Headaches: A common, challenging comorbidity Psychiatric Times

TALE from the clinic

-Series Editor Nidal Moukaddam, MD, PhD

In this episode of Stories From the Clinic: The Art of Psychiatry, we look into a common neuropsychiatry-related comorbidity: headaches. This condition of the neuropsychiatric system is a frequent comorbidity among various psychiatric diagnoses and is often difficult to manage due to its significant connection with somatization.

Case Study

“Mr Wright” is a 37-year-old male with no medical comorbidities and has been living in his home in the United States for more than 10 years. He was seen by primary care for a 4 month background of headaches that weren’t responding to nonsteroidal anti-inflammatory medications available over-the-counter (NSAIDs). The patient is prescribed amitriptyline 25 mg daily at bedtime and is then referred to the department of psychiatry for “anxiety” with no other notes about the signs of anxiety. The patient is afraid that they will label him “crazy” as well as unhappy because his struggles are not being treated with seriousness.

He is physically healthy with excellent grooming habits, however the man is a bit hesitant in the psychiatric examination. He says he’s lived with his spouse and child and works in the restaurant. There are teenaged children that are not living with him, however the reports say that he has a great relationship with them.

In describing his headaches When describing his headaches, Mr. Wright states that they last throughout the day and cover areas surrounding his bilateral temples as well as the occipital zone but the pain can be transferred between these regions. He’s tried lying down for a rest however the relief from discomfort is only temporary. He’s not able to focus on driving, and has had to miss several working days because he did not think he was able to pay attention when driving. He is able to stretch his neck at several different positions in our conversation to alleviate the pain. Along with a lot of eye blinking that he is unaware of. He denies that a premonitory feeling was which occurred before his motions.

After multiple inquiries about the causes of his stress at the time when his headaches began, Mr. Wright can recall the incident that occurred one week prior to their onset The incident occurred when he was assisting his sister in his home following an argument between her and husband. His brother-in law had held him in a gun-point situation outside of his home. He fled to security, and his brother-in-law later went away. The sister who was with him has now gone and the patient believes that the stress of an unkind relationship with his sister continues to be a problem for his sister as well as the other members of the family. He remembers an incident similar to this about 20 years ago, when the patient was chased by a family member from another in his country of origin. At the time, Mr. Wright felt there was a danger to his safety, and needed to escape towards safety. Since the time, he’s been a nervous person generally. He has not received any treatment for mental health (including therapy).

He is not experiencing the typical signs of Posttraumatic Stress Disorder (PTSD) such as flashbacks, nightmares, and avoiding the arousal of heightened levels.

A review of the chart shows that Mr. Wright was examined in the emergency room twice following his visit to his primary physician. One time the patient complained of severe chest pain. Negative EKG as well as cardiac enzymes resulted in an admission to the hospital. In the next instance, he was screened for sexual contact that was not protected by an unidentified individual. Mr. Wright was hesitant to discuss any of these incidents of his interactions with medical professionals, and the psychiatrist opted not to speak about them.

Amitriptyline was recommended to him at 25 mg with his main doctor two weeks ago. He is taking it for the last two weeks when that he’s unable to fall asleep. It has been helpful to him however, he is unable to get any relief from headaches. He’s unable to express the connection between a potentially life-threatening incident and the beginning in his headaches.

After the consultation, both physician and patient are in agreement that the amitriptyline treatment should be maintained, however the patient needs to use it more often to get the most effective therapeutic results.


As per a systematic review of a global burden of disease across the United States, in 2017, the 5 highest incidence rates of neurological diseases included migraines and tension-type headaches.1 Migraines have consistently been among the top 3 neurological diseases in terms of disability-adjusted life years.2 As a testament to how frequently psychiatrists and neurologists see patients with headaches and psychiatric diagnoses, in 2019, the most frequent psychiatric comorbidities in individuals with primary headaches in the United States were anxiety and depression, followed by posttraumatic/stressor and trauma-related stress disorder. The comorbidities mentioned above are present in 25 percent, 23% and 15 percent of the general population according to. 3

It is therefore inevitable that you will encounter patients suffering from both principal and second headaches in the psychiatric clinic. The recognition of headaches is a valuable instrument to assess the health for our patients. The headache can trigger and perpetuating causes of psychiatric disorders and are important in determining the most effective pharmacological treatments.

