The comorbidity of migraine with anxiety and depression is well established, both in clinically based studies and in epidemiologic samples from community populations.  The physiologic overlap between migraine and depression is considerable, and antidepressants or mood stabilizers often help both conditions.  In the vast majority of migraine patients who suffer from depression, anxiety is a complicating factor.  The anxiety disorder often precedes the age of onset of migraine, with depression following afterward.  It is likely that shared environmental and genetic factors link migraine and depression.

Several studies have shown that incidences of bipolar I and bipolar II were found to be increased in migraineurs.  Recent studies have confirmed that at least 7% of headache patients fit into the bipolar spectrum and 40 to 50% of bipolar patients have migraines.

The clinical spectrum of bipolar disorders is an evolving concept.  It is the milder end of the bipolar spectrum that tends to be missed; look for those with persistently agitated, angry personalities, with frequent depressions and/or “too much energy”, with a strong bipolar or depressive family history.  They may not have a clear hypomanic or manic episode.  Soft bipolar signs include: early (teens) depression, severe depression, quick onset depression, “bipolar” reaction to certain meds (up all night, mind racing, etc.), agitated angry depression, very high anxiety and mood swings, poor response to medication, and moody personality.  Sleep disorders are commonly seen.  Cyclical depression “for no reason”, with high anxiety, is common for bipolar depression.

Recognizing bipolarity and establishing the bipolar diagnosis is essential for a client’s therapeutic implications.  Undiagnosed bipolar patients often are given a number of antidepressants, with predictable hypomanic (poor) results.  Mood stabilizers often are very helpful for the moods and headaches.  Divalproex sodium (Depakote) is effective for mania, hypomania, depression associated with bipolar disorder, and for headache prevention.  Divalproex sodium has become one of the primary migraine and chronic daily headache preventives.  Lamictal is also becoming one of the most commonly used mood stabilizers and is one of the only effective medications for bipolar depression.  Additionally, the new antiepiletics may prove to be helpful for bipolar disorders and/or migraine. 

The recognition of increased comorbidity between migraine and bipolar illness has important clinical implications.  By broadening our concept of the bipolar realm, we can improve outcome in these patients.  Recognition of the milder end of the bipolar spectrum is crucial, as the clinical stakes for missing bipolar ilness are enormous. 

Unfortunately, medications used for bipolar patients are often more effective for the manic/hypomanic symptoms, leaving the depression frequently untreated.  Bipolar patients spend the majority of their time in depression, and we need better medications.  Many patients need two to four meds (such as Lamictal, Lithium, and an antidepressant).

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