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Ask the Mental Health Expert Archives 2001-2004

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Complex Combination of Conditions

Q. I am a 31-year-old white male suffering from major depressive disorder and generalized anxiety disorder. Throughout the years I've been on a myriad of SSRIs and other medications. I also have been suffering, since puberty, from classic and contemporary migraines, for which I have taken different types of pain and migraine medications.

I was recently diagnosed with schizoaffective disorder. What are the best treatments for me with these disorders and migraines? Is there a connection between migraine headaches and depression and/or anxiety disorders? I ask this because during or after an anxiety or panic attack I get a migraine or tension headache.

If there is no answer, is there research being conducted about a possible connection between mental disorders and migraines?

A. You have a complex combination of conditions, and it would be inappropriate for me to speculate on what the best treatments for you would be. That depends greatly on what you have taken in the past; how well you tolerated them; what treatments you have not yet had, etc. Careful attention would need to be paid to the risk of drug-drug interactions, as well. That said, I will try to provide you with some options to discuss with your doctor(s), based on some of the latest research.

But first--to answer your second question--there is some evidence linking migraine headache with certain psychiatric conditions. For example, in one survey of about 1000 young adults, a strong association was found in those with migraine and the incidence of major depression, panic disorder, and generalized anxiety disorder (Breslau et al, J Psychiatr Research 1993;27:211-221).

Furthermore, in a recent U.S. community sample of individuals with probable bipolar disorder vs. those without it, there was a correlation between bipolar disorder and the presence of several conditions. Anxiety (30% vs. 6% in those without bipolar disorder), panic attacks (18% vs. 4%), migraine (24% vs. 11%), asthma (17% vs. 10%), and allergies (42% vs. 29%) were significantly more common in those with probable bipolar disorder.

What do these associations mean? We don't really know. It is tempting to speculate that some underlying genetic predisposition may be the missing link. This, in turn, may affect the likelihood of abnormalities in certain brain chemicals. For example, the function or levels of the neurotransmitter serotonin is thought to be abnormal in depression, anxiety, and in migraine. (Of course, this is grossly over-simplifying the situation--many other factors, both biochemical and psychological, are also involved in these conditions).

Regarding migraine and anxiety, it has long been reported that the migraine headache often comes on not during a stressful event, but in the aftermath--as a sort of let down phenomenon. So, if you tend to get these headaches after a panic attack, it would certainly make sense to go after the panic attacks very aggressively.

In addition to medications, cognitive-behavioral therapy (CBT) may be very helpful for panic attacks. I think it's also important that you try to pin down the basis for the diagnosis of schizoaffective disorder, since this is probably a rather motley collection of related conditions. To the extent that schizoaffective disorder resembles bipolar disorder, the treatments may be similar. In addition to mood stabilizers (such as lithium and lamotrigine), atypical antipsychotics, such as olanzapine and risperidone, may be useful in schizoaffective and bipolar conditions.

It's not clear to me what effect these agents would have on your migraine headaches, but I'm not aware of any prohibition of these agents based on a migraine diagnosis. Valproic acid [divalproex, Depakote] has a role in the management of bipolar disorder, panic disorder, and perhaps schizoaffective disorder, as well as in the long-term management of migraine headaches.

So--in theory--it might be a broad spectrum agent that could be of use in your case. Interestingly, a medication used in the past for seizures has recently found a place in the management of bipolar disorder and possibly also migraine (D'Andrea et al, Cephalalgia. 1999 Jan;19(1):64-6)-this medication is called lamotrigine. It may or may not be appropriate for you, and carries with it some important risks and side effects. However, it does have antidepressant effects in bipolar and probably also unipolar depression, and may be worth discussing with your doctor. I hope your treatment works out well for you.

December 2003

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