For one thing, the reality of living with the pain and disability that migraine causes may contribute to depression. Likewise, the fear and anticipation of a future migraine attack can cause anxiety in many people. But is there more to the connection? Learn what the experts say about the link between migraine, anxiety and depression, as well as what treatment options can help you manage these conditions.
Can Migraine Cause Depression?
It’s very common to have both migraine and depression, according to Loretta Mueller, DO, a headache specialist at Cooper University Health Care in Cherry Hill, New Jersey. “Depression is at least 2 to 3 times more common in people with migraine,” Dr. Mueller says. “It seems to be a bidirectional relationship, which means if you have depression, you’re more likely to get migraine, or if you get migraine, you’re more likely to also have depression,” says Mueller. According to the American Migraine Foundation, some people become depressed after living with migraine attacks for months or years, while others start having migraine attacks after living with depression. Migraine often causes people to retreat to a dark room and miss work as well as social activities, which can have a major impact on quality of life. Research published in Neurology found that having both migraine and depression was significantly associated with lower quality of life measures for both physical and mental health.
Can Migraine Cause Anxiety?
Research has shown that anxiety is even more closely linked with migraine than depression, says Mueller. It’s estimated that as many as half of people with chronic migraine also have anxiety, according to the American Migraine Foundation. “People with a higher burden of migraine are more likely to have anxiety. They have increased migraine frequency and a higher likelihood of transitioning over into chronic migraine,” says Mueller. The International Headache Society (IHS) defines chronic migraine as headache occurring on 15 or more days per month for at least three months, and on at least eight days of the month the headache has the symptoms of a migraine headache. RELATED: Expert Advice on Managing Chronic Migraine Studies have shown that people who have depression and migraine together often have anxiety as well, according to Mueller. “It’s rare for people with migraine to just have that depression component without having anxiety, too,” she says. “The relationship between anxiety and migraine is bidirectional as well, but it’s more likely to start with anxiety earlier in life, and with migraine developing a few years after that,” she says.
Depression and Anxiety More Common in Migraine With Aura
The strongest association between the two mood disorders and migraine is in people with migraine with aura, she adds. “About a third of people with migraine get aura during their attacks. This can be a visual aura, or more rarely a sensory aura or an aura that causes weakness,” she says. People with this type of migraine seem to be even more vulnerable to the anxiety-depression link,” she says.
Do People With Migraine Have Panic Attacks?
People with migraine are more likely to have generalized anxiety disorder, which can be an ongoing “on edge” feeling, rather than have panic attacks, says Mueller. There are some people with migraine who do have panic attacks, which may be related to an underlying problem with the autonomic nervous system, she says. “That’s why you get the palpitations, high heart rate, and something like a surge of anxiety with the panic attack,” she says.
Medication Overuse Headache May Be More Likely if You Have Migraine and Anxiety
People with anxiety are more likely to develop medication-overuse headache or rebound headache, says Mueller. Medication-overuse headache is a chronic daily headache that happens when acute medications for headache or migraine are used more than two to three days per week, according to the American Migraine Foundation. “This can happen because often people with migraine who also have anxiety tend to treat early, because they’re more likely to have that anticipatory anxiety that the headache is going to escalate,” explains Mueller. Medication-overuse headache is linked with most of the drug categories used to treat migraine attacks, including triptans, ergotamines, opioids, and over-the-counter pain relievers such as acetaminophen (Tylenol), nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen, and combination pain relievers that contain aspirin and caffeine. RELATED: 10 Things You Need to Know About Medication-Overuse Headache
What About Other Types of Headache and Depression and Anxiety?
People who experience cluster headache are also at a higher risk of anxiety and depression, especially when they also have coexisting migraine, according to a study published in May 2020 The Journal of Headache Pain. Cluster headaches are so named because they come in clusters — daily for a month or more, for example, and then none for a year. A cluster headache occurs suddenly, often waking the person from sleep, and lasts between 15 minutes and three hours. A runny nose and tearing on the side with the pain is also common. According to the study, anxiety and depression can improve in people with both cluster headache and migraine during periods of remission. “There’s less of a link between tension headaches and depression and anxiety,” says Mueller. “In tension headaches you don’t have the nausea, sound sensitivity, or throbbing pain as you do with migraine headache.”
Can Antidepressants Help With Migraine?
