ISSN (Print) : 2348–263X

Original Article
ISSN (Online) : 2348-2648
MVP Journal of Medical Sciences, Vol 9(1), 57-61, January-June 2022 DOI: 10.18311/mvpjms/2022/v9i1/280

Psychiatric Co-Morbidity in Patients

Presenting with Primary Headache
Shuchi Pande1*, Sunil G. Gupte2 and Yogesh Pawar3
Former PG Resident, Department of Psychiatry, Dr. Vasantrao Pawar Medical College, Hospital and
1

Research Centre, Adgaon, Nashik − 422203, Maharashtra, India; drshuchipande@gmail.com

2
Professor and Head, Department of Psychiatry, Dr. Vasantrao Pawar Medical College, Hospital and
Research Centre, Adgaon, Nashik − 422203, Maharashtra, India
3
Assistant Professor Department of Psychiatry, Dr. Vasantrao Pawar Medical College, Hospital and
Research Centre, Adgaon, Nashik − 422203, Maharashtra, India

Abstract
Background: Headache is a common neurological disorder and most disabling conditions in the worldwide. Psychiatric
disorders can occur with at least two to three-fold greater frequencies among the patients presenting with headache than
among general population. The presence of psychiatric co-morbidity further complicates headache management and
portends a poorer prognosis. Therefore, the present study of psychiatric co-morbidity in patients presenting with primary
headache and to know the nature and extent of psychiatric co-morbidity associated with headache among the patients
was undertaken. Methods: Present sample consists of 62 patients who presented with the complaints of headache to
the department of Psychiatry and Neuropsychiatry from August 2016 to June 2018 was included in the study. MINI 7.0.0
was applied to elicit the presence of any Psychiatric disorder. Results: In this study 65% of the patients presenting with
headache had co-morbid psychiatric disorders. Out of 65% of the psychiatric illnesses; 43.55% had MDD, 14.52% had
GAD, 3.23% had Panic disorder and 3.23%had Social phobia among the patients presenting with headache. Conclusions:
Patients presenting with headache have high levels of co-morbid psychiatric disorders. In view of the present findings, the
management of patients presenting with headache should include the detail assessment of coexisting psychopathology
and treatment of both coexisting conditions.

Keywords: Chronic Daily Headache, Cluster-Type Headache, Migraine, Psychiatric Co-Morbidity, Tension-Type
Headache

1. Introduction Headaches are commonly associated with psychiatric

disorders where psychiatrists are often consulted for
Headache is a common neurological disorder that ranks the evaluation and treatment of people suffering from
among the top 10 most disabling conditions for both it. Most headaches are not associated with significant
men and women worldwide and at least 40 percent organic disease; many people are susceptible to headaches
of individuals in the world are suffering from severe at times of emotional stress. The relationship between
disabling headache1, 2. Every year, about 80 percent of headache and psychiatric disorders is complex.
the population is estimated to suffer from headache at Numerous studies have been done to look whether
least once, and 10 to 20 percent of the population goes psychological problem is a cause or the consequences
to physicians with headache as their primary complaint. of headache which are still remains controversial3.
Headaches are also a major cause of absenteeism from Psychiatric disorders occur with at least two to three-
work and of avoidance in social and personal activities. fold greater frequencies among the patients presenting
Severe headaches also have major economic impact due with headache than among general population, and the
to medical expenses2. prevalence increases in clinical population especially

