Borderline personality disorder and migraine.

BACKGROUND: Borderline personality disorder (BPD) may be disproportionately common in the migraine patient population, but specific migraine features in the BPD subgroup remain incompletely characterized. PURPOSE: To define more clearly the clinical characteristics of migraine patients with BPD, to evaluate their clinical response to aggressive headache management, and to assess the sensitivity of an instrument intended to screen for the presence of BPD. METHODS: We evaluated 50 consecutive patients with migraine and previously documented BPD, 50 consecutive patients with migraine of all types and no history of BPD, and 50 patients with migraine and no history of BPD matched to the first group for age, gender, and headache frequency. We assessed a variety of demographic and clinical variables at baseline, and to all patients we administered the McLean Screening Instrument for Borderline Personality Disorder (MSI-BPD). Patients in Groups 1 and 3 were treated for their headaches via a uniform pharmacologic management program. Treatment outcome was assessed after 6 months. RESULTS: In this series of migraine patients, coexisting BPD was associated with female gender, more pervasive headache, more migraine-related disability, a higher prevalence of medication overuse headache, more unscheduled visits for acute migraine treatment, a higher prevalence of active, self-reported depression, and a lower likelihood of responding to pharmacologic therapy intended for headache management. The MSI-BPD was insensitive in detecting BPD. CONCLUSIONS: Migraine patients with coexisting BPD are clinically distinct from the migraine patient population as a whole; in particular, they are more severely affected by their headache disorder and more treatment refractory. Simple screening instruments used to detect BPD may be ineffective in the headache clinic setting.

Predictors of a negative response to topiramate therapy in patients with chronic migraine.

OBJECTIVE: To identify variables predictive of a negative response to prophylactic therapy with topiramate in patients with chronic migraine. BACKGROUND: While certain of the newer antiepileptic drugs (AEDs) have emerged as promising or definitely effective therapies for migraine prevention, we continue to lack biologic or clinical variables predictive of treatment response to these or other widely used prophylactic therapies. METHODS: A consecutive series of 170 patients with IHS-defined migraine who were experiencing 15 or more days of headache per month were treated with topiramate according to a uniform dosing protocol. Variables examined for their potential value in predicting treatment response included age, gender, prior experience with prophylactic therapy, prior experience with divalproex sodium specifically, headache frequency and, if present, duration of chronic daily headache (CDH). A positive treatment response was defined as a 50% or greater reduction in headache days during the second treatment month relative to the patient's pretopiramate baseline. Only patients who completed the treatment phase and achieved the 50 mg BID target dose were analyzed (efficacy analysis). Each variable prospectively selected was evaluated in regards to treatment outcome via a paired t-test, and a multiple regression analysis of all variables subsequently was performed. RESULTS: A total of 116 patients completed at least 60 days of treatment and consequently were available for analysis. In the efficacy analysis, 45 (38.8%) of the 116 responded positively to topiramate. Neither age nor gender influenced treatment response. Those patients with CDH of more than 6 months duration, patients who previously had tried and failed more than three prophylactic agents and patients who previously had failed to respond to divalproex sodium were more likely to be nonresponders, but after multiple regression analysis the only statistically significant predictor of a negative treatment response was CDH of more than 6 months duration (P<.001). CONCLUSIONS: Patients with chronic migraine who are treated with topiramate may respond positively at a rate approaching that reported from placebo-controlled trials involving topiramate or other AEDs administered to less severely afflicted migraineurs. Our analysis suggests that patients with chronic migraine least likely to respond to topiramate would be those with extensive and negative previous experience with prophylactic therapy, previous failure to respond to divalproex sodium, CDH, and, most notably, CDH of more than 6 months duration.