Psychiatric comorbidities in patients with headaches

https://doi.org/10.1016/j.spmd.2004.04.003Get rights and content

Abstract

Migraine and tension-type headaches are not, in and of themselves, psychiatric disorders. Nevertheless, there is a strong association between these headache diagnoses and a number of psychiatric disorders, especially depression and anxiety. Although most individuals with headaches in the general population do not have comorbid psychiatric disorders, many patients do, especially those presenting to specialty clinics. Moreover, there is some evidence indicating that psychiatric comorbidity is a negative prognostic indicator in children and adults with headache. Thus, the identification and treatment of psychiatric illness is necessary, beginning at an early age. In this study we provide an overview of the current literature on comorbidity of psychiatric illness and the most common headache disorders: migraine; tension type; and “chronic daily headache” (ie, chronic migraine, chronic tension type). We briefly discuss the assessment of psychiatric illness in medical (nonpsychiatric) settings and provide pharmacologic and behavioral treatment recommendations. Finally, we briefly examine the role of behavioral medicine in headache management, which appears to be especially important for headache patients with psychiatric comorbidity.

Section snippets

Migraine

Several clinic-based studies utilizing the original diagnostic criteria of the International Headache Society1 and well-validated psychiatric assessments have reported increased rates of depression and anxiety in individuals with migraine.2, 3, 4, 5, 6 Although clinic-based studies can be influenced by selection bias (eg, distressed patients more likely to seek treatment), the association between psychiatric disorders and migraine reported in clinic-based studies also has been observed in

Tension-type headache

Population-based studies of headache and psychiatric comorbidity have infrequently focused on tension-type headache. The prevalence of mood and anxiety disorders does not appear to be elevated in episodic (headaches occurring <15 days per month) tension-type headache.9 However, this finding cannot be generalized to chronic tension-type headache (CTTH; headaches occurring ≥15 days monthly, as defined by the Headache Classification Subcommittee of the International Headache Society, International

Chronic daily headache

Chronic daily headache (CDH) refers to a heterogeneous group of headaches characterized as daily or near-daily headache with primarily migrainous features (chronic migraine; headaches occurring ≥15 days monthly in the absence of medication overuse, as defined by the IHCD220) or primarily tension-type features (chronic tension-type headache). Psychiatric comorbidity has been reported in 40% to 90% of patients with primary CDH in clinical samples.5, 6, 21 The most frequent diagnoses are comorbid

Comorbid psychiatric disorders and headache prognosis

Clinical wisdom suggests that psychiatric comorbidity would predict a poorer headache prognosis, although this has rarely been investigated. A recent longitudinal study suggests that the presence of psychiatric disorders (especially multiple psychiatric disorders) is predictive of poor outcome for headache.4 In an 8-year prospective follow-up study of 100 young headache sufferers, Guidetti and colleagues4 found that 86% of headache sufferers who had two or more comorbid psychiatric disorders in

Assessment of comorbid psychiatric disorders

The Primary Evaluation of Mental Disorders (PRIME-MD)30 is a diagnostic tool that can easily be used to assess the presence of comorbid psychiatric disorders in most medical settings. The PRIME-MD consists of a self-administered 26-item symptom checklist completed by the patient to screen for five of the most common DSM disorders: mood disorders; anxiety disorders (panic disorder, generalized anxiety disorder); eating disorders; alcohol abuse or dependence; and somatization disorders. The

Treatment of psychiatric comorbidity

In this section we focus on depression and panic disorder because they are the psychiatric disorders with the highest prevalence in patients with headache disorders. We present recommendations for pharmacologic and nonpharmacologic interventions, and suggest that combined treatment, or a multidisciplinary approach, should be considered for treating headache complicated by psychiatric comorbidity. Readers interested in additional information about managing these and other comorbid psychiatric

Behavioral medicine

Albert Schweitzer noted that “the greatest discovery of any generation is that human beings can alter their lives by altering the attitudes of their minds.” Behavioral medicine asserts that a person’s behavior influences the course of illness as well as the outcome. This does not imply guilt or blame for an illness, but rather emphasizes the role of the individual in the management of the illness. Lifestyle, or behavioral, factors that typically affect headache disorders include stress, sleep

Conclusions

Both population-based research and clinical experience have revealed a clear-cut association between the most commonly occurring headache types (migraine and tension type) and a number of psychiatric disorders (especially depression and anxiety). Whereas most headache sufferers in the general population do not experience diagnosable psychiatric disorders, a disproportionate number of patients who present for treatment do—most particularly patients who present to specialty clinics. Psychiatric

References (102)

  • D Marazziti et al.

    Headache, panic disorder and depressionComorbidity or a spectrum?

    Neuropsychobiology

    (1995)
  • D.D Mitsikostas et al.

    Comorbidity of headache and depressive disorders

    Cephalalgia

    (1999)
  • V Guidetti et al.

    Headache and psychiatric comorbidityClinical aspects and outcome in an 8-year follow-up study

    Cephalalgia

    (1998)
  • K.D Juang et al.

    Comorbidity of depressive and anxiety disorders in chronic daily headache and its subtypes

    Headache

    (2000)
  • A.P Verri et al.

    Psychiatric comorbidity in chronic daily headache

    Cephalalgia

    (1998)
  • K.R Merikangus et al.