*Author for correspondence

 Psychiatric Co-Morbidity in Patients Presenting with Primary Headache

with chronic daily headache. The presence of psychiatric 2.1 Statistical Analysis
co-morbidity further complicates headache management
The data obtained was represented as percentages and
and portends a poorer prognosis for headache treatment.
numerical data. The data collected is summarized in
The challenge for future studies is to employ research
the form of tables and respective histograms as depicted
methods and designs that accurately identify and
below. The outcome of the study was analyzed using SPSS
classifies the subsets of headache with psychiatric
software-19 version.
disorders, evaluate their impact on headache symptoms
and treatment, and identify optimal behavioral and
pharmacological treatment strategies4, 5. 3. Results
The data collected is summarized in the form of tables
2. Methods and respective histograms as depicted below. The results
of these studies show that the M.I.N.I. has acceptably high
This hospital based - cross sectional study included patients
validation and reliability scores, but can be administered
presenting with headache who visited to Psychiatry
in a much shorter period of time (18.7±11.6 minutes)
outpatient department of a tertiary care hospital and
than the above referenced instruments. It can be used by
research center Dr. Vasant Rao Pawar Medical College,
clinicians, after a brief training session.
Nashik, India. Sixty-two patients belongs to the age group
Figure 1 shows socio demographic profile of the study
of 18-60 years of either sex was included.
population. The study group consisted of 62 primary
Those who are diagnosed by physician/psychiatrist to
headache patients, the age range being between 18-60
have primary headache for ex. migraine with or without
years. Majority of patients belonged to age group between
aura, tension-type headache (episodic/chronic) and
mixed headache and who are ready to give the consent
were included in the study. Patients who are suffering
from serious or debilitating medical illness and patients
with secondary headache due to any other underlying
medical condition such as Head and neck trauma, Cranial
or cervical vascular disorder, Intracranial disorders were
excluded. The study was approved by the institutional
ethical clearance and informed consent was obtained
from all the patients who were included in the study.
Semi structured proforma for recording socio-
demographic variables, medical and psychiatric history
was used. Patients with headache were categorized using Figure 1. Distribution among the study population based
ICHD III (International classification of headache). Semi on age group.
structured proforma for recording socio-demographic
variables, medical and psychiatric history, ICD 10
(International Classification of Mental and Behavioral
disorders) and ICHD -III (International Classification of
Headache Disorders, 3rd edition) were used as tools.
Mini International Neuropsychiatric Interview
(MINI) was designed as a brief structured interview
for the major Axis-I and axis-II psychiatric disorder in
DSM-V and ICD-10. Validation and reliability studies
have been done comparing the M.I.N.I. to the SCID-P
for DSM-III-R and the CIDI (a structured interview
developed by the World Health Organization for lay
interviewers for ICD-10). Figure 2. Gender-wise distribution of patients among the
study population with headache.

58 Vol 9 (1) | January-June 2022 | https://mvpjms.org/index.php/mvpjms MVP Journal of Medical Sciences

 Shuchi Pande, Sunil G. Gupte and Yogesh Pawar

Table 1. Distribution of patients among the study 4. Discussion

population with type of headache
Type of Headache Frequency Percentage In the present study, Majority of patients belonged to age
group between 30 to 50 years (54.84%) followed by 18 to
Tension Type Headache 39 62.90%
30 years (35.48%) and more than 50 years (9.68%); where
Migraine 21 33.87% females were found to be predominates (56.45%) over men
Cluster Headache 2 3.23% (43.55%). The headache that affects disproportionately
more in women than in men in our study can be due
Total 62 100.00%
to gender based violence, socioeconomic disadvantage,
Tension–type of headache accounts to 62.90% of the income inequality, low or subordinate social status,
sample studied and is the most common type of headache unremitting responsibility for the care of others.
(Table 1). Previous studies by Lipton et al.6 had found the high
prevalence of headache among the young adults which is
almost similar to our study findings. Indian study by Jain
AP et al., 50 has also similar results (70.4% were in the age
group of 21 to 40 with a mean age at presentation was 31.2
years) to present study findings.
Another study by Mansur et al.7 which is not
consistent to present study findings as their study have
found that 37% of the patients presenting with headache
were below the age of 18 years, 40.27% were within the
range of 18-49 years and only 3.32% were belong to the
Figure 3. Distribution of Psychiatric co-morbidity among age group of more than 50 years. This difference in their
the patients with headache. study was due to the inclusion of all the age groups ranged
from 12 years to more than 65 years, and differences in
Table 2. the methodology.
Psychiatric Morbidity Frequency Percentage In present study population tension-type of headache
was found to be the commonest type of headache with
MDD* 27 43.55%
a prevalence of 62.90% followed by migraine headache
GAD** 9 14.52% (33.87%) and least were cluster headache (3.23%).
Panic D/O 2 3.23% Previous studies which had found the results similar
Social Phobia 2 3.23% to our study are: Stovner et al.8 has found that tension-
Nil 22 35.48% type headache were more (46%) common than migraine
(11%) and least was cluster headache (0.2%-0.3%);
Total 62 100.00%
Kandil et al.9 TTH (64%) was found to be high prevalence
*MDD-Major Depressive disorder, **GAD- Generalized followed by migraine (31%) and least were cluster type
Anxiety disorder. of headache (4%). This high prevalence of tension-type
headache is shown to have a major impact on patients’ job
30 to 50 years (54.84%) followed by 18 to 30 years (35.48%) performance and quality of life, leading to an economic
and more than 50 years (9.68%). burden on family members.
Figure 2 shows female predominance (56.45%) The overall prevalence of psychiatric co-morbidity
amongst study population as compared to male (43.55%). among the patients presenting with headache were
Psychiatric morbidity like MDD, GAD, Social phobia 65%, which was assessed by using MINI in our study.
and panic disorder was present in 43.55%, 14.52%, 3.22% Many other studies are in line with our study findings.
and 3.23% of study population respectively. 35.48% of Bera et al.10 reported that, the psychiatric co-morbidity
population had no psychiatric illness. Most common in subjects of migraine and TTH was 62.5% and 60%
psychiatric morbidity is MDD (43.55%) followed by GAD, respectively with no differences between both the groups.
panic disorder and social phobia (Figure 4 & Table 2). However, co-morbidities were much higher as compared

