Migraine 26 Mar, 2024 Read Time: 7 mins

Migraine and neuropsychiatric comorbidities

For people with migraine, cognitive dysfunction is cited as one of the major disabling factors during an attack. Executive function testing and imaging studies confirm these findings, with differences between people who don’t experience migraine extending into the interictal period. Dr Raquel Gil-Gouveia, from the Hospital da Luz, Lisboa, Portugal, discussed her and others’ work on this topic at the 2023 edition of the International Headache Congress (IHC) in Seoul, South Korea. There is also a strong relationship between migraine and sleep difficulties: as explained by Dr Mamoru Shibata, an Assistant Professor at the Department of Neurology of Keio University School of Medicine, in Tokyo, Japan, occurrence of one is more likely to trigger the other. Imaging studies show this may be related to disturbances in the hypothalamic sleep-wake centres. As discussed by Dawn Buse, a Clinical Professor of Neurology at Albert Einstein College of Medicine in New York City, USA, there are also comorbidities between migraine and psychiatric disorders, most notably depression and anxiety. The relationship is bidirectional, with occurrence of depression being more likely to lead to migraine and vice versa, potentially due to shared genetic and/or environmental factors. Treatments aimed at both migraine and psychiatric comorbidities can help in both realms.

Cognitive dysfunction and migraine

Cognitive problems, such as concentration difficulties, intellectual disturbances, speech difficulties, and impaired thinking, can be observed during a migraine attack from the pre-ictal to the postdrome phases.1 Especially during the headache phase of migraine, the majority of patients report changes in mental abilities.2 Executive function and speech testing during a migraine attack confirm patients’ reports of cognitive difficulties3-5, and an imaging study in patients with high frequency episodic and chronic found blunted task-related deactivation during a migraine attack in areas involved in cognitive and executive functions.6 

Cognitive difficulties may not be confined to the migraine period. Indeed, another imaging study carried out in the interictal period in patients with low frequency episodic migraine showed correlations between decreased gray matter density in the frontal lobe Brodman Area 9 and decreased performance in a set shifting task.7 

People with migraine cite cognitive difficulties as one of the most disabling factors of migraine1

This is important, explained Professor Gil-Gouveia, as patients report cognitive difficulties as one of the two main causes of migraine-related disability, alongside pain.2,8 This can lead to development of ‘cognophobia,’ or the “fear of not being able to perform adequately during an attack”, which can lead to fear-avoidance behaviors.9 

Sleep-related disorders and migraine

Poor sleep quality is a well-known trigger for migraine and is associated with higher attack frequency, especially in people with chronic migraine.10-15 Even for headache-free individuals, insomnia is linked to the new development of migraine.16 Conversely, the risk for insomnia increases in people with migraine with increasing headache pain, intensity, and occurrence.12,13,16-18 While there is also comorbidity between poor sleep quality and depression or anxiety in people with migraine,10 the migraine-insomnia link cannot be explained by such comorbidities alone.13

The sleep-wake cycle typically follows a circadian rhythm, which is controlled by specific proteins in the suprachiasmatic nucleus.19 Mutations in the gene encoding these proteins are associated with an advanced sleep phase syndrome and migraine.20 “These data indicate,” said Dr Shibata, “that circadian rhythm and migraine have a shared disease mechanism.” 

Hypothalamic hyperactivation during migraine may lead to sleep difficulties23

Wake-promoting circuits and projections occur in the brain between the lateral hypothalamus, tuberomammillary nucleus, locus coeruleus, and raphe nucleus. The hypothalamic ventrolateral preoptic nucleus is the main sleep-promoting centre. The balance between these systems dictates a person’s ‘flip’ from sleep to wakefulness and vice versa.21 The hypothalamus also has a role in appetite regulation, stress, and mood.22 In the preictal period of a migraine, hypothalamic hyperactivation occurs in response to trigeminal visual or nociceptive stimuli. There is also enhanced functional coupling between spinal trigeminal nuclei and the hypothalamus. According to Dr Shibata, this “suggests the hypothalamus disinhibits the trigeminal system in the preictal phase.” In the ictal phase, there is increased coupling between the dorsal rostral pons and the hypothalamus.23

A number of treatments for comorbid migraine and insomnia that may improve sleep quality and time and decrease headache frequency, intensity, or symptoms have been examined. These include cognitive and behavioural therapy;24 a ketogenic diet;25 nerve blockage with lidocaine;26 and, in patients without a baseline ‘negative emotional state,’ botulinum toxin.11

Psychiatric disorders and migraine

Lifetime associations of migraine with major depression, panic disorder and several phobias are high.27 One large USA-based study found that for people with migraine, the odds ratio of comorbid depression or anxiety is 3.18 (p<0.001), meaning approximately a three-fold increased risk of this comorbidity. Odds increase with increasing number of headache days for both comorbidities.17,28 Depression and anxiety are also risk factors for migraine chronicity,17 and the strength of this association is highly-dependent on the severity of depression.29 There is also an association between medication overuse headache and depression or anxiety.30

The relationship between migraine and depression is bidirectional,31 with prodromal occurrence of either more likely to lead to development of the other.32 Such comorbidity between migraine and depression may be due to shared environmental and genetic risk factors.33 

Shared genetic and environment factors may contribute to migraine and psychiatric comorbidities

While there may be concerns with regards to migraine treatment response and comorbid psychiatric disorders, Professor Buse discussed how this may not be the case. A study of botulinum toxin treatment showed significant responses in people with comorbid migraine and depression.34 Another study found that, compared to people with a mood or anxiety disorder, people with such comorbidity experienced greater decreases in migraine days following preventive treatment (b-blocker plus behavioural migraine management) that could be explained by the fact that they went from higher headache disability scores prior to treatment to similar scores following long-term treatment follow-up.35

Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.

References

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