Neurol India Home 

Year : 2014  |  Volume : 62  |  Issue : 5  |  Page : 516--520

A comparative study of psychiatric comorbidity, quality of life and disability in patients with migraine and tension type headache

Sagar Chandra Bera1, Sudhir K Khandelwal1, Mamta Sood1, Vinay Goyal2,  
1 Department of Psychiatry, Neurosciences Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
2 Department of Neurology, Neurosciences Center, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India

Correspondence Address:
Sagar Chandra Bera
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi - 110 029


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.

How to cite this article:
Bera SC, Khandelwal SK, Sood M, Goyal V. A comparative study of psychiatric comorbidity, quality of life and disability in patients with migraine and tension type headache.Neurol India 2014;62:516-520

How to cite this URL:
Bera SC, Khandelwal SK, Sood M, Goyal V. A comparative study of psychiatric comorbidity, quality of life and disability in patients with migraine and tension type headache. Neurol India [serial online] 2014 [cited 2020 Sep 22 ];62:516-520
Available from:

Full Text


Headache is one of the most common presenting complaints in people attending primary care centers and majority of them have primary headache 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],[11],[12],[13]

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],[16],[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.

 Materials and Methods

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 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],[27],[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],[30],[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.

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.


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).

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).

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 < 0.017 taken as significant after Bonfeorroni correction). But no significant difference was found between group B and C for any specific psychiatric disorder.{Table 1}

Data for quality of life was analyzed as per instructions in the manual of WHOQOL-26 BREF version using one way ANOVA. We did not find any statistically significant difference between group A and group B, although both the headache groups had significantly lower quality of life compared to Group C (P = 0.001) in all the four domains [Table 2]. There was no statistically significant difference in the mean scores of disability in between group A and group B (P = 0.41) [Table 3]. HIT was not used for group C.{Table 2}{Table 3}


In this study the point prevalence of any psychiatric disorder in both types of headaches was about three times more than in the control subjects. There was significant impairment in the quality of life on all domains in the patients with both types of headache compared to headache free controls. There was significant disability present in patients with both types of headache. However, there was no statistically significant difference between the two headache groups on measures of quality of life and disability.

The psychiatric comorbidity in subjects of migraine and TTH in this study was very high, 62.5% and 60% respectively with no difference in between both the groups. However, comorbidities were much higher as compared to healthy control (22.5%). Other studies have also found high frequency of psychiatric comorbidity in patients of migraine and TTH and this comorbidity was significantly higher than healthy controls. [4],[5],[8],[9],[33],[34],[35] Studies carried out in clinic-based samples also did not find differences in prevalence of psychiatric comorbidity between patients with migraine and patients with TTH. [9],[36],[37] Depression emerged as most prevalent psychiatric disorder in both the headache groups with no intergroup difference. Migraine patients had significantly higher rate of depression compared to headache free control, similar to other studies. [4],[6],[7] The rates of depression in TTH was quite high, however, it failed to reach any significant difference as compared to healthy controls. Merikangas et al. did not find any significant difference in the frequency of major depression in patients with TTH as compared to headaches free control. [38] Social phobