Home Medicine Migraine headache and bipolar disorders: Common comorbidities
Article Publicly Available

Migraine headache and bipolar disorders: Common comorbidities

  • Egil W. Martinsen EMAIL logo
Published/Copyright: April 1, 2016
Download Article (PDF)
Become an author with De Gruyter Brill
Author Information Explore this Subject
Scandinavian Journal of Pain
From the journal Scandinavian Journal of Pain Volume 11 Issue 1

1 Awareness of bipolar disorder when treating migraine headache

In this issue Leo and Singh [1] present interesting findings on the relationship between migraine headache and bipolar disorder. The connection between chronic pain and mental disorders is well known from the literature, and previous studies have consistently shown that the combination of migraine headache and depression is rather common. This paper adds to our knowledge by its findings that comorbid bipolar disorder also is often seen, and that it seems to be the second most prevalent comorbid mental disorder after major depressive disorder among migraine headache sufferers. As the authors state, the finding of increased prevalence of bipolar disorder in migraine headache does not say anything about the underlying mechanisms, and at this point of time these remain speculative [1].

2 Bipolar or major depressive disorder?

There are two main classes of affective disorders; bipolar and depressive disorders. The life time prevalence of bipolar disorders is about 2%, while depression hits a much larger number [2]. Bipolar disorders are classified in two categories. The diagnosis of bipolar I disorder requires at least one full blown manic episode, and this is diagnostically often quite clear-cut. In bipolar II the elevated episode is hypomania. The diagnosis of hypomania is often not so obvious. The differential diagnosis between bipolar II and borderline personality disorder, both more common among women, may be complicated [2].

It is important for the clinician considering prescription of antidepressant medication to a patient with migraine headache to be aware of the possibility that the depressive episode may be part of a bipolar disorder. Unrecognized bipolar disorder is not uncommon [3]. Treatment of bipolar depression is different from that of unipolar depression. While antidepressant medication is the first choice in unipolar depression, this is much more controversial in bipolar depression. The therapeutic effect is uncertain, and the risk of negative effects is substantial. There is a risk of eliciting a manic episode, and the issue has also been raised whether the use of antidepressant medication in bipolar disorder may lead to higher frequency of affective episodes, so called rapid cycling, which is an unhealthy course of the disease. For the moment we have no reliable ways of diagnosing whether a depressive episode is the first sign of bipolar disorder. The perhaps most useful approach is to ask about family history. Bipolar disorder often runs in families, and it is one of the most hereditary mental disorders. And we can ask our patients to be aware of the possibility that antidepressant medication may precipitate a manic or hypomanic episode, and to take contact if they fear that this is happening. But we have no secure ways of predicting whether the depressed person in front of us later will develop manic or hypomanic episodes.

3 A broader perspective on treatment: CBT, life style changes, and regular exercise

Treatment of comorbid disorders with combinations of medication increases the possibility of side effects and drug interactions. One way of dealing with this is to use other forms of treatment in addition to the pharmacological. In the management of mental disorders, various forms of psychological treatments are available. Cognitive behavioural therapy (CBT) is by far the most studied and best documented, but also other forms show almost similar effect sizes [4]. In the treatment of a major depressive episode, antidepressant medication and CBT fare about equal, but the relapse rate is lower among those who have received CBT [5]. Also in bipolar disorder CBT is documented to be effective [6]. There is also emerging evidence for the usefulness of CBT in the management of chronic pain, also migraine and other forms of headaches [7,8]. CBT may therefore be useful both for the pain and the comorbid mental disorder. And even if people do not develop comorbid mental disorders, many experience substantial levels of mental distress following years with pain, and psychological methods may be useful here as well. Recent studies argue for a broader perspective in the treatment of long lasting pain [9].

CBT is intuitively easy to understand, and the basic principles are not too complicated. The method is therefore possible to learn also for doctors from outside psychiatry. In Norway there has been a great interest in learning CBT among doctors dealing with chronic pain, and also general practitioners find this approach to be useful [10].

Another important topic for people living with long lasting or recurring disorders is lifestyle. Keeping the structure of the day with regular meals and sleeping at night is beneficial for people with mental disorders and for those with migraine [11]. Among lifestyle habits regular physical exercise has been most studied. People with mental disorders in general are sedentary compared to the general population. Starting to exercise is often useful, and the usefulness of exercise is well documented in depression and anxiety disorders [12]. Exercise is also useful in chronic pain. Lumbar pain has been most focused, but recent studies indicate that it is also useful in migraine [13]. This field of research is in an early phase. Exercise intervention studies involving people with long lasting pain disorder alone or in combination with mental disorders are warranted. For these common disorders self-help methods are import, as the health care system never can meet the need for treatment in the population.

