Study Summary: Link Between Migraine and Suicidal Behaviors

Background

Migraine is a prevalent condition, affecting more than one-tenth of the general population. Comorbid psychiatric disorders, such as depression, anxiety, and posttraumatic stress disorder (PTSD), are common among patients with migraine. Study results have shown that, even controlling for comorbid depression, patients with migraine seem to be at a greater risk of suicidal behaviors, which include suicidal ideation and suicide plans and attempts.¹

Although some studies have investigated the risk of suicide among patients with migraine, data on suicidal behaviors in these patients are lacking. In addition, prior studies have been small and focused on targeted populations rather than being nationally representative. To address this data gap, Friedman and colleagues sought to investigate the relationship between migraine and suicidal behaviors among adult inpatients across the United States. They also sought to determine the impact of comorbid disorders—specifically, depression, anxiety, and PTSD—on this association.¹

Study Design

Researchers from Harvard and Johns Hopkins performed a cross-sectional study to investigate associations among migraine, psychiatric disorders, and suicidal behaviors. The study included patients 18 years and older in the United States and utilized information on hospitalizations occurring from 2007 to 2012 available from the Nationwide Inpatient Sample database, a nationwide database that collects billing data on adult inpatient hospital stays.¹

Friedman and colleagues collected patients’ demographic data, including age, smoking status, sex, race, income, length of hospital stay, and total hospital charges. Investigators also gathered information on patients’ diagnoses related to migraine (eg, migraine, tension-type headache, and headache), suicidal behaviors (eg, suicidal ideation, self-inflicted harm), and psychiatric disorders (eg, depression, anxiety, and PTSD) using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes. Several statistical tests were performed to elucidate relationships among the variables.¹

Results

Researchers analyzed data related to 156,172,826 hospitalizations. Hospitalized patients were more likely to be female (59.9%), 50 years or older (63.7%), and white (57.4%). A majority of patients also had 2 or more comorbidities (63.8%).¹

Of all hospitalizations, 1.4% were associated with a migraine diagnosis,1.6% had a suicidal behavior diagnosis, 11.5% of hospitalizations were associated with depression (specified as nonpsychotic), 4.9% with anxiety, and 0.54% with PTSD. Patients with migraine were more likely to have anxiety, depression, or PTSD, compared with individuals without migraine (P <.0001), and to have 2 or more comorbid conditions (P <.0001). After making adjustments for potentially confounding factors, including age, sex, race, income, year, and hospital characteristics, Friedman and colleagues also demonstrated that patients with migraine were more than twice as likely to demonstrate suicidal behaviors compared with individuals without migraine (Table).¹

After stratifying hospitalizations by diagnosis (depression, anxiety, or PTSD) and again adjusting for potential confounders, the researchers repeated their analysis. Their results indicated that patients with migraine with depression had a 20% reduced risk of developing suicidal behaviors, while patients with migraine without depression had a more than 2-fold greater risk. In addition, patients with migraine with anxiety had a slightly greater risk of developing suicidal behaviors, while those without anxiety were more than twice as likely to develop these behaviors. Lastly, they showed that patients with migraine with PTSD had no increased risk of developing suicidal behaviors, while those without PTSD were almost twice as likely to develop them (Table).¹

Implications

The findings from this study revealed that patients hospitalized with migraine are at a greater risk of having comorbid psychiatric disorders such as depression, anxiety, and PTSD compared with hospitalized patients without migraines. In addition, researchers reported that hospitalized patients with migraine are also at higher risk of developing suicidal behaviors.¹

Friedman and colleagues did not detect a link between specific psychiatric conditions and suicidal behavior among patients with migraine. They speculated this might be because patients with migraine with comorbid psychiatric disorders are receiving treatment that reduces their risk for suicidal behaviors.¹

The strengths of this study include the very large sample size and inclusion of a nationally representative population. The authors acknowledged the study’s limitations, including that suicidal behaviors in some hospitalizations may have been misclassified because the use of ICD-9-CM codes prevented differentiation among certain suicidal behaviors. In addition, the researchers suggested that their study may have underestimated the prevalence of suicidal behaviors because many affected individuals fail to report them due to the stigma associated with psychiatric conditions.¹

Friedman and colleagues stressed the importance of additional research to further assess how comorbid psychiatric disorders affect the link between migraine and suicidal behaviors and underscored the need for clinicians to screen patients with migraine for psychiatric comorbidities.¹

Reference

1. Friedman LE, Zhong QY, Gelaye B, Williams MA, Peterlin BL. Association between migraine and suicidal behaviors: a nationwide study in the USA. Headache. 2018;58(3):371-380. doi: 10.1111/head.13235.