Association Between Migraine and Suicidal Behaviors

A Nationwide Study in the USA

Lauren E. Friedman, PhD; Qiu-Yue Zhong, MD, ScM; Bizu Gelaye, PhD, MPH; Michelle A. Williams, ScD; B. Lee Peterlin, DO


Headache. 2018;58(3):371-380. 

In This Article


In our study, migraineurs are significantly more likely to have psychiatric disorders, including depression, anxiety, and PTSD than those without migraine. Compared to hospitalizations without migraine, migraineurs had a 2.07-fold increased odds of suicidal behaviors (95%CI: 1.96–2.19). This is comparable to previous studies on the association between migraine and suicidal behaviors, including suicidal ideation and suicide attempts. A recent meta-analysis of 148,977 participants from six studies evaluating the association between migraine and suicidal ideation found a 31% increased odds of suicidal ideation among migraineurs (95%CI: 1.10–1.55) compared with non-migraineurs.[7] In a large health maintenance organization in Michigan, Breslau et al. found a 2.7-fold increased odds of suicide attempts among participants with migraine and without major depression (migraine without aura: OR: 2.7, 95%CI: 0.7–9.5; migraine with aura: OR: 4.3, 95%CI: 1.2–15.7). Among participants with both migraine and major depression, there was an association between migraine and suicide attempts (migraine without aura: OR: 10.9, 95%CI: 3.1–38.6; migraine with aura: OR: 23.2, 95%CI: 8.4–63.8).[18] In a subsequent longitudinal study, Breslau et al. found a 4.43-fold increased odds of suicide attempts among migraineurs as compared to those with no headache history (95%CI: 1.93–10.2).[28]

Our study used ICD-9-CM diagnosis codes to identify hospitalizations with suicidal behaviors. Two previous studies used ICD diagnosis codes to investigate the association between migraine and suicidal behaviors and found similar results. Singhal et al. examined associations between chronic illnesses and self-harm (ICD-9 codes E950–E959 and ICD-10 codes X60–X64, X66–X84) and a certified cause of death from suicide (ICD-9 codes 9 E950–E959 and ICD-10 X60–X84). Specifically, among migraineurs there was a reported increased risk of self-harm (rate ratio [RR]: 1.8, 95%CI: 1.7–1.8) and death from suicide (RR: 1.3, 95%CI: 1.0–1.8).[13] Similarly, Ilgen et al. showed an association between migraine and suicide death after controlling for comorbid psychiatric disorders (hazard ratio: 1.34, 95%CI: 1.02–1.77).[12] Taken together, migraineurs have an increased risk of suicidal behaviors.

In separate analyses performed within strata defined by psychiatric diagnosis, migraineurs without diagnosed depression, anxiety, or PTSD had increased odds of suicidal behaviors (Table 2). Conversely, migraineurs with depression, anxiety, or PTSD diagnoses had reduced or similar odds of suicidal behaviors compared to non-migraineurs with comorbid psychiatric disorder. It is also possible that migraineurs with diagnosed comorbid psychiatric disorders are receiving additional care that may mitigate their risk for suicidal behaviors. In a longitudinal cohort study among migraineurs, a decrease in headache frequency and intensity was associated with decreased depression symptoms after prophylactic treatment.[29] Comorbid anxiety and depression do not influence the medications taken by migraineurs; however, they do influence perceived treatment efficacy and satisfaction.[30] Antidepressant medications have also been shown to be effective in treating migraine and depressive symptoms concurrently, as well as migraine with concurrent anxiety.[31,32] Migraine chronicity and previously diagnosed disorders may also affect whether individuals sought out medicine or other treatment options and may influence the effects that we see in hospitalizations with comorbid depression, anxiety, or PTSD. Psychological factors, including anxiety, depression, and anger may also influence headache development, headache pain intensity, and response to treatments.[33] In a study of Brazilian women, migraineurs were more likely to report widespread chronic pain. Additionally, women with either depression or chronic migraines were more likely to report lower scores on the health-related quality of life index.[34] It has also been suggested that although migraine and depression are distinct disorders, migraineurs with comorbid depression may be a genetically unique subset of patients.[35] Patients with more severe depression are at an increased risk of chronic migraine onset. Among participants in the American Migraine Prevalence and Prevention (AMPP) study, the risk of transformation from episodic to chronic migraine increased in a dose-dependent way with depression severity.[36] Additionally, previous studies show that untreated migraines may hinder the remission of depression. In a longitudinal study of patients with depression and no pharmacotherapy, comorbid migraine was associated with significantly more anxiety and somatic symptoms, and lower remission rates.[37]

The strengths of our study include the use of a large sample size and a nationally representative population. Despite these strengths, our study has limitations. Suicidal behaviors were classified based on hospital administrative codes; therefore, we cannot distinguish between suicidal ideation, suicidal attempts, and non-suicidal self-inflicted injuries. This may potentially lead to misclassification of suicidal behaviors. Additionally, the use of hospital administrative codes lacks temporal information about these diagnoses and relevant clinical context. ICD-9 codes are collected for billing purposes and rely on accurate discharge coding of medical conditions. Additionally, baseline chronic conditions may not be reported if they do not affect current care or reasons for hospitalization, which would result in underestimations of the prevalence of suicidal behaviors and comorbid mood and stress disorders. The under diagnosis of chronic conditions, including migraine, is likely to be non-differential between groups and lead to an attenuation of reported odds ratios towards the null.[38] Furthermore, we did not distinguish between migraine sub-types (with aura vs without aura), as the coding error for migraine subtypes is higher than the error for migraine.[39] Chronic migraineurs report significantly more emergency department visits and hospitalizations than episodic migraineurs in some studies[40] but not all.[41,42] Suicidal behaviors among individuals with migraine with aura are consistently higher compared to migraine without aura patients.[4,15,16,18,28] Additionally, suicidal behaviors are most likely underreported due to stigmas associated with psychiatric conditions, which may make our estimates of the comorbidity of migraine and suicidal behaviors more conservative. Our study also may have unmeasured confounding associated with additional risk factors for suicidal behaviors that were not investigated. For example, physical pain conditions, including musculoskeletal, arthritis, fibromyalgia, abdominal, and pelvic pains have previously been associated with suicidal behaviors.[43,44] Lastly, our use of a cohort of adult hospital inpatients warrants caution when generalizing to community based populations.