Headache Chronification: Screening and Behavioral Management of Comorbid Depressive and Anxiety Disorders

Authors

  • Todd A. Smitherman PhD,

    1. From the Head Pain Center, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, USA (TA Smitherman, DB Penzien); Department of Family Medicine, Kaiser Permanente, Woodland Hills, CA, USA (M Maizels).
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  • Morris Maizels MD,

    1. From the Head Pain Center, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, USA (TA Smitherman, DB Penzien); Department of Family Medicine, Kaiser Permanente, Woodland Hills, CA, USA (M Maizels).
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  • Donald B. Penzien PhD

    1. From the Head Pain Center, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS, USA (TA Smitherman, DB Penzien); Department of Family Medicine, Kaiser Permanente, Woodland Hills, CA, USA (M Maizels).
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  • Conflict of Interest: No

Todd A. Smitherman, Head Pain Center, Department of Psychiatry and Human Behavior, University of Mississippi Medical Center, Jackson, MS 39216, USA.

Abstract

A growing body of literature implicates comorbid psychopathology as a risk factor for chronification of headache. Despite their prevalence, comorbid psychiatric conditions are not routinely assessed among headache patients. Consequently, efforts to manage such conditions are not commonplace either. The present article briefly reviews a variety of strategies and measures for psychiatric screening among headache patients, focusing primarily on those that have been validated in medical settings, that can be administered quickly, and that involve minimal associated costs. We also describe basic strategies for behavioral management of comorbid depression and anxiety in headache patients.

Abbreviations:
BDI-II

Beck Depression Inventory

BDI-PC

Beck Depression Inventory-Primary Care

GAD

generalized anxiety disorder

GAD-7

Generalized Anxiety Disorder Seven-Item Scale

PHQ-9

Patient Health Questionnaire Depression Module

PSYCHOPATHOLOGY AND HEADACHE CHRONIFICATION

Although many headache patients do not suffer from a comorbid psychological disorder, epidemiological research consistently confirms that headache patients (particularly those with migraine and chronic tension-type headache) are approximately 2 to 5 times more likely to suffer from a depressive or anxiety disorder than are individuals without headache disorders.1-6 More specifically, 22-32% of migraineurs will meet criteria for major depression at one point in their lifetime;1,3 similarly, 51-58% of migraineurs will meet criteria for at least one anxiety disorder, with panic disorder and phobias being particularly prevalent. 1,6 A relatively smaller but growing body of literature has implicated psychiatric comorbidity as a risk factor for the transformation of episodic headache into chronic and daily headache syndromes (chronification), including medication-overuse headache.6-8 Many patients with chronic migraine and chronic tension-type headache endorse higher levels of depression and anxiety than do their nonheadache counterparts.9-10 Comorbid depression and anxiety also are associated with poorer long-term headache outcomes and satisfaction with treatment,4,11 considerably higher medical costs and health care utilization,12 and increased headache-related disability.11

Taken together, these findings are consistent with an evolving conceptualization that views headache as a progressive disorder with identifiable and modifiable risk factors.7,13-15 Recognition and management of psychiatric comorbidity is potentially of great value in preventing headache chronification, although empirical studies of this kind are quite limited. The focus of the present article is thus on describing basic strategies for screening and behavioral management of comorbid psychopathology. We focus specifically on depression and anxiety in view of recent empirical findings suggesting that screening for depression alone is insufficient.11 The strategies reviewed here are intended to be those that can be used for patients with low to moderate levels of comorbid psychopathology, with minimal associated costs, and in the context of contemporary behavioral and pharmacological management of recurrent headache.