Vol 9 (1) | January-June 2022 | https://mvpjms.org/index.php/mvpjms MVP Journal of Medical Sciences 59

 Psychiatric Co-Morbidity in Patients Presenting with Primary Headache

to healthy controls (22.5%) in their study; Singh et al.11 2. Amanda K, Kathleen M. Physical and mental comorbidity
found that psychiatric co-morbidity was seen in 53.3% of of headache in a nationally representative sample of U.S.
the patients presenting with chronic daily headache. adults. Psychosom Med., 2008; 70(7):773-780. https://
In the present study, Psychiatric morbidity like MDD, doi.org/10.1097/PSY.0b013e31817f9e80. PMid:18725426
GAD, Social phobia and panic disorder was present in PMCid: PMC2933379.
3. Zuraida NZ, Parameswaran R. Prevalence of depression
43.55%, 14.52%, 3.22% and 3.23% of study population
among patients with headache in Kuala Lumpur, Malaysia.
respectively. 35.48% of population had no psychiatric
Malaysian J Psych., 2007; 16(2).
illness. Most common psychiatric morbidity is MDD 4. Lake AE, Rains JC, Penzien DB, Lipchik GL. Headache
(43.55%) followed by GAD, panic disorder and social and psychiatric comorbidity: Historical context,
phobia. Many other studies are in line with our study clinical implications and research relevance. Headache,
findings. Bera et al.12 reported that, the psychiatric 2005; 45:493-506. https://doi.org/10.1111/j.1526-
co-morbidity in subjects of migraine and TTH was 62.5% 4610.2005.05101.x. PMid:15953266.
and 60% respectively with no differences between both 5. Antonaci F, Nappi G, Galli F, Manzoni GC, Calabresi P,
the groups. However, co-morbidities were much higher Costa A. Migraine and psychiatric comorbidity: A review
as compared to healthy controls (22.5%) in their study; of clinical Findings. J Headache Pain, 2011; 12:115-
Singh et al.13 found that psychiatric comorbidity was 125. https://doi.org/10.1007/s10194-010-0282-4. PMid:
seen in 53.3% of the patients presenting with chronic 21210177 PMCid: PMC3072482.
6. Lipton RB, Mansur H. Headache, study of 3350 cases.
daily headache. Verri et al.14 also reported that, 25.8%
Bangladesh J Neuroscience, 2001; 17(1):1-5.
had depression, 17% had dysthymia among the patients
7. Mansur, Jain AP, Chauhan B, Bhat AD. Sociodemographic
presenting with headache; Fillipis et al.15 has found that
and clinical profile of headache -A rural hospital-based
28% had moderate to severe depression in patients with study. IACM, 2007; 8(1):26-28.
headache. Merikangas et al.16 did not find any significant 8. Stovner LJ, Andree C. Prevalence of headache in Europe:
difference in the frequency of major depression among A review for the Eurolight project. J Headache Pain, 2010;
the patients with TTH as compared to headaches free 11(4):289-299. https://doi.org/10.1007/s10194-010-0217-
control. 0. PMid:20473702 PMCid: PMC2917556.
9. Kandil MR, Hamed SA, Fadel KA, Youssef AH, Mohammed
AB, Hamed et al. Epidemiology of Tension-Type Headache
5. Conclusion (TTH) in Assuit Governorate, Egypt. Journal of Neurology
and Neuroscience, 2014; 5(1):2.
