East Asian Arch Psychiatry 2014;24:10-15

ORIGINAL ARTICLE

Dr Imran Jahangirali Ratnani, MBBS, Department of Psychiatry, Government Medical College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat, India.
Dr Bharat Navinchandra Panchal, MD, Department of Psychiatry, Government Medical College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat, India.
Dr Deepak Sachchidanand Tiwari, MD, Department of Psychiatry, Government Medical College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat, India.
Dr Ashok Ukabhai Vala, MD, Department of Psychiatry, Government Medical College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat, India.

Address for correspondence: Dr Imran Jahangirali Ratnani, Room No. 133, Department of Psychiatry, Government Medical College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat, India 364001.
Tel: (91) 9925056695; Fax: (91-278) 2422011; Email: drijratnani@gmail.com

Submitted: 16 September 2013; Accepted: 11 October 2013

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Introduction

Headache is a common cause for medical consultation.¹ Tension-type headache (TTH) is the most common cause for primary headache (69%), followed by migraine headache (16%).² Headache often results in considerable disability and poor quality of life.² The present lifetime disability attributable to migraine of 0.5 in terms of disability- adjusted life years is equal to or more than that of several other major chronic illnesses such as hypertension, breast cancer, and rheumatoid arthritis.¹ Psychiatric illnesses are commonly associated with headache. The relationship of anxiety disorders and depression with migraine has been established in various studies.^3-5 Anxiety is the commonest 10 © 2014 Hong Kong College of Psychiatrists co-morbidity affecting about 75% of patients⁶; its association with migraine is stronger than that with depression,³ and the presence of anxiety disorders is an independent risk factor for depression in patients with migraine.⁴ Panic disorder and phobia are the most common anxiety diagnoses among migraineurs.⁷ There is paucity of clinical literature concerning the association of anxiety disorders in relation to headache.

At present, it is difficult to clinically distinguish migraine from TTH, as the International Headache Society’s main definition of TTH allows an admixture of nausea, photophobia, or phonophobia in various combinations, although the appendix definition does not.² This illustrates the difficulty in distinguishing migraine from TTH.

Migraine is associated with anxiety, depression, and poor quality of life.² To our best knowledge, there is no published evidence on the association of panic disorder with severity of anxiety symptoms among patients with headache. Thus, in the present study, we evaluated the prevalence of panic disorder among patients with headache, and the possible association of panic disorder with severity of anxiety symptoms and quality of life in the patients with headache.

Methods

A total of 100 consecutive patients of both genders between 18 and 60 years, and having headache as a presenting complaint for at least 3 months were recruited from the psychiatry outpatient department of a tertiary care hospital from April 2012 to July 2012. Patients with severe mental illnesses including schizophrenia, bipolar mood disorder, cognitive impairment, chronic disabling illnesses, negative symptoms, dementia, and poor attention, as well as those unable to give verbal replies were excluded from the study. Patients on antidepressant, antipsychotic or antianxiety medications in the last 2 months were also excluded. Causes for secondary headache involving organic aetiologies like systemic infection, head injury, vascular disorders, subarachnoid haemorrhage and brain tumours were ruled out with clinical examination.

Participants were interviewed by the principal investigator on demographic variables like age, gender, residence, religion, marital status, education, socio- economical status, and tobacco use. Duration and characteristics of headache (dull aching, throbbing or mixed) were recorded. The visual analogue scale (VAS) was used for recording the severity of headache using self-rating on a scale of 0 to 10.⁸ History and family history of headache or any other psychiatric consultation were recorded.

