Bipolar Disorder and Migraines – Bipolar Disorder Center

People who have bipolar disorder have a greater chance of having migraine headaches than others. While the reason for this is not fully understood, experts have learned how to manage both conditions with the same approaches.

A migraine is a very painful, recurring type of headache that’s characterized by throbbing pain (often on only one side of the head), light sensitivity, nausea, and vomiting, and it’s more common among women — approximately 18 percent of women get migraines, compared with 7 percent of men.

The Connection Between Bipolar Disorder and Migraine

Between 25 and 40 percent of people who have bipolar disorder also have migraines. “They go side by side in the same person, but they don’t cause each other,” says Lawrence Robbins, MD, an assistant professor of neurology at Rush Medical College in Chicago and a headache specialist at the Robbins Headache Clinic in Northbrook, Ill. Dr. Robbins explains that the likely link is shared inherited brain chemistry, meaning that certain aspects of brain chemistry are the same for migraines and bipolar disorder.

Although the exact chemistry involved is not yet understood, it has been speculated that serotonin plays a role. Serotonin is a neurotransmitter, a chemical in the brain that transmits messages between nerve cells, and that also constricts blood vessels. Low serotonin levels have been linked with depression.

Lifestyle Factors That Affect Both Bipolar Disorder and Migraine

Bipolar disorder and migraine are linked in another way: They share common triggers, such as stress, anxiety, and sleep disruption.

“When I see a patient [with bipolar disorder] complaining about headaches, the most common reason is sleep disruption — something changed in the patient’s environment,” says Suresh Sureddi, MD, an assistant professor of psychiatry at the University of Texas Southwestern Medical Center in Dallas and a director of Lifepath Systems, a community mental health clinic in Plano, Texas. “It could be as simple as the person has gotten extremely stressed.” Indentifying and dealing with the stress and the changes in the patient’s sleep patterns, says Dr. Sureddi, “takes care of it most of the time.”

Other environmental factors can trigger a migraine as well, such as new medications or a change in medications, a new perfume or fragrance, or a food you’d previously avoided because of your migraines. If you have bipolar disorder and your migraines suddenly worsen, it’s important to let your doctor know whether you’ve made any such changes. Controlling these and other triggers may be a big help in managing your migraines.

How to Manage Bipolar Disorder and Migraine

Both bipolar disorder and migraine headaches can be managed with medications — and some medications can help with both conditions.

“We try to minimize medications, so with bipolar and migraines, we use treatments that could help both,” says Robbins. “Comorbidities [other conditions that coexist with bipolar disorder] determine where we go with migraine medications. With hypertension, for example, we would use hypertension medications.” This is because some antihypertensive medications can help prevent migraines. In addition to medications, many people see benefits from psychotherapy, exercise, cutting back on alcohol, and maintaining a regular sleep schedule.

Both mania and depression often bring with them anxiety, tension, and stress — some of the common triggers of migraines. “If your moods are unstable, address the core problem,” says Sureddi. “Getting your moods under control may in turn control your migraines, though some patients will need migraine medications as well.” Managing your bipolar symptoms in tandem with taking migraine meds may be the answer to relieving your pain.

Bipolar Affective Disorder and Migraine

Case Rep Med. 2012; 2012: 389851.

Department of Neurology, Fachklinikum Brandis, Am Wald, 04821 Brandis, Germany

Academic Editor: B. Carpiniello

Received 2012 Jan 2; Revised 2012 Mar 9; Accepted 2012 Mar 11.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC.

Abstract

This paper consists of a case history and an overview of the relationship, aetiology, and treatment of comorbid bipolar disorder migraine patients. A MEDLINE literature search was used. Terms for the search were bipolar disorder bipolar depression, mania, migraine, mood stabilizer. Bipolar disorder and migraine cooccur at a relatively high rate. Bipolar II patients seem to have a higher risk of comorbid migraine than bipolar I patients have. The literature on the common roots of migraine and bipolar disorder, including both genetic and neuropathological approaches, is broadly discussed. Moreover, bipolar disorder and migraine are often combined with a variety of other affective disorders, and, furthermore, behavioural factors also play a role in the origin and course of the diseases. Approach to treatment options is also difficult. Several papers point out possible remedies, for example, valproate, topiramate, which acts on both diseases, but no first-choice treatments have been agreed upon yet.

1. Introduction

Both bipolar disorder and migraine are not uncommon diseases. Whereas disorders of bipolar spectrum have an occurrence rate between 0.4 and 1.4% depending on different studies [1], migraine has rates from 10 to 30% [22]. More often than noticed, bipolar disorder occurs together with migraine. In a study of patients suffering from bipolar disorder (both type I and II), Ortiz et al. [2] found comorbid migraine in 24.5% of all bipolar cases and McIntyre et al. [3] of 24.8% (versus a general population rate of 10.3%). Contrary to that, Holland et al. [4] found a much lower prevalence of 4.7%. Nevertheless, comorbidity of both diseases seems to be an underestimated problem. In short, the main characteristics of bipolar disorder are recurrent episodes of depressive and manic states. Migraine is a usually unilateral headache often combined with nausea, photophobia, and others. As with bipolar disorder, migraine is divided into different subtypes, such as migraine with aura and without, or familial hemiplegic migraine among others.

2. Case History

A patient in his middle fifties has been suffering from mood disturbances since adolescence. The patient’s family history hints of “nerve diseases” of his mother and of his aunt and grandmother on the mother’s side. For several days, he was overactive and, as his brother once told him, “mad.” The patient, during his hyperactive phase, often tried to convince his brother to do wayward things. After some days of hyperactivity, the patient’s mood switched overnight to being deeply depressed, with avolition and a gloomy mood that lasted for many weeks. When this pattern first appeared, it occurred every one or two months; but, in its later appearances, the switching occurred monthly or within a fortnight. The patient never underwent therapy. At the age of 20, he had a head injury caused by an accident with his motorcycle. (More specific data about this event were not available.) After that, a migraine developed, which at first was never severe, and occurred four times a year. These early migraines occurred independently of his bipolar disorder. In the last ten years, however, the migraine became extremely severe on occasion and was linked to his bipolar disorder. The linkage is that manic states were always followed by migraine attacks with depressive mood. With these severe migraines, the patient experiences withdrawal, loss of interests, sleep disturbances, and recurrent suicidal fantasies. In addition to these migraines which follow after manic states, other migraines occur independently of manic states. In these last ten years, severe migraine attacks begin with aura symptoms such as a zigzag pattern in visual field, narrowing of visual field (tunnel view), blurred vision, and flashes. Then, speech arrest follows and palsy develops starting with lips, face, neck, and extremities, mostly on the right site. Anterograde amnesia follows on such a phase which lasts some hours in different degrees of severity. Speech arrest is usually the longest lasting symptom. Migraine headaches endure from 1 to 3 days. Manic states usually last a few days, depressive ones some weeks.

In recent, MRI scan was nothing abnormal detected. EEG in symptom-free intervals revealed an unstable alpha rhythm but no major changes. Routine laboratory data and parameters for thyroid gland, borreliosis, and lues showed no abnormalities.

In the case just described, the beginning of the bipolar disorder, presumably of type I, precedes the onset of migraine attacks. It is a migraine of a complicated type. In the differential, a familial hemiplegic migraine is possible.

3. Relationship between Migraine and Bipolar Disorder

The literature broadly supports comorbidity of migraine and bipolar disorder. Datta and Kumar [5] reported on a 19-year-old patient with hypomania as an aura of migraine. In a review, Antonaci et al. [6] unravelled a coincidence of migraine and affective anxiety disorders and, especially, a “trend towards an association of migraine and bipolar disorder” (see also [7]). Most studies support that migraine is associated not only with bipolar disorder but also with major depression, panic disorder, social phobia [8, 9], drug abuse [10], suicide, and neurological and internal diseases too, for instance stroke or hypertension [11]. Vice versa, according to a review of literature of McIntyre et al. [12], subjects with other neurological diseases, such as epilepsy or multiple sclerosis, seem to have a higher occurrence of bipolar disorder.

Are There Differences in Prevalence of Comorbidities? —

Dilsaver et al. [13] found a higher prevalence of migraine in bipolar patients than in those who suffer from major depressive disorder. In a study by Ortiz and colleagues [2], which distinguished bipolar I from bipolar II patients, a higher prevalence of migraine in bipolar II subjects was apparent and, in addition, higher rates were found for suicidal tendencies and anxiety disorders. Patients with a major depressive episode who had a family history of bipolar disorder had an increased risk of suffering from migraine [14]. Patients with unipolar depression and migraine have more depressive episodes in the course of time and more often a positive family history of migraine compared to those without comorbid migraine [15].

Does Migraine Influence the Course of Bipolar Disorder? —

According to Brietzke et al. [16], patients with both bipolar I and bipolar II disorder who suffer from comorbid migraine had more mood episodes, especially depressive ones. Furthermore, they found a higher occurrence rate of other psychiatric and general medical comorbidities.

4. Is There a Common Aetiology of Bipolar Disorder and Migraine?

Different gene regions are suspect as being responsible for association of bipolar disorder with migraine, but results in studies differ. One recent study [17] found no evidence that polymorphisms of the genes ANK3 and CACNA1C in migraine patients were associated with an elevated risk for bipolar disorder. Another recent study [18, 19], which investigated genomewide associations, found some gene regions which differed in bipolar patients depending on whether they were susceptible to migraine or not. Holland and Agius [20] saw “much overlap in neuropathological mechanisms” in both diseases. Besides genetics, they discussed altered expression of neurotrophic factors, cellular calcium physiology, endoplasmatic reticulum function, neuronal loss and pointed out the important question of sensitisation which is still controversially discussed: do recurrent episodes in either the diseases facilitate further ones?

Others bring up white matter hyperintensities for discussion. Gunde et al. [21] argued that high rates of such signs, detected in neuroimaging, play an important role both in bipolar disorder and migraine, and a substantial proportion of the hyperintensities would be related to the comorbidity of both diseases.

5. Treatment Options for Comorbid Bipolar/Migraine Patients

Although there are no evidence-based treatment suggestions for people with bipolar disorder and comorbid migraine, it seems reasonable that substances which act on both bipolar disorder and migraine could be used to ward off relapse. A problem in this approach is that the particular substances which are the drugs of choice for prophylactic treatment of migraine—the beta antagonists—could make depressive symptoms worse. On the other hand, valproate, which theoretically acts on both disorders, has only an off-label status in migraine prophylaxis [22]. Nevertheless, several papers see benefits from valproate and other substances. Finocchi et al. [23] suggested valproate and topiramate as a mood stabilizer in migraine without aura and lamotrigine in migraine with aura. Even amitriptyline could be used for prevention of mood episodes and migraine attacks. Serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are recommended in migraine patients for comorbid depression and anxiety. Caution should be exercised when triptans are combined with SSRIs or SNRIs because of a possible risk of serotonin syndrome [24].

In this vein, also neuroleptics which have already been used broadly as mood stabilizers are worth consideration, but, in relation to migraine, no sufficient studies exist [25]. Last but not least, the literature (see [26]) suggests that behavioural and cognitive-behavioural therapies are helpful for patients with a comorbid bipolar/migraine diagnosis.

6. Discussion

Migraine is an important comorbid disease in bipolar patients. It not only strengthens the cause of bipolar disorder but also worsens the recurrence rate with regard to depressive episodes. Bipolar II patients have a higher susceptibility of having comorbid migraine.

The literature survey with regard to the origins of both diseases indicates a variety of theories and working points. It is important to consider both the multifactor genesis of affective diseases and the influence of psychic disorders on neurological disorders such as migraine. We do not know yet whether bipolar disorder has causal or merely accidental connections with migraine. Nor do we know what organic or psychic conditions might exactly link the diseases, or why some patients have the comorbidities and others do not. Furthermore, many other psychic and neurological disorders can be comorbid with bipolar disorder.

There is no proven treatment regimen for migraine with comorbid bipolar disorder, so that pharmacological therapy is still a matter of trial and error. Nevertheless, some remedies seem to have effects on both of the diseases, but one must be wary of purchasing the benefit of a remedy in one disease by worsening the other.

References

1. Goodwin FK, Jamison KR. Manic-Depressive Illness. Oxford University Press; 2007. [Google Scholar]2. Ortiz A, Cervantes P, Zlotnik G, et al. Cross-prevalence of migraine and bipolar disorder. Bipolar Disorders. 2010;12(4):397–403. [PubMed] [Google Scholar]3. McIntyre RS, Konarski JZ, Wilkins K, Bouffard B, Soczynska JK, Kennedy SH. The prevalence and impact of migraine headache in bipolar disorder: results from the Canadian Community Health Survey. Headache. 2006;46(6):973–982. [PubMed] [Google Scholar]4. Holland J, Agius M, Zaman R. Prevalence of co-morbid bipolar disorder and migraine in a regional hospital psychiatric outpatient department. Psychiatria Danubina. 2011;23(supplement 1):S23–S24. [PubMed] [Google Scholar]5. Datta S, Kumar S. Hypomania as an aura in migraine. Neurology India. 2006;54(2):205–206. [PubMed] [Google Scholar]6. Antonaci F, Nappi G, Galli F, Manzoni GC, Calabresi P, Costa A. Migraine and psychiatric comorbidity: a review of clinical findings. Journal of Headache and Pain. 2011;12(2):115–125. [PMC free article] [PubMed] [Google Scholar]7. Jerrell JM, McIntyre RS, Tripathi A. A cohort study of the prevalence and impact of comorbid medical conditions in pediatric bipolar disorder. Journal of Clinical Psychiatry. 2010;71(11):1518–1525. [PubMed] [Google Scholar]8. Jette N, Patten S, Williams J, Becker W, Wiebe S. Comorbidity of migraine and psychiatric disorders—a national population-based study. Headache. 2008;48(4):501–516. [PubMed] [Google Scholar]9. Ratcliffe GE, Enns MW, Jacobi F, Belik SL, Sareen J. The relationship between migraine and mental disorders in a population-based sample. General Hospital Psychiatry. 2009;31(1):14–19. [PubMed] [Google Scholar]10. Pompili M, Di Cosimo D, Innamorati M, Lester D, Tatarelli R, Martelletti P. Psychiatric comorbidity in patients with chronic daily headache and migraine: a selective overview including personality traits and suicide risk. Journal of Headache and Pain. 2009;10(4):283–290. [PMC free article] [PubMed] [Google Scholar]11. Wang SJ, Chen PK, Fuh JL. Comorbidities of migraine. Frontiers in Neurology. 2010;1, article 16 [Google Scholar]12. McIntyre RS, Soczynska JK, Beyer JL, et al. Medical comorbidity in bipolar disorder: reprioritizing unmet needs. Current Opinion in Psychiatry. 2007;20(4):406–416. [PubMed] [Google Scholar]13. Dilsaver SC, Benazzi F, Oedegaard KJ, Fasmer OB, Akiskal KK, Akiskal HS. Migraine headache in affectively Ill Latino adults of Mexican American origin is associated with bipolarity. Primary Care Companion to the Journal of Clinical Psychiatry. 2009;11(6):302–306. [PMC free article] [PubMed] [Google Scholar]14. Dilsaver SC, Benazzi F, Oedegaard KJ, Fasmer OB, Akiskal HS. Is a family history of bipolar disorder a risk factor for migraine among affectively ill patients? Psychopathology. 2009;42(2):119–123. [PubMed] [Google Scholar]15. Oedegaard KJ, Fasmer OB. Is migraine in unipolar depressed patients a bipolar spectrum trait? Journal of Affective Disorders. 2005;84(2-3):233–242. [PubMed] [Google Scholar]16. Brietzke E, Moreira CL, Duarte SV, et al. Impact of comorbid migraine on the clinical course of bipolar disorder. Comprehensive Psychiatry. In press. [PubMed] [Google Scholar]17. Wöber-Bingöl Ç, Tropeano M, Karwautz A, et al. No association between bipolar disorder risk polymorphisms in ANK3 and CACNA1C and common migraine. Headache. 2011;51(5):796–803. [PubMed] [Google Scholar]18. Oedegaard KJ, Greenwood TA, Johansson S, et al. A genome-wide association study of bipolar disorder and comorbid migraine. Genes, Brain and Behavior. 2010;9(7):673–680. [PMC free article] [PubMed] [Google Scholar]19. Oedegaard KJ, Greenwood TA, Lunde A, et al. A genome-wide linkage study of bipolar disorder and co-morbid migraine: replication of migraine linkage on chromosome 4q24, and suggestion of an overlapping susceptibility region for both disorders on chromosome 20p11. Journal of Affective Disorders. 2010;122(1-2):14–26. [PMC free article] [PubMed] [Google Scholar]20. Holland J, Agius M. Neurobiology of bipolar disorder—lessons from migraine disorders. Psychiatria Danubina. 2011;23(supplement 1):S162–s165. [PubMed] [Google Scholar]21. Gunde E, Blagdon R, Hajek T. White matter hyperintensities: from medical comorbidities to bipolar disorders and back. Annals of Medicine. 2011;43(8):571–580. [PMC free article] [PubMed] [Google Scholar]22. Hufschmidt A, Lücking CH, editors. Neurologie Compact. Leitlinien für Klinik und Praxis. Stuttgart, Germany: Thieme; 2003. [Google Scholar]23. Finocchi C, Villani V, Casucci G. Therapeutic strategies in migraine patients with mood and anxiety disorders: clinical evidence. Neurological Sciences. 2010;31:S95–S98. [PubMed] [Google Scholar]24. Evans RW, Tepper SJ, Shapiro RE, Sun-Edelstein C, Tietjen GE. The FDA alert on serotonin syndrome with use of triptans combined with selective serotonin reuptake inhibitors or selective serotonin-norepinephrine reuptake inhibitors: American headache society position paper. Headache. 2010;50(6):1089–1099. [PubMed] [Google Scholar]25. Dusitanond P, Young WB. Neuroleptics and migraine. Central Nervous System Agents in Medicinal Chemistry. 2009;9(1):63–70. [PubMed] [Google Scholar]26. Baskin SM, Smitherman TA. Migraine and psychiatric disorders: comorbidities, mechanisms, and clinical applications. Neurological Sciences. 2009;30(1):S61–S65. [PubMed] [Google Scholar]

Bipolar Affective Disorder and Migraine

Case Rep Med. 2012; 2012: 389851.

