Negative impact of episodic migraine on a university population: quality of life, functional impairment, and comorbid psychiatric symptoms

(Headache 2011;51:581‐589) Background.— Migraine is associated with significant negative impact, including reduced quality of life, impaired functioning, and comorbid psychiatric disorders. However, the impact of migraine on university students is understudied, despite their high prevalence of migraine and psychiatric disorders and their frequent use in research studies. Objectives.— The aim of this cross‐sectional study was to evaluate the impact of migraine among college students on quality of life, functional impairment, and comorbid psychiatric symptoms. Methods.— Three hundred and ninety‐one students (76.73% female, mean age = 19.43 ± 2.80 years) completed well‐validated measures of migraine and migraine‐related disability, quality of life, and comorbid psychiatric symptoms. They also quantified impairment in school attendance and home functioning and reported the number of medical visits during the preceding 3 months. Results.— One hundred and one (25.83%) met conservative screening criteria for episodic migraine; their mean score on the Migraine Disability Assessment Questionnaire was 9.98 ± 12.10. Compared to those not screening positive for migraine, the migraine‐positive group reported reduced quality of life on 5 of 6 domains, as well as a higher frequency of missed school days (2.74 vs 1.36), impaired functioning at home (2.84 vs 1.21 days), and medical visits (1.86 vs 0.95). They also reported more symptoms of both depression and anxiety than controls, although differences in functional impairment remained after controlling for these comorbid psychiatric symptoms. These differences were highly statistically significant and corroborated by evidence of clinically significant impairment; the corresponding effect sizes were modest but non‐trivial. Conclusions.— Episodic migraine is associated with negative impact in numerous domains among university students. These findings replicate and extend those of studies on other samples and have implications for future research studies with this population.     

Psychiatric comorbidity of migraine

Migraine affects nearly 12% of the adult population in the United States and causes significant lost productivity and decrements in health-related quality of life. The burden of migraine and the challenge in managing it are increased by the comorbid psychiatric conditions that occur in association with it. Studies in both clinical and community-based settings have demonstrated an association between migraine and a number of specific psychiatric disorders. This review will focus on the relationships between migraine and depression, generalized anxiety disorder, panic disorder, and bipolar disorder. In large scale population-based studies, persons with migraine are from 2.2 to 4.0 times more likely to have depression. In longitudinal studies, the evidence supports a bidirectional relationship between migraine and depression, with each disorder increasing the risk of the other disorder. Migraine is also comorbid with generalized anxiety disorder (Odds Ratio [OR] 3.5 to 5.3), panic disorder (OR 3.7), and bipolar disorder (OR 2.9 to 7.3). A diagnosis of migraine should lead to a heightened level of diagnostic suspicion for these comorbid psychiatric disorders. Similarly, a diagnosis of one of these psychiatric disorders should increase vigilance for migraine. Treatment plans for migraine should be mindful of the comorbid conditions.     

Migraine, Personality, and Psychiatric Comorbidity

The purpose of this report is to examine the association between migraine and personality, taking into account history of co-occurring psychiatric disorders. Data came from an epidemiologic study of young adults in the Detroit, Michigan metropolitan area. Migraine, defined according to 1988 IHS criteria, and major depression and anxiety disorders were ascertained by a structured diagnostic interview. Migraine was associated with neuroticism, but not with extraversion or psychoticism, measured by the Eysenck's Personality Questionnaire. The association remained significant, when sex and history of major depression and anxiety disorders were controlled. An excess of 25% of persons with migraine alone, uncomplicated by psychiatric comorbidity, scored in the highest quartile of neuroticism. The results suggest that migraine sufferers might be more vulnerable to psychopathology and poor adjustment to their medical condition.     

