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3 Articles in this Series
Introduction
Migraine: Neurologic and Psychiatric Management
Occupational Therapy in Pain Management
Opioid Prescribing: Calculating Risk in the Context of Today's Crises

Migraine: Neurologic and Psychiatric Management

A PAINWeek 2021Meeting Summary, featuring expertise from Charles Argoff, MD, Michael Clark, MD, MPH, MGA and Richard Lipton, MD

Many advances in the management and treatment for migraine have been made in the past few years, but many clinicians may be failing to recognize another important fact. Psychiatric comorbidities and migraine often coexist, and can complicate treatment.

That was the key message shared by neurologist Charles Argoff, MD, professor of neurology and director of the Comprehensive Pain Center at Albany (NY) Medical College – and a psychiatrist –Michael R. Clark, MD, MPH, MBA, professor of psychiatry and behavioral sciences, George Washington School of Medicine and Health Sciences, in their PAINWeek 2021 talk, "Who's on First? Psychiatric and Neurologic Management of Migraine."

"Major depression is one of the most common comorbidities," said Dr. Clark, but by no means the only one. "I think these patients [with psychiatric comorbidities] are normally going to be in your practice," Dr. Argoff added. So, clinicians in both specialties should not only expect to encounter these patients but also be prepared to develop a treatment plan for them.

As part of their talk, Drs. Clark and Argoff gave an update on migraine statistics and diagnosis and then discussed a few sample case histories, with suggested questions and treatment approaches to consider.

Listen to a case chat with Dr. Argoff on assessing chronic headache.

Migraine Statistics and Diagnostics

Migraine affects 1 in 5 women in the US, and three times as many women as men, the doctors said. Patients with migraine have 1.5 times more office visits and more than two times as many ED visits and inpatient admissions.1

The ID Migraine screener, a validated tool, can save time in making a diagnosis. It asks three simple questions:

  • Has a headache limited your activities for a day or more in the past 3 months?
  • Are you nauseated or sick to your stomach when you have a headache?
  • Does light bother you when you have a headache?

If the answer to 2 of the 3 questions is affirmative, a migraine diagnosis is likely, according to the tool.2

The likely coexistence of both migraine and psychiatric diagnoses points to the need and opportunity for different specialists to collaborate to deliver the best possible treatments, the doctors urged.

Migraine and Major Depression

A 33-year-old woman with refractory migraine and depressed mood reported a diagnosis of classic migraine since age 14, with increased frequency after that. Her treatment progressed from abortive to preventive, but her headache-free periods became fewer and the headaches less responsive to treatment.

Her depression diagnosis was made in college, with anhedonia and fatigue. Treatment with SSRIs led to sexual dysfunction; TCAs caused sedation; bupropion worsened the headaches. When looking at the coexistence of depression and chronic pain, the doctors noted, it's important to realize many patients with depression report pain symptoms at the time of diagnosis. 

Among the take-home points for this case history is the medication used, Dr. Clark said. His take is that TCAs are the ''old gold standard," SSRIs have been overly used, and SNRIs should be the current focus of treatment in such cases.

Migraine and Medication Misuse

The second case presented was of a 56-year-old man with low back pain and headache with a history of a motor vehicle accident with a TBI.  He reported pain ''everywhere"  but the worst pain in the low back, shoulders and neck. The headaches he had were pulsating, linked with sensitivity to light and noise, and included nausea, dizziness, vomiting and fatigue.

He had been treated with a host of medications, ranging from opioids, gabapentin, muscle relaxants and OTC analgesics. He was referred to neurology with a diagnosis of post-concussive migraine; his care team included primary care, physical medicine and rehabilitation, and sports medicine professionals.

Among the questions clinicians would need to address in this scenario: is post-concussive headache a subset of migraine and whether aberrant drug-taking behavior (ADTB) applies. Further, does the patient need a psychiatric referral?

Conclusions from the clinic professionals who observed the patient were that he was ''stuck" repeating a deviant behavior. He identified as ''needing" his medication and ADTB has become a way of life rather than a disruption of life.