4 Psychosocial interventions and self-help strategies in comorbid pain and mental disorders

Comorbid mental disorders are common among people with long lasting pain, and depressive and bipolar disorders are most often seen [1]. Psychosocial interventions and self-help strategies are useful for both conditions, and may reduce the chances for negative consequences of drug combinations.

DOI of refers to article: http://dx.doi.org/10.1016/j.sjpain.2015.12.002.

Tel.:+47 90 67 75 96

References

[1] Raphael J, Singh J. Migraine headache and bipolar disorders comorbidity: a systematic review of the literature and clinical implications. Scand J Pain 2016;11:136–45.Search in Google Scholar

[2] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 5th ed. Arlington, VA: American Psychiatric Association; 2013.Search in Google Scholar

[3] Hughes T, CardnoA, West R, Marino-Francis F, Featherstone I, Rolling K, Locker A, McLintock K, House A. Unrecognised bipolar disorder among UK primary care patients prescribed antidepressants: and observational study. Br J Gen Pract 2016;66:e71–7.Search in Google Scholar

[4] Cuipers P, Karyotaki E, Weitz E, Andersson G, Hollon SD, van Straten A. The effects of psychotherapies for majordepression in adults on remission, recovery and improvement: a meta-analysis. J Affect Disord 2014;159:118–26.Search in Google Scholar

[5] Cuipers P, Berking M, Andersson G, Quigley L, Kleiboer A, Dobson KS. A meta-analysis of cognitive-behavioural therapy for adult depression, alone and in combination with other treatments. Can J Psychiatry 2013;58: 376–85.Search in Google Scholar

[6] Swartz HA, Swanson J. Psychotherapy for bipolar disorder in adults: a review of the evidence. Focus (Am Psychiatr Publ) 2014;12:251–66.Search in Google Scholar

[7] Christiansen S, Jurgens TP, Klinger R. Outpatient combined group and individual cognitive-behavioral treatment for patients with migraine and tension-type headache in a routine clinical setting. Headache 2015;55: 1072–91.Search in Google Scholar

[8] Harris P, Loveman E, Clegg A, Easton S, Berry N. Systematic review of cognitive behavioural therapy for the management of headaches and migraines in adults. Br J Pain 2015;9:213–24.Search in Google Scholar

[9] Gaul C, Liesering-Latta E, Schafer B, Fritsche G, Holle D. Integrated multidisciplinary care of headache disorders: a narrative review. Cephalalgia 2015, pii:0333102415617413 [Epub ahead of print].Search in Google Scholar

[10] Aschim B, Lundevall S, Martinsen EW, Frich JC. General practitioners’ experiences using cognitive behavioural therapy in clinical practice: a qualitative study. Scand J Prim Health Care 2011;29:176–80.Search in Google Scholar

[11] Woldemanuel YW, Cowan RP. The impact of regular lifestyle behavior in migraine: a prevalence case-referent study. J Neurol 2016[Epub ahead of print].Search in Google Scholar

[12] Martinsen EW. Physical activity in the prevention and treatment of anxiety and depression. Nord J Psychiatry 2008;62:25–9.Search in Google Scholar

[13] Irby MB, Bond DS, Lipton RB, Niclas B, Houle TT, Penzien DB. Aerobic exercise for reducing migraine burden: mechanisms, markers, and models of change processes. Headache 2015, http://dx.doi.org/10.1111/head.12738 [Epub ahead of print].Search in Google Scholar
Published Online: 2016-04-01
Published in Print: 2016-04-01

