Migraine and Bipolar Disorder

Written by: Kylie Petrarca RN, BSN

Medically reviewed by: Dr. Alexandra Conway

Edited by: Melissa Calise and Leigh Serth

What is Bipolar Disorder?

Bipolar disorder is a mental health condition that affects 2.1% of the global population.¹ It is characterized by drastic mood and behavior changes ranging from depression to hypomania and mania.² Manic episodes may include elevated or irritable mood states, decreased need for sleep, racing thoughts, high energy or activity levels, and can be characterized at times by engagement in risky and/or reckless behavior compared to hypomania which occurs for a shorter time and is less severe.² Depression is a low energy state, often resulting in feelings of sadness, withdrawal from others and loss of self worth. 

Bipolar 1 disorder: occurs when someone has at least one manic episode and may experience hypomania and/or major depressive episode before or after the manic episode. 

Bipolar 2 disorder: occurs when someone experiences at least one major depressive episode and at least one hypomanic episode but never a manic episode. Depressive states may be longer than in Bipolar 1.

Cyclothymia: A form of bipolar disorder that consists of many hypomanic and depressive episodes, more days than not over at least a two year period in adults. These episodes are typically less severe than major depression and mania or hypomania episodes in type 1 and type 2 bipolar disorder.

A study found that “women and men with bipolar disorder died 9.0 and 8.5 years earlier on average than the rest of the population, respectively.”³ The decrease in life expectancy could be due to the high-risk or reckless behavior commonly exhibited in bipolar disorder. In addition, another study reported that the suicide rates are higher among those with bipolar disorder (7.8% males, 4.8% females) than in those without a psychiatric disorder.⁴ Risk factors for suicide in people with bipolar disorder include: diagnosis at an early age, previous suicide attempts, family history of suicide, history of mental or substance disorders, childhood trauma and more. 

How are Migraine and Bipolar Disorder Related?

“There seems to be a bidirectional relationship between migraine and bipolar disorder. Patients suffering from migraine with aura are three times more likely to suffer from bipolar disorder than the general population. Conversely, about one-third of patients with bipolar disorder have migraine.”⁵ A study found the prevalence of migraine was 32.7% in individuals with type 1 bipolar disorder and 54.17% in those with type 2.⁵ 

Reasons for these high rates of co-occurrence could be: 

• Genetics: A study found those who have a family history of bipolar disorder and experienced one major depressive episode had an increased risk of migraine.⁶ 
• White matter hyperintensities (WMH) are lesions in the brain that show up on MRI imaging. It appears the presence of significant white matter hyperintensities in early/mid adulthood in those with bipolar disorder may contribute to migraine and bipolar co-occurring.⁷ 
• Inflammatory markers: Certain inflammatory factors such as tumor necrosis factor alpha (TNF-α) and some interleukins were found to be increased during a manic episode of bipolar disorder and in an acute migraine attack.⁸ 
• Neurotransmitters: “The neurotransmitters that are suspected to be involved in bipolar disorder include dopamine, norepinephrine, serotonin, GABA (gamma-aminobutyrate), glutamate, and acetylcholine.”⁹ Similarly, neurotransmitters that may be involved in migraine pathophysiology are serotonin, dopamine and glutamate.¹⁰

Commonalities Between Bipolar Disorder and Migraine

1. Epilepsy, Multiple Sclerosis, ADHD and Anxiety are comorbidities of both bipolar disorder and migraine.
2. The occurrence of migraine and bipolar disorder has been associated with childhood trauma. A study of 1348 subjects with migraine found that 58% reported histories of childhood trauma, either abuse or neglect.¹¹ Childhood trauma is also associated with bipolar disorder and has been connected to an earlier onset of the disease, number of lifetime mood episodes, suicide ideation and attempts and the presence of psychotic features.¹² 
3. Both migraine and bipolar can be chronic illnesses with episodic features and worsened by stress.⁵
4. Migraine and bipolar are responsive to similar medications and psychotherapy.

What Treatments Are Used for Bipolar Disorder and Migraine?

First line preventive treatments for migraine are tricyclic antidepressants such as amitriptyline and nortriptyline and beta blockers such as propranolol. Both of these medications classes may produce negative effects in bipolar disorder. In those with bipolar disorder, tricyclic antidepressants may trigger manic episodes and aggravate the progression of bipolar disorder while beta blockers may exacerbate depressive symptoms.^1,6 Therefore, these medications should not be used in patients with migraine and bipolar disorder.

The first line treatment options for bipolar disorder are mood stabilizers (lithium, lamotrigine, carbamazepine), anticonvulsants (topiramate, valproate) and atypical antipsychotics (quetiapine, olanzapine, aripiprazole). Some of these medications are also used to help prevent migraine attacks. 

