Psychiatry - October 2008 - (Page 21)

[trend watch] migraine. As seen in Figure 2, 5HT-1 agonists represent 42 percent of migraine treatment. Pain products, both narcotic and non-narcotic, account for an additional 21 percent of migraine therapy. Antiepileptic agents, primarily topiramate, comprise 13 percent of migraine treatments. Psychiatric medications, such as TCAs, are not commonly used in the treatment of migraine (3.5% of medication uses). EXPERT COMMENTARY by Todd A. Smitherman, PhD To whom do migraineurs take their troubles? These trend data confirm that migraine patients are far more likely to seek treatment in primary care or neurology practice settings than in the office of psychiatrists. Despite this fact, however, the high rates of psychiatric comorbidity among migraineurs1–3 position psychiatrists uniquely to treat particularly challenging migraine patients. Approximately 20 to 30 percent of migraineurs will at some point merit a diagnosis of major depression, while approximately 50 percent will be diagnosed with an anxiety disorder.2–4 Comorbid anxiety and depressive disorders among migraineurs have been linked to increased medical costs, increased disability, poorer prognosis, and the progression of migraine from episodic to chronic forms.5,6 Because of the prevalence and detrimental impact of psychiatric comorbidities, all psychiatrists should screen migraine patients for depression and anxiety and also be alert for the presence of migraine in those patients who present exclusively with common psychiatric symptoms. Psychiatrists should also be attentive to the possibility of sleep dysregulation and disorders, which are also common in migraine patients.7 FIGURE 1. Specialty mix for treatment of migraine (5.5 million patients) Source: SDI Health VONA, Migraine (ICD-9 Diagnosis Code, 346), August 2007 to July 2008. 43% 21% 13% 6% 5% 3% FIGURE 2. Treatment of migraine—Includes treatments accounting for at least 1% of migraine therapies; KEY: BBs/CCBs=beta blockers/calcium channel blockers; TCAs=tricyclic antidepressants Source: SDI Health PDDA, Migraine (ICD-9 diagnosis 346) August 2007 to July 2008. Figure 2 confirms the huge impact that the introduction of triptans (5HT-1 agonists) has had on the landscape of migraine treatment. These migraine-specific agents are generally well tolerated, have relatively simple pharmacokinetics, and have welldemonstrated efficacy. Triptans are recommended by the US Headache Consortium8 as an appropriate frontline treatment for acute management of moderate to severe migraine in those without clinical contraindications and when nonspecific medication has failed. The goal of acute treatment with triptans is to treat attacks quickly, without recurrence, and to minimize the use of “rescue medications.” In many cases of complex psychiatric comorbidities and migraine, however, treatment regimens may need to go beyond [OCTOBER] Psychiatry 2008 21

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Psychiatry - October 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Treatment of Migraine and the Role of Psychiatric Medications Play Therapy: A Case-based Example of a Nondirective Approach Delirium and Antipsychotics: A Systematic Review of Epidemiologyand Somatic Treatment Options Severely Mood-disordered Youth Respond Less Well to Treatment in a Community Clinic than Youth with Bipolar Disorder Beyond Informed Consent: The Ethics of Informing, Anticipating, and Warning Asthma: Wheezing, Woes, and Worries Classified Advertising Journal Watch Information for Authors

Psychiatry - October 2008

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