Although most individuals with recurrent headache disorders in the general population do not experience severe psychopathology, population-based studies and clinical investigations find high rates of comorbidity between headache and mood and anxiety disorders. When present, psychiatric disorders may complicate headache treatment and portend a poorer treatment response. The negative prognosis associated with psychiatric comorbidity emphasizes the importance of the identification of psychopathology among those with headache beginning at an early age, and suggests that the treatment of psychiatric comorbidity is warranted to improve the outcome of headache management.In this article we describe the mood and anxiety disorders most commonly associated with migraine, tensiontype headache, and chronic daily headache. We provide recommendations for the assessment of comorbid mood and anxiety disorders as well as a brief overview of treatment options. Last, we discuss the clinical implications of mood and anxiety disorders on the treatment and outcome of headache.

Visual auras (VAs) of 100 patients with migraine with aura were studied by questionnaire. Visual auras accompanied the patients' first headache (HA) in 39% of patients. Only 19% had VAs with every attack. Patients with VAs over the entire HA history had a high frequency (greater than 50%) of attacks with VA; patients with VA during only part of the HA history had a low frequency (less than 50%) of attacks with VA. The auras occurred exclusively prior to the HA in 57%. The free interval between the end of the VA and the start of the HA was usually (75%) shorter than 30 minutes. Most (59%) patients had VAs that lasted from 1 to 30 minutes. They started in the periphery of the visual fields in 56%. The most common phenomena described were: small bright dots (42%), flashes of light (39%), "blind spots" (32%), and "foggy vision" (27%). Fortification spectra was reported by only 20%. Although most (65%) patients had a combination of phenomena, the majority (72%) had only one uniform constellation of manifestations. There was no clear-cut relationship between side of VA and side of HA. Migraine VA is a pleomorphic and complex symptom. Many patients not qualifying for the diagnostic criteria of migraine with aura, as proposed by the International Headache Society (IHS), unequivocally present with visual phenomena that strongly suggest this diagnosis.

Migraine is often comorbid with psychiatric disorders such as major depression, bipolar disorder, and anxiety disorders. Although most of the research on psychiatric comorbidities and migraine is of an epidemiologic nature, a growing body of literature has investigated possible mechanisms underlying this relationship, such as medication overuse, serotonergic dysfunction, ovarian hormone fluctuations, and central sensitization. The present article overviews this growing literature and notes strategies for the clinical management of migraine patients with psychiatric comorbidities.

We assessed the psychological profile of a large sample of patients with chronic daily headache (CDH) seen in tertiary care. We used a case-control design to study 791 patients who fell into the following categories: ARH group, chronic migraine with analgesic overuse (analgesic rebound headache, ARH), n=399; CM group, chronic migraine (CM) without analgesic overuse, n=158; and new daily persistent headache (NDPH) group, n=69. These groups were compared to two control groups: 1, migraine, n=100; 2, chronic posttraumatic headache (CPTH), n=65. We assessed personality and psychopathology with the Minnesota multiphasic personality inventory (MMPI)-2. The number of patients with Tscores > or =65 and < or =40 were analyzed by the two-sided Fischer's exact test. The ARH and CM groups had a higher number of subjects with T-scores > or =65, when compared to the migraine group, on the following scales: 1 (hypochondrias), 2 (depression), 8 (schizophrenia) and 0 (social introversion). No differences were observed between the NDPH and migraine groups. Considering CPTH as the control group, the pattern we found was quite the opposite of that described above: NDPH group presented a higher number of subjects with T-scores > or =65 on the following scales: 1, 2, 7 (psychasthenia) and 8. ARH and CM groups had significantly higher T-scores for scale 7 alone. NDPH showed T-scores < or =40 in scale 9 when compared to both control groups. We conclude that: (1) psychopathological factors are common in CDH patients, and appear to be a consequence of the chronification process; (2) low scores on scale 9 (hypomania) may relate to the development of NDPH; (3) psychopathological profiles differ among the subgroups of CDH and the MMPI-2 is reliable in identifying such patterns; and (4) psychological assessment is an essential step in the evaluation and treatment of patients with CDH.

We conclude, given the limitations of an open-label study design and the small sample size, that montelukast shows potential as an effective, well-tolerated prophylactic agent in migraine. Double-blinded, placebo-controlled studies are warranted. In addition, the leukotrienes, as suggested previously in the literature, may play a role in the pathogenesis of migraine.

SYNOPSIS Three headache specialists independently evaluated one hundred and fifty patient headache histories and classified them into separate diagnostic categories. Personality data from selected scales of the MMPI and frontalis electromyographic readings during three stimulus conditions were compared between migraine patients and combination headache patients. Patients were also asked to rate the perceived level of stress elicited by the three conditions (sitting comfortably at rest, performing mental arithmetic, and imagining a severe headache). Results indicated that raters could reliably classify patients into the migraine or combination headache group, as well as differentiate either of those groups from other headache diagnoses. Subjects in the combination group had higher MMPI scores on scale one (hypochondriasis), scale two (depression), scale three (hysteria), and scale seven (psychasthenia). There was no significant difference in frontalis muscle tension between the two groups although both showed a significant amount of muscular reactivity to the stress induction conditions. Subjects were accurate in their perception of this reactivity. Methodological suggestions were made regarding future phychophysiological research with headache patients.

The personality trait of neuroticism has been associated with migraine, although research is needed to clarify potential moderators of this relationship and the extent to which neuroticism reflects a stable disposition or instead is a function of general somatic distress or situational influences. With the possible exception of harm avoidance, research has not consistently identified any other personality trait unique among migraineurs. Personality disorders have been researched less extensively, but existing data suggests that borderline personality disorder, in particular, is associated with increased negative impact of migraine, risk for medication overuse, and poor response to treatment that is likely of greater clinical importance than any personality trait per se.

This article reviews the challenges in managing the more complicated headache patient. These patients often have chronic daily headache or high-frequency disabling migraine. Some patients have problems adhering to treatment regimens, which may reduce treatment efficacy and in some patients lead to medication misuse and overuse. Medication overuse may transform headache to daily and reduce the effectiveness of acute and preventive therapies. There is an elevated risk of mood and anxiety disorders in migraine, with even greater risk in chronic migraine. Personality disorders may further compromise treatment efforts. Current research is reviewed on these issues and clinical suggestions are provided for more effective management of these challenging patients.