Migraine Co-morbidity


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Migraines most commonly affect adults in their 30s and 40s, but they frequently start at puberty and also can affect children. Women are up to three times more likely than men to have migraines. Though statistics specifically for ocular migraines are unavailable, approximately 15 to 18 percent of women and 6 percent of men in the United States suffer from migraine headaches, according to WHO.

According the the World Health Organization (WHO), migraines "almost certainly" have a genetic basis, and some studies say 70 percent of people who suffer from the disorder have a family history of migraine headaches.

Migraine is associated with a number of neurological and psychiatric disorders, including stroke, epilepsy, depression, and anxiety disorders. Feinstein (1970) coined the term “co morbidity,” which now refers to a greater than coincidental association of two conditions in the same individual (Lipton and Silberstein, 1994). Possible explanations for co morbidity include the following:

(1) shared environmental or genetic risk factors;
(2) one condition causing the other; and
(3) the random co-occurrence of the two disorders.

The nonrandom co-occurrence of two conditions may be attributable to methodological artifacts, including sampling bias, in which samples are from clinical populations that are not representative of disease in the general population, and assessment bias, in which the co occurrence of the two conditions is an artifact of overlapping diagnostic criteria and lack of an appropriate comparison group to control for factors that may confound the association.

Understanding the co morbidity of migraine is important from both clinical and research perspectives (Lipton and Silberstein, 1994). Co morbidity has implications for headache diagnosis. Migraine has substantial symptomatic overlap with several of the conditions co morbid with it. For example, both migraine and epilepsy can cause transient alterations of consciousness as well as headache. This problem of differential diagnosis is well recognized. Less well recognized is the problem of concomitant diagnosis.

For conditions that are co morbid with migraine, the presence of migraine should increase, not reduce, the index of diagnostic suspicion. Co morbidity also has important implications for treatment. Co morbid conditions may impose therapeutic limitations but may also create therapeutic opportunities. For example, when migraine and depression occur together, an antidepressant may successfully treat both. Antiepileptic agents, such as divalproex sodium, gabapentin, and topiramate, may prevent attacks of both migraine and epilepsy. Additionally, the study of co morbidity may provide epidemiologic clues to the fundamental mechanisms of migraine.

Many studies of co morbidity have methodological limitations. Studies of co morbidity require reliable and valid definitions and systematic ascertainment of the conditions being studied. Some studies conducted prior to the introduction of the International Headache Society (IHS) diagnostic criteria for migraine (Headache Classification Committee of the International Headache Society, 1988) used idiosyncratic definitions of migraine (i.e., frequent headache, classical migraine with neurologic prodromes).

Clinic-based studies often used thorough clinical evaluations, but selection or ascertainment bias may have influenced measures of co morbidity. Epidemiologic studies often rely on systematic screening of large populations. These studies generally use validated methods to ascertain case status, which are less labor-intensive than clinic-based evaluations.

We believe that definitive co morbidity studies must be conducted in population samples to avoid the influence of selection or ascertainment bias. In this chapter, we consider the conditions whose co morbidity with migraine is supported by population studies: stroke, epilepsy, psychiatric disease, and Raynaud’s syndrome. We also briefly review the evidence linking migraine and essential tremor.


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Aaron L Shechter
Richard B Lipton
Stephen D Silberstein

Editors: Silberstein, Stephen D.; Lipton, Richard B.; Dalessio, Donald J.








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