Among the approaches to address this patient’s concerns: talk about the conflict of wills, confront his reluctance to change, strengthen the provider-patient relationship, and help him strive to make better choices.

Changing a habit must focus on identifying the routine, experimenting with rewards and isolating the cue. Dr. Clark suggested: Have the patient ask himself where he was when the cue occurred, the time, his emotional state, who else is nearby and what action came before the urge for ADTB?

Next, a plan must be put into place—what to do when urge strikes—if the routine is going to change.

Migraine and Borderline Personality Disorder

A 28-year-old woman with uncontrollable headaches was diagnosed with migraine during adolescence. She had trouble becoming independent after college. She experimented with recreational drugs and showed anger over the lack of treatment progress, as well as anxiety. She had obtained medications from multiple consultations but was requesting even more to find the ''right fit."

Questions to ask, Dr. Argoff suggested: Would you diagnose an active migraine syndrome? What type of mental health professional would you consult?

This patient also had borderline personality disorder (BPD), a comorbidity that is far from rare in people with chronic pain conditions, including migraine. Published research has shown a that 30% of patients with chronic pain have BPD.

BPD is marked by frantic efforts to avoid real or imagined abandonment. There is often a pattern of unstable, intensive personal relationships. Impulsivity (sex, spending, binge eating, etc.) is a common behavior. (More about borderline personality disorder on our sister site Psycom Pro.)

The goals for treating BPD and chronic pain are similar, including improving functioning and the patient’s ability to tolerate discomfort, as well as the development of improved coping skills. Clinicians, noted the speakers, should emphasize and encourage behaviors based on thoughts, not feelings.

Practical Takeaways for Clinicians

It's important to help patients understand that change is possible, Dr. Clark told Practical Pain Management (PPM). A clinician should help them realize ''they have the capacity to design and execute a plan of change and you will help them." 

As for these challenging cases, he said, ''It's really not that they are untreatable or too difficult to manage. If you are aware of these problems and comorbidities, they become really manageable cases." (More on chronic medical and psychiatric comorbidities.)

The coexistence of the two conditions should not surprise clinicians, added Richard Lipton, MD, the Edwin S. Lowe Professor and Vice Chair of Neurology at Albert Einstein College of Medicine, New York, who reviewed Dr. Clark and Dr. Argoff’s presentation, noted "Should a doctor expect to see these patents? Yes – if they look for pain in their patients with depression or anxiety and look for psychiatric comorbidities in their patients with migraine and other pain disorders." 

While the patients can be challenging, Dr. Lipton agreed clinicians shouldn't give up.  "The key is to recognize all the problems that are present and develop a plan that addresses them," he said. "In my practice, I have a team that helps manage difficult patients and the support of colleagues makes it easier. And when patients improve, that can be incredibly gratifying."

In his practice, Dr. Lipton screens new patients with headache disorders for depression, using the PHQ-9 and for anxiety using the GAD-7. He is vigilant about other possible comorbidities, too, psychiatric or otherwise.  "Similarly, it may be good practice to look for pain in patients with depression." In this context, he said, the ID-migraine tool, which he developed and validated, may be useful.

Disclosures: Dr. Argoff reports consulting work/advisory board for BSDI, Vertex Teva, Amgen, Lilly, Neumentum, Collegium, Lundbeck, Gruenenthal, Redhill Pharma. Dr. Clark has no disclosures. Dr. Lipton consults for several migraine pharmaceutical companies and holds stock options in Biohaven and CntrlM.

 

Sources

  1. Migraine Research Foundation. Migraine facts. Available at: https://americanmigrainefoundation.org/?s=migraine+facts Accessed September 2021.
  2. Lipton, RB, Dodick D, Sandovsky R. A self-administered screener for migraine in primary care: the ID migraine validation study." Neurol. 2003;12:61(3) 375-82.
  3. Sansone RA, Sansone LA. Chronic pain syndromes and borderline personality. Innovations in Clinical Neurosci. 2012: 9(1):10-4.
Next summary: Occupational Therapy in Pain Management
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