. Once diagnosed, depression and anxiety should be treated, both to improve the success of mi-
graine treatment and to improve the patient’s quality of life. Patients with recurring headaches are much more
likely to overuse and misuse, rather than abuse, pain medications. It is important to be alert for signs that the pa-
tient may be misusing medication. Behavioral approaches can surround and support pharmacological therapy.
Conclusions.—Migraine is often comorbid with psychiatric disorders, particularly depression and anxiety. The
relationship is likely based on shared mechanisms and successful treatment is possible.
Key words: migraine, depression, anxiety, substance overuse and misuse, behavioral medicine
Abbreviations: DSM-IVPC, Diagnostic and Statistical Manual of Mental Disorders, Primary CareVersion;
PRIME-MD, Primary Evaluation of Mental Disorders; HRQOL, health-related quality of life;
5-HT, 5-hydroxytryptamine; SSRIs, selective serotonin reuptake inhibitors
(Headache. 2002;42:934-944)

The symptoms and suffering of patients with
migraine must be seen in the context of the human
experience. Psychiatric issues are prominent among
patients with more difficult headache problems, partic-
ularly chronic daily headache. Patients with chronic
From the New England Center for Headache, Stamford, Con-
necticut, and Atlas Biomedical Communications, Columbia,
Maryland.
Address all correspondence to Fred D. Sheftell, MD, New En-
gland Center for Headache, 778 Long Ridge Road, Stamford,
CT 06902-1251, USA.
Accepted for publication July 5, 2002.
daily headache often present with a sense of empti-
ness, sadness, and pain that may be visible even in
their facial expressions. We review psychiatric issues
that accompany migraine and how to address them.
The “difficult” headache patient, often one with
chronic daily headache (Table 1), can usually be
identified as refractory to the “usual” pharmacologi-
cal and nonpharmacological approaches. He or she
presents with intractable pain and often overuses,
misuses, or is dependent on medication. This person
has frequent emergency room visits and generally has
ongoing compliance issues. One can note a decreased
ability to function and multiple referrals, providers,

934
Headache
Table 1.—Clinical Features of Chronic Daily Headache
Daily or near daily mild to moderate headache
Superimposed episodes of migraine defined by the
International Headache Society criteria
Sleep disorder*
Decreased energy*
Anhedonia*
Decreased concentration*
Decreased libido*
Daily or near daily comsumption of symptomatic medications
in most cases
*Symptoms common to depressive disorders.
and tests. When treating a difficult patient, one must
consider psychiatric issues and how they relate to pri-
mary headache disorders.
RELATIONSHIP OF PSYCHIATRIC
CONSIDERATIONS AND PRIMARY
HEADACHE DISORDERS
Psychiatric factors and migraine may interact in
three general ways. Psychiatric factors may be etio-
logical, but this is extremely rare. The second possi-
bility is psychophysiological or biobehavioral. In this
case there is a real physiological disorder that can be
influenced by psychological factors (which is true of
virtually any medical disorder). The last interaction is
psychiatric comorbidity, in which two disorders coex-
ist, and that is the focus here.1
Etiological Considerations.—Somatoform pain dis-
orders are one type of etiological consideration. This is
a disorder in which there is a persistent complaint of
pain without a physical cause or the pain and impair-
ment is greater than would be expected from the phys-
ical findings. Hypochondriasis, somatization disorder,
and pain disorder comprise subgroups of somatoform
disorders. Hypochondriasis is noted when patients
have a preoccupation with physical symptoms, so that
any change from the norm is interpreted as pathology.
These patients constantly seek reassurance from their
doctors that they are not ill. This is not quite delu-
sional. Somatization disorder patients have complaints
on many different medical axes.2
Malingering is rarely seen, even in posttraumatic
headache disorders involving litigation. Cases of fac-
935
titious disorder and Munchausen by proxy, in which
people pretend to suffer from migraine to gain sym-
pathy and support, can occur but are rare.3 In delu-
sional disorder, somatic type, the patient may inter-
pret real pain caused by structural problems in some
delusional way (snakes are in his head or the radio
tower is beaming things at her). It is important to
note that though the pain may be ascribed to a delu-
sional system, the origin of the pain may indeed be
real and requires a thorough evaluation.
Psychophysiological or Biobehavioral.—Adler4 was
the first to use the term psychobiology, linking psy-
chological and biological factors. Selye,5 Cannon,6
Bernard,7 and Pavlov8 did the early work linking the
external and internal milieu and describing how
external stress can impact physiology. Alexander and
Benedek9 were among the first to talk about psycho-
logical and somatic factors in a model of psychoso-
matic disorders, now termed psychophysiological.
The “migraine personality” has been written
about extensively. Harold Wolff, who reviewed his
charts and found that many migraine patients tended
to be rigid obsessional people with high expectations
of themselves, coined the term.10 Recently, “psycho-
logical factors affecting medical conditions” has re-
placed “psychosomatic conditions” in the Diagnostic
and Statistical Manual of Mental Disorders, Primary
Care Version (DSM-IVPC).2 The DSM-IVPC em-
phasizes the use of nine diagnostic algorithms for the
most prevalent psychiatric disorders in primary care.
Headache and Psychiatric Comorbidity.—Before dis-
cussing headache and psychiatric comorbidity, it is im-
portant to understand the possible mechanisms of co-
morbidity, of which there are several.1 The relation
between two disorders may be a result of chance. One
disorder can cause another disorder: Diabetes can
cause diabetic neuropathy. There might be shared en-
vironmental risks: Head trauma can cause both post-
traumatic epilepsy and posttraumatic headache. Envi-
ronmental or genetic risk factors may produce a brain
state that gives rise to both conditions, that is, there
may be some common biology underlying both condi-
tions. This last mechanism seems to be the most likely
one underlying comorbidity of migraine and psychiat-
ric disorders. A simple way of looking at the relation-
ship between pain and depression would be to say that
936 October 2002

