Psychiatric comorbidity in patients with migraine: A standardized interview-based study.

We studied a total of 146 patients (66 males, 80 females) with migraine. Their age ranged from 18 to 60 years (mean = 29 ± 9 years). The sample consisted mainly of the patients who were single (54.1%) and unemployed (84.2%) and those who belonged to urban background (64.4%), middle socioeconomic status (78.1%), and Hindu religion (66.4%) [ Table 1 ]. The sample had a median duration of migraine of 0.56 years with a mean frequency of 6.71 (± 3.22) attacks per month. Out of 146 patients with migraine, only 43 (29.5%) of them were diagnosed with migraine with aura while the remaining majority were patients without aura. In the majority of the patients, the headache was of severe intensity and pulsatile and it had negative impact on the normal routine. Predominant aggravating factors for headaches were sun exposure, strong smell, exercise, and routine work. Predominant associated symptoms with headache were photophobia/phonophobia (55.5%) and nausea and/or vomiting (34.2%). Most of the patients reported an attack of the headache to be relieved with medications. Only 13 (8.9%) of the all patients reported a past history of any psychiatric illness. A family history of either migraine or of any psychiatric illness was reported by a few patients only [ Table 2 ]. Sociodemographic details of patients with migraine ( N =146) SD – Standard deviation Clinical details of patients with migraine ( N =146) Out of 146 patients with migraine, 103 (70.55%) of them had one/more comorbid ICD-10 psychiatric diagnoses. [ Figure 1 ]. Among the individual comorbid psychiatric diagnoses of the patients with migraine, depressive episode (17.1%) was the most common while delusional disorder (4.1%) was the least common one. Other comorbidities are given in Table 3 . Out of multiple sociodemographic and clinical details gathered from the patients, only a few like marital status, socioeconomic status, duration of migraine, the severity of migraine, diagnosis of migraine, and psychiatric disorder in the family were significantly correlated with one or more psychiatric comorbidity in patients with migraine [ Table 4 ]. The patients with comorbid “recurrent depressive episodes” (N = 10) were mostly married [90% vs 41.9%; χ 2 = 7.523 (1), P < .05], significantly more in number from lower socioeconomic status (40% vs 9.3%; χ 2 = 5.966 (1), P <.05), and they had a significantly higher family history of psychiatric illness [30% vs 4.7%; χ 2 = 6.102 (1), P <.05] in comparison with the patients without any psychiatric comorbidity (N = 43). Similarly, the patients with comorbid mixed and other anxiety disorders (N = 9) were significantly more in number from lower socioeconomic backgrounds [55.6% vs 9.3%; χ 2 = 11.125 (1), P <.01] and with the presence of aura with migraine [55.6% vs 16.3%; χ 2 = 6.468 (1), P <.05]. The patients with comorbid “obsessive-compulsive disorder” (N = 9) were significantly more in number from lower socioeconomic status [44.4% vs 9.3%; χ 2 = 7.06 (1), P <.05] and with severe nature of migraine headaches [88.9% vs 48.8%; χ 2 = 4.84 (1), P <.05]. The patients with comorbid “depressive episode” [40% vs 16.3%; χ 2 = 4.744 (1), P <.05], “generalized anxiety disorder” [50% vs 16.3%; χ 2 = 5.91 (1), P <.05], and “conversion (dissociative) disorder” [60% vs 16.3%; χ 2 = 8.378 (1), P <.05] individually were significantly more in number in terms of the presence of aura with migraine. The migraine patients with comorbidity of “delusional disorder” (N = 6) and of “dysthymia” (N = 15) individually had significantly higher mean duration of migraine whereas the migraine patients with comorbidity of “depressive episode” (N = 25) and of “post-traumatic stress disorder” (N = 7) individually had a significantly lower mean duration of migraine, in comparison with the patients without any psychiatric comorbidity. Such comparison was statistically not significant for individual psychiatric comorbidities like panic disorder, adjustment disorders, and somatoform disorders. Overall, the group of migraine patients with at least a single psychiatric comorbidity (N = 103) was also compared to the group of patients with nil comorbidity (N = 43) and the former appeared to be significantly more in number in terms of lower socioeconomic status [27.2% vs 9.3%; χ 2 = 5.668 (1), P <.05] and presence of aura with migraine [35% vs 16.3%; χ 2 = 5.09 (1), P <.05] than the latter. Comorbidity of any psychiatric diagnosis in patients with migraine Prevalence of ICD-10 psychiatric diagnoses in patients with migraine ( N =146) *Some of the patients had more than one coexisting disorder hence total exceeds 103 Clinical and sociodemographic information of migraine patients with and without psychiatric illness is compared NPC – No Psychiatric Comorbidity; APC – Any Psychiatric Comorbidity; DD – Delusional Disorder; BAD – Bipolar Affective Disorder; DE – Depressive Episode; RDE – Recurrent Depressive Episodes; D – Dysthymia; MAD – Mixed & other anxiety disorders; OCD – Obsessive-Compulsive Disorder; GAD – Generalized Anxiety Disorder; PTSD – Post-Traumatic Stress Disorder; CD – Conversion (Dissociative) Disorders. * P <0.05; ** P <0.01; *** P <0.001; NS – Statistically not significant

The prevalence of comorbid psychiatric disorders in migraine patients is very high (70.5%). Lower socioeconomic status and the presence of aura with migraine are two important patient-related factors linked with the occurrence of any psychiatric comorbidity in migraine. There are no conflicts of interest.

