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Clinical Review State of the Art Review

Management of chronic migraine

BMJ 2022; 379 doi: https://doi.org/10.1136/bmj-2021-067670 (Published 10 October 2022) Cite this as: BMJ 2022;379:e067670

Rapid Response:

Re: Management of chronic migraine- sowing the “SEEDS” of co-morbid ADHD

Dear Editor

We are grateful to Hovaguimian & Roth for their timely review [1] of chronic migraine. They rightly discuss risk factors and comorbidity, yet we would like to emphasise the importance of identifying and treating ADHD, which the review does not mention at all.

ADHD is common in those with migraine: in children [2], approx. 10% of those with migraine had ADHD and 19.4% of those with chronic migraine had ADHD. ADHD and migraine are also associated in adults [3], particularly in women, although the evidence base is smaller than in children. Higher ADHD symptom scores correlate with higher risk of migraine, particularly migraine with aura, but not with non-migraine headache [4]. In teenagers admitted for status migrainosus [5], among those who did not respond to initial treatment 41.2% had ADHD.

The authors’ clinical experience fits with this correlation between migraine and ADHD.

The review highlights risk and lifestyle factors associated with migraine: caffeine (and alcohol) intake, exercise, obesity, depression, sleep disorders, skipping meals and fluids, chronic pain conditions, medication overuse and stressors. These are all very common in ADHD. Sleep disorders and eating disorders are common in ADHD and many other patients with ADHD can literally forget to eat or drink due to mind-wandering (or are too disorganised to be able to plan and shop for meals).

Hovaguimian & Roth remind us to consider the “SEEDS” mnemonic “Sleep, Exercise, Eat, Diary, Stress”, but many patients with ADHD find it very difficult to stick to routines and to maintain diaries and other regular schedules (e.g. for exercising and for sleep). The inability to execute plans, no matter how well constructed, is often very stressful for those with ADHD. This stress may feed into the emotional dysregulation that is intrinsic to ADHD.

ADHD in adults is often unrecognised, but can be serious, with a 12.7-year reduction in life expectancy [6] if untreated. However, there is good evidence [7] that symptoms and objective outcomes improve on treatment. Unfortunately, we found no randomised controlled trials assessing the effects on migraine of treating ADHD but treating ADHD does improve many of the risk factors and lifestyle factors that Hovaguimian & Roth highlight as contributing to migraine. Our anecdotal experience is that treating ADHD also improves migraine frequency.

Therefore, we would urge those working in migraine clinics to consider ADHD, particularly in patients with ‘difficult to treat’ migraine; and to advocate for better access to diagnosis and treatment for them. There is a very sensitive and specific simple screening tool for ADHD, the ASRS [8], recommended by the WHO. This consists of just six questions, takes a few minutes, and does not require a clinician for completion.

1 Hovaguimian A & Roth J. Management of chronic migraine BMJ 2022;379:e067670
2 Arruda MA, Arruda R, Guidetti V, Bigal ME. ADHD Is Comorbid to Migraine in Childhood: A Population-Based Study. J Atten Disord. 2020 May;24(7):990-1001.
3 Hansen TF, Hoeffding LK, Kogelman L, et al. Comorbidity of migraine with ADHD in adults. BMC Neurol. 2018 Oct 16;18(1):147.
4 Carpenet C, Guichard E, Tzourio C, Kurth T. Self-perceived attention deficit and hyperactivity symptom levels and risk of non-migraine and migraine headaches among university students: A cross-sectional study. Cephalalgia. 2019 May;39(6):711-721.
5 Goenka A, Fonseca LD. Rate and Predictors of Intractable Status Migrainosus among Patients Aged 13-18 Years. Neurohospitalist. 2023 Jan;13(1):5-12.
6 Barkley, R. A., & Fischer, M. (2019). Hyperactive Child Syndrome and Estimated Life Expectancy at Young Adult Follow-Up: The Role of ADHD Persistence and Other Potential Predictors. Journal of Attention Disorders, 23(9), 907–923.
7 Faraone SV, Banaschewski T, Coghill D, et al. The World Federation of ADHD International Consensus Statement: 208 Evidence-based conclusions about the disorder. Neurosci Biobehav Rev. 2021 Sep;128:789-818.
8 Kessler RC, Adler L, Ames M, et al The World Health Organization Adult ADHD Self-Report Scale (ASRS): a short screening scale for use in the general population. Psychol Med. 2005 Feb;35(2):245-56.

Competing interests: Dr Leaver serves on the executive committee & Dr Parry serves on the advisory committee of the UK Adult ADHD Network (UKAAN see https://www.ukaan.org/)

22 January 2023
Laurence Leaver
GP
Dr Allyson Parry
Green Templeton College, Oxford
Jericho HC, Walton St., Oxford OX2 6NW