pain causes depression or that pain is a form of somatic
depression. However, the relationship is probably
more complex than that and most likely based on com-
mon biological mechanisms.
Table 2 depicts possibilities for headache and
psychiatric comorbidity, depending on presence of
disorders in Axis I to Axis III of the DSM-IVPC.2
Axis I is the acute presenting problem such as mood
or affective disorders (dysthymia, major depression,
bipolar disorder), anxiety disorders, substance-related
disorders, and “psychological factors affecting medi-
cal conditions” (formerly known as psychosomatic
disorders). Axis II is the underlying character disor-
der, if any, and Axis III is the physical symptom
(headache). It has been said that Axis I disorders are
within the patient and Axis II disorders are between
the patient and others. On the left side of the table,
headache is accompanied by no Axis I or Axis II dis-
orders. Treatment is very straightforward. In the mid-
dle of the table, headache is accompanied by major
depression but no Axis II disorder. And in the right
column there are disorders in all three axes. As one
moves from left to right, patient treatment becomes
more complex and more challenging.
Affective Disorder Comorbidity with Migraine.—
Breslau et al11 found that, compared with control sub-
jects, patients with migraine are four to five times
more likely to have affective disorders, including dys-
thymia, major depression, and bipolar disorder (Ta-
ble 3). In other studies, Breslau et al12 found that pa-
tients with migraine were three times more likely to
develop depression and patients with depression
were three times as likely to develop migraine than
control subjects. Panic disorder was similar, but pa-
tients with severe nonmigraine headache did not
show the same correlation: Nonmigraine headache
was predictive of psychiatric disorder, but the reverse
was not true.12
MAJOR DEPRESSION
Overview of Depression.—The lifetime preva-
lence for major depression is up to 17.1% and is
approximately twice as great in women as men.13,14
Depression is generally underdiagnosed and under-
treated.14,15 Untreated depression has a high impact
on mortality and morbidity, with an economic burden
estimated to be $44 billion per year.16,17 However,
with appropriate therapy, most patients can be treated

Table 2.—Headache and Psychiatric Comorbidity (Multiaxial Examples)

Axis I Axis I Axis I

No disorder Major depression Major depression

Somatization
Substance abuse

Axis II Axis II Axis II

No disorder No disorder Borderline personality

Axis III Axis III Axis III

“Migraine without aura” (MO) “MO” “MO”

Chronic tension-type headache Chronic tension-type headache Chronic tension-type headache
Analgesic rebound/medication Analgesic rebound/medication Analgesic rebound/medication
induced headache induced headache induced headache

