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Headache attributed to psychiatric disorders
Handbook of Clinical Neurology, Vol. 97 (3rd series) Headache G. Nappi and M.A. Moskowitz, Editors # 2011 Elsevier B.V. All rights reserved
Chapter 55
Headache attributed to psychiatric disorders VINCENZO GUIDETTI 1 * FEDERICA GALLI, 1 AND FRED SHEFTELL 2 Department of Child and Adolescent Neurology, Psychiatry and Rehabilitation, Sapienza, University of Rome, Rome, Italy 2 New England Center for Headache, Stamford, CT, USA
1
INTRODUCTION The association between psychiatric illness and headache is widely recognized. “Headache attributed to psychiatric disorder” is a new category of secondary headache introduced in the second edition of the International Classification of Headache Disorders (ICHD-II) (Headache Classification Subcommittee of the International Headache Society, 2004). It represents a new, but not conclusive, step toward a better systematization of the topic “headache and psychological factors.” The interest in headache disorders from a psychiatric viewpoint is also growing, as described in recent papers on this topic (Cahill and Murphy, 2004; Allet and Allet, 2006). Neurology and psychiatry are progressively facing each other on this area, looking for likely shared mechanisms, diagnostic and therapeutic lines (Sheftell and Atlas, 2002; Low et al., 2003; Cologno et al., 2005; Hung et al., 2006). From the early 1990s the involvement of psychological factors in headache disorders has been clearly identified as “psychiatric comorbidity.” The term “comorbidity” is a general medical word that dates back to Feinsten (1970). Initially, it related to the occurrence of two distinct diseases in the same patient: “additional ailment in a patient with a particular index disease.” The current conceptualization of the term implies an association which is more than casual, but likely not causal, between an index disease or disorder and one or more coexisting physical or psychological pathology. The adoption of Feinsten’s definition does not imply per se the assumption of a hierarchy between the “index disorder” and the “additional” ones, whether in relation to our main focus, or consid-
ering a disease or disorder as the starting point of our analysis, or in terms of a time sequence. In part, the applicability of the definition to the medical field has been facilitated by the knowledge of biological mechanisms explaining the occurrence of some diseases (e.g., diabetes). The transposition of the conceptualization to the psychiatric field is more recent, but not straightforward. Contents and implications of the concept of “comorbidity” have suggested reconsiderations and reframings over time. Comorbidity refers to “disorders” (behavioral and psychological problems that are deviant from “normality”) and/or “diseases” (well defined as clinical entities), not to the existence of related co-occurring symptoms (syndrome). However, recognizing comorbidities may be an initial step in identifying new syndromes. Additionally, clarifying the direction, meaning, and weight of comorbidities has pathophysiological, nosological, course, and treatment implications. However, the study of comorbidity may present a series of difficulties related to the current understanding of etiology and pathophysiology of diseases at the center of our attention. Sometimes, as happens in the subject of headache, we proceed against a background where many issues need to be clarified. The question is amplified in psychiatry, and even more troublesome when the co-occurrence of psychiatric and no psychiatric variables is analyzed. In the psychiatric field, we mainly deal with disorders, not diseases (Angold et al., 1999). To date, knowledge of the etiology and pathophysiology of most psychiatric disorders is at best inferential. Research and clinical approaches to comorbidity need to take several issues into consideration.