© 2016 Scandinavian Association for the Study of Pain

Articles in the same Issue

  1. Editorial comment
  2. Psychophysiological effects of threatening a rubber hand that is perceptually embodied in healthy human subjects
  3. Original experimental
  4. A preliminary investigation into psychophysiological effects of threatening a perceptually embodied rubber hand in healthy human participants
  5. Editorial comment
  6. Analysis of C-reactive protein (CRP) levels in pain patients – Can biomarker studies lead to better understanding of the pathophysiology of pain?
  7. Clinical pain research
  8. Serum C-reactive protein levels predict regional brain responses to noxious cold stimulation of the hand in chronic whiplash associated disorders
  9. Editorial comment
  10. Importance of early diagnosis of complex regional pain syndrome (CRPS-1 and CRPS-2): Delayed diagnosis of CRPS is a major problem
  11. Clinical pain research
  12. Delayed diagnosis and worsening of pain following orthopedic surgery in patients with complex regional pain syndrome (CRPS)
  13. Editorial comment
  14. Associative learning mechanisms may trigger increased burden of chronic pain; unlearning and extinguishing learned maladaptive responses should help chronic pain patients
  15. Original experimental
  16. When touch predicts pain: predictive tactile cues modulate perceived intensity of painful stimulation independent of expectancy
  17. Editorial comment
  18. Low back pain among nurses: Common cause of lost days at work and contributing to the worldwide shortage of nurses
  19. Observational study
  20. Pain-related factors associated with lost work days in nurses with low back pain: A cross-sectional study
  21. Editorial comment
  22. Assessment of persistent pelvic pain after hysterectomy: Neuropathic or nociceptive?
  23. Clinical pain research
  24. Characterization of persistent pain after hysterectomy based on gynaecological and sensory examination
  25. Editorial comment
  26. Transmucosal fentanyl for severe cancer pain: Nasal mucosa superior to oral mucosa?
  27. Original experimental
  28. Facilitation of accurate and effective radiation therapy using fentanyl pectin nasal spray (FPNS) to reduce incidental breakthrough pain due to procedure positioning
  29. Editorial comment
  30. Why do we have opioid-receptors in peripheral tissues? Not for relief of pain by opioids
  31. Clinical pain research
  32. Peripheral morphine reduces acute pain in inflamed tissue after third molar extraction: A double-blind, randomized, active-controlled clinical trial
  33. Editorial comment
  34. Chronic pain and psychological distress among long-term social assistance recipients – An intolerable burden on those on the lowest steps of the socioeconomic ladder
  35. Clinical pain research
  36. The co-occurrence of chronic pain and psychological distress and its associations with salient socio-demographic characteristics among long-term social assistance recipients in Norway
  37. Editorial comment
  38. Fifty years on the Visual Analogue Scale (VAS) for pain-intensity is still good for acute pain. But multidimensional assessment is needed for chronic pain
  39. Clinical pain research
  40. Patient reported outcome measures of pain intensity: Do they tell us what we need to know?
  41. Editorial comment
  42. Postoperative pain documentation 30 years after
  43. Topical review
  44. Postoperative pain documentation in a hospital setting: A topical review
  45. Editorial comment
  46. Aspects of pain attitudes and pain beliefs in children: Clinical importance and validity
  47. Observational study
  48. The Survey of Pain Attitudes: A revised version of its pediatric form
  49. Editorial comment
  50. The role of social anxiety in chronic pain and the return-to-work process
  51. Clinical pain research
  52. Social Anxiety, Pain Catastrophizing and Return-To-Work Self-Efficacy in chronic pain: a cross-sectional study
  53. Editorial comment
  54. Advances in understanding and treatment of opioid-induced-bowel-dysfunction, opioid-induced-constipation in particular Nordic recommendations based on multi-specialist input
  55. Topical review
  56. Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction–Recommendations of the Nordic Working Group
  57. Observational study
  58. Opioid-induced constipation, use of laxatives, and health-related quality of life
  59. Editorial comment
  60. Migraine headache and bipolar disorders: Common comorbidities
  61. Systematic review
  62. Migraine headache and bipolar disorder comorbidity: A systematic review of the literature and clinical implications
  63. Editorial comment
  64. The role of catastrophizing in the pain–depression relationship
  65. Clinical pain research
  66. The mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain: A longitudinal analysis
  67. Announcement
  68. May 26-27, 2016 Scandinavian Association for the Study of Pain, Reykjavik, Iceland May 25, 2016 PhD course
https://doi.org/10.1016/j.sjpain.2016.02.001

