It’s hard to imagine a time when Seymour Diamond, MD, was not focused on headache. But in 1960, the executive chairman and founder of the National Headache Foundation (NHF) and director emeritus of the Diamond Headache Clinic in Chicago spent his time in general medicine.
“I had a large family practice and I did research, but I knew nothing about headache,” he laughs.
That year, Dr. Diamond was approached by Merck, Sharpe, and Dohme (now Merck & Co.), a pharmaceutical company that was investigating the use of amitriptyline (a tricyclic antidepressant) to treat somatic complaints, or those relating to the psyche. The drug was marketed for treatment of depression in 1961, and Dr. Diamond undertook a study to examine the positive impact amitriptyline had on his own patients’ somatic complaints. During a presentation of his results, he was approached by Lester Blumenthal, MD, then secretary of the American Association for the Study of Headache (now the American Headache Society), who wondered if Dr. Diamond had considered the use of the same tricyclics to treat headaches. That inspired Dr. Diamond to examine the drug’s benefits for both headache and depression.
Today, the ties between major depression and migraine are well documented. The conditions share some symptoms: trouble sleeping, decreased energy, decreased concentration, pain. But it wasn’t until the early 1960s, when Dr. Diamond’s research was published in the journal Headache, that the world learned that the very medication that brought positive responses for depressive patients was also effective at treating migraine.
Major depression and migraine are two pain-filled, stigmatized conditions. But people who experience the comorbidity can rest assured that treatment is available and hope can be restored.
A Bidirectional Relationship
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) classifies major depressive disorder as a mood disorder characterized by “feelings of sadness or emptiness; reduced interest in activities that used to be enjoyed; sleep disturbances (either not being able to sleep well or sleeping to much); loss of energy or a significant reduction in energy level; difficulty concentrating, holding a conversation, paying attention, or making decisions that used to be made fairly easily; [and/or] suicidal thoughts or intentions.”
For people who experience head pain and depression, the headaches are likely to be migraines and they often arise in the early morning along with other significant depressive symptoms, notes Robert Shulman, MD, associate chair of clinical services in the department of psychiatry at Rush University Medical Center in Chicago. This is called a “diurnal variation,” whereby one experiences the worst of their symptoms first thing upon awakening and may note a lightening of symptoms toward the evening hours.
The research is clear that the relationship between migraine and depression is bidirectional, meaning depression can trigger migraine and migraine can trigger depression. According to a study published in the March 2012 issue of the journal Headache:
- People with major depressive episodes are 40 percent more likely to develop migraine than people who don’t experience depression, and
- People with migraine are 80 percent more likely to develop major depressive episodes than people who don’t experience migraines.
Some 20 million people in the United States experience depression, according to the National Institutes of Health. Despite this high incidence, depression seems stigmatized in society, so much so that people who feel depressed may not report it to their physician.
“People don’t usually talk about feeling depressed to their primary care physician unless they have a long-standing relationship,” Dr. Shulman says. “But they will go in and complain of pain and sleep problems, and it is the tuned-in physician who knows how to ask a couple of extra questions to figure it out.”
Dr. Diamond says the patient’s medical history “reveals the comorbidity.” Whether through discussion of social relationships or life stresses, or through admission that the patient is experiencing a vise-like, steady pressure in the head at night or in the morning, a physician should be able to make a diagnosis of depression and migraine once certain symptoms are revealed. Dr. Shulman adds that the physician should take it a step further by exploring just how serious the condition is. Additional questions can reveal whether the patient is suicidal or whether the pain has led to drug or alcohol abuse.
“Some physicians are afraid to ask about suicidal thoughts because they have this notion that if they bring it up, they may put those thoughts into the patient’s mind. But if somebody’s not suicidal, they’re not going to consider it just because you asked a question,” Dr. Shulman says. “I think that because suicidal thoughts are stigmatized as ‘weakness in the soul,’ if the physician brings it up in a non-judgmental way, the patient can actually feel relief because their depression may have been previously stigmatized by society.”
If a patient reveals an intention to act on suicidal thoughts or notes a current or past substance abuse, he or she may be referred to a psychiatrist for evaluation and could be admitted for inpatient care, Dr. Shulman says. Otherwise depression and headache are treated with a variety of traditional, psychiatric and psychological therapies.
Treatment for Migraine and Depression
Because of the bidirectional nature of this comorbidity, treatment can be directed at the depression, the migraine or both. The thinking is that once you treat the migraine, this will relieve some of the hopelessness that comes with depression; or once you treat depression, depression-related migraines should be relieved. In a 2008 NHF survey, only 32 percent of respondents reported taking one medication to treat both depression and headache. Instead, 75 percent used medication to treat their depression, and 95 percent used medication to treat their headaches.
Treatment for depression depends on the type of depression: anxious, flat or empty, or a mix. “When you throw in headache or chronic pain disorder, the pain data is clear that the best antidepressants to use in pain are those that can treat both the anxious and the empty feelings of depression,” Dr. Shulman says.
