Clinical manifestations

Presentation and course

Listed below are the various headache most often associated with psychological factors.

Tension-type headache. Tension-type headaches are the headaches seen most often in medical practice. Although organic factors are believed to be involved in most cases, most individuals who have tension-type headache also have associated emotional stress (80). Frequently, the fundamental psychic factors are unconscious, although patients are typically aware of their anxiety. The headache may be associated with insufficient coping strategies in the face of various degrees of psychological stress. Yucel and colleagues noted that, compared with healthy controls, patients with tension-type headaches were more likely to experience depressive thoughts and alexithymia (an inability to identify emotion) (119). Tension-type headache sufferers report experiencing more everyday mild stressors, judge these stressors to have high impact, and use less successful strategies for coping with daily stressors. These individuals may also have greater pain sensitivity, reduced pain thresholds, and increased muscle tenderness (11).

Migraine headache. Migraine has been more intensely studied than any other form of headache. Many have theorized that specific personality traits are characteristic of migraine sufferers (31; 46). Friedman reported that personality manifestations in migraine embraced a variety of primarily unconscious emotional factors, including hostility, identification with a family figure, a wish to remain in a position of dependency, or a means to gain love, affection, or attention (45).

Saper and Lake were even more specific in their observation that patients with borderline personality disorder seem to have increased tendency towards migraine and severe headaches (96). Huber and Henrich compared migraineurs with healthy controls, using the Minnesota Multiphasic Personality Inventory and other questionnaires, to find that the migraineurs rated themselves as less calm, less capable of relaxing, more irritable, and more likely to respond to situations with a sense of internal stress, than the healthy controls (55). Viticchi and colleagues observed significant obsessive-compulsive disorder traits among chronic migraine patients, more so among men than women (111). Stress was the most common precipitation factor for migraine attack (84). In a study with women migraineurs, the results showed that stress, influenced by anxiety and depression, was a more powerful trigger for migraines than menstruation (82). However, the notion that pathologic personality traits cause migraine is controversial; no single personality pattern exists that could describe all migraine patients.

Kowacs and colleagues found that migraineurs had higher scores for depressive and anxiety disorders (63). Most subjects with migraine and depression also have a history of at least one anxiety disorder. Comparing the psychological variables between acute or episodic with chronic migraine, patients with chronic migraine were depressed, exhibited a lack of anger control (36), and had higher hysteria scores (03). Children and adolescents with migraine were also at higher risk of anxiety and depression symptoms and disorders (40). These studies indicate that the association between migraine and depression is most likely bidirectional (ie, each disorder increases the risk for development of the onset of the other disorder).

Conversion headache. There is often a delay in diagnosing conversion headache. The physician may believe that emotional factors play a role in headaches, but conversion headaches initially do not stand out in any remarkable way from other types of headaches. Patients will often deny any disturbing emotional relationships or events in their lives. This denial is the basis for the conversion reaction, as the patient unconsciously copes with psychological distress by “converting” the underlying conflict into a more manageable physical symptom. Most patients show a calm indifference to the pain. This affective indifference is often a valuable clue in diagnosing conversion headache (79).

Cluster headache. There is less clear evidence of the role of neuropsychological factors in cluster headache. Patients with cluster headache were found to have anankastic, anxious, histrionic, schizoid, impulsive, and paranoid personality traits (77) and were also obsessive-compulsive, narcissistic, and avoidant (88). A cross-sectional study compared cognitive and emotional functioning in individuals with episodic and chronic cluster headaches with healthy controls. The findings revealed that having cluster headaches was associated with worse working memory, mood disturbance, and increased rates of anxiety (108). One limitation of the study was its small sample size. In a large population-based cohort study, patients with cluster headaches were found to have 5.6 times greater odds of developing depression when compared to controls. Suicidal ideation was two to three times higher as compared to controls, but the actual act of suicide seems rare. Suicidal tendencies are more common in chronic and active than inactive cluster headache patients (97).