Articles in the same Issue

  1. Editorial comment
  2. Psychophysiological effects of threatening a rubber hand that is perceptually embodied in healthy human subjects
  3. Original experimental
  4. A preliminary investigation into psychophysiological effects of threatening a perceptually embodied rubber hand in healthy human participants
  5. Editorial comment
  6. Analysis of C-reactive protein (CRP) levels in pain patients – Can biomarker studies lead to better understanding of the pathophysiology of pain?
  7. Clinical pain research
  8. Serum C-reactive protein levels predict regional brain responses to noxious cold stimulation of the hand in chronic whiplash associated disorders
  9. Editorial comment
  10. Importance of early diagnosis of complex regional pain syndrome (CRPS-1 and CRPS-2): Delayed diagnosis of CRPS is a major problem
  11. Clinical pain research
  12. Delayed diagnosis and worsening of pain following orthopedic surgery in patients with complex regional pain syndrome (CRPS)
  13. Editorial comment
  14. Associative learning mechanisms may trigger increased burden of chronic pain; unlearning and extinguishing learned maladaptive responses should help chronic pain patients
  15. Original experimental
  16. When touch predicts pain: predictive tactile cues modulate perceived intensity of painful stimulation independent of expectancy
  17. Editorial comment
  18. Low back pain among nurses: Common cause of lost days at work and contributing to the worldwide shortage of nurses
  19. Observational study
  20. Pain-related factors associated with lost work days in nurses with low back pain: A cross-sectional study
  21. Editorial comment
  22. Assessment of persistent pelvic pain after hysterectomy: Neuropathic or nociceptive?
  23. Clinical pain research
  24. Characterization of persistent pain after hysterectomy based on gynaecological and sensory examination
  25. Editorial comment
  26. Transmucosal fentanyl for severe cancer pain: Nasal mucosa superior to oral mucosa?
  27. Original experimental
  28. Facilitation of accurate and effective radiation therapy using fentanyl pectin nasal spray (FPNS) to reduce incidental breakthrough pain due to procedure positioning
  29. Editorial comment
  30. Why do we have opioid-receptors in peripheral tissues? Not for relief of pain by opioids
  31. Clinical pain research
  32. Peripheral morphine reduces acute pain in inflamed tissue after third molar extraction: A double-blind, randomized, active-controlled clinical trial
  33. Editorial comment
  34. Chronic pain and psychological distress among long-term social assistance recipients – An intolerable burden on those on the lowest steps of the socioeconomic ladder
  35. Clinical pain research
  36. The co-occurrence of chronic pain and psychological distress and its associations with salient socio-demographic characteristics among long-term social assistance recipients in Norway
  37. Editorial comment
  38. Fifty years on the Visual Analogue Scale (VAS) for pain-intensity is still good for acute pain. But multidimensional assessment is needed for chronic pain
  39. Clinical pain research
  40. Patient reported outcome measures of pain intensity: Do they tell us what we need to know?
  41. Editorial comment
  42. Postoperative pain documentation 30 years after
  43. Topical review
  44. Postoperative pain documentation in a hospital setting: A topical review
  45. Editorial comment
  46. Aspects of pain attitudes and pain beliefs in children: Clinical importance and validity
  47. Observational study
  48. The Survey of Pain Attitudes: A revised version of its pediatric form
  49. Editorial comment
  50. The role of social anxiety in chronic pain and the return-to-work process
  51. Clinical pain research
  52. Social Anxiety, Pain Catastrophizing and Return-To-Work Self-Efficacy in chronic pain: a cross-sectional study
  53. Editorial comment
  54. Advances in understanding and treatment of opioid-induced-bowel-dysfunction, opioid-induced-constipation in particular Nordic recommendations based on multi-specialist input
  55. Topical review
  56. Definition, diagnosis and treatment strategies for opioid-induced bowel dysfunction–Recommendations of the Nordic Working Group
  57. Observational study
  58. Opioid-induced constipation, use of laxatives, and health-related quality of life
  59. Editorial comment
  60. Migraine headache and bipolar disorders: Common comorbidities
  61. Systematic review
  62. Migraine headache and bipolar disorder comorbidity: A systematic review of the literature and clinical implications
  63. Editorial comment
  64. The role of catastrophizing in the pain–depression relationship
  65. Clinical pain research
  66. The mediating role of catastrophizing in the relationship between pain intensity and depressed mood in older adults with persistent pain: A longitudinal analysis
  67. Announcement
  68. May 26-27, 2016 Scandinavian Association for the Study of Pain, Reykjavik, Iceland May 25, 2016 PhD course
Sign up now to receive a 20% welcome discount
Institutional Access
How does access work?
Have an idea on how to improve our website?
Please write us.
© 2025 De Gruyter Brill
Downloaded on 29.12.2025 from https://www.degruyterbrill.com/document/doi/10.1016/j.sjpain.2016.02.001/html
Scroll to top button