While often used to treat depression, clinical trials have shown serotonin norepinephrine reuptake inhibitors (SNRIs) such as Effexor® and Cymbalta®, and selective serotonin reuptake inhibitors (SSRIs) such as Prozac®, to be less effective for migraine treatment, says Jan Lewis Brandes, MD, director of the Nashville Neuroscience Group at St. Thomas Health Services, assistant clinical professor of neurology at Vanderbilt University in Nashville and a member of the NHF Board of Directors.
Rather, the antidepressants that are considered the best for migraine and depression are the tricyclics—the very medications that Dr. Diamond researched in the 1960s. Specifically, pain responds “quicker and at lower doses” with amitriptyline than what would typically be needed to treat a major depressive episode, Dr. Shulman says. But tricyclics are generic medications, and because there isn’t a brand name attached to them, Dr. Diamond says most physicians aren’t aware of tricyclics.
Depression and migraine may also be treated with monoamine oxidase inhibitors (MAOIs) such as Nardil®. However, MAOIs are rarely prescribed because they come with risk for serious side effects. Dr. Diamond says MAOIs are usually prescribed only for the most well-informed patients.
Dr. Brandes adds that patients who have migraine and depression “will likely need a preventive medication for migraine and a preventive medication for depression. Using one drug for both is an ideal concept but often does not work, or is simply not likely to result in efficacious outcomes.”
Aside from medication, headache specialists may prescribe transcranial magnetic stimulation (TMS), biofeedback or other behavioral treatment. TMS uses technology similar to magnetic resonance imaging (MRI) to focus the magnetic field on a specific part of the brain, changing the blood flow to alleviate depression. Biofeedback involves tracking the body’s functions and using visualization and stress-relief techniques to manage them. A psychologist may teach biofeedback, which can help patients “learn to recognize some of their automatic responses and how to wrestle their thoughts away from them so they can focus on things that are more health related,” Dr. Shulman says.
Exercise and diet, while not curative, can keep depression from worsening and can help prevent new episodes of depression, Dr. Shulman says.
Regardless of how you treat it or prevent it, Dr. Diamond stresses that it is important to catch the comorbidity and treat it early. “As with any condition, the earlier you treat someone, the less chronic it becomes.”
Julie’s Story
Julie McDonald, 35, has had migraines since childhood. But after she finished high school, she finally saw a headache specialist who diagnosed her with migraine and chronic daily headache. By her mid-twenties, the pain intensified.
“I was in constant pain and felt really helpless and hopeless,” recalls McDonald, who lives in Green Briar, Ark. “It felt like everything I wanted in life was slipping away from me. I was in law school at the time and couldn’t complete school; I couldn’t really enjoy my marriage or my friends.”
That hopelessness was later diagnosed as clinical depression.
“It’s a paralyzing and suffocating feeling, and it feels like it will never end,” McDonald says. “It disrupts everything in my life: how I sleep, how I eat, who I want to be around and what I feel like doing, how I feel about myself. It’s a crushing weight.”
Despite the need for support, McDonald says she felt the stigma associated with depression and hid it for fear that others would see her as sick. But “you can’t just will yourself to get better,” she says.
McDonald manages her headache and depression with support from her husband and parents as well as a cadre of medications. She also had a manual vagus nerve stimulator implanted in her chest. McDonald wasn’t sure if the device was relieving her pain until the battery began to weaken last year and her depression came back with a vengeance. Dr. Diamond noted that this stimulator (a battery-powered device attached to a wire that runs up to the vagal nerve in the neck and stimulates it to relieve pain) is a last resort for treatment.
For others experiencing this comorbidity, McDonald recommends meeting with a psychologist as soon as possible to discuss ways to cope and to find a way to contribute to society on your good days. McDonald volunteers for non-profits and says her volunteer work has helped her overcome feelings of powerlessness. She also recommends building a support system and letting your family know what you’re going through.
“For my family, it has brought a different depth of understanding,” she says. “It forces me to let my guard down and that’s good for relationships.”
Depression Among Other Headache Types
People with chronic migraine are more likely to have depression than people with episodic migraine, according to the American Migraine Prevalence and Prevention study (sponsored by the National Headache Foundation). Further, migraineurs are more likely to have major depression than people with other types of headaches. For this reason, the comorbidity of migraine and depression has been studied in more depth than the comorbidities of depression and other headache disorders. However, depression does exist among other headache populations.
Among patients with common subtypes of chronic daily headache, 70 percent of patients with transformed migraine experience depression and 59 percent of patients with chronic tension-type headache experience depression, according to research published in the Nov.-Dec. 2011 issue of the journal Headache.
A study from the January 2011 issue of the journal Headache showed that 51 percent of patients with New Daily Persistent Headache, a rare chronic daily headache characterized by new onset of daily headache, had a history of depression.
Interestingly, though research into the comorbidity of depression and cluster headache is rare, one study published in the April 2012 issue of the journal Headache showed only 8 percent of people with cluster headache experienced anxiety and depression.
Stress, Headache and Depression in the Military
Military servicemen and women are no strangers to headache and depression. According to research published in the June 2008 issue of the journal Headache, 47 percent of troops surveyed during the last three months of a one-year combat tour in Iraq screened positive for migraine, probable migraine or non-migraine headache. Furthermore, 18.5 percent of all returning servicemen and women meet the criteria for depression or post-traumatic stress disorder, according to a 2008 study from the RAND Corporation.
