Patients with refractory chronic migraine may also have a high prevalence of comorbidities, including anxiety, depression, bipolar spectrum, and personality disorders.
Patients with refractory chronic migraine (RCM) experience a great deal of disability related to their chronic headaches. Significant abuse in childhood, whether sexual, physical, or emotional, may predispose a person to the development of RCM, separately or in conjunction with other central sensitization syndromes such as fibromyalgia, irritable bowel syndrome, chronic pelvis pain, and temporomandibular disorder .
Important comorbidities include anxiety, depression, bipolar spectrum, personality disorders (PDs), somatization, and post-traumatic stress disorder.
Bipolar Spectrum
The bipolar spectrum is seen relatively often in headache patients, particularly among migraineurs. The depression and hypomania of the bipolar spectrum complicate treatment in RCM patients, and this must be recognized. The clinical spectrum of bipolar is an evolving concept: mania is better recognized than is hypomania with milder bipolar features. Symptoms of mania include euphoric mood, distractibility, flight of ideas, grandiosity, thoughtlessness, risk-taking, increase in general activity, excessive involvement in pleasurable activities (sex, spending, gambling), pressured speech, excited or irritable mood, and insomnia. Hypomanias, with milder versions of these symptoms, can be missed if a doctor relies solely on the patient’s own history; it is important to talk with a family member or significant other to get a complete history. In addition, brooding or irritable pessimism may be a manifestation of hypomania. During these periods, many people will lose jobs or damage relationships.
Approximately 4% of the population suffers from bipolar disorder, but bipolar illness is seen with increased frequency in the migraine population. Studies have indicated that from 7.2% to 8.6% of migraine patients fit the definition for bipolar spectrum. Conversely, several studies have indicated an increased risk for migraine in patients with bipolar spectrum disorders. One study indicated that in bipolar patients, 14.9% of the men and 34.7% of the women had a lifetime occurrence of migraine. Additional studies of the bipolar population resulted in a lifetime migraine prevalence of 39.8% for men and 44% for women.
Recognizing bipolarity in headache patients has a significant impact. When bipolar disorder is not recognized, these patients often are given antidepressants alone, with predictably poor results. While of some benefit, these medications generally are not effective for the bipolar spectrum and may trigger mania or hypomania. The presence of bipolar illness complicates the treatment of RCM. Mood stabilizers that help both conditions, such as lamotrigine or sodium valproate, are important. Atypical antipsychotics—quetiapine (Seroquel, others), olanzapine (Zyprexa, others), aripiprazole (Abilify), etc.—sometimes help both headaches and moods. Psychotherapy plays a vital role with these patients.
Personality Disorders and Migraine
In patients with certain PDs, failure on the part of the physician to recognize Axis II pathology puts both doctor and patient at risk. Patients with antisocial, borderline, or paranoid PDs may wreak havoc on an unsuspecting medical practice.
Approximately 10% to 15% of people have features of a PD. There are a number of PDs, and some exhibit more dangerous and difficult behavior than others. The general characteristics of PDs include lack of insight, poor response to psychotherapy and other therapeutic interventions, difficulty with attachments and trust, a sense of entitlement, and the creation of chaos and distress among family, friends, and coworkers. Comorbid substance abuse is common. PDs range from the mild to the very severe. Patients with PDs will take on various roles: victim, rescuer, or persecutor. When they turn persecutor, they can be dangerous to the person they have their sights set on. Seeing a therapist for a long time helps to some degree. However, goals and expectations must be limited. The plasticity of the brain is important, with some people improving naturally over time.
Antisocial Personality Disorder
These people have no regard for the rights of others. They tend to be irritable and impulsive in demeanor. They are exploitative, often seeing themselves as superior, and can be very opportunistic in getting what they want. Antisocial people are deceitful, may steal from those around them, and often have trouble with the law. They rarely show remorse.
Borderline Personality Disorder
This type of personality shows instability of mood, poor self-image, and pervasive abandonment fears. There is an identity disturbance and major boundary issues. Borderline personality disorder (BPD) patients usually demonstrate impulsiveness, and quick shifts of depression to anxiety to irritability. There are chronic feelings of emptiness or severe loneliness, plus anger and even suicidal behavior. Under stress, they can become paranoid. Problems with drug abuse or other addictive behaviors may coexist, as well as sleep disturbances with insomnia.
Patients with severe BPD will react with high drama and create chaos for everyone around them. They tend to have a split view, seeing people as wonderful or terrible, with nothing in between. Suicide becomes more likely as patients age into their upper twenties and thirties. Suicide also is more common within a week of discharge from a psychiatric unit.
One study found that BPD comorbidity with migraine is associated with increased disability from the headaches. In addition, among those with BPD, there was an increase in medication overuse headache, and headaches were more severe. There was a higher degree of depression among those with BPD, more unscheduled visits for acute headache treatment, and a lesser chance of adequate response to headache medications. Patients with BPD were more severely affected by headaches, and more inclined to be refractory to treatment.
Another study indicated that the incidence of BPD was increased in migraineurs. A study of 1,000 migraineurs indicated that 5.5% of patients had a moderate or severe BPD. There is ample evidence that transformed migraine is associated with more prevalent psychopathology, including PD, than is episodic migraine. BPD itself is the mental health equivalent of chronic pain. These patients suffer constantly with feelings of depression, anxiety, and loneliness.
Prognosis
There are other PDs that are not as dangerous for the people around them. Although PD characteristics seem extreme, they often are overlooked, and health care providers may react by treating these patients in a dysfunctional manner. The problem begins with not recognizing the PD patient.
Patients with refractory chronic migraine may also have a high prevalence of comorbidities, including anxiety, depression, bipolar spectrum, and personality disorders.
The 2 most important prognostic indicators for those with PD are impulsivity and substance abuse. Treatment for those with PD necessitates a caring, but stern, approach. Limits must be set on physician contact, including telephone calls, and no abuse of staff should be tolerated. Referral to mental health professionals should be emphasized. Psychotherapists and psychiatrists who are experienced with this population are vital to the adequate management of the patient. Many PD patients do not do well with traditional, insight-oriented therapy but are better managed long-term with a dialectical behavioral approach. For a therapy to be beneficial, it must be consistent and long-term. A psychoeducational approach may also be helpful. Unfortunately, many PD patients will not continue in therapy, even with encouragement and support. Therapeutic goals for the PD patient are relatively modest.
Medications, though limited, may be beneficial for the impulsivity, aggression, self-mutilation, anxiety, and depression components of PD. While there are no specific medications indicated for those with PD, the mood symptoms are more amenable to pharmacotherapy. Antidepressants, mood stabilizers, and antipsychotics may ameliorate symptoms. Some of these medications may lessen headache pain as well. PD patients with severe, chronic pain present additional challenges for treatment. It is important to limit and closely monitor addicting medications: opioids and benzodiazepines are best avoided, particularly for those with BPD. The diagnosis of a moderate or severe PD alters both our goal and approach, and greatly complicates the treatment for chronic migraine.