Increasing Complexity and Difficulty

Headache
Table 3.—Comorbidity of Migraine and Affective Disorder
from Breslau et al11
Odds Ratios
Dysthymia 4.4
Major depression 3.7
Manic episode 5.4
Bipolar disorder 5.1
successfully, even though depression may be a life-
long disorder.17,18
Major clinical depression is a common psychiat-
ric disorder in which patients present with a constel-
lation of symptoms. Both medical and psychiatric
illnesses may be associated with depression, with
headache being the most frequent somatic complaint.
Successful outcomes in regard to headache manage-
ment are severely compromised if depression is not
recognized and properly treated. Effective treat-
ments for depression are available, but depression is
still often under- or misdiagnosed. The costs associ-
ated with not treating or undertreating depression
can be extremely high.
Tools for Recognizing Depression.—Formal tools
for recognizing depression include the Hamilton,19
Fig 1.—Depressed patients present with a constellation of symptoms.
937
Zung,20 or Beck21 Inventories or Scales and PRIME-
MD (PRIMary Evaluation of Mental Disorders).22
There is also the Minnesota Multiple Personality In-
ventory, but this requires some skill and time to ad-
minister.23 In the clinical evaluation, migraine should
be sought if depression is the chief complaint or, con-
versely, depression should be sought if migraine is
found.
PRIME-MD is a system for diagnosis of mental
disorders in primary care. It consists of a self-admin-
istered 26-item patient questionnaire (positive in 40%)
to screen for the 5 most common DSM disorders seen
in the primary care setting: mood disorders, anxiety
disorders, eating disorders, alcohol abuse or depen-
dence, and somatoform disorders. The Clinician
Evaluation Guide is then used to evaluate the patient
questionnaire. With practice, the PRIME-MD takes
about 12 minutes to administer.
Depression and Medical Illness.—Krishnan24 stud-
ied a group of patients with stroke and found that the
longer the medical problem existed, the greater the
chances that a patient became depressed. “One of
the biggest factors for the development of depression
in this [cohort] was their perception of the lack of so-
cial support they were given during illness.”24 Reduc-
ing the symptoms of depression in chronically ill pa-
tients may play a large role in improving their
physical health.
938
Although not necessarily viewed as a chronic ill-
ness, migraine should probably be treated as if it
were. Just as we would not consider the depression
associated with Parkinson disease, multiple sclerosis,
or stroke to be causative, we should give patients
with migraine the same view and understanding. De-
pressed patients present with a constellation of symp-
toms (Figure 1).
Depression and Migraine.—A recent population-
based study captured the experience of patients with
migraine who never consulted a physician about their
headaches and those who did. Lipton et al25 com-
pared health-related quality of life (HRQOL) and
depression in a group with migraine with a group
without migraine in the United States and the United
Kingdom. Results were similar in both countries—
migraineurs had significantly decreased HRQOL and
significantly higher prevalence of depression than
nonmigraineurs, and those with a higher frequency of
attacks had a poorer HRQOL. Migraine and depres-
sion were highly comorbid, and each exerts a signifi-
cant and independent influence on HRQOL.
Neurotransmitters and Migraine.—There is evi-
dence for involvement of both monoamine (serotonin
and dopamine) and peptide (endorphin and encepha-
lin) neurotransmitters in depression. Endorphins and
encephalins are involved in both mood control and
pain control.
Serotonin (5-hydroxytryptamine [5-HT]) in par-
ticular has been implicated in mood disorders, anxiety
disorders, sleep disorders, eating disorders, obsessive-
compulsive disorder, migraine, and tension-type head-
ache.26,27 A number of different classes of 5-HT recep-
tors have been identified and named 5-HT1 through
5-HT7. There is good evidence for the involvement of
5-HT1 receptors in migraine, because the effective
triptan medications are 5-HT1 agonists.28
Evidence is accumulating that dopamine is also
intimately involved in migraine. Migraine prodrome
is often characterized by dopaminergic symptoms
(yawning, mood changes, nausea, vomiting),29 and an-
tidopaminergic compounds can often be helpful in
treating them.30 Patients with migraine have an in-
creased density of dopamine receptors on peripheral
lymphocytes compared with control subjects, perhaps
reflecting that the dopaminergic system is under
October 2002
functioning.31 There is also evidence that migraine is
associated with a particular dopamine -hydroxylase
allele.32
Role of Learned Helplessness in the Comorbidity of
Depression and Migraine.—The classic work of Seligman33
reviewed the role of learned helplessness as a factor
in the genesis of depression. Helplessness is defined as
