Look for link to mental illness, abuse in choosing migraine care

Research suggests that unless these conditions are addressed, headaches will not get better.

By Victoria Stagg Elliott — Posted July 2, 2007

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The detection of mental illness and previous physical, emotional or sexual abuse is crucial to choosing effective treatment strategies for patients with migraines and other forms of severe headaches, said several presenters at the American Headache Society meeting in Chicago in June.

"These patients, for whatever reason, just don't seem to do as well," said Gretchen Tietjen, MD, lead author of a paper finding a high prevalence of depression among women with migraines who had some form of emotional abuse. "Maybe they need higher doses of medication or different approaches." She is also professor and chair of the Neurology Dept. at the University of Toledo in Ohio.

It has long been recognized that migraineurs have a rate of psychiatric illness higher than that of the general population, and research at this meeting further confirmed this concept. One study concluded that 8.6% of patients presenting to a headache clinic for migraine treatment also had bipolar spectrum disorder. This condition also was noted in 6.6% of those with cluster headache and 4.5% of those with chronic tension headaches.

Previous studies have suggested that this disorder has a prevalence in the general population of 1% to 3%. Experts said this condition, in particular, was important to recognize in those receiving headache treatment because antidepressants are sometimes used for this purpose. These drugs are not recommended for patients who are bipolar.

"Under-recognition is a major problem," said Lawrence Robbins, MD, lead author on that paper and assistant professor of neurology at Chicago's Rush Medical College. "We really need to distinguish bipolar from unipolar depression."

Psychiatric issues are also associated with more disabling and frequent headaches, and it's not always clear what should be treated first. Experts urged the use of medications most likely to address both headaches and the psychiatric disorder, and avoidance of psychotropic drugs that have headache as a possible side effect.

Some studies also suggest that it might be effective to focus efforts, pharmacologic or otherwise, on the mental health problem. Notably, one paper indicated that, in the case of posttraumatic stress disorder, treating this illness may be the best approach for reducing head pain.

Researchers prospectively followed eight patients with PTSD and disabling headaches. The patients were treated with psychotherapy, social support and medications but did not receive specific headache drugs. Half had complete resolution of their headaches, and the other half cut the frequency by 50%. This paralleled improvements in PTSD symptoms, particularly those tied to sleep, although researchers said this study was too small to draw significant conclusions.

"The strength is that patients were closely followed over two years, so it generated the hypothesis, but it's too small to draw broad generalizations," said James L. Griffith, MD, lead author on the paper and professor of psychiatry and neurology at George Washington University Medical Center in Washington, D.C. "It makes sense that if you treat the psychiatric disease the headaches will improve, but this has not yet been the subject of adequate scientific study."

Several papers further confirmed the link between past abuse and head pain and suggested that patients are amenable to questions on this subject.

"If you don't ask, they're never going to tell," said Elliott Schulman, MD, a neurologist at Lankenau Hospital in Wynnewood, Pa. "If you're treating them for any kind of pain condition, you have got to know, because it's going to really influence what you do regarding treatment."

His study found that patients believed that asking about sexual abuse was appropriate within the context of a headache history. Along with fellow researcher and psychology graduate student Elizabeth Musewicz, he intends to follow these patients to determine how dealing with the sexual abuse history affects head pain.

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American Headache Society (link)

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