The prevalence and impact of migraine headache in bipolar disorder: results from the Canadian Community Health Survey

OBJECTIVE: To report on the prevalence of comorbid migraine in bipolar disorder and the implications for bipolar age of onset, psychiatric comorbidity, illness course, functional outcome, and medical service utilization. BACKGROUND: Migraine comorbidity is differentially reported in bipolar versus unipolar depressed clinical samples. The bipolar disorder-migraine association and its consequences have been infrequently reported in epidemiological studies. METHODS: Data for this analysis were derived from respondents (n = 36 984) to the Canadian Community Health Survey - Mental Health and Well-Being (CCHS). Respondents reporting a lifetime WHO-CIDI-defined manic episode and physician-diagnosed migraine (lifetime) were compared to respondents without migraine on sociodemography, course of illness, and medical service utilization indices. RESULTS: An estimated 2.4% of the sample met criteria for bipolar disorder. Persons with bipolar disorder had a relatively higher prevalence of migraine versus the general population (24.8% vs. 10.3%; P < .05). The sex-specific prevalence of comorbid migraine in bipolar disorder was 14.9% for males and 34.7% for females. Bipolar males with comorbid migraine were more likely to live in a low income household (P < .05); receive welfare and social assistance (P < .05); report an earlier age of onset of bipolar disorder (P < .05); and have a higher lifetime prevalence of comorbid anxiety disorders (P < .05). Bipolar males with comorbid migraine were also more likely to utilize primary (P < .05) and mental health care services (P < .05) . Bipolar females with comorbid migraine had more comorbid medical disorders (P < .05) and were more likely to require help with personal or instrumental activities of daily living when compared to bipolar females without migraine. CONCLUSION: Bipolar disorder with comorbid migraine is prevalent and associated with greater dysfunction and medical service utilization, notable in males. Opportunistic screening and surveillance for bipolar and comorbid migraine is warranted.     

The impact of migraine on patients with major depressive disorder

BACKGROUND: The impact of migraine and other headache types among psychiatric outpatients with major depressive disorder (MDD) has not been fully described. OBJECTIVE: To investigate the impact of migraine on the severity, physical, and anxiety symptoms in patients with MDD and to examine the interaction between headache and depression. METHODS: This clinic-based study enrolled consecutive psychiatric outpatients meeting DSM-IV criteria for MDD. Headache types were diagnosed based on the International Classification of Headache Disorders, 2nd edition (2004). Three psychometric instruments were used to evaluate anxiety, depression, and physical components: the Hamilton Depression Rating Scale, the Beck Depression Inventory, and the Hospital Anxiety and Depression Scale. In addition, the interactions between headache and their depressive episode were also evaluated. RESULTS: Compared with patients without migraine, MDD patients with comorbid migraine (n = 73, 48.3%) had higher physical and anxiety scores on the three psychometric instruments. Migraine accounted for 5% to 11% of the variance of the total scores on the three psychometric scales. Approximately half (48.5%) of patients reported headache worsening during or after a depressive episode. CONCLUSIONS: Our study found that comorbidity of migraine in patients with MDD was associated with more anxiety and physical symptoms. Headache should not be considered as only a somatic symptom of depression, but should be treated as an important comorbid disorder because it might exacerbate or interact with depression during a depressive episode.     

The economic impact of migraine: an analysis of direct and indirect costs

OBJECTIVE: This study examined whether individuals with migraine incurred greater direct and indirect costs than a matched group free of migraines. METHODS: Using population-based survey data, we matched individuals with migraine (n = 1087) and a migraine-free control group one-to-one for age, sex, employment status, and number of comorbidities. We assessed the prior six months' direct medical care in terms of self-reported hospital days and emergency department and physician visits. Costs were computed by multiplying utilization by unit costs and summing across categories. Indirect costs were calculated based on the number of days missed from employment or household activities. RESULTS: The sample was 80% female and had an average of 39 years and 0.4 comorbid conditions. Two-thirds were employed. Migraineurs had higher direct medical costs over the prior six months (522 dollars versus 415 dollars, P =.039), primarily due to a greater frequency of physician and emergency department visits. The cost of lost productivity for the migraine group was also higher, by more than 200 dollars (P =.014). The combined total for direct and indirect costs was 1,242 dollars for migraineurs and 929 dollars for the comparison group (P =.006). Additional analyses comparing those with moderate versus severe migraine demonstrated that more severe migraineurs had higher costs for lost productivity (1,021 dollars versus 251 dollars, P<.001) and higher costs when direct and indirect costs were combined (1,656 dollars versus 685 dollars, P<.001). CONCLUSION: Migraine is an expensive illness and two-thirds of the financial burden is linked to indirect costs. Consequently, individuals with migraine, employers, and insurance companies all have an economic stake in reducing the migraine burden.     