Participants were interviewed for the symptoms of anxiety disorders like panic disorder, agoraphobia and for the diagnosis of panic disorder with agoraphobia (PA) and panic disorder without agoraphobia (PoA) using clinician- administered interview as per the DSM-IV-TR criteria.⁹ The diagnosis was confirmed by a consultant psychiatrist holding a master degree in psychiatry and with more than 25 years of experience in the subject. Hamilton Anxiety Rating Scale (HAM-A), a 14-item observer-rated scale, was used to assess the severity of the anxiety symptoms.¹⁰ The participants were asked to complete the 26-item World Health Organization Quality of Life Scale brief version (WHOQOL-BREF) which is a self-rating questionnaire for assessment of the quality of life in the domains of physical health, psychological health, social relationship, and environment.¹¹

Qualitative data were expressed as percentages and quantitative data were expressed as median ± interquartile range. The statistical analysis was done with GraphPad InStat version 3.06 (San Diego, California, US). Proportions of participants were compared by using Chi-square test while scores of VAS, HAM-A, and WHOQOL-BREF were compared by using Mann-Whitney test or Kruskal-Wallis test followed by Dunn’s post-hoc multiple comparisons. A p value of < 0.05 was considered statistically significant.

Written informed consent was obtained from every participant. Prior approval for the study was obtained from the local ethics committee.

Results

These 100 participants (24 males and 76 females) were divided into 3 groups according to severity of their anxiety symptoms and were assessed by HAM-A. HAM-A scores of ≤ 17 were classified as mild, 18-24 as mild to moderate, and ≥ 25 as moderate to severe. Table 1¹² shows demographic variables of these participants. The frequency of panic disorder among the patients presenting with headache was 67%; PA was noted in 23% of subjects and PoA in 44% of subjects. Severity of anxiety symptoms did not differ with various demographic variables including age, gender, residence, religion, marital status, education, socio- economic status, tobacco use, severity, characteristic and duration of headache, as well as history and family history of headache or psychiatric consultations. Participants with panic disorder had significantly higher HAM-A score (p < 0.0001) and poor quality of life in all domains of WHOQOL-BREF except in the social relationship domain. The HAM-A score and quality of life in subjects with PA did not differ significantly from those with PoA (Table 2). Besides, those with daily headache had significantly higher HAM-A score (p = 0.04) and poor quality of life in the psychological health domain of WHOQOL-BREF (p = 0.04) than those with intermittent headache (Table 3). Those with high HAM-A scores had poor quality of life in all the domains of WHOQOL-BREF (p < 0.0001). Among all the domains, the psychological health domain score reduced significantly as anxiety score increased (Table 4).

Discussion

Psychiatric disorders such as anxiety disorders and depression are more common among patients with recurrent headache than in the general population.^3,13 A majority of participants in this study were women (76%). According to a prospective study,¹⁴ women were 4 times more likely to develop migraine in comparison with men. Unlike that for migraine, the female-to-male ratio for TTH is 5:4, suggesting that the prevalence of TTH is slightly higher in women than in men.¹⁵ Our finding suggested that the severity of anxiety symptoms did not differ with demographic variables of age, gender, residence, religion, education, and socio-economical status. Similar findings were reported in an earlier study by Mercante et al.¹⁶

In contrast to data from an earlier study¹⁶ that headache intensity was higher among patients with anxiety disorder compared with the controls, the severity of headache was not associated with severity of anxiety symptoms in this study. This difference may be attributed to cross-cultural variation, the subjective nature in expressing pain severity, and the poor reliability of the self-rating VAS used for assessing the severity of pain. In the present study, the severity of anxiety symptoms was independent of the characteristics of headache like dull aching, throbbing, or mixed headache.

Patients complaining of daily headache showed higher scores for anxiety symptoms and poorer scores for quality of life in the psychological health domain than those with intermittent headache. This finding is in accordance to data from earlier studies^16,17 which found that the symptoms of depression and anxiety disorders were more common in chronic than episodic migraine and TTH. Patients with chronic daily headache are likely to show poor quality of life across all the 8 domains of the self-administered 36-item Short Form questionnaire used to measure health-related functions, except that of physical functioning.^18-20 Patients with chronic migraine have higher rate of anxiety disorders and are twice as likely to report anxiety disorders than those with episodic migraine.^21,22 Recent data^23,24 also showed that co-morbid anxiety disorders and depression have a role in the progression of episodic migraine to chronic migraine.

