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Original Article
A comparative study of psychiatric comorbidity, quality of life and disability in patients with migraine and tension type headache Sagar Chandra Bera, Sudhir K. Khandelwal, Mamta Sood, Vinay Goyal1 Departments of Psychiatry, and 1Neurology, Neurosciences Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
Abstract Objectives: To compare psychiatric co‑morbidity, quality of life and disability between patients of migraine and tension type headache and healthy controls. Materials and Methods: Study subjects included 40 consecutive adult patients each with migraine and tension type of headache (TTH) of either gender fulfilling International Headache Society‑II criteria and suffering for 2 years They were recruited from a headache clinic in a tertiary care teaching hospital and were assessed on Mini International Neuropsychiatric Interview (MINI), World Health Organization Quality of Life‑BREF (WHOQOL-BREF) Hindi version and the Headache Impact Test‑6 (HIT‑6). Age and sex matched 40 healthy controls were assessed on MINI and WHOQOL-BREF. The three groups were compared for statistical significance on various scales. Results: Depression emerged as the most prevalent psychiatric disorder in both the headache groups. There was significant impairment in quality of life on all domains along with functional disability in subjects with both types of headache. Conclusion: Psychiatric comorbidity, especially depression is common in patients with migraines and tension type headache. Quality of life and functional ability are significantly impaired in these patients. The clinician should remain aware of consequences of prolonged headache, and should provide timely intervention.
Address for correspondence: Dr. Sagar Chandra Bera, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi ‑ 110 029, India. E‑mail: [email protected] Received : 02-05-2014 Review completed : 24-08-2014 Accepted : 05-10-2014
Key words: Disability, migraine, psychiatric comorbidity, quality of life, tension
type headache
Introduction Headache is one of the most common presenting complaints in people attending primary care centers and majority of them have primary headache Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.144445
516
syndromes. [1] The reported lifetime and one year prevalence rates in adult population were 64% and 46% respectively.[2] Headache disorders are associated with disability in both the genders, more so in women.[3] Epidemiological studies have established a strong association between primary headaches and psychiatric disorders[4] and the reported prevalence was 66.1%,[5] depressive and anxiety disorders being the common disorders. [4,6,7] The reported rates of psychiatric comorbidity ranged between 69-87% in migraine and 45-56% in tension type of headache (TTH). [4,5,8,9] Psychiatric comorbidity complicates the management of patients with headache and it's association leads to poor prognosis.[10‑13] Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
[Downloaded free from http://www.neurologyindia.com on Thursday, November 13, 2014, IP: 202.177.173.189] || Click here to download free Android application fo journal Bera, et al.: Psychiatric co-morbidity, quality of life and disability in migraine and tension type headache
World Health Organization (WHO) defines the quality of life as an individual’s perception of his/her position in life in the context of the culture and value systems, and in relation to his/her goals, expectations, standards and concerns. [14] That headache impacts quality of life has been well–established in a number of studies.[15‑17] Previous studies reported 68-94% of patients have moderate to severe disability on the functioning of activities of daily living.[18,19] However, majority of the studies assessing headache related disability have focused only on migraine. In India, Rao et al. reported prevalence of headache disorders to be 23% in general population, contributing significantly to disease burden.[20] A few Indian studies have reported a higher psychiatric comorbidity rates, however, these studies were retrospective in nature and thus may not reflect the true frequency.[21] The other limitations include: non‑application of specialized instruments and standard criteria for diagnosis of headache disorders,[22] and study of only depressive and anxiety symptoms.[23] In India quality of life was assessed in clinic‑based patients with migraine using Short Form‑36. However, there is lack of normative data on short form- 36 in Indian subjects.[23] There are no studies on psychiatric comorbidity and quality of life in patients with TTH and also on the disability in patients with headache disorders from India. Hence is the present study.
validation and reliability scores. [25] World Health Organization Quality of Life‑BREF (WHOQOL-BREF) Hindi version was used to assess quality of life. It has good to excellent psychometric properties. [26‑28] The Headache Impact Test‑6 (HIT‑6), a likert type, six item questionnaire, was used to measure impact of headache on the daily life of the respondent, and it has demonstrated utility for generating quantitative and pertinent information on the impact of headache.[29‑31] The HIT‑6 exhibits excellent accessibility and ease of use.[32] The controls were assessed only on MINI and WHOQOL‑BREF. Institute Ethics Committee has given the ethical clearance for the study. Patients diagnosed with psychiatric comorbidity were referred to psychiatric services.
