Depression and Anxiety in Migraine Patients
Thank you to Todd A. Smitherman, PhD and Steven M. Baskin, PhD for their contributions to this spotlight!
One in every six people in the US will experience depression at some point in their lifetime, and nearly three out of every ten will suffer from an anxiety disorder.
Having migraine increases your risk for experiencing depression or anxiety, however, the exact reason why is unknown.
Individuals with chronic migraine (migraine and other headaches occurring at least 15 days each month) are at the greatest risk for depression/anxiety.
For many people, depression or anxiety begins months or years after their migraines—partially because migraine can be so debilitating. Many other people, however, develop migraine after living with depression or anxiety for some time. This indicates that depression and anxiety is not always a response to living with migraine.
Depression and anxiety can worsen migraine by making patients less adherent to their migraine treatment. They also contribute to using acute headache medications (triptans, prescription or over-the-counter analgesics, etc.) more than twice a week, which can make headaches more frequent.
Like migraine, depression and anxiety run in families. If you have a first-degree relative with one of these conditions you are more likely to have it yourself. Depression and anxiety are common in individuals with migraine, but they are very treatable.
Warning Signs of Depression/Anxiety
“Depression” is more than just feeling sad for a few days—it’s normal to feel depressed for a while after someone close to you dies.
Depression occurs when a person feels very sad or empty* or shows little interest in activities they normally enjoy. Symptoms last most of the day, nearly every day for at least 2 weeks (children often have difficulty describing feelings of sadness and may instead be very irritable for prolonged periods of time).
In addition to feeling depressed or losing interest in activities, depression also causes other symptoms:
- Changes in your weight or appetite (without trying)
- Changes in your sleeping pattern (sleeping lots more or less than usual)
- Changes in activity (moving very slowly)
- Feeling tired or having little energy
- Trouble concentrating and having thoughts of worthlessness or suicide
When depression is severe, the person may stop going to school or work and spend long periods of time at home and in bed.
“Anxiety” involves two major symptoms:
- Extreme fear or worry about particular things or people
- Behaviors to avoid exposure to these things or people
The most common forms of anxiety involve:
- Panic attacks: sudden, intense rushes of fear that are usually unpredictable.
- Social anxiety: avoidance of social situations due to fears of being judged negatively by other people.
- Generalized anxiety: chronic, uncontrollable worry about a number of things that have not yet happened—like one’s health, finances, job, future, etc.
- Post-traumatic stress: fear and avoidance of things that remind a person of a past traumatic event he or she experienced, often when one’s life is in danger.
Both depression and anxiety disorders increase risk for suicide. Warning signs of suicide include:
- Talking or writing about death
- Giving away important possessions
- Talking about feeling like a burden to other people
- Increased use of alcohol or drugs
- Reckless behavior
- Extreme social withdrawal or isolation
- Making calls or visits to others to say goodbye
- Thoughts of hopelessness (that things will never get better in the future)
*If you or someone you know has serious thoughts about suicide, share your concerns openly with your healthcare professional or call the National Suicide Prevention Lifeline at: 1(800) 273-8255. Depression is rarely permanent, and many effective treatment options are available.
How to Treat Depression and Anxiety
Depression and anxiety are very treatable, and two major treatments are available: psychotherapy and medications.
Psychotherapy is a type of treatment where a licensed therapist (usually a psychologist, counselor, or social worker) helps you gain understanding about:
- What causes and maintains your symptoms
- Psychological or social patterns that make your symptoms worse
- Strategies and skills you can use to improve your symptoms
Studies show that lots of different types of therapies can help with depression and anxiety. Those with the best evidence are called Cognitive Behavioral Therapies. These therapies improve depression and anxiety by helping to learn to change behaviors that maintain your depression/anxiety symptoms, and changing how you think about challenges in your life and how you react to those challenges. Other evidence-based therapies may improve depression and/or anxiety by addressing your relationships with important people in your life, using mindfulness to cope with stress, or learning to manage changes in emotions.
Choosing a therapist is the first step. You may want to ask your doctor if they can refer you to see a therapist. If you are a student, your university may offer therapy services. Also, you can call your local community mental health center. You may also find a therapist through inquiring among your friends or religious communities.
Therapy only works if you do it! Once you have found a therapist you connect with, really commit to attending every session and practicing the skills you are learning outside of therapy. Talking with someone can feel good in the moment, and that is an important piece of therapy. However, long-term change happens when people use the tools that you learn in therapy in your daily life. If your therapist teaches you new ways to breathe, use them every day! If you learn new ways to think about stressful events, try to practice those new thinking skills the next time something stressful happens.