*Correspondence to: Professor Vincenzo Guidetti, Department of Child and Adolescent Neurology, Psychiatry and Rehabilitation, “Sapienza”, University of Rome, Via dei Sabelli 108, 00185 Rome, Italy, Tel: 0039-06-44712-255, Fax: 0039-06-4957857, E-mail: [email protected]
658 V. GUIDETTI ET AL. Mental disorders such as comorbid diseases and Davis, 1993; Breslau et al., 1994), with one increasing increase the risk for an impaired functional status or the first onset of the other. quality of life, as shown by different studies analyzing The hypothesis of a shared biological predisposition diverse disorders (Gijsen et al., 2001). These aspects, between migraine and depression has been suggested on and related diagnostic and prognostic implications, the basis of similarities in biological aspects (role of serosuggest consideration of psychiatric disorders in the tonergic system) (Glover et al., 1993; Haythornthwaite, clinical setting. 1993; Silberstein, 1994). Initially, most studies on psychiatric comorbidity FROM “MIGRAINE PERSONALITY” TO were in migraine. Further studies demonstrated that PSYCHIATRIC COMORBIDITY IN the presence of psychiatric disorders is related to MIGRAINE severe and frequent headache (Breslau et al., 2000) rather than to migraine. A characteristic set of psychological features has been observed among migraine sufferers since the last cenCHRONIC DAILY HEADACHE AND tury. Moersch (1924) reported mild mental and physical PSYCHIATRIC COMORBIDITY depression, anxiety, apathy, lack of energy, and fatiMore recently, attention has turned to the comorbid gue. Liveing (1978) considered depression and drowsiassociation between chronic daily headache (CDH) ness as characteristics of migraineurs. Emotional and psychiatric disorders. All studies agree that CDH disturbance is one of three causes of migraine, patients demonstrate a higher number of psychiatric together with gastric and menstrual disturbances. disorders than other headache subtypes. Peters (1987) stated that migraine occurs “most freStudies on CDH have been almost entirely based on quently in delicate males and females of a highly nera clinical population, with few exceptions (Guitera vous temperament . . . apt to be reproduced by any et al., 2002; Juang et al., 2004; Wang et al., 2006). unusual excitement, by joy, hope, fear, excessive pleaThe relatively low prevalence of CDH in the general sure, anxiety, fasting, fatigue”. Anstie (1987) sugpopulation may explain the difficulty of carrying out gested that migraine follows a period of bodily a study on non-clinical samples, but doubts remain on changes, and then “the patient begins to suffer headlikely biases of findings (the so-called Berkson’s bias, ache after any unusual fatigue or excitement”. namely the tendency of self-selected patients to consult Wolff (1937) proposed the definition of “migraine specialists). personality,” mainly characterized by perfectionism The prevalence of psychiatric disorders is higher in and rigidity. Although his investigations concerned CDH patients than in other headache patients. Estimigrainous adults, he suggested that, as children, they mates of prevalence of psychiatric comorbidity in were shy, withdrawn, and obedient, but occasionally CDH patients range from 64–66.1% (Juang et al., could become inflexible, obstinate, and rebellious. 2000; Puca et al., 2000) to 90% (Verri et al., 1998), Wolff’s conclusions were based on his observations mostly anxiety and/or mood disorders, with higher after a review of his patients’ charts and his notes. scores in women than men with CDH (Mitsikostas From the beginning of the 1990s, the subject began to and Thomas, 1999). undergo a systematic conceptualization in terms of “psyIt is noteworthy that chronic pain in general is chiatric comorbidity” by prospective population-based related to the co-occurrence of depression and anxiety, studies on young adults (Merikangas et al., 1990; Breslau opening up diagnostic (Arnstein et al., 2004), treatment et al., 1991; Breslau and Davis, 1993; Merikangas, 1994). (Verma and Gallagher, 2001), and etiological (Gallagher Merikangas et al. (1993, 1994) suggested that many of and Verma, 1999; Blackburn-Munro and Blackburnthe psychological features frequently related to migraine Munro, 2001) issues. are more akin to psychopathological symptoms than to Studies on CDH patients are not always easy to personality characteristics, so much so that a syndromic compare since different classification systems have relationship with a peculiar time sequence (anxiety, been used. Some studies deal with CDH only on the migraine, and depression) has been suggested (Merikanbasis of a high “frequency” of crises or analyzing gas et al., 1990; Merikangas, 1994). Her conclusion is that “severe headache without migrainous features” (not Woff’s description of the “migraine personality” may ICHD criteria). However, these studies contribute to have reflected “subsyndromal” descriptions of anxiety emphasize the higher occurrence of psychiatric disorand depressive symptomatology. This remark had been ders in CDH than in migraine. The lifetime prevalence supported by Breslau and Davis’s population-based study of major depression is three times higher in persons (1993), even though a bidirectional influence between with migraine and in persons with “severe headaches” migraine and depression has been suggested (Breslau