Screening for Comorbid Psychopathology.— Psychiatric screening may take many forms in a clinical setting: verbal questioning, administration of disorder-specific or multidimensional screening measures, and/or utilization of a structured diagnostic interview. In most cases, verbal or questionnaire screening is most practical and time-efficient; structured diagnostic interviews are most appropriate to confirm a suspected diagnosis or when the clinical presentation is particularly complex. More detailed assessment is often warranted among patients who are refractory to usual care and who present to headache specialty clinics. Some headache patients are reticent to discuss psychological symptoms; screening often may be facilitated by first asking the patient about related psychological sequelae (eg, sleep difficulties, energy level, social support) and then transitioning to a discussion about the relationship between stress and headache. Unrelieved pain may be the source of anxiety or depression, as well as patient behaviors that appear pathological. Recognition and treatment of comorbid affective disorders is important, but diagnosis of personality disorders16 should be based strictly on DSM-IV-TR criteria.17

Depression.— Verbal screening for depression is most effective when it focuses on the 2 hallmark symptoms of depression as they have occurred over the previous 2 weeks: (1) depressed mood, and (2) loss of interest in usual activities (anhedonia).18 Endorsement of either symptom merits further assessment and should be followed by more in-depth questions (including inquiries about suicidal ideation) and/or administration of a depression-specific questionnaire measure. Numerous self-report measures exist for depression screening,19 and such measures aid in identifying adult primary care patients who are depressed.20

Three of the most commonly used self-report measures for assessing depression are the Beck Depression Inventory-II (BDI-II),21 the BDI-Primary Care (BDI-PC),22 and the Patient Health Questionnaire depression module (PHQ-9).23 These measures all have strong psychometric properties, include questions about cognitive (nonsomatic) symptoms of depression, and can be completed by most patients in five minutes or less. Assessment of cognitive symptoms of depression is critical due to the presence of transdiagnostic symptoms,24 or those symptoms that may result from either headache or depression (eg, sleep disturbances, fatigue, concentration problems) as well as various medication regimens (including headache prophylactics). Because of its brevity, high predictive value, correspondence with diagnostic criteria of depression, and availability at no cost, the PHQ-9 may be the best available depression screening tool for use by primary care clinicians.25 Readers interested in a comprehensive overview of available screening measures for depression, as well as sources to obtain such measures, should consult Maizels, Smitherman, and Penzien.26

Anxiety.— Anxiety disorders are the most common class of psychiatric disorder in the general population,27 and many who suffer from anxiety disorders present initially in primary care settings.28 Screening for anxiety, however, is often more difficult than for depression due to the diffuse nature of anxiety and to the numerous manifestations it may take. Anxious patients do not always appear anxious, and symptoms of the various anxiety disorders (panic disorder, generalized anxiety disorder [GAD], obsessive-compulsive disorder, phobias, etc.) are somewhat distinct from one another. Generally, however, the hallmark symptoms of anxiety are chronic, uncontrollable worry or fear and unpleasant sensations of physiological arousal. In clinical settings, verbal screening may be informative so long as it is targeted to specific anxiety phenomena. For example, questioning a patient about difficulty controlling chronic worry, fear of having panic attacks, or obsessions/compulsions is likely to be much more informative than asking only about “anxiety” more generally. As with depression, the astute clinician must attempt to differentiate problematic symptoms that may be a function of the underlying headache condition from those related to psychiatric disturbance. Dizziness and nausea may be a function of migrainous headache or panic disorder, while muscle tension, insomnia, and concentration problems may present in chronic headache syndromes or in any number of anxiety disorders.

Unfortunately, most screening measures that have been utilized in primary care settings inquire about global anxiety symptoms rather than about specific anxiety disorders. Two of the most common such measures that enjoy moderate psychometric support are the Beck Anxiety Inventory29 and the State-Trait Anxiety Inventory (STAI).30 A recently developed instrument that assesses the cardinal features of GAD has been validated among primary care patients. The Generalized Anxiety Disorder 7-Item Scale (GAD-7)31 is recommended as the measure-of-choice for assessment of GAD in medical settings; the GAD-7 is sensitive also to detection of panic disorder, social phobia, and posttraumatic stress disorder.32 Although they typically are not used as routine screening instruments in medical settings, administration of disorder-specific measures used more commonly in mental health settings is often warranted to evaluate individuals who screen positive on a broad-based anxiety measure or when further information is needed.26 Such disorder-specific measures are reviewed in detail by Maizels et al.26

