Table 2 Summary of mechanisms and implications for therapy
Disorder | Possible Mechanisms | Implications for treatment | |
|---|---|---|---|
Potential Benefits | Caveats (and potential antidotes) | ||
Depression | - Heritability - Genes (e.g. 5-HT transporter gene, D2 receptor gene) - Neurotransmitter systems (serotonin, dopamine, GABA) - HPA axis - “neuro-limbic” pain network | - Effects of serotonin agonists in both disorders - Specific antidepressants are recommended for migraine and depression (e.g., amitriptyline) - Specific migraine agents can have positive effects for migraine and depression (e.g., onabotulinum toxin A) - Combined pharmacotherapy and psychotherapy can have synergistic effects - Psychotherapy is recommended for migraine and depression (could help to increase adherence to pharmacotherapy or help to use less / no pharmacotherapy) | - Flunarizine and beta-blockers are contraindicated for depression (diagnostic procedures should always include diagnosing for depression) - Patients may not speak about it because of fearing stigma / shame (therapist should try to create an appreciative atmosphere) - Antidepressants recommended for migraine and depression differ in optimal dose for each treatment (weighing of benefits and risks) |
Bipolar disorder | - Heritability - Neurotransmitter systems (serotonin, dopamine, glutamate) - Alterations in sodium/calcium channels, pro-inflammatory cytokines | - Effects of antiepileptic drugs in both disorders - Valproate and topiramate (lamotrigine?) can have positive effects for migraine and BD - Psychotherapy is recommended as addition to pharmacotherapy in BD (could help increasing adherence to pharmacotherapy) | - SSRIs and SNRIs have the risk of exacerbating mania or initiating a more rapid cycling course (diagnostic procedures should always include diagnosing for [hypo]manic symptoms, also in family history) - Manic episodes may result in risky behavior (i.e., not taking medication) |
Anxiety Disorders | - Heritability - Neurotransmitter systems (serotonin, GABA) - Ovarian hormones | - CBT recommended for migraine and anxiety disorders | - Patients may show avoidant behavior and be skeptical about treatment options - Patients may not speak about anxiety due to several reasons, e.g., subthreshold levels (Therapist should be aware of subthreshold symptoms) |
Stress and PTSD | - Central sensitization - Neurotransmitter systems (serotonin) | - CBT (especially stress management) recommended for migraine and stress-related disorders | - Patients may not speak about previous traumatic events |
Personality disorders | - ? | - ? | - Personality disorders seem to negatively influence treatment outcome (personality should be considered an influencing factor) |
Substance use behavior / disorders | - Depression and other comorbid disorders as associated disorder | - Managing substance use might prevent MOH | - Migraine could be associated with more liberal medication intake (diagnostic procedures should always cover questions on substance use) |
Somatoform disorders | - ? | - Reduction in headache may be accompanied by a decrease in somatic symptoms | - Somatic symptoms may complicate treatment (e.g., avoidance behavior) |
Eating disorders | - Depression as associated disorder | - For specific subgroups, treating the eating disorder (i.e., avoid fasting, skipping meals, etc.) could reduce headache symptoms | - Eating disorders may be characterized by specific behavior (i.e., avoid fasting, skipping meals, etc.) that may trigger migraine (diagnostic procedures should always cover questions on potential triggers) - Eating disorders are often linked to depression (diagnostic procedures should always include diagnosing for depression) - Patients may not speak about it because of fearing stigma / shame and may hide it with clothes (therapist should be perceptive for eating disorder symptoms) |