Department of Neurology, Fachklinikum Brandis, Am Wald, 04821 Brandis, Germany

Academic Editor: B. Carpiniello

Received 2012 Jan 2; Revised 2012 Mar 9; Accepted 2012 Mar 11.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC.

Abstract

This paper consists of a case history and an overview of the relationship, aetiology, and treatment of comorbid bipolar disorder migraine patients. A MEDLINE literature search was used. Terms for the search were bipolar disorder bipolar depression, mania, migraine, mood stabilizer. Bipolar disorder and migraine cooccur at a relatively high rate. Bipolar II patients seem to have a higher risk of comorbid migraine than bipolar I patients have. The literature on the common roots of migraine and bipolar disorder, including both genetic and neuropathological approaches, is broadly discussed. Moreover, bipolar disorder and migraine are often combined with a variety of other affective disorders, and, furthermore, behavioural factors also play a role in the origin and course of the diseases. Approach to treatment options is also difficult. Several papers point out possible remedies, for example, valproate, topiramate, which acts on both diseases, but no first-choice treatments have been agreed upon yet.

1. Introduction

Both bipolar disorder and migraine are not uncommon diseases. Whereas disorders of bipolar spectrum have an occurrence rate between 0.4 and 1.4% depending on different studies [1], migraine has rates from 10 to 30% [22]. More often than noticed, bipolar disorder occurs together with migraine. In a study of patients suffering from bipolar disorder (both type I and II), Ortiz et al. [2] found comorbid migraine in 24.5% of all bipolar cases and McIntyre et al. [3] of 24.8% (versus a general population rate of 10.3%). Contrary to that, Holland et al. [4] found a much lower prevalence of 4.7%. Nevertheless, comorbidity of both diseases seems to be an underestimated problem. In short, the main characteristics of bipolar disorder are recurrent episodes of depressive and manic states. Migraine is a usually unilateral headache often combined with nausea, photophobia, and others. As with bipolar disorder, migraine is divided into different subtypes, such as migraine with aura and without, or familial hemiplegic migraine among others.

2. Case History

A patient in his middle fifties has been suffering from mood disturbances since adolescence. The patient’s family history hints of “nerve diseases” of his mother and of his aunt and grandmother on the mother’s side. For several days, he was overactive and, as his brother once told him, “mad.” The patient, during his hyperactive phase, often tried to convince his brother to do wayward things. After some days of hyperactivity, the patient’s mood switched overnight to being deeply depressed, with avolition and a gloomy mood that lasted for many weeks. When this pattern first appeared, it occurred every one or two months; but, in its later appearances, the switching occurred monthly or within a fortnight. The patient never underwent therapy. At the age of 20, he had a head injury caused by an accident with his motorcycle. (More specific data about this event were not available.) After that, a migraine developed, which at first was never severe, and occurred four times a year. These early migraines occurred independently of his bipolar disorder. In the last ten years, however, the migraine became extremely severe on occasion and was linked to his bipolar disorder. The linkage is that manic states were always followed by migraine attacks with depressive mood. With these severe migraines, the patient experiences withdrawal, loss of interests, sleep disturbances, and recurrent suicidal fantasies. In addition to these migraines which follow after manic states, other migraines occur independently of manic states. In these last ten years, severe migraine attacks begin with aura symptoms such as a zigzag pattern in visual field, narrowing of visual field (tunnel view), blurred vision, and flashes. Then, speech arrest follows and palsy develops starting with lips, face, neck, and extremities, mostly on the right site. Anterograde amnesia follows on such a phase which lasts some hours in different degrees of severity. Speech arrest is usually the longest lasting symptom. Migraine headaches endure from 1 to 3 days. Manic states usually last a few days, depressive ones some weeks.

In recent, MRI scan was nothing abnormal detected. EEG in symptom-free intervals revealed an unstable alpha rhythm but no major changes. Routine laboratory data and parameters for thyroid gland, borreliosis, and lues showed no abnormalities.

In the case just described, the beginning of the bipolar disorder, presumably of type I, precedes the onset of migraine attacks. It is a migraine of a complicated type. In the differential, a familial hemiplegic migraine is possible.

3. Relationship between Migraine and Bipolar Disorder

The literature broadly supports comorbidity of migraine and bipolar disorder. Datta and Kumar [5] reported on a 19-year-old patient with hypomania as an aura of migraine. In a review, Antonaci et al. [6] unravelled a coincidence of migraine and affective anxiety disorders and, especially, a “trend towards an association of migraine and bipolar disorder” (see also [7]). Most studies support that migraine is associated not only with bipolar disorder but also with major depression, panic disorder, social phobia [8, 9], drug abuse [10], suicide, and neurological and internal diseases too, for instance stroke or hypertension [11]. Vice versa, according to a review of literature of McIntyre et al. [12], subjects with other neurological diseases, such as epilepsy or multiple sclerosis, seem to have a higher occurrence of bipolar disorder.

Are There Differences in Prevalence of Comorbidities? —

Dilsaver et al. [13] found a higher prevalence of migraine in bipolar patients than in those who suffer from major depressive disorder. In a study by Ortiz and colleagues [2], which distinguished bipolar I from bipolar II patients, a higher prevalence of migraine in bipolar II subjects was apparent and, in addition, higher rates were found for suicidal tendencies and anxiety disorders. Patients with a major depressive episode who had a family history of bipolar disorder had an increased risk of suffering from migraine [14]. Patients with unipolar depression and migraine have more depressive episodes in the course of time and more often a positive family history of migraine compared to those without comorbid migraine [15].

Does Migraine Influence the Course of Bipolar Disorder? —

According to Brietzke et al. [16], patients with both bipolar I and bipolar II disorder who suffer from comorbid migraine had more mood episodes, especially depressive ones. Furthermore, they found a higher occurrence rate of other psychiatric and general medical comorbidities.

4. Is There a Common Aetiology of Bipolar Disorder and Migraine?

Different gene regions are suspect as being responsible for association of bipolar disorder with migraine, but results in studies differ. One recent study [17] found no evidence that polymorphisms of the genes ANK3 and CACNA1C in migraine patients were associated with an elevated risk for bipolar disorder. Another recent study [18, 19], which investigated genomewide associations, found some gene regions which differed in bipolar patients depending on whether they were susceptible to migraine or not. Holland and Agius [20] saw “much overlap in neuropathological mechanisms” in both diseases. Besides genetics, they discussed altered expression of neurotrophic factors, cellular calcium physiology, endoplasmatic reticulum function, neuronal loss and pointed out the important question of sensitisation which is still controversially discussed: do recurrent episodes in either the diseases facilitate further ones?

Others bring up white matter hyperintensities for discussion. Gunde et al. [21] argued that high rates of such signs, detected in neuroimaging, play an important role both in bipolar disorder and migraine, and a substantial proportion of the hyperintensities would be related to the comorbidity of both diseases.

5. Treatment Options for Comorbid Bipolar/Migraine Patients

Although there are no evidence-based treatment suggestions for people with bipolar disorder and comorbid migraine, it seems reasonable that substances which act on both bipolar disorder and migraine could be used to ward off relapse. A problem in this approach is that the particular substances which are the drugs of choice for prophylactic treatment of migraine—the beta antagonists—could make depressive symptoms worse. On the other hand, valproate, which theoretically acts on both disorders, has only an off-label status in migraine prophylaxis [22]. Nevertheless, several papers see benefits from valproate and other substances. Finocchi et al. [23] suggested valproate and topiramate as a mood stabilizer in migraine without aura and lamotrigine in migraine with aura. Even amitriptyline could be used for prevention of mood episodes and migraine attacks. Serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are recommended in migraine patients for comorbid depression and anxiety. Caution should be exercised when triptans are combined with SSRIs or SNRIs because of a possible risk of serotonin syndrome [24].

In this vein, also neuroleptics which have already been used broadly as mood stabilizers are worth consideration, but, in relation to migraine, no sufficient studies exist [25]. Last but not least, the literature (see [26]) suggests that behavioural and cognitive-behavioural therapies are helpful for patients with a comorbid bipolar/migraine diagnosis.

6. Discussion

Migraine is an important comorbid disease in bipolar patients. It not only strengthens the cause of bipolar disorder but also worsens the recurrence rate with regard to depressive episodes. Bipolar II patients have a higher susceptibility of having comorbid migraine.

The literature survey with regard to the origins of both diseases indicates a variety of theories and working points. It is important to consider both the multifactor genesis of affective diseases and the influence of psychic disorders on neurological disorders such as migraine. We do not know yet whether bipolar disorder has causal or merely accidental connections with migraine. Nor do we know what organic or psychic conditions might exactly link the diseases, or why some patients have the comorbidities and others do not. Furthermore, many other psychic and neurological disorders can be comorbid with bipolar disorder.

There is no proven treatment regimen for migraine with comorbid bipolar disorder, so that pharmacological therapy is still a matter of trial and error. Nevertheless, some remedies seem to have effects on both of the diseases, but one must be wary of purchasing the benefit of a remedy in one disease by worsening the other.

References

1. Goodwin FK, Jamison KR. Manic-Depressive Illness. Oxford University Press; 2007. [Google Scholar]2. Ortiz A, Cervantes P, Zlotnik G, et al. Cross-prevalence of migraine and bipolar disorder. Bipolar Disorders. 2010;12(4):397–403. [PubMed] [Google Scholar]3. McIntyre RS, Konarski JZ, Wilkins K, Bouffard B, Soczynska JK, Kennedy SH. The prevalence and impact of migraine headache in bipolar disorder: results from the Canadian Community Health Survey. Headache. 2006;46(6):973–982. [PubMed] [Google Scholar]4. Holland J, Agius M, Zaman R. Prevalence of co-morbid bipolar disorder and migraine in a regional hospital psychiatric outpatient department. Psychiatria Danubina. 2011;23(supplement 1):S23–S24. [PubMed] [Google Scholar]5. Datta S, Kumar S. Hypomania as an aura in migraine. Neurology India. 2006;54(2):205–206. [PubMed] [Google Scholar]6. Antonaci F, Nappi G, Galli F, Manzoni GC, Calabresi P, Costa A. Migraine and psychiatric comorbidity: a review of clinical findings. Journal of Headache and Pain. 2011;12(2):115–125. [PMC free article] [PubMed] [Google Scholar]7. Jerrell JM, McIntyre RS, Tripathi A. A cohort study of the prevalence and impact of comorbid medical conditions in pediatric bipolar disorder. Journal of Clinical Psychiatry. 2010;71(11):1518–1525. [PubMed] [Google Scholar]8. Jette N, Patten S, Williams J, Becker W, Wiebe S. Comorbidity of migraine and psychiatric disorders—a national population-based study. Headache. 2008;48(4):501–516. [PubMed] [Google Scholar]9. Ratcliffe GE, Enns MW, Jacobi F, Belik SL, Sareen J. The relationship between migraine and mental disorders in a population-based sample. General Hospital Psychiatry. 2009;31(1):14–19. [PubMed] [Google Scholar]10. Pompili M, Di Cosimo D, Innamorati M, Lester D, Tatarelli R, Martelletti P. Psychiatric comorbidity in patients with chronic daily headache and migraine: a selective overview including personality traits and suicide risk. Journal of Headache and Pain. 2009;10(4):283–290. [PMC free article] [PubMed] [Google Scholar]11. Wang SJ, Chen PK, Fuh JL. Comorbidities of migraine. Frontiers in Neurology. 2010;1, article 16 [Google Scholar]12. McIntyre RS, Soczynska JK, Beyer JL, et al. Medical comorbidity in bipolar disorder: reprioritizing unmet needs. Current Opinion in Psychiatry. 2007;20(4):406–416. [PubMed] [Google Scholar]13. Dilsaver SC, Benazzi F, Oedegaard KJ, Fasmer OB, Akiskal KK, Akiskal HS. Migraine headache in affectively Ill Latino adults of Mexican American origin is associated with bipolarity. Primary Care Companion to the Journal of Clinical Psychiatry. 2009;11(6):302–306. [PMC free article] [PubMed] [Google Scholar]14. Dilsaver SC, Benazzi F, Oedegaard KJ, Fasmer OB, Akiskal HS. Is a family history of bipolar disorder a risk factor for migraine among affectively ill patients? Psychopathology. 2009;42(2):119–123. [PubMed] [Google Scholar]15. Oedegaard KJ, Fasmer OB. Is migraine in unipolar depressed patients a bipolar spectrum trait? Journal of Affective Disorders. 2005;84(2-3):233–242. [PubMed] [Google Scholar]16. Brietzke E, Moreira CL, Duarte SV, et al. Impact of comorbid migraine on the clinical course of bipolar disorder. Comprehensive Psychiatry. In press. [PubMed] [Google Scholar]17. Wöber-Bingöl Ç, Tropeano M, Karwautz A, et al. No association between bipolar disorder risk polymorphisms in ANK3 and CACNA1C and common migraine. Headache. 2011;51(5):796–803. [PubMed] [Google Scholar]18. Oedegaard KJ, Greenwood TA, Johansson S, et al. A genome-wide association study of bipolar disorder and comorbid migraine. Genes, Brain and Behavior. 2010;9(7):673–680. [PMC free article] [PubMed] [Google Scholar]19. Oedegaard KJ, Greenwood TA, Lunde A, et al. A genome-wide linkage study of bipolar disorder and co-morbid migraine: replication of migraine linkage on chromosome 4q24, and suggestion of an overlapping susceptibility region for both disorders on chromosome 20p11. Journal of Affective Disorders. 2010;122(1-2):14–26. [PMC free article] [PubMed] [Google Scholar]20. Holland J, Agius M. Neurobiology of bipolar disorder—lessons from migraine disorders. Psychiatria Danubina. 2011;23(supplement 1):S162–s165. [PubMed] [Google Scholar]21. Gunde E, Blagdon R, Hajek T. White matter hyperintensities: from medical comorbidities to bipolar disorders and back. Annals of Medicine. 2011;43(8):571–580. [PMC free article] [PubMed] [Google Scholar]22. Hufschmidt A, Lücking CH, editors. Neurologie Compact. Leitlinien für Klinik und Praxis. Stuttgart, Germany: Thieme; 2003. [Google Scholar]23. Finocchi C, Villani V, Casucci G. Therapeutic strategies in migraine patients with mood and anxiety disorders: clinical evidence. Neurological Sciences. 2010;31:S95–S98. [PubMed] [Google Scholar]24. Evans RW, Tepper SJ, Shapiro RE, Sun-Edelstein C, Tietjen GE. The FDA alert on serotonin syndrome with use of triptans combined with selective serotonin reuptake inhibitors or selective serotonin-norepinephrine reuptake inhibitors: American headache society position paper. Headache. 2010;50(6):1089–1099. [PubMed] [Google Scholar]25. Dusitanond P, Young WB. Neuroleptics and migraine. Central Nervous System Agents in Medicinal Chemistry. 2009;9(1):63–70. [PubMed] [Google Scholar]26. Baskin SM, Smitherman TA. Migraine and psychiatric disorders: comorbidities, mechanisms, and clinical applications. Neurological Sciences. 2009;30(1):S61–S65. [PubMed] [Google Scholar]

Bipolar Affective Disorder and Migraine

Case Rep Med. 2012; 2012: 389851.