HEADACHE ATTRIBUTED TO PSYCHIATRIC DISORDERS compared with controls (Breslau et al., 2000). Frequency of headache, but not headache severity, seems to be related to depression, anxiety, and high disability rate (Marcus, 2000). Similar findings refer to the occurrence of panic disorder, which is related not only to migraine headache, but also to “severe headache” without migrainous features (Breslau et al., 2001). Attempts have been made to find specific relationships between CDH subtypes and different psychiatric disorders. Transformed migraine seems to have the higher rates of psychiatric comorbidity (78%: 57% major depression, 11% dysthymia, 30% panic disorder, 8% generalized anxiety disorder) than chronic tension-type headache (64%: 51% major depression, 8% dysthymia, 22% panic disorder, 1% generalized anxiety disorder) (Juang et al., 2000). Another study (Puca et al., 2000) found the highest prevalence of psychiatric disorders in patients with coexisting migraine and chronic tension-type headache (72.2%) compared to chronic migraine (70.3%) and chronic tension-type headache (50%). However, studies are lacking of comparable diagnostic systems for the classification of both CDH and psychiatric disorders, and the results are currently unclear. A new issue in the topic of CDH is represented by the role of psychiatric disorders in medication overuse headache (MOH). According to the ICHD-II (Headache Classification Subcommittee of the International Headache Society, 2004), MOH refers to headache attributed to abuse of abortive medications that may remit only when analgesics are withdrawn. Although there exists very little literature on this topic, we know that psychiatric comorbidity is an important factor for the transformation of sporadic headache into chronic headache. Atasoy et al. (2005) reported the involvement of psychiatric disorders in 68% of MOH patients evolving from episodic tension-type headache and 54% evolving from migraine (but in only 35% of chronic tension-type without analgesic overuse). Radat et al. (2005) noted in their study that the onset of psychiatric comorbidity was likely to precede the onset of medication overuse, perhaps suggesting that patients may choose their medication of overuse to treat their psychiatric comorbidity (e.g., opiates/benzodiazepines, butalbital). In regard to personality disorders, some studies are beginning to demonstrate the role of personality disorders in MOH (e.g., obsessive-compulsive personality disorder) (Atasoy et al., 2005), opening up the possibility of the likely role of substance dependence patterns (Lake, 2006). Psychiatric comorbidity may represent an obstacle for drug treatment effectiveness (Curioso et al., 1999), but also another point on which to act when
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treating headaches. In fact, the occurrence of psychiatric disorders may influence the treatment, for instance by combining drug and non-drug therapy according to the whole case history. This aspect stresses the importance of multidisciplinary work with CDH patients, from diagnosis to therapy. Psychiatric comorbidity should be carefully analyzed in the diagnostic process, in order to choose the best treatment options. A psychological evaluation is the conditio qua non for a complete framing of the CDH patient and for tailoring the treatment according to the peculiarities of the case (Lebovits, 2000; London et al., 2001). Pharmacological and non-pharmacological therapies should be combined in the treatment of CDH (Holroyd et al., 2001; Lake, 2001). However, evidence-based data on non-pharmacological therapies are wanting, even if well-done studies have been realized in both adults and children or adolescents (Rockicki et al., 1997; Andrasik et al., 2002; Larsson and Andrasik, 2002). Studies should be performed to evaluate the effectiveness of such therapies and the different applications according to different CDH types and comorbid disorders. On the pharmacological side, antidepressant medications have been the most widely studied in the prophylactic therapy of CDH (Redillas and Solomon, 2000) but their mechanism of action is unknown and likely not related to the antidepressive action. The understanding of factors involved in the chronification and prognosis of headache is another point that should be analyzed. The role of analgesic overuse cannot explain all cases of CDH, as has been shown by the cases of CDH with onset in children or adolescents, in as much as only a minor percentage seems to be related to it. On the other hand, psychiatric disorders may be related to the chronification of headache (Guidetti et al., 1998; Galli et al., 2004), leading to the imperative need for assessing and treating it, from its onset at an early age. An aspect to note, but still poorly understood, is that different kinds of chronic pain are related to the presence of psychiatric disorders (mainly anxiety and mood disorders) (Williams et al., 2006).
FROM PSYCHIATRIC COMORBIDITY TO HEADACHE ATTRIBUTED TO PSYCHIATRIC DISORDERS ICHD-II (Headache Classification Subcommittee of the International Headache Society, 2004) advances an innovative categorization for headache related to psychological factors. The new classification is a first step toward a better systematization of the topic “headache and psychiatric disorders,” even though,
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to date, there is limited evidence to support psychiatric causes of headache, as outlined in the general comment introducing the section of ICHD-II. For the first time, there is a recognition of a “direction” (headache attributed to psychiatric disorders) in this relationship in the main body of the ICHD-II, even though it is only related to somatization and psychotic disorders. The previous classification (Headache Classification Committee of the International Headache Society, 1988) recognized psychosocial stress, anxiety, and depression as potential “causes” of headache, but only in regard to tension-type headache. The ICHD-II does not give criteria to diagnose headache characteristics (“no typical characteristics known”), stressing the fact that migraine, tension-type, and cluster headache may be attributed to psychiatric disorders. A general rule allowing the attribution of headache to psychiatric disorder is the temporal connection, with head pain first appearing in close relationship to a psychiatric disorder, and resolving or improving when psychiatric disorder remits. When a pre-existing primary headache is made worse in close relation to psychiatric disorder, both diagnoses may be made. However, both the primary headache and headache attributed to psychiatric disorder may be diagnosed if clinical judgment deems it convenient. The diagnostic categories provided by ICHD-II do not complete the list of the