Migraine and psychiatric comorbidity: a review of clinical findings

Migraine is an extremely common disorder. The underlying mechanisms of this chronic illness interspersed with acute symptoms appear to be increasingly complex. An important aspect of migraine heterogeneity is comorbidity with other neurological diseases, cardiovascular disorders, and psychiatric illnesses. Depressive disorders are among the leading causes of disability worldwide according to WHO estimation. In this review, we have mainly considered the findings from general population studies and studies on clinical samples, in adults and children, focusing on the association between migraine and psychiatric disorders (axis I of the DSM), carried over after the first classification of IHS (1988). Though not easily comparable due to differences in methodology to reach diagnosis, general population studies generally indicate an increased risk of affective and anxiety disorders in patients with migraine, compared to non-migrainous subjects. There would also be a trend towards an association of migraine with bipolar disorder, but not with substance abuse/dependence. With respect to migraine subtypes, comorbidity mainly involves migraine with aura. Patients suffering from migraine, however, show a decreased risk of developing affective and anxiety disorders compared to patients with daily chronic headache. It would also appear that psychiatric disorders prevail in patients with chronic headache and substance use than in patients with simple migraine. The mechanisms underlying migraine psychiatric comorbidity are presently poorly understood, but this topic remains a priority for future research. Psychiatric comorbidity indeed affects migraine evolution, may lead to chronic substance use, and may change treatment strategies, eventually modifying the outcome of this important disorder.     

Psychiatric comorbidity and psychosocial stress in patients with tension-type headache from headache centers in Italy. The Italian Collaborative Group for the Study of Psychopathological Factors in Primary Headaches

A multicenter study was carried out in 10 Italian Headache Centers to investigate the prevalence of psychosocial stress and psychiatric disorders listed by the IHS classification as the "most likely causative factors" of tension-type headache (TTH). Two hundred and seventeen TTH adult outpatients consecutively recruited underwent a structured psychiatric interview (CIDI-c). The assessment of psychosocial stress events was carried out using an ad hoc questionnaire. The psychiatric disorders that we included in the three psychiatric items of the fourth digit of the IHS classification were depressive disorders for the item depression, anxiety disorders for the item anxiety, and somatoform disorders for the item headache as a delusion or an idea. Diagnoses were made according to DSM-III-R criteria. At least one psychosocial stress event or a psychiatric disorder was detected in 84.8% of the patients. Prevalence of psychiatric comorbidity was 52.5% for anxiety, 36.4% for depression, and 21.7% for headache as a delusion or an idea. Psychosocial stress was found in 29.5% of the patients and did not differ between patients with and without psychiatric comorbidity. Generalized anxiety disorder (83.3%) and dysthymia (45.6%) were the most frequent disorders within their respective psychiatric group. The high prevalence of psychiatric disorders observed in this wide sample of patients emphasizes the need for a systematic investigation of psychiatric comorbidity aimed at a more comprehensive and appropriate clinical management of TTH patients.     

Clinical features, classification and prognosis of migraine and tension-type headache in children and adolescents: a long-term follow-up study

We performed a long-term follow-up examination in children and adolescents with migraine and tension-type headache (TTH) in order to investigate the evolution of clinical features and headache diagnoses, to compare International Classification of Headache Disorders (ICHD)-I and ICHD-II criteria and to identify prognostic factors. We re-examined 227 patients (52.4% female, age 17.6 +/- 3.1 years) 6.6 +/- 1.6 years after their first presentation to a headache centre using identical semistructured questionnaires. Of 140 patients initially diagnosed with migraine, 25.7% were headache free, 48.6% still had migraine and 25.7% had TTH at follow-up. Of 87 patients with TTH, 37.9% were headache free, 41.4% still had TTH and 20.7% had migraine. The number of subjects with definite migraine was higher in ICHD-II than in ICHD-I at baseline and at follow-up. The likelihood of a decrease in headache frequency decreased with a changing headache location at baseline (P < 0.0001), with the time between baseline and follow-up (P = 0.0019), and with an initial diagnosis of migraine (P = 0.014). Female gender and a longer time between headache onset and first examination tended to have an unfavourable impact. In conclusion, 30% of the children and adolescents presenting to a headache centre because of migraine or TTH become headache-free in the long-term. Another 20-25% shift from migraine to TTH or vice versa. ICHD-II criteria are superior to those of ICHD-I in identifying definite migraine in children and adolescents presenting to a headache centre. The prognosis is adversely affected by an initial diagnosis of migraine and by changing headache location, and it tends to be affected by an increasing time between headache onset and first presentation.     