This study presents a rigorous work of a standardized interview-based study of different psychiatric conditions comorbid in migraine patients who attended a tertiary care center in India. Overall, around 70% of the patients with migraine had comorbidity of at least one psychiatric diagnosis. These results are consistent with past research conducted in India.[ 13 14 15 16 25 ] These researchers too have reported an overall comorbidity of at least one psychiatric diagnosis in the range of 60-85% [ Table 5 ]. However, the present study differs from others in terms of the use of the ICD-10 symptom checklist, a comprehensive tool to establish the psychiatric comorbidities as per the ICD-10 diagnostic classification system, in the patients of migraine who were enrolled in the study only after they scored above the cut-off (=2) on GHQ-12, a screening tool. Prevalence and correlates of psychiatric comorbidities in patients with migraine across different Indian studies MINI – Mini International Neuropsychiatric Interview; HADS – Hospital Anxiety and Depression scale; GAD – Generalized anxiety disorder; OCD – Obsessive-compulsive disorder; PTSD – Post-traumatic stress disorder In the present study, among individual psychiatric diagnoses, depressive episode (17.1%) was the most common while delusional disorder (4.1%) was the least common. Mood disorders [like depressive episode (17.1%), recurrent depressive episodes (6.8%), dysthymia (10.3%), and bipolar affective disorder (7.5%)] and anxiety disorders [like panic disorder (5.5%), generalized anxiety disorder (8.2%), mixed and other anxiety disorders (6.2%), and obsessive-compulsive disorder (6.2%)] were two common diagnostic categories comorbid in such patients. The remaining comorbid diagnoses were post-traumatic stress disorder (4.8%), adjustment disorders (5.5%), dissociative (conversion) disorders (6.8%), and somatoform disorders (6.2%). Earlier, some Indian studies have reported major depressive disorder[ 13 14 16 ] to be the commonest while others have mentioned anxiety disorders[ 15 25 ] to be the commonest among individual psychiatric comorbidities in migraine patient [see Table 5 ]. In our study, while applying the ICD-10 symptom checklist, the clinical interview-assisted labeling of ICD-10 psychiatric diagnoses yielded fairer clinical conditions which might not be expected to appear with simple rating scale-based approaches. This may be the reason why the prevalence of individual psychiatric comorbidities in the present study differs from that in other studies. In literature, addressing the cooccurrence of chronic physical sickness and mental illness has been proposed to be the fourth revolution in psychiatry.[ 26 ] In this context, a comprehensive evaluation of the correlates of psychiatric comorbidities of migraine is desirable. In the present study, the patients of migraine were thoroughly enquired about their sociodemographic and clinical details and such variables were evaluated for their relationship with different psychiatric comorbidities. Out of a long list, sociodemographic factors like marital status and socioeconomic status as well as clinical factors like duration and severity of migraine, presence of aura with migraine, and family history of psychiatric illness were found to be significantly associated with one or more psychiatric comorbidities with migraine. Earlier, many studies[ 13 14 25 ] from India have also attempted to seek such correlates of psychiatric comorbidities in migraine patients but a fruitful conclusion of such associations is missing [see Table 5 ]. In general, any association of demographic or clinical parameters of the patients with individual psychiatric comorbidities is difficult to establish in cross-sectional studies with smaller sample sizes. For this to happen, a larger population of each diagnosis comorbid with migraine should be analyzed in detail to establish a solid relationship with any particular sociodemographic or clinical detail of migraine patients. Beyond individual psychiatric comorbidities, the broader group of migraine patients with any psychiatric comorbidity (N = 103) was significantly associated with two patient-related factors such as lower socioeconomic status and the presence of aura with migraine. The association of a deteriorating socioeconomic status increasing the chance of the occurrence of one or more psychiatric comorbidity in migraine can be inferred from the reports of some systematic reviews[ 27 28 ] in which poorer mental health outcomes were highly correlated with poverty in low- and middle-income nations like India. Another link between psychiatric comorbidity and the occurrence of aura with migraine is also important. Earlier, in many research works, it has been found that the migraine patients with aura have higher chances of psychiatric comorbidity in general[ 29 ] and depression[ 30 ] and suicidal ideation[ 31 ] in particular. In a recent original research, it has been found that the obsessive-compulsive disorder (both subclinical and clinical cases) were significantly in higher frequency in migraine patients with aura than those without aura.[ 32 ] In present study, a link between presence of aura in migraine and comorbidity of depression, mixed anxiety disorder, generalized anxiety disorder, and conversion disorder was found but there was no such association with obsessive-compulsive disorder. Overall, the findings of the present study are relevant at a time when the general awareness about the psychological consequences of different physical illnesses is on the rise. Undoubtedly, psychiatric issues are consistently linked to migraine[ 5 ] but their presentations may differ across different geographical locations.