Prognosis and complications

There is little doubt as to the negative impact and complications facing adults (44) and pediatric (90) headache sufferers alike. When psychological factors are at play, prognosis depends on the nature and severity of psychopathology, the patient's motivation toward treatment and recovery, and the skill of the practitioner. The date from American Registry for Migraine Research between February 2016 and June 2019 showed anxiety and depression were associated with migraine-related disability, reduced work productivity, and career success (83). Headache frequency, the number of headache days (HDs) per month, is associated with higher risk of anxiety and depression, severe disability, and lower quality of life. Irimia and colleagues found the risk of anxiety is higher in patients having ≥ 3HDs, depression ≥ 19HDs, and very severe disability ≥ 10HDs per month (57). The longer duration, more frequent migraine attacks, and headache with substantial to severe impact were predictors of both disability and impairment in quality of life; in addition, comorbid psychiatric conditions were found to be a significant contributory factor (91). Other prognostic indicators include an insecure style of attachment along with depressive symptomatology, female sex, and number of headache days per month (95). Giri and colleagues evaluated the bidirectional relationship between migraine, tension-type headache, and affective disorders in a large-scale, population-based 11-years longitudinal study (48). They found patients with migraine or tension-type headache were about 30% increased risk of depression, whereas depression more than doubled risk of migraine, a 40% increased risk of tension-type headache. In addition, higher risk of anxiety was found for migraine with aura than for migraine without aura. Adolescent headache, particularly migraine, is associated with anxiety, mood, and behavior disorders in a nationally representative sample of U.S. youth, and headache is highly prevalent among youth with mental disorders (54). A study by Carasco and Kroner-Herwig showed that children 9 to 15 years of age who suffered from weekly headaches and exhibited highly dysfunctional coping strategies (internalizing or externalizing symptoms, anxiety sensitivity, and somatosensory amplification) had reduced probability of headache remission (21). Furthermore, behavior disturbances among children and adolescents may also be a complication of headache.

Clinical vignette

A 32-year-old mother of three presented to the psychiatric emergency service with complaints of headache and numbness. She was a graduate student and was the sole parent of her three children. Over the past 6 months, she had begun a job in food delivery on top of her studies and parenting. Four months prior to the presentation, she began to notice headaches, which became essentially daily headaches. The pain was holocephalic, pressure-like, and somewhat fluctuated through the day, although it worsened in the early morning and late afternoon hours. The headache was occasionally associated with feelings of fear, as well as malaise. She denied nausea, photophobia, and phonophobia, and did not notice worsening of the headache with exertion. During one week, her mother visited and she noticed that the quantity and duration of headaches were significantly reduced that week.

She presented to psychiatry with complaints of excessive tension and concerns that she may have a brain tumor causing her symptoms. Neurologic consultation was requested.

Her past history was remarkable for episodic tension-type headaches as a teenager, but she was otherwise well. She had been using ibuprofen and acetaminophen for analgesia over the past 4 months. Her remaining history was noncontributory. The neurologic examination was completely normal, with pericranial tenderness noted on examination. Computerized tomography of the brain was entirely normal.

The patient was diagnosed with chronic tension-type headache with pericranial tenderness (IHS 2.3.1). She was reassured that neurologic examination and neuroimaging did not demonstrate any evidence of a brain tumor. Education about the importance of emotional and physical stressors on her headache syndrome was provided. It was explained that her life stressors were contributing to her headache. It was suggested that she ask family members to assist with parenting during times of excessive stress surrounding her studies and work. She agreed that awareness and acceptance of her limitations were important to improving her current health. She declined psychotherapy but agreed to pharmacotherapy with amitriptyline starting at 10 mg nightly, increasing up to 50 mg nightly over 4 weeks. One month later, her headache frequency was decreased to 14 days of the month, and the headache severity was improved.

Biological basis

Etiology and pathogenesis

The biological bases for headache are well documented and established. The role of psychological factors in headache, although widely accepted, remains complex and multifaceted. Research in this area, although limited, seems to indicate that psychological factors may act on the body through central subcortico-cortical pathways (16; 25; 22) and hormonal pathways (81). Psychophysiological mechanisms involve the influence of prolonged or intense emotional states or chronically held attitudes on the body. These attitudes or emotions (either conscious or unconscious) bring about physiological changes to prepare for actions or consequences. Psychosomatic illnesses eventually produce physical symptoms (49).