Behavioral Management of Comorbid Psychopathology.— Behavioral (and cognitive-behavioral) strategies for managing comorbid psychopathology stress the importance of altering behaviors and thoughts that incidentally maintain depression and anxiety. Often, such strategies can be implemented in conjunction with pharmacotherapy and also to facilitate adherence to pharmacotherapy, with the ultimate goal of minimizing the potential for headache chronification. Because it emphasizes some degree of personal control over negative emotional states, behavioral management is appealing and empowering to many headache patients. Moreover, strategies for managing comorbid psychopathology are quite similar to the mainstays of behavioral treatments for headache and thus can be integrated easily into existing treatment protocols.33 Despite their differences, headache and comorbid depression or anxiety are each addressed using relatively similar behavioral techniques (stress management training, modifying negative thinking patterns, relaxation training, etc.). Although they are anchored in common strategies, there are particular nuances to the management of depression vs anxiety.

Behavioral Management of Depression.— Most behavioral strategies for managing depression can be categorized as either: (1) promoting increases in enjoyable and productive activities (“behavioral activation”)34,35 or (2) modifying negative and self-defeating patterns of thinking (“cognitive restructuring”).36,37 Most depressed patients, particularly those reporting some degree of anhedonia, can readily identify previously enjoyed activities that are now neglected. Depressed patients characteristically assume that they will resume such activities once their depression abates; this belief inadvertently maintains their depression by reducing their access to positive reinforcement in the present. The precise nature of avoided activities varies widely across patients, although there are some commonalities: low social support, reduced physical activity/exercise, and decreased goal-directed activities. For some patients, simply instructing them to identify and re-initiate avoided activities may be sufficient to increase their activity levels and improve their moods (eg, emphasizing the importance of resuming valued social activities or writing an “exercise prescription,” in which the patient is instructed to begin exercising regularly). For others, particularly those whose headaches further compound their inactivity, the clinician may need to take a more active role in helping the patient schedule specific activities that are enjoyable and productive (providing a sense of accomplishment). A graded approach is ideal, in which activities of increasing intensity are progressively scheduled and in which the patient continually monitors his or her compliance with activity scheduling and resulting effects on mood.38

Depressed patients typically hold negative beliefs related to personal failure or hopelessness about the future.36 Such beliefs may be expressed in their failure to comply with pharmacotherapy (for headache or depression symptoms), reluctance to increase activity levels, and tendency to focus only on negative events that confirm their beliefs. Management of depression thus often combines some degree of behavioral activation with a concomitant focus on modifying these patterns of depressive cognitions. Patients should be taught to consciously recognize these assumptions and beliefs, develop a greater degree of objectivity about them, and begin to develop more rational and productive ways of thinking.37 Oftentimes, increases in activity can be used as initial “evidence” that long-held beliefs are in fact inaccurate and maladaptive.

Behavioral Management of Anxiety.— Like strategies for managing depression, behavioral management of anxiety incorporates techniques to decrease avoidance behaviors and modify maladaptive thinking. Avoidance of feared stimuli perpetuates anxiety through a process of negative reinforcement: avoidance temporarily removes the unpleasant state of anxiety but ultimately prevents the patient from learning that feared stimuli are relatively harmless. Behavioral management thus focuses on increasing exposure to feared stimuli. Many behaviors associated with anxiety can be conceptualized as avoidance in that they are designed to reduce the discomfort associated with anxiety: compulsive behaviors that characterize obsessive-compulsive disorder, chronic worry in GAD, over-reliance on anxiolytic medications and the presence of a trusted friend in panic disorder, and the like. Strategies for decreasing avoidance promote prolonged exposure to feared stimuli while limiting or restricting the typical avoidance response. Exposure may be accomplished imaginally (eg, retelling a traumatic event) or in the actual feared context (eg, public speaking, shopping in a crowded store). Initial reluctance to engage in exposure often can be allayed by having the clinician model the desired behavior, verbally reinforce progress, and design practices collaboratively with the patient.