likely psychiatric disorders that may be causally related to headache, and do not overcome the concept of psychiatric comorbidity. The appendix of the ICHD-II makes a list of various psychiatric disorders (major depressive disorder, panic disorder, generalized anxiety disorder, undifferentiated somatoform disorder, social phobia, separation anxiety disorder, and post-traumatic stress disorder) that are candidates to be inserted in the main body of the classification when a sufficient degree of scientific evidence is presented. However, the vast majority of headaches occurring in association with psychiatric disorders are not to be attributed to psychopathology (a close temporal relationship is not fitting), and we may only refer to comorbidity. The mechanisms through which psychiatric disorders give rise to headache are not clear. Several studies have clarified, though, that the most common relationship between psychiatric illness and headache is bidirectional and associational rather than causative (Breslau et al., 1991). This relationship is especially clear in the case of mood disorders and migraine. The underlying neurochemistry of many primary headache disorders, especially migraine, has much in common with the neurochemistry (indole and biogenic amines) of various psychiatric illnesses (Breslau et al., 1991). The greater
risk a patient with migraine or depression has of developing the other disorder seems related in most cases to shared underlying serotonergic abnormalities of the central nervous system (Glover et al., 1993). Even if association is the most common relationship between psychiatric illnesses and headache disorders, though, this does not preclude the possibility of a causal relationship in some conditions. Only such conditions are classified by criteria provided by the ICHD-II. However, further studies are warranted because headache disorders attributable to psychiatric conditions are probably more rarely diagnosed (Loder and Biondi, 2005) than they occur. The suspicion is that the ongoing understanding of the pathophysiological mechanisms of headache (mainly for migraine) is making it more difficult to give a diagnosis in terms of headache causally related to psychological/psychiatric factors. The mechanisms through which psychiatric disorders give rise to headache are not clear. However, we can hypothesize a predisposition (genetic? environmental?) to develop headache of any kind, at the outset triggered by the occurrence of a psychiatric disorder. On the one hand, this interpretation may facilitate the overcoming of the mind–body dichotomy that seems to continue to permeate issues in regard to certain clinical approaches to headache disorders. On the other hand, the therapeutic implications must be taken into account to improve outcome. We know that the presence of psychiatric disorders predicts a worse prognosis for every headache subtype (Guidetti et al., 1998; Galli et al., 2004). It is clear that a complete diagnosis and treatment planning should not leave aside a psychiatric assessment as well. Patients with CDH with the absence of personality and mood/anxiety disorders are relatively easier to treat than patients with mood/anxiety and personality disorders (Sheftell and Atlas, 2002).
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Holroyd KA, O’Donnell FJ, Stensland M et al. (2001). Management of chronic tension-type headache with tricyclic antidepressant medication, stress management therapy, and their combination: a randomized controlled trial. JAMA 285: 2208–2215. Hung CI, Liu CY, Juang YY et al. (2006). The impact of migraine on patients with major depressive disorder. Headache 46: 469–477. Juang KD, Wang SJ, Fuh JL et al. (2000). Comorbidity of depressive and anxiety disorders in chronic daily headache and its subtypes. Headache 40: 818–823. Juang KD, Wang SJ, Fuh JL et al. (2004). Association between adolescent chronic daily headache and childhood adversity: a community-based study. Cephalalgia 24: 54–59. Lake AE (2001). Behavioral and nonpharmacologic treatments of headache. Med Clin North Am 85: 1055–1075. Lake AE (2006). Medication overuse headache: biobehavioral issues and solutions. Headache 46 (Suppl. 3): 88–97. Larsson B, Andrasik F (2002). Relaxation treatment of recurrent headaches in children and adolescents. In: V Guidetti, G Russell, M Sillanpa¨a¨ et al. (Eds.), Headache and Migraine in Childhood and Adolescence. Martin Dunitz, London, pp. 307–316. Lebovits AH (2000). The psychological assessment of patients with chronic pain. Curr Rev Pain 4: 122–126. Liveing E (1978). On Migrim, Sick-Headache, and Some Allied Disorders: A Contribution to the Pathology of Nerve Storms. J & A Churchill, London. Loder E, Biondi D (2005). Headache attributed to psychiatric disorder: a case series. Psychosomatics 46: 326–333. London LH, Shulman B, Diamond S (2001). The role of psychometric testing and psychological treatment in tensiontype headache. Curr Pain Headache Rep 5: 467–471. Low NCP, Galbaud du Fort G, Cervantes P (2003). Prevalence, clinical correlates, and treatment of migraine in bipolar disorder. Headache 43: 940–949. Marcus DA (2000). Identification of patients with headache at risk for psychological distress. Headache 40: 373–376. Merikangas KR (1994). Psychopathology and headache syndromes in the community. Headache 34: S17–S26. Merikangas KR, Angst J, Isler H (1990). Migraine and psychopathology. Results of the Zurich cohort study of young adults. Arch Gen Psychiatry 47: 849–853. Merikangas KR, Merikangas JR, Angst J (1993). Headache syndromes and psychiatric disorders: association and familial transmission. J Psychiatr Res 2: 197–210. Mitsikostas DD, Thomas AM (1999). Comorbidity of headache and depression. Cephalalgia 19: 211–217. Moersch FP (1924). Psychic manifestations in migraine. Am J Psychiatry 3: 698–716. Peters JC (1987). A treatise on headache. In: JN Blau (Ed.), Migraine. Chapman and Hall, London, pp. 367–386. Puca F, Guazzelli M, Sciruicchio V (2000). Psychiatric disorders in chronic daily headache: detection by means of the SCID interview. J Headache Pain 1: S33–S37.