The contribution of both genetic and environmental factors in headache syndromes may eventually result in psychologically influenced headaches. Psychological stress, including both major stressful events and daily hassles, can trigger headache and also increase the intensity of headache (112). Stress can increase sensitivity to pain and lower the pain threshold in sensory receptors, making individuals more prone to headache pain and intensity; furthermore, chronic stress has been found to increase pain sensitivity in both headache sufferers and healthy controls (23).

Tension-type headache and brain metabolites were investigated with proton magnetic resonance spectroscopy, and a correlation between low choline/creatine ratio in the primary somatosensory cortex and high trigger point count was found (74). Central factors leading to exacerbation of headaches may occur through involuntary contractions of head and neck muscles, a loss of inhibition through supraspinal pathways, or supraspinal hypersensitivity to nociception (41; 72; 76; 69; 20).

Another potential factor in headache’s psychological and functional etiology is sleep disruption. Although the relationship between a sleep disorder and a headache syndrome is unclear and probably complex, changes in duration and sleep quality can affect headache syndromes (89). Petit and colleagues hypothesized that sleep deprivation-induced transcriptional changes may trigger migraine by reducing glycogen availability, which slows clearance of extracellular potassium and glutamate. Inadequate astrocytic glycogen turnover may be one of the mechanisms linking migraine, mood disorders, and sleep (87). Even “moderate” sleep problems have been associated with headache (odds ratio 3.60, 95% CI), with the association increasing as the sleep disturbance worsens (18). The association between headache and sleep disturbances is strongest for headaches that occur during the night or early morning, not including hypnic headache. Sleep fragmentation, insomnia, and hypersomnia all have a relationship to headache syndrome exacerbation (58).

Although the role of dietary factors in migraine is not well understood and may be overrated, some research suggests it may be important. Commonly reported migraine triggers include wine, cheese, chocolate, and processed meats (43). In a study using a large, nationally representative sample of women, the results found no differences in dietary intake among women with and without migraine. However, among normal-weight women, those with migraine had reduced dietary quality (39). Another study found that lower sodium intake was associated with a decreased risk of headache (05). Physical exercise has also been considered effective for treating migraine (62). The exact mechanism for this association is unknown. Additionally, obesity has been linked with the prevalence and frequency of migraine in both adults and youth (110).

Shared genetic basis of migraine and mental disorders was investigated by Bahrami and colleagues (14). They identified specific loci shared between migraine, and depression and schizophrenia, implicating shared molecular mechanisms.

Epidemiology

Headache disorder is among the most common medical complaints worldwide. “Head pain” was the fifth leading cause of emergency department visits overall in the United States and was among the top 20 reasons for outpatient office visits (103). A 1-year prevalence of 26% for tension headache of 14% for migraine was estimated globally, higher among female and individuals aged between 20 and 50 years of age (47). The 2011 National Health Interview Survey interviewed 101,875 adults from 39,509 households and found that overall age-adjusted prevalence of severe headache or migraine in the previous 3 months among adults aged 18 or older was 16.6% (10.8% for males and 22.3% for females) (National Center for Health Statistics 2011). In Norway, comparing the time periods of 2017 to 2019 and 2006 to 2008, the 1-year prevalence of tension-type headache was 20.7% versus 15.9%, migraine was 11.1% versus 12.0%, and medication overuse headache was 0.3% versus 1.0% with high risk in young age, female, depression, or anxiety (52). Since the declaration of COVID-19 as a pandemic, headache was the most common reported symptom in 32.3% of 906 healthcare workers, and depression, anxiety, stress, and PTSD were significantly associated with the presence of physical symptoms (26).

