Psychiatric comorbidity of chronic daily headache: impact, treatment, outcome, and future studies

Chronic headache with medication overuse: Long-term prognosis after withdrawal therapy

Background Knowledge about long-term outcomes after medication withdrawal therapy for chronic headache, including tension type and migraine headache is lacking. Methods We re-examined 56 patients an average of nine years after they participated in a medication withdrawal study with a one-year follow-up. We collected and compared data on headache, use of medication, quality of life, quality of sleep, anxiety, depression, and labor participation one and nine years after the start of withdrawal therapy. Results Headache days per month decreased from 16.7 (14.0-19.3) at one year to 13.3 (10.6-15.9) at nine years (P = 0.007). The proportion of patients meeting the criteria for chronic headache decreased from 27/56 (48%) at one year to 18/56 (32%) at nine years (P = 0.004). Medication overuse was reported in seven (13%) patients at one year and 18 (32%) at nine years (P = 0.013). The majority of patients overusing medication at nine years (10/18) belonged to a group of 14 patients who had a poor early response to withdrawal therapy and had sustained chronic headache after nine years. After excluding patients receiving retirement pensions, the proportion who received disability benefits increased from 21/55 (38%) at one year to 30/49 (61%) at nine years (P = 0.003). Conclusion Improvements after withdrawal therapy for chronic headache last at least nine years, with a parallel increase in the use of disability benefits. However, a high proportion of patients with a poor initial response to withdrawal therapy and sustained chronic headache overuse medication.

Prevalence, Pattern and Predictors of use of Complementary and Alternative Medicine (CAM) in Migraine Patients Attending a Headache Clinic in Italy

The use of complementary and alternative medicine (CAM) in migraine is a growing phenomenon about which little is known. This study was undertaken to evaluate the rates, pattern and presence of predictors of CAM use in a clinical population of patients with different migraine subtypes. Four hundred and eighty-one migraineurs attending a headache clinic were asked to undergo a physician-administered structured interview designed to gather information on CAM use. Past use of CAM therapies was reported by 31.4% of the patients surveyed, with 17.1% having used CAM in the previous year. CAM therapies were perceived as beneficial by 39.5% of the patients who had used them. A significantly higher proportion of transformed migraine patients reported CAM treatments as ineffective compared with patients suffering from episodic migraine (73.1% vs. 50.7%, P < 0.001). The most common source of a recommendation of CAM was a friend or relative (52.7%). In most cases, migraineurs' recourse to CAM treatments was specifically for their headache (89.3%). Approximately 61% of CAM users had not informed their medical doctors of their CAM use. The most common reason for deciding to try a CAM therapy was that it offered a ‘potential improvement of headache’ (47.7%). The greatest users of CAM treatments were: patients with a diagnosis of transformed migraine; those who had consulted a high number of specialists and reported a higher lifetime number of conventional medical visits; those with a comorbid psychiatric disorder; those with a high income; and those whose headache had been either misdiagnosed or not diagnosed at all. Our findings suggest that headache clinic migraine patients, in their need of and quest for care, seek and explore both conventional and CAM approaches. Physicians should be made aware of this patient-driven change in the medical climate in order to prevent misuse of healthcare resources and to be better equipped to meet patients' needs.

Update of Inpatient Treatment for Refractory Chronic Daily Headache

Chronic daily headache (CDH) is a group of headache disorders, in which headaches occur daily or near-daily (>15 days per month) and last for more than 3 months. Important CDH subtypes include chronic migraine, chronic tension-type headache, hemicrania continua, and new daily persistent headache. Other headaches with shorter durations (<4 h/day) are usually not included in CDH. Common comorbidities of CDH are medication overuse headache and various psychiatric disorders, such as depression and anxiety. Indications of inpatient treatment for CDH patients include poor responses to outpatient management, need for detoxification for overuse of specific medications (particularly opioids and barbiturates), and severe psychiatric comorbidities. Inpatient treatment usually involves stopping acute pain, preventing future attacks, and detoxifying medication overuse if present. Multidisciplinary integrated care that includes medical staff from different disciplines (e.g., psychiatry, clinical psychology, and physical therapy) has been recommended. The outcomes of inpatient treatment are satisfactory in terms of decreasing headache intensity or frequency, withdrawal from medication overuse, reducing disability, and improving life quality, although long-term relapse is not uncommon. In conclusion, inpatient treatment may be useful for select patients with refractory CDH and should be incorporated in a holistic headache care program.

