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The Bipolar Spectrum in Migraine, Cluster, and
Chronic Tension Headache
Lawrence Robbins, M.D.
Posted: February 2007  

The bipolar spectrum has been shown to occur with increased frequency in migraineurs. Previous studies have primarily focused on bipolar I and II. The current study also includes the "softer, milder" end of the bipolar spectrum. Identifying and recognizing bipolar illness is not simply an academic exercise; the clinical stakes for missing the bipolar diagnosis are enormous. This study, in addition to migraine, also evaluated the bipolar spectrum in cluster headache, as well as chronic tension headache (without migraine).

Patients with the 3 primary headache types were evaluated for lifetime prevalence of the bipolar spectrum. In the current study, we expanded the definition of bipolar disorder, not otherwise specified, to include those with hyperthemic temperaments. In addition, we included depressed patients with persistently agitated, angry personalities, who had a strong family history of bipolar, and/or a hypomanic reaction to an antidepressant. These patients, along with those who have "persistent temperamental instability", with a strong bipolar family history, constitute part of the milder end of the bipolar spectrum. It is these milder bipolar patients who tend to be missed and underdiagnosed.

1200 consecutive migraine patients were evaluated according to DSM-IV guidelines. Results: Bipolar 1: 24     Bipolar II: 28     Bipolar NOS: 34     Cyclothymic: 17.     Total Bipolar spectrum for migraineurs: 103 (8.6%).

287 cluster headache
patients were seen over 18 years. Results: Episodic cluster (141):  
Bipolar 1: 2     Bipolar II: 4     Bipolar NOS: 1     Cyclothymic: 2    Total episodic: 9 (6.4%). Chronic cluster (146):     Bipolar 1: 2     Bipolar NOS: 2     Cyclothymia: 4     Total chronic: 10 (6.8%).    Total Bipolar spectrum for cluster patients: 19 (6.6%).

292 patients with chronic tension type headache,
without migraine, were evaluated. Results: Bipolar I: 5     Bipolar II: 3     Bipolar NOS: 3     Cyclothymia: 2.     Total Bipolar spectrum for chronic tension headache: 13 (4.5%).

The bipolar spectrum is seen relatively often in headache patients, particularly among migraineurs (8.6%). Cluster headache patients had a slightly lower prevalence of bipolar (6.6%). Chronic tension headache patients, without migraine, had the least percentage of bipolar, (4.5%). The reason for the lower prevalence among tension headache patients, versus migraine, is unclear.