TALE from the clinic
– Series Editor Nidal Moukaddam, MD, PhD
In this edition of Tales From the Clinic: The Art of Psychiatry, we look into a common neuropsychiatry comorbidity, headaches. Headaches are a frequent co-morbidity that can be found in a wide range of psychosis diagnoses. The neuropsychiatric issue is often difficult to manage due to the fact that it has a significant relationship with somatization.
“Mr Wright” is a 37-year-old man without medical conditions that has resided living in his home in the United States for more than 10 years. Mr. Wright was referred to primary care for a 4 month history of headaches that weren’t responding to the over-the counter non-steroidal anti-inflammatory drug (NSAIDs). The patient is prescribed amitriptyline 25, mg before bed each day. He is also admitted to psychiatry to treat “anxiety” with no other notes about the signs of anxiety. The patient is concerned that about being labeled “crazy” or “crazy” and frustrated that his condition isn’t being treated with seriousness.
He is healthy and has excellent grooming, but there is some hesitation in the psychiatric examination. He claims to have lived with his spouse and child and works in an eatery. There are teenage children that do not reside with him, however he is said to have a great relationship with his children.
In describing his headaches when describing his headaches Wright states that they last throughout the day and cover the temples of his bilateral and occipital zone, even though the pain could spread between the two areas. He’s tried to lie down and relax, but the relief in pain lasts only a few minutes. He’s not able to focus on driving, and has had to miss several working days because he did not think he could pay attention when driving. He is able to stretch his neck at various angles in our interactions to ease the pain. He also does this with a lot of eye blinking that he is unaware of. He denies that a premonitory feeling was that occurred before his motions.
After numerous inquiries about his stressors at the time when his headaches began, Mr. Wright can recall an incident that took place a week before the headaches began The incident occurred when he was assisting his sister at home after a dispute between her and husband. The brother-in-law was holding him in a gun-toting situation outside of his house. He fled inside to safety, and the brother-in law had left. The sister who was with him has now quit and the patient is concerned that the stress of an unhealthy relationship between his sister and her persists and is acceptable to his sister as well as the other family members. He recalls an incident similar to this more than 20 years ago, when he was pursued by a family member from his country of origin. In that moment, Mr. Wright was also concerned that there was a danger to his safety. He was forced to flee to safety. Since the time, he’s been anxious generally. He has never had any form of mental health treatment (including psychotherapy) prior to that.
He has not been able to identify the usual signs of posttraumatic stress disorder (PTSD) such as flashbacks, nightmares, and avoiding the arousal of the body.
A review of the chart shows that Mr. Wright was admitted to the ER two times since his visit with his primary healthcare provider. In one instance the patient experienced severe chest pain. Negative EKG as well as cardiac enzymes resulted in an ER discharge. In the second instance it was determined that he had sexual contact that was not protected with an unidentified person. Mr. Wright was hesitant to speak about any of these incidents of his interactions with the medical system and the psychiatrist opted not to talk about them.
He was introduced to amitriptyline 25 mg with his main physician 2 weeks ago and he is taking it when that he’s unable to fall asleep. He has found it helpful however he is not able to relieve headaches. He is not able to articulate any connection between an event that could be life-threatening and the beginning the onset of headaches.
At the end of the appointment, both patient and doctor both agree to keep taking amitriptyline. However, they both agree that the patient needs to be taking it more frequently to achieve the best therapeutic outcomes.
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 diagnosis, 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 and in 15% of the general population, respectively. 3
It is therefore inevitable that we will encounter patients suffering from both the primary as well as secondary headaches within the field of psychiatric care. The recognition of headaches can be an effective instrument to assess the health that our patients enjoy. The headache can trigger and be perpetuating causes of psychiatric disorders and are crucial in determining the most effective pharmacological treatments.
