Association between migraine and suicidal behavior among Ethiopian adults

Migraine is an under diagnosed and recurrent headache that is associated with sensitivity to light, nausea, or a reduced ability to function [1]. Migraine is a highly prevalent neurological disorder, affecting 1 out of every 10 individuals globally [1‐3]. In Africa, though it is estimated that 5–10% of the population suffer from migraines [4, 5]; there is a scarcity of researches focusing on migraine.Higher prevalence have been reported among urban residents [4, 6], and women [5‐8]. Earlier studies have also shown that migraine is higher among young adults (18–29) years [5].

Depending on the level of intensity during each episodes, migraine often has direct and immediate impact on patients’ daily activities. Its manifestations range from inability to lead a productive life due to loss of work/school days to withdrawal from social and leisure activities which ultimately affect the quality of life [9, 10]. Additionally, migraine disorders have been associated with psychiatric comorbidities including substance abuse, mood and anxiety disorders, depression, and suicidal behaviors [11‐20]. Suicidal thoughts and behaviors (hereafter referred to as suicidal behaviors) which include suicidal ideation, plans, and attempts are predictors of completed suicide [21, 22].

Annually more than half a million people die due to suicide; while three-fourth of this deaths are in low and middle income countries (LAMICs) [23].Despite the profound personal, societal, and economic consequences both these problems have; knowledge pertaining to their association remain limited, particularly in LAMICs. Though previous research have shown the association between migraine and suicidal behaviors [16, 19, 20, 24]; no studies in sub-Saharan Africa have investigated this association. Due to the high burden of migraine in sub-Saharan Africa and the existing knowledge gap, we sought to evaluate the extent to which migraine headaches are associated with suicidal behaviors, including suicidal ideation, plan, and attempts, in a well-characterized study of urban dwelling Ethiopian adults.

A total of 1060 individuals with a mean age of 35.7 ± 12.1 years took part in this study. Of those, the majority were women (60%), married (51.3%) and had a low educational level (< grade 6) (44.7%). Current smoking and Khat use was reported by 4.1% and 20.6% of participants, respectively. When asked about their health status more than half of the participants reported having a good, very good, or excellent physical (56.2%) and mental health (65.9%). Percentage of those having depression (life time and in past year) was 24.7% while any suicidal behavior was 15.1% (Table 1).

Any suicidal behavior was reported by 160 (15.1%) study participants; which included suicidal ideation (14.5%), suicide plan (6.1%) or suicide attempt (4.2%). Characteristics of study participants by migraine status is also presented in Table 1. Migrainuers were more likely to be women, have less education and were more likely to report their physical or mental health status as fair or poor. Participants with migraine were also more likely to report depression (both past year and lifetime) and suicidal behaviors, including suicide ideation, plan, or attempt (p ≤ 0.001).

Characteristics of the study population according to suicidal behavior are shown in Table 2. Participants with any suicidal behavior were more likely to be women, married, and more likely to have self-reported fair/poor physical and mental health status. Participants with any suicidal behaviors were also more likely to have past year or lifetime depression (p < 0.01).

The presence of migraine was associated with a 2.91-fold increased odds of suicidal behavior (OR: 2.91, 95% Cl: 2.06–4.12) as compared to participants without migraine. After adjusting for confounders including age, sex, education, and BMI, migrainuers were 2.71-times more likely to report suicidal behaviors compared to non-migrainuers (AOR:2.71, 95% CI: 1.89–3.89). The results remained similar after further adjusting for khat chewing and past year alcohol consumption (AOR: 2.70, 95% CI: 1.88–3.89). When life time history of depression was added to the model, the association between migraine and suicidal behaviors was greatly attenuated and became statistically insignificant (AOR: 1.49, 95% CI: 0.93–2.39) (Table 3).

We next explored the association between migraine and suicidal behavior after stratifying by past year depression status (Table 4). Among individuals without a history of depression (in the past year), the odds of suicidal behavior was 2-times higher among those with migraine as compared to those without migraine in a fully adjusted model (AOR: 2.27, 95% Cl: 1.49–3.46). Among individuals with a history of depression (in the past year), the odds of suicidal behavior was modestly increased but did not reach statistical significance for migraineurs as compared with those without migraine (AOR: 1.64 95% CI: 0.40–6.69).