Department of Neurology, Fachklinikum Brandis, Am Wald, 04821 Brandis, Germany

Academic Editor: B. Carpiniello

Received 2012 Jan 2; Revised 2012 Mar 9; Accepted 2012 Mar 11.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC.

Abstract

This paper consists of a case history and an overview of the relationship, aetiology, and treatment of comorbid bipolar disorder migraine patients. A MEDLINE literature search was used. Terms for the search were bipolar disorder bipolar depression, mania, migraine, mood stabilizer. Bipolar disorder and migraine cooccur at a relatively high rate. Bipolar II patients seem to have a higher risk of comorbid migraine than bipolar I patients have. The literature on the common roots of migraine and bipolar disorder, including both genetic and neuropathological approaches, is broadly discussed. Moreover, bipolar disorder and migraine are often combined with a variety of other affective disorders, and, furthermore, behavioural factors also play a role in the origin and course of the diseases. Approach to treatment options is also difficult. Several papers point out possible remedies, for example, valproate, topiramate, which acts on both diseases, but no first-choice treatments have been agreed upon yet.

1. Introduction

Both bipolar disorder and migraine are not uncommon diseases. Whereas disorders of bipolar spectrum have an occurrence rate between 0.4 and 1.4% depending on different studies [1], migraine has rates from 10 to 30% [22]. More often than noticed, bipolar disorder occurs together with migraine. In a study of patients suffering from bipolar disorder (both type I and II), Ortiz et al. [2] found comorbid migraine in 24.5% of all bipolar cases and McIntyre et al. [3] of 24.8% (versus a general population rate of 10.3%). Contrary to that, Holland et al. [4] found a much lower prevalence of 4.7%. Nevertheless, comorbidity of both diseases seems to be an underestimated problem. In short, the main characteristics of bipolar disorder are recurrent episodes of depressive and manic states. Migraine is a usually unilateral headache often combined with nausea, photophobia, and others. As with bipolar disorder, migraine is divided into different subtypes, such as migraine with aura and without, or familial hemiplegic migraine among others.

2. Case History

A patient in his middle fifties has been suffering from mood disturbances since adolescence. The patient’s family history hints of “nerve diseases” of his mother and of his aunt and grandmother on the mother’s side. For several days, he was overactive and, as his brother once told him, “mad.” The patient, during his hyperactive phase, often tried to convince his brother to do wayward things. After some days of hyperactivity, the patient’s mood switched overnight to being deeply depressed, with avolition and a gloomy mood that lasted for many weeks. When this pattern first appeared, it occurred every one or two months; but, in its later appearances, the switching occurred monthly or within a fortnight. The patient never underwent therapy. At the age of 20, he had a head injury caused by an accident with his motorcycle. (More specific data about this event were not available.) After that, a migraine developed, which at first was never severe, and occurred four times a year. These early migraines occurred independently of his bipolar disorder. In the last ten years, however, the migraine became extremely severe on occasion and was linked to his bipolar disorder. The linkage is that manic states were always followed by migraine attacks with depressive mood. With these severe migraines, the patient experiences withdrawal, loss of interests, sleep disturbances, and recurrent suicidal fantasies. In addition to these migraines which follow after manic states, other migraines occur independently of manic states. In these last ten years, severe migraine attacks begin with aura symptoms such as a zigzag pattern in visual field, narrowing of visual field (tunnel view), blurred vision, and flashes. Then, speech arrest follows and palsy develops starting with lips, face, neck, and extremities, mostly on the right site. Anterograde amnesia follows on such a phase which lasts some hours in different degrees of severity. Speech arrest is usually the longest lasting symptom. Migraine headaches endure from 1 to 3 days. Manic states usually last a few days, depressive ones some weeks.

In recent, MRI scan was nothing abnormal detected. EEG in symptom-free intervals revealed an unstable alpha rhythm but no major changes. Routine laboratory data and parameters for thyroid gland, borreliosis, and lues showed no abnormalities.

In the case just described, the beginning of the bipolar disorder, presumably of type I, precedes the onset of migraine attacks. It is a migraine of a complicated type. In the differential, a familial hemiplegic migraine is possible.

3. Relationship between Migraine and Bipolar Disorder

The literature broadly supports comorbidity of migraine and bipolar disorder. Datta and Kumar [5] reported on a 19-year-old patient with hypomania as an aura of migraine. In a review, Antonaci et al. [6] unravelled a coincidence of migraine and affective anxiety disorders and, especially, a “trend towards an association of migraine and bipolar disorder” (see also [7]). Most studies support that migraine is associated not only with bipolar disorder but also with major depression, panic disorder, social phobia [8, 9], drug abuse [10], suicide, and neurological and internal diseases too, for instance stroke or hypertension [11]. Vice versa, according to a review of literature of McIntyre et al. [12], subjects with other neurological diseases, such as epilepsy or multiple sclerosis, seem to have a higher occurrence of bipolar disorder.

Are There Differences in Prevalence of Comorbidities? —

Dilsaver et al. [13] found a higher prevalence of migraine in bipolar patients than in those who suffer from major depressive disorder. In a study by Ortiz and colleagues [2], which distinguished bipolar I from bipolar II patients, a higher prevalence of migraine in bipolar II subjects was apparent and, in addition, higher rates were found for suicidal tendencies and anxiety disorders. Patients with a major depressive episode who had a family history of bipolar disorder had an increased risk of suffering from migraine [14]. Patients with unipolar depression and migraine have more depressive episodes in the course of time and more often a positive family history of migraine compared to those without comorbid migraine [15].

Does Migraine Influence the Course of Bipolar Disorder? —

According to Brietzke et al. [16], patients with both bipolar I and bipolar II disorder who suffer from comorbid migraine had more mood episodes, especially depressive ones. Furthermore, they found a higher occurrence rate of other psychiatric and general medical comorbidities.

4. Is There a Common Aetiology of Bipolar Disorder and Migraine?

Different gene regions are suspect as being responsible for association of bipolar disorder with migraine, but results in studies differ. One recent study [17] found no evidence that polymorphisms of the genes ANK3 and CACNA1C in migraine patients were associated with an elevated risk for bipolar disorder. Another recent study [18, 19], which investigated genomewide associations, found some gene regions which differed in bipolar patients depending on whether they were susceptible to migraine or not. Holland and Agius [20] saw “much overlap in neuropathological mechanisms” in both diseases. Besides genetics, they discussed altered expression of neurotrophic factors, cellular calcium physiology, endoplasmatic reticulum function, neuronal loss and pointed out the important question of sensitisation which is still controversially discussed: do recurrent episodes in either the diseases facilitate further ones?

Others bring up white matter hyperintensities for discussion. Gunde et al. [21] argued that high rates of such signs, detected in neuroimaging, play an important role both in bipolar disorder and migraine, and a substantial proportion of the hyperintensities would be related to the comorbidity of both diseases.

5. Treatment Options for Comorbid Bipolar/Migraine Patients

Although there are no evidence-based treatment suggestions for people with bipolar disorder and comorbid migraine, it seems reasonable that substances which act on both bipolar disorder and migraine could be used to ward off relapse. A problem in this approach is that the particular substances which are the drugs of choice for prophylactic treatment of migraine—the beta antagonists—could make depressive symptoms worse. On the other hand, valproate, which theoretically acts on both disorders, has only an off-label status in migraine prophylaxis [22]. Nevertheless, several papers see benefits from valproate and other substances. Finocchi et al. [23] suggested valproate and topiramate as a mood stabilizer in migraine without aura and lamotrigine in migraine with aura. Even amitriptyline could be used for prevention of mood episodes and migraine attacks. Serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are recommended in migraine patients for comorbid depression and anxiety. Caution should be exercised when triptans are combined with SSRIs or SNRIs because of a possible risk of serotonin syndrome [24].

In this vein, also neuroleptics which have already been used broadly as mood stabilizers are worth consideration, but, in relation to migraine, no sufficient studies exist [25]. Last but not least, the literature (see [26]) suggests that behavioural and cognitive-behavioural therapies are helpful for patients with a comorbid bipolar/migraine diagnosis.

6. Discussion

Migraine is an important comorbid disease in bipolar patients. It not only strengthens the cause of bipolar disorder but also worsens the recurrence rate with regard to depressive episodes. Bipolar II patients have a higher susceptibility of having comorbid migraine.

The literature survey with regard to the origins of both diseases indicates a variety of theories and working points. It is important to consider both the multifactor genesis of affective diseases and the influence of psychic disorders on neurological disorders such as migraine. We do not know yet whether bipolar disorder has causal or merely accidental connections with migraine. Nor do we know what organic or psychic conditions might exactly link the diseases, or why some patients have the comorbidities and others do not. Furthermore, many other psychic and neurological disorders can be comorbid with bipolar disorder.

There is no proven treatment regimen for migraine with comorbid bipolar disorder, so that pharmacological therapy is still a matter of trial and error. Nevertheless, some remedies seem to have effects on both of the diseases, but one must be wary of purchasing the benefit of a remedy in one disease by worsening the other.

References

1. Goodwin FK, Jamison KR. Manic-Depressive Illness. Oxford University Press; 2007. [Google Scholar]2. Ortiz A, Cervantes P, Zlotnik G, et al. Cross-prevalence of migraine and bipolar disorder. Bipolar Disorders. 2010;12(4):397–403. [PubMed] [Google Scholar]3. McIntyre RS, Konarski JZ, Wilkins K, Bouffard B, Soczynska JK, Kennedy SH. The prevalence and impact of migraine headache in bipolar disorder: results from the Canadian Community Health Survey. Headache. 2006;46(6):973–982. [PubMed] [Google Scholar]4. Holland J, Agius M, Zaman R. Prevalence of co-morbid bipolar disorder and migraine in a regional hospital psychiatric outpatient department. Psychiatria Danubina. 2011;23(supplement 1):S23–S24. [PubMed] [Google Scholar]5. Datta S, Kumar S. Hypomania as an aura in migraine. Neurology India. 2006;54(2):205–206. [PubMed] [Google Scholar]6. Antonaci F, Nappi G, Galli F, Manzoni GC, Calabresi P, Costa A. Migraine and psychiatric comorbidity: a review of clinical findings. Journal of Headache and Pain. 2011;12(2):115–125. [PMC free article] [PubMed] [Google Scholar]7. Jerrell JM, McIntyre RS, Tripathi A. A cohort study of the prevalence and impact of comorbid medical conditions in pediatric bipolar disorder. Journal of Clinical Psychiatry. 2010;71(11):1518–1525. [PubMed] [Google Scholar]8. Jette N, Patten S, Williams J, Becker W, Wiebe S. Comorbidity of migraine and psychiatric disorders—a national population-based study. Headache. 2008;48(4):501–516. [PubMed] [Google Scholar]9. Ratcliffe GE, Enns MW, Jacobi F, Belik SL, Sareen J. The relationship between migraine and mental disorders in a population-based sample. General Hospital Psychiatry. 2009;31(1):14–19. [PubMed] [Google Scholar]10. Pompili M, Di Cosimo D, Innamorati M, Lester D, Tatarelli R, Martelletti P. Psychiatric comorbidity in patients with chronic daily headache and migraine: a selective overview including personality traits and suicide risk. Journal of Headache and Pain. 2009;10(4):283–290. [PMC free article] [PubMed] [Google Scholar]11. Wang SJ, Chen PK, Fuh JL. Comorbidities of migraine. Frontiers in Neurology. 2010;1, article 16 [Google Scholar]12. McIntyre RS, Soczynska JK, Beyer JL, et al. Medical comorbidity in bipolar disorder: reprioritizing unmet needs. Current Opinion in Psychiatry. 2007;20(4):406–416. [PubMed] [Google Scholar]13. Dilsaver SC, Benazzi F, Oedegaard KJ, Fasmer OB, Akiskal KK, Akiskal HS. Migraine headache in affectively Ill Latino adults of Mexican American origin is associated with bipolarity. Primary Care Companion to the Journal of Clinical Psychiatry. 2009;11(6):302–306. [PMC free article] [PubMed] [Google Scholar]14. Dilsaver SC, Benazzi F, Oedegaard KJ, Fasmer OB, Akiskal HS. Is a family history of bipolar disorder a risk factor for migraine among affectively ill patients? Psychopathology. 2009;42(2):119–123. [PubMed] [Google Scholar]15. Oedegaard KJ, Fasmer OB. Is migraine in unipolar depressed patients a bipolar spectrum trait? Journal of Affective Disorders. 2005;84(2-3):233–242. [PubMed] [Google Scholar]16. Brietzke E, Moreira CL, Duarte SV, et al. Impact of comorbid migraine on the clinical course of bipolar disorder. Comprehensive Psychiatry. In press. [PubMed] [Google Scholar]17. Wöber-Bingöl Ç, Tropeano M, Karwautz A, et al. No association between bipolar disorder risk polymorphisms in ANK3 and CACNA1C and common migraine. Headache. 2011;51(5):796–803. [PubMed] [Google Scholar]18. Oedegaard KJ, Greenwood TA, Johansson S, et al. A genome-wide association study of bipolar disorder and comorbid migraine. Genes, Brain and Behavior. 2010;9(7):673–680. [PMC free article] [PubMed] [Google Scholar]19. Oedegaard KJ, Greenwood TA, Lunde A, et al. A genome-wide linkage study of bipolar disorder and co-morbid migraine: replication of migraine linkage on chromosome 4q24, and suggestion of an overlapping susceptibility region for both disorders on chromosome 20p11. Journal of Affective Disorders. 2010;122(1-2):14–26. [PMC free article] [PubMed] [Google Scholar]20. Holland J, Agius M. Neurobiology of bipolar disorder—lessons from migraine disorders. Psychiatria Danubina. 2011;23(supplement 1):S162–s165. [PubMed] [Google Scholar]21. Gunde E, Blagdon R, Hajek T. White matter hyperintensities: from medical comorbidities to bipolar disorders and back. Annals of Medicine. 2011;43(8):571–580. [PMC free article] [PubMed] [Google Scholar]22. Hufschmidt A, Lücking CH, editors. Neurologie Compact. Leitlinien für Klinik und Praxis. Stuttgart, Germany: Thieme; 2003. [Google Scholar]23. Finocchi C, Villani V, Casucci G. Therapeutic strategies in migraine patients with mood and anxiety disorders: clinical evidence. Neurological Sciences. 2010;31:S95–S98. [PubMed] [Google Scholar]24. Evans RW, Tepper SJ, Shapiro RE, Sun-Edelstein C, Tietjen GE. The FDA alert on serotonin syndrome with use of triptans combined with selective serotonin reuptake inhibitors or selective serotonin-norepinephrine reuptake inhibitors: American headache society position paper. Headache. 2010;50(6):1089–1099. [PubMed] [Google Scholar]25. Dusitanond P, Young WB. Neuroleptics and migraine. Central Nervous System Agents in Medicinal Chemistry. 2009;9(1):63–70. [PubMed] [Google Scholar]26. Baskin SM, Smitherman TA. Migraine and psychiatric disorders: comorbidities, mechanisms, and clinical applications. Neurological Sciences. 2009;30(1):S61–S65. [PubMed] [Google Scholar]

Bipolar Affective Disorder and Migraine

Case Rep Med. 2012; 2012: 389851.