Antidepressants can be effective for anxiety or depression, says Mueller. “A class of antidepressants that can often address both conditions is called serotonin-norepinephrine reuptake inhibitors (SNRIs),” says Mueller. Antidepressants, including SNRIs, are also sometimes prescribed to prevent migraine attacks, and according to a review of antidepressant classes for migraine prevention published in March 2019 in Current Treatment Options in Neurology, “SNRIs … may be the most effective treatments in patients with comorbid depression and migraine.” Some of the drugs in the SNRI class include:
Pristiq (desvenlafaxine) and Fetzima (levomilnacipran) are both approved to treat depression.Cymbalta (duloxetine) is approved to treat depression, anxiety, and certain types of chronic pain.Effexor XR (venlafaxine) is approved to treat depression, certain anxiety disorders, and panic disorder.
How Do You Treat Migraine and Anxiety?
Another class of antidepressants that are sometimes prescribed for migraine, anxiety, and depression is the SSRIs, the serotonin reuptake inhibitors, says Mueller. SSRIs approved to treat depression that may also help manage anxiety include:
Celexa (citalopram)Lexapro (escitalopram)Prozac (fluoxetine)Paxil, Pexeva (paroxetine)Zoloft (sertraline)
“These drugs are sometimes used in migraine prevention, and they can be very effective for anxiety disorder and panic disorder, as well as for many people with depression,” says Mueller. If the anxiety and depression can be managed through one of these medications, the migraine symptoms often get better, she says. “Sometimes another preventive medication may be prescribed in addition to one of these antidepressants or anti-anxiety medications, depending on the patient,” adds Mueller. Older antidepressants, known as tricyclic antidepressants, can also be used as a preventive treatment for migraine, she says. “These drugs have been around since the 1970s. They have more side effects, but they don’t tend to be as bothersome, because we use much lower doses to treat migraine than what is used to treat depression. That dose can often help with migraine prevention but typically wouldn’t be high enough to treat depression or anxiety,” she says.
Other Medical Conditions Must Be Considered When Treating Migraine
Treating migraine and headache can be less straightforward than treating other types of conditions, says Mueller. “With headache you have to look at the whole picture and any comorbidities, or other health conditions, that the person might have,” she says. In addition to depression and anxiety, other comorbidities that may accompany migraine include post-traumatic stress disorder (PTSD), asthma, allergies, IBS, hypertension, Crohn’s disease, COPD, chronic fatigue, sleep disorders, fibromyalgia, epilepsy, multiple sclerosis (MS), and stroke, according to American Migraine Foundation. “We often try to choose a medication that will address both conditions when possible, and we want to avoid prescribing anything for migraine that might aggravate another condition,” she says. For example, tricyclic antidepressants are often avoided in managing migraine in people with bipolar disorder, because they may cause a shift into mania, says Mueller.
What About Psychotherapy or Mindfulness to Help With Migraine, Depression, and Anxiety?
If you can use cognitive behavioral therapy (CBT) along with medication it can be effective in managing migraine, depression and anxiety, says Mueller. “That cognitive behavioral therapy arm seems to really add benefit. One problem is that in many cases insurance doesn’t cover therapies such as CBT,” she says. Mindfulness training may be helpful for people with migraine because it helps people respond to stress differently, according to Rebecca Wells, MD, associate professor of neurology at Wake Forest Baptist Health in North Carolina, director of the Comprehensive Headache Program and associate director of clinical research at the Center for Integrative Medicine. Stress is often cited as a trigger for both migraine and anxiety. Dr. Wells was the lead author in a study published in Headache which tested the effectiveness of eight-week mindfulness-based intervention. They found that compared with individuals who had not learned the practice, people who completed the intervention had improvements in their headache duration and their disability. RELATED: How Psychotherapy Can Help With Migraine
What Is the Role of Sleep in Migraine, Depression, and Anxiety?
A sleep disorder, which can include difficulty getting to sleep or staying asleep, can have an impact on migraine, depression, and anxiety, says Strauss. People with migraine are between 2 and 8 times more likely to have a sleep disorder, and people with chronic migraine report having almost double the rate of insomnia compared with people with less frequent headaches, according to the American Migraine Foundation. Not enough sleep or getting poor quality sleep increases the chances that a person with migraine to have a mood disorder. Some medications used to treat migraine can have an impact on sleep, says Mueller. For example, certain antidepressants can make you sleep more, while others have an activating effect, making it harder to go to sleep or stay asleep, according to a paper published in 2017 in Current Psychiatry Reports. Make sure you share any sleep issues with your doctor so that it can be factored in when deciding on a treatment strategy. There’s also good evidence that cognitive based behavior therapy can be helpful for insomnia, adds Strauss. RELATED: 6 Sleep Tips for People With Migraine
