SCOTTSDALE, ARIZ. (FRONTLINE MEDICAL NEWS)Patients with migraine often have comorbid psychiatric conditions, but anxiety disorders particularly exacerbate pain, hypervigilance, and the tendency to catastrophize, said Steven Baskin, Ph.D.

“Anxiety is the driver of distress across most emotional disorders,” said Dr. Baskin, a psychologist at the New England Institute for Neurology and Headache in Stamford, Conn. The lifetime prevalence of anxiety disorders among migraineurs is 51%-58%, which is almost twice their lifetime rate of major depression, he added.

Panic disorder is particularly common in migraine patients, with an odds ratio of approximately 10 for migraine with aura and 3 for migraine without aura. However, community studies have also linked migraine to increased odds of generalized anxiety disorder, phobias, and obsessive-compulsive disorder, he said at a symposium sponsored by the American Headache Society.

Anxiety tends to worsen headache symptoms and disability, erodes short-term treatment satisfaction, and decreases therapeutic compliance to a greater extent than depression does, Dr. Baskin said. “Psychological interventions that target anxiety sensitivity may be helpful for headache,” he added.

These therapies include a “top down” approach based on cognitive-behavioral therapy, and a “bottom up” approach based on mindfulness, said Dr. Cynthia Stonnington, chair of the department of psychiatry and psychology at the Mayo Clinic, Phoenix. Cognitive therapy teaches migraineurs to reappraise their situation by focusing on past examples of their resilience and support system instead of catastrophizing their pain, she said. And mindfulness-based therapy trains patients to “make room by breathing, by being aware of what is happening in the body,” she added. “The more you can accept without judgment, and without all that stress and anxiety, the more you will be able to cope with that situation.”

Both therapeutic approaches help to lower the stress response, thereby helping to improve headache symptoms, Dr. Stonnington added. “Patients may be operating outside of their window of tolerance for much of their life without realizing it.”

Taking a longitudinal history also is important to accurately assess psychiatric disorders in migraineurs, Dr. Baskin emphasized. For example, anxiety disorders generally emerge before the onset of episodic migraine, while major depressive disorder typically follows it, he noted.

Genetics, early childhood trauma, and somatic sensitivity all affect the likelihood of anxiety disorders, Dr. Baskin said. Patients can be genetically more likely to develop neurotic personality traits, while severe illness or abuse during childhood can erode perceptions of control in adulthood, he said. Headache in patients who were mistreated as children “is more disabling and more likely to transform from episodic to chronic,” he noted.

In addition, some patients are acutely sensitive to bodily signals of stress or anxiety, such as increased heart rate, Dr. Baskin said. “These patients can feel their bodies, they notice something awry, and they fear it; they think this benign sensation is harmful, is potentially catastrophic,” he said. They are more likely to fear pain, to be affected by headache triggers, to have more frequent and disabling headaches, and to engage in maladaptive thoughts and behaviors, compared with patients with migraine who do not have a comorbid anxiety disorder, he said. Examples of maladaptive thoughts include, “I need to be completely headache free,” “Having migraines is intolerable,” “All these medications have horrible side effects,” and, “If I worry about it, I might prevent it,” he noted.

Patients with comorbid migraine and anxiety disorders also may view themselves as fragile, debilitated, easily unnerved, and helpless in the face of their condition, which tends to further worsen their disability, Dr. Baskin added. Patients also may frequently seek to control situations, see themselves as too special to deserve headaches or, conversely, worry about public humiliation about their migraines, he said.

Dr. Baskin reported serving on advisory boards and speakers bureaus and receiving research support from Allergan, Depomed, and Teva.


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