Dra. María Isabel Zamora

Migraine goes beyond being simply a headache; it is a complex neurological disease that frequently accompanies symptoms related to mental health. It affects more than 5 million people in Spain. Additionally, approximately 1.5 million Spaniards suffer from chronic migraine, characterized by occurring 15 or more days per month. Chronic migraine significantly reduces productivity, deteriorates quality of life, and leads to disability rates four to six times higher than those with episodic migraine. Despite its neurological origin, migraine often coexists with various psychiatric disorders such as depression, anxiety disorders, insomnia, bipolar disorder, etc., complicating its management and treatment. These mental health issues not only exacerbate the burden of migraine symptoms but also increase the risk of increased frequency and treatment resistance over time.

Many migraine patients face not only severe headaches but also persistent feelings of sadness and hopelessness. Depression affects a significant number of migraine individuals, impacting their quality of life and making pain management difficult. The relationship between depression and migraine is especially strong in cases of chronic migraine, where both conditions often worsen each other’s symptoms. Symptoms such as persistent sadness, loss of interest in activities, changes in appetite or weight, sleep disturbances, and difficulty concentrating can complicate migraine management. Treating depression with a combination of medication and psychotherapy can help improve overall mood and resilience, thus facilitating coping with the challenges posed by migraine. At Sinews MTI, a team of psychiatry and psychology professionals is available to offer assistance.

Anxiety disorders, such as generalized anxiety disorder, obsessive-compulsive disorder, and panic disorder, are also common among migraine patients. Moreover, stress and uncertainty of living with migraines can intensify anxiety symptoms, creating a cycle where anxiety triggers migraines and, in turn, migraines increase anxiety. This cycle can make managing both migraine and anxiety challenging, perpetuating and worsening both conditions.

Symptoms such as excessive worry, restlessness, muscle tension, and sleep difficulties can significantly impact the migraine experience. Therapeutic approaches like cognitive-behavioral therapy (CBT) are effective in managing anxiety symptoms, thereby alleviating their impact on migraine frequency and severity.

Stress activates the hypothalamic-pituitary-adrenal (HPA) axis, a regulatory system that controls the body’s response to stress. When a person experiences stress, whether emotional, physical, or psychological, the hypothalamus releases the CRH hormone (corticotropin-releasing hormone), which stimulates the pituitary gland to release ACTH (adrenocorticotropic hormone). This in turn acts on the adrenal glands to produce cortisol, essential for regulating the stress response. Cortisol is crucial for various bodily functions, including pain response. However, elevated and chronic levels of cortisol due to prolonged stress can have long-term negative consequences on health and contribute to pain sensitization.

Stress significantly affects health and migraines. Studies indicate that patients with chronic migraines report more stressful events preceding the chronification of their migraines compared to those with episodic migraines. Chronic stress and recurrent migraines can trigger structural changes in the central nervous system, increasing sensitivity to pain. Pain sensitization involves an enhanced response of the nervous system to painful stimuli. Functional magnetic resonance imaging studies have shown increased brain activation in response to pain in individuals with chronic migraines. Paradoxically, sudden reduction in stress can also increase the risk of migraine the following day, due to the abrupt reversal of stress-induced anti-inflammatory effects that alleviate pain.

Stress also influences psychiatric disorders; stressful or traumatic events, especially in childhood, increase vulnerability to major depression and other mental disorders. Chronic stress can induce genetic/epigenetic changes that alter the response to future stressors, thereby increasing susceptibility to migraines and psychiatric disorders. In the context of migraines, chronic stress may not only trigger episodes of acute pain but also contribute to pain chronification and heightened sensitivity to migraine triggers. Activation of the HPA axis and the resulting increase in cortisol levels may perpetuate chronic migraines and amplify pain perception in patients. Effectively managing stress not only prevents migraines but also improves overall physical and mental health. Consult with our neuropsychiatrist for guidance on your case.

There is a bidirectional relationship between migraine and bipolar disorder, especially migraine with aura. Approximately one-third of patients with bipolar disorder have migraines, with a higher prevalence in bipolar disorder type II. Both conditions share an episodic nature, sensitivity to stress, and family history, potentially linked through dysfunctions in calcium channels. Bipolar disorder, characterized by alternating periods of depression and mania or hypomania, can complicate migraine management. Mood instability associated with bipolar disorder can exacerbate the frequency and severity of migraines. Effective management of bipolar disorder through mood stabilizers, antipsychotic medications, and psychotherapy can help reduce migraine episodes and improve overall stability.

Sleep disorders are frequently reported by patients with migraines and are both a trigger and a consequence of migraines. Conditions such as insomnia, sleep apnea, and restless leg syndrome are common among migraine patients. Poor sleep quality can increase the frequency and severity of migraines, creating a vicious cycle that is difficult to break. Managing sleep disorders can lead to significant improvements in migraine symptoms. Improving sleep hygiene through regular sleep schedules, creating a suitable rest environment, and avoiding stimulants before bedtime can help reduce migraine frequency. For conditions such as sleep apnea, medical interventions such as continuous positive airway pressure (CPAP) therapy may be necessary to improve both sleep quality and migraine management.