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Radat F, Creach C, Swendsen JD et al. (2005). Psychiatric comorbidity in the evolution from migraine to medication overuse headache. Cephalalgia 24: 519–522. Redillas C, Solomon S (2000). Prophylactic pharmacological treatment of chronic daily headache. Headache 40: 83–102. Rockicki LA, Holroyd KA, France CR et al. (1997). Change mechanisms associated with combined relaxation/EMG biofeedback training for chronic tension headache. Appl Psychophysiol Biofeedback 22: 21–41. Sheftell FD, Atlas SJ (2002). Migraine and psychiatric comorbidity: from theory and hypotheses to clinical application. Headache 42: 934–944. Silberstein SD (1994). Serotonin (5-HT) and migraine. Headache 34: 408–417.
Verma S, Gallagher RM (2001). The psychopharmocologic treatment of depression and anxiety in the context of chronic pain. Curr Pain Headache Rep 6: 30–39. Verri AP, Cecchini P, Galli C et al. (1998). Psychiatric comorbidity in chronic daily headache. Cephalalgia 18 (Suppl. 21): 45–49. Wang SJ, Fuh JL, Lu SR et al. (2006). Daily headache in adolescents: prevalence, impact, and medication overuse. Neurology 66: 193–197. Williams LJ, Jacka FN, Pasco JA et al. (2006). Depression and pain: an overview. Acta Neuropsychiatrica 18: 79–97. Wolff HG (1937). Personality features and reactions of subjects with migraine. Arch Neurol Psychiatry 37: 895.
Chapter 55
Headache attributed to psychiatric disorders VINCENZO GUIDETTI 1 * FEDERICA GALLI, 1 AND FRED SHEFTELL 2 Department of Child and Adolescent Neurology, Psychiatry and Rehabilitation, Sapienza, University of Rome, Rome, Italy 2 New England Center for Headache, Stamford, CT, USA
1
INTRODUCTION The association between psychiatric illness and headache is widely recognized. “Headache attributed to psychiatric disorder” is a new category of secondary headache introduced in the second edition of the International Classification of Headache Disorders (ICHD-II) (Headache Classification Subcommittee of the International Headache Society, 2004). It represents a new, but not conclusive, step toward a better systematization of the topic “headache and psychological factors.” The interest in headache disorders from a psychiatric viewpoint is also growing, as described in recent papers on this topic (Cahill and Murphy, 2004; Allet and Allet, 2006). Neurology and psychiatry are progressively facing each other on this area, looking for likely shared mechanisms, diagnostic and therapeutic lines (Sheftell and Atlas, 2002; Low et al., 2003; Cologno et al., 2005; Hung et al., 2006). From the early 1990s the involvement of psychological factors in headache disorders has been clearly identified as “psychiatric comorbidity.” The term “comorbidity” is a general medical word that dates back to Feinsten (1970). Initially, it related to the occurrence of two distinct diseases in the same patient: “additional ailment in a patient with a particular index disease.” The current conceptualization of the term implies an association which is more than casual, but likely not causal, between an index disease or disorder and one or more coexisting physical or psychological pathology. The adoption of Feinsten’s definition does not imply per se the assumption of a hierarchy between the “index disorder” and the “additional” ones, whether in relation to our main focus, or consid-
ering a disease or disorder as the starting point of our analysis, or in terms of a time sequence. In part, the applicability of the definition to the medical field has been facilitated by the knowledge of biological mechanisms explaining the occurrence of some diseases (e.g., diabetes). The transposition of the conceptualization to the psychiatric field is more recent, but not straightforward. Contents and implications of the concept of “comorbidity” have suggested reconsiderations and reframings over time. Comorbidity refers to “disorders” (behavioral and psychological problems that are deviant from “normality”) and/or “diseases” (well defined as clinical entities), not to the existence of related co-occurring symptoms (syndrome). However, recognizing comorbidities may be an initial step in identifying new syndromes. Additionally, clarifying the direction, meaning, and weight of comorbidities has pathophysiological, nosological, course, and treatment implications. However, the study of comorbidity may present a series of difficulties related to the current understanding of etiology and pathophysiology of diseases at the center of our attention. Sometimes, as happens in the subject of headache, we proceed against a background where many issues need to be clarified. The question is amplified in psychiatry, and even more troublesome when the co-occurrence of psychiatric and no psychiatric variables is analyzed. In the psychiatric field, we mainly deal with disorders, not diseases (Angold et al., 1999). To date, knowledge of the etiology and pathophysiology of most psychiatric disorders is at best inferential. Research and clinical approaches to comorbidity need to take several issues into consideration.