In primary headaches like migraine or tension headaches there isn’t a source of nociceptive activity, such as hemorrhage, or inflammation. There are many theories that have tried to explain the connection between stress as well as primary headaches. Studies on the connections between anxiety and headaches demonstrate that the primary trigger factors for primary headaches are sleep and distress problems. 4 Stress is also linked to the transition from chronic migraines into chronic migraines which carry a larger burden of illness. 5 Interestingly the repeated exposure to trauma, despite not having an official diagnosis of PTSD, is common in chronic migraine headaches in comparison to healthy 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 imbalance between the perception of threat and the ability to manage the threat could apply to the subjective perception of pain that occurs in migraines as well as to other pain disorders. 6 Among personality traits, the locus or control being perceived to be internal as opposed to external is associated with better outcomes for headaches.
In the current COVID-19 pandemic it is believed that the impact of a the sudden shift in the psychosocial environment caused by the shut-down of those suffering from prior migraines is being investigated. Contrary to the belief that headaches will get worse in the future, at least one study found improvements. The study reveals a reduction in the frequency and intensity of migraine for adolescents as COVID-19 is elimination at the end of 2020 in Italy by 2020. 7 It is possible to see that the decrease in social and academic pressures could be a factor in improving the quality of life and highlight the significance of psychosocial intervention on patients suffering from migraines. Additionally, it is interesting to determine whether there is an increase in migraine presentations to psychiatrists and neurologists because of the constant anxiety caused by the pandemic. This is in addition to and above migraines in patients who suffer from neuropsychiatric disorders caused by COVID-19 virus the disease itself.
of Neuropsychiatry of Headache
Migraine headaches are associated with a variety of psychiatric disorders, the most significant correlation is with depression anxiety, depression, and bipolar disorder. There is evidence that there is a shared genetic predisposition as well in structural and functional changes in the brain regions that regulate pain that include the amygdala, the anterior cingulate cortex, and the periaqueductal grey in headaches and disorders of the emotional. In addition, they have similar problems on the HPA axis and the common mechanism of operation for treatment options.
Central sensitization is frequently utilized to explain the causes of pain which include migraine. People suffering from chronic migraines (as as compared to those with episodic migraines) suffer from more somatic complaints. The effect of pain sensitization on episodic migraines has also been studied for episodic migraines. A recent study suggests that the slow repetition of pain sensitization may be an effective diagnostic indicator for intermittent migraines. 8
Serotonin, norepinephrine and other components of the GABAergic system have have been linked to the causes of psychiatric aswell as primary headaches on the basis of neurotransmitters. This is why the evidence supporting the use of serotonin and norepinephrine Reuptake inhibitors (SNRIs) as well as tricyclic antidepressants (TCAs) which are targeted at these receptors to prevent treatment of migraines is still strong.
Pearls in Management
Treating psychiatric issues in patients seeking treatment for headaches could provide a distinct advantage in breaking down barriers to discussing ways to improve mental health. When setting objectives for treatment, it could be helpful to inform patients on the benefits that SSRIs, NSAIDs, and TCAs in the treatment of headaches and anxiety and mood issues. This can assist patients in communicating their mental health concerns even in the face of stigma. Sometimes, offering such an SNRI as well TCA as a medication for headaches can help in ensuring the adherence of patients who are unable to express their pain.
One of the biggest problems when it comes to managing headaches is that the process of initiating SNRIs or TCAs to treat headaches can be a risk in itself for causing headaches. An attentive examination of the time frame for headaches that are caused by medications can aid in the separation of symptoms that are superimposed. Clinicians could benefit from considering withdrawal as a cause of headache aggravation in patients suffering from psychiatric disorders who have chronic headaches and an history of noncompliance. Venlafaxine is prominent in this regard due to its withdrawal-related symptoms.
