Migraine – Introduction

Some of you will know it has been my view for some time that the association between migraine and depression is closer than has generally been recognised. Evidence is now accumulating that this covers the genetics, pathophysiology and treatment of these two conditions.

The fact that both are common conditions does mean chance associations will be relatively common. Two epidemiological studies have both come up with similar statistics for an association between migraine, anxiety, and depression. That association is greater than can be explained by chance.

Merikangas’ prospective study suggests that for Migraineurs the lifetime course in 80% of cases is that anxiety precedes migraine, and in 75% depression succeeds migraine. A second large (but retro-spective) study produced reassuringly similar figures. Suicide attempt rates in migraineurs without depression were slightly elevated (7.1% vs 2.2% in controls); in migraine plus depression suicide attempt rate was high at 31.8%. This compared to depression alone at 16.5%.

Recent genetic studies further substantiate an association. These originate from Steven Peroutka who with Solomon Snyder just lost the race to ‘discover’ endorphins (to Hughes and Kosterlitz) and who then went on to become a leading world figure in 5-HT receptor sub-typing.

Their recent paper (Peroutka, S) about the genetics of depression and migraine concludes:–
‘These data indicate that migraine with aura, anxiety disorders, and major depression can be components of a distinct clinical syndrome associated with allelic variations within the DRD2 gene. Clinical recognition of this genetically based syndrome has significant diagnostic and therapeutic implications’.

This evidence suggests the wisdom of looking carefully for depressive symptoms in all those with migraine; it is logical that treatment decisions will be strongly influenced by co-morbidity.

Migraineurs without diagnosed depression may still have an increased risk of suicide.

When patients manifest both depression and migraine it is important to treat both conditions. It is useful to screen migraineurs for both past and family history of depression (especially bipolar disorder) and panic attacks. This will guide treatment. The association of migraine with bipolar disorder will influence antidepressant choice. for instance, Epilim may be considered for possible or definite bipolar cases.

This is a common problem and a fascinating area of therapeutics; it will reward your efforts with many grateful patients.


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