June is National Migraine & Headache Awareness Month, a time in which organizations such as the Coalition for Headache and Migraine Patients (CHAMP) and the National Headache Foundation spread awareness about the debilitating impact this condition can have on patients. This year’s theme from CHAMP is “Educate Yourself, Educate Others.”¹
Education is critical because while many people may be aware of the pain migraine and headache disorders can cause, they may not be as informed on the different ways the conditions can manifest and affect patients. A migraine can have a significant impact on a person’s ability to perform their daily routine, causing them stress and affecting their quality of life. Migraine disorders are often associated with psychiatric comorbidities, which can worsen the stress a patient is experiencing.
If a patient is at risk of developing migraine, they should be aware of this association. What are some of the psychiatric comorbidities that patients with migraine and headache disorders may be at an increased risk of developing?
Anxiety disorders are among the most common psychiatric comorbidities associated with migraine and headaches. A 2022 review in Cureus examined studies on the correlation between the two and concluded that there was a bidirectional relationship.² The recurrent headaches of a migraine disorder can lead to anxiety and distress, which can increase the risk of chronic migraine. The way these disorders interact with one another can be particularly detrimental to a patient’s quality of life, and the researchers concluded that screening for current or future presence of anxiety disorders should be part of migraine care.
Other studies have come to similar conclusions, including those focused on specific types of patients with migraine. Researchers of a 2022 study published in Hospital Pediatrics found associations between migraine and a number of psychiatric comorbidities, including anxiety disorders, in pediatric patients.³ Of the 21,436 patients examined in the study, 32% presented psychiatric comorbidities, with anxiety as the top diagnosis (11.2%). Pediatric patients with psychiatric comorbidities were more likely to have longer hospital stays and higher treatment costs.
Another study, published in BMJ Open, used Japan’s National Health and Wellness Survey to look for associations between migraine and comorbidities and found patients with migraine had a significantly higher rate of anxiety and social anxiety than patients who did not report migraine disorders.⁴
Post-Traumatic Stress Disorder
Post-traumatic stress disorder (PTSD) is another psychiatric condition the researchers have found to be much more frequently reported among patients with migraine than those without. Via the survey, 7.7% of the 378 patients with migraine disorder had PTSD as a comorbidity compared to just 0.7% of the 1,512 patients without migraine.
While PTSD cannot cause a migraine disorder, it has been posited that patients with migraine can be 3 to 4 times more likely to develop PTSD.⁵ Similarly bidirectional in nature, the stress of PTSD symptoms can increase the risk of more frequent headaches, which in turn may cause more difficulty for a patient already dealing with the stress of their trauma.
Studies that cite anxiety disorders as a common psychiatric comorbidity for migraine often similarly mention depression. In the aforementioned Hospital Pediatrics study, for example, 6.7% of pediatric patients presented with depression.³
It has also been suggested that the type of migraine may affect a patient’s risk for depression. A 2020 study in Headache: The Journal of Head and Face Pain concluded that the psychiatric comorbidities of patients with migraine disorder played a role in the likelihood of headache-related disability.⁶ The investigators found that subjects with chronic migraine were more likely to have depression than those with episodic migraine; this was also true for subjects with anxiety and subjects with both. The researchers also identified that although having only depression or anxiety was highly associated with increased headache-related disability, having both was associated with a significantly higher risk of disability.
The correlation between migraine and depressive disorders, including major depressive disorder, make it paramount that your patients keep an eye on their mental health. Working to make sure they are receiving treatment for depressive disorders may help reduce the risk of headache-related disability.
Panic disorder is a similarly burdensome psychiatric condition that has been associated with migraine and headaches. Though also a bidirectional association, it has been estimated that patients with migraine may be as much as 9.6 times more likely to be diagnosed with panic disorder.⁷ The combination of migraine symptoms and the physical effects of a panic attack can make it difficult to perform daily tasks.
There is an association between migraine and bipolar disorder, and it has been suggested that parental migraine may be a risk factor for bipolar disorder even if the parent does not have bipolar disorder.⁸ Migraine symptoms may make it more difficult to manage the symptoms of bipolar disorder, and more research is needed on the underlying mechanisms of the two.
Patients who experience migraines but don’t have psychiatric comorbidities can still have comorbidities that are likely to affect their stress and mental health. Researchers of a 2022 study in The Journal of Headache and Pain examined the behavioral and psychological factors in patients with migraine but without psychiatric comorbidities and found that issues with sleep were a consistent factor.⁹ Subjects with chronic migraine presented with more severe insomnia symptoms than a control group, as well as poorer sleep quality and greater sleep disturbances. Subjects with episodic migraine had better sleep quality than those with chronic migraine, but still had worse quality and more severe symptoms of insomnia than the healthy control.
Sleeping difficulties can cause patients to struggle with their mental health and can affect their ability to perform daily tasks, which may be made worse when also managing migraine symptoms. Given the many different ways migraine can affect a patient’s mental health, it’s important that treatment addresses a patient’s psychiatric symptoms.
1. About MHAM. National Migraine & Headache Awareness Month. https://www.migraineheadacheawarenessmonth.org/about-mham/. Accessed May 30, 2023.
2. Kumar R, Asif S, Bali A, Dang AK, Gonzalez DA. The development and impact of anxiety with migraines: a narrative review. Cureus. 2022 Jun 29;14(6):e26419. doi: 10.7759/cureus.26419. PMID: 35923673; PMCID: PMC9339341.
3. Kafle M, Mirea L, Gage S. Association of psychiatric comorbidities with treatment and outcomes in pediatric migraines. Hosp Pediatr. 2022;12(3):e101-105. doi:10.1542/hpeds.2021-006085
4. Kikui S, Chen Y, Ikeda K, Hasebe M, Asao K, Takeshima T. Comorbidities in patients with migraine in Japan: a cross-sectional study using data from National Health and Wellness Survey. BMJ Open. 2022 Nov 30;12(11):e065787. doi: 10.1136/bmjopen-2022-065787. PMID: 36450434; PMCID: PMC9716839.
5. Pedersen T. PTSD and headaches: relationship and risk. Psych Central. https://psychcentral.com/health/ptsd-headaches. Updated June 9, 2022. Accessed May 31, 2023.
6. Lipton RB, Seng EK, Chu MK, et al. The effect of psychiatric comorbidities on headache‐related disability in migraine: results from the chronic migraine epidemiology and outcomes (CaMEO) study. Headache. 2020;60(8):1683-1696. doi:10.1111/head.13914
7. Dresler, T., Caratozzolo, S., Guldolf, K. et al. Understanding the nature of psychiatric comorbidity in migraine: a systematic review focused on interactions and treatment implications. J Headache Pain 20, 51 (2019). https://doi.org/10.1186/s10194-019-0988-x
8. Duan J, Yang R, Lu W, Zhao L, Hu S, Hu C. Comorbid bipolar disorder and migraine: from mechanisms to treatment. Front Psychiatry. 2021 Jan 11;11:560138. doi: 10.3389/fpsyt.2020.560138. PMID: 33505322; PMCID: PMC7829298.
9. Pistoia, F., Salfi, F., Saporito, G. et al. Behavioral and psychological factors in individuals with migraine without psychiatric comorbidities. J Headache Pain 23, 110 (2022). https://doi.org/10.1186/s10194-022-01485-x