Coping strategies among adolescents with chronic headache and mental health problems: a cross-sectional population-based study

To examine prevalence of mental health problems among adolescents with chronic headache and compare internal and external coping strategies in young people with chronic headaches with and without mental health problems. This study is based on a cross-sectional survey undertaken in Akershus County in Norway. A total of 19,985 adolescents were included in the study, covering lower secondary and upper secondary students, aged 13-19 years. Chronic headache was measured with a single item question based on headache frequency. Mental health was assessed by using the strengths and difficulties questionnaire (SDQ). Internal and external coping strategies were assessed through seven options for answering the question: What do you do/what happens when you are burdened by painful thoughts and feelings? Adolescents with chronic headaches showed more frequent mental health problems overall (23 %) compared to those without chronic headache (6 %). Logistic regression analyses showed that those adolescents having both chronic headaches and comorbid mental health problems more frequently used internal coping strategies, such as keeping feelings inside (OR 2.05), using abusive substances (OR 1.79) and talking oneself out of problems (OR 1.55), compared to those without mental health problems. Groups with mental health problems, especially with chronic headache, less frequently used the external strategy of talking to others about their problem than controls (OR 0.7-0.8). Factor analyses revealed significant differences in profiles of coping strategies between groups. We suggest that attention should be paid towards the high risk group that has both chronic headaches and mental health problems and their tendency to use destructive internal coping strategies.

Psychiatric comorbidity of chronic daily headache: focus on traumatic experiences in childhood, post-traumatic stress disorder and suicidality

The fifth edition of the Diagnostic and Statistic Manual (DSM-5) reclassified some mental disorders recently. Post-traumatic stress disorder (PTSD) is in a new section termed "trauma- and stressor-related disorder". Community-based studies have shown that PTSD is associated with a notably high suicidal risk. In addition to previous findings of comorbidity between chronic daily headache (CDH) and both depressive disorders and anxiety disorders, recent data suggest that frequency of childhood maltreatment, PTSD, and suicidality are also increased in CDH. CDH patients with migraine aura are especially at risk of suicidal ideation. Research suggests that migraine attack, aura, frequency, and chronicity may all be related to serotonergic dysfunction. Vulnerability to PTSD and suicidality are also linked to brain serotonin function, including polymorphisms in the serotonin transporter gene (5-HTTLPR). In the present review, we focus on recent advances in knowledge of traumatic experiences in childhood, PTSD, and suicidality in relation to migraine and CDH. We hypothesize that vulnerability to PTSD is associated with migraine attack, migraine aura, and CDH. We further postulate that these associations may explain some of the elevated suicidal risks among patients with migraine, migraine aura, and/or CDH. Field studies are required to support these hypotheses.

Association of psychiatric co-morbidity and efficacy of treatment in chronic daily headache in Indian population

OBJECTIVE

To study the prevalence of psychiatric co-morbidity in patients of chronic daily headache (CDH) and compare the efficacy of treatment between various type of headache associated with psychiatric co-morbidity.

MATERIALS AND METHODS

Prospective case control cohort study, 92 consecutive patients of CDH meeting eligibility criteria. The diagnosis of various subtypes of CDH was made according to the IHS criteria. Age, sex, educational, marital and socioeconomic status, matched controls were also selected. Patients were evaluated with the Mini International Neuropsychiatric Interview (MINI) scale at the time of enrolment and at 3 months.