Department of Neurology, Fachklinikum Brandis, Am Wald, 04821 Brandis, Germany

Academic Editor: B. Carpiniello

Received 2012 Jan 2; Revised 2012 Mar 9; Accepted 2012 Mar 11.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC.

Abstract

This paper consists of a case history and an overview of the relationship, aetiology, and treatment of comorbid bipolar disorder migraine patients. A MEDLINE literature search was used. Terms for the search were bipolar disorder bipolar depression, mania, migraine, mood stabilizer. Bipolar disorder and migraine cooccur at a relatively high rate. Bipolar II patients seem to have a higher risk of comorbid migraine than bipolar I patients have. The literature on the common roots of migraine and bipolar disorder, including both genetic and neuropathological approaches, is broadly discussed. Moreover, bipolar disorder and migraine are often combined with a variety of other affective disorders, and, furthermore, behavioural factors also play a role in the origin and course of the diseases. Approach to treatment options is also difficult. Several papers point out possible remedies, for example, valproate, topiramate, which acts on both diseases, but no first-choice treatments have been agreed upon yet.

1. Introduction

Both bipolar disorder and migraine are not uncommon diseases. Whereas disorders of bipolar spectrum have an occurrence rate between 0.4 and 1.4% depending on different studies [1], migraine has rates from 10 to 30% [22]. More often than noticed, bipolar disorder occurs together with migraine. In a study of patients suffering from bipolar disorder (both type I and II), Ortiz et al. [2] found comorbid migraine in 24.5% of all bipolar cases and McIntyre et al. [3] of 24.8% (versus a general population rate of 10.3%). Contrary to that, Holland et al. [4] found a much lower prevalence of 4.7%. Nevertheless, comorbidity of both diseases seems to be an underestimated problem. In short, the main characteristics of bipolar disorder are recurrent episodes of depressive and manic states. Migraine is a usually unilateral headache often combined with nausea, photophobia, and others. As with bipolar disorder, migraine is divided into different subtypes, such as migraine with aura and without, or familial hemiplegic migraine among others.

2. Case History

A patient in his middle fifties has been suffering from mood disturbances since adolescence. The patient’s family history hints of “nerve diseases” of his mother and of his aunt and grandmother on the mother’s side. For several days, he was overactive and, as his brother once told him, “mad.” The patient, during his hyperactive phase, often tried to convince his brother to do wayward things. After some days of hyperactivity, the patient’s mood switched overnight to being deeply depressed, with avolition and a gloomy mood that lasted for many weeks. When this pattern first appeared, it occurred every one or two months; but, in its later appearances, the switching occurred monthly or within a fortnight. The patient never underwent therapy. At the age of 20, he had a head injury caused by an accident with his motorcycle. (More specific data about this event were not available.) After that, a migraine developed, which at first was never severe, and occurred four times a year. These early migraines occurred independently of his bipolar disorder. In the last ten years, however, the migraine became extremely severe on occasion and was linked to his bipolar disorder. The linkage is that manic states were always followed by migraine attacks with depressive mood. With these severe migraines, the patient experiences withdrawal, loss of interests, sleep disturbances, and recurrent suicidal fantasies. In addition to these migraines which follow after manic states, other migraines occur independently of manic states. In these last ten years, severe migraine attacks begin with aura symptoms such as a zigzag pattern in visual field, narrowing of visual field (tunnel view), blurred vision, and flashes. Then, speech arrest follows and palsy develops starting with lips, face, neck, and extremities, mostly on the right site. Anterograde amnesia follows on such a phase which lasts some hours in different degrees of severity. Speech arrest is usually the longest lasting symptom. Migraine headaches endure from 1 to 3 days. Manic states usually last a few days, depressive ones some weeks.

In recent, MRI scan was nothing abnormal detected. EEG in symptom-free intervals revealed an unstable alpha rhythm but no major changes. Routine laboratory data and parameters for thyroid gland, borreliosis, and lues showed no abnormalities.

In the case just described, the beginning of the bipolar disorder, presumably of type I, precedes the onset of migraine attacks. It is a migraine of a complicated type. In the differential, a familial hemiplegic migraine is possible.

3. Relationship between Migraine and Bipolar Disorder

The literature broadly supports comorbidity of migraine and bipolar disorder. Datta and Kumar [5] reported on a 19-year-old patient with hypomania as an aura of migraine. In a review, Antonaci et al. [6] unravelled a coincidence of migraine and affective anxiety disorders and, especially, a “trend towards an association of migraine and bipolar disorder” (see also [7]). Most studies support that migraine is associated not only with bipolar disorder but also with major depression, panic disorder, social phobia [8, 9], drug abuse [10], suicide, and neurological and internal diseases too, for instance stroke or hypertension [11]. Vice versa, according to a review of literature of McIntyre et al. [12], subjects with other neurological diseases, such as epilepsy or multiple sclerosis, seem to have a higher occurrence of bipolar disorder.

Are There Differences in Prevalence of Comorbidities? —

Dilsaver et al. [13] found a higher prevalence of migraine in bipolar patients than in those who suffer from major depressive disorder. In a study by Ortiz and colleagues [2], which distinguished bipolar I from bipolar II patients, a higher prevalence of migraine in bipolar II subjects was apparent and, in addition, higher rates were found for suicidal tendencies and anxiety disorders. Patients with a major depressive episode who had a family history of bipolar disorder had an increased risk of suffering from migraine [14]. Patients with unipolar depression and migraine have more depressive episodes in the course of time and more often a positive family history of migraine compared to those without comorbid migraine [15].

Does Migraine Influence the Course of Bipolar Disorder? —

According to Brietzke et al. [16], patients with both bipolar I and bipolar II disorder who suffer from comorbid migraine had more mood episodes, especially depressive ones. Furthermore, they found a higher occurrence rate of other psychiatric and general medical comorbidities.

4. Is There a Common Aetiology of Bipolar Disorder and Migraine?

Different gene regions are suspect as being responsible for association of bipolar disorder with migraine, but results in studies differ. One recent study [17] found no evidence that polymorphisms of the genes ANK3 and CACNA1C in migraine patients were associated with an elevated risk for bipolar disorder. Another recent study [18, 19], which investigated genomewide associations, found some gene regions which differed in bipolar patients depending on whether they were susceptible to migraine or not. Holland and Agius [20] saw “much overlap in neuropathological mechanisms” in both diseases. Besides genetics, they discussed altered expression of neurotrophic factors, cellular calcium physiology, endoplasmatic reticulum function, neuronal loss and pointed out the important question of sensitisation which is still controversially discussed: do recurrent episodes in either the diseases facilitate further ones?

Others bring up white matter hyperintensities for discussion. Gunde et al. [21] argued that high rates of such signs, detected in neuroimaging, play an important role both in bipolar disorder and migraine, and a substantial proportion of the hyperintensities would be related to the comorbidity of both diseases.

5. Treatment Options for Comorbid Bipolar/Migraine Patients

Although there are no evidence-based treatment suggestions for people with bipolar disorder and comorbid migraine, it seems reasonable that substances which act on both bipolar disorder and migraine could be used to ward off relapse. A problem in this approach is that the particular substances which are the drugs of choice for prophylactic treatment of migraine—the beta antagonists—could make depressive symptoms worse. On the other hand, valproate, which theoretically acts on both disorders, has only an off-label status in migraine prophylaxis [22]. Nevertheless, several papers see benefits from valproate and other substances. Finocchi et al. [23] suggested valproate and topiramate as a mood stabilizer in migraine without aura and lamotrigine in migraine with aura. Even amitriptyline could be used for prevention of mood episodes and migraine attacks. Serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are recommended in migraine patients for comorbid depression and anxiety. Caution should be exercised when triptans are combined with SSRIs or SNRIs because of a possible risk of serotonin syndrome [24].

In this vein, also neuroleptics which have already been used broadly as mood stabilizers are worth consideration, but, in relation to migraine, no sufficient studies exist [25]. Last but not least, the literature (see [26]) suggests that behavioural and cognitive-behavioural therapies are helpful for patients with a comorbid bipolar/migraine diagnosis.

6. Discussion

Migraine is an important comorbid disease in bipolar patients. It not only strengthens the cause of bipolar disorder but also worsens the recurrence rate with regard to depressive episodes. Bipolar II patients have a higher susceptibility of having comorbid migraine.

The literature survey with regard to the origins of both diseases indicates a variety of theories and working points. It is important to consider both the multifactor genesis of affective diseases and the influence of psychic disorders on neurological disorders such as migraine. We do not know yet whether bipolar disorder has causal or merely accidental connections with migraine. Nor do we know what organic or psychic conditions might exactly link the diseases, or why some patients have the comorbidities and others do not. Furthermore, many other psychic and neurological disorders can be comorbid with bipolar disorder.

There is no proven treatment regimen for migraine with comorbid bipolar disorder, so that pharmacological therapy is still a matter of trial and error. Nevertheless, some remedies seem to have effects on both of the diseases, but one must be wary of purchasing the benefit of a remedy in one disease by worsening the other.

References

1. Goodwin FK, Jamison KR. Manic-Depressive Illness. Oxford University Press; 2007. [Google Scholar]2. Ortiz A, Cervantes P, Zlotnik G, et al. Cross-prevalence of migraine and bipolar disorder. Bipolar Disorders. 2010;12(4):397–403. [PubMed] [Google Scholar]3. McIntyre RS, Konarski JZ, Wilkins K, Bouffard B, Soczynska JK, Kennedy SH. The prevalence and impact of migraine headache in bipolar disorder: results from the Canadian Community Health Survey. Headache. 2006;46(6):973–982. [PubMed] [Google Scholar]4. Holland J, Agius M, Zaman R. Prevalence of co-morbid bipolar disorder and migraine in a regional hospital psychiatric outpatient department. Psychiatria Danubina. 2011;23(supplement 1):S23–S24. [PubMed] [Google Scholar]5. Datta S, Kumar S. Hypomania as an aura in migraine. Neurology India. 2006;54(2):205–206. [PubMed] [Google Scholar]6. Antonaci F, Nappi G, Galli F, Manzoni GC, Calabresi P, Costa A. Migraine and psychiatric comorbidity: a review of clinical findings. Journal of Headache and Pain. 2011;12(2):115–125. [PMC free article] [PubMed] [Google Scholar]7. Jerrell JM, McIntyre RS, Tripathi A. A cohort study of the prevalence and impact of comorbid medical conditions in pediatric bipolar disorder. Journal of Clinical Psychiatry. 2010;71(11):1518–1525. [PubMed] [Google Scholar]8. Jette N, Patten S, Williams J, Becker W, Wiebe S. Comorbidity of migraine and psychiatric disorders—a national population-based study. Headache. 2008;48(4):501–516. [PubMed] [Google Scholar]9. Ratcliffe GE, Enns MW, Jacobi F, Belik SL, Sareen J. The relationship between migraine and mental disorders in a population-based sample. General Hospital Psychiatry. 2009;31(1):14–19. [PubMed] [Google Scholar]10. Pompili M, Di Cosimo D, Innamorati M, Lester D, Tatarelli R, Martelletti P. Psychiatric comorbidity in patients with chronic daily headache and migraine: a selective overview including personality traits and suicide risk. Journal of Headache and Pain. 2009;10(4):283–290. [PMC free article] [PubMed] [Google Scholar]11. Wang SJ, Chen PK, Fuh JL. Comorbidities of migraine. Frontiers in Neurology. 2010;1, article 16 [Google Scholar]12. McIntyre RS, Soczynska JK, Beyer JL, et al. Medical comorbidity in bipolar disorder: reprioritizing unmet needs. Current Opinion in Psychiatry. 2007;20(4):406–416. [PubMed] [Google Scholar]13. Dilsaver SC, Benazzi F, Oedegaard KJ, Fasmer OB, Akiskal KK, Akiskal HS. Migraine headache in affectively Ill Latino adults of Mexican American origin is associated with bipolarity. Primary Care Companion to the Journal of Clinical Psychiatry. 2009;11(6):302–306. [PMC free article] [PubMed] [Google Scholar]14. Dilsaver SC, Benazzi F, Oedegaard KJ, Fasmer OB, Akiskal HS. Is a family history of bipolar disorder a risk factor for migraine among affectively ill patients? Psychopathology. 2009;42(2):119–123. [PubMed] [Google Scholar]15. Oedegaard KJ, Fasmer OB. Is migraine in unipolar depressed patients a bipolar spectrum trait? Journal of Affective Disorders. 2005;84(2-3):233–242. [PubMed] [Google Scholar]16. Brietzke E, Moreira CL, Duarte SV, et al. Impact of comorbid migraine on the clinical course of bipolar disorder. Comprehensive Psychiatry. In press. [PubMed] [Google Scholar]17. Wöber-Bingöl Ç, Tropeano M, Karwautz A, et al. No association between bipolar disorder risk polymorphisms in ANK3 and CACNA1C and common migraine. Headache. 2011;51(5):796–803. [PubMed] [Google Scholar]18. Oedegaard KJ, Greenwood TA, Johansson S, et al. A genome-wide association study of bipolar disorder and comorbid migraine. Genes, Brain and Behavior. 2010;9(7):673–680. [PMC free article] [PubMed] [Google Scholar]19. Oedegaard KJ, Greenwood TA, Lunde A, et al. 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Bipolar Affective Disorder and Migraine

Case Rep Med. 2012; 2012: 389851.

Department of Neurology, Fachklinikum Brandis, Am Wald, 04821 Brandis, Germany

Academic Editor: B. Carpiniello

Received 2012 Jan 2; Revised 2012 Mar 9; Accepted 2012 Mar 11.

This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

This article has been cited by other articles in PMC.

Abstract

This paper consists of a case history and an overview of the relationship, aetiology, and treatment of comorbid bipolar disorder migraine patients. A MEDLINE literature search was used. Terms for the search were bipolar disorder bipolar depression, mania, migraine, mood stabilizer. Bipolar disorder and migraine cooccur at a relatively high rate. Bipolar II patients seem to have a higher risk of comorbid migraine than bipolar I patients have. The literature on the common roots of migraine and bipolar disorder, including both genetic and neuropathological approaches, is broadly discussed. Moreover, bipolar disorder and migraine are often combined with a variety of other affective disorders, and, furthermore, behavioural factors also play a role in the origin and course of the diseases. Approach to treatment options is also difficult. Several papers point out possible remedies, for example, valproate, topiramate, which acts on both diseases, but no first-choice treatments have been agreed upon yet.

1. Introduction

Both bipolar disorder and migraine are not uncommon diseases. Whereas disorders of bipolar spectrum have an occurrence rate between 0.4 and 1.4% depending on different studies [1], migraine has rates from 10 to 30% [22]. More often than noticed, bipolar disorder occurs together with migraine. In a study of patients suffering from bipolar disorder (both type I and II), Ortiz et al. [2] found comorbid migraine in 24.5% of all bipolar cases and McIntyre et al. [3] of 24.8% (versus a general population rate of 10.3%). Contrary to that, Holland et al. [4] found a much lower prevalence of 4.7%. Nevertheless, comorbidity of both diseases seems to be an underestimated problem. In short, the main characteristics of bipolar disorder are recurrent episodes of depressive and manic states. Migraine is a usually unilateral headache often combined with nausea, photophobia, and others. As with bipolar disorder, migraine is divided into different subtypes, such as migraine with aura and without, or familial hemiplegic migraine among others.

