Are Migraine and Generalized Anxiety Disorder Related?

Everybody on earth has some degree of stress or anxiety.  They might not be able to talk about it or identify it, but anxiety is part of  the universal human condition.  As a practicing neurologist and headache doctor I learned that many persons when asked if they were “anxious or stressed” would answer “no” but their stress would be revealed later in the interview by complaints of poor memory, trouble sleeping, or constant pain in the back of their neck, jaw, or shoulders.

People may say that their boss is a “pain in the neck,” a symptom common with the muscle tension part of Generalized Anxiety Disorder (GAD) which includes tension in the neck and shoulders.  The boss is the problem, but the patient gets the pain—in his neck.  This is a backward way of a patient saying they are stressed, especially by their boss who may be demanding and strict.

Half of persons with insomnia have GAD, the most common cause of sleeplessness.  Some people think that have Alzheimer’s dementia because they can never remember things well, yet they test well cognitively and really just have poor concentration, another cardinal GAD symptom.

Mental tension means “time pressure” or the feeling of having to work under the pressure of the clock to get a project done.  Such a person may feel he doesn't have time for lunch and so he misses a meal and gets a "hungry headache."  All these scenarios describe anxiety situations.

Many persons with Migraine have difficulty grasping what is driving their headaches. An explanation of Migraine triggers might help them.

Read my article, “List of Common Migraine Triggers” on my website, www.doctormigraine.com.

Read my Mini Book on Migraine Here.



This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, podcaster, YouTube video producer, and blogger.

Migraine and Generalized Anxiety Disorder are 40% comorbid, a term that means these two medical conditions occur more often than by chance.  40% comorbid means that these 2 medical conditions occur together 40% of the time.  Migraine is a complicated, disabling medical problem that comes with one-sided, moderate to severe headaches, which are throbbing and are associated with sensitivity to light and noise, and nausea and vomiting.

Generalized Anxiety Disorder is commonly associated with patients who perceive stress or tension in their lives, who don’t sleep well, and complain of chronic tightness in the muscles of their neck, back, and shoulders.

Definition of GAD.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) generalized anxiety disorder is defined as:

The patient complains of symptoms of excessive anxiety and worry about a variety of topics, events, or activities.  The worry could be about employment or the patient’s own or a family member’s health.

The worry is difficult to control and not related to a threat or prevalent risk.  Patients with GAD spend a lot of their daytime worrying about something.

The patient’s anxiety and worry come with at least 3 of the following symptoms.

The symptoms occur for more days than not during the past six months.

The symptoms cause significant distress or social impairment.

The patient has at least three ancillary symptoms which are:

Restlessness or mental tension

Fatigability, easy tiring.

Poor concentration as if the mind goes blank.

Irritability

Increased muscle tension and soreness in the neck, shoulders, jaw, or teeth, grinding or bruxism.

Trouble sleeping which may come with difficulty falling asleep, maintaining sleep, night restlessness or unsatisfying sleep.

Exclusion of diagnosis of GAD.

The focus of anxiety or worry is not another disorder (for example, panic disorder).

The symptoms are not part of a mood disorder, psychotic disorder, or pervasive developmental disorder.

The symptoms do not relate to substance use.

The symptoms are not due to an organic medical condition.

Definition of Migraine without aura according to the International Classification of Headache Disorders 3rd edition (ICHD3).

Description:

Recurrent headache disorder manifesting in attacks lasting 4-72 hours.  Typical characteristics of the headache are unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity and association with nausea and/or photophobia and phonophobia.

Diagnostic criteria:

A. At least five attacks fulfilling criteria B-D

B. Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)

C. Headache has at least two of the following four characteristics:

1.     unilateral location

2.     pulsating quality

3.     moderate or severe pain intensity

4.     aggravation by or causing avoidance of routine physical activity (e.g., walking or climbing stairs)

D. During headache at least one of the following:

nausea and/or vomiting

photophobia and phonophobia

Not better accounted for by another ICHD-3 diagnosis.

See my article, What is Migraine?” on my website, www.doctormigraine.com.

