Britt Talley Daniel M.D.

7777 Forest Lane Suite B-220

972 566-4556

Dallas, Texas 75230

Approximately 40% of persons who have migraine will have stress or anxiety issues.  The most common medical diagnosis here is called generalized anxiety disorder which may be abbreviated as GAD.  Migraine and GAD are comorbid which means that they occur more likely statistically together than would be expected.  Migraine is said to be a genetic problem while anxiety is discussed as familial.

Many persons will say, instead of admitting anxiety, that they have “pressure or stress or worries” but all these are really about the same thing.  The DSM-IV is the large standard diagnostic text book from the American Psychiatric Association which lists psychiatric diagnoses and the check list below details how a doctor might diagnose GAD.

DSM-IV Criteria For the Diagnosis of GAD (Generalized Anxiety Disorder)

The patient experiences excessive anxiety and worry

The anxiety is difficult to control

The anxiety is on several subjects

Symptoms occur for more days than not (or > 50% of the time) for the past six months

The patient experiences significant distress or social impairment (withdrawn, sees no one)

There may be at least three ancillary symptoms:

Ancillary Symptoms

Restlessness/mental tension (time pressure)

Fatigability

Poor concentration

Irritability (for intrapersonal relationships)

Muscle tension (tension in neck, shoulders, back, teeth clenching or grinding)

Sleep disturbance

Exclusions

Focus of anxiety/worry is not another disorder (for example, panic disorder)

Not part of a mood disorder, psychotic disorder, or pervasive developmental disorder

Not substance related

Not organic

DSM-IV= Diagnostic and Statistical Manual of Mental Disorders, fourth edition

BTD 10/30/09

Britt Talley Daniel MD

7777 Forest Lane Suite B-220

Dallas, Texas 75230

Migraine Aggravating Factors/Triggers

Many patients refer to “migraine triggers” but ICDH II differentiates between a migraine trigger which is something that causes an attack within 24 hours, like red wine inducing a migraine, and an “aggravating factor” like stress which builds up over weeks to produce migraine.

Chabriat, et al,[i] wrote in 1999 in Headache on “Precipitating factors of headache.  A prospective study in a national control-matched survey in migraineurs and non-migraineurs.”  They screened prospective factors in a migraine and non-migraine group of patients who kept a diary for a 3-month period.  The most frequent precipitating factors in both groups were:

“fatigue and/or sleep, stress, food and/or drinks, menstruation, heat/cold weather, and infections in both groups.”

Kelman[ii] writing in Cephalalgia in 2007 on “The triggers or precipitants of the acute migraine attack” listed stress at a frequency of 79 % and food at 26.9 %.   The table of frequency of individual migraine triggers from his article was:

Trigger                              Frequency

Stress                                             79.7%

Hormones (in women)           65.1%

Not eating                                    57.3%

Weather                                        53.2%

Sleep disturbance                     49.8%

Perfume or odor                       43.7%

Neck pain                                     38.4%

Light (s)                                        38.1%

Alcohol                                         37.8%

Smoke                                            35.7%

Sleeping late                               32.0%

Heat                                                30.3%

Food                                               26.9%

Exercise                                        22.1%

Sexual activity                             5.2%

Kelman is not going by ICDH-II here which refers to stress as an “aggravating factor”, not a “trigger.”  However, his list is interesting and I keep a copy of this article in my office to hand out.

Another observation here is that many patients will focus on the different foods that may aggravate migraine and not recognize stress in their lives which is the most aggravating feature of migraine.

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i Danchot J, Michel P, Joire JE, Henry P.  Precipitating factors of headache.  A prospective study in a national control-matched survey in migraineurs and nonmigraineurs.  Headache.  1999;39(5):335-338.

[ii] Kelman L.  The triggers or precipitants of the acute migraine attack.  Cephalalgia. 2007;27(5):394-402.