Tension-type headache and psychiatric comorbidity

Much of the contemporary literature on headache disorders focuses on migraine headaches, despite the fact that tension-type headache (TTH) is highly prevalent and can be as debilitating as migraines. This article reviews the current literature on prevalence rates of psychiatric disorders in TTH populations, psychologic factors associated with TTH, and psychiatric disorders and their relationships with treatment outcomes in TTH. Key conclusions of this review include 1) prevalence rates of TTH vary across clinical and population-based samples; 2) greater TTH chronicity is associated with increased affective distress; 3) Axis II personality disorders may play an important role in TTH prevalence rates and psychologic functioning but have been understudied to date; and 4) maladaptive coping is common in persons with TTH.     

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.     

Psychological and social stressors and psychiatric comorbidity in patients with migraine without aura from headache centers in Italy: a comparison with tension-type headache patients

A multicenter study was carried out to investigate the prevalence of psychosocial stressors and psychiatric comorbidity in patients suffering from migraine without aura (MWO) according to the International Headache Society criteria. Two hundred four adult MWO outpatients underwent a structured psychiatric interview (CIDI-c) to determine the presence of anxiety, and mood and somatoform disorders according to DSM-III-R criteria. An ad hoc questionnaire was used to assess psychosocial stress events. Anxiety disorders were found in 39.2% of the sample, mood disorders occurred in 23.0% and somatoform disorders in 21.6%. Psychosocial stressors were identified in 22.5% of the migraineurs without any difference between patients with and without psychiatric comorbidity. No correlation was found between psychiatric comorbidity and migraine duration or frequency. When the migraine patients were compared with a homogeneous group of tension-type headache sufferers, a higher frequency of psychiatric comorbidity was found in the latter group (56.4% vs. 77.8%, p = 0.01). These data suggest that migraine as well as tension-type headache are associated with an increased vulnerability to psychiatric disorders. Whether this is related to a common genetic susceptibility or is the effect of a psychoneurobiological loop related to the stress response activation remains to be investigated. Received: 3 January 2000 / Accepted in revised form: 27 March 2000     

An epidemiological study of headache in Florianopolis, Brazil

The aim of this study was to estimate the 1-year prevalence of headache, migraine, tension-type headache (TTH) and chronic daily headache (CDH), and the degree of association of migraine with some sociodemographic characteristics of the population of Florianopolis, Brazil. This is a cross-sectional, door-to-door, population-based study. In 300 randomly selected households, 625 subjects, aged 15-64 years, responded to a structured questionnaire. The 1-year prevalence of headache was 80.8%, of migraine 22.1%, of TTH 22.9%, and of CDH 6.4%. Migraine and CDH were significantly more prevalent in females than in males. Migraine was significantly associated with the following variables: low household income, low electricity consumption, and divorced or widowed marital status. We have shown high prevalences of migraine and CDH in Florianopolis, close to the higher rates of previous studies. There was a preponderance of migraine in females, divorced or widowed, with a low socioeconomic level.     

Characteristic and overlapping features of migraine and tension-type headache

OBJECTIVE: This epidemiological survey was conducted to investigate comprehensive characteristic and overlapping features of migraine and tension-type headache (TTH) disorders classified based on International Classification of Headache Disorders-II. METHODS: The stratified cohort of this study was composed of 2504 schoolchildren aged 10 to 17 years. A 38-item questionnaire inquiring all characteristic features of primary headache syndromes mandatory for classification was applied to selected 483 children with recurrent headache in the last 6 months. RESULTS: Migraine was diagnosed in 227 (47.0%) of 483 children and TTH in 154 (31.9%). Out of 125 children with definite migraine, 73 (58.4%) reported tension-type symptoms and 94 (68.1%) of 138 children with definite TTH reported migraine-type symptoms. Pressing pain (21%) and lack of aggravation of pain by physical activity (34%) were the major tension-type features in patients with migraine. Throbbing quality (43%) and aggravation by physical activity (30%) determined the main migraine-type features in patients with TTH. CONCLUSION: The frequent co-occurrence of migraine and TTH symptoms suggests the presence of a common pathogenesis.     

