Review articlePsychiatric perspectives on headache and facial pain☆
Section snippets
Stress and headache
Stressful life events, major and minor, are known to be associated with the onset, exacerbation, and maintenance of headache. In one study of headache risk factors, stress was found to be a more important precipitant of migraine than was change in the weather or onset of menstruation [3]. Severe headache can follow closely significant adverse life events such as a new diagnosis of major illness, or death or serious injury in a close family member [4]. Sheftell proposed that the learned
Depressive spectrum disorders
The association of headache with depression is clearly established. In the case of migraine, the association is bidirectional, suggesting a possible shared neurochemical basis likely involving the serotonergic system [8], [9]. It is the frequency rather than the severity of headache that predicts the presence of depression [10], with the association being particularly strong for women with transformed migraine [11]. Patients with chronic tension-type headache are three to 15 times more likely
Criteria for major depressive episode
- A.
Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depressed mood or (2) loss of interest or pleasure.
- (1)
Depressed mood most of the day, nearly every day, as indicated by either subjective report (eg, feels sad or empty) or observation made by others (eg, appears tearful). Note: in children and adolescents, can be irritable mood.
- (2)
Markedly diminished interest or pleasure
- (1)
Diagnostic criteria for dysthymic disorder
- A.
Depressed mood for most of the day, for more days than not, as indicated either by subjective account or observation by others, for at least 2 years. Note: in children and adolescents, mood can be irritable and duration must be at least 1 year.
- B.
Presence, while depressed, of two (or more) of the following:
- (1)
Poor appetite or overeating
- (2)
Insomnia or hypersomnia
- (3)
Low energy or fatigue
- (4)
Low self-esteem
- (5)
Poor concentration or difficulty making decisions
- (6)
Feelings of hopelessness
- (1)
- C.
During the 2-year period (1 year
Anxiety disorders
The symptom of anxiety is highly prevalent in the general population, and is frequently reported by patients who suffer from headache, particularly those with chronic or frequent headaches. Anxiety can coexist with depression or be independently associated with headache. Holroyd studied a cohort of 245 chronic tension-type headache patients versus matched control subjects and found that the tension headache patients were three to 15 times more likely to be diagnosed with anxiety or mood
Criteria for panic attack
A discrete period of intense fear or discomfort, in which four (or more) of the following symptoms develop abruptly and reach a peak within 10 minutes:
- (1)
Palpitations, pounding heart, or accelerated heart rate
- (2)
Sweating
- (3)
Trembling or shaking
- (4)
Sensation of shortness of breath or smothering
- (5)
Feeling of choking
- (6)
Chest pain or discomfort
- (7)
Nausea or abdominal distress
- (8)
Feeling dizzy, unsteady, lightheaded, or faint
- (9)
Derealization (feelings of unreality) or depersonalization (being detached from oneself)
- (10)
Fear of losing
Diagnostic criteria for generalized anxiety disorder
- A.
Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
- B.
The person finds it difficult to control the worry.
- C.
The anxiety and worry are associated with three (or more) of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months). Note: only one item is required in children.
- (1)
Restlessness or feeling keyed up or on edge
- (2)
Being
- (1)
Diagnostic criteria for pain disorder (associated with psychological factors)
- A.
Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.
- B.
The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
- C.
Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.
- D.
The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or
Diagnostic criteria for somatization disorder
- A.
A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.
- B.
Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:
- (1)
Four pain symptoms: a history of pain related to at least four different sites or functions (eg, head, abdomen, back, joints,
- (1)
Management of somatization disorder
- 1.
The patient should have only one doctor, preferably an internist or family practice physician.
- 2.
The patient should be seen on a regular basis (usually once weekly or once every two weeks), whether they are symptomatic or not.
- 3.
Visits should be short (15–20 minutes) and have a definite start and end time.
- 4.
The physician should listen to the patient's complaint(s). The complaint(s) may be viewed as a communication rather than as a specific call to action.
- 5.
The physician should minimize the use of tests
Summary
For a subset of headache patients, an understanding of psychological antecedents and interpersonal difficulties is an important part of the headache evaluation. This subset includes patients with chronic headache, frequent headache, treatment-refractory headache, analgesic misuse problems, and serious compliance issues. Inadequate coping with stress is central to the persistence of headache in many such patients. Other patients present to the headache specialist but actually suffer from a
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2013, Nasal Physiology and Pathophysiology of Nasal DisordersMental turmoil, suicide risk, illness perception, and temperament, and their impact on quality of life in chronic daily headache
2008, Journal of Headache and Pain
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The authors wish to thank American Psychiatric Publishing, Inc., for permission to use the Diagnostic Criteria for Major Depressive Episode, Dysthymic Disorder, Panic Attack, Generalized Anxiety Disorder, Somatization Disorder, and Pain Disorder from Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC: American Psychiatric Association, 2000.