What drives where we go with headache meds are comorbidities: psychological, medical, the GI system etc.. If someone has high blood pressure, we treat with that type of med, if another person has irritable bowel syndrome(a “serotonin” central sensitization syndrome, common among headache sufferers), we avoid meds that irritate the GI tract, or use others that help the symptoms.
The most prevalent comorbidities are the psychological ones: anxiety, depression, bipolar, ADHD. We have articles on this site about all of these. These are, in a sense, not really “psychological”; they are physical, inherited differences in the brain(the limbic system, for instance, is crucial in anxiety, particularly the little almond shaped Amygdala, which is bigger in those with anxiety and fires constantly). You could, in experimental research types of scans, do a scan and almost predict who has anxiety…same with chronic migraine, with scans that focus on the white matter of the brain.
Most people are familiar with anxiety and depression, and there are a # of good resources and books; however, bipolar depression is a spectrum that still is missed by patients and health providers. Bipolar is common(about 8% of migraine sufferers, and maybe 4% of the general population, depending upon how you define it). The clinical stakes for missing bipolar are enormous; people just bounce from one antidepressant to another, with predictably poor results. Bipolar itself is a poor name, with most people thinking of bipolar as a “crazy person who has severe emotional swings”…but 85 to 90% of those with the bipolar brain chemistry are just depressed, with a tendency(sometimes) towards anxiety/irritability/and too much energy. I look at bipolar as basically depression “plus”, with those features listed. People often mix up bipolar with personality disorders, which are an entirely different category. I would hope that with(coming in 2012) DSM 5(psychiatric categories) that they would get rid of the terrible name “bipolar”, for it just inhibits the diagnosis. More on this later…….

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