Definition of Tension Type Headache

Tension Type Headache has the following criteria:

A. At least 10 episodes fulfilling criteria.

B. Headache lasting from 30 minutes to 7 days.

C. Headache has at least two of the following characteristics.

1.      Bilateral location

2.      Pressing/tightening (non-pulsating) quality

3.      Mild or moderate intensity

4.      Not aggravated by routine physical activity such as walking or climbing stairs

D. Headache has both of the following:

No nausea or vomiting (anorexia may occur)

Nosology

Migraine without aura was previously called “Common Migraine” while Migraine with aura was called “Classical Migraine.”  Many patients mistakenly believe that unless one has visual type auras with seeing holes, spots, or zig-zag lines the diagnosis is not migraine. 

Many online writers erroneously discuss muscle tension as part of migraine, yet these features go with Tension Type Headache.

Tension Type Headache has been called muscle contraction headache, psychomyogenic headache, stress headache, ordinary headache, essential headache, idiopathic headache, and psychogenic headache.

Read my article, “Migraine or Tension Type Headache?” on my website, www.doctormigraine.com.

Generalized Anxiety Disorder has been called “stress” and “nervousness.”

Epidemiology/Prevalence

Migraine is an extremely disabling condition and first in frequency of all disabling neurological diseases. 

Almost 3 % of worldwide disability attributable to a specific disease, in terms of years lived with a disability, is due to migraine.

Twenty-five % of women and 6% of men have migraine.

The overall prevalence of migraine is 12%.

40 to 50% of Americans living with migraine also have anxiety. 

Persons with migraine may be up to 5 times more likely to have anxiety than persons who don’t.

Migraine is a multifactorial disorder which links genetic, hormonal, environmental, dietary, sleep, and psychological aspects differently in each individual.

Migraine is a bio-behavioral disorder.

Generalized anxiety disorder (GAD) is highly prevalent.  In the United States, the lifetime prevalence of GAD is estimated to be about 5% and the current prevalence to be about 2% to 3%.

The National Comorbidity Survey (NCS; conducted from 1990 to 1992) found that lifetime prevalence rates for any anxiety disorder were 30.5% for women and 19.2% for men (Kessler et al., 1994).

Prevalence rates were also higher in women than men for each anxiety disorder examined, including panic disorder (PD; 5.0% vs. 2.0%), agoraphobia (AG; 7.0% vs. 3.5%), specific phobia (15.7% vs. 6.7%), social anxiety disorder (SAD; 15.5% vs. 11.1%), generalized anxiety disorder (GAD; 6.6% vs. 3.6%; Kessler et al., 1994), and posttraumatic stress disorder (PTSD; 10.4% vs. 5.0%; Kessler, et al., 1995).

The course of GAD is chronic and can be worsened by poor family relationships, comorbid personality disorders, and comorbid depression.

A 2017 Canadian population health survey showed that 6% of people with migraine had experienced GAD in the past 12 months, compared with only 2.1% of those without migraine. This study confirms the findings of previous research regarding the strong association between migraine and GAD.

Anxiety disorders are the most common psychiatric conditions in the United States, affecting more than 18% of the adult population each year.

Generalized anxiety disorder, characterized by excessive and persistent worry accompanied by physical symptoms, affects an estimated 3.1 percent of these adults.

The anxiety disorders that have shown the strongest association with migraine are GAD, obsessive-compulsive disorder, and panic disorder.

Studies have shown that people with GAD may be more likely to develop migraine and that those with migraines may be at a higher risk for GAD.

Untreated anxiety disorders such as GAD may contribute to shifting from episodic migraine (fewer than 15 migraines per month, to chronic migraine (15 or more migraines per month, 8 of which have migraine features).

Many times,  this shift occurs because of overtreating their headaches with pain killers, resulting in medication overuse headache and chronic migraine.

Studies in families and identical twins have found that generalized anxiety disorder is about 32% heritable, indicating that although genes contribute to vulnerability, environmental factors play a larger role. Epidemiological studies report that women account for two-thirds of those affected.

Tension-Type Headache is a highly prevalent condition that can be disabling.

Published estimates of the prevalence of tension-type headache vary over a wide range from 1.3% to 65% in men and 2.7% to 86% in women.

Anxiety can after some time, or in case of major anxiety, lead to tension-type headache.  If you are anxious, your entire body tenses up and your body also becomes exhausted.  This can cause tension, especially tension in the neck, to remain in the body.

