Psychiatric comorbidity of headache in a medical relief camp in a rural area

Background: Headache is one of the most common complaints seen by primary care physicians, but very few well-planned studies have been conducted to know its prevalence. Aim: To study the prevalence of headache and associated psychiatric morbidity . Methods: A medical relief camp was held in village Mavta (near Ratlam in Madhya Pradesh) in 2002. Of a total of 1350 registered subjects, 80 with primary complaints of headache were referred to our expert team of psychiatrists. Results: Sixty-nine subjects (86.25%) had psychiatric morbidity—mainly affective disorders (depression) and panic disorder, dysthymia, alcohol and nicotine dependence. Subjects with migraine and depression were mostly women with onset of symptoms at an early age. Subjects with less education; who were unmarried or had lost a spouse; those with a nuclear family; who were unemployed and those with a family history and past history of mental illness, were all susceptible to headache and depression. Conclusion: Disturbed sleep, free floating anxiety, sad mood, lack of pleasure, body ache and fatigue were the main presenting complaints along with headache.


INTRODUCTION
In the Indian setting too, subjects present to general Headache is a nearly universal phenomenon with a one-year practitioners with predominant complaints of migraine or prevalence of 90% and a life-time prevalence of 99%. Headache migraine-type headache. But very few well-planned studies is one of the most common complaints seen by primary care have been conducted to study the prevalence of headache physicians. In the United S tates of America, 9% of adults and associated psychiatric morbidity. The present study was consult physicians for headache during a year, of which 83% planned keeping the above facts in view .
resort to self-medication 1  psychiatrists with primary complaints of headache. Of these, is implicated. A history of migraine is associated with increased 69 patients (86.25%) were found to have a primary psychiatric life-time rate of anxiety disorders, illicit drug abuse disorders, diagnosis. These patients were examined for the nature, course, nicotine dependence and suicide attempts. 5 Merikangas et al. duration, type of headache as well as nature of associated also observed a strong association between migraine and complaints. depression, bipolar illness, anxiety and panic disorder. 6 The statistics used were expressed as percentages.   Figure 1 shows the break-up of neurological diagnosis of headache of the 80 patients according to the International Headache Society (IHS, 1988) classification. 7 Migraine (with or without aura) was the most common complaint (44, 55%) followed by tension headache (26, 32.5%).

DISCUSSION
It was not until the end of the nineteenth century that Freud categorically associated the concepts of psychopathology with commonplace migraine. Wolff has been credited with developing the influential notion of 'the migraine personality' that he characterized as a medley of 'personality features and reactions dominant in individuals with migraine', including 'feelings of insecurity with tension manifested as inflexibility , conscientiousness, meticulousness, perfectionism, and resentment'. 9 Numerous epidemiological studies have revealed that psychiatric disorders (e.g. depression and anxiety) occur with greater frequency among recurrent headache patients than among the general population. 5,6 Sixty-nine out of 80 subjects Longitudinal data indicate that relative to men, women are four-times more likely to develop migraine and two-times more likely to develop major depression. 9 Fifty subjects (72.5%) were between 20 and 60 years of age. Most of the subjects with migraine had onset during teenage or early twenties while those with tension headache had a middle age onset; they were mostly women. Sixty subjects (86.5%) were earning less than Rs 2000 and were more susceptible to onset of headache as well as psychiatric morbidity.
In comparison, this study shows MDD (32%), dysthymia (13%), panic disorder with agoraphobia (14.5%), phobia (2.9%), somatoform disorder (6%), substance dependence (26%) including nicotine dependence. The incidence of MDD, dysthymia, panic disorder is comparable, but the results of this study report no GAD, OCD or bipolar disorder. 9, 10 Wacogne et al. 11 measured the intensity of stress, anxiety and depression in a sample of 141 migraineurs compared with a control group of 109 non-migraine workers matched for age and sex. Their results indicated that stress and anxiety were higher in the migraine group than in the control group. The main symptoms were 'morning fatigue', 'intrusive thoughts about work', 'feeling under pressure', 'impatience', and 'irritability'. In the present study, disturbed sleep (30%), free floating anxiety (25%), sad mood (17%), lack of pleasure (14.5%), body ache (14.5%), fatigue (11.6%) were the main complaints.
Headache may be a form of 'somatization' 12 (a term used for the pathology , e.g. depression) when patients cannot verbalize their mental symptoms but present them by way of somatic symptoms. It was also called 'depressive equivalent' and was considered a typical manifestation of depression in non-industrialized countries. 13,14 This hypothesis has been challenged by Patel 2 who proved that this phenomenon is also common in industrialized countries. This may be a crosscultural phenomenon. However, there is at least some evidence that headache can be a manifestation of a somatoform disorder. 15 The most common somatoform disorder associated with headache was 'undifferentiated somatoform disorder'. In somatoform disorder, headache would represent only one of many medically unexplained somatic complaints such as fatigue, loss of appetite, gastrointestinal symptoms, and urinary complaints. 10 Recent characterizations of psychopathology and headache have implicated shared neuropathic mechanisms between migraine and affective disorders and bidirectional influences. Both concepts refer to neuroplastic processes in corticolimbic structures, where an expanding corticolimbic field becomes activated by both nociceptors and psychological stimuli over a period of time, resulting in an integrated relationship between migraine (or pain) and psychiatric disturbance in susceptible individuals. 9 Evidence suggests that patients with elevated psychological symptoms are more likely to seek medical assistance. When present, psychiatric comorbidity often complicates management of headache and portends a poorer prognosis for treatment of headache. These results indicate that patients with long history and high frequency of headaches might benefit from psychiatric evaluation. 16 Physicians must be sensitized to look for psychiatric symptoms in patients presenting with headache.

CONCLUSIONS
• Headache was the main somatic presentation of psychiatric morbidity in nearly 80% of subjects in this study.
• The associated psychiatric morbidity included depression, dysthmia, anxiety, somatoform disorder , phobia and substance abuse.
• Middle-aged women with migraine were more likely to have psychiatric morbidity.
• Also, people who were illiterate, unemployed, or had lost a spouse and with a family and past history of mental illness were more likely to develop mental illness.
• Disturbed sleep, free floating anxiety , sad mood, lack of pleasure, body ache and fatigue were the main presenting complaints along with headache.

LIMITATIONS
• The authors were not able to use any specialized instruments to rate anxiety, depression, etc. due to paucity of time.
• The data were presented merely as percentages. • Better planned, longitudinal studies are required to study this area further.