*Correspondence to: Professor Vincenzo Guidetti, Department of Child and Adolescent Neurology, Psychiatry and Rehabilitation, “Sapienza”, University of Rome, Via dei Sabelli 108, 00185 Rome, Italy, Tel: 0039-06-44712-255, Fax: 0039-06-4957857, E-mail: [email protected]
658 V. GUIDETTI ET AL. Mental disorders such as comorbid diseases and Davis, 1993; Breslau et al., 1994), with one increasing increase the risk for an impaired functional status or the first onset of the other. quality of life, as shown by different studies analyzing The hypothesis of a shared biological predisposition diverse disorders (Gijsen et al., 2001). These aspects, between migraine and depression has been suggested on and related diagnostic and prognostic implications, the basis of similarities in biological aspects (role of serosuggest consideration of psychiatric disorders in the tonergic system) (Glover et al., 1993; Haythornthwaite, clinical setting. 1993; Silberstein, 1994). Initially, most studies on psychiatric comorbidity FROM “MIGRAINE PERSONALITY” TO were in migraine. Further studies demonstrated that PSYCHIATRIC COMORBIDITY IN the presence of psychiatric disorders is related to MIGRAINE severe and frequent headache (Breslau et al., 2000) rather than to migraine. A characteristic set of psychological features has been observed among migraine sufferers since the last cenCHRONIC DAILY HEADACHE AND tury. Moersch (1924) reported mild mental and physical PSYCHIATRIC COMORBIDITY depression, anxiety, apathy, lack of energy, and fatiMore recently, attention has turned to the comorbid gue. Liveing (1978) considered depression and drowsiassociation between chronic daily headache (CDH) ness as characteristics of migraineurs. Emotional and psychiatric disorders. All studies agree that CDH disturbance is one of three causes of migraine, patients demonstrate a higher number of psychiatric together with gastric and menstrual disturbances. disorders than other headache subtypes. Peters (1987) stated that migraine occurs “most freStudies on CDH have been almost entirely based on quently in delicate males and females of a highly nera clinical population, with few exceptions (Guitera vous temperament . . . apt to be reproduced by any et al., 2002; Juang et al., 2004; Wang et al., 2006). unusual excitement, by joy, hope, fear, excessive pleaThe relatively low prevalence of CDH in the general sure, anxiety, fasting, fatigue”. Anstie (1987) sugpopulation may explain the difficulty of carrying out gested that migraine follows a period of bodily a study on non-clinical samples, but doubts remain on changes, and then “the patient begins to suffer headlikely biases of findings (the so-called Berkson’s bias, ache after any unusual fatigue or excitement”. namely the tendency of self-selected patients to consult Wolff (1937) proposed the definition of “migraine specialists). personality,” mainly characterized by perfectionism The prevalence of psychiatric disorders is higher in and rigidity. Although his investigations concerned CDH patients than in other headache patients. Estimigrainous adults, he suggested that, as children, they mates of prevalence of psychiatric comorbidity in were shy, withdrawn, and obedient, but occasionally CDH patients range from 64–66.1% (Juang et al., could become inflexible, obstinate, and rebellious. 2000; Puca et al., 2000) to 90% (Verri et al., 1998), Wolff’s conclusions were based on his observations mostly anxiety and/or mood disorders, with higher after a review of his patients’ charts and his notes. scores in women than men with CDH (Mitsikostas From the beginning of the 1990s, the subject began to and Thomas, 1999). undergo a systematic conceptualization in terms of “psyIt is noteworthy that chronic pain in general is chiatric comorbidity” by prospective population-based related to the co-occurrence of depression and anxiety, studies on young adults (Merikangas et al., 1990; Breslau opening up diagnostic (Arnstein et al., 2004), treatment et al., 1991; Breslau and Davis, 1993; Merikangas, 1994). (Verma and Gallagher, 2001), and etiological (Gallagher Merikangas et al. (1993, 1994) suggested that many of and Verma, 1999; Blackburn-Munro and Blackburnthe psychological features frequently related to migraine Munro, 2001) issues. are more akin to psychopathological symptoms than to Studies on CDH patients are not always easy to personality characteristics, so much so that a syndromic compare since different classification systems have relationship with a peculiar time sequence (anxiety, been used. Some studies deal with CDH only on the migraine, and depression) has been suggested (Merikanbasis of a high “frequency” of crises or analyzing gas et al., 1990; Merikangas, 1994). Her conclusion is that “severe headache without migrainous features” (not Woff’s description of the “migraine personality” may ICHD criteria). However, these studies contribute to have reflected “subsyndromal” descriptions of anxiety emphasize the higher occurrence of psychiatric disorand depressive symptomatology. This remark had been ders in CDH than in migraine. The lifetime prevalence supported by Breslau and Davis’s population-based study of major depression is three times higher in persons (1993), even though a bidirectional influence between with migraine and in persons with “severe headaches” migraine and depression has been suggested (Breslau