Materials and Methods
Of the 108 patients with headache screened 80 (Group A migraine 40 and Group B TTH 40) patients met the inclusion criteria. Similarly of the 48 accompanying persons approached for inclusion as control; 40 persons met the inclusion criteria (Group C).
The study subjects, 40 patients each with migraine and TTH, were recruited from the outpatient headache clinic at a tertiary care teaching hospital in north India. The inclusion criteria were disease duration for 2 years and age-range 18-50 years of either sex. The diagnosis of headache type was made using International Headache Society‑II (IHS‑II) criteria.[24] The subjects with known psychiatric disorder, major physical morbidity, other neurological disorders and substance and alcohol dependence other than tobacco were excluded. Control group included 40 healthy subjects in the age-group of 18-50 years of either gender recruited from the headache clinic. The subjects and controls who were conversant in English or Hindi and willing to give informed consent were included. Neurologist assessed the neurologic status and the psychiatric comorbidity, quality of life and disability was assessed by psychiatry consultants. Mini International Neuropsychiatric Interview (MINI) was used for making diagnosis of major depressive disorder, suicidality, panic disorder, generalized anxiety disorder, agoraphobia, social phobia, and obsessive‑compulsive disorder using respective modules. MINI is a brief structured diagnostic interview for psychiatric disorders, and it has acceptably high Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
Statistical analysis was done using Statistical Package for Social Science‑version 15 (SPSS‑15). In case of continuous variables t‑test was done, and for qualitative variables Pearson Chi‑square were applied. Multiple comparisons done by Pearson Chi‑square/Fisher exact with Bonferroni correction for analysis of psychiatric comorbidity. Data for quality of life was analyzed as per instructions in the manual of WHOQOL‑26 BREF version using one way ANOVA.
Results
Mean age was: 33.45 years (± 6.59), 31.75 years (± 5.35) and 32.95 years (± 4.73) for groups A, B and C respectively. Sample comprised of 65%, 60% and 55% females in group A, B and C respectively. Sample comprised of 62.5%, 52.5% and 62.5% married person in group A, B and C respectively. Occupational status of the study population (N = 120) was: professionals (18.3%), workers (25%), home‑makers (39.2%), students (5%), and unemployed (12.5%). Educational status of the study populations (N = 120) was: illiterate (10%), educated up to middle (28.3%), matric (17.5%), intermediate (9.2%), graduate (20%), and post‑graduate (15%). Rural background of the sample was in: 52.5%, 45% and 47.5% in group A, B and C respectively. There were no significant differences among all three groups for age (P = 0.38), sex (P = 0.56), marital status (P = 0.63), occupation (P = 0.55), education (P = 0.99) and residence (P = 0.79). The average duration of headache was 6.15 (± 2.69) and 6.77 (± 2.33) years for group A and B respectively and no significant difference was observed between group A and B (P = 0.584). 517
[Downloaded free from http://www.neurologyindia.com on Thursday, November 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for journal Bera, et al.: Psychiatric co-morbidity, quality of life and disability in migraine and tension type headache
Prevalence of psychiatric disorders among three groups is given in Table 1. Multiple comparison done by Pearson Chi‑square/Fisher exact test with Bonferroni correction showed no significant difference between group A and B for overall presence of psychiatric co‑morbidity (P = 0.81). In groups A (P = 0.001) and B (P = 0.001), number of persons having any psychiatric disorder was significantly more than group C. Major depressive disorder and social phobia were significantly more common in patients in group A compared to group C (P = 0.008 and 0.012 respectively; P
Original Article
A comparative study of psychiatric comorbidity, quality of life and disability in patients with migraine and tension type headache Sagar Chandra Bera, Sudhir K. Khandelwal, Mamta Sood, Vinay Goyal1 Departments of Psychiatry, and 1Neurology, Neurosciences Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