Our results show that migraine is significantly associated with suicidal behaviors (including suicidal ideation, plan, or attempts), after adjusting for confounders including age, sex, BMI, education, khat use, and past year alcohol consumption. However, when lifetime depression was fitted in the model, a statistically significant association was not observed. Following further analysis to understand the effect of depression; it was found that migrainuers without history of depression in the past year had a 2.27-fold increased odds of suicidal behaviors as compared to non-migrainuers.

Migraine had a strong positive association with increased odds of suicidal ideation and attempts; this association has been also established from previous studies in high income countries including the US, Canada, Taiwan, Norway, Italy, and Korea [15, 20]. For example, a recent study among members of a Health Maintenance Organization in Michigan found that migraineurs had an increased risk of suicidal attempts during a 2 year follow-up [19]. The pooled analysis from a recent meta-analysis also found that migraine with aura was associated with increased odds of suicidal ideation (AOR: 1.31; 95% CI: 1.10–1.55), while no statistical association was observed for migraine without aura [31]. Similarly, suicidal attempts were found to be 3 to 7 times higher among those with migraines in a two- year follow up study [14, 16].

Chronic migraine is often comorbid with other conditions such as depression;a recent study in India found significant comorbidity between psychiatric disorders, including anxiety, depressive disorders, suicidality, and headache disorders [32]. Likewise, a study from Lima, Peru found that migrainuers without depression had an 1.8-fold increased odds of suicidal ideation while those with both migraine and depression had a 4.1 folds increased odds after adjusting for confounder [20]. This is contrary to our finding, adding history of life-time depression to the model resulted in no statically significant association between migraine and suicidal behaviors.However when we stratified individuals with their current (past year) depression status; participants with migraine and no depression has 2.27 fold increased odds of suicidal behavior (95% CI: 1.49–3.46). In line with this, Pompili et al. in their review found that the association of migraine and suicidal attempts was not necessarily due to coexting depression; but rather the chronic pain and loss of pleasure to engage in activities that is an independent risk factor for suicide [33].

Previous studies have documented the biological links between migraine and suicidal behaviors. Investigators suggest that the levels of cortisol and functioning of the hypothalamic-pituitary-adrenocortical (HPA) axis are affected by stressful events. Specifically, HPA activity has been found to be correlated with low grade cognitive stress in migraineurs [34]. Individuals with history of suicidal attempts were also found to have lower basal cortisol levels [35]. Furthermore in a study conducted among adolescent females, HPA-axis responses were associated to stress and risk of suicidal ideation [36]. Stressful events, including migraines, depression, and suicidal behaviors, may also be associated with serotonin levels. Changes in regulation and abnormalities of serotonergic mechanisms, including serotonin transporters, receptors, and metabolites have been associated with migraines and suicidal behaviors [37, 38]. Lastly chronic pain conditions, including migraine headaches, have been associated with suicidality [39‐41]. Specifically, Ilgen et al. found an association between measures of head pain and suicidal ideation or attempts [40]. Chronic pain patients have an increased prevalence of suicidal ideation and attempts [42].

In the present study, there are a few limitations that should be considered. We used a cross-sectional study design which limits our inferences on the temporality between migraine and suicidal behaviors. Additionally, our hospital-based study population may limit our study findings generalizability to a broader general population. Our study used interviewer administered questionnaires in which the participants were asked questions about their physical and mental health, due to the social desirability bias participants may under-report their history of suicidal thought and behaviors and substance use. Migraine status could also be under reported as it could be affected by recall bias.

Migraine is associated with increased odds of suicidal behaviors, including suicidal ideation, plans, and attempts, among urban Ethiopian adults. Studies should further investigate this comorbidity and possible risk factors for these disorders. Efforts should also be made to raise awareness about the burdens posed by migraine among the public as well as health professionals. In addition, health professionals should be aware of the comorbidity between migraine, depression, and suicidal thought and behaviors to implement effective screening and treatment of these comorbid disorders.