HEADACHE ATTRIBUTED TO PSYCHIATRIC DISORDERS compared with controls (Breslau et al., 2000). Frequency of headache, but not headache severity, seems to be related to depression, anxiety, and high disability rate (Marcus, 2000). Similar findings refer to the occurrence of panic disorder, which is related not only to migraine headache, but also to “severe headache” without migrainous features (Breslau et al., 2001). Attempts have been made to find specific relationships between CDH subtypes and different psychiatric disorders. Transformed migraine seems to have the higher rates of psychiatric comorbidity (78%: 57% major depression, 11% dysthymia, 30% panic disorder, 8% generalized anxiety disorder) than chronic tension-type headache (64%: 51% major depression, 8% dysthymia, 22% panic disorder, 1% generalized anxiety disorder) (Juang et al., 2000). Another study (Puca et al., 2000) found the highest prevalence of psychiatric disorders in patients with coexisting migraine and chronic tension-type headache (72.2%) compared to chronic migraine (70.3%) and chronic tension-type headache (50%). However, studies are lacking of comparable diagnostic systems for the classification of both CDH and psychiatric disorders, and the results are currently unclear. A new issue in the topic of CDH is represented by the role of psychiatric disorders in medication overuse headache (MOH). According to the ICHD-II (Headache Classification Subcommittee of the International Headache Society, 2004), MOH refers to headache attributed to abuse of abortive medications that may remit only when analgesics are withdrawn. Although there exists very little literature on this topic, we know that psychiatric comorbidity is an important factor for the transformation of sporadic headache into chronic headache. Atasoy et al. (2005) reported the involvement of psychiatric disorders in 68% of MOH patients evolving from episodic tension-type headache and 54% evolving from migraine (but in only 35% of chronic tension-type without analgesic overuse). Radat et al. (2005) noted in their study that the onset of psychiatric comorbidity was likely to precede the onset of medication overuse, perhaps suggesting that patients may choose their medication of overuse to treat their psychiatric comorbidity (e.g., opiates/benzodiazepines, butalbital). In regard to personality disorders, some studies are beginning to demonstrate the role of personality disorders in MOH (e.g., obsessive-compulsive personality disorder) (Atasoy et al., 2005), opening up the possibility of the likely role of substance dependence patterns (Lake, 2006). Psychiatric comorbidity may represent an obstacle for drug treatment effectiveness (Curioso et al., 1999), but also another point on which to act when
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treating headaches. In fact, the occurrence of psychiatric disorders may influence the treatment, for instance by combining drug and non-drug therapy according to the whole case history. This aspect stresses the importance of multidisciplinary work with CDH patients, from diagnosis to therapy. Psychiatric comorbidity should be carefully analyzed in the diagnostic process, in order to choose the best treatment options. A psychological evaluation is the conditio qua non for a complete framing of the CDH patient and for tailoring the treatment according to the peculiarities of the case (Lebovits, 2000; London et al., 2001). Pharmacological and non-pharmacological therapies should be combined in the treatment of CDH (Holroyd et al., 2001; Lake, 2001). However, evidence-based data on non-pharmacological therapies are wanting, even if well-done studies have been realized in both adults and children or adolescents (Rockicki et al., 1997; Andrasik et al., 2002; Larsson and Andrasik, 2002). Studies should be performed to evaluate the effectiveness of such therapies and the different applications according to different CDH types and comorbid disorders. On the pharmacological side, antidepressant medications have been the most widely studied in the prophylactic therapy of CDH (Redillas and Solomon, 2000) but their mechanism of action is unknown and likely not related to the antidepressive action. The understanding of factors involved in the chronification and prognosis of headache is another point that should be analyzed. The role of analgesic overuse cannot explain all cases of CDH, as has been shown by the cases of CDH with onset in children or adolescents, in as much as only a minor percentage seems to be related to it. On the other hand, psychiatric disorders may be related to the chronification of headache (Guidetti et al., 1998; Galli et al., 2004), leading to the imperative need for assessing and treating it, from its onset at an early age. An aspect to note, but still poorly understood, is that different kinds of chronic pain are related to the presence of psychiatric disorders (mainly anxiety and mood disorders) (Williams et al., 2006).