Talk to your doctor if you are experiencing any symptoms of depression or anxiety. There are several types of medications that your doctor may recommend to help treat depression and anxiety. Some of these medications may help with headache symptoms; for example, some depression medications like amitriptyline can also reduce migraine frequency. However, usually you need a much higher dose to treat the depression than the dose you would take for migraine, so your doctor may determine that you need different medications to target each condition. The medications with the best evidence for treating depression and anxiety problems are types of drugs called SSRIs and SNRIs. While good for depression and anxiety, they are not particularly effective for headache. Your doctor can look at your symptoms, and help find the best type of medication or combination of medication for you.
Sometimes it helps to talk to physicians who specialize in treating depression, anxiety, and other aspects of mental health. Psychiatrists are physicians who have specialist training in treating mental health. If you feel it would be helpful, you can ask your primary care physician or headache specialist for a referral to a psychiatrist.
You can also use the following tool to find a licensed psychiatrist:
Even when you start a new medication, your symptoms will probably not get better right away—it can take several weeks to notice improvement when starting a new medication. It is really important to take your medication exactly the way your doctor recommends, even if you don’t see changes right away. Be sure to take your medication exactly the way your doctor says, and call your doctor right away if you experience any new symptoms.
Exercise. Exercise isn’t just great for your physical health—it’s great for your mental health too! Regular exercise can help prevent depression, and some studies show that it is as effective for treating depression as medication or psychotherapy.
Talk to your doctor about starting or maintain a program of regular aerobic exercise: one that increases your heart rate, uses multiple muscles groups, and that you can do for 30-60 minutes at least 3 times each week. Most importantly, pick a form of exercise that you enjoy doing! Many people find they are more likely to exercise if they do it with another person, so see if a family member or friend wants to join you!
Be active socially. It’s easy to lose interest in social activities and spending time with family and friends when you’re feeling down or anxious, but avoiding activities and people will only make you feel worse. Don’t wait until your mood improves to attend events, spend time with others, or go out to do things you normally enjoy.
Force yourself to be active socially even if you don’t feel like it—that will help your mood improve faster than waiting on it to happen! A good social support network is one of the best predictors for successful recovery from depression.
Don’t neglect your sleep.
Depression and anxiety can have a big impact on your sleep, and your sleep, in turn, can make your headaches worse. It’s important to make sure you are getting the right amount of sleep:
- Most adults need between seven and nine hours of sleep each night, and children need even more.
- Stick to a schedule—try to go to bed and get out of bed around the same time every day, even on the weekends.
- Don’t lie in bed when you’re not trying to sleep. It’s easy when you’re depressed to spend a lot of extra time in bed, but that won’t help your mood and will only make it harder to sleep at night.
<strong”>Manage Sources of Stress.
It’s easy to let stress get the best of you when you’re feeling blue or anxious.
- Set aside some time for yourself on a regular basis (relaxation, exercise, meditation, vacation, etc). Don’t wait until you feel better!
- Keep a journal. Writing down your thoughts and feelings (both positive and negative) on a daily basis can be a powerful tool for helping overcome depression and anxiety. Aim to write for at least 15 minutes each day in a quiet place without distractions.
- Take care of basic hygiene and housework. It’s easy to lose interest in keeping up your appearance and keeping your house clean when you’re not feeling well. Taking time on your appearance will actually help you feel a bit better, and staying on top of minor housework will help everything seem less overwhelming. Spend a few minutes each day putting away dishes or running loads of laundry, and don’t be afraid to ask someone to help you.
Don’t keep thoughts of suicide to yourself. It’s not uncommon to have thoughts of suicide if you believe you’re never going to feel better. People very rarely stay depressed permanently and there are lots effective treatments available. If you have thoughts about suicide, don’t keep them all to yourself. Share them honestly with your doctor or therapist so that they can help develop a plan to help you stay safe and start feeling better.
Depression and Anxiety Look Different in Everyone
No two people are exactly alike—the same is true for depression and anxiety! Every person is different, so depression and anxiety look different across a population.
For example, although many people with depression have poor appetite and experience weight loss, some people actually have increased appetite and experience weight gain. This is most common for people who experience depression during the winter months.
Some people may feel as if they’re having a heart attack during a panic attack, others will instead feel like they’re going crazy or losing control. Some people with generalized anxiety may always show up 30 minutes early because they worry about being late, whereas other people with generalized anxiety may spend so much time worrying that they are always 30 minutes late.
Depression and anxiety are common and they run in families. You may have a friend or family member who has depression or anxiety, and their symptoms may look different from yours. That’s ok! There is no “right” or “wrong” way to experience depression and anxiety. If you have symptoms that are bothering you and you think they might be depression or anxiety, talk to your doctor or other health professional.
Similarly, there is no one “right” way to treat depression and anxiety. Treatments that worked well for people you know may not work for you. You may need a different kind of treatment or a different amount. Your friend might really like a particular therapist or type of therapy, but neither work well for you. That is ok! The right treatment for you is the treatment that helps you feel better. Be patient…it may take a couple tries of different treatments before you find the one that works best for you.