RESULTS

CDH accounted for 28% of all headache patients. The mean age of presentation was 30.2 ± 10.3 years, male: Female ratio of 28:64 and mean duration of 4.56 ± 0.56 years. Chronic migraine (CM) accounted for 59 patients, chronic tension type headache (CTTH) 22 patients, new daily persistent headache (NDPH) 3 patients and miscellaneous 8 patients. Psychiatric co-morbidity was present in 53.3% patients with CDH, and was more common in CM (62.7%) as compared to CTTH (36.4%). Single psychiatric co-morbidity was seen in 26 patients, while 23 patients had multiple co-morbidity. Major depressive episode, anxiety disorder, agoraphobia and dysthymia were significant psychiatric co-morbidities. Patients with CM were treated with topiramate or divalproex sodium ER and CTTH were treated with amitriptyline. 55 patients came for follow up at 3 months, improvement in headache was seen in 29 patients.

CONCLUSION

Psychiatric co-morbidity was present in more than 50% patients with CDH and its presence along with a duration of ≥2 years was associated with a poor response to treatment.

Tension-type headache and systemic medical disorders

Tension-type headache (TTH) is the most common form of headache in the general population. Diagnosis of TTH is based merely on clinical features and on careful exclusion of all possible causes of headache. Most of the headaches that present in the context of medical disorders (e.g., hypothyroidism, sleep disorders, and hypertensive crisis) have clinical features overlapping with those of TTH; medical history and specific features of the systemic disorder are usually the clues to establish a correct diagnosis. Some medical disorders may worsen a preexisting TTH, and is also possible the comorbidity of TTH with psychiatric disorders and fibromyalgia.

Chronic headache and comorbidities: a two-phase, population-based, cross-sectional study

BACKGROUND

Studies using resources of a public family health program to estimate the prevalence of chronic daily headaches (CDH) are lacking.

OBJECTIVES

To estimate the 1-year prevalence of CDH, as well as the presence of associated psychiatric and temporomandibular disorders (TMD) comorbidities, on the entire population of a city representative of the rural area of Brazil.

METHODS

This was a cross-sectional, population-based, 2-phase study. In the first phase, health agents interviewed all individuals older than 10 years, in a rural area of Brazil. In the second stage, all individuals who reported headaches on 4 or more days per week were then evaluated by a multidisciplinary team. CDH were classified according to the second edition of the International Classification of Headache Disorders (ICHD-2). Medication overuse headache was diagnosed, as per the ICHD-2, after detoxification trials. Psychiatric comorbidities and TMD were diagnosed based on the DSM-IV and on the Research Diagnostic Criteria for Temporomandibular Disorders criteria, respectively.

RESULTS

A total of 1631 subjects participated in the direct interviews. Of them, 57 (3.6%) had CDH. Chronic migraine was the most common of the CDH (21, 36.8%). Chronic tension-type headache (10, 17.5%), medication overuse headache (13, 22.8%) and probable medication overuse headache (10, 17.5%) were also common. Psychiatric disorders were observed in 38 (67.3%) of the CDH subjects. TMD were seen in 33 (58.1)% of them.

CONCLUSIONS

The prevalence of CDH in the rural area of Brazil is similar to what has been reported in previous studies. A significant proportion of them have psychiatric comorbidities and/or TMD. In this sample, comorbidities were as frequent as reported in convenience samples from tertiary headache centers.