    Migraine and psychopathologyResults of the Zurich Cohort Study of young adults

    Arch Gen Psychiatry

    (1990)
  • K.R Merikangus et al.

    Headache syndromes and psychiatric disordersAssociation and familial transmission

    J Psychiatr Res

    (1993)
  • W.F Stewart et al.

    Migraine headaches and panic attacks

    Psychosom Med

    (1989)
  • W.F Stewart et al.

    Comorbidity of migraine and panic disorder

    Neurology

    (1994)
  • N Breslau et al.

    Headache types and panic disorderDirectionality and specificity

    Neurology

    (2001)
  • N Breslau et al.

    Migraine and major depressionA longitudinal study

    Headache

    (1994)
  • N Breslau et al.

    Headache and major depressionIs the association specific to migraine?

    Neurology

    (2000)
  • S.D Silberstein et al.

    MigraineAssociation with personality characteristics and psychopathology

    Cephalalgia

    (1995)
  • M Siniatchkin et al.

    Coping styles of headache sufferers

    Cephalalgia

    (1999)
  • N Breslau et al.

    Comorbidity of migraine and major affective disorders

    Neurology

    (1994)
  • The International Classification of Headache Disorders(IHCD2)

    (2004)
  • K Holroyd et al.

    Psychosocial correlates and impact of chronic tension-type headaches

    Headache

    (2000)
  • F Puca et al.

    Psychiatric comorbidity and psychosocial stress in patients with tension-type headache from headache centers in Italy

    Cephalalgia

    (1999)
  • N.T Mathew

    Transformed migraine

    Cephalalgia

    (1993)
  • F Radat et al.

    Psychiatric comorbidity is related to headache induced by chronic substance use in migraineurs

    Headache

    (1999)
  • K.A Barton et al.

    The failure of intensive self-regulatory treatment with chronic daily headacheA prospective study

    Appl Psychophysiol Biofeedback

    (2001)
  • L Kudrow

    Paradoxical effects of frequent analgesic use

    Adv Neurol

    (1982)
  • N.T Mathew et al.

    Drug induced refractory headacheclinical features and management

    Headache

    (1990)
  • N.T Mathew et al.

    Intractable chronic daily headacheA persistent neurobehavioral disorder

    Cephalalgia

    (1989)
  • R.L Spitzer et al.

    Utility of a new procedure for diagnosing mental disorders in primary careThe PRIME-MD 1000 study

    JAMA

    (1994)
  • A.T Beck et al.

    An inventory for measuring depression

    Arch Gen Psychiatry

    (1961)
  • A.T Beck et al.

    Beck Depression Inventory-II Manual

    (1996)
  • W.M Reynolds et al.

    Hamilton Depression Inventory: A Self-Report Version of the Hamilton Depression Rating Scale. Professional Manual

    (1995)
  • A.T Beck et al.

    Beck Anxiety Inventory

    (1993)
  • C.D Spielberger et al.

    STAI Manual for the State-Trait Anxiety Inventory (“Self-Evaluation Questionnaire”)

    (1970)
  • G.L Lipchik et al.

    Psychiatric and psychologic factors in headache

  • J.R Saper et al.

    Borderline personality disorder and the chronic headache patientReview and management recommendations

    Headache

    (2002)
  • J Saper et al.

    Headache in the abuse-prone individual

  • R.C Kessler et al.

    Lifetime and 12-month prevalence of DSM-III-R disorders in the United StatesResults from the National Comorbidity Survey

    Arch Gen Psychiatry

    (1994)
  • P.E Greenberg et al.

    The economic burden of depression in 1990

    J Clin Psychiatry

    (1993)
  • (1993)
  • Diagnostic and Statistical Manual of Mental Disorders

    (1994)
  • Gray RN, Goslin RE, McCrory DC, et al: Drug Treatments for the Prevention of Migraine. Technical Review 2.3....
  • S.D Silberstein

    Practice parameterEvidence-based guideline for migraine headache (an evidence-based review)

    Neurology

    (2000)
  • R.B Kaniecki

    A comorbidity-directed algorithmic approach to the outpatient management of chronic migraine

    Headache

    (2004)
  • Cited by (31)

    • Physical–Mental Comorbidity of Pediatric Migraine in the Philadelphia Neurodevelopmental Cohort

      2019, Journal of Pediatrics
      Citation Excerpt :

      Given the specificity of the association between migraine with anxiety and mood disorders, comorbid psychopathology also may influence the prognosis and progression of migraine headache. This is especially relevant, because behavioral and psychological risk factors may be implicated in the increase in severity and chronicity of headaches.38-40 Incorporation of comorbid disorders into treatment of children with migraine may facilitate modification of the trajectories of both conditions across the lifespan.

    • Overattachment and perceived disability in chronic migraineurs

      2013, Clinical Neurology and Neurosurgery
      Citation Excerpt :

      The World Health Organization (WHO) has ranked migraine 19th among all causes of disability worldwide (12th in women) [5]. Migraine is associated with financial costs related to medical care and lost productivity, functional impairment, reduced quality of life, and increased rates of comorbid medical and psychiatric conditions [2,6–24]. Several studies have documented an increase in comorbidity of mood and anxiety disorders in people with migraine [8,10,25–32].

    View all citing articles on Scopus
    View full text