In children and young adults aged 7 to 21 years, tension-type headache occurs with a prevalence of 20% (25% for females and 14% for males). Over the past 4 decades, the incidence of migraine with aura in 7-year-old children has increased from 5.2 per 1000 person-years in 1974 to 41.3 per 1000 person-years in 2002. Likewise, the increase in the rates of migraine without aura was from 14.5 per 1000 person-years in 1974 to 91.9 in 2002. It is not yet clear if this large increase in incidence can be attributed to changes in children's lifestyles (12).

Finally, it is difficult to determine the number of instances in which psychological factors are primarily implicated in headache. Further complicating etiologic data are that no studies exist regarding the incidence or prevalence of conversion headache.

Prevention

Although no specific psychological methods of prevention are known, many of the factors below have been observed to predict headache. Those factors should be prevented or mitigated.

Psychotherapy and biofeedback are appropriate supplements in not only the treatment of pain, but also in prevention, providing patients with an effective skill set to manage their lives and cope with pain (32).

Differential diagnosis

Conversion headaches should not be classified with headaches related to psychosis or delusional states or hypochondriasis. A conversion headache may be differentiated from the head pain described by the psychotic patient because the patient invariably displays other manifestations of psychosis (tangential thinking, hallucinations or delusions, loose associations, and asocial behaviors). The hypochondriacal patient will be noticeably anxious, not only about the headaches, but about many additional body functions that he or she fears are malfunctioning; the patient with conversion headache will usually only complain about headaches. Patients with somatization disorders also have numerous complaints affecting many organ systems (114).

Many patients with primarily psychological headaches are overly concerned about serious disease or brain tumors. Although most serious diseases associated with headache are rare, the physician must be alert to the possibility of headache-related brain tumors. A distinguishing feature of brain tumor headaches is the appearance of a headache that occurs for the first time in middle age or later, or the appearance of a new headache in a patient with chronic headache. In such cases, diagnostic tests, such as a contrast-enhanced CT scan or an MRI, are indicated.

Associated or underlying disorders

It is important to consider psychiatric comorbidities in the face of a headache syndrome.

Medication overuse headache is a largely underdiagnosed health condition and is now the third most frequent type of headache (34). Medication overuse headache is defined as occurring when a headache sufferer experiences headache for 15 or more days per month and is overusing medication for pain (53). Additionally, in order to be considered a medication overuse headache, within 2 months of discontinuation of the overused medication, headache must revert to its previous episodic pattern (53). Although all medications prescribed for treatment of headache can cause medication overuse headache (30), the most commonly overused headache medications are triptans, opioids, and analgesics, or any combination, thereof (101).

The proportion of chronic daily headache sufferers in the general population who meet criteria for medication overuse headache is about 30% (101). A pilot study examining tertiary headache clinics reported that 85% of headache patients were overusing medication (66). Interestingly, Zeeberg and colleagues showed that 45% of patients with chronic daily headache and high medication use, treated for 2 months with medication withdrawal alone, showed significant improvement in their headaches (120). Peak prevalence for medication overuse headache in women is in their mid-50s, with 5% of women in this age range meeting the diagnostic criteria for medication overuse headache (29).

A study of French patients with either migraine or medication overuse headache indicated that those patients with medication overuse headache were more likely to suffer mood or anxiety disorders (92). In a case-control study, patients with medication overuse headache showed a high rate of emotion regulation difficulties, depression, and anxiety compared with healthy controls (73). However, it remains unclear if psychiatric comorbidity should be considered as a risk factor for the worsening of headache syndromes, or rather as a risk factor for medication overuse, which contributes to worsening of headache frequency and risk of chronic daily headache (92).

Diagnostic workup

The most important part of headache diagnosis is the history. Four brief communication methods can help this process: empathy, patient education, elicitation of patient perspective, and attention to nonverbal communication (98). These brief communication strategies can be accomplished by clinicians in general, not just psychiatrists and psychologists. There is evidence that these techniques improve outcome, compliance, and patient satisfaction (98).

All patients with headache should receive a complete physical and neurologic examination, even if the headaches are believed to be psychogenic. Appropriate diagnostic studies, such as a CT scan, an EEG, or possibly an MRI, may be necessary to rule out organic causes or potential serious diseases. Most patients with headache have normal results.