Genetic link

Migraine is a complicated, genetically related, neurovascular disorder which clusters in families.  Specific genes for hemiplegic migraine have been determined but for the usual occurring types of migraine, which are migraine without aura and migraine with aura, the best that can be said now is that migraine is a polygenic condition.

Generalized Anxiety Disorder (GAD) is related to migraine 40% of the time.  GAD especially relates to chronic migraine.

Age affected

Migraine starts usually in the teens or early 20s. It is most common in the 30 to 40 age group.  At least 90% of people with migraine experience a first attack before the age of 40.

Migraine generally improves with ageing, usually after age 50.

GAD usually first appears from young adulthood through the mid-50s.  One study reported that only 3% of patients first developed generalized anxiety disorder after age 65.

The disorder tends to be chronic, however, with symptoms that fluctuate in intensity over time. The typical life stresses that occur with old age, such as the death of a loved one or personal illness, may cause symptoms to flare up.

Neurologic workup

Patients with migraine or generalized anxiety disorder need to have medical tests to rule out possible medical conditions.

A normal MRI scan of the brain with and without contrast will usually eliminate concerning brain disease and can be very reassuring to the anxious migraine patient.

Blood work such as a CBC, sed rate, urine analysis, thyroid panel, and electrolytes should be done.

Common medical problems that may mimic anxiety include:

Heart disease.

Diabetes.

Thyroid problems, such as hyperthyroidism.

Respiratory disorders, such as chronic obstructive pulmonary disease (COPD) and asthma.

Drug misuse or withdrawal.

Duration of attack

A single migraine attack by definition lasts 4-72 hours.  This time element gets confusing with overtreatment with pain killers or headache medicine which may lead into medication overuse headache and chronic migraine so that headaches occur every day, or very frequently.

In generalized anxiety disorder, the person has persistent worry or anxiety that lasts for at least several months.  The Diagnostic and Statistical Manual for Mental Disorders 5, (DSM5) sets the minimum to 6 months.

Prognosis

Prognosis is directly related to patient compliance and appropriate medical treatment.

Migraine now has a number of very competent acute therapy and chronic treatment options that patients may pursue. 

Treatment with triptans, such as sumatriptan, at onset of a migraine produces a headache free state for 80% in 2 hours. 

The new CGRP drugs for migraine prevention, such as Aimovig, which is delivered by subcutaneous injection once a month can reduce migraine attacks to 50% in half of patients, 75% in a quarter of patients, and 100% in another quarter.

Generalized anxiety disorder may be treated by psychiatric consultation and the judicious as needed, short term use of one of the benzodiazepine drugs such as Xanax or Klonopin.

The patient may be treated with one of the Selective Serotonin Receptor Inhibitors (SSRI), such as Lexapro, given for chronic treatment as one a day.

The patient should be instructed in and do Cognitive Behavioral Therapy (CBT) which is a non-drug treatment helpful for anxiety.

Aerobic exercise is great for anxiety conditions.

Talk with your spouse, girl or boyfriend, friend, or counselor, priest, preacher, or rabbi. Talking with someone is helpful for anxiety.

What about the other Anxiety Disorders? Do they relate with Migraine?

Panic disorder is comorbid with Migraine. 40% of persons with panic disorder have Migraine and many people have a simultaneous attack of a Migraine and a panic attack happen at the same time. Many of these persons, bothered by chest pain or body tingling will report to the emergency room immediately.

Obsessive Compulsive Disorder, also known as OCD, is aligned with the anxiety disorders also, especially with Chronic Migraine due to Medication Overuse Headache, MOH.

People with MOH accelerate their genetically inherited Migraine headaches by overtreating with pain killer medications. Most of them end up with prolonged, bothersome, and disabling Migraine headaches.

MOH may be treated by a headache specialist with education to not overtreat and to limit all over the counter pain killers, triptans, and ergotamine to no more than treatment 2 days a week.

There is no place for the use of opioid narcotics or butalbital in the treatment of Migraine or any other headache.

Check out my Big Book on Migraine Here.

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All the best.

Follow me at:  www.doctormigraine.com, Pinterest, Amazon books, Spotify podcasts, and YouTube.

Britt Talley Daniel MD