Headache, anxiety and depressive disorders: the HADAS study

The objective of this paper was to assess prevalence and characteristics of anxiety and depression in migraine without aura and tension-type headache, either isolated or in combination. Although the association between headache and psychiatric disorders is undisputed, patients with migraine and/or tension-type headache have been frequently investigated in different settings and using different tests, which prevents meaningful comparisons. Psychiatric comorbidity was tested through structured interview and the MINI inventory in 158 adults with migraine without aura and in 216 persons with tension-type headache or migraine plus tension-type headache. 49 patients reported psychiatric disorders: migraine 10.9%, tension-type headache 12.8%, and migraine plus tension-type headache 21.4%. The MINI detected a depressive episode in 59.9, 67.0, and 69.6% of cases. Values were 18.4, 19.3, and 18.4% for anxiety, 12.7, 5.5, and 14.2%, for panic disorder and 2.3, 1.1 and 9.4% (p = 0.009) for obsessive–compulsive disorder. Multivariate analysis showed panic disorder prevailing in migraine compared with the other groups (OR 2.9; 95% CI 1.2–7.0). The association was higher (OR 6.3; 95% CI 1.4–28.5) when migraine (with or without tension-type headache) was compared to pure tension-type headache. This also applied to obsessive–compulsive disorder (OR 4.8; 95% CI 1.1–20.9) in migraine plus tension-type headache. Psychopathology of primary headache can reflect shared risk factors, pathophysiologic mechanisms, and disease burden.

Do psychiatric comorbidities influence headache treatment outcomes? Results of a naturalistic longitudinal treatment study

This study examined if the presence of one or more psychiatric disorders influences headache treatment outcomes in patients in headache specialty treatment centers. Using a naturalistic, longitudinal design, 223 patients receiving preventive therapy for headache disorders completed 30-day daily diaries that assessed headache days/month and severity at acute therapy baseline and 6-month evaluation and also provided data on headache disability and quality of life at acute therapy baseline, preventive therapy initiation, preventive therapy adjustment, and 6-month evaluation visits. Psychiatric diagnoses were determined using the Primary Care Evaluation for Mental Disorders (PRIME MDs). Of the 223 patients, 34% (n = 76) had no psychiatric disorder, 21% (n = 46) were diagnosed with Depression-Only; 13% (n = 29) were diagnosed with Anxiety-Only; and 32% (n = 72) were diagnosed with Depression-and-Anxiety. Prior to initiating new preventive therapy, patients with one or more psychiatric disorders reported more frequent and disabling headaches and poorer life quality compared to patients with no psychiatric disorders. Rates of improvement in headache days/month, disability, and quality of life were significant and comparable across the four groups. Contrary to clinical wisdom, patients with psychiatric disorders respond very favorably to contemporary headache treatments administered in headache specialty treatment centers.

Recommendations for the management of migraine in paediatric patients

Migraine is a common and disabling condition in children and adolescents. The complexity of migraine on a pathogenetic and clinical level results from the interaction between biological, psychological and environmental factors. Appropriate management requires an individually tailored strategy giving due consideration to both pharmacological and non-pharmacological measures. Ibuprofen (7.5-10.0 mg/kg) and acetaminophen (15 mg/kg) are safe and effective, and should be considered for symptomatic treatment. Sumatriptan nasal spray (5 and 20 mg) is also likely to be effective, but at the moment, should be considered for the treatment of adolescents only. With reference to prophylactic drug treatment, the available data suggest that flunarizine (5 mg/day) is likely to be effective and pizotifen and clonidine are likely to be ineffective. The efficacy data regarding propranolol, nimodipine and trazodone are conflicting. Insufficient evidence is available on cyproheptadine, amitriptyline, divalproex sodium, topiramate, levetiracetam, gabapentin or zonisamide. The management of migraine in children needs an individualised therapeutic approach, directed to the whole person of the child, taking into account the developmental perspective and the high rate of psychiatric comorbidities. It is the authors' opinion that for the prophylaxis of migraine, interventions such as identification and avoidance of trigger factors, regulation of lifestyle, relaxation, biofeedback, cognitive behavioural treatment and psychological or psychotherapeutic interventions (e.g., psychodynamics) could be much more effective than pharmacotherapy.

The effectiveness of hospitalization in the treatment of paediatric idiopathic headache patients

BACKGROUND

Headache is a disease that has a high social impact in the paediatric as well as in the adult population, often resulting in a significant reduction in the young patient's quality of life, reflected primarily in a greater number of days off school and increasingly frequent recourse to symptomatic drugs. The idea for this study came from the clinical impression that some paediatric headache patients might benefit more from inpatient than outpatient care.