“the psychological state that frequently results when
events are uncontrollable.” Furthermore, depression
and anxiety are related to uncontrollability and unpre-
dictability. In this model, depression is caused by the be-
lief that action is futile. One can see how responses to re-
current disabling migraine attacks might be viewed as
learned helplessness, because migraine attacks are gen-
erally unpredictable and, if poorly treated, also uncon-
trollable. We believe this paradigm may be another
mechanism of psychiatric comorbidity, which has not
been addressed in the headache literature. By recogniz-
ing migraine and following the treatment paradigms of
the U.S. Headache Consortium and Primary Care Net-
work, we can prevent learned helplessness and depres-
sion from developing.34,35 For moderate to severe
episodes, evidence strongly suggests triptans are ap-
propriate. Preventive strategies can reduce attack fre-
quency and intensity, and appropriate acute agents can
mitigate helplessness by giving sufferers tools to control
the episodes.34 The model of learned helplessness further
supports the need for cognitive behavioral interventions,
modification of lifestyles, and trigger reduction.
Pharmacological Treatment for Depression and
Migraine.—After making a diagnosis it is necessary
to monitor treatment every few weeks (Figure 2). Re-
sponse to treatment should be assessed at week 6,
and if the patient shows clear improvement the treat-
ment should be continued for an additional 6 weeks.
If there is a complete remission, medication is contin-
ued for 4 to 9 months and maintenance treatment is
considered. After 1 episode of major depression, the
chance of recurrence is 50%.36,37 If the patient is only
somewhat better, the dose can be increased. Treat-
ment should be continued, monitoring every 2 weeks,
and assessed at week 12 for treatment response. If
there is not complete response at that point, a referral
to a psychiatrist or psychopharmacologist or change
in medications might be considered. It may be faster
and easier to augment medication rather than switch-
Headache
Fig 2.—Agency for Health Care Policy and Research guidelines for treating major depression. 18
ing it. One of the more common augmenting strate-
gies for selective serotonin reuptake inhibitors (SSRIs)
is bupropion.38 Goals of therapy for depression are
remission of all signs and symptoms, restore occupa-
tional and social function, reduce acute risk of sui-
cide, reduce the likelihood of relapse and recurrence,
and improve long-term outcome.18
Tricyclic and related cyclic antidepressants work
well in treating headache, although they are no longer
used much in treating depression, because therapeutic
doses for depression are high and side effects become
problematic. Although SSRIs are extremely useful in
treating depression and certain anxiety disorders, they
are less useful in treating headache. For comorbid mi-
graine and depression it is possible to combine a tricy-
clic antidepressant with an SSRI, but the interactions
should be carefully considered.38
Monoamine oxidase inhibitors are excellent anti-
depressants, but they are not used as much as the
other agents because of the dietary restrictions needed
when they are taken. There are some anecdotal data
for the utility of the newer medications, including bu-
propion,39 nefazadone,40 trazadone,41 and venlafaxine42
in migraine, and they have been shown to be useful in
depression. The efficacy of all antidepressants is es-
sentially identical, so choice is a matter of side effect
profiles and treatment target.
Although the efficacy of antidepressants in suffi-
939
cient doses is comparable, Slaby and Tancredi43 re-
cently reviewed evidence for choosing an agent based
on presenting symptoms and behaviors mediated by
specific neurotransmitters. Serotonin influences mood,
sleep, cognition, nociception, appetite, and sexual be-
havior. Dopamine modulates mood, cognition, drive,
aggression, pleasure seeking, motivation, and aggres-
sion. And norepinephrine impacts mood, learning,
memory, sleep-wake cycles, functions of the hypotha-
lamic-pituitary axis, and the sympathetic system. By
carefully evaluating the constellation of symptoms in
the patient with depression, one may be better able to
select an agent that may influence specific behaviors.
For example, a patient with addictive behaviors may
be best treated with dopaminergic agents such as bu-
propion. Sertraline combines serotonergic and dopa-
minergic actions, paroxetine affects both noradrener-
gic and serotonergic activity, and monoamine oxidase
inhibitors modulate all the monoamines.
COMORBIDITY OF DEPRESSIVE
DISORDERS WITH ANXIETY DISORDERS
There is a fairly high comorbidity of depression
and anxiety (Table 4),13 and the same issue arises in
considering the relationship between anxiety and de-
pression as between migraine and tension-type head-
ache: Are they part of the same spectrum or are they
940 October 2002