Pharmacological approaches to managing migraine and associated comorbidities--clinical considerations for monotherapy versus polytherapy

Comorbidity is defined as an illness that occurs more frequently in association with a specific disorder than would be found as a coincidental association in the general population. Conditions that are frequently comorbid with migraine include depression, anxiety, stroke, epilepsy, sleep disorders, and other pain disorders. In addition, many common illnesses occur concomitantly (at the same time) with migraine and influence the treatment choice. Migraine management, and especially migraine prevention, can be challenging when patients have comorbid or concomitant illnesses. The objectives of this initiative are to review the literature on managing patients who have migraine and common comorbidities, present additional clinical approaches for care of these difficult patients, and evaluate the areas in which research is needed to establish evidence-based guidelines for the management of migraine with associated comorbid conditions.     

Migraine and psychiatric comorbidity: from theory and hypotheses to clinical application

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, psychophysiologically 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 environmental risks: Head trauma can cause both posttraumatic epilepsy and posttraumatic headache. And there may be environmental 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 underlying 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 depression 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 migraine 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 patient 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.     

The impact of interferon Beta and natalizumab on comorbid migraine in multiple sclerosis

Background.— Some multiple sclerosis (MS)‐specific therapies may exacerbate a comorbid migraine. Whereas data regarding the impact of interferon beta (IFNB) on this comorbidity have been reported, studies on the role of natalizumab (NTZ) are still lacking. Purpose.— Our aim was to compare the impact of IFNB and NTZ on the frequency and disability of comorbid migraine in MS patients. Methods.— We performed a longitudinal evaluation on MS patients with comorbid migraine previously assessed at our center and retested for the present study, by comparing data from 33 patients originally treated with IFNB and thereafter switched to NTZ vs 30 patients continued currently to receive IFNB. Results.— Longitudinal analysis showed a significant reduction of migraine frequency (from a mean value of 8.4 to 5.1 days per month; P = .034) and Migraine Disability Assessment Scale (MIDAS) score (from a mean value of 14.2 to 10.5; P = .045) in the subgroup patients switched from IFNB to NTZ but not in those remaining in the IFNB recipient, irrespective of level of fatigue, trait anxiety, depression, alexithymia, or other clinical variables. Conclusions.— Our findings suggest that NTZ did not exacerbate comorbid migraine in MS patients and support the hypothesis that IFNB might represent an important trigger for migraine worsening.     

Impaired functioning and quality of life in severe migraine: the role of catastrophizing and associated symptoms

Migraine characteristics are associated with impaired functioning and quality of life (Fn/QoL), but the impact of other factors on Fn/QoL in headache patients is largely unexplored. We examined catastrophizing, comorbid anxiety/depression and migraine characteristics as related to Fn/QoL, and explored the consistency of these relationships across five Fn/QoL measures. We evaluated 232 frequent migraine sufferers for comorbid psychiatric diagnosis, and they completed anxiety, depression and catastrophizing measures, recorded migraine characteristics in a diary and completed five Fn/QoL measures (four self-report questionnaires, one diary disability measure). Backward regression revealed catastrophizing and severity of associated symptoms (photophobia, phonophobia, nausea) independently predicted Fn/QoL across all five measures (beta weights 0.16-0.50, all P < 0.01). This is the first demonstration that a psychological response to migraines (catastrophizing) is associated with impaired Fn/QoL independent of migraine characteristics and other demographic and psychological variables. Severity of associated symptoms also emerged as an important contributor to Fn/QoL.     

