February 13 Highlight and Commentary

Depression in patients with headache

Jelinski et al. analyzed prospectively collected data from 712 patients referred to headache specialists. Factors independently associated with depression were younger age; being unemployed, on disability pension, or welfare; being widowed, separated, or divorced; and a diagnosis of transformed migraine or headache associated with head trauma or cervical spine disorder.

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Predictors of depression in patients referred to headache specialists

Commentary by Linda S. Williams, MD, and Matthew J. Bair, MD, MS

Pain and depression not only commonly co-occur, but this co-occurrence is also associated with increased morbidity vs either condition alone, negatively impacts treatment response for either condition, and may share common neurotransmitter and neurophysiologic pathways.^1,2 This co-occurrence has been documented in primary care settings, in patients referred to a general neurology outpatient clinic, and specifically in patients with headache.^3–5

Although the relationship between pain and depression is widely accepted, the bidirectional nature of this relationship remains complex and not fully elucidated. Depression amplifies the physiologic response to pain. Similarly, pain-related functional limitations frequently lead to the development of depressive symptoms. Jelinski et al. highlight this relationship in patients with headache, and further explore associations between specific headache types and depression.⁶ As expected, this study found a high prevalence of depression (27) among the total sample of headache patients, with the highest prevalence in those with transformed migraine, head trauma, or cervical spine disease. When headache type was controlled for in the analysis, remaining factors associated with depression included younger age, being unemployed or on disability/welfare, being more socially isolated, and reporting greater headache impact and disability.

Although the study is limited by inherent selection bias, by its cross-sectional nature, and by a lack of control for clustering of observations within sites, this study reminds us that the care of patients with headache should include standardized depression screening. Moreover, a subsequent plan for guideline-based depression treatment is a part of providing high quality care. Despite the “Psychiatry” in the accrediting American Board of Psychiatry and Neurology, neurologists often leave depression screening and treatment to psychiatrists and primary care providers. This study underscores the fact that patients with headache, especially chronic debilitating headache, frequently have co-existing major depressive disorder. Neglecting depression assessment and subsequent treatment may thus negatively impact the response to headache treatments. Moreover, antidepressants have been shown to be effective in the treatment of chronic headache.^7,8 Given the common co-occurrence and overlapping treatments between headache and depression, we need to develop innovative treatment models that incorporate assessment and treatment of both conditions in order to delivery quality care and improve patient outcomes.

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