Frieda Wiley, PharmD, BCGP, is a writer and pharmacist.
Add value by optimizing medications, decreasing pill burden.
It is no secret that psychiatric conditions may predispose individuals to various comorbidities, including migraines. Similarly, patients with migraines tend to have a higher risk of developing psychiatric complaints.1
The complexity of treating migraines is amplified when the patient also has psychiatric comorbidities. The spectrum of presentation and symptomatology in this population subset creates a prime opportunity for pharmacists to make sizeable contributions in managing these conditions.
Migraine management in patients with psychiatric conditions must take into account the complications that plague both disease states.
“Compliance and adherence are the biggest pitfalls because studies have shown that patients [with psychiatric conditions] are more likely to over- or underuse [medications],” said Rania El-Desoky, PharmD, BCPS, a postdoctoral fellow in the department of pharmacy practice and translational research at the University of Houston College of Pharmacy in Texas.
Both disease states can have severe consequences. Taking a nonsteroidal anti-inflammatory drug (NSAID) or triptan either more frequently than prescribed or at a higher dose can trigger migraines—a phenomenon known as medication overuse headache.2
Conversely, medication underuse has its own set of hurdles, which El-Desoky finds particularly challenging when trying to optimize therapy in patients with migraines. Such is the case with prophylactic migraine therapy, which typically takes 4 to 12 weeks before symptoms start to improve. Often discouraged by not experiencing immediate results, many patients either stop taking prophylactic medications regularly or discontinue them altogether.
Poor adherence can give rise to a prescribing cascade, and the increasing complexity of the patient’s drug regimen can often worsen outcomes. Because patients with psychiatric conditions often have multiple prescriptions, adding migraine therapy can become a delicate balancing act when trying to prevent issues related to polypharmacy.
“The key here is to optimize the patients’ medications and decrease the pill burden,” El-Desoky said. She recommends choosing a preventative migraine medication that also can address other comorbidities the patients have. Venlafaxine makes a good choice for a patient who has posttraumatic stress disorder in addition to migraines. Nortriptyline and amitriptyline ease insomnia and depression as well as migraine symptoms.
Some medications routinely used in migraine management are not appropriate for certain psychiatric conditions. For instance, β-blockers and the calcium channel blocker verapamil can worsen depressive symptoms and should be avoided in patients with depression, according to Lama Al-Khoury, MD, associate clinical professor of neurology at the University of California, Riverside, School of Medicine.
Serotonin-norepinephrine reuptake inhibitors (SNRIs) should be avoided in patients who have bipolar disorder because they can trigger hypermanic episodes. Instead, a mood stabilizer such as divalproex sodium (Depakote) may be a better choice. Al-Khoury warns against the use of divalproex in women of childbearing age because of its teratogenicity.
Medications that can potentiate serotonergic effects, including serotonin syndrome, should be avoided or used with care in patients with migraines. Al-Khoury advises pharmacists to educate patients taking antidepressants/serotonergic medications to limit using abortive therapies such as triptans to no more than 2 days per week to prevent their serotonin levels from surging to dangerous limits. El-Desoky encourages pharmacists also to look for less-obvious culprits such as cyclobenzaprine and tramadol.
Experts say pharmacists have numerous opportunities to enhance patient care in this patient population.
Communication. Even when questioned directly, a patient’s migraine or psychiatric condition can affect their ability to remember their medication history. As a result, they may forget to mention a medication or supplement. The negative stigmas associated with migraine and psychiatric conditions may cause some patients to omit the frequency of intake. Pharmacists’ access to prescription records and their increased patient interaction can help bridge the gap.
“It’s always appreciated when pharmacists flag potential interactions in patients who may not be as forthcoming with all [their] medications, along with the frequency and dosing,” said Cristina Wohlgehagen, MD, a headache specialist and neurologist at Texas Health Presbyterian Hospital Dallas.
Education. The accessibility and frequent patient-clinician interaction make pharmacists excellent resources for providing patient information. Pharmacists can remind patients about potentially bothersome symptoms and teach them to recognize signs of harmful adverse effects (AEs).
The teaching aspect proves particularly critical with regards to improving adherence. El-Desoky urges her colleagues to ensure patients understand the importance of taking prophylactic medications regularly as prescribed and emphasizing it may take up to 12 weeks before their symptoms improve. Patients should leave the encounter understanding the importance of not skipping doses.
Documentation. Both El-Desoky and Al-Khoury encourage patients to keep headache diaries to document the frequency, time, and resolution of their migraines.
Consider nonpharmacological options when possible. “Pharmacological therapy is not appropriate for every patient—especially patients [with psychiatric conditions] who are already taking many medications and struggle with [adherence],” Al-Khoury said.
In some cases, this might entail investigating underlying causes of a patient’s migraines. Stress triggers migraines in 70% of those with the condition.3
Patients facing insomnia and sleep disruption may benefit from a sleep study. “Sleep is critical, and a sleep study should be conducted when obstructive sleep apnea is suspected because you can sometimes avoid medications in these patients,” Al-Khoury said. Helping patients modify their daily habits, lifestyle, and sleep may be the only tool they need to gain control of their migraines. Al-Khoury sometimes uses melatonin or other insomnia treatments in patients with migraines and insomnia.
Individualize treatment. Migraine management in patients with psychiatric disorders is highly complex and variable. Clinicians should customize treatment based on the individual patient’s comorbidities, preferences, socioeconomic situation, lifestyle, and other circumstances.
Enacting weight management strategies is especially important in patients who are depressed and have poor body image. It may make sense to avoid initiating antimigraine therapies that also cause weight gain in patients who are already overweight. Tricyclic antidepressants should be avoided in such patients. If patients suffer from migraines in addition to depression and anxiety, venlafaxine makes a suitable substitution, as it is less likely to cause weight gain. Duloxetine and gabapentin should be avoided altogether.
Monitoring. Monitoring is critical in this patient population, as many medications have bothersome AEs or other challenges. For example, high-dose venlafaxine therapy can raise blood pressure, and the pharmacist should follow up with patients when they refill their prescriptions or visit the pharmacy for other reasons.
Similarly, pharmacists’ recurring patient encounters offer numerous opportunities to assess the patient’s progress and reinforce adherence. El-Desoky recommended encouraging patients to use pill boxes and medication organizers. Although mobile device apps, phone messages, and alarms can also serve as helpful reminder tools, El-Desoky noted that her patients experienced greater benefit from making medication charts.
“I’ve made charts for patients to check off whether they took their meds,” she said. “From what I’ve seen, visual aids tend to be the most effective in helping people remember to take their meds.”
Despite the continued push toward collaborative practice, the health care industry remains largely fragmented regardless of the profession. Even with the prevalence of migraines in patients with psychiatric conditions, fewer than 1% of psychiatrists treat them.1 Similarly, pharmacist-physician interactions generally remain rare.
“I have rarely seen multidisciplinary interactions between pharmacists and physicians outside large academic facilities where you tend to have neurologists, psychiatrists, and pharmacists on board,” Al-Khoury said.
Despite this hurdle, El-Desoky seems optimistic and encourages pharmacists to capitalize on in-pharmacy services and any other opportunities to demonstrate their value and ability to educate patients and other health care professionals.
“Every facility has an opportunity for pharmacists and other practitioners to present their knowledge,” she said. “Tell them, ‘I’m here and able to help.’”