We know that headaches are common in the general population, but they are particularly common among patients with psychiatric problems. According to one review, (Pompili M et al., J Headache Pain 2009; 10(4):283-290) patients with depression have a 46% lifetime prevalence of migraine, while bipolar patients have a 51% prevalence. Patients with migraines have triple the risk of developing depression than patients without migraines.
In this article, we’ll review how to handle patients with headaches in a psychiatric practice. How do we distinguish migraine headaches from tension headaches from more dangerous secondary headaches that may be caused by a tumor or by hypertension? When should we refer headache patients to a neurologist? How should we treat these patients, both pharmacologically and psychotherapeutically?
Textbooks will tell you that headaches come in essentially two varieties: primary (migraine, tension-type, and cluster) and secondary (caused by an underlying intracranial problem).
While tension-type headaches (46% prevalence) are more common than migraines (25% prevalence), migraines are more likely to drive patients to seek medical attention, because they are usually more severe and debilitating. Migraine headaches are different from tension-type headaches in several ways. They are often unilateral rather than bilateral; they usually cause a throbbing, rather than a static pain; one third are associated with a prodromal aura; they often are accompanied by nausea and vomiting (so-called “sick headaches”); and patients often complain of photophobia, meaning that bright light makes the headache worse.
In one study a simple three question screen was remarkably predictive of migraine. These three questions are:
1. Are you nauseated or sick to your stomach when you have a headache?
2. Have the headaches limited your activities for a day or more in the last three months?
3. Does light bother you when you have a headache?
When two of these questions are answered “yes,” the positive predictive value for migraine was 93%; when all three were answered positively, the predictive value was 98% (Lipton RB et al., Neurology 2003;61:375-382).
There’s a tendency among nonspecialists to view tension-type headaches as being a waste-basket category for anything that is not a migraine, but in reality these headaches have fairly specific diagnostic criteria. According to the International Headache Society, tension-type headaches must meet at least two of the following criteria: 1. Pressing or tightening (nonpulsating) quality; 2. Mild to moderate intensity (meaning not so severe as to prohibit any normal activities); 3. Bilateral location; and 4. No aggravation from walking on stairs or similar activities. Furthermore, tension-type headaches must mean both of the following: 1. No nausea or vomiting; and 2. Only one of the following can be present: photophobia or phonophobia. Tension-type headaches typically last from 30 minutes to seven days. Patients will describe a “band of pain” extending from the forehead around both temples to the back of the head.
Cluster headaches are rare and are described as an excruciating “boring” pain, often over one eye, lasting from 15 minutes to several hours. They may occur several times per day or night. I have a patient, a man in his early 30s with depression and OCD, who gets cluster headaches about once a year, and he is rendered completely out of commission for several weeks. The condition has played havoc with his ongoing efforts to complete a technical degree, and to move out of his parent’s house problems that, in turn, have complicated his psychiatric treatment.
When should we refer to a neurologist? The short answer: almost always. Anybody who has severe or chronic headaches might have a secondary cause, and neurologists are experts at ruling this out. The workup will include a detailed neurologic exam, with an emphasis on the fundoscopic exam, and may or may not include a brain MRI, depending on the results of the exam and the neurologist’s judgment or philosophy.
Tension-type headaches. Once a secondary cause of a headache has been ruled out by a neurologist, psychiatrists are generally qualified to treat headache disorders, largely because of the great overlap between psychiatric drugs and headache drugs.
For an episode of tension-type headaches, aspirin (500-1000 mg) and ibuprofen (400 mg) work well, and better than acetaminophen (1000 mg) (see Loder E and Rizzoli P, Brit Med J 2008; 336:88-92 for a good review of tensiontype headache management). When these over-the-counter meds don’t work, you can move on to bigger guns such as Fioricet, which is a combination of acetaminophen (325 mg), butalbital (50 mg), and caffeine (40 mg). Why is this triad of drugs so effective? Well, acetaminophen is a standard analgesic, butalbital is a barbiturate that relaxes the scalp’s muscle contractions, and caffeine relaxes blood vessels, improving blood flow to scalp muscles. Fioricet works for both tension and migraine headaches, but it is addictive and can cause intermittent headaches to convert to chronic headaches.