Because avoidance behavior perpetuates the belief that anxiety symptoms themselves are harmful, many treatment protocols for anxiety also emphasize the importance of changing anxious patterns of thinking. Contrary to depression, however, the core beliefs associated with anxiety typically are related to danger and vulnerability (ie, of symptoms, places, other people, or the world as a whole).39 Anxiety-disordered individuals typically overestimate the likelihood of the occurrence of feared events and view such events as more catastrophic than they actually are. Helping patients realistically assess their coping skills, teaching such skills when they are lacking, and having patients chart the actual occurrence of feared outcomes often is helpful in modifying these patterns of thinking. Additional strategies such as relaxation training and instruction in general stress management may be implemented as well, as these represent common components of behavioral headache treatments that are applicable also to anxiety. The Table provides a brief overview of behavioral strategies for managing comorbid psychopathology.

Table Table.—. Strategies for Behavioral Management of Comorbid Pyschopathology in Headache Patients
Depression
• Educate the patient about the relationship between thoughts, behaviors, and emotions
• Articulate that changing thoughts and behaviors can help improve depression
• Help the patient develop a plan to identify and increase avoided activities
• Increase access to positive reinforcement in the patient's environment
• Implement methods for expanding the patient's social support network
• Limit exposure to contexts associated with negative emotions
• Have the patient chart out, hour-by-hour, his or her activities during the course of a week
• Have the patient self-monitor desired behaviors and patterns of negative thinking
• Focus on generating rational alternatives to these patterns
• Have the patient identify and list his or her positive qualities and achievements
• Advise the patient in initiation of a regular program of physical activity/exercise
• Provide training in active coping skills and/or general stress management
• Help patients realize they can live a valued life despite their chronic pain
• Encourage the initiation of a new hobby or action toward achieving a neglected long-term goal
• Be alert to the potential for medication-overuse and underlying sleep disturbances
Anxiety
• Educate the patient about the relationship between thoughts, behaviors, and emotions
• Articulate that changing thoughts and behaviors can help improve anxiety
• Help the patient identify overt and covert methods of avoiding feared stimuli
• Decrease avoidance behavior through imaginal or in vivo exposure exercises
• Have the patient write in a diary about a past traumatic experience and associated emotions
• Have the patient monitor avoidance behaviors and patterns of negative thinking
• Focus on generating rational alternatives to these patterns
• Have the patient chart fearful predictions and the actual incidence of their occurrence
• Relaxation training (such as progressive muscle relaxation commonly used with headache)
• Instruct the patient to set aside 20-30 minutes each night for worry (rather than worrying throughout the entire day)
• Advise the patient in initiation of a regular program of physical activity/exercise
• Provide training in active coping skills and/or general stress management
• Help patients realize they can live a valued life despite their chronic pain
• Be alert to the potential for medication-overuse and underlying sleep disturbances

Nearly all headache patients would benefit from attention to psychological factors during assessment and treatment of headache. In clinical practice, however, a comprehensive biobehavioral program may not be feasible, because of either limited availability or patient reluctance to consider psychological factors that relate to their headaches. Referral to a behavioral health specialist is warranted when a patient's comorbid psychopathology is severe or does not respond to the brief interventions described above, or in situations wherein headache is clearly exacerbated by ongoing lifestyle issues. Behavioral health specialists are usually psychologists who are located within academic medical centers/universities or large medical practices, although many comprehensive headache centers now employ such professionals. When behavioral health specialists are not available, referral to a general clinical psychologist or psychiatrist is appropriate. Ongoing collaboration between the referring physician and the behavioral health specialist increases the likelihood of a successful patient outcome.

CONCLUSIONS

Comorbid psychiatric disorders represent a modifiable risk factor in the transformation and chronification of migraine and tension-type headache. Screening for depression and anxiety should be incorporated to assess for the presence of comorbid psychopathology, and we have reviewed strategies and tools for psychiatric screening with headache patients. Basic behavioral strategies for managing modest levels of comorbid psychopathology can be integrated relatively easily into existing headache management protocols and emphasize the importance of modifying perpetuating behaviors and maladaptive cognitions.

Ancillary