FROM PSYCHIATRIC COMORBIDITY TO HEADACHE ATTRIBUTED TO PSYCHIATRIC DISORDERS ICHD-II (Headache Classification Subcommittee of the International Headache Society, 2004) advances an innovative categorization for headache related to psychological factors. The new classification is a first step toward a better systematization of the topic “headache and psychiatric disorders,” even though,
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to date, there is limited evidence to support psychiatric causes of headache, as outlined in the general comment introducing the section of ICHD-II. For the first time, there is a recognition of a “direction” (headache attributed to psychiatric disorders) in this relationship in the main body of the ICHD-II, even though it is only related to somatization and psychotic disorders. The previous classification (Headache Classification Committee of the International Headache Society, 1988) recognized psychosocial stress, anxiety, and depression as potential “causes” of headache, but only in regard to tension-type headache. The ICHD-II does not give criteria to diagnose headache characteristics (“no typical characteristics known”), stressing the fact that migraine, tension-type, and cluster headache may be attributed to psychiatric disorders. A general rule allowing the attribution of headache to psychiatric disorder is the temporal connection, with head pain first appearing in close relationship to a psychiatric disorder, and resolving or improving when psychiatric disorder remits. When a pre-existing primary headache is made worse in close relation to psychiatric disorder, both diagnoses may be made. However, both the primary headache and headache attributed to psychiatric disorder may be diagnosed if clinical judgment deems it convenient. The diagnostic categories provided by ICHD-II do not complete the list of the likely psychiatric disorders that may be causally related to headache, and do not overcome the concept of psychiatric comorbidity. The appendix of the ICHD-II makes a list of various psychiatric disorders (major depressive disorder, panic disorder, generalized anxiety disorder, undifferentiated somatoform disorder, social phobia, separation anxiety disorder, and post-traumatic stress disorder) that are candidates to be inserted in the main body of the classification when a sufficient degree of scientific evidence is presented. However, the vast majority of headaches occurring in association with psychiatric disorders are not to be attributed to psychopathology (a close temporal relationship is not fitting), and we may only refer to comorbidity. The mechanisms through which psychiatric disorders give rise to headache are not clear. Several studies have clarified, though, that the most common relationship between psychiatric illness and headache is bidirectional and associational rather than causative (Breslau et al., 1991). This relationship is especially clear in the case of mood disorders and migraine. The underlying neurochemistry of many primary headache disorders, especially migraine, has much in common with the neurochemistry (indole and biogenic amines) of various psychiatric illnesses (Breslau et al., 1991). The greater
risk a patient with migraine or depression has of developing the other disorder seems related in most cases to shared underlying serotonergic abnormalities of the central nervous system (Glover et al., 1993). Even if association is the most common relationship between psychiatric illnesses and headache disorders, though, this does not preclude the possibility of a causal relationship in some conditions. Only such conditions are classified by criteria provided by the ICHD-II. However, further studies are warranted because headache disorders attributable to psychiatric conditions are probably more rarely diagnosed (Loder and Biondi, 2005) than they occur. The suspicion is that the ongoing understanding of the pathophysiological mechanisms of headache (mainly for migraine) is making it more difficult to give a diagnosis in terms of headache causally related to psychological/psychiatric factors. The mechanisms through which psychiatric disorders give rise to headache are not clear. However, we can hypothesize a predisposition (genetic? environmental?) to develop headache of any kind, at the outset triggered by the occurrence of a psychiatric disorder. On the one hand, this interpretation may facilitate the overcoming of the mind–body dichotomy that seems to continue to permeate issues in regard to certain clinical approaches to headache disorders. On the other hand, the therapeutic implications must be taken into account to improve outcome. We know that the presence of psychiatric disorders predicts a worse prognosis for every headache subtype (Guidetti et al., 1998; Galli et al., 2004). It is clear that a complete diagnosis and treatment planning should not leave aside a psychiatric assessment as well. Patients with CDH with the absence of personality and mood/anxiety disorders are relatively easier to treat than patients with mood/anxiety and personality disorders (Sheftell and Atlas, 2002).
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