Non-pharmacological treatment options for bipolar disorder includes social rhythm therapy, neuromodulation, psychotherapy (e.g. cognitive behavioral therapy) and deep transcranial magnetic stimulation (dTMS). Neuromodulation and psychotherapy are used as non-pharmacological treatments for migraine as well.

What Type of Doctor Should I See For Bipolar Disorder and Migraine?

Migraine is best treated by a neurologist that specializes in headaches but some people may choose to use their primary care provider or other specialist that is experienced in migraine. A psychiatrist is the preferred doctor to diagnose and treat bipolar disorder. A psychiatrist can complete additional training to specialize in bipolar disorder. Psychotherapy can be helpful for someone with bipolar disorder therefore a psychologist or clinical psychotherapist may also be involved. The primary care physician should also be involved. Together, a multidisciplinary approach between the psychiatrist, psychologist, primary care physician and possibly even a social worker can best provide support and treatment for bipolar disorder and migraine.

A Note to Patients and Providers 

Healthcare providers, especially primary care providers should be aware of the comorbidity between both conditions to make appropriate referrals. It is unclear why bipolar 2 disorder is more prevalent among those with migraine, but any history of stressful life events including trauma should be incorporated into assessment and treatment planning. If you are experiencing signs and symptoms of migraine and bipolar disorder be sure to inform all of your healthcare providers as the co-occurrence of these conditions can dictate treatment protocols. Neurologists should be aware of the risks associated with prescribing tricyclic antidepressants and beta blockers to those who have both migraine and bipolar disorder, especially those who have not yet been diagnosed with bipolar disorder and/or are presenting with a current major depressive episode (history of mania and hypomania should be thoroughly screened for with a validated symptom measure).

Allied Partners 

Thank you to our partners, Mental Health America and the Brain Donor Project for your support!

Resources 

1. Mental Health of America: Bipolar Disorder – Causes, Treatments and More

2. Learn about the process of becoming a brain donor at braindonorproject.org.

Thank you to our Sponsor!

References 

1. Duan J, Yang R, Lu W, Zhao L, Hu S and Hu C (2021) Comorbid Bipolar Disorder and Migraine: From Mechanisms to Treatment. Front. Psychiatry 11:560138. doi: 10.3389/fpsyt.2020.560138. https://www.frontiersin.org/articles/10.3389/fpsyt.2020.560138/full
2. https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders
3. Crump C, Sundquist K, Winkleby MA, Sundquist J. Comorbidities and Mortality in Bipolar Disorder: A Swedish National Cohort Study. JAMA Psychiatry. 2013;70(9):931–939. doi:10.1001/jamapsychiatry.2013.1394. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1714400
4. Nordentoft M, Mortensen PB, Pedersen CB. Absolute Risk of Suicide After First Hospital Contact in Mental Disorder. Arch Gen Psychiatry. 2011;68(10):1058–1064. doi:10.1001/archgenpsychiatry.2011.113. https://pubmed.ncbi.nlm.nih.gov/21969462/
5. Minen MT, Begasse De Dhaem O, Kroon Van Diest A, et alMigraine and its psychiatric comorbidities Journal of Neurology, Neurosurgery & Psychiatry 2016;87:741-749. https://jnnp.bmj.com/content/87/7/741
6. Engmann B. (2012). Bipolar affective disorder and migraine. Case reports in medicine, 2012, 389851. https://doi.org/10.1155/2012/389851
7. https://www.tandfonline.com/doi/full/10.3109/07853890.2011.595733
8. https://www.ajmc.com/view/understanding-the-link-between-bipolar-disorder-migraine
9. https://www.gracepointwellness.org/4-bipolar-disorder/article/11204-neurochemistry-and-endocrinology-in-bipolar-disorder
10. Gasparini, C. F., & Griffiths, L. R. (2013). The biology of the glutamatergic system and potential role in migraine. International journal of biomedical science : IJBS, 9(1), 1–8. https://www.ncbi.nlm.nih.gov/labs/pmc/articles/PMC3644410/
11. Tietjen, G.E., Brandes, J.L., Peterlin, B.L., Eloff, A., Dafer, R.M., Stein, M.R., Drexler, E., Martin, V.T., Hutchinson, S., Aurora, S.K., Recober, A., Herial, N.A., Utley, C., White, L. and Khuder, S.A. (2010), Childhood Maltreatment and Migraine (Part I). Prevalence and Adult Revictimization: A Multicenter Headache Clinic Survey. Headache: The Journal of Head and Face Pain, 50: 20-31. https://doi.org/10.1111/j.1526-4610.2009.01556.x
12. Aas, M., Henry, C., Andreassen, O.A. et al. The role of childhood trauma in bipolar disorders. Int J Bipolar Disord 4, 2 (2016). https://doi.org/10.1186/s40345-015-0042-0

*The contents of this blog are intended for general informational purposes only and do not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. The writer does not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.