Migraine and mental health: Heads I win, minds you lose

Summary

Francine Gilmore, a patient with vestibular migraine, has written a report in a personal capacity* examining a patient safety gap where migraine prescribing overlaps with mental health risk. Drawing on Freedom of Information responses from 26 organisations and related evidence, the report identifies fragmented safeguards, unclear ownership and potential barriers to suitable treatment for clinically complex patients. In this blog, Francine shares her experience, the findings from her report and the actions she would like to see taken. The findings point to a clear need for change: migraine pathways must make mental health risk visible, owned in governance, recorded in clinical systems and reviewed for patient-safety learning.

*The full report can be downloaded from the attachment at the end of the page.

Content

My (wobbly) journey

I did not set out to write a patient safety report. I was trying to understand why so many medicines with potential contraindications had been offered to me.

Quite literally a year to the date, since returning from the USA after my 30th birthday, I have been living with ongoing symptoms of what is now known to be vestibular migraine. The dizziness is relentless. When the dizziness starts, I am a safety risk. The headache pain can make life unbearable. So can photophobia, when ordinary light becomes too much to tolerate. Sunglasses are my new best friend.

Somewhere along the way, I entered a state of medical hypervigilance. I was angry, frightened and exhausted. It felt as though, in trying to repair my physical health, I was once again being asked to risk my mental health. Every treatment decision felt like a game of medical Whac-a-Mole: solve the migraine problem, worry about mental health issues popping up later.

Returning to full-time work has been a huge achievement. But doing so while still managing pain, dizziness and photophobia has also shown me how much invisible effort this condition demands.

Yet migraine is only part of my picture.

I also live with bipolar disorder and have a history of suspected serotonin syndrome (a serious condition caused by medications that build up high levels of serotonin in the body requiring hospitalisation). That means migraine treatment is not simply about whether a drug might help. It is also about whether it could destabilise my mental health, interact with other risks or cause another kind of harm.

There. I have disclosed it publicly, likely where my professional networks will see it. But I am saying it because it matters and I know the risks. Managed mental illness should not be a nice to have consideration; it should make joined-up prescribing decisions more important.

Before appointments, I print reports listing the medicines I am concerned about. I sit there trying to explain what I can and cannot take, aware that I may sound difficult, but also aware that I am the person who will live with the consequences if those risks are missed. I could probably deliver a TED Talk entitled 10 Things I Hate About Migraine Prophylaxis Options. The trouble is that there are considerably more than ten.

The evidence

The report is based on Freedom of Information responses and related information routes. The project file covers 26 organisations or evidence routes and more than 30 documents, so 1000+ pages of evidence. I used AI as a research and drafting tool, but every substantive finding was checked against the underlying evidence. Given the volume of material and the impact of disabling migraine, this was an accessibility tool as much as a drafting tool.

The Migraine Trust states that migraine affects around one in seven people. My report also cites systematic review evidence showing increased odds of depression in people with migraine, increased odds of anxiety, and estimated bipolar disorder prevalence among people with migraine of 5.9% in population studies and 9% in clinic-based studies. The relationship is clinically relevant because migraine, mood disorders and some preventive medicines can overlap through neurological, psychiatric and medication-safety pathways. For patients already managing mental health medication, migraine prescribing is rarely a cleanly separate issue.

There is also crossover in the medicines themselves. Amitriptyline, venlafaxine and nortriptyline are antidepressants and migraine preventives, while topiramate and valproate raise neuropsychiatric or psychiatric safety considerations. Greater occipital nerve blocks may also involve steroid exposure. Only last week I was offered lamotrigine and had to point out that this is also a centrally acting medicine with psychiatric relevance, particularly for someone with bipolar disorder.

What I found in my research was a system that could point to safeguards in theory, but not clearly show who owned the risk in practice.

NICE guidance, the British National Formulary, product warnings, local formularies, prescribing systems, referral routes and clinical judgement all matter. For patients like me, that gap affects which medicines feel safe to try, how much responsibility we are forced to carry and whether the whole picture is visible to the people making decisions.

It also affects access. Some patients cannot safely use standard migraine preventives because of psychiatric history, psychotropic medication, previous adverse reactions or physical contraindications.

If access to some specialist treatments depends on trying previous prophylaxis options, pathways need to show how contraindication, intolerance or clinical unsuitability are recorded and counted. Otherwise, patients can fall into a cruel gap: too complex for the standard route but not clearly signposted towards safer alternatives

The report makes practical recommendations:

• clearer flagging of mental health and medication-safety risks         
• defined ownership of the prescribing interface    
• triggers for psychiatry or specialist pharmacy input    
• better documentation and escalation processes    
• recognition of contraindication, intolerance and clinical unsuitability when assessing access to specialist migraine treatments.

Parliamentary questions asked

On the eve of Patient Safety Learning publishing my report and blog, something unexpected happened.

A number of parliamentary questions had already been tabled in the House of Commons about the issues the report raises. To me, the early answers seemed to confirm the gap the report had identified. On 15 June 2026, the Department of Health and Social Care (DHSC) said it had made no specific assessment of national arrangements for identifying, recording and acting on psychiatric history, psychotropic medication or previous psychiatric adverse drug reactions before someone starts a preventive migraine treatment. A second answer pointed to the Getting It Right First Time (GIRFT) programme as a way of reducing variation in migraine access.

That sounded promising, until two follow up answers narrowed the position again. The DHSC then confirmed it had no plans to look any further than its 15 June position. Asked whether GIRFT covers governance for this prescribing interface, it confirmed on 1 July that it does not. GIRFT sets no formal governance requirements here. Those decisions are left to local providers and commissioners.

Then came the House of Lords answer. On 6 July, the Government confirmed that the Medicines and Healthcare products Regulatory Agency (MHRA) now plans to review the evidence on mental health and related risks for licensed migraine prophylaxis medicines after receiving a report from a patient. It will consider whether product warnings need updating, and will look at suspected adverse drug reactions reported in the psychiatric disorders category. The answer records that this followed a report made to the MHRA.

So the question is no longer just whether the risks are recognised. It is this: if the MHRA moves, how quickly will the rest of the system move with it?