In this study, the frequency of panic disorders in patients with headache was 67%, while frequencies of PA and PoA were 23% and 44%, respectively. The frequency of panic disorder among individuals with headache varied from 4.5 to 27% in earlier studies.^25,26 The diagnosis of panic disorder was made with the help of DSM-IV-TR, which allows diagnosis of panic disorder in less frequent attacks. As the patients were recruited from the tertiary care psychiatry outpatient department, which is the specialised referral centre in the area, the patients with more severe symptoms were more likely to be referred by other medical professionals in this study compared with previous studies^25,26 on general population in general medical setting. In our study, women represented more than three quarters (76%) of the study population, whereas another study⁹ revealed that they were 2 to 3 times more likely to suffer from panic disorder than men. These could be the probable reasons for higher frequency of panic disorder in our study. The only published Indian study,²⁷ performed in a rural camp, showed a 14.5% frequency of PA. In this study, patients with panic disorders (PA and PoA) showed higher anxiety symptoms and poorer quality of life in most domains (except in the social relationship domain) of the WHOQOL-BREF than those without panic disorders. Perhaps the structure of questions in the WHOQOL-BREF may explain this finding; there are only 3 questions in the WHOQOL-BREF for evaluating the quality of life in the social relationship domain, while there are 7, 6, and 8 questions for evaluating the physical health, psychological health, and environmental domains, respectively. The severity of anxiety symptoms and quality of life did not differ significantly among patients with PA or PoA. These findings are in accordance with data from earlier studies.^13,16

One population-based study²⁸ showed that panic disorder was strongly associated with migraine (odds ratio [OR] = 3.7; 95% confidence interval, 2.2-6.2 in severe headache disorders vs. OR = 3.0; 95% confidence interval, 1.5-5.8 in non-headache controls).

In this study, patients with severe anxiety symptoms showed poorer quality of life across all domains. Other studies^9,16,29 have demonstrated that patients with anxiety disorders are likely to have severe disability.

A community-based longitudinal study¹³ found that individuals with a history of migraine attack are likely to experience an episode of anxiety disorder or depression on follow-up. This finding suggests that depression, panic disorder, and migraine have a common predisposition and are not merely psychological consequences of headache. Another longitudinal study³ showed that anxiety disorders may precede migraine, and depression may follow it. Causal relationship between anxiety disorders and headache needs to be investigated further. Since anxiety disorders frequently coexist with headache, we recommend screening for anxiety disorders in patients with headache so as to facilitate their early identification and early treatment.

Limitations

Although this is the first study to examine the association of panic disorder with severity of anxiety symptoms and quality of life among participants with headache, it has several limitations such as recruiting subjects from a single centre, an open-label study, and a small sample size. As participants were recruited from the psychiatry outpatient department of a tertiary care hospital, they did not represent the general population. Being a cross-sectional study, cause-effect relationship for headache and anxiety disorders cannot be established. As such, prospective cohort studies to examine such association are recommended.

Conclusions

This study showed that there was high frequency of panic disorder among patients with headache. Patients with severe anxiety symptoms had poorer quality of life. Patients with daily headache showed more severe anxiety symptoms and poorer quality of life than those with intermittent headache. Patients with panic disorders (PA and PoA) showed higher scores for anxiety symptoms and poorer quality of life than those without.

Declaration

The authors declared no source of financial support and conflict of interest in this study.

Acknowledgements

We would like to thank Prof Mukesh Samani, Head of Department of Psychiatry, P. D. U. Medical College, Rajkot, Gujarat, India for guidance about applying World Health Organisation Quality of Life (WHOQOL-BREF) scale, as well as Dr Divyesh R. Mandavia, Tutor, Department of Pharmacology, Government Medical College, Bhavnagar, Gujarat, India for guidance in statistical analysis, manuscript preparation, editing, and review.

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