Abstract Objectives: To compare psychiatric co‑morbidity, quality of life and disability between patients of migraine and tension type headache and healthy controls. Materials and Methods: Study subjects included 40 consecutive adult patients each with migraine and tension type of headache (TTH) of either gender fulfilling International Headache Society‑II criteria and suffering for 2 years They were recruited from a headache clinic in a tertiary care teaching hospital and were assessed on Mini International Neuropsychiatric Interview (MINI), World Health Organization Quality of Life‑BREF (WHOQOL-BREF) Hindi version and the Headache Impact Test‑6 (HIT‑6). Age and sex matched 40 healthy controls were assessed on MINI and WHOQOL-BREF. The three groups were compared for statistical significance on various scales. Results: Depression emerged as the most prevalent psychiatric disorder in both the headache groups. There was significant impairment in quality of life on all domains along with functional disability in subjects with both types of headache. Conclusion: Psychiatric comorbidity, especially depression is common in patients with migraines and tension type headache. Quality of life and functional ability are significantly impaired in these patients. The clinician should remain aware of consequences of prolonged headache, and should provide timely intervention.
Address for correspondence: Dr. Sagar Chandra Bera, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi ‑ 110 029, India. E‑mail: [email protected] Received : 02-05-2014 Review completed : 24-08-2014 Accepted : 05-10-2014
Key words: Disability, migraine, psychiatric comorbidity, quality of life, tension
type headache
Introduction Headache is one of the most common presenting complaints in people attending primary care centers and majority of them have primary headache Access this article online Quick Response Code:
Website: www.neurologyindia.com PMID: *** DOI: 10.4103/0028-3886.144445
516
syndromes. [1] The reported lifetime and one year prevalence rates in adult population were 64% and 46% respectively.[2] Headache disorders are associated with disability in both the genders, more so in women.[3] Epidemiological studies have established a strong association between primary headaches and psychiatric disorders[4] and the reported prevalence was 66.1%,[5] depressive and anxiety disorders being the common disorders. [4,6,7] The reported rates of psychiatric comorbidity ranged between 69-87% in migraine and 45-56% in tension type of headache (TTH). [4,5,8,9] Psychiatric comorbidity complicates the management of patients with headache and it's association leads to poor prognosis.[10‑13] Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
[Downloaded free from http://www.neurologyindia.com on Thursday, November 13, 2014, IP: 202.177.173.189] || Click here to download free Android application fo journal Bera, et al.: Psychiatric co-morbidity, quality of life and disability in migraine and tension type headache
World Health Organization (WHO) defines the quality of life as an individual’s perception of his/her position in life in the context of the culture and value systems, and in relation to his/her goals, expectations, standards and concerns. [14] That headache impacts quality of life has been well–established in a number of studies.[15‑17] Previous studies reported 68-94% of patients have moderate to severe disability on the functioning of activities of daily living.[18,19] However, majority of the studies assessing headache related disability have focused only on migraine. In India, Rao et al. reported prevalence of headache disorders to be 23% in general population, contributing significantly to disease burden.[20] A few Indian studies have reported a higher psychiatric comorbidity rates, however, these studies were retrospective in nature and thus may not reflect the true frequency.[21] The other limitations include: non‑application of specialized instruments and standard criteria for diagnosis of headache disorders,[22] and study of only depressive and anxiety symptoms.[23] In India quality of life was assessed in clinic‑based patients with migraine using Short Form‑36. However, there is lack of normative data on short form- 36 in Indian subjects.[23] There are no studies on psychiatric comorbidity and quality of life in patients with TTH and also on the disability in patients with headache disorders from India. Hence is the present study.
validation and reliability scores. [25] World Health Organization Quality of Life‑BREF (WHOQOL-BREF) Hindi version was used to assess quality of life. It has good to excellent psychometric properties. [26‑28] The Headache Impact Test‑6 (HIT‑6), a likert type, six item questionnaire, was used to measure impact of headache on the daily life of the respondent, and it has demonstrated utility for generating quantitative and pertinent information on the impact of headache.[29‑31] The HIT‑6 exhibits excellent accessibility and ease of use.[32] The controls were assessed only on MINI and WHOQOL‑BREF. Institute Ethics Committee has given the ethical clearance for the study. Patients diagnosed with psychiatric comorbidity were referred to psychiatric services.