2. Case History

A patient in his middle fifties has been suffering from mood disturbances since adolescence. The patient’s family history hints of “nerve diseases” of his mother and of his aunt and grandmother on the mother’s side. For several days, he was overactive and, as his brother once told him, “mad.” The patient, during his hyperactive phase, often tried to convince his brother to do wayward things. After some days of hyperactivity, the patient’s mood switched overnight to being deeply depressed, with avolition and a gloomy mood that lasted for many weeks. When this pattern first appeared, it occurred every one or two months; but, in its later appearances, the switching occurred monthly or within a fortnight. The patient never underwent therapy. At the age of 20, he had a head injury caused by an accident with his motorcycle. (More specific data about this event were not available.) After that, a migraine developed, which at first was never severe, and occurred four times a year. These early migraines occurred independently of his bipolar disorder. In the last ten years, however, the migraine became extremely severe on occasion and was linked to his bipolar disorder. The linkage is that manic states were always followed by migraine attacks with depressive mood. With these severe migraines, the patient experiences withdrawal, loss of interests, sleep disturbances, and recurrent suicidal fantasies. In addition to these migraines which follow after manic states, other migraines occur independently of manic states. In these last ten years, severe migraine attacks begin with aura symptoms such as a zigzag pattern in visual field, narrowing of visual field (tunnel view), blurred vision, and flashes. Then, speech arrest follows and palsy develops starting with lips, face, neck, and extremities, mostly on the right site. Anterograde amnesia follows on such a phase which lasts some hours in different degrees of severity. Speech arrest is usually the longest lasting symptom. Migraine headaches endure from 1 to 3 days. Manic states usually last a few days, depressive ones some weeks.

In recent, MRI scan was nothing abnormal detected. EEG in symptom-free intervals revealed an unstable alpha rhythm but no major changes. Routine laboratory data and parameters for thyroid gland, borreliosis, and lues showed no abnormalities.

In the case just described, the beginning of the bipolar disorder, presumably of type I, precedes the onset of migraine attacks. It is a migraine of a complicated type. In the differential, a familial hemiplegic migraine is possible.

3. Relationship between Migraine and Bipolar Disorder

The literature broadly supports comorbidity of migraine and bipolar disorder. Datta and Kumar [5] reported on a 19-year-old patient with hypomania as an aura of migraine. In a review, Antonaci et al. [6] unravelled a coincidence of migraine and affective anxiety disorders and, especially, a “trend towards an association of migraine and bipolar disorder” (see also [7]). Most studies support that migraine is associated not only with bipolar disorder but also with major depression, panic disorder, social phobia [8, 9], drug abuse [10], suicide, and neurological and internal diseases too, for instance stroke or hypertension [11]. Vice versa, according to a review of literature of McIntyre et al. [12], subjects with other neurological diseases, such as epilepsy or multiple sclerosis, seem to have a higher occurrence of bipolar disorder.

Are There Differences in Prevalence of Comorbidities? —

Dilsaver et al. [13] found a higher prevalence of migraine in bipolar patients than in those who suffer from major depressive disorder. In a study by Ortiz and colleagues [2], which distinguished bipolar I from bipolar II patients, a higher prevalence of migraine in bipolar II subjects was apparent and, in addition, higher rates were found for suicidal tendencies and anxiety disorders. Patients with a major depressive episode who had a family history of bipolar disorder had an increased risk of suffering from migraine [14]. Patients with unipolar depression and migraine have more depressive episodes in the course of time and more often a positive family history of migraine compared to those without comorbid migraine [15].

Does Migraine Influence the Course of Bipolar Disorder? —

According to Brietzke et al. [16], patients with both bipolar I and bipolar II disorder who suffer from comorbid migraine had more mood episodes, especially depressive ones. Furthermore, they found a higher occurrence rate of other psychiatric and general medical comorbidities.

4. Is There a Common Aetiology of Bipolar Disorder and Migraine?

Different gene regions are suspect as being responsible for association of bipolar disorder with migraine, but results in studies differ. One recent study [17] found no evidence that polymorphisms of the genes ANK3 and CACNA1C in migraine patients were associated with an elevated risk for bipolar disorder. Another recent study [18, 19], which investigated genomewide associations, found some gene regions which differed in bipolar patients depending on whether they were susceptible to migraine or not. Holland and Agius [20] saw “much overlap in neuropathological mechanisms” in both diseases. Besides genetics, they discussed altered expression of neurotrophic factors, cellular calcium physiology, endoplasmatic reticulum function, neuronal loss and pointed out the important question of sensitisation which is still controversially discussed: do recurrent episodes in either the diseases facilitate further ones?

Others bring up white matter hyperintensities for discussion. Gunde et al. [21] argued that high rates of such signs, detected in neuroimaging, play an important role both in bipolar disorder and migraine, and a substantial proportion of the hyperintensities would be related to the comorbidity of both diseases.

5. Treatment Options for Comorbid Bipolar/Migraine Patients

Although there are no evidence-based treatment suggestions for people with bipolar disorder and comorbid migraine, it seems reasonable that substances which act on both bipolar disorder and migraine could be used to ward off relapse. A problem in this approach is that the particular substances which are the drugs of choice for prophylactic treatment of migraine—the beta antagonists—could make depressive symptoms worse. On the other hand, valproate, which theoretically acts on both disorders, has only an off-label status in migraine prophylaxis [22]. Nevertheless, several papers see benefits from valproate and other substances. Finocchi et al. [23] suggested valproate and topiramate as a mood stabilizer in migraine without aura and lamotrigine in migraine with aura. Even amitriptyline could be used for prevention of mood episodes and migraine attacks. Serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are recommended in migraine patients for comorbid depression and anxiety. Caution should be exercised when triptans are combined with SSRIs or SNRIs because of a possible risk of serotonin syndrome [24].

In this vein, also neuroleptics which have already been used broadly as mood stabilizers are worth consideration, but, in relation to migraine, no sufficient studies exist [25]. Last but not least, the literature (see [26]) suggests that behavioural and cognitive-behavioural therapies are helpful for patients with a comorbid bipolar/migraine diagnosis.

6. Discussion

Migraine is an important comorbid disease in bipolar patients. It not only strengthens the cause of bipolar disorder but also worsens the recurrence rate with regard to depressive episodes. Bipolar II patients have a higher susceptibility of having comorbid migraine.

The literature survey with regard to the origins of both diseases indicates a variety of theories and working points. It is important to consider both the multifactor genesis of affective diseases and the influence of psychic disorders on neurological disorders such as migraine. We do not know yet whether bipolar disorder has causal or merely accidental connections with migraine. Nor do we know what organic or psychic conditions might exactly link the diseases, or why some patients have the comorbidities and others do not. Furthermore, many other psychic and neurological disorders can be comorbid with bipolar disorder.

There is no proven treatment regimen for migraine with comorbid bipolar disorder, so that pharmacological therapy is still a matter of trial and error. Nevertheless, some remedies seem to have effects on both of the diseases, but one must be wary of purchasing the benefit of a remedy in one disease by worsening the other.

References

1. Goodwin FK, Jamison KR. Manic-Depressive Illness. Oxford University Press; 2007. [Google Scholar]2. Ortiz A, Cervantes P, Zlotnik G, et al. Cross-prevalence of migraine and bipolar disorder. Bipolar Disorders. 2010;12(4):397–403. [PubMed] [Google Scholar]3. McIntyre RS, Konarski JZ, Wilkins K, Bouffard B, Soczynska JK, Kennedy SH. The prevalence and impact of migraine headache in bipolar disorder: results from the Canadian Community Health Survey. Headache. 2006;46(6):973–982. [PubMed] [Google Scholar]4. Holland J, Agius M, Zaman R. Prevalence of co-morbid bipolar disorder and migraine in a regional hospital psychiatric outpatient department. Psychiatria Danubina. 2011;23(supplement 1):S23–S24. [PubMed] [Google Scholar]5. Datta S, Kumar S. Hypomania as an aura in migraine. Neurology India. 2006;54(2):205–206. [PubMed] [Google Scholar]6. Antonaci F, Nappi G, Galli F, Manzoni GC, Calabresi P, Costa A. Migraine and psychiatric comorbidity: a review of clinical findings. 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Journal of Headache and Pain. 2009;10(4):283–290. [PMC free article] [PubMed] [Google Scholar]11. Wang SJ, Chen PK, Fuh JL. Comorbidities of migraine. Frontiers in Neurology. 2010;1, article 16 [Google Scholar]12. McIntyre RS, Soczynska JK, Beyer JL, et al. Medical comorbidity in bipolar disorder: reprioritizing unmet needs. Current Opinion in Psychiatry. 2007;20(4):406–416. [PubMed] [Google Scholar]13. Dilsaver SC, Benazzi F, Oedegaard KJ, Fasmer OB, Akiskal KK, Akiskal HS. Migraine headache in affectively Ill Latino adults of Mexican American origin is associated with bipolarity. Primary Care Companion to the Journal of Clinical Psychiatry. 2009;11(6):302–306. [PMC free article] [PubMed] [Google Scholar]14. Dilsaver SC, Benazzi F, Oedegaard KJ, Fasmer OB, Akiskal HS. Is a family history of bipolar disorder a risk factor for migraine among affectively ill patients? Psychopathology. 2009;42(2):119–123. [PubMed] [Google Scholar]15. Oedegaard KJ, Fasmer OB. Is migraine in unipolar depressed patients a bipolar spectrum trait? Journal of Affective Disorders. 2005;84(2-3):233–242. [PubMed] [Google Scholar]16. Brietzke E, Moreira CL, Duarte SV, et al. Impact of comorbid migraine on the clinical course of bipolar disorder. Comprehensive Psychiatry. In press. [PubMed] [Google Scholar]17. Wöber-Bingöl Ç, Tropeano M, Karwautz A, et al. No association between bipolar disorder risk polymorphisms in ANK3 and CACNA1C and common migraine. Headache. 2011;51(5):796–803. [PubMed] [Google Scholar]18. Oedegaard KJ, Greenwood TA, Johansson S, et al. A genome-wide association study of bipolar disorder and comorbid migraine. Genes, Brain and Behavior. 2010;9(7):673–680. [PMC free article] [PubMed] [Google Scholar]19. Oedegaard KJ, Greenwood TA, Lunde A, et al. A genome-wide linkage study of bipolar disorder and co-morbid migraine: replication of migraine linkage on chromosome 4q24, and suggestion of an overlapping susceptibility region for both disorders on chromosome 20p11. Journal of Affective Disorders. 2010;122(1-2):14–26. [PMC free article] [PubMed] [Google Scholar]20. Holland J, Agius M. Neurobiology of bipolar disorder—lessons from migraine disorders. Psychiatria Danubina. 2011;23(supplement 1):S162–s165. [PubMed] [Google Scholar]21. Gunde E, Blagdon R, Hajek T. White matter hyperintensities: from medical comorbidities to bipolar disorders and back. Annals of Medicine. 2011;43(8):571–580. [PMC free article] [PubMed] [Google Scholar]22. Hufschmidt A, Lücking CH, editors. Neurologie Compact. Leitlinien für Klinik und Praxis. Stuttgart, Germany: Thieme; 2003. [Google Scholar]23. Finocchi C, Villani V, Casucci G. Therapeutic strategies in migraine patients with mood and anxiety disorders: clinical evidence. Neurological Sciences. 2010;31:S95–S98. [PubMed] [Google Scholar]24. Evans RW, Tepper SJ, Shapiro RE, Sun-Edelstein C, Tietjen GE. The FDA alert on serotonin syndrome with use of triptans combined with selective serotonin reuptake inhibitors or selective serotonin-norepinephrine reuptake inhibitors: American headache society position paper. Headache. 2010;50(6):1089–1099. [PubMed] [Google Scholar]25. Dusitanond P, Young WB. Neuroleptics and migraine. Central Nervous System Agents in Medicinal Chemistry. 2009;9(1):63–70. [PubMed] [Google Scholar]26. Baskin SM, Smitherman TA. Migraine and psychiatric disorders: comorbidities, mechanisms, and clinical applications. Neurological Sciences. 2009;30(1):S61–S65. [PubMed] [Google Scholar]

Are Migraines and Bipolar Disorder Related?

The prevalence is usually between 10% and 15% in epidemiological studies, and migraine is more common in women than in men (Silberstein and Lipton, 1993). Neurochemical disturbances are thought primarily to involve the serotonergic (Silberstein, 1994) and the dopaminergic systems (Hargreaves and Shepheard, 1999). Drugs acting on serotonergic neurons or receptors may induce migraine headaches, and migraine patients are more sensitive than others to dopaminergic stimulation. In familial hemiplegic migraine, dysfunctional neuronal calcium channels have been found (Hargreaves and Shepheard, 1999).

Comorbidity of Migraine and Affective Disorders

A total of 102 patients, 79% of them inpatients between 18 and 65 years old, with major affective disorders were interviewed in two studies (Fasmer, 2001; Fasmer and Oedegaard, 2002). In the first study, we interviewed 62 consecutively admitted patients with major affective disorders and examined the frequency of migraine in patients with unipolar and bipolar disorders (BD) (Fasmer, 2001). In the second study, we recruited an additional 40 patients; and in the entire group of patients (n=102), we looked more closely at the clinical characteristics of the patients with migraine compared to those without migraine (Fasmer and Oedegaard, 2001). We used a clinical interview based on criteria from the DSM-IV, supplemented with Akiskal’s criteria for affective temperaments (Akiskal and Akiskal, 1992; Akiskal and Mallya, 1987). Bipolar I disorder (BDI) was diagnosed according to DSM-IV, while bipolar II disorder (BDII) encompassed patients with either discrete hypomanic episodes or an affective temperament (cyclothymic or hyperthymic), in addition to major depressive episodes. We employed the criteria of the International Headache Society (1988) to diagnose migraine.

In both studies, we found migraine to be a common comorbid disorder in patients with unipolar depressive disorder or BD, affecting approximately half of the patients in each group. However, most of the patients we interviewed did not present migraine headaches as a prominent complaint, and often a history of migraine was not noted in the hospital records. The most interesting finding was a substantial difference between patients with BDI and BDII, with migraine being clearly more prevalent in the BDII than in the BDI group. In our second study, 82% of the patients with BDII had migraine, compared to 27% of the patients with BDI (Figure). There is much evidence, including our own, indicating that patients with BDI and BDII represent two different nosological conditions (Coryell, 1996). Our results are similar to those of Endicott (1989), who found, among patients with major affective disorders, the highest frequency of migraine (51%) in patients having characteristics similar to patients with BDII as defined in the present study.

The most noteworthy findings concerning the clinical characteristics were that patients with migraine had a higher frequency of affective temperaments (47% versus 22% in patients without migraine) and a higher number of anxiety disorders. They were more likely to have panic disorder (51% versus 24%) and agoraphobia (58% versus 27%) than the patients without migraine. Symptoms during depressive episodes were similar, except that the migraine patients reported irritability and suspiciousness with increased frequency.

In two epidemiological studies, one from Zurich, Switzerland, (Merikangas et al., 1990) and one from Detroit (Breslau and Davis, 1992), a clear relationship between migraine and major affective disorders has been found (Breslau et al., 1994). In the Zurich study, people with migraine had a threefold-increased one-year prevalence of bipolar spectrum disorders (9% versus 3%), a nonsignificant increase in manic episodes and a twofold-increased prevalence of major depression (15% versus 7%).

Although these results cannot be directly compared to ours, they show that the association of migraine and affective disorders is not only found in such a selected group as we have studied. In these epidemiological studies, people with migraine also had an increased frequency of anxiety disorders. In the study by Breslau and Davis (1992), the frequency was doubled, compared to people without migraine, and the association was especially strong for panic disorder, with a sixfold increase. In contrast to these findings in patients with affective disorders, a study of patients with schizophrenia found no increased frequency of migraine (Kuritzky et al., 1999).

In our second study, the age of onset of the first anxiety disorder (most often a specific phobia) for patients with migraine was 15 years of age. This was earlier than the onset of migraine (21 years), which again was earlier than the onset of the first depressive episode (26 years). The first hypomanic episode occurred at age 28 (Figure). These chronological relationships are in agreement with previous studies. The high prevalence of anxiety disorders in patients with major affective disorders and comorbid migraine supports the hypothesis that there is a syndromal relationship between migraine, anxiety and depression (Merikangas et al., 1990). We would add that bipolar features should be included as part of this syndrome, and possibly the presence of migraine may be used to delineate a distinct subgroup of the major affective disorders.

Treatment Considerations for Both Disorders

To our knowledge, there are no studies that have specifically examined responses to drug treatment in patients with major affective disorders and comorbid migraine. Guidelines for pharmacological treatment must, therefore, be based on data from the neurological literature combined with data from the treatment of major depressive disorder, BDII and panic disorder.

Concerning antidepressants, amitriptyline (Elavil, Endep) is the drug that has been best studied in the prophylactic treatment of migraine and has been shown to reduce the frequency of attacks by 40%. This effect seems to be unrelated to its effect on depression (Ramadan et al., 1997). Selective serotonin reuptake inhibitors are less effective than either amitriptyline or propanolol (Inderal) (Silberstein, 1998).

In open studies, lithium has been shown to be useful in some patients with migraine (Medina and Diamond, 1981), however, others have reported worsening of migraine with lithium (Peatfield and Rose, 1981). Carbamazepine (Tegretol) does not seem to have any effect in patients with migraine (Post and Silberstein, 1994).

Several studies, both open and controlled, have shown that valproate (Depakene) has prophylactic effect in migraine, reducing the number of attacks, duration of headache and intensity of pain (Silberstein, 1996). Valproate thus has effect on the three main symptom groups in patients with migraine and comorbid affective disorders: headaches, mood instability and panic attacks (Freeman et al., 2002).

In the acute treatment of migraine, triptans, which exert their effect by a combination of vasoconstriction and decreased release of inflammatory mediators (Blier and Bergeron, 1995), are usually employed. The oldest and best-studied is sumatriptan (Imitrex). Although sumatriptan apparently has limited ability to penetrate the blood-brain barrier (Millson et al., 2000), it has been implicated in adverse events resembling the serotonin syndrome, when combined with centrally acting serotonergic drugs. However, the number of reported cases is small, and most patients seem to tolerate this combination without problems (Gardner and Lynd, 1998).

It is theoretically possible that the risk of depressive illness may be increased by the use of triptans, especially the newer ones which have enhanced lipophilicity, but this could not be confirmed in a recent study of consulting rates in general practice (Millson et al., 2000).

Acknowledgement

This research has been supported financially by the legacy of Gerda Meyer Nyquist Gulbrandson and Gerdt Meyer Nyquist.

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Spranger M, Spranger S, Schwab S et al. (1999), Familial hemiplegic migraine with cerebellar ataxia and paroxysmal psychosis. Eur Neurol 41(3):150-152.

90,000 Bipolar disorder (BAD), its signs, types and treatments

Manifestations of various emotions, a change in a person’s mood, manifestations of both sadness and joy are normal and depend on many factors – from temperament and character to events that occur from outside. However, when these changes are excessive, often occurring unexpectedly and for no apparent reason, emotions get out of control, or the person remains in a cardinally positive or negative mood for a long time, bipolar disorder can be diagnosed with a high degree of probability.This disease was first described at the end of the 19th century by the famous German psychiatrist Emil Kripelin, calling it manic-depressive psychosis. Many world famous personalities such as Vincent Van Gogh, Isaac Newton, Ludwig van Beethoven, Abraham Lincoln suffered from this ailment. The pronounced form of this disease, which in the international classification of diseases is called bipolar affective disorder (BAD), is detected in 3% of the world’s population.

Bipolar personality disorder – general information

According to statistics, bipolar disorder affects people from 14 to 44 years old.Unlike adults, children and adolescents experience more frequent mood swings from mania to depression, sometimes several times a day. 90% of young people make their debut precisely from the phase of depression or melancholy. Another feature of bipolar disorder is that, due to the low level of diagnosis, the patient can live with this disease for 5-10 years without knowing the cause of the painful symptoms.

Bipolar disorder is most often diagnosed in people whose immediate family has had a similar problem.The causes of this disease are unknown, but stress, overstrain, and various diseases can provoke the manifestation of its symptoms. However, having fenced off a person from the influence of these factors, it is impossible to get rid of the problem; you need to seek help from a psychotherapist.

Bipolar disorder is a disease that cannot be completely eliminated. But with the right medication and psychotherapy, the quality of life is significantly improved and the periods between phases are lengthened.The person remains socialized and able to work.

Symptoms and signs

From the name it is clear that we are talking about two different poles of affective manifestations, that is, manifestations of mood. One of these conditions is depression. Depression in bipolar disorder is pronounced, with vivid symptoms. It can last up to a year and is manifested not only by a lowered mood, lack of the ability to take pleasure and interest in current events, but also psychosis, when ideas of self-accusation arise, the patient feels inferior, unnecessary, poisoning the life of others.Also, nihilistic thoughts about suffering some kind of serious illness are inherent, despite medical evidence to the contrary. Delusional thoughts can also occur, as well as suicidal thoughts and even attempts.

Another pole of bipolar disorder is a hypomanic state or hypomania, the characteristic signs of which are an increased euphoric emotional background, the patient is constantly in motion, hyperactive, characterized by very fast, associative speech. The patient is constantly cheerful, often hypersexual, almost always awake or asleep 2-3 hours a day.

Hypomania is often followed by a manic bipolar state with psychotic manifestations. The patient develops convictions of his own greatness, he believes that he is capable of anything, feels that he has a special calling in this world or that he is a descendant of great people. In detailed manic episodes of mania with psychotic manifestations, anger, irritability, and direct aggression often occur. This condition leads the patient to extremely unpleasant and sometimes dangerous situations.

In addition to the typical symptoms of the disease, there are also a large number of comorbid mental disorders. Mental disorders that accompany the underlying disease are called comorbid ones. The most common disorder of this kind is anxiety, which is manifested, among other things, by nonspecific autonomic symptoms, including sweating, palpitations, tremors of the limbs, various disorders of the gastrointestinal tract, dizziness, headaches, choking, and many others.In the case when these signs appear suddenly, mainly in public places, they are usually called panic attacks.

Types of bipolar disorder

Bipolar disorder can be of types Ι and.

Type bipolar disorder is a condition in which the patient has persistent manias, that is, overexcitement, ecstatic inappropriate behavior, manic psychosis, as well as severe depression. Symptoms of this type are more severe and hospitalization is indicated in most cases.

Bipolar disorder is characterized by short periods of hypomania followed by periods of major depression. Hypomania is a pre-manic state with less active manifestations. Hypomania lasts a very short period of time – from several days to several hours, so sometimes patients do not even notice them and do not inform the doctor about it. Only careful, painstaking work with the patient can reveal hypomania, make the correct diagnosis and prescribe treatment.

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Phases of bipolar disorder

There are several phases of bipolar personality disorder:

1. Depressive (unipolar depression).People experience depressed mood, despair and discouragement, complain of lack of energy and mental concentration, can eat and sleep too much or very little.

At the peak of bipolar depressive disorder, depersonalization and derealization may occur. The boundaries of their own “I” and the world around them become blurred, patients experience difficulties in perceiving what is happening. Familiar places seem new, the color scheme of the surrounding world changes, the patient constantly experiences a feeling of “déjà vu”.Sounds become muffled, even if someone speaks very close, it seems to the patient that the voice comes from afar.

2. Manic (hypomanic). In this state, patients are full of energy, overly happy or optimistic, euphoric and have extremely high self-esteem. At first glance, these are positive signs, but when a person experiences large-scale manic episodes, these symptoms and such an emotional state can go to dangerous extremes. A patient in this phase may indiscriminately spend huge amounts of money or behave inadvertently without realizing the full danger.In conversation, people can choke on words, speak at high speeds, or jump from one thought to another. These episodes can also be accompanied by delusions of grandeur or making serious decisions without thinking about the further consequences.

The following stages of development can be distinguished in the development of the manic phase:

• Hypomania – increased excitement, emotional uplift.
• Mania – all signs are more pronounced, aggression, irritability, irascibility and rage are possible.
• Peak phase. The patient is constantly experiencing nervous excitement, he cannot relax. All his emotions are “heated” to the limit, coordination of movements is disturbed, thoughts are illogical and abrupt, in speech he constantly jumps from one sentence to another.
• Relief of symptoms. The patient gradually calms down. Movement disorders are declining. Thinking speed and heightened emotional mood remain unchanged.
• Return to normal.

3. Mixed. Sometimes people have complaints that are characteristic of both depression and mania at the same time. They may also experience frequent phase changes – 4 or more episodes over a one year period.

In the intervals between depressive and manic phases in bipolar disorder, there is a light interval during which the general background of mood becomes relatively stable, the person continues to adequately respond to certain events, the emotional sphere is under his control.This is the main criterion for remission of bipolar disease.

Bipolar disorder in women

According to statistics, type bipolar disorder occurs with the same frequency in men and women, and type disease is more often diagnosed in women. It is also known that the female course of the disease is characterized by fast cycles and mixed episodes. Comorbid conditions are often eating disorders, borderline personality disorder, alcohol or drug dependence, and drug abuse.Women are more susceptible to such somatic diseases as migraine (intense headaches), thyroid pathology, diabetes, obesity.

For women, a special technique is being developed to alleviate this disorder, since from adolescence to menopause there is a specificity of hormonal changes that must be taken into account. In addition, psychotropic substances, which are supposed to stabilize the condition, can adversely affect the intrauterine development of the fetus if the woman is in the position.It is noted that in the first trimester of pregnancy, this disorder is milder, but after childbirth, they often have to deal with postpartum depression. Thus, at each stage of the development of the female body, a competent doctor must revise and adjust the treatment regimen. Often in the treatment of women, a complex method is used that combines drug therapy and cognitive-behavioral or interpersonal therapy with a psychotherapist. This approach gives the fastest results.

Treatment of bipolar personality disorder

Attempts to get rid of bipolar disorder on their own do not bring the desired result and, ultimately, lead to an aggravation of the situation, including the development of drug or alcohol dependence. Keeping a mood diary can help in diagnosing the disease, where the patient records all his thoughts, emotions, feelings, changes in mood. Such records will help the doctor to assess in detail the mental state and make the correct diagnosis.If you suspect bipolar disorder, you should consult a doctor, and the sooner a person realizes that he has a disease and comes to the clinic for help, the sooner he will be provided with professional help and the painful symptoms will be replaced by a stable state. It is impossible to get rid of the disease on its own, since a person cannot fully adequately assess not only his actions, but also the alternation of the phases of the disease.

Bipolar disorder is one of the few mental disorders in which drug treatment is indicated in 100% of cases, and psychotherapy is an auxiliary tool.This disease is incurable, but its diagnosis and treatment is extremely important. Treatment can reduce the number of episodes, their severity and intensity, as well as prevent negative life events, help prevent breakdowns, job loss, and even suicidal attempts. Thus, the quality of life of a patient with bipolar disorder who is being treated will be several times higher than that of a person who neglects treatment. If the patient loses touch with reality and harms himself and others, he is subject to hospitalization, outpatient treatment in this case is not permissible.

If you have a disease, it is recommended to exclude coffee, strong tea, alcoholic and energy drinks from your diet in order not to provoke an over-excited state. If possible, you should stop smoking and in no case take even light drugs. It is also very important to establish a sleep schedule, sleep at least 8 hours a day and try to go to bed at about the same time. Learn to recognize mood swings and notice early onset of new episodes.

If you suspect you have bipolar personality disorder, you do not need to panic, only a doctor can diagnose the disease, so you need to make an appointment with a psychotherapist with extensive experience in managing such patients at our MedAstrum clinic. If the diagnosis is confirmed, the doctor will draw up the necessary drug treatment, if necessary, appoint psychotherapeutic sessions and give recommendations for further adjusting the lifestyle. You can make an appointment on your own on the website or by contacting our administrators.

90,000 Migraine: why we know so little about the most common disease in the world

• Lauren Sharkey
• BBC Future

September 6, 2018

Every fifth woman in the world suffers from migraine, migraine is the second most common disease, which limit performance. However, surprisingly little is known about , her research is under-funded, and many doctors do not even consider migraine to be a real neurological disorder.

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The first time I felt a migraine was one evening after school. The dull headache turned into a sharp throbbing, vision blurred, and the light from the lamp in my room brought terrible suffering. Eventually I vomited.

This cycle of symptoms has recurred many times in recent years. Subsequently, he made me quit my job and feel completely helpless.

Migraines are often dismissed as “it’s just a headache.”

But while a “normal” headache can usually be managed with paracetamol, migraines are not easily overcome. A migraine attack can seriously unsettle.

The Health Gap series focuses on gender inequalities in health and medicine. Other articles in this series:

In addition, the cause of this disease is not precisely defined (hormonal changes or abnormal brain activity are only speculations), just as there is no established way to treat it.

It is not surprising that an international study of the state of human health, which was carried out in 195 countries of the world every year from 1990 to 2016, put migraine in the second place among diseases that significantly limit human performance for many years.

Migraine brings significant economic costs – in the UK alone, 25 million sick days are given annually because of it.

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Unlike a common headache, migraine brings unbearable anguish, it is often accompanied by visual impairment and vomiting

But despite its huge impact on health and the economy, migraine remains one of the least studied diseases whose research has not received the necessary funding for years.

This disorder is also much more common in women. Overall, one in five women and only one in 15 men suffer from migraines.

The causes of migraine remain largely unclear. Although a study by Arizona State University in April this year suggests that it is associated with a condition where estrogen rises and the sodium proton exchanger NHE1 declines.

Pain increases without sufficient NHE1.”The results of the study show that women are more prone to migraines because fluctuations in their sex hormones lead to changes in their NHE1 levels,” explains researcher Emily Galloway.

However, migraine remains one of the least studied diseases in the world. For example, in the United States, where migraine affects about 15% of the population, funding for her research in 2017 amounted to $ 22 million.

For comparison, 13 times more has been allocated for research on asthma, which affects half the number of Americans.), and diabetes – 50 times more ($ 1.1 billion).

Although, of course, asthma and diabetes are potentially life-threatening diseases.

The effectiveness of the study of migraine is also reduced by the fact that medical research, according to tradition, is usually carried out on males, although migraine is predominantly a female disease.

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Migraine affects one in five women and only one in 15 men

Given the prevalence of migraine among women, this apparent neglect may be the result of doctors often underestimating women’s complaints of pain.

Another reason is the misconception that migraines are associated with mental illness. The myth of female hysteria has been around for centuries and is a classic manifestation of gender bias in medicine.

Medicine headache

Pulsating headache is one of the oldest diseases of mankind, indicated in written sources.

Descriptions of migraine come across in ancient Egyptian manuscripts 1200 BC. and Hippocrates.

However, the discovery of migraine is usually attributed to the ancient Greek physician Areteus from Cappadocia. He was the first in the second century to accurately describe the symptoms of the disease – the localization of pain on the one hand and the frequency of attacks.

The word “migraine” itself comes from the Greek hemicrania, which means “half of the skull”.

The causes and treatment of migraines have been surrounded by superstition throughout history.

In the Middle Ages, migraines were treated with bloodletting and witchcraft or with a clove of garlic inserted into an incision in the temple.

As a remedy for migraines, some doctors have recommended trepanation – drilling holes in the skull. It was believed that this barbaric procedure helps to release evil spirits from the body of a person who apparently suffered from a mental disorder.

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The ancient Greek doctor Areteus from Cappadocia was the first to accurately identify the symptoms of migraine

The fact that migraine mainly affects women, doctors noticed only in the 19th century.

Migraine has been called a disease of “working class mothers” and attributed to mental disorders in women due to heavy daily work, lack of sleep, frequent breastfeeding and malnutrition.

Headache in women was associated with hysteria and was often ridiculed; it is still the subject of jokes and anecdotes.

On the other hand, “migraine was also considered a disease of the aristocrats,” explains Joanna Kempner, associate professor of sociology at Rutgers University.

“They say that the upper class have a more delicate nervous system, which allows men to engage in arts and sciences.”

“And since women were believed to be less capable of intellectual activity, their nervous system was overwhelmed.” Unlike a common headache, migraine is unbearable, it is often accompanied by visual impairment and vomiting

American neuropathologist Harold G. Wolf, has identified a clear difference between migraines in men and women.

Whereas in ambitious and successful men migraines occurred due to fatigue, Wolf believed that the cause of headaches in women was the inability to accept a female role primarily in sexual life.

Dr. Wolff said that his patients perceive sex “as a marriage duty at best, but often as an unpleasant duty.”

Kempner adds: “by the end of the 20th century, the word migraine had acquired a strong association with a neurotic housewife, and some vocabularies do record it as a synonym for“ wife. ”

Reason matters

health actually exists.Several studies have shown that migraines are often associated with certain mental illnesses, such as bipolar and anxiety disorders, and depression.

Another study found that about one in six migraine patients seriously considered suicide.

“But is migraine the cause of these disorders?” Asks Messud Ashina, professor of neurology and director of the Migraine Research Unit at the Danish Headache Research Center.

“Migraine is a very common condition and therefore the chances of coincidental coincidence with other disorders are quite high,” he says.

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People with migraine are more likely to suffer from depression and anxiety and have suicidal thoughts

“On the other hand, it is not surprising that migraine contributes to anxiety, because it can always catch a person by surprise , interfere with his professional or family plans, “says Esme Fuller Thomson, director of the Institute for Life and Aging at the University of Toronto, which is researching the link between migraines and suicide.

The feeling of helplessness that often grips the migraine patient can also exacerbate depression.

However, despite the prevalence of migraine and the severe consequences of its attacks, many experts do not consider it a serious illness.

Part of this attitude to migraine lies in its status as a predominantly “female” ailment and reflects gender bias in medicine.

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Despite the debilitating effects of migraine, many experts do not consider it a real neurological disease

Statistics confirm that doctors, as a rule, pay less attention to women’s complaints, and the diagnosis of the patient usually occurs for a longer time than in male patients.

There seems to be a way out

Fortunately, there is already a new drug for migraine – although it is still at the trial stage. This is a monthly injection of erenumab that blocks the brain receptor that triggers the migraine attack.

(In May 2018, the US Food and Drug Administration approved a similar drug that acts on the CGRP receptor).

“The key is that this drug is specifically designed to treat migraines,” explains Amaal Starling, assistant professor of neurology at the Mayo Clinic in Scottsdale, Arizona.

“This increases its effectiveness and reduces side effects,” adds the specialist.

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A new drug, developed specifically for the treatment of migraines, and not headache symptoms, should ease the fate of sufferers

It is difficult to disagree with this. For migraine treatment, I am prescribed beta blockers, a drug taken three times a day for several months, commonly used to treat angina and high blood pressure.

As it turned out later, the drug also helps against migraines. But it has a huge list of contraindications and side effects, such as extreme tiredness and dizziness with the possibility of a heart attack if you suddenly stop taking it.

Other current treatments for migraine include electromagnetic treatments using handheld devices. They send magnetic impulses to the brain to alter the electrical environment of neurons and reduce “hyperexcitability.”

I have not had a migraine in almost six months and I started to reduce my beta blocker dose.I would like to give up medications altogether. But recently I had another attack.

A couple of months ago I was taken to the hospital with suspected heart attack. Fortunately, this was a false alarm. But this case showed how important it is to get a drug for migraine, which would not affect the vital organs.

I hope we will have this invention soon.

You can read the original of this article in English on the BBC Future website.

questions of comorbidity – the topic of a scientific article on clinical medicine read the text of the research work for free in the electronic library CyberLeninka

ACTUAL ARTICLES

AFFECTIVE SPECTRUM DISORDERS IN CHRONIC MIGRAINE:

QUESTIONS OF COMORBIDITY

O.S. Antipova

Moscow Research Institute, Moscow

The high level of interrelation of chronic and transformed forms of migraine with disorders of the affective spectrum is recognized by the majority of authors studying this issue. At the same time, as one of the most authoritative researchers in this field, 8.B. Schner-Sien (1995), the high comorbidity of chronic cephalalgias with disorders of the affective spectrum is more likely to be stated by researchers than systematically studied.The subject of this review is the issues of pathogenetic comorbidity and the mutual influence of chronic migraine and affective spectrum disorders.

Chronic migraine (HM) refers to a condition in which migraine headache occurs for 15 or more days a month for three months or more in the absence of drug abuse. According to the definition of the International Classification of Headache, 2nd revision (ICGB-2), chronic migraine is referred to as “1.5. Complications of migraine “, along with conditions such as status migraine, persistent aura without a heart attack, migraine infarction, and epileptic seizure caused by migraine. HM is one of the variants of chronic daily headache and accounts for about half of all cases.

teas of primary chronic cephalalgias (Katsarava Z. et al., 2004; Bigal M.E., Serrano D., Reed M., Lipton R.B., 2008).

Most patients with HM have a history of episodic migraine attacks without an aura.As chronicity progresses, the headache may lose its distinct paroxysmal character, while the intensity of pain and the severity of concomitant symptoms – photo-, osmophobia and phonophobia, nausea, vomiting – decrease. Over time, headaches occur in the patient almost daily and completely cease to correspond to the clinical picture of a “migraine attack”. Sometimes attacks become more frequent, their intensity decreases, but the frequency of occurrence remains. That is why a number of authors (Mathew N.T., Stubits E., Nigam M. P., 1982; Sandrini G. et al., 1993) prefer to use the term “transformed migraine” in the description of the main clinical variant of HM. This term is used in cases when a patient with HM can be identified in the history of a period of qualitative and quantitative transformation of headache. Transformed migraine is often caused by the abuse of analgesics, but it can form without the participation of this factor. At the same time, there are subtypes of CM that develop de novo, without a transformation period.

The relevance of studies on HM is determined by the general population prevalence of this form of headache, which, according to different authors, ranges from 0.4% to 2.4% (Castillo J. et al., 1999; Katsarava Z. et al., 2008 ; Scher AI, Lipton RB, Stewart WF, Bigal M., 2009). Patients suffering from HM are socially active people of young working age. HM leads to a significant violation of their quality of life, work capacity and a decrease in the level of social functioning.The detection of HM in some cases is difficult, and many forms of HM are refractory to standard preventive pharmacotherapy.

Within the framework of this review, we are most interested in affective pathology, its comorbidity with migraine and its role in the transformation of episodic forms of migraine into chronic

nichny. The first clinical descriptions indicating that patients with migraine, as a rule, have affective disorders, appeared at the end of the 19th century.There are indications of the presence of depression, irritability, memory and attention disorders in patients with primary cephalgia (in particular, migraine), dating back to 1895 (Gentili C., Panicucci P., Guazzelli M., 2005). In 1937, H. Wolff described the traits of a “migraine personality” characterized by conscientiousness, increased responsibility, perfectionism, affective rigidity and resentment. In a few studies, it was shown that these personality traits, combined with increased anxiety and a tendency to a hypothetical response, are characteristic of patients with chronic and transformed forms of migraine (Catarci T., Clifford Rose F., 1992).

Epidemiological studies of the comorbidity of affective pathology and migraine have been systematically conducted in the United States and Western Europe since the late 90s. last century. Most works with a cross-sectional design confirm a high level of relationship between migraine and affective spectrum disorders, reaching 50-60% (Mer-cante JP et al., 2005; Buse DS et al., 2005; Hung CI et al., 2006; Lipton R.B. et al., 2008). In the case of chronic forms of migraine, the level of comorbidity is even higher and is 80-90% (Verri A.P., Proietti Cecchini A. et al., 1998).

In the structure of comorbidity of migraine with mental pathology, depression comes first – both primary and repeated episodes (Breslau N. et al., 1998; 2000; Puca F., 2000; Buse D.S. et al., 2005). At the same time, migraine is more often combined with depressive episodes developing within the framework of bipolar disorder type II (Merikangas K.R., Angst J., Isler H., 1990; Breslau N., 1998; Robbins L., Ludmer C., 2000; Calabrese G. et al., 2003). Less common in epidemiological studies in patients with migraine, dysthymia, panic disorder, generalized anxiety disorder, social phobias and eating disorders are detected (Saper JR, 1987; Juang KD et al., 2000; Merikangas KR et al., 2002) … Interestingly, somatoform and conversion

disorders are more often combined with episodic forms of migraine.

Isolation of bipolar disorder type II, characterized by alternation of major depressive episodes and hypomania, from the circle of recurrent depressions, allowed a new look at the factor of bipolarity in the development of migraine. In 1989 N.A. Endicott, in his work on the psychophysiological correlates of bipolarity, showed that migraine is more common in patients with bipolar II disorder compared with recurrent depression.Later works of other authors confirm the close relationship between migraine and various types of bipolar spectrum disorders, especially in young patients (Merikangas KR, Angst J., Isler H., 1990; Breslau N., 1998; Robbins L., Ludmer C., 2000 ; Calabrese G. Et al., 2003).

In discussing the results of epidemiological studies, studies with a longitudinal design are of most interest, since they make it possible not only to reveal the level of associations of one condition with another, but also to determine whether one disease is a predisposition for another, or both diseases affect each other.Clarification of these questions is of great importance for clinical practice and the study of the pathogenetic mechanisms of diseases.

Today, the concept of a bidirectional relationship between migraine and depression dominates, according to which both diseases contribute to the development of each other (Breslau N. et al., 1998; 2000; Puca F., 2000). Longitudinal studies have shown that patients with major depression are three times more likely to develop new migraines in their lifetime than the general population (Fasmer O.B., Oedegaard K.J., 2001). In patients with migraine, depressive episodes develop five times more often (Breslau N., Schultz L.R., Stewart W.F. et al., 2000).

Similar results have been obtained for migraine and panic disorder (Stewart W.F., Linet M.S., Celento-no D.D., 1989; Breslau N., Davis G.C., 1993). Most prospective studies have demonstrated bidirectional

character of the relationship between these disorders.Thus, according to N. Breslau et al. (2000), new cases of panic disorder occur in patients with migraine 3.6 times more often compared with the incidence in the general population. In turn, in patients with panic disorder, the development of migraine during the observation period is observed 2 times more often than in individuals without panic disorder. Depression and panic disorder increase the risk of developing migraine, but do not affect the risk of developing other primary cephalgias, which seems to indicate the pathogenetic specificity of this relationship (Breslau N.et al., 2000).

At the same time, in addition to the concept of a bidirectional relationship, there is another opinion: the connection between migraine and affective spectrum disorders comes from common risk factors that can increase the likelihood of the formation of any of these diseases (Swartz K.L., Pratt L.A., Armenian H.K., 2000). Disorders of the affective spectrum, and primarily depression, being with migraine in a relationship of pathogenetic comorbidity, have common genetic prerequisites and neurobiological mechanisms of development and chronization (Simon G.E. 1999; Tracey I. et al., 2002; Andrasik F. et al., 2005; Danilov A.B., 2010).

As part of the discussion of the results of epidemiological studies, it should be emphasized that by identifying a particular affective disorder on the basis of operational diagnostic criteria, we arrive at an artificial separation of depression and anxiety disorders. In modern classifications of diseases (ICD-10, DSM-IV), anxiety disorders are increasingly considered as independent nosological units, although in real clinical practice, these diagnostic criteria can correspond to erased, atypical, somatized and masked depressive episodes or residual symptoms after a depressive episode ( Krasnov V.N., 2008; 2010). To understand such complex relationships, the concept of a spectrum of affective disorders is well suited (Winokur G. et al., 1973, 1983; Angst J. et al., 1998, 2007; Angst J., 2009; Krasnov V.N., 2010). Presented –

that anxiety and depression have common hereditary and genetic prerequisites, pathogenetic mechanisms, risk factors and close clinical relationships are traditional for psychiatry (Lewis A., 1934;

Weitbrecht H. J. 1973; Krasnov V.N., 2008, 2010).

In this regard, the data of a prospective study conducted by K.R. Merikangas et al. (1993), who hypothesized that the presence of an anxiety disorder in a patient induces or accelerates the development of migraine, which, in turn, acts as a kind of trigger for the subsequent development of a clinically delineated depressive episode over the next 4-5 years.This hypothesis echoes the results of our own clinical observations, according to which the presence of subaffective fluctuations in a patient with migraine at a young age with the prevalence of anxiety and psychovegetative symptoms, as well as migraine attacks associated with anxiety-vegetative paroxysms, significantly increases the risk of developing extensive episodes of endogenomorphic anxiety or anxious depression after 35-40 years.

Among the predictors of migraine chronicity, it is customary to distinguish two main ones: an initially high frequency of headache and the abuse of symptomatic anti-migraine drugs (ergotamine, triptans) and / or opioids and combined analgesics with the formation of an abusal headache (Lu S.R., Fuh J. L., Chen W. T., 2001; Zwart J. A., Dub G., Hagen K., 2003; Lipton R.B., 2008). In addition, risk factors for chronic migraine include: female sex, age over 40, obesity (BMI> 30), frequent use of caffeine and caffeine-containing drugs, snoring and sleep apnea syndrome, and the presence of encephalopathy of various origins. Non-modifiable risk factors include a low level of education, low socioeconomic status, and migrant status (Scher A.I. et al., 2003; Bigal M.E. et al., 2002).The presence of other chronic pain syndromes in a patient with migraine (for example, fibromyalgia) is also discussed, while the development of the phenomena of central sensitization is important. Opre-

A divided role is played by the frequent use of analgesics by patients suffering from migraine for reasons not associated with migraine attacks.

Moving on to the discussion of the role of comorbid affective pathology in the transformation of episodic migraine pains into chronic ones, it should be noted that today there is no unambiguous idea of ​​this.Many authoritative researchers in this field believe that the presence of anxiety disorder in a patient with migraine and, more importantly, depression, dramatically increases the risk of chronic pain syndrome (Juang KD et al., 2000; Buse DS et al., 2005; Wang SJ et al. .,

2007). Other authors do not find such a connection (Breslau N. et al., І998; 2000). The role of the bipolar factor in the process of migraine chronicity remains unexplored.

Only one thing can be said for sure: the level of comorbidity of HM and disorders of the affective spectrum is extremely high, in chronic and transformed forms of the disease it reaches 80-90%, compared with 60-70% in episodic forms (Verri A.P., Proietti Cecchini A. et al., 1998).

Given that HM is a complication of migraine, a similar comorbidity profile with affective spectrum disorders can be assumed. However, a number of studies have shown that clinically outlined endogenomorphic depressive episodes are detected in patients with HM about twice as often as in episodic forms. So, D.S. Buse et al. (2005) in a cross-sectional study of 24 thousand patients with migraine showed that depression and anxiety disorders are detected in chronic forms of migraine twice more often than in episodic ones.In an earlier prospective study, M.K. Chung, D.E. Kraybill (І990) demonstrated that depressive episodes are more common in patients who have had chronic migraine for more than five years.

For chronic migraine and affective spectrum disorders, no systemic prospective studies have yet been conducted to support the concept of bi-directional relationships. At the same time, it has been shown quite convincingly that HM is often combined with chronic

and prolonged forms of depression (Hung S.I. et al., 2005). It is assumed that this is due to the presence of common factors and predictors of chronicity for both migraine and depression. These include hereditary predisposition, disturbances in the system of serotonergic regulation, disturbances in the processes of neuronal plasticity, imbalance of stress-realizing and stress-limiting mechanisms, female sex, the presence of residual organic “soil”, obesity, a high level of stressful events during life, personality disorders.

In a number of works, the presence of comorbid affective pathology in HM is considered as a factor of an unfavorable prognosis in relation to the effectiveness of standard pharmacotherapy for migraine (Tabeeva G.R., Yakhno N.N., 2010; Azimova Yu.E., Margulis M.V., Tabeeva G.R., 2010; Artemenko A.R., 2010). The authors of these works discuss the pathophysiological foundations of the formation of refractory migraine in patients with depression, associated with a general genetic predisposition to a chronic type of course, dysregulation of monoamine systems, aggravation of the phenomena of central sensitization, and impairment of the processes of neuronal plasticity.

A certain role is played by the fact that HM patients have low adherence to psychopharmacotherapy, do not consider it necessary to take thymostabilizers and antidepressants, or skip taking them.These patients usually consider themselves to be physically ill, the manifestations of anxiety and depression are regarded as a natural psychological reaction to somatic suffering, they are reluctant to seek help from psychiatrists, often do not come for repeated consultations and do not follow the recommendations. As a result, only 20-30% of patients with transformed and chronic forms of migraine receive adequate complex psychotherapeutic and pharmacotherapeutic assistance for comorbid affective pathology (Lipton R.B., 2008). Refusal of treatment is a frequent manifestation of para-suicidal behavior for this category of patients (Pompilli M., et al., 2010). In addition to the negative consequences directly related to the somatic state, depression contributes to a decrease in work ability

property, loss of job and increased cost of treatment for such patients.

As an independent predictor of migraine chronicity, it is customary to isolate alimentary obesity (Bigal M.E. et al., 2002). Some mechanisms of obesity development in migraine patients are of interest. In a number of clinical cases, such patients develop an endogenomorphic episode of anxiety depression, usually with a tendency to protracted course. Depression usually contributes to an increased frequency of migraine attacks. Upon recovery from depression, residual subaffective symptoms often remain with psychovegetative, anxiety-phobic, and dysthymic disorders. At the same time, metabolic and metabolic disorders with eating disorders in the form of increased appetite, stressful eating, and nighttime food excesses can be observed.Sometimes increased appetite is observed in the structure of hypomanic and mixed episodes. Eating disorders may come to the fore in the clinical picture of masked subaffective episodes preceding syndromally delineated depression. Long-term eating disorders lead to obesity, which in turn contributes to the chronicity of migraines.

Recently, when discussing the mechanisms of chronicity of migraine, great importance is attached to stress resistance and psychological characteristics of patients.Many authors note the fact of the accumulation of stressful and traumatic events in the course of the life history of such patients (Lipton R.B.,

2008). There is information about the role of the dysfunctional nature of relationships in the patient’s microsocial environment, insufficiently developed communication skills and skills of problem-solving behavior, maladaptive strategies for coping with stress, education in “painful” families.

Patients with HM are distinguished by a combination of a high level of personal anxiety with ambition, diligence, affective rigidity, resentment and perfectionism.In the motivational sphere, these patients are fixed at up to

people are usually successful in achieving significant goals in life. Social status and professional success occupy an important place in the structure of self-esteem of HM patients. That is why even patients with frequent and severe migraine attacks continue to work, actively participate in social life, and strive to maintain their previous level of achievement.

Social anxiety can manifest itself in the form of fear of expectation of a migraine attack and early intake of anti-migraine drugs.In many cases, this contributes to the abuse of combined analgesics, triptans, the formation of abusal headaches and the transformation of episodic migraines into chronic ones. Excessive use of symptomatic anti-migraine drugs or combined analgesics is one of the reasons that migraine attacks become more frequent and take on the character of a mixed headache, combining symptoms of migraine and tension headache. Without correction of the abusal factor, patients rarely respond to preventive therapy.

In conclusion, it should be noted that the issues of the pathogenetic comorbidity of chronic migraine and affective spectrum disorders have not yet been studied. Of particular interest is the study of common pathogenetic links, the role of chronic stress, as well as systemic changes in the psychophysiological reactivity of the organism in the development and chronicity of migraine and depression. Possibly, further study of predictors, pathogenesis and structural and dynamic features of affective disorders in patients with chronic migraine will help to optimize approaches to the diagnosis and treatment of these conditions, improve the quality of life of patients and improve the prognosis of this severe disease.

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90,000 Treatment of headaches and migraines

Each person periodically experiences a headache, which is associated with various external factors and quickly disappears without requiring any treatment.But about 15% of people suffer from frequent, sometimes severe headaches and need examination and treatment.

In most cases, the headache is primary, i.e. is not a manifestation of any disease. Primary headaches include migraines and tension headaches.

But in 10% of cases, the headache can be secondary, arising as a consequence of other diseases, such as hypertension, infections, tumors, pathology of the cerebral vessels and eye diseases.

Tension headache is the most common type of headache. Infrequent attacks can last from half an hour to several days. In chronic forms of the disease, the frequency of attacks exceeds 15 times a month. During such attacks, the pain is pressing, without clear localization, with a feeling of pressure all over the head. The attacks are mild and can be relieved with conventional pain relievers, but frequent and severe attacks require constant prophylactic treatment.

In the center “Matzpen” tension headache is treated by a combination of drug treatment with psychotherapy and physiotherapy methods.

Migraine is the second most frequent treatment after tension headache. Migraine attacks are usually severe and require treatment. The frequency of seizures is influenced by various factors such as lack of sleep, dehydration, noise, nutrition, fatigue, and overall physical condition. Migraine tendencies can be hereditary. The attacks usually last from several hours to several days. According to statistics, women suffer from migraines 2 times more often than men, since there is a connection between attacks and the menstrual cycle.Migraine headache is usually one-sided, throbbing, may be accompanied by nausea, vomiting. Light and noise during a seizure aggravate the headache.

About 25% of patients experience an “aura” – a special condition that precedes an attack. Most often, the aura is manifested by visual impairment, a feeling of fogging, light flashes, lightning. With this condition, there is no headache, it lasts no more than an hour. At the end of the aura, an attack begins.

For the treatment of migraine attacks, the Matspen center uses both nonspecific pain relievers and drugs designed specifically for the relief of migraine attacks.In addition, psychotherapy is one of the most effective and necessary methods of migraine treatment.

90,000 Chronic headache: evidence-based medicine data

One of the most common reasons for visiting a neurologist is chronic cephalalgia (CC), which is characterized by the presence of headache episodes for more than 15 days a month for 3 or more months. The diagnosis requires careful examination of patients, including neuroimaging techniques, to exclude other causes of chronic headache development.It should be noted that, in general, the diagnosis and treatment of HC is a difficult clinical task for a doctor, the successful solution of which can significantly improve the quality of life of many patients.
R.B. Halker et al. in the article “Chronic daily headache: an evidence-based and systematic approach to a challenging problem”, published in the journal Neurology, an attempt was made to summarize the available evidence-based medicine data and systematize approaches to solving this urgent problem.
Primary headache
Short-term headache
Short-term headache is characterized by a duration of about 4 hours and requires differential diagnosis with primary CC, which includes chronic cluster headache, trigeminal cephalalgia, characterized by intense orbital or temporal pain (accompanied by nasal congestion or watery eyes).Chronic cluster headache is pain noted for at least one year with remissions lasting up to a month, often requires differentiation from paroxysmal hemicrania (short-term unilateral headaches resembling neuralgia, with injection of the conjunctiva and lacrimation) and cephalalgia without lacrimation and injection of the sclera. They differ, first of all, in duration and frequency (Table 1).
Hypnic headache usually occurs in old age and occurs daily exclusively during sleep, often at the same time.Patients often wake up with a moderate diffuse headache (lasting less than one hour). In this case, lithium preparations, melatonin, indomethacin and caffeine are effective.

Prolonged headache
Prolonged headache includes migraine, tension headache, hemicranias continua , and chronic daily headache. Tricyclic antidepressants and cognitive-behavioral therapy are used to treat tension headaches. Hemicrania continua – moderately severe prolonged unilateral headache, often with exacerbation episodes, characterized by intense headache lasting from several hours to a day, which is accompanied by disorders of the cranial nerves. In this case, the use of short courses of indomethacin (25-75 mg
three times per day). Tension headache resembling clinically chronic cephalalgia is pain of a pressing or constrictive character of moderate intensity, accompanied by phono- or photophobia, nausea (in accordance with the International Classification of Disorders Associated with Headache).Chronic cephalalgia is a severe headache with a remission period of less than 3 days, and patients can often indicate its expected onset with an accuracy of one hour. According to clinical observations, this type of headache does not respond well to recommended therapy and requires a detailed study of the comorbid background.

Headache due to drug abuse
In a number of patients, when migraine attacks or tension headaches are relieved for more than 10 days a month, an abusal headache is noted, which develops with the frequent use of analgesics or combined drugs containing caffeine, codeine, barbiturates, opioids, as well as drugs containing ergotamine or triptan.A drug abuse headache is characterized by the following features:
• tendency to increase in frequency subsequently;
• frequent night awakenings;
• the nature of the headache loses its original features, resembling a tension headache;
• lowering the threshold of headache;
• a gradual increase in the dose of pain relievers is required;
• headaches occur at the same time, the effectiveness of pain relievers is reduced.
Proceeding from this, patients with HC should avoid uncontrolled intake of analgesics, including combined ones, due to the high risk of developing tolerance, drug dependence, as well as impaired renal, liver and gastrointestinal tract function.Particular attention should be paid to the accompanying chronic headache symptoms of depression and an increase in the level of anxiety, which requires drug correction, adherence to sleep / wakefulness and the inclusion of optimal behavioral therapy. In addition, it is necessary to inform the patient about the possibility of deterioration of the condition with the gradual cancellation of the usual doses of medications, which can last from 2 to 10 days. Non-combination pain relievers, including ergot, triptans, and some combination drugs are discontinued shortly, while opioids and butalbital-containing drugs are phased out gradually.At the same time, the use of phenobarbital is advisable when canceling drugs containing butalbital, and small doses of clonidine are able to stop withdrawal symptoms in case of opioid abuse. It is also possible to use non-steroid anti-inflammatory drugs, dihydroergotamine or corticosteroids in limited doses (no more than twice a week), which can significantly improve the quality of life of patients with CC.
Therapeutic approaches to the treatment of migraine and chronic cephalalgia
Migraine is a chronic headache with a frequency of 15 or more days per month
(> 8 episodes meet the criteria for seizure seizures) for at least 3 months, in the absence of drug abuse.It should also be borne in mind that about 2/3 of patients with migraine indicated episodes of excess of the recommended anti-migraine drugs. This shows the advisability of prescribing prophylactic agents without abrupt cancellation of the drugs used by the patient (the recommended cancellation period is
for at least 2 weeks). The majority of persons with migraine indicated the presence of such attacks earlier with their gradual increase. However, in 30%, a more drastic change in the course of the disease is possible. At the same time, risk factors according to controlled studies are: frequency of seizures of more than 4 per month, obesity (body mass index 30), an increase in the recommended dose of anti-migraine drugs, stress, trauma, bottom–
level of education / socioeconomic status, history of episodes of migraine attacks.Adequate drug and non-drug therapy, avoidance of risk factors, increased physical activity, moderate dehydration, control of symptoms of depression and anxiety levels (relaxation techniques, biofeedback, cognitive-behavioral therapy) can improve the quality of life of people with CC.
Patients suffering from migraine with frequent attacks, treatment-resistant cephalgias or headaches due to the abuse of antimigraine drugs require preventive treatment, taking into account the summation of the effects.The choice of medication must be carried out taking into account the concomitant diseases. Avoid prescribing funds that negatively affect their course. Several studies have evaluated several drugs recommended for the prevention of chronic headache and migraine (Table 2).

Thus, in a double-blind, placebo-controlled study of the efficacy of small doses of topiramate (50 mg / day) in the treatment of migraine and abusal headache, a decrease in the frequency of attacks per month was shown compared with placebo, as well as a decrease in the number of days with migraine attacks compared with basic indicators.The number of patients in this study who responded to therapy (decrease in seizure frequency> 50% within a month) was 71% in the treatment group and 7% in placebo.
In other larger randomized, double-blind clinical trials conducted in the United States and Europe, in which the efficacy of topiramate in patients with migraine or headache that develops due to persistent overdose of antimigraine drugs, similar trends were noted, confirming the positive effect of topiramate as a prophylactic agent in the treatment of migraine and chronic headache.

A pooled analysis of the efficacy of onabotulinotoxin A in the treatment of individuals with CC, migraine and tension headache, according to data from several double-blind, placebo-controlled studies, showed a significant reduction in the incidence of headache compared with placebo (onabotulinotoxin A – -8.4, placebo – – 6.6; p In addition, the efficacy of gabapeptin at a dose of
2400 mg / dayAfter 12 weeks of treatment, the average frequency of migraine attacks per month was 2.7 (baseline – 4.2) in the gabapentin group and 3.5 (baseline – 4.1) in the placebo group (p Results of a study of the efficacy of tizanidine in combination therapy for prevention of chronic cephalalgia showed its superiority in comparison with placebo in the main indicators (headache index, average number of days with cephalalgia, average intensity and duration of headache).
Another placebo-controlled trial investigated the possibility of using fluoxetine (starting dose of 20 mg) in the complex treatment of chronic cephalalgia.The data obtained indicated an increase in the number of days without the presence of cephalalgia compared with patients in the placebo group.
As a result of studying the ability of sodium valproate to arrest attacks of CC (migraine, tension headache), a decrease in the level of pain and the frequency of attacks was found, which was more pronounced in the group of people with migraine compared to those in the placebo group.
Thus, the correct definition of the type of cephalalgia, a thorough study of the comorbid background, a multidisciplinary approach to the examination and treatment of patients with HC will reduce the burden of headache among the population of many countries.

Prepared by Evgeniya Solovyova

90,000 Depression in disguise | | Bipolar.su

Today you can find many variants of the so-called. erased, “masked” depressions. In such cases, the patient may not be bothered at all by a decrease in physical activity, mood, a slowdown in the rate of reactions, and only one symptom may be observed, for example, pain, loss of appetite, or insomnia. If this symptom is the only one, it significantly complicates the diagnosis of the condition by a private psychoanalyst or psychiatrist.

Indeed, depression can sometimes take on the most unexpected forms. In this case, before still revealing the real cause of the ailment, a person can walk in a circle from one doctor to another for many years. Complaints of stomach, headaches, indigestion, skin itching, pressure drops after the examination are not confirmed.

What are the masks behind this ailment most often?

It happens that depression is hidden under the facial pains.In this case, its manifestations resemble neuralgia of the glossopharyngeal or trigeminal nerves of the mandibular and temporal joints, dental disease. The pains are quite severe, people, driven to despair, remove absolutely healthy teeth.
Abdominal syndrome. It manifests itself as painful, unpleasant sensations in the abdomen: heaviness, pain, feeling of cold or heat. This condition may be accompanied by constipation, nausea, diarrhea, and loss of appetite. The state of health becomes worse in the morning and at night.Often with similar symptoms, a person comes to the hospital with suspicion of food poisoning, appendicitis, cholecystitis. Surgical and / or therapeutic treatment that is aimed at combating such ailments does not bring results.
Headache without definite localization. The sensations can be different: there is a burning sensation, an iron hoop seems to squeeze the head, etc. in this situation, pain relievers are practically powerless. Often an imitation of the pain syndrome of this kind is vegetative-vascular dystonia or migraine.

It happens that depression takes the form of joint diseases, sciatica, neuralgia or muscle pain. This mask of depression is called arthralgia. After X-ray and other studies, it becomes clear that there are no joint and nerve lesions in the pain zone.
Cold or burning sensation in the chest, pain in the heart, palpitations … To distinguish this mask from actual cardiovascular diseases, you just need to do a cardiogram. The results of the examination for depression do not confirm the complaints.

In the early stages, depression can also manifest itself in sexual dysfunctions. In this case, there may be a tendency to coitus in the morning, deterioration of erection, delayed ejaculation. What does the psychoanalyst do in such cases? First of all, he understands the causes of the disorder, antidepressants are often prescribed.

Source: [link] http://obrydlo.ru [/ link]

Concomitant use of carbamazepine and lithium in the treatment of outpatients with bipolar disorder with fast cycles without psychiatric comorbidity: a randomized, double-blind, placebo-controlled trial | Aliyev

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