Biopsychosocial Model

In primary headaches such as migraine or tension headaches there is no reason to believe that there is a nociceptive cause such as hemorrhage, or inflammation. There are many theories that have attempted to explain the relationship between stress and the onset of primary headaches. The results of studies that have examined the connections between stress and primary headaches clear that the main trigger factors for primary headaches are stress and sleep problems. 4 Stress has been associated with the change from chronic migraines into chronic migraines which carry a larger burden of illness. 5 Interestingly repeatedly exposed to trauma regardless of an official diagnosis of PTSD, is more prevalent in people who suffer from chronic migraine headaches when compared to adults who do not suffer from migraines.

Biopsychosocial variables are believed to play a role in the perception of headaches. Transactional models suggest that the gap between the perception of threat and the ability to face the threat may be applied to the subjective feeling of pain that occurs in migraines and to any other type of pain syndrome. 6 Among personality traits, the locus of control is perceived as external versus internal is a predictor for better outcome for headache.

In the COVID-19 epidemic, the significance of a sudden shift in the mental health due to the shutdown in people with prior migraines is being investigated. Contrary to the belief that headaches are likely to worsen, findings from at the very least one study indicate improvements. The results show a decrease in frequency and intensity of migraine among adolescents during the closure within Italy from 2020. 7 It is possible to infer that the decrease in social and academic pressures was beneficial in this improvement. It is also important to highlight the importance of psychosocial treatment in patients suffering from migraines. Additionally, it is fascinating to know whether there’s an increase in migraine presentations to psychiatrists and neurologists because of the constant anxiety caused by the pandemic, which is over and beyond migraines in patients who suffer from the neuropsychiatric consequences of COVID-19 itself.

of Neuropsychiatry of Headache

Migraine headaches have a bidirectional connection with a range of mental illnesses, with the most significant correlation is with depression anxiety, depression, and bipolar disorder. There is evidence of a shared genetic predisposition, aswell being structural and functional changes in brain regions that control pain such as the amygdala the anterior cingulate cortex, and the periaqueductal grey in the affective and migraine disorders. Additionally, they share problems within the HPA axis, as well as similar mechanisms for action for treatments.

Central sensitization is commonly used to explain conditions that cause pain which include migraine. People suffering from chronic migraines (as contrasted with episodic migraines) suffer more from somatic complaints. The significance of pain sensitization in episodic migraines is also being studied in the context of episodic migraines. A recent study suggests that evoked pain sensitization may be a useful diagnostic indicator for intermittent migraines. 8

Serotonin, norepinephrine and norepinephrine, as well as the GABAergic system have have been linked to the cause of psychiatric and primary headaches on the neurotransmitters level. Therefore, the evidence to use serotonin and norepinephrine Reuptake inhibitors (SNRIs) and tricyclic antidepressants (TCAs) which are targeted at these receptors to prevention-based treatment of migraines remains solid.

Pearls in Management

Treating psychiatric issues in patients who are seeking treatment for headaches could provide a distinct advantage when it comes in addressing the issue of improving mental health. When setting goals for treatment it could be beneficial to explain to the patient the benefits of SNRIs and TCAs in the management of headaches and anxiety and mood issues. It can help patients communicate their needs for mental health even in the face of stigma. Sometimes, offering such an SNRI as well as TCA as a headache medication is a great way to improve compliance to treatment for patients who struggle to communicate their feelings.

One of the biggest difficulties when it comes to managing headaches is that introducing the use of SNRIs or TCAs to treat headaches can be a source of headaches. Careful consideration of the time frame for headaches caused by medication can help in the separation of symptoms that are superimposed. Clinicians might benefit from considering the withdrawal of medication as a possible cause for headache exacerbation in treating patients suffering from psychiatric disorders with comorbid headaches and having a history of nonadherence. Venlafaxine is prominent in this regard due to its withdrawal symptoms.

Researchers of a variety of studies have not been able to prove the effectiveness of making use of selective serotonin reuptake inhibitors (SSRIs) to prevent migraine Relapses. One of the most researched SSRIs are fluoxetine. It to the present, has inconsistent evidence of its effectiveness for primary headaches. 9 Other clinical trials of sertraline as well as citalopram have not shown any advantages when compared to TCA as well as placebo. So, if a person who has previously received treatment using SSRIs is put on TCAs to treat headaches and headaches, it is necessary be mindful of the potential advantages and risks when switching from monotherapy using the use of a TCA or continuing treatment with both medication. If the patient has reported positive clinical results, they can be treated using low dosages of both medications and be monitored for any adverse reactions. Patients may be taught about the early signs of serotonin syndrome when being treated in an outpatient setting.