Shared Mechanisms and Comorbidities in Neurologic and Psychiatric Disorders

Migraine may be comorbid with several other neurologic and psychiatric conditions, including mood disorders (eg, depression, anxiety, panic disorder), epilepsy, stroke, and essential tremor. Comorbidity presents physicians with opportunities and challenges for both diagnosis and treatment. All diseases must be considered, and therapeutic strategies may need to be modified to avoid potential drug interactions. Comorbidities also may provide clues to the pathophysiologies and any shared mechanisms of the two disorders. Longitudinal studies have demonstrated a bidirectional influence between migraine and major depression, but not between migraine and other severe headache. Migraine is strongly and consistently associated with panic disorder. The risk of migraine in epilepsy is increased particularly in individuals with head trauma, partial seizures, and a positive family history of migraine. The influence is bidirectional. There is also growing evidence of an association between migraine and stroke, particularly among women of childbearing age and individuals who experience migraine with aura. Lastly, a bidirectional association between migraine and essential tremor also exists. These findings suggest that migraine, major depression, epilepsy, and essential tremor share one or more common etiologies. Clinicians should be mindful of them as they design treatment strategies, and also should consider the use of a single pharmacologic agent that is effective for all conditions.     

Psychological and Behavioral Issues in the Management of Migraine in Children and Adolescents

Purpose of Review

It is sometimes assumed that children and adolescents with migraine have a psychiatric or behavioral comorbidity, a belief that can be stigmatizing. This review will examine the recent literature addressing this area to determine if pediatric and adolescent migraineurs are at increased risk for psychiatric comorbidity and to discuss management strategies.

Recent Findings

A large systematic review of pediatric and adolescent studies concluded anxiety and depression were not associated with onset of recurrent headaches. Children with increasing migraine frequency have reduced school attendance. Pediatric migraineurs have mildly lower quality of life (QOL) scores than healthy peers but not abnormally low. Finally, children with higher migraine frequency as well as migraineurs with aura were more likely to report suicidal ideation.

Summary

Migraine is a primary neurologic disorder. Migraine and psychiatric disorders may be comorbid; however, at this time, it can be difficult to clearly delineate some migraine features from psychiatric diagnoses with the current screening tools available. The majority of pediatric migraineurs do not have behavioral comorbidities; however, when such comorbidities occur, they should be addressed and appropriately managed. We need more accurate ways of delineating psychiatric and behavioral comorbidities from the migraine phenotype.

     

Endometriosis is associated with prevalence of comorbid conditions in migraine

OBJECTIVE: To examine the headache characteristics of women with migraine and endometriosis (EM), and differences in the prevalence of comorbid conditions between female migraineurs with EM, without EM and nonheadache controls. BACKGROUND: Migraine and EM are common conditions in women of reproductive age, and both are influenced by ovarian hormones. The comorbidity of migraine and EM is newly recognized, but reasons for the association are uncertain. METHODS: This is a cross-sectional study of female headache outpatients and healthy controls conducted at University of Toledo and Duke University in 2005 and 2006. After a headache specialist determined headache frequency and diagnosis (based on criteria of the second International Classification of Headache Disorders), patients completed a self-administered electronic survey with information on demographics, headache-related disability, menstrual disorders, premenstrual dysphoric disorder (PMDD), vascular event risk, and comorbid conditions, including irritable bowel syndrome (IBS), fibromyalgia (FM), chronic fatigue syndrome (CFS), interstitial cystitis (IC), depression, and anxiety. RESULTS: Study enrolled 171 women with migraine and 104 controls. EM was reported more commonly in migraineurs than in controls (22% vs 9.6%, P < .01). Frequency of chronic headache was higher in migraineurs with EM compared to without EM (P= .002) and median headache-related disability scores were also higher in the EM group (P= .025). Symptoms of PMDD were more common in migraineurs, but frequency did not differ by EM status. Migraineurs with EM reported more menorrhagia, dysmenorrhea, and infertility compared to the migraine cohort without EM and to controls. Depression, anxiety, IBS, FM, CFS, and IC were more common in migraine with EM group than in controls. Anxiety (OR = 2.2, 95% CI 1.0-4.7), IC (OR = 10.6, 95% CI 1.9-56.5), and CFS (OR = 3.6, 95% CI 1.1-11.5) were more common in migraine with EM group, than in the cohort with migraine without EM. CONCLUSION: Prevalence of EM is higher in women with migraine than in nonheadache controls. Migraineurs with EM have more frequent and disabling headaches, and are more likely to have other comorbid conditions affecting mood and pain, compared to migraineurs without EM.     

