Migraine headache occurs in 12% of the American population. Twenty% of women and six% of men have migraine headache. Ten% of persons in America develop depression. Migraine headache is the 5th most common cause of disability and the 10th most common cause of a visit to the emergency room. The three most painful conditions are migraine, a kidney stone, and childbirth.

Migraine is a complicated neurologic process involving the ganglia of the trigeminal nerve, the cerebral arteries, and the thalamus. In the process three inflammatory and vasodilating neurochemicals are released—Neurokinin A, Substance P, and calcitonin gene-related peptide (CGRP).

Serotonin neurotransmitters located on the trigeminal nerve and cranial arteries are reduced during migraine. Low serotonin levels are also linked to depression.

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 Depression are comorbid medical problems. Comorbid means that two medical conditions occur together more commonly than by chance. Migraine and Depression are 50% comorbid.

This means that half of persons with depression have migraine also. The exact reason for this relationship is currently unknown. The incidence of the connection with depression is higher in persons with migraine with aura and with medication overuse headache.

Read my Mini eBook on Migraine here.

Definition of Migraine.

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:

At least five attacks

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

Headache has at least two of the following four characteristics:

unilateral location

pulsating quality

moderate or severe pain intensity

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

During headache at least one of the following:

nausea and/or vomiting

photophobia and phonophobia

Definition of Depression

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM) 5, a person who suffers from major depressive disorder must either have a depressed mood or a loss of interest or pleasure in daily activities consistently for at least a two-week period.

This mood must represent a change from the person's normal mood. Social, occupational, educational, or other important functioning must also be negatively impaired by the change in mood.

A depressed mood caused by substances (such as drugs, alcohol, medications) or which is part of a general medical condition is not considered to be major depressive disorder. Major depressive disorder cannot be diagnosed if a person has a history of manic, hypomanic, or mixed episodes (e.g., a bipolar disorder) or if the depressed mood is better accounted for by schizoaffective disorder and is not superimposed on schizophrenia, schizophreniform disorder, delusional disorder or psychotic disorder.

Further, the symptoms are not better accounted for by bereavement (i.e., after the loss of a loved one) and the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

DSM5 list of symptoms:

Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). (In children and adolescents, this may be characterized as an irritable mood.)

Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day

Significant weight loss when not dieting or weight gain (e.g., a change of more than 5 of body weight in a month) or decrease or increase in appetite nearly every day.

Insomnia or hypersomnia nearly every day

Psychomotor agitation or retardation nearly every day

Fatigue or loss of energy nearly every day

Feelings of worthlessness

Excessive or inappropriate guilt nearly every day

Diminished ability to think or concentrate, or indecisiveness, nearly every day

Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.

Related statements

Age of onset

Migraine usually starts in mid to late adolescence, peaks in the thirties, and diminishes after that.

Middle aged women aged 40-59 years old have the highest rates of depression. The lowest rates of depression are seen among teenage boys age 12 to 17 and men over the age of 60.

Sexual preference

Women have migraine 3 times more than men and depression 2 times more than men.

Genetic link

Major depression increased the risk for migraine, and migraine increased the risk for major depression. This bidirectional association, with each disorder increasing the risk for first onset of the other, was not observed in relation to other severe headaches.

Migraine is thought to be genetically linked but polygenic in origin. This means that multiple, complex gene relations are found with migraine.

Familial Hemiplegic Migraine (FHM) is known to relate to the genes listed below:

CACNA1A

ATP1A2

SCNA1A

The familial forms of hemiplegic migraine identified are referred to as FHM1, FHM2, and FHM3, respectively. Each type of FHM is caused by mutations in a different gene. FHM patients have four times increased odds for lifetime depression.

Depression has around 50% of cases where the cause is genetic or related to “heritability.”  The other 50% of depression cases are unrelated to genes but due to conditions that seem to predispose to depression:

Loss of a parent in early life

Severe childhood physical or sexual abuse

Childhood emotional and physical neglect

Severe life stress

Epidemiology

Migraine affects approximately 12% of Americans each year.

Migraine is 3 times more common among women than men (20% vs 6%).

Migraine attacks peak in prevalence between ages 25 and 55.

Migraine is a chronic disease which occurs episodically.

Other psychiatric relationships

Major depressive disorder (MDD) occurs 2 to 4 times more in migraine patients.

Lifetime rates of MDD range from 22% to 32% among those with episodic migraine and are as high as 57% among those with chronic migraine.

Migraineurs have a 3- to 4-fold increase risk for bipolar disorder and for suicide attempts.

Among migraine sufferers, anxiety disorders are twice as common as depression, and migraineurs have a 3- to 5-fold increase in risk for various anxiety disorders compared with controls.

Panic disorder, phobias, PTSD, and generalized anxiety disorder (GAD) are most common among migraineurs.

There is no current evidence that improved control of depression helps to control migraines. However, it is important to identify and treat depression in patients with migraine because it is a significant predictor of migraine chronification.10 Furthermore, migraineurs who suffer from depression are more likely to be refractory to migraine treatments and to suffer from medication overuse and disability.

Depression is by far the most prevalent, representing 99% of all mind-brain illness, schizophrenia and major psychotic illness represent the remaining 1%. The umbrella of depression encompasses Major Depressive Disorder and its related mood disorders including bipolar disorder, postpartum depression, post-traumatic stress syndrome, anxiety disorder and suicide.

Depression in the United States affects over 18 million adults (one in ten) in any given year.

Depression is the leading cause of disability for ages 15-44.

Depression is the primary reason why someone dies of suicide about every 12 minutes–over 41,000 people a year.

Homicide claims less than 16,000 lives each year, according to 2013 CDC.

Depression in the Workplace

Causes 490 million disability days from work each year in the U.S.

Accounts for $23 billion in lost workdays each year.

Takes an economic toll over $100 billion each year from U.S. business.

Depression Internationally affects over 300 million people worldwide, regardless of culture, age, gender, religion, race, or economic status.

Depression is one of the most debilitating conditions on the world, with severe depression rated in the same disability category as terminal stage cancer.

Depression is the leading cause of disability worldwide and is a major contributor to the overall global burden of disease.

Comment on SSRI and SNRI treatment.

SSRIs and SNRIs work well for treatment of depression, anxiety, PTSD, and panic disorder, but they do not work for migraine prevention.

Check out my Big Book on Migraine here.

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All the best.

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Britt Talley Daniel MD