If the provider feels that psychological influences are causing the headache, psychological testing may help confirm the hypothesis. The Minnesota Multiphasic Personality Inventory (MMPI-2, MMPI-2-RF) and the Millon Behavioral Medical Diagnostic (MBMD) are often useful in identifying and treating psychological factors in patients with headache. Patients with conversion headaches typically demonstrate a satisfied indifference despite bitter complaining, bizarre and dramatic descriptions of headache pain, and angry denial of any emotional difficulties (79).

Other measures may be used to detect specific levels of depression or anxiety. The Beck Depression Inventory provides a measure of the presence and degree of depression. The State-Trait Anxiety Inventory evaluates the presence of anxiety both at the time of assessment (state anxiety) and as an enduring personality construct (trait anxiety). The Migraine Disability Assessment Scale (MIDAS) identifies the impact of headache on functioning in a range of different areas. These tests may be helpful in detecting stress, anxiety, and tension associated with common headaches or in revealing anxiety associated with a conversion mechanism.

In young children, identification of idiopathic headache is challenged by the absence of a clear, clinical definition of the condition (15).

Management

The complicated interplay of physiology, neurochemistry, and environment on headache lends itself perfectly to a multidisciplinary approach. In addition to providing headache evaluation, long-term treatment, and maintenance of gains, psychological services can also help prevent episodic headaches from becoming chronic by providing life management and coping skills (94).

Various groups of patients with headache should be considered for referral for more focused psychological services. These include those with existing comorbid psychological disorders or self-disclosed history of trauma or abuse; those with limited coping mechanisms or support systems; patients who seek to gain control over their headaches outside of medications; and those who are treatment resistant or do not get anticipated benefits from medical/pharmacological treatment.

The most efficacious treatments include relaxation, guided imagery, mindfulness meditation, biofeedback, and cognitive behavioral therapy. In addition, methods of psychoeducation, stress management, behavioral activation, and prevention offer skill sets that can be utilized long after patients discontinue therapy. Benefits of incorporating psychological care in the treatment plan of patients include improving patient self-efficacy as active members in their own care, streamlining the communication between physicians and patients, and providing patients with a thorough treatment plan that will address the far-reaching effects of headache on quality of life.

Not only do psychological factors figure prominently into the course and progression of headache disorder, but these factors also significantly impact the headache sufferers’ health-related quality of life. Health-related quality of life issues relate to the impact that health issues and treatments have on patients’ functioning and well-being and should be considered in any thorough discussion of headache treatment. Health-related quality of life (HRQoL) is an aspect of overall quality of life that includes an individual’s health state and physical and mental health status (24). So, although the severity of headache symptoms is an important factor in HRQoL, psychological factors are also prominent in influencing HRQoL and headache-related disability (107). Headache-related disability is closely associated with HRQoL, yet it is also distinct. According to the World Health Organization, a disability is a restriction or lack of ability to perform an activity within the range considered normal for most people (118). Generally, improvements in health status equate to improved HRQoL and reduced headache-related disability (71). Psychotherapy and cognitive behavioral interventions aimed at promoting effective coping can improve quality of life across headache disorders.

Learning effective coping strategies can be considered an integral part of headache treatment and a key component in improved prognosis. Lake has identified several coping styles that are considered adaptive when managing headache pain (67). These include a balanced use of distraction and body awareness, proactive (as opposed to reactive) coping (in other words, making plans in advance on how to deal with different situations), balanced interpersonal discussions of pain, acceptance of having pain, and commitment to setting goals and engaging in activities, regardless of pain. In fact, research by Ciere and colleagues suggests that perceptions of goal hindrance and attainability because of headache may have a more negative effect on mood than headache per se (28). This suggests that helping patients with headache to manage goal-oriented activities can have a beneficial effect on mood, even if goals have to be modified, thereby improving headache patients’ HRQoL and ultimately prognosis.