Evolution of headache in childhood and adolescence: an 8-year follow-up

Objective . Headache is a notable problem in clinical practice and a frequent symptom in childhood and adolescence. The main aim of the present study is to analyze the evolution of migraine and tension headache (TH) using an 8-year follow-up. Method . 100 subjects (F60, M40; mean age 17.9; SD 2.6; range 12–26), randomly selected among all patients first seen in 1988 at the Headache Center, were directly contacted. We employed IHS criteria both in 1988 (the data were taken by the clinical charts) and 1996. We took into account changes in headache types and improvement, unchanging, worsening or remission of headache. This analysis was made with regard to gender differences and age at onset of headache, too. The chi-squared test is employed. Findings . High tendency to remit (34%) or improve (45%) was recorded. A worsening situation was seen in 6% and an unchanging situation in 15%. In 1988, we had 57% migraine without aura (MwoA), 7% migraine with aura, 28% episodic tension-type headache (ETTH), and 8% chronic TH (CTTH). In 1996, we saw 30% MwoA, 2% MwA, 31%, ETTH, and 3% CTH. Migraine shows a lower tendency to remit than TH (28.1% vs 44.4%) MwoA persists in the same form in 43.8% and becomes ETH in 26.3%. ETTH persists in the same form in 26.3% and changes in MwoA in 10.7%. Of headache-free subjects, we recorded a high tendency to remit (34%) and improve (95%); 13 were females (21.7%) and 21 were males (52.5%). The course of headache is not related to age at onset. Conclusion . Headache with juvenile onset changes its characteristics over time, with a high tendency to remit (mostly in males) or improve. The implications for pathophysiology and the role of hormonal factors are called into question.     

Migraine,tension-type headache,and transformed migraine

Migraine and tension-type headache (TTH) are highly prevalent primary headaches that remain underdiagnosed and undertreated in clinical practice. The similarities and differences between migraine and TTH may impose diagnostic challenges as well as management difficulties. In addition, the possibility of migraine chronification or transformation in daily or near-daily headache raises the potential level of interaction between pathophysiologic mechanisms of TTH and migraine. The continuum concept is a possible key to the understanding of this association. Future studies are necessary to clarify epidemiology, pathophysiology, and management of these two most prevalent headaches.     

Comorbidity in Finnish migraine families

The objective of the study was to investigate comorbidity of migraine in Finnish migraine families. One thousand consecutive participants in the Finnish Migraine Gene Project reported their medical illnesses in addition to migraine and headache. Migraine patients (n=678) reported significantly more hypotension (OR 1.43, CI 95% 1.02–2.01), allergy (OR 1.83, CI 95% 1.34–2.51) and psychiatric disorders (OR 4.09, CI 95% 2.11–7.92) compared to their family members without migraine (n=322). Subgroup analyses demonstrated that especially women and the group fulfilling the criteria for both migraine with and without aura were likely to have additional disorders besides their migraine. Interestingly, male migraineurs with aura reported a significant association with stroke and epilepsy. Familial migraine is comorbid with hypotension, allergy and psychiatric disorders. The association between migraine with aura and stroke and epilepsy among men of the studied families warrants further study. Clinical, pathophysiological and genetic implications of these results are discussed.     

Disability,quality of life,productivity impairment and employer costs of migraine in the workplace

BackgroundMigraine is the leading cause of days lost due to disability in the world among people less than 50 years of age. There is a paucity of evidence on the impact of migraine and other headache disorders and the cost and productivity losses in the workplace.MethodsEmployee population survey assessed prevalence, characteristics, and disability of headache disorders at a Japanese information technology company. This study was supported by the World Health Organization Western Pacific Region Office and International Headache Society.Results2458 (1963men, 495 women) out of 2494 responded to the survey that utilized ICHD-3 beta criteria. Among these, 13% (205 male/123 female) had migraine (M), 53% (1093 male/207 female) had tension-type headache (TTH) and 4% (61 male/27 female) had migraine and TTH (M/TTH). The number of days when productivity at work was reduced by half or more because of headache was significantly higher in migraine compared to TTH. The norm-based scoring of SF-12v2 was significantly lower in M/TTH and M than TTH. The economic loss due to absenteeism for migraine was calculated to be $ 238.3US$/year/person for day-off and 90.2US$/year/person for half-day off using migraine disability assessment score (MIDAS). The economic loss due to presenteeism for migraine was calculated to be $ 375.4US$/year/person using MIDAS and 2217US$/year/person using work productivity and activity impairment questionnaire (WPAI). Furthermore, estimated cost of productivity loss associated with presenteeism using WPAI was calculated at 21.3 billion US$/year in Japan as a whole.ConclusionsThis study revealed a high prevalence and disease burden among employees with migraine that is associated with substantial losses in productivity and employer cost. These results support the development and implementation of workplace programs to improve migraine management in the workplace and reduce the burden and costs associated with lost workplace productivity.Supplementary InformationThe online version contains supplementary material available at 10.1186/s10194-021-01243-5.     