Table 4.—Comorbidity of Depressive Disorders with Role of Learned Helplessness in the Comorbidity of
Anxiety Disorders13 Anxiety and Migraine.—Seligman33 reviewed the re-
lationship between learned helplessness and anxiety,
Major Depression Comorbid With Comorbid (%) stating that “anxiety results from unpredictable
shocks” and anxiety is greater with unpredictable
Panic disorder 9.9 versus predictable “trauma.” Anxiety may be chronic
Simple phobia 24.3 during unpredictable events and intermittent with
Social phobia 27.1
predictable events. His work suggests that the ability
Generalized anxiety disorder 17.2
Any anxiety disorder 58.0 to control an aversive event (ie, migraine) reduces
anxiety. Again, we suggest a possible further relation-
ship between migraine and psychiatric comorbidity,
in this case anxiety disorders, and the need for early
totally separate disorders? Anxiety and depressive dis- recognition and appropriate interventions.
orders can often be treated with similar medication.
Anxiety disorders are much more prevalent SUBSTANCE ABUSE, OVERUSE,
among people with migraine than among the general AND MISUSE
population (Table 5),11 so physicians should be look- Substance abuse is defined as recurrent adverse
ing for these disorders in their migraine patients. Al- consequences related to repeated substance use.
though the lifetime prevalence of panic phenomenol- Most patients with recurrent headache are not sub-
ogy is not extremely high (Figure 3), morbidity is stance abusers, rather they are substance “overusers”
(Figure 4).44,45 and “misusers.” Substance overuse is a nonpejorative
Drugs used to treat panic disorders are similar to term to reflect the use of medication beyond appro-
those used to treat depression: SSRIs, tricyclic antide- priate use solely in the pursuit of pain relief and in
pressants, monoamine oxidase inhibitors, and newer the absence of behavioral issues. Substance misuse is
agents.46 In addition, high-potency benzodiazepines similar except that there are added destructive pat-
may be useful. In the beginning, short-acting benzo- terns of use such as manipulative behavior, multi-
diazepines are useful while preventive strategies are sourcing, and so on. For a more detailed discussion,
being put in place, but on an ongoing basis the longer see Saper and Sheftell.47
acting ones, such as clonazepam, are preferable. Many medications can be used excessively, but
Other approaches that may be useful include com- certain ones, including mixed analgesics, benzodiaz-
bined treatments, the antiepileptic drugs, and -block- epines, ergotamine tartrate, meperidine, and butor-
ers, which decrease sympathetic outflow. phanol nasal spray, are more likely to be overused by
patients with headache pain.47 Signs that the patient
may be misusing medication include new patients
asking for narcotics before their first visit, nighttime
calls when another doctor is covering, eliciting sym-
pathy with less than credible stories, and specific re-
Table 5.—Lifetime Prevalence of Anxiety Disorders quests for a particular opiate.
in Migraine11
Patients whose families have a history of alcohol-
ism or drug abuse are more vulnerable to drug over-
Migraine Control use. To manage a patient identified as a medication
Group Group
overuser or misuser, suspicion may be warranted:
Corroborate the story as soon as possible, prescribe
Panic disorder 11% 2%
small amounts of medications with no refills, use one
Anxiety disorder 10% 2%
Obsessive-compulsive disorder 9% 2% prescriber and one pharmacy, do not replace lost bot-
tles, and suggest alternate means of pain control.
Headache
Fig 3.—Lifetime prevalence of panic. 44
Also consider a formal signed pain medication agree-
ment capturing the above guidelines. Patients de-
serve appropriate and effective pain treatment, which
can actually reduce the likelihood of medication
overuse and misuse.
AXIS II DISORDERS
Axis II disorders, particularly borderline person-
ality disorder, are extremely difficult to deal with
even in the context of a psychiatric setting, let alone
the office practice of primary or specialty care.
Borderline Personality Disorder.—The essential fea-
ture of borderline personality disorder is a pervasive
pattern of unstable interpersonal relationships, mood,
and self-image accompanied by five of the following2:
Fig 4.—Panic disorder morbidity. 45
941
• Unstable relationships alternating between
overidealization and devaluation
• Impulsive and self-destructive behavior
• Affective instability, mood shifts
• Inappropriate intense anger
• Recurrent suicidal threats or gestures
• Persistent identity disturbance (eg, uncertainty
regarding self-image, goals, career choice,
friends, values, etc.)
• Chronic emptiness or boredom
• Concerns regarding real or imagined aban-
donment
A typical patient with borderline personality may
present in the following way: “Thank god I found you!”