While previous studies suggested a relationship between migraines and substance abuse, recent research indicates that this association may be confounded by factors such as depression and other psychiatric disorders. For example, patients with migraines tend to consume less alcohol, possibly due to its potential to trigger headaches.

However, abuse of other substances such as medications used to treat migraines can be a concern. Excessive use of medications, particularly analgesics, can lead to medication overuse headache, which worsens the frequency and intensity of the headaches. Addressing substance abuse issues through proper medical guidance, counseling, and support groups is critical for effective migraine management. Get advice on substance abuse from our psychiatry team.

Chronic migraine often evolves from episodic migraine and is linked to various risk factors such as depression, anxiety, obesity, and excessive medication use. Depression is especially important and increases the risk of chronic migraine. Effectively treating these psychiatric conditions can prevent migraine from worsening. It is crucial to adopt treatment approaches that consider both neurological and psychiatric aspects to improve quality of life.

Several hypotheses attempt to explain the bidirectional relationship between migraine and psychiatric disorders. These include shared genetic factors, common environmental triggers, and dysfunctions in systems such as serotonin regulation and the hypothalamic-pituitary-adrenal axis. Chronic stress and central sensitization are proposed mechanisms linking migraines to conditions such as depression and anxiety. Understanding these mechanisms can guide the development of targeted therapies that address both migraine and its psychiatric comorbidities.

Neuroimaging studies highlight abnormal brain function and connectivity in areas involved in emotional processing among migraine patients. Regions such as the anterior cingulate cortex, insula, and prefrontal cortex show altered activity patterns during pain and sensory processing, potentially contributing to the emotional aspects of migraines and comorbid psychiatric symptoms. These insights from brain imaging research underscore the importance of a comprehensive approach in migraine treatment that considers both neurological and psychological factors. By addressing the brain’s role in both pain and emotion, more effective and holistic treatment plans can be developed.

Despite the challenges, there are effective treatment options that can help manage both migraines and associated mental health problems. Initially, primary care physicians are the first point of contact for patients with migraines and typically prescribe pain relief medication for acute episodes. When primary care physicians deem it necessary for specialist intervention, patients are referred to neurologists, who are responsible for evaluating and managing specific migraine treatments.

For acute migraine attacks, pain relievers such as ibuprofen and triptans are effective options for quick and efficient pain relief. Additionally, depending on the frequency and severity of migraines, neurologists may recommend preventive pharmacological treatments such as beta-blockers (e.g., propranolol), antidepressants (such as amitriptyline), and antiepileptics (like valproic acid and topiramate). In cases where these treatments are insufficient or poorly tolerated, newer pharmacological approaches have been developed, such as monoclonal antibodies targeting calcitonin gene-related peptide (CGRP), which have shown high effectiveness in migraine prevention by significantly reducing the frequency and severity of episodes.

Furthermore, when treatment response is unsatisfactory, a psychiatric evaluation is crucial. This allows for the detection of psychiatric comorbidities that may contribute to poor treatment response or migraine chronification. Psychiatrists can identify and treat conditions such as anxiety disorders, depression, or other emotional issues that might impact the frequency and severity of migraines, using medication when necessary. At Sinews MTI, we have psychiatrists who will help you address psychiatric comorbidities.

In addition, behavioral therapies play a crucial role in the comprehensive treatment of migraines and their associated complications. These interventions, guided by specialized psychologists, use techniques such as cognitive-behavioral therapy (CBT) and stress management strategies to develop effective coping skills. Seek help from our psychologists.

This combination of treatments not only addresses the physical aspects of migraines but also focuses on psychiatric and psychological aspects, thereby improving the quality of life for patients.

In conclusion, migraine is a neurological condition that profoundly impacts the productivity and quality of life of millions of individuals. Despite its neurological basis, migraine often coexists with a spectrum of psychiatric comorbidities including depression, bipolar disorder, anxiety disorders, stress, sleep disorders, and substance abuse. These conditions not only increase healthcare utilization but also elevate the risk of migraine chronification and worsen overall disability.

Effective management of these psychiatric comorbidities is crucial to optimize migraine treatment outcomes and enhance the quality of life for affected individuals. Psychiatrists play a pivotal role in this context, employing a biopsychosocial approach to address the biological, psychological, and social dimensions of migraine comorbidities.

Adapting treatment approaches that integrate pharmacological and behavioral therapies is imperative, especially for patients with psychiatric comorbidities, to ensure comprehensive and personalized care in migraine management.

María Isabel Zamora is a physician with a double specialty in Psychiatry and Neurology. She has experience in the care of patients in general psychiatry consultations, and in a more specialized way, in the care of patients who combine psychiatric and neurological symptoms. She has worked with psychogeriatric patients and patients with functional diversity. She has experience in cognitive impairment, psychological and behavioral symptoms of dementia, psychiatric symptoms related to neurological disorders or chronic pain, autism, ADHD, adaptive disorders, depression, anxiety, addictions, bipolar disorder, obsessive-compulsive disorder, sleep disorders, eating disorders, etc.