Furthermore, many physicians have concerns about the likelihood of serotonin-related serotonin disorder in those taking antidepressants that are prescribed triptans to prevent migraines. migraines. While there was a black-box warning about this interaction, findings from an electronic health record study conducted in 2018 did not reveal any connection between serotonin syndrome and co-use of SSRIs as well as SNRIs or triptans. 10

In patients who suffer from drug-overuse headaches there is a higher incidence of psychiatric comorbidities may be more common. 11 Some mention the similarity with the use of compulsive medications for headaches and those with obsessive compulsive disorder. In this regard, the addition of the behavioral treatment for this segment of patients can improve results for headaches.

It could be beneficial that neurologists prescribe regular psychotherapy for patients suffering from chronic migraines. Forecasting models and behavioral interventions that incorporate stress factors are effective in the management of migraine. The behavioral treatments that are proven effective for migraine control include: stress management as well as relaxing therapy, therapy as well as mindfulness-based treatments, biofeedback as well as acceptance and commitment therapy. Researchers of certain studies note that even though the intensity or frequency of headaches decreases however, there is no improvement in the physiological markers that cause headaches like tension in muscles. In a groundbreaking study on electromyographic biofeedback participants perceived the source of their headaches as having an internal source of control, and also as being more self-efficacious (ie that they are capable of altering their headaches) in the aftermath of the treatment. 12

Final Thoughts

In the final analysis, when dealing with this diverse patient population, it’s important to avoid labeling or stigmatization. Patients are typically worried about physical ailments that are ignored or being advised that “the symptoms are just in the head.” A an appropriate therapeutic relationship will lead to discussion of treatment options that are open and opens the way for effective management of illness.

“Dr Shamim has been psychiatrist from Houston, Texas.


1. GBD 2017 US Neurological Disorders Collaborators; Feigin VL, Vos T, Alahdab F, et al. A Study of the Burden and Impact of Neurological Disorders across the US Between 1990 and 2017 A Global Burden of Disease Study. JAMA Neurol. 2021;78(2):165-176.

2. GBD 2019 Injuries and Diseases Collaborators. The global burden for 369 ailments and injuries in 204 nations and territories between 1990 and 2019 A systematic analysis for The Global Burden of Disease Study 2019. Lancet. 2020;396(10258):1204-1222.

3. Caponnetto V, Deodato M, Robotti M, et al; European Headache Federation School of Advanced Studies (EHF-SAS). Primary headache disorder-related comorbidities Review of the literature and meta-analysis. J Headache Pain. 2021;22(1):71.

4. Yokoyama M, Yokoyama T, Funazu K, et al. The relationship between stress and headache alcohol consumption as well as exercise, sleep and other health issues in the Japanese population. J Headache Pain. 2009;10(3):177-185.

5. Xu J, Kong F, Buse DC. Predictors of episodic migraine’s transformation to chronic migraine: A comprehensive review of and meta-analysis cohort studies of observation. Cephalalgia. 2020;40(5):503-516.

6. Lazarus RS, Folkman S. Stress, Appraisal, and Coping. Springer Publishing Company; 1984.

7. Dallavalle G, Pezzotti E, Provenzi L, et al. The symptoms of migraine improve after the COVID-19 lockdown an array of adolescents and children. Front Neurol. 2020;11:579047.

8. De la Coba P, Bruehl S, Del Paso GAR. Slowly repeated provoked pain (SREP) as an indicator of central sensitization for migraine patients with episodic attacks. Sci Rep. 2021;11(1):4582.

9. Silberstein SD, Holland S, Freitag F, et and Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. A new guideline based on evidence: pharmacologic treatment of episodic headache prevention for adults Report by the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78(17):1337-1345.

10. Orlova orlova Y, Rizzoli P, Loder E. Association of coprescription of triptan antimigraine medications and selective serotonin reuptake inhibitors or selective norepinephrine-reuptake inhibitors of antidepressants for serotonin-related syndrome. JAMA Neurol. 2018;75(5):566-572.

11. Kristoffersen E, Straand J Russell MB, Lundqvist C. Disabilities anxiety and depression among patients suffering from headaches caused by medication in primary treatment The BIMOH study. Eur J Neurol. 2016;23(suppl 1):28-35.

12. Holroyd KA, Penzien DB, Hursey KG, et al. Mechanisms of change involved in EMG Biofeedback Training: changes in the brain that cause improvement for tension headache. J Consult Clin Psychol. 1984;52(6):1039-1053.