or “Those other doctors never listened to me and they
942
didn’t say very nice things about you!” After some time
has passed, these patients become disgruntled: “You’re
just like all the rest,” “You’re never there when I need
you,” “I knew you’d do this to me.”
When dealing with patients with borderline per-
sonality, it is best to be very clear about expectations
and patient responsibility and to set limits early regard-
ing missed appointments, lost medications, and so on.
It is extremely important to set appropriate bound-
aries, avoiding familiarity and first names. Engagement
in psychotherapy should be a prerequisite in dealing
with active borderline patients, and treatment contracts
regarding appointments and terms of engagement
should be considered.
BEHAVIORAL MEDICINE
Behavioral medicine asserts that a person’s behav-
ior can influence the course of medical illness and treat-
ment outcome. It is important to incorporate behavioral
medicine into our approach to treating patients with mi-
graine, because a variety of behavioral approaches sur-
rounds and supports pharmacological therapies. Behav-
ioral approaches include cognitive behavioral therapy;
stress management; time management; diet and proper
exercise; monitoring possible triggers, medication intake
and effect, and headache frequency, intensity, and dura-
tion (calendars); biofeedback; and type A modification.
Stress and Lifestyle Modification.—To modify type
A behavior, the adage “learn to play more at work
and work less at play” can be a place to start. Also,
intensity levels should be evaluated and stressors
Fig 5.—Educational model: “stick of dynamite.”
October 2002
identified (eg, family, work, interpersonal) to make
life changes and to evaluate their impact.
Locus of Control.—Locus of control refers to
whether one views the outcomes of their actions as de-
pendent on what they do (internal control) or on
events outside their personal control (external con-
trol). Patients with an external locus of control are
characterized by a “Cure me!” approach, whereas pa-
tients with an internal locus of control are character-
ized by a more collaborative “How can we work to-
gether?” position. A headache-specific locus of control
scale has shown that an external locus of control is as-
sociated with higher levels of depression, poor pain
coping strategies, and greater disability.48 By learning
pain management techniques and other means of con-
trolling migraines, patients can see themselves as more
able to affect their own lives. Patients who are more
confident that they can prevent and manage their
headaches have less headache-related disability.49
Patient Education.—The goals of patients educa-
tion are as follows:
• To manage headache episodes in the situations
they occur (home, work, etc)
• To become their own “primary caregivers” and
manage attacks in the absence of the health
care provider
• To initiate headache management activities
• To make effective use of medical therapies
• To alter daily routines to support headache
management
Headache
The “stick of dynamite” model (Figure 5) can be
useful in educating patients. The aim is to contain the
explosion made possible by the underlying biology.
To this end, preventive medication can be used to
come between outside “triggers” and the underlying
biology. Also, it is possible to decrease the triggers
and thus avoid stimulating the explosion.
Support groups can be a useful adjunct. They pro-
vide the patient with the sense that they are not alone.
They may also provide education, an opportunity for
patients to share experiences and gain mutual support,
and an appropriate forum for family involvement.
In conclusion, migraine is often comorbid with
psychiatric disorders, particularly depression and anx-
iety, and their relationship is likely based on shared
mechanisms. Learned helplessness may be a further
avenue of explanation of psychiatric comorbidity.
Comorbid psychiatric disorders on both Axis I and II
must be recognized and addressed to improve out-
comes. The most complex problems with disorders
on both Axis I and II, and particularly the borderline
patient, often require more intensive multidisci-
plinary approaches. Successful treatment is possible,
but migraine for many is a lifelong disorder charac-
terized by remissions and exacerbations.
Psychiatric comorbidity is certainly one of the
more confounding factors in patients with chronic
headache syndromes. As health care providers, we
can deal with it to the extent that we are comfortable.
However, competent and interested psychiatric and
psychological colleagues are needed who understand
the fundamental biology of headache and do not just
view these patients as people psychodynamically
troubled or full of repressed anger.
Acknowledgment: Supported by an unrestricted edu-
cational grant from Merck & Co.
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