AIM

The aim of our study was to compare the effectiveness of hospitalization to outpatient care of patients with newly diagnosed frequent and disabling headache.

METHODS

A pragmatic randomized open-label trial was conducted at the Child Neurology Clinic of the University of Pavia, Italy. Children and adolescents with a 2- to 6-month moderate-to-severe migraine or tension-type headache history were randomized to hospital admission or outpatient assessment and followed for 6 months. The efficacy of the two therapeutic strategies was measured by counting the number of responders in each arm. Other end points included the mean frequency and duration of attacks, the number of drug prescriptions taken to control pain, and the number of patients and physicians expressing satisfaction with treatment.

RESULTS

The study population included 27 girls and 23 boys aged 8 through 18 years with migraine (23 cases) or tension-type headache (27 cases). Compared to outpatient assessment, hospital admission was correlated to a significant increase in the number of responders: 0 vs. 44% (1 month), 0 vs. 68% (3 months), and 12 vs. 68% (6 months). The mean frequency and duration of attacks were significantly lower in hospitalized patients (p < 0.0001). Hospitalization was correlated with a significant reduction of patients with severe headache (p < 0.005), a reduction of drug use, and a higher number of satisfied patients and physicians (p < 0.05). Logistic regression analysis confirmed the higher responder rate among hospitalized patients after adjusting for age, sex, diagnosis, and headache characteristics or admission.

CONCLUSIONS

We think hospitalization reduces the emotional mechanisms that provoke stress in children and often induce or favour headache attacks. If these mechanisms can be interrupted, the management of disease may become easier and with enduring benefits.

Cluster headache: Myths and the evidence

Although cluster headache (CH) has been the focus of a great deal of research, it also has been the focus of a great deal of speculations that have been repeated commonly as fact. The authors conducted a thorough review of the literature and an informal poll of several noted headache experts to investigate the truth behind common myths and hypotheses regarding CH. They then present an overview of some of these more common hypotheses, observations, and myths, and offer a brief review of the existing evidence supporting or negating the theories. These include gender, genetics, suicidality, homicidality, physical appearance, personality, and psychologic features of the patient with CH.

Depressive Symptoms and Insecure Attachment as Predictors of Disability in a Clinical Population of Patients With Episodic and Chronic Migraine

OBJECTIVES

To define predictors of migraine-related disability in patients with episodic and chronic migraine referred to a specialty migraine clinic, focusing on depressive symptoms and insecure attachment style that, because of their association with responses to pain and physical illness, might be predictive of greater migraine-related disability.

BACKGROUND

The Migraine Disability Assessment questionnaire (MIDAS) has proved to be a reliable and easy-to-use instrument to assess migraine-related disability. As clinicians are increasingly using MIDAS in their diagnostic and treatment decisions for patient care, an understanding of the factors influencing migraine-related disability is essential for a rationale use of such an instrument.

METHODS

Two-hundred patients suffering from episodic migraine without aura (EM), and chronic migraine (CM) with and without medication overuse, and referred to a specialty headache clinic were evaluated using the MIDAS, the Beck Depression Inventory (BDI), and the Attachment Style Questionnaire (ASQ). Diagnosis of episodic and chronic migraine was operationally defined according to the International Headache Society (IHS) and Silberstein-Lipton criteria.

RESULTS

Multiple regression analysis showed that, in the total sample, disability was higher in those patients with CM, more severe depressive symptoms, an insecure style of attachment (as reflected by a lower score on the ASQ confidence scale), and experiencing more severe headache pain intensity. In the subgroup of patients with episodic migraine, an insecure style of attachment emerged as the most significant predictor of disability (other significant predictors were female sex and number of headache days per month). In contrast, in the subgroup of patients with CM, the only significant predictor of the total MIDAS score was a greater severity of depressive symptoms.

CONCLUSIONS

Our findings demonstrate the relevance of attachment style, an enduring psychological trait not evaluated in previous studies, in influencing the disability level in patients with migraine and confirm the role of comorbid depressive symptoms in modulating the impact of migraine on every day functioning.