Headache Attributed to Psychiatric Disorder

Nutan Vaidya

K. Michael A. Welch

INTRODUCTION

Headaches in psychiatrically ill patients are due to (a) psychologic stress (e.g., stress at work causing muscle contraction), (b) psychiatric disorders (e.g., headache secondary to anxiety disorder or depression), (c) neurologic and general medical illness, and (d) iatrogenic causes (e.g., headache secondary to medication or procedures such as electroconvulsive therapy [ECT]). A diagnosis of headache attributable to psychiatric disorders is definite if it improves after effective treatment or spontaneous remission of the psychiatric disorder. If the psychiatric disorder cannot be treated or does not remit spontaneously, a diagnosis of headache probably attributed to psychiatric disorder is given.

The focus of this chapter is on headache in patients with depression, mania, anxiety, and somatoform and psychotic disorders. Headaches that are comorbid with psychiatric disorders and iatrogenic headaches are covered elsewhere in the book. The revised International Classification for Headache Disorders (ICHD-II) (29) covers headache attributed to somatization and psychotic disorders under section 12, but headache attributed to other psychiatric illnesses such as depression, anxiety disorders, and somatoform disorders are covered in the appendix under section A12.

MOOD DISORDERS AND HEADACHE

Mood disorders include disturbances of intense emotion, from extreme sadness to elation. Cognitive, behavioral, somatic, sleep, and appetite disturbances are some accompanying features.

Diagnoses of mood disorders, which are included in the DSM-IV-TR (3) and ICD-9 and -10 (International Classification of Diseases) (61), include unipolar (patients with sad or apathetic mood), bipolar (patient with elation, often alternating, or simultaneously occurring with sadness; elation alone is enough to receive a diagnosis of bipolar), and secondary (mood disturbance is secondary to a general medical or neurologic illness) disease.

Headache in Unipolar Depression

International Headache Society (IHS) code and diagnosis: A12.3 Headache attributable to major depressive disorder

World Health Organization (WHO) code and diagnosis: R51 Headache attributed to psychiatric disorder

Short description: Depressed patients report somatic symptoms such as headache (migraine and nonmigrainous headache) (12,13,64), chronic pain, and fatigue. The prevalence of somatic symptoms varies between 45 and 90% (50). Similarly, patients with primary headaches such as migraine or tension-type headache are more likely to have major depression or dysthymic disorder than those with secondary headache disorders (30,46). Indeed, 50 to 70% of patients with frequent primary headaches or “chronic daily headache” have major depression or dysthymia (58). Also, a presentation of chronic daily headache or morning headache may suggest a depressive illness (30,45).

Chronic tension-type headache may be attributed to a physiologic response to depression (16,38,63). The episodic form of tension-type headache, however, is not always associated with depression (41).

An increased frequency and severity of headache can lead to depression. Alternatively, depression leading to headache has been shown to be true for migrainous headache but not for severe headache without migraine. Breslau et al. reported that the risk for migraine in patients with depression was three times higher than in persons without depression (10,12). Patients with migraine had a
five times higher risk for developing depression than those without a history of headache. This bidirectional association between migraine and depression suggests shared pathophysiologic mechanisms, which could be genetically determined.

Women and elderly patients with depression are more likely to complain of headache than male patients (30,48).

Pathophysiology

Serotonergic and noradrenergic pathways are present in brain structures that are involved in mood (15) and nociception (58), which suggests that dysregulation in these systems may underlie depression and various headache disorders (14,39).

Headache in patients with major depression could be a side effect of psychotropic medications, such as selective serotonin reuptake inhibitors (SSRIs) (55,57), or part of an SSRI discontinuation syndrome (7). Anecdotally, such headaches often are nonmigrainous.

Treatment

Traditional antidepressants are helpful in the treatment of depressed patients with migraine or tension-type headache (56). Newer antidepressants such as venlafaxine may be effective (1) and would undermine anticholinergic side effects of the traditional antidepressants, but evidence from large-scale controlled studies is needed before recommending these treatments. The efficacy of SSRIs in migraine is not fully established (56).

Headache in Bipolar Disorder

IHS diagnosis and code: There is no specific category of headache attributable to a bipolar disorder.

WHO code and diagnosis: R51 Headache attributed to psychiatric disorder

Short description: The most common form of headache in patients with bipolar disorder is migraine, but other types have been reported (41). It has been suggested that many patients with an initial diagnosis of unipolar mood disorder in fact have bipolar disease (19), but this conclusion is not accepted universally (11).

The prevalence of migraine in bipolar patients ranges between 20% and 40% (20,36), and it is more prevalent in type II than type I bipolar disease (20). Migraine is more common in women with bipolar disorder than in men (8,20). Bipolar patients with migraine are younger, are more educated, and had fewer psychiatric hospitalizations (34). Perhaps better prognosis is correlated with younger age and education rather than with migraine (21).

Bipolar patients with migraine have more left-sided headaches than unipolar patients with migraine who have more right-sided headache (21). A differential hemispheric involvement in bipolar and unipolar mood disorders may have pathogenic significance that needs further elucidation. It has been suggested that bipolar disease and migraine share common mechanisms rather than one leading to the other (47).

Cluster and tension-type headaches are also seen with bipolar disorder (37). Furthermore, medication-induced headache can occur in association with lithium toxicity (6).

Treatment

Valproic acid should be the treatment of choice because it is effective against both mania and migraine (4,23,62). Anticonvulsants, such as gabapentin and topiramate, have demonstrated efficacy in migraine but may not be as effective for mania (59). Lamotrigine is effective in the depressed phase of bipolar disorder but may not be effective in migraine (51).

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