Iman Adibi Department of Neurology Isfahan Luniversity of Medical Sciences Global Burden of Disease Study 2010 Migraine Tension Headache Depression What is the epidemiology of comorbid migraine and depressive disorders ID: 913851
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Slide1
Overlap of Migraine, Tension-type Headache and Depression
Iman AdibiDepartment of Neurology , Isfahan Luniversity of Medical Sciences
Slide2Global Burden of Disease Study 2010
Slide3Migraine
Tension Headache
Depression
Slide4What is the epidemiology of comorbid migraine and depressive disorders?
Slide5Migraine and Depression
suicidal ideation and attempts are greater in patients with migraine the association with MDD is stronger in patients who have migraine with auraDepressionDepressionDepression
Depression
Depression
Depression
Migraineur
Healthy
Migraine
Migraine
Migraine
Migraine
Healthy
Depressed
Slide6What is the pathophysiology of comorbid migraine and depression?
Slide7Migraine and Depression
Shared Mechanisms
Genetic factors Serotonin (5-HT) system Dopaminergic systemGABA in cerebrospinal fluid Hypothalamic-pituitary adrenal (HPA) axisSpecific pain-modulating brain areas Psychological Stress and personality trait
Slide8Few studies have specifically considered TTH in depression
people with
episodic
TTH were found no more likely than controls to experience anxiety or mood disorders
people with
chronic
TTH were twice as likely to be suffering from depression
Anxiety and depression are associated with headache exacerbations in individuals with TTH
TTH and Depression
Slide9TTH and Migraine
co
-existing TTH may worsen the prognosis of migrainemajor depressive episodesAnxiety obsessive–compulsive disturbance.osmophobia and phonophobia seem highly predictive of both anxiety and depression in TTH dysfunction of similar brain structures (insular, hippocampus or amygdala)?
Slide10Should patients with
headache be screened for depression?
Slide11Depression
Screening Tools in Migraine Patient Health Questionnaire-9 (PHQ-9)Hospital Anxiety and Depression Scale (HADS)Beck
Depression InventoryHamilton Depression rating scale.
Slide12Treatment strategy
Avoid choosing
a drug that may worse the comorbid disorderWhen possible, treat both conditions with a single agent When a single agent has insufficient effect or is not tolerated, two different drugs must be usedNo current guidelines exist for the treatment of comorbid migraine and depression
Slide13Antidepressants for Headache
Tricyclic
antidepressantsAmitriptyline : level B “probably effective” rating ( drop out) Clomipramine : level B negative evidence “probably ineffective”Nortriptyline is less active at the histamine and muscarinic receptors and therefore has a lower side effect profileDoxepin has less anticholinergic effect than either amitriptyline or nortriptyline
Slide14Antidepressant for Headache
Selective serotonin reuptake inhibitors
(SSRI):cases of headache or migraine worsening with use of SSRIs have been described Fluoxetine, Sertraline, Fluvoxamine, received a rating of “level U: inadequate or conflicting data to support or refute medication use”other SSRIs did not have adequate evidence to receive a rating
Slide15Antidepressant for Headache
Serotonin and norepinephrine reuptake inhibitors
(SNRI):headache worsening has been reported Venlafaxine: 75 to 150 mg (vestibular migraine) the level of evidence assessment for duloxetine for migraine prevention is likely to equal that of venlafaxine in future guidelines.
Slide16Other Treatments
Mirtazapine
: more formally for chronic tension–type headache, but not for migraineOnabotulinumtoxin: A significantly reduces headache as well as depressive and anxiety symptomsFlunarizine and beta-blockers : may be contraindicated in the presence of depression.
Slide17Other Treatments
Magnesium
: 500 mg per day (Magnesium citrate or glycinate). modulates the activity of NMDA and GABA receptors, and can also affect the functions of the hypothalamic-pituitaryadrenal axis Topiramate: can produce anxiety, depression, or agitation Divalproex and olanzapine: can produce marked weight gain or sedation that further demoralize an already depressed patient.
Slide18Caution:
patients co-afflicted with bipolar disorder and migraine tended to present with depression
initially.bipolar disorder may go unrecognized, and therefore, untreated.
Slide19Caution:
antidepressants in BPD (SNRI or TCA):
ManiaHypomaniaRapid cycling The rate of antidepressant-induced switch into mania may be more common in migraineurs as compared to those without migraine
Slide20Any Question?
Slide21See the IHS website for more information
and to join online
Belong to the
International Headache Society (IHS)
Headache/neurology specialists from Iran can join
free of charge
as an Associate Member
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