Migraine and Depression

It’s not unusual for Migraine patients to also have some form of Depression. In the past, some have theorized that there is a “migraine personality” that is at risk for both conditions. This has largely been disproved, although the mythology still perpetuates stigma and poor treatment for many.

“Depression” is a descriptive term that is often used to describe a diagnostic group of mental disorders known as Mood Disorders. According to the DSM-IV TR, there are 10 distinct Mood Disorders.

  1. Major Depressive Disorder
  2. Dysthymic Disorder
  3. Depressive Disorder NOS
  4. Bipolar I Disorder
  5. Bipolar II Disorder
  6. Cyclothymic Disorder
  7. Bipolar Disorder NOS
  8. Mood Disorder Due to a General Medical Condition
  9. Substance-Induced Mood Disorder
  10. Mood Disorder NOS

Most people think of Major Depressive Disorder when they refer to “depression”. However, a “depressed mood” can accompany any of these disorders (and other conditions not classified as Mood Disorders). This state of mind can be life threatening if not properly treated. In the best cases an unrelenting or frequently cycling negative mood is treated with a combination of anti-depressant medications and psychotherapy.

If you are struggling with depressive symptoms, it is important to get an accurate diagnosis, just as with Migraines. Effective treatment starts with accurate diagnosis. It is my opinion that there is sometimes a rush to diagnose Migraine patients with Major Depressive Disorder when the symptoms are better explained by Migraine Disease itself.

You see, there is this often-ignored rule-out criteria with every single mental health disorder. The rule-out states: “The symptoms are not due to the direct physiological effects of a substance or a general medical condition.” If there is a substance (or medication) or a health problem that better explains the depressive symptoms, the only diagnosis that can be accurately made is Substance-Induced Mood Disorder or Mood Disorder Due to a General Medical Condition.

A more accurate diagnosis changes the way health care professionals view a patient with depressive symptoms! No longer are they seen as “psychiatric” but rather “medical” and their symptoms are taken much more seriously by health care professionals. Instead of viewing the person as “having pain because they are depressed”, the patient is now viewed as a “legitimate patient” with “legitimate symptoms” of a “legitimate illness”.

For the record, I am firmly grounded in the camp that believes mind/body/spirit cannot be separated. What happens to one happens to the other. It is a travesty that our health care system is still so far behind on this issue. Maybe someday I’ll write a blog about that.

Today is the day to challenge the myth that “migraineurs are all depressed”. I have no doubt that many migraineurs do experience Depression. I have just as much certainty that just as many Migraine patients are being irresponsibly diagnosed with Major Depression when every single one of their depressive symptoms can be better explained by Migraine itself. This faulty (and sometimes ignorant and/or laissez-faire) diagnosing leads to improper medical treatment of symptoms and the devaluing of each Migraine patient who struggles with depressive symptoms.

Below are the exact diagnostic criteria for Major Depressive Episode taken from the DSM-IV TR shown side-by-side with rational explanations of how Migraine itself can manifest the exact same symptoms.

Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition or mood-incongruent delusions or hallucinations.
1. 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). Note:In children and adolescents, can be irritable mood Migraine patients can appear to be experiencing depressed mood due to negative facial expressions which are a result of experiencing pain or other symptoms of Migraine. Observers may report this as a depressed mood. Patient may be tearful due to pain.
2. Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) Migraine patients can appear to have lost interest or pleasure because of their lack of socialization or engaging in work or hobbies due to fear of triggers or because they are experiencing painful symptoms. They can appear to have “given up on life”.
3. 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. Note: In children, consider failure to make expected
Migraine patients frequently struggle with maintaining healthy weight due to cyclic vomiting, lack of exercise, or days spent in bed. Many medications used to treat Migraines cause weight gain or loss.
4. Insomnia or hypersomnia nearly every day Migraine patients may experience sleep disruptions due to medication side effects, the symptoms of a migraine attack, or other co-morbid conditions. These sleep disruptions may also be contributing to the frequency and severity of attacks.
5. Psychomotor agitation or retardation nearly every day observable by others, not merely subjective feelings of restlessness or being slowed down) Migraine patients often present with slowed motor reflexes due to the migraine itself or side effects of medications. Some rescue medications can trigger psychomotor agitation, such as Benadryl or Ativan. Some IV medications may even trigger dystonic reactions.
6. Fatigue or loss of energy nearly every day Migraine patients are frequently tired or lack energy due to either symptoms of migraine or side effects of medication. Chronic sufferers may experience daily fatigue.
7. Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) Migraine patients often report feeling guilty, but the guilt is directly related to symptoms, lifestyle alterations, and limitations of the illness. This often gets interpreted by mental health providers as a symptom of depression rather than a manifestation of the illness.
8. Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others Cognitive problems (i.e. “brain fog”) are common symptoms of a Migraine postdrome. Patients also have difficulty thinking during other phases due to migraine-induced anxiety or pain. Chronic patients can experience these symptoms daily. Cognitive problems are also common side effects of many medications.
9. 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. Migraine patients can and do entertain thoughts of suicide when the pain is severe, long-lasting, or when the symptoms of Migraine threaten to isolate the patient from loved ones, favored hobbies, or gainful employment. This symptom usually abates when patients are able to regain a sense of hope from compassionate doctors who provide effective treatments.
10. The symptoms do not meet criteria for a Mixed Episode. Migraine patients can appear manic at times due to their ever-changing brain chemistry. This is neither Depression nor Mania, but rather a symptom of Migraine itself.
11. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Migraine symptoms are the cause for patient distress. Mood
12. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). Every one of these symptoms may be explained by Migraine itself, so it is clearly not always Depression.
The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Now before you all call up your doctors and/or dump out your antidepressants on the say-so of one slightly crazy therapist Migraineur, here is my word of caution:

Never, never, never suddenly stop taking prescribed medication without consulting your physician. This can exacerbate your symptoms or create new problems. Work with your doctors to find the right solution. It just might be worth making sure your doctors are fully aware of how many of your symptoms are due to Migraine before you blindly accept an anti-depressant. Ideally, medications used to treat both Migraine and depressive symptoms should be managed by the same prescribing physician for accurate diagnosis and comprehensive care. Great care should be taken in the use of anti-depressants for Migraine patients who also use triptans as their first-line abortive due to the risk of Serotonin Syndrome.

Regardless of the reason for the depressed mood, many migraine patients can and do benefit from psychotherapy using CBT, DBT, and Family Systems strategies from professionals who are familiar with the symptoms of both conditions and are capable and willing to collaborate with other health care providers to give you the best care for a very unique situation.

Regardless of your diagnosis, if you are thinking of hurting yourself or someone else, please tell someone. Visit the National Suicide Prevention Lifeline, call 1-800-273-TALK, call 911, or go to your nearest Emergency Room. Your life is too precious to lose.


Leave a Reply

Your email address will not be published.