Psychiatric disorders in chronic daily headache: detection by means of the SCID interview

The identification of possible individual or/and environmental factors responsible for the chronic evolution of headache has represented a critical issue in recent years. The goal of this research was to enroll adult chronic daily headache (CDH) sufferers and to seek for psychiatric disorders, as possible transformation factor, by means of a complex neuropsychological investigation. The psychiatric evaluation was performed using the Structured Clinical Interview (SCID), according to the DSM-IV diagnostic criteria. The overall prevalence of psychiatric disorders according to DSM-IV criteria was 66.1%. No statistical difference was found in psychiatric comorbidity according to gender (women, 68.9% men, 52,4%). The prevalence of psychiatric disorders was 69.7% in drug abusers (classified in accordance with clinical interview) and 57.1% in non-abusers (the difference was not statistically significant). Comparing the three subtypes of CDH, a psychiatric disorder was found in 50% of chronic tension-type headache patients, in 72.2% of those with chronic coexisting migraine and tension-type headache(CT vs. CCMT-TH, p<0.01) and in 70.3% of patients with chronic migraine.     

Migraine, Personality, and Psychiatric Comorbidity

The purpose of this report is to examine the association between migraine and personality, taking into account history of co-occurring psychiatric disorders. Data came from an epidemiologic study of young adults in the Detroit, Michigan metropolitan area. Migraine, defined according to 1988 IHS criteria, and major depression and anxiety disorders were ascertained by a structured diagnostic interview. Migraine was associated with neuroticism, but not with extraversion or psychoticism, measured by the Eysenck's Personality Questionnaire. The association remained significant, when sex and history of major depression and anxiety disorders were controlled. An excess of 25% of persons with migraine alone, uncomplicated by psychiatric comorbidity, scored in the highest quartile of neuroticism. The results suggest that migraine sufferers might be more vulnerable to psychopathology and poor adjustment to their medical condition.     

Psychiatric disorders and headache familial recurrence: a study on 200 children and their parents

The main aim of the study was to examine the relationship between headache and familial recurrence of psychiatric disorders in parents and their children. Headache history and symptomatology have been collected in a clinical sample of 200 patients and their families, using a semi-structured interview (ICHD-II criteria). Psychiatric comorbidity was assessed by DSM-IV criteria. Chi squares and a loglinear analysis were computed in order to evaluate the main effects and interactions between the following factors: frequency and headache subtypes (migraine/not-migraine) in children, headache (migraine/not-migraine-absent/present) in parents, headache (absent/present) in grandparents, and psychiatric comorbidity (absent/present) have been analyzed: 94 mothers (47%) and 51 fathers (25.5%) had at least one psychiatric disorder, mainly mood and anxiety disorders. Considering the significant prevalence of Psi-co in children (P < 0.0001), we compared it with the presence of familiarity to headache: a significant interaction has been found (P < 0.05) showing that migraineurs with high familial recurrence of headache had a higher percentage (74.65%) of psychiatric disorders, than no-migraineurs (52.17%). Absence of headache familial loading seems to be related to psi-co only in no-migraine headache (87.5 vs. 45.5%). The occurrence of psychiatric disorders is high in children with headache, but a very different pattern seems to characterize migraine (familial co-transmission of migraine and Psi-Co?) if compared with non-migraine headache.     

Temporomandibular disorders and tension-type headache

Pathologies currently defined as temporomandibular disorders may be different in nature. Temporomandibular joint (TMJ) disorders and craniofacial and cervical myogenous pain (MP) are distinct pathologies but may be superimposed and share some etiologic factors. Tension-type headache (TTH) may often be associated with craniofacial and cervical pain, and the same pharmacologic and nonpharmacologic treatment may be efficacious for both. Psychiatric comorbidity (depression and/or anxiety disorder) is less frequent in sheer TMJ disorders, compared with MP and TTH. A screening for the presence of an underlying psychiatric disorder should be part of the clinical evaluation in patients suffering from headache and facial pain.     