Materials and Methods
Of the 108 patients with headache screened 80 (Group A migraine 40 and Group B TTH 40) patients met the inclusion criteria. Similarly of the 48 accompanying persons approached for inclusion as control; 40 persons met the inclusion criteria (Group C).
The study subjects, 40 patients each with migraine and TTH, were recruited from the outpatient headache clinic at a tertiary care teaching hospital in north India. The inclusion criteria were disease duration for 2 years and age-range 18-50 years of either sex. The diagnosis of headache type was made using International Headache Society‑II (IHS‑II) criteria.[24] The subjects with known psychiatric disorder, major physical morbidity, other neurological disorders and substance and alcohol dependence other than tobacco were excluded. Control group included 40 healthy subjects in the age-group of 18-50 years of either gender recruited from the headache clinic. The subjects and controls who were conversant in English or Hindi and willing to give informed consent were included. Neurologist assessed the neurologic status and the psychiatric comorbidity, quality of life and disability was assessed by psychiatry consultants. Mini International Neuropsychiatric Interview (MINI) was used for making diagnosis of major depressive disorder, suicidality, panic disorder, generalized anxiety disorder, agoraphobia, social phobia, and obsessive‑compulsive disorder using respective modules. MINI is a brief structured diagnostic interview for psychiatric disorders, and it has acceptably high Neurology India | Sep-Oct 2014 | Vol 62 | Issue 5
Statistical analysis was done using Statistical Package for Social Science‑version 15 (SPSS‑15). In case of continuous variables t‑test was done, and for qualitative variables Pearson Chi‑square were applied. Multiple comparisons done by Pearson Chi‑square/Fisher exact with Bonferroni correction for analysis of psychiatric comorbidity. Data for quality of life was analyzed as per instructions in the manual of WHOQOL‑26 BREF version using one way ANOVA.
Results
Mean age was: 33.45 years (± 6.59), 31.75 years (± 5.35) and 32.95 years (± 4.73) for groups A, B and C respectively. Sample comprised of 65%, 60% and 55% females in group A, B and C respectively. Sample comprised of 62.5%, 52.5% and 62.5% married person in group A, B and C respectively. Occupational status of the study population (N = 120) was: professionals (18.3%), workers (25%), home‑makers (39.2%), students (5%), and unemployed (12.5%). Educational status of the study populations (N = 120) was: illiterate (10%), educated up to middle (28.3%), matric (17.5%), intermediate (9.2%), graduate (20%), and post‑graduate (15%). Rural background of the sample was in: 52.5%, 45% and 47.5% in group A, B and C respectively. There were no significant differences among all three groups for age (P = 0.38), sex (P = 0.56), marital status (P = 0.63), occupation (P = 0.55), education (P = 0.99) and residence (P = 0.79). The average duration of headache was 6.15 (± 2.69) and 6.77 (± 2.33) years for group A and B respectively and no significant difference was observed between group A and B (P = 0.584). 517
[Downloaded free from http://www.neurologyindia.com on Thursday, November 13, 2014, IP: 202.177.173.189] || Click here to download free Android application for journal Bera, et al.: Psychiatric co-morbidity, quality of life and disability in migraine and tension type headache
Prevalence of psychiatric disorders among three groups is given in Table 1. Multiple comparison done by Pearson Chi‑square/Fisher exact test with Bonferroni correction showed no significant difference between group A and B for overall presence of psychiatric co‑morbidity (P = 0.81). In groups A (P = 0.001) and B (P = 0.001), number of persons having any psychiatric disorder was significantly more than group C. Major depressive disorder and social phobia were significantly more common in patients in group A compared to group C (P = 0.008 and 0.012 respectively; P