[ 8 ] Recently, many studies have highlighted the issue of biological bases of different medical and psychiatric comorbidities in migraine. A bidirectional link between migraine and different physical conditions like stroke, diabetes mellitus, hypothyroidism, and endometriosis has been found.[ 33 ] A similar and strong link between migraine and mental conditions like anxiety, depression, and suicidality has also been established by the researchers.[ 34 35 ] Some of the researchers have claimed that migraine and certain psychiatric disorders share common neuropathic mechanisms.[ 33 36 ] Therapists need to recognize the comorbid psychiatric conditions and include them in the therapeutic processes for the better management of such patients.[ 37 ] Nonpharmacological management like CBT (cognitive behavior therapy) and even the use of medications to prevent migraine headaches may be affected by psychiatric disorders in migraine.[ 8 ] Healthcare providers need to address various psychiatric issues in patients with migraine during assessment and management. This issue is also relevant during the policy-making over such subjects for a better outcome in such patients. The target population may not be accurately represented by the purposive sampling method from a tertiary care hospital’s outpatient clinics. Smaller sample sizes limited the prediction of individual psychiatric comorbidities of patients with migraine. Small number in each group further reduces the generalization.

In a tertiary care facility in North India, the Department of Psychiatry conducted this hospital-based cross-sectional study. Permission from Institutional Ethics Committee (IEC/51/16/SEP dated 07/09/2016) was obtained before starting the study. The target population comprised patients with migraine attending the Psychiatry and General Medicine outpatient departments. After obtaining informed consent, the adult (age range 18-60 years) patients with migraine were enrolled in the study with the help of the purposive sampling technique. Diagnosis of migraine (either with aura or without aura) was made using the recent International Headache Society (I.H.S.) criteria for migraine.[ 18 ] Patients’ sociodemographic details (e.g., age, sex, marital status, etc.) and clinical details (e.g., total duration of migraine, diagnosis of migraine, etc.) were recorded on a self-prepared datasheet. It is a self-administered screening tool used to identify the participant’s present level of mental disturbances and disorders.[ 19 20 ] In the present study, a Hindi-translated version[ 21 ] of GHQ-12 was used and the patients with migraine scoring above the cut-off score of 2 on the GHQ-12 were enrolled. The ICD-10 symptom checklist[ 17 ] is a semi-structured, reliable, and valid instrument intended for clinicians’ assessment of psychiatric symptoms and syndromes. The symptoms on the checklist are divided into the F0/F1 module (organic and psychoactive substance use syndromes), F2/F3 module (psychotic and affective syndromes), F4/5 module (neurotic and behavioral syndromes), and F6 module (neurotic and behavioral syndromes) (personality disorders). According to the Clinical Descriptions and Diagnostic Guidelines of the ICD-10 Classification of Mental and Behavioral Disorders, each module essentially represents a compilation of pertinent ICD-10 symptoms and characteristics.[ 22 ] For a clinical professional with experience, no special training is needed to use the checklist. He or she should be acquainted with the ICD-10 criteria and the checklist’s fundamental format, nevertheless. The symptom glossary for ICD-10,[ 23 ] which offers succinct descriptions of the symptoms and words used in the checklist, is included with the ICD-10 symptom checklist. The instrument also consists of (1) a Face sheet and (2) a Screener. Users can enter their major and/or subsidiary ICD-10 diagnoses as well as their level of confidence in the diagnosis on the face Sheet. The Screener asks the user to code the main factor(s) that led to the diagnosis of the patient as having a psychiatric disease, such as the existence of psychological complaints, medically unexplained somatic problems, or behavior that deviates from socially acceptable norms. Another portion asks the user to code the principal syndrome category or categories for which the patient is being screened after identifying the psychiatric case. The Kuppuswamy's socioeconomic status scale[ 24 ] was utilized to ascertain the socioeconomic status of the sample in the Indian context. It is based on a composite score of 3-29 that takes into account the family’s monthly income, education, and occupation of the head of the household. The education and profession of the household head typically remain constant over time, but the income loses significance when the Indian rupee’s value declines. For the present study, the scale updated in 2016 was utilized. The acquired data were then tallied and statistically analyzed using IBM SPSS version 22 (IBM, Atlanta, USA). The distributions of categorical variables of sociodemographic details were presented with percentages (n%) while continuous variables were expressed in terms of Mean (± standard deviation). The comparison between groups (based on the presence or absence of psychiatric morbidity) was done using the Chi-square (χ 2 ) test with Fisher’s exact test (where applicable) for categorical variables. For normally distributed continuous variables (like age in years), independent t test was applied. The level of significance considered in our study was P < 0.05.