Psychiatry - October 2008 - (Page 22)

[trend watch] acute treatment with a triptan and focus also on prevention. Most of the selective serotonin reuptake inhibitors (SSRIs) commonly prescribed for affective disorders have not shown strong efficacy for migraine.9 Griffith and Razavi10 have provided details about pharmacological management of migraine patients with affective comorbidities. They note that the optimal antidepressant is one that has demonstrated dual efficacy in treating both migraine and depression/anxiety. For depression, candidate dual-action medications include serotonin/norephinephrine reuptake inhibitor (SNRIs) (such as venlafaxine) and TCAs (such as amitriptyline). These medications have shown separate efficacy for depression and headache, and amitriptyline in particular has demonstrated Grade A quality evidence for migraine.8 However, the trend data confirm that TCAs are prescribed relatively infrequently, likely due to their side effect profile and narrow therapeutic index. Panic patients with migraine may benefit from venlafaxine, TCAs, and monoamine oxidase inhibitor (MAOIs).10 Frequently, however, the dose needed to control depression or anxiety far exceeds that needed to control migraine. A prudent strategy in the attempted use of a single agent to treat both conditions is to utilize dosing guidelines from the psychiatric literature while monitoring for adverse events. Bipolar patients may benefit from anticonvulsants and mood stabilizers that have shown promise in reducing migraines, such as valproate and olanzapine.10 Because many of the pharmacological agents with demonstrated efficacy for psychiatric conditions have not been found particularly effective for migraine, ultimately many patients 22 Psychiatry 2008 [ O C T O B E R ] will require multiple agents to address both conditions effectively. In such cases, prescribing psychiatrists necessarily should attend to potential drug interactions, contraindications, and the potential for medication overuse (which frequently causes headache, particularly with analgesics). Clearly, further clinical trials are needed to guide the utilization of various pharmacological agents in the treatment of the migraine patient with psychiatric comorbidities. Other studies are needed to discern the mechanisms of action responsible for the therapeutic effects of some psychotropic medications on migraine. Psychiatrists will likely play a significant role in these future studies, because they are often presented with some of the most challenging and complex migraine patients. The migraine patient with psychiatric comorbidities is an exemplar complex patient, successful treatment of whom requires knowledge of and extrapolation from the efficacy literature as well as sound clinical judgment. 6. 7. 8. 9. 10. progression. Curr Pain Headache Rep. 2008;12:224–229. Smitherman TA, Maizels M, Penzien DB. Headache chronification: screening and behavioral management of comorbid depressive and anxiety disorders. Headache. 2008;48:45–50. Rains JC, Poceta JS. Headache and sleep disorders: review and clinical implications for headache management. Headache. 2006;46:1344–1363. Silberstein SD for the US Headache Consortium. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review). Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55:754–763. Loder E, Biondi D. General principles of migraine management: the changing role of prevention. Headache. 2005;45(Suppl 1):S33–S47. Griffith JL, Razavi M. Pharmacological management of mood and anxiety disorders in headache patients. Headache. 2006;46(Suppl 3):S133–S141. REFERENCES 1. Baskin SM, Lipchik GL, Smitherman, TA. Mood and anxiety disorders in chronic headache. Headache. 2006;46(Suppl 3):76–87. Breslau N. Psychiatric comorbidity in migraine. Cephalalgia. 1998;18(Suppl 22):S56–S61. Hamelsky SW, Lipton RB. Psychiatric comorbidity of migraine. Headache. 2006;46:1327–1333. Radat F, Swendsen J. Psychiatric comorbidity in migraine: a review. Cephalalgia. 2005;25:165–178. Smitherman TA, Penzien DB, Maizels M. Anxiety disorders and migraine intractability and 2. 3. 4. 5. 22

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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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