Depressive disorders were the most predominant
10. Bera SC, Sudhir K, Sood KM, Goyal V. A comparative
co-morbid psychiatric disorders among the patients
study of psychiatric comorbidity, quality of life and
presenting with headache followed by anxiety spectrum
disability in patients with migraine and tension type
disorders. Young adults and female gender were most headache. Neurology India, 2014; (62)5. https://doi.
likely to suffer from co-morbid psychiatric disorders org/10.4103/0028-3886.144445. PMid:25387621.
among the patients presenting with headache. Tension- 11. Singh AK, Shukla R, Trivedi JK, Singh D. Association of
type of headache was the found most common type of psychiatric co-morbidity and efficacy of treatment in
headache followed by migraine and least were cluster chronic daily headache in Indian population. J Neurosci
type headache. There is a high incidence of co-morbid Rural Pract, 2013; 4:132-139. https://doi.org/10.4103/0976-
psychiatric conditions associated with Headache. 3147.112736. PMid:23914085 PMCid: PMC3724287.
Ethical approval: The study was approved by the 12. Bera SC, Sudhir K, Sood KM, Goyal V. A comparative
Institutional Ethics Committee. study of psychiatric comorbidity, quality of life and
disability in patients with migraine and tension type
headache. Neurology India, 2014; 5(62). https://doi.
6. References org/10.4103/0028-3886.144445. PMid:25387621.
13. Singh AK, Shukla R, Trivedi JK, Singh D. Association of
1. Hussain AAM, Mohit MA, Ahad MA, Alim MA. A psychiatric co-morbidity and efficacy of treatment in
study on psychiatric co-morbidity among the patients chronic daily headache in Indian population. J Neurosci
with migraine. TAJ, 2008; 21(2):108-111. https://doi. Rural Pract, 2013; 4:132-139. https://doi.org/10.4103/0976-
org/10.3329/taj.v21i2.3787. 3147.112736. PMid:23914085 PMCid:PMC3724287.

60 Vol 9 (1) | January-June 2022 | https://mvpjms.org/index.php/mvpjms MVP Journal of Medical Sciences

 Shuchi Pande, Sunil G. Gupte and Yogesh Pawar

14. Verri AP, Cecchini PA, Galli C, Granella F, Sandrini 13:551-555. https://doi.org/10.1007/s10194-012-0480-3.
G, Nappi G. Psychiatric comorbidity in chronic daily PMid:22940870 PMCid: PMC3444538.
headache. Cephalalgia, 1998; 18(21):45-49. https://doi. 16. Merikangas M, Mateen FJ, Dua1 T, Steiner T, Saxena S.
org/10.1177/0333102498018S2112. PMid:9533671. Headache disorders in developing countries: Research
15. Filippis D, Teixeira AL, Costa EAC, Silva Jr AAD, Moreira over the past decade. Cephalalgia. Inter J Headache,
dos Santos A, Go’mez RS, Kummer A, et al. Psychiatric 2008; 28(11):1107-1114. https://doi.org/10.1111/j.1468-
comorbidities of chronic migraine in community and 2982.2008.01681.x. PMid:18727634.
tertiary care clinic samples. J Headache Pain, 2012;

How to cite this article: Pande S, Gupte SG, Pawar Y. Psychiatric

Co-Morbidity in Patients Presenting with Primary Headache. MVP J.
Med. Sci. 2022; 9(1): 57-61.

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