Depression and anxiety: effect on the migraine-obesity relationship

OBJECTIVE: To discern the effects of depression and anxiety on the migraine-obesity relationship. BACKGROUND: Migraine and obesity are highly prevalent conditions and are both independently linked to psychiatric conditions, mainly depression and anxiety. METHODS: Data are from an ongoing cross-sectional multicenter study on comorbid conditions in clinic patients seeking treatment for headache. The diagnosis of migraine was determined by the examining physician based on the International Classification of Headache Disorders (ICHD)-II criteria. Participants completed a self-administered questionnaire with information on demographics, headache features, and physician-diagnosed comorbid medical and psychiatric disorders. The questionnaire included scales for measuring current depression (PHQ-9), anxiety (BAI), and headache-related disability (HIT-6). RESULTS: A total of 721 migraineurs (88% women) from 8 different headache treatment centers were included in this study (mean age = 42 years, SD = 12). Aura was reported in 45% and chronic headache (>or=15 headache days/month) in 35% of the participants. Prevalence of obesity in our population was 30% and only 38% had normal weight. Obesity was more common in men (P= .004), African Americans (P= .026), and in lower education (P= .05) and household income (P=.05) groups. Current depression (PHQ-9 score >or=10) was noted in 42% and current anxiety (BAI score >or=8) in 70% of the obese migraineurs. In ordinal logistic regression, obesity was associated with current depression (odds ratio [OR]= 1.86, 95% confidence interval [CI]: 1.25 to 2.78) and anxiety (OR = 1.58, 95% CI: 1.12 to 2.22). A significant effect of depression on the body mass index (BMI) and headache frequency relationship was noted. Obese migraineurs with depression were more likely to have higher headache frequency (OR = 4.16, 95% CI: 1.92 to 8.99) and headache-related disability (OR = 7.10, 95% CI: 2.69 to 18.77) compared to normal weight migraineurs without depression. Similarly, obese migraineurs with anxiety were more likely to have higher headache frequency (OR = 1.96, 95% CI: 1.07 to 3.61) and headache-related disability (OR = 3.59, 95% CI: 1.64 to 7.86) compared to normal weight migraineurs without depression. Compared to migraineurs with either current depression or anxiety, those with both these conditions were more likely to have higher headache frequency (OR = 3.18, 95% CI: 1.86 to 5.43) and headache disability (OR = 6.13, 95% CI: 2.58 to 14.59). CONCLUSION: Depression and anxiety were common in obese migraineurs. The relationship of obesity with migraine frequency and migraine-related disability is modified by depression and by anxiety, with the strongest effect observed in migraineurs with both depression and anxiety.     

