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Mood and Anxiety Disorders in Chronic Headache
Baskin SM, Lipchik GL, Smitherman TA.
Posted: May 2007  
Headache 2006;46 [Suppl 3]:S76-S87

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.

"Those with headache are at higher risk for mood and anxiety disorders than are individuals in the general population; these findings are particularly salient for the patient with chronic daily headache as well as medical overuse headache. This interplay between mood/anxiety problems and medication overuse may be an important factor in the chronification of episodic headache. It is likely that psychiatric comorbidity renders headache patients more refractory to treatment; however, there is a paucity of research in this area.

"In our clinical practices, we have observed that untreated or undertreated depressive disorders can negatively affect headache treatment. Many patients with depressive disorders are discouraged, helpless, and hopeless. Thus, they tend to give us easily on treatment while medications (for headache and/or depression) are being adjusted. Headache patients with comorbid anxiety can also pose treatment challenges. Some anxious patents are so fearful that they might get a headache they overuse headache medication or self-medicate. Other anxious headache patients are exquisitely sensitive to medication side effects and some are fearful of harmful effects. Some believe that the physician has "missed something" in the workup and may request additional studies as they are fearful of more significant pathology.

"Patients who have epilepsy, diabetes, stroke, respiratory disorders, and ischemic heart disease also have poorer outcomes if they are suffering from comorbid depression. Conversely, treatment of depression may improve the outcome after acute myocardial infarction or stroke. Future research should focus on extending these findings to chronic headache. Studies are needed to explore whether pharmacologic and behavioral treatments for one (or both) comorbid condition(s) affect the other.

"Researchers are just beginning to look at algorithms for medication management of comorbid headache and psychiatric illness. A recent study used an algorithm calling for the use of SSRIs for migraineurs with depression and anxiety, TCAs for those with insomnia, and antiepileptic agents for the remaining patients. Using this approach, approximately tow-thirds of this sample were significantly improved in headache frequency and disability indices after 1 year. The authors concluded that comorbid psychiatric illness might help guide the selection of preventive pharmacologic agents for this subset of migraineurs. Similar studies exploring the matching of psychological (behavioral) treatments to headache and particular comorbid psychiatric conditions are needed.

"Clearly, more research is needed in understanding shared biologic mechanisms and identifying the most efficacious pharmacologic and psychotherapeutic strategies to treat these comorbid disorders. The combination of pharmacologic and psychologic therapies may ultimately lead to the best outcomes in treating many patients with psychiatric comorbidity. For others, treating either the headache or psychiatric problem may be sufficient (eg, depression may remit after successful headache treatment). Making use of a behavioral referral for assistance with headache management may be an ideal way to address comorbidity in patients who are resistant to exploring psychiatric factors."