Numerous studies have not been able to determine the effectiveness of the use of selective serotonin reuptake inhibitors (SSRIs) to prevent migraine Relapses. One of the most researched SSRIs are fluoxetine. It to the present time, has conflicting research on its efficacy in the treatment of primary headaches. 9 Other studies of sertraline and citalopram have not shown any advantages when compared to TCA as well as placebo. Therefore, if a patient already receiving treatment with an SSRI is put on TCAs to treat headaches it is necessary to weigh the advantages and risks in switching treatment to monotherapy TCA or continuing treatment with both medication. If the patient is demonstrating positive clinical results, they may be treated using low doses of both categories with a close eye on adverse reactions. Patients may be informed about the early signs of serotonin syndrome when they are treated in an outpatient setting.
In addition, many doctors worry about the likelihood of triggering serotonin syndrome among people taking antidepressants. They are advised triptans to stop instances of migraines. Although there was an Blackbox warning regarding this interaction the electronic health record study conducted in 2018 failed to detect any link between serotonin-related syndrome when using SSRIs as well as SNRIs as well as triptans. 10
In patients who suffer from overuse of medication headaches there is a higher incidence of psychiatric disorders is more prevalent. 11 Some mention the similarity between the intake of medications that cause compulsive migraine episodes and obsessive-compulsive disorder. In this regard, the addition of the behavioral treatment for this group of patients could improve the outcomes of headaches.
It could be beneficial that neurologists prescribe psychotherapy frequently to manage patients suffering from chronic migraines. The use of behavioral strategies and forecasting models that incorporate stress factors appear to be effective in controlling migraine. The behavioral treatments that are proven to be effective for migraine prevention include relaxation therapy, stress management and cognitive behavioral therapy. They also include mindfulness-based treatments, biofeedback as well as acceptance and commit therapy. Certain studies show that, although the frequency of headaches or intensity decreases however, there is no improvement in the physiological indicators that cause headaches like muscle tension. In a groundbreaking study of electromyographic biofeedback participants saw that their headaches as having a greater internal control mechanism and as self-efficacious (ie they were capable of controlling their headaches) in the aftermath of treatments. 12
When dealing with the complex population of patients it is crucial to stay clear of stigmatizing and labeling. Patients are often worried about physical ailments being ignored and being informed that “the symptoms are just in the head.” The development of a the right therapeutic relationship can go far in facilitating discussion of treatment options in a non-judgmental manner and can lead to effective treatment management.
Dr. Shamim is an assistant Professor of psychiatry at Baylor College of Medicine, Menninger Department of psychiatry. She is a specialist in cooccurring psychiatric and neurological diseases.
1. GBD 2017 US Neurological Disorders Collaborators; Feigin VL, Vos T, Alahdab F, et al. The burden of neurological disorders across the US from 1990 to 2017: A study of the burden of disease across the globe. JAMA Neurol. 2021;78(2):165-176.
2. GBD 2019 Injuries and Diseases Collaborators. World burden from 369 ailments and injuries in 204 nations and territories between 1990 and 2019 A systematic analysis for GBD 2019. 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). The comorbidities of primary headache disorders A literature review 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 and exercise, sleep and other health issues in the Japanese population. J Headache Pain. 2009;10(3):177-85.
5. Xu J, Kong F, Buse DC. Predictors of episodic migraine’s transformation to chronic migraine: A thorough review, meta-analyse and systematic analysis of studies of observational cohorts. Cephalalgia. 2020;40(5):503-516.
6. Lazarus R, Folkman S. Stress, Appraisal and Coping. Springer Publishing Company; 1984.
7. Dallavalle G, Pezzotti E, Provenzi L, et al. Improvement in migraine symptoms through the COVID-19 lockdown the group of adolescents and children. Front Neurol. 2020;11:579047.
8. De la Coba P, Bruehl S, del Paso GAR. Slowly repeated painful evoked (SREP) as an indicator of central sensitization for migraine sufferers 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 drug treatment for intermittent migraine in adult patients The 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 with serotonin syndrome. JAMA Neurol. 2018;75(5):566-572.
11. Kristoffersen ES Straand J Russell MB, Lundqvist C. Disabilities depression, anxiety and dissociation in patients suffering from medication-related headache 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;52:1039-1053.
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