“ People don’ t usually talk about feeling depressed to their primary care physician unless they have a long-standing relationship,” Dr. Shulman says.“ But they will go in and complain of pain and sleep problems, and it is the tuned-in physician who knows how to ask a couple of extra questions to figure it out.”
Dr. Diamond says the patient’ s medical history“ reveals the comorbidity.” Whether through discussion of social relationships or life stresses, or through admission that the patient is experiencing a vise-like, steady pressure in the head at night or in the morning, a physician should be able to make a diagnosis of depression and migraine once certain symptoms are revealed. Dr. Shulman adds that the physician should take it a step further by exploring just how serious the condition is. Additional questions can reveal whether the patient is suicidal or whether the pain has led to drug or alcohol abuse.
“ Some physicians are afraid to ask about suicidal thoughts because they have this notion that if they bring it up, they may put those thoughts into the patient’ s mind. But if somebody’ s not suicidal, they’ re not going to consider it just because you asked a
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( North of Chicago) Lawrence Robbins, M. D. 25 years experience Specializing in“ difficult to treat” headaches For C-V, articles, daily blog: www. headachedrugs. com Northbrook, IL( 30 min. from O’ HARE) 847-480-9399 question,” Dr. Shulman says.“ I think that because suicidal thoughts are stigmatized as‘ weakness in the soul,’ if the physician brings it up in a nonjudgmental way, the patient can actually feel relief because their depression may have been previously stigmatized by society.”
If a patient reveals an intention to act on suicidal thoughts or notes a current or past substance abuse, he or she may be referred to a psychiatrist for evaluation and could be admitted for inpatient care, Dr. Shulman says. Otherwise depression and headache are treated with a variety of traditional, psychiatric and psychological therapies.
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Because of the bidirectional nature of this comorbidity, treatment can be directed at the depression, the migraine or both. The thinking is that once you treat the migraine, this will relieve some of the hopelessness that comes with depression; or once you treat depression, depression-related migraines should be relieved. In a 2008 NHF survey, only 32 percent of respondents reported taking one medication to treat both depression and headache. Instead, 75 percent used medication to treat their depression, and 95 percent used medication to treat their headaches.
Treatment for depression depends on the type of depression: anxious, flat or empty, or a mix.“ When you throw in headache or chronic pain disorder, the pain data is clear that the best antidepressants to use in pain are those that can treat both the anxious and the empty feelings of depression,” Dr. Shulman says.
While often used to treat depression, clinical trials have shown serotonin norepinephrine reuptake inhibitors( SNRIs) such as Effexor ® and Cymbalta ®, and selective serotonin reuptake inhibitors( SSRIs) such as Prozac ®, to be less effective for migraine treatment, says Jan Lewis Brandes, MD, director of the Nashville Neuroscience Group at St. Thomas Health Services, assistant clinical professor of neurology at Vanderbilt University in Nashville and a member of the NHF Board of Directors.
Rather, the antidepressants that are considered the best for migraine and depression are the
30 HEAD WISE | Volume 2, Issue 2 • 2012