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

OBJECTIVE: To investigate the frequency of depressive and anxiety disorders in patients with chronic daily headache. BACKGROUND: There is a lack of data in the literature on the extent of psychiatric comorbidity in patients with different subtypes of chronic daily headache. METHODS: We recruited consecutive patients with chronic daily headache seen in a headache clinic from November 1998 to December 1999. The subtypes of chronic daily headache were classified according to the criteria proposed by Silberstein et al. A psychiatrist evaluated the patients according to the structured Mini-International Neuropsychiatric Interview to assess the comorbidity of depressive and anxiety disorders. RESULTS: Two hundred sixty-one patients with chronic daily headache were recruited. The mean age was 46 years, and 80% were women. Transformed migraine was diagnosed in 152 patients (58%) and chronic tension-type headache in 92 patients (35%). Seventy-eight percent of patients with transformed migraine had psychiatric comorbidity, including major depression (57%), dysthymia (11%), panic disorder (30%), and generalized anxiety disorder (8%). Sixty-four percent of patients with chronic tension-type headache had psychiatric diagnoses, including major depression (51%), dysthymia (8%), panic disorder (22%), and generalized anxiety disorder (1%). The frequency of anxiety disorders was significantly higher in patients with transformed migraine after controlling for age and sex (P =.02). Both depressive and anxiety disorders were significantly more frequent in women. CONCLUSION: Psychiatric comorbidity, especially major depression and panic disorders, was highly prevalent in patients with chronic daily headache seen in a headache clinic. These results demonstrate that women and patients with transformed migraine are at higher risk of psychiatric comorbidity.     

Behavioral and nonpharmacologic treatments of headache

Cognitive-behavioral analysis and the multiaxial assessment of relevant behavioral domains (headache frequency and severity, analgesic and abortive use and misuse, behavioral and stress-related risk factors, comorbid psychiatric disorders, and degree of overall functional impairment) help set the stage for CBT of headache disorders. Controlled studies of CBTs for migraine, such as biofeedback and relaxation therapy, have a prophylactic efficacy of about 50%, roughly equivalent to propranolol. Cluster headache responds poorly to behavioral treatment. The persistent overuse of symptomatic medication impedes the effectiveness of behavioral and prophylactic medical therapies. Behavioral treatment can help sustain improvement after analgesic withdrawal, however, and prevent relapse in cases of analgesic overuse. Cognitive factors (e.g., an enhanced sense of self-efficacy and internal locus of control) appear to be important mediators of successful behavioral treatment. Patients with CDH are more likely to overuse symptomatic medication (and in some cases abuse analgesics), have more psychiatric comorbidity; have more functional impairment and disability, and are at least as likely to experience stress-related intensification of headache as patients whose episodic headaches occur less than 15 days per month. Despite the significance of these behavioral factors, patients with CDH (particularly those with migrainous features) are less likely to benefit from behavioral treatment without concomitant prophylactic medication than is the case for episodic TTH and migraine sufferers. Continuous daily pain may be more refractory to behavioral treatment as a solo modality than CDH marked by at least some pain-free days or periods of time. The combination of behavioral therapies with prophylactic medication creates a synergistic effect, increasing efficacy beyond either type of treatment alone. Compliance-enhancement techniques, including behavioral contracts for patients with severe personality disorders, can increase adherence to behavioral recommendations. CBT has earned an important place in the comprehensive treatment of patients with episodic migraine/TTH and severe, treatment-resistant chronic daily headache.     

Mood and Anxiety Disorders in Chronic Headache

Although most individuals with recurrent headache disorders in the general population do not experience severe psychopathology, population-based studies and clinical investigations find high rates of comorbidity between headache and mood and anxiety disorders. When present, psychiatric disorders may complicate headache treatment and portend a poorer treatment response. The negative prognosis associated with psychiatric comorbidity emphasizes the importance of the identification of psychopathology among those with headache beginning at an early age, and suggests that the treatment of psychiatric comorbidity is warranted to improve the outcome of headache management.
In this article we describe the mood and anxiety disorders most commonly associated with migraine, tension-type headache, and chronic daily headache. We provide recommendations for the assessment of comorbid mood and anxiety disorders as well as a brief overview of treatment options. Last, we discuss the clinical implications of mood and anxiety disorders on the treatment and outcome of headache.     

Primary headache and comorbidity with mood and anxiety disorders: an example of the psycho-neuro-biological loop

Although an association between primary headache and psychiatric disorders, has been recognised for over 100 years, this association has been investigated systematically only recently. The nature of this association has also been examined in recent studies. Real comorbidity implies that primary headache and psychiatric disorders are indipendent phenomena, i.e. a casual co-presence, while the frequency of their association suggests different and deeper links. Literature data show that psychiatric comorbidity in migraine and tension-type headache is very similar (88% and 85% respectively). Anxiety disorders is the most frequent association (54,9% and 52,5% respectively) followed by mood disorders (34,4% and 36,4% respectively). We discuss the available evidence on the psycho-neurobiological cascade of events possibly linking primary headache to mood and anxiety disorders.