Posted by dougW (220.127.116.11) on December 18, 2001 at 20:34:13:
In Reply to: Question for medical professionals posted by Todd on December 18, 2001 at 18:47:50:
While this article deals mainly with migraines (the M word), I think we came draw many of the same conclusions for CH. the full article is available at http://primarycare.medscape.com/Medscape/neurology/TreatmentUpdate/2000/tu07/public/toc-tu07.html
You will have to cut and paste it, and you'll need a medscape account (its free). So.....
Neurology Treatment Updates
Migraine, Cluster, Trigeminal Neuralgia, and Mood Disorders: Common Ground for Treatment CME
Author: Stephen D. Silberstein, MD
Comorbity has been defined as the presence of any additional coexistent condition in a patient with a particular index disease." More recently, however, comorbidity is considered to be an association between 2 disorders that is more than coincidental.
Comorbidity may occur in a number of different circumstances. First. it may be an artifact in which the conditions are not really associated but appear to be because of coincidence, selection, or assessment bias. For example, it is well known that patients who seek clinic care more commonly go to the clinic if they have 2 diseases than if they have only 1 ("Burkson's bias"). Thus, in a clinic-based series, patients are likely to suffer more than 1 disorder, however, they are not comorbid conditions. Second, 1 condition may cause another and thus set up a comorbid relationship; that is, hypertension may cause stroke. Conditions may also share common risk factors: head trauma can cause both epilepsy and migraine. And finally, independent risk factors may produce a brain state that predisposes to comorbid conditions; for example, hypertension can predispose a person to stroke and dementia.
Comorbidity can complicate any diagnosis because of the overlapping symptoms. For example, in patients with both epilepsy and migraine, an aura may originate from either epilepsy or migraine. Thus, when diagnosing a patient with headaches, it is essential to also look for and rule out potential comorbid conditions.
For patients with more than 1 disease, treatment should be modified to include all conditions. Whenever possible, diseases and disorders that coexist with migraine are best managed with a single drug that acts on all. For example, one can treat migraine, hypertension, and ischemic heart disease with beta-blockers or calcium channel blockers. Migraine, mania, and epilepsy can all be managed with a mood-stabilizing antiepileptic drug (AED), such as divalproex, topiramate, or gabapentin. Depression and migraine may both respond to tricyclic antidepressants or a selective serotonin reuptake inhibitor (SSRI). In the overweight patient with migraine, topiramate might be a good therapeutic choice.
However, treatment for certain diseases may aggravate others and this also must be considered when prescribing for comorbid conditions. For example, antidepressants (particularly bupropion), neuroleptics, and sumatriptan all may increase seizure frequency in patients with epilepsy. Beta-blockers can exacerbate depression.
Debate continues over the existence of a "migraine personality". The classic migraine patient was generally thought to possess obsessive and rigid personality traits. However, nonspecific changes appear on the Minnesota Multiphasic Personality Inventory (MMPI) that can improve with treatment, suggesting that these findings are not intrinsic to the patient's personality. Other personality measures suggest an association between migraine and neuroticism. Migraine patients do have more anxiety, tension, and depression.
Migraine and Behavioral Disorders
Migraine patients do exhibit more psychopathology than controls. According to a study by Merikangas and colleagues, migraine doubles the risk of major depression, triples the risk of mania and phobia, and quadruples the risk of generalized anxiety (Figure 2). Although the risk for these disorders is significantly higher in those with migraine, most migraineurs do not suffer from these types of psychopathology.
Breslau and colleagues compared lifetime prevalence of various affective disorders in migraine patients vs controls and found that the prevalences of anxiety and phobias in migraineurs are twice that in controls; the prevalence of depression is 3.5 times higher; panic disorder, more than 5 times higher; and obsessive-compulsive disorder, more than 4 times higher in migraineurs than in those without migraine.
There is also a bidirectional relationship between migraine and depression. Not only do patients with migraine have a higher risk for developing depression, patients with depression have a similarly higher risk of developing migraine. In another study, Breslau and colleagues followed a cohort of migraineurs for 3 years to assess how many developed depression; at the same time, a cohort of patients with major depression was followed to learn how many would develop migraine within 3 years. The migraine cohort was 3 times more likely to develop major depression within 3 years than controls. Likewise, those with major depression were 3 times more likely to develop migraine, compared with controls. Furthermore, Breslau and colleagues[22,23] found that the incidence of suicide attempts in women with migraine with aura was 5 times that of controls. In men with migraine with aura, the incidence was more than 7 times higher than that of controls
Although patients with other types of severe headache can develop depression, major depression does not increase the risk for severe nonmigraine headache. This finding suggests that there may be shared causes for migraine and depression; whereas, in patients with nonmigraine headache, it is the severe pain that causes depression.
Panic attacks are also a risk factor for migraine. In 1 series, Stewart and associates found that 5.5% of men and 9.5% of women with panic disorder comprise 25% of reported migraine headaches.
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