Psychotherapy. Although different forms of psychotherapy can be used to help headache patients gain greater perspective on their headache condition, better manage stress that may be contributory, or learn more adaptive coping skills, cognitive behavioral therapy has been more well-researched in the treatment of headache than any other form of psychotherapy. Cognitive behavioral techniques can help patients change their feelings and achieve a greater sense of control by changing their thinking and coping strategies (59). Cognitive behavioral therapy has the advantage of effecting change in a relatively short period of time. Focusing on the thinking process enables interventions that can make the headache patient a more active participant in the treatment process. A study by Christiansen and associates found that a combination of 10 group therapy and three individual cognitive behavioral therapy sessions yielded both medical and psychological benefits – reducing headache frequency and intensity while also reducing catastrophizing (27).

Although cognitive behavioral therapy tends to be underutilized with pediatric headache populations, Ernst and colleagues, working with 10- to 17-year-olds, found that supplementing standard medical practice with cognitive behavioral therapy (eight weekly treatment sessions and two booster sessions) resulted in fewer headache days and improved quality of life (no or minimal disability) at the 1-year follow-up (37). These gains were superior to those made by a control group that received headache education.

Additional psychotherapeutic approaches have shown promise in working with headache patients. Acceptance and Commitment Therapy (ACT) is a mindfulness-based approach that encourages the observation and awareness of symptoms but reduces their impact by making a commitment to move forward rather than spending effort on cognitively disputing them (75; 104)

Positive Psychology is more of a philosophy and evidence-based theoretical orientation than a formalized psychotherapeutic approach (99; 86). Rooted in cognitive behavioral therapy, it places an emphasis on strength-building by encouraging active steps toward well-being despite the presence of physical pain. Like Acceptance and Commitment Therapy, Positive Psychology places its focus elsewhere than the pain, while not rejecting the fact that headache is a part, but not the entirety, of one’s definition of self.

Biofeedback. Biofeedback is a process that enables an individual to learn how to change physiological activity to improve health and performance (17). Patients learn skills that enable them to directly alter physiological states. During training sessions, the feedback on the computer screen provides the patient with concrete evidence of internal changes, thus, supporting the direct relationship between thoughts, feelings, and behavior and the impact on the body. A study showed that biofeedback added to traditional pharmacological therapy reduced headache frequency and analgesic intake for medication overuse headache (93). Research provides convincing support of the effectiveness of biofeedback for various medical and psychological disorders (105). Emerging digital health technologies, including smartphones and wearable sensors, have provided new possibilities of administering biofeedback (56).

Additionally, patients with headache display a variety of irregular breathing patterns, such as very fast-paced or shallow breathing, supporting the need to train patients in diaphragmatic breathing. Each of these areas is targeted in biofeedback training, with a focus on the interplay between all physiological mechanisms and headache measures, such as frequency, intensity, or duration. Relaxation techniques and stress management are typically incorporated into biofeedback therapy.

Relaxation. In randomized, controlled studies of relaxation training in children and adolescents suffering from recurrent tension-type headache, a therapist-administered relaxation approach was proven to be superior to self-help or school nurse–administered relaxation training approaches (68). Total headache activity, the number of headache days, peak headache intensity, and medication usage were significantly reduced after relaxation treatment within a 6- to 10-month follow-up period (68). Age-specific interventions are important given that children and adolescents experience an interaction between pain, depressive symptoms, and disability differently (70). Additionally, children with both episodic and chronic headache disorders who had at least two biofeedback therapy sessions were found to benefit significantly.

Meditation. Meditation, particularly mindfulness-based stress reduction programs, are mind/body interventions that teach mindfulness meditation/yoga. Research has shown that mindfulness-based stress reduction is effective, safe, and feasible for adults with headaches with regards to headache duration, reduction of headache frequency, disability, and improved overall well-being (116; 10; 50; 51; 102; 38).

Onabotulinumtoxin A injection. Onabotulinumtoxin A injection treatment of patients with both chronic migraine and major depressive disorder led to a significant reduction of disease severity of both chronic migraine and major depressive disorder in eight studies (02). Al-Hashel and colleagues treated patients with chronic migraine over 36 months with 155 units of onabotulinumtoxin A. They found improvement in quality of life in 81% patients and a reduction in symptoms of anxiety and depression (04).