High prevalence of menstrual migraine comorbidity in patients with premenstrual dysphoric disorder: Retrospective survey

To the Editor:

A strong association between migraine and mental disorders has been reported in several epidemiological and clinical studies. Previously, we reported a high comorbidity rate (61.1%) of migraine observed in outpatients with panic disorder (1). Therefore, I have paid attention to comorbid migraine in patients with various mental disorders. Premenstrual dysphoric disorder (PMDD) is a newly classified specific diagnostic category as one of the depressive disorders in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (2). The features of PMDD include the expression of depression that occurs repeatedly during the premenstrual phase of the cycle and remits around the onset of menses or shortly thereafter. Premenstrual syndrome (PMS) differs from PMDD in that there is no stipulation of affective symptoms and severity. There is no report on the comorbidity of migraine and PMDD. Therefore, in this preliminary retrospective survey from chart recordings, I investigated the prevalence of migraine, especially menstrual migraine that fulfilled the criteria of International Classification of Headache Disorders, third edition beta (ICHD-3 beta) (3) in patients diagnosed with PMDD based on the DSM-5 criteria.

This study was approved by the ethics committee of Tokyo Women's Medical University. Eighty-three female patients who met the DSM-5 (2) criteria for PMDD were recruited in this survey. Their age ranged from 20 to 49 (33.8 ± 6.9; mean ± SD) years.

Of 83 patients with PMDD, 57 (68.7%) were diagnosed with migraine; 48 (57.8%) had migraine without aura (ICHD-3 code 1.1), nine (10.8%) had migraine with typical aura (1.2.1), 26 were not diagnosed with migraine, and two had no data on headache. Of the 48 patients with migraine without aura, 44 (91.7%) had menstrual migraine, 16 had pure menstrual migraine without aura (A1.1.1), and 28 had menstrually related migraine without aura (A1.1.2). Of the nine patients with migraine with aura, eight had menstrual migraine.

In this retrospective survey, the prevalence of migraine comorbidity in patients with PMDD was as high as 68.7%. In most patients (91.7%) with PMDD and migraine without aura, attacks occurred on day 1 ± 2 (i.e. days –2 to +3) of menstruation, so that they were diagnosed with pure menstrual or menstrually related migraine without aura. It is important to interpret our results with caution because this survey was retrospective, based on chart recordings. However, the prevalence of migraine in our patients with PMDD was several times higher than that in the normal population. Approximately 10% of patients with PMDD were diagnosed with migraine with typical aura. Generally, PMDD is treated with a selective serotonin reuptake inhibitor. However, in gynecology, oral contraceptives are often used for PMDD treatment. Adequate caution is necessary when prescribing pharmacotherapy for PMDD, because oral contraceptives are contraindicated in migraine with typical aura.

To confirm our preliminary results, a larger, well-controlled prospective study is warranted.