Acute and abortive medications are indicated for patients with infrequent migraines. Triptans are the abortive agents of choice, and generic sumatriptan remains the most cost-effective option for patients. Other triptans that include additional agents or use alternative delivery systems (ie, sublingual, intranasal, transdermal) may benefit patients who have difficulty with oral or needle-based formulations or experience nausea or stomach upset. Despite the FDA’s black box warning, empirical data indicate that risk of serotonin syndrome among patients receiving a triptan and other serotonergic agent (for depression/anxiety) is incredibly low, with most affected patients experiencing mild symptoms that remit on discontinuation of one of the medications.26
Other commonly used acute and abortive medications include ergotamine derivatives, opioids, and other analgesics. Continuous opioid therapy for headache should be avoided except as a last resort, particularly for those with severe psychopathology or a history of substance abuse, because opioid use at a frequency of even 2 or 3 days per week can increase headache frequency, render migraine refractory to other treatments, and beget MOH.
Any effective acute or abortive medication (even over-the-counter analgesics) can lead to MOH, but the risk of MOH is highest with opioid analgesics. The most common cause of chronic migraine is opiate overuse, and migraineurs who take opiates 10 or more times per week should be assumed to have MOH until proved otherwise. Patients with MOH often prove highly refractory to headache treatment until they undergo withdrawal from the overused medication. These patients should be referred to a neurologist, preferably a headache specialist, for management of their headache. Because they are also the patients most likely to have psychiatric comorbidity, close collaboration between psychiatrist/mental health practitioner and neurologist is essential for treatment success.
A final treatment option is to supplement pharmacotherapy with behavioral management of migraine or the psychiatric disorder. Over the past 4 decades, behavioral headache treatments (including relaxation training, biofeedback, cognitive-behavioral therapy/stress-management training) have amassed a sizable evidence base that shows improvement rates that are competitive with prophylactic pharmacotherapies for migraine.27
The strength of this evidence has led numerous professional practice organizations to recommend use of behavioral headache treatments alongside pharmacological treatments for primary headache. Mild to moderate depression responds equally well to behavioral therapy as to medication. Patients with panic disorder, obsessive-compulsive disorder, and PTSD are best treated with exposure therapy because it is more effective than medication and because benzodiazepine use can function as an avoidance mechanism and lead to addiction.
Mild depression or anxiety among migraineurs often is sufficiently managed nonpharmacologically and improves as headache decreases. Migraineurs with more severe affective distress are likely to require pharmacological management of the psychiatric comorbidity and/or intensive psychotherapy from a mental health provider with expertise in behavioral medicine.
Migraine, particularly chronic migraine, as well as other chronic headaches, have high rates of comorbidity with mood and anxiety disorders. Migraine and psychiatric disorders share underlying pathophysiological mechanisms, with bidirectional, interdependent effects. Psychiatric comorbidity complicates headache and may portend a poorer prognosis for treatment. Emerging evidence suggests that the psychiatric disorder itself may contribute to transformation of episodic migraine to chronic and daily headaches.
Effective treatment for comorbid mood and anxiety disorders requires screening headache patients and accurately diagnosing specific psychiatric disorders when present. Many well-validated and relatively simple screening tools exist to facilitate recognition of psychiatric comorbidity and quantification of psychiatric symptoms. Pharmacological interventions that target both headaches and comorbid depressive or anxiety disorders, which often require separate agents by condition, can lead to improved headache treatment outcomes.
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