Table 5.

Approach to patients with overlapping migraine, GWI, CFS, FM, and other disorders (adapted from Maizels et al., 2012).

Intervention	Benefit
Clinical evaluation	Evaluate personality style (e.g., perfectionism, caregiver), lifestyle factors (“pressure cooker”), life circumstances (e.g., an abusive relationship), other stressors, coping skills, and psychiatric comorbidity that have a profoundly negative impact on quality of life.
Patient education	Limbic functions regulate mood, emotion, perceptions, and responses to stressors, personality, coping styles, and cognitive function.
	These have beneficial and detrimental effects on affect, fatigue and pain.
	Depression and anxiety are important risk factors for migraine transformation (Lipton, 2009). Affective dysfunction should be anticipated with this complex of unpredictable complaints and current unsatisfactory treatment options.
Physician education	Conceptualizing these illnesses as dysfunctional pain, interoceptive, cognitive, and other brain networks is novel, and more difficult to appreciate than a specific genetic, neurotransmitter, or brainstem nucleus problem.
	This realization opens the way to diagnosis, lays a solid foundation for the patient–doctor relationship and expands the scope of therapeutic options.
Treatment	Although there is not as yet evidence to show that treating psychiatric comorbidity influences headache outcomes, it appears clinically prudent to do so.
	Non-pharmacologic treatments such as cognitive behavioral therapy, carefully prescribed activity levels, acupuncture, tai chi, and other efforts to “retrain the brain” are often neglected aspects of treatment.
	Combinations of low dose pharmaceutical, physical, cognitive, and other therapies are likely to be superior to single modalitie (Holroyd et al., 2009, 2010).
Research	Atypical responses to stressors will play a critical role in the identification of biomarkers, neuroimaging characteristics, future diagnostic algorithms, pathophysiological mechanisms, and logical and beneficial treatments.
	The impact of triptan drugs, topiramate, and other migraine therapies on GWI and CFS functional status has not been studied.
Limitations	Identification of unrecognized exacerbating factors, inadequate non-pharmacologic treatment, and the presence of comorbid conditions such as anxiety, pain, and migraine is an essential component of building a satisfactory healthful relationship (Lipton et al., 2003).
	Set attainable limits and goals for cognitive and physical activities, and expectations of benefits from current medical treatments.
	Regular follow-up can ensure treatment compliance and reinforce the security of on-going clinical care without the perception of abandonment or rejection felt by many GWI and CFS patients.