Sex differences in pain, suicidal ideation, and suicide attempts in patients with migraine

Objective: To examine sex-specific associations between non-cephalic pain and suicidal ideation and suicide attempts in patients with migraine, controlling for depression and other risk factors for suicide.

Background: In patients with migraine, co-occurring pain conditions are common and are associated with worse physical and psychosocial function, but the association with suicide has not been determined.

Methods: In this cross-sectional analysis, we included 10,690 patients with migraine who were consecutively recruited from headache clinics. All participants provided information on sociodemographic status, headache, Widespread Pain Index (WPI), suicidal ideation, and suicide attempts. Relative risks (RRs and 95% confidence intervals [CIs]) for factors associated with suicidal ideation and suicide attempts were calculated.

Results: In this migraine cohort, more females reported non-cephalic pain than males (78.7% [6511/8271] vs. 66.7%, [1613/2419]; p < 0.001). The prevalences of suicidal ideation and suicide attempts were higher in female patients than male patients in those aged 20-59 years (p < 0.001), and the differences diminished after the age of 60 years. In female patients, a WPI ≥4 was associated with increased suicidal ideation and suicide attempts, and dysmenorrhea was associated with suicidal ideation (RR 1.27, 95% CI 1.12-1.43), while lower back pain was associated with both suicidal ideation (RR1.35, 95% CI 1.18-1.55) and suicide attempts (RR 1.48, 95% CI 1.19-1.84). In male patients, a WPI ≥2 was associated with increased suicidal ideation, and no individual pain site was associated with suicidal ideation or suicide attempts. In both sexes, there was a dose-response association between the number of pain sites and suicidal ideation and suicide attempts; and pain that had lasted for 2 years and extreme pain intensity were associated with suicide attempts.

Conclusion: Non-cephalic pain was associated with suicidal ideation and suicide attempts, with observed differences in pain threshold and individual pain sites found between sexes. Patients with migraine and co-occurring pain conditions, chronic pain, or extreme pain are distinct subgroups of patients at risk of suicide who require sex-specific and integrated risk assessment by multidisciplinary teams.