Generally, when headaches become chronic, neurologists try to switch from “abortive” drugs (those that stop the headache in its tracks) to prophylactic drugs. The best prophylactic drug for chronic tension headaches is amitriptyline, usually dosed from 10 mg up to 75 mg one or two hours before bedtime; nortriptyline may be as effective, with fewer side effects. While the newer antidepressants such as the SSRIs and SNRIs are somewhat effective as well, they are not as effective as amitriptyline.
Migraine headaches. Migraines come in many varieties, ranging from mild and rare to severe and frequent. I have had two migraines in my life. Each was triggered by looking briefly at the sun, and each began with a strange visual aura like hundreds of translucent overlapping gears spinning frenetically. The aura lasted about 15 minutes, followed by the onset of a pulsing left-sided headache. On each occasion, I took 600 mg of ibuprofen, and felt the need to lie down in a dark room. Within two hours or so, I recovered.
I describe this case to illustrate the spectrum of migraines and their treatment. Anybody who presents themselves to a specialist will have had migraines far more severe and more frequent. While over-the-counter analgesics are effective for milder cases, often you need to ramp up treatment to drugs such as Fioricet, codeine, and various narcotics, all of which are considered acceptable treatments for the occasional migraine. But for more severe and frequent migraines, the preferred abortive treatments are triptans (such as sumitriptan and rizatriptan) which have replaced the ergots as the treatment of choice. There are now seven different triptans to choose from and each company will brandish studies to convince you theirs is best. Because of this complexity, neurologists are usually the better specialists to initiate treatment with a triptan.
More important is for psychiatrists to know something about the controversy surrounding the safety of combining triptans with SSRIs. In 2006, the FDA issued an alert that combining triptans with either SSRIs or SNRIs can cause serotonin syndrome. The agency said this was based on 27 cases gathered over five years. The announcement was met widely with skepticism, because millions of patients had been combining triptans with SSRIs over the years and serotonin syndrome had rarely, if ever, been reported in the literature. Despite requests, the FDA has not made details of these 27 cases of supposed serotonin syndrome public, and a recent review concluded that “withholding these medications due to fears of serotonin syndrome is difficult to justify” (Wenzel R et al., Ann Pharmacother 2008;42(11): 1692 -1696).
Most of the drugs effective as prophylactics against migraines (as opposed to abortive drugs) are well-known to psychiatrists, including amitriptyline, nortriptyline, Depakote (divalproex sodium), Neurontin (gabapentin), and Topamax (topiramate). Effective non-psychiatric prophylactic agents include the beta blockers propranolol and atenolol, and the ACE inhibitor verapamil. This is a good list to keep in mind for those “two-fer” opportunities, such as when you are choosing something for a depressed patient with migraines (go with the tricyclics) or for a migraine patient with bipolar disorder (the obvious choice would be Depakote).
While few psychiatrists will be investing in a biofeedback machine, this treatment may be the most effective non-pharmacological approach for headaches, especially tension-type headaches. One recent meta-analysis found that biofeedback was more effective than headache monitoring, placebo, and relaxation therapies (Nestoriuc Y et al., J Consult Clin Psychol 2008;76:(3):379–396).
Headache clinics often have psychologists and psychiatrists on staff and they have developed techniques that you can incorporate into your practice for patients with comorbid depression or anxiety and migraine headaches. Called “behavioral medicine,” these are typically versions of cognitive behavioral therapy. The usual strategy is to determine how much the patient is allowing headache to limit activities, and to encourage them to “get back out there”, on the theory that they are inadvertently reinforcing their depressed mood through passivity. Help the patient make a list of enjoyable activities and come up with a graded schedule for re-engaging in life. Such techniques have been shown helpful in decreasing headache severity in some studies (Smitherman TA et al., Headache 2007;48(1):45-50).
Other techniques that have some empirical support for relief of chronic headaches include standard progressive muscle relaxation exercises and acupuncture.
TCPR VERDICT: Psychiatrists have a major role in headache treatment, ranging from psychopharmacology to psychotherapy.