Improving care through health economics analyses: cost of illness and headache

The impact of headache disorders is a problem of enormous proportions, both for individual and society. The medical literature tried to assess its effects on individuals, by examining prevalence, distribution, attack frequency and duration, and headache-related disability, as well as effects on society, looking at the socio-economic burden of headache disorders [Rasmussen (Cephalalgia 19:20-23, 1999)]; [Lanteri-Minet et al. (Pain 102:143-149, 2003)]. The issue of costs represents an important problem too, concerning both direct and indirect costs. Direct costs concern mainly expenses for drugs. Migraine has a considerable impact on functional capacity, resulting in disrupted work and social activities: many migraineurs do not seek medical attention because they have not been accurately diagnosed by a physician or do not use prescribed medication [Solomon and Price (Pharmacoeconomics 11:1-10, 1997)]. Indirect costs associated with reduced productivity represent a substantial proportion of the total cost of migraine as well. Migraine has a major impact on the working sector of the population, and therefore, determining the indirect costs outweighs the direct costs. This study will explain the notion of cost of illness, examining how it could be applied in such a framework. Then, an overview of the studies aimed at measuring direct and indirect costs of migraine and headache disorders will be carried out, later shifting on to the relationship between costs and quality of life for people affected by headache disorders. Finally, a brief review on advantages of new pharmaceuticals and preventive treatments for migraine for patients and society will outline improvements in the context of cost-effectiveness and cost-utility analysis.     

Recognition and therapeutic management of migraine in 2004, in France: results of FRAMIG 3, a French nationwide population-based survey

OBJECTIVE: To evaluate the proportion of migraineurs who are self-aware of their disease in France, to determine the factors (disability, quality of life, psychiatric comorbidities, and medical consultation) that may promote self-awareness of migraine, and to assess the influence of these factors on migraine attacks. BACKGROUND: New recommendations for migraine diagnosis and medical management were released in 2003 by the French medicoeconomic evaluation service (ANAES). In addition, the revised classification of headache disorders recently issued by the International Headache Society includes probable migraine as a form of migraine. However, strict and probable migraine now appear to be part of the same spectrum of disease. METHODS: Subjects with migraine (strict or probable) according to the revised classification were identified by a postal questionnaire from a large representative sample of the French adult population. Migraine-related disability was assessed using the MIDAS questionnaire, anxiety and depression by the Hospital Anxiety and Depression scale (HADS), and health-related quality of life (HRQoL) by the 8 concepts of the Short-Form 12 (SF-12) questionnaire. Migraine management was assessed according to the use of recommended or nonrecommended treatments, and treatment efficacy according to the set of 4 questions designed by the ANAES. RESULTS: Of the 10,532 subjects interviewed, 1,179 subjects (21.3%) were identified as migraineurs. Sixty percent of all migraine subjects were not self-aware that they had migraine. Medical consultation, duration of migraine history, severe intensity of attacks, impact on daily living, and female gender promoted self-awareness of migraine. On the other hand, HRQoL and anxiety and depression scores were not different between subjects self-aware or not self-aware of migraine. Only 20% of all migraine subjects were medically followed-up. Quality of the first medical consultation appears determinant for continued consulting. Subjects self-aware of migraine more frequently used recommended acute treatments of migraine, which proved more effective than nonrecommended treatments as assessed according to the ANAES set of questions. CONCLUSIONS: Migraine medical diagnosis and follow-up remain low in France. Careful medical consultation is a prime factor for migraine subject self-awareness of migraine, continued consultation, and use of recommended medications for the treatment of migraine attacks.     

Gabapentin in the treatment of migraine and epilepsy comorbid with mood and anxiety disorders

This open prospective study assessed the use of gabapentin in migraine and epilepsy comorbid with mood and anxiety disorders. After a 4-week baseline period, gabapentin was used as adjunctive treatment in 14 adult patients with both epilepsy and migraine disorders for 3 months. The outcomes were compared with a control group of 14 sex-matched patients with the same disorders, not treated with gabapentin. Both groups were assessed on the Cornell dysthymia rating scale (CDRS), Beck depression inventory (BDI), and Hamilton anxiety scale. A total of 8 (57%) gabapentin-treated patients showed a significant improvement in migraine vs. 3 (21.4%) of the controls. In comparison with controls, the gabapentin-treated group had a significant decrease in CDRS and BDI scores (p<0.05). The results suggest a particular role for gabapentin in the treatment of patients with both epilepsy and migraine comorbid with mood and anxiety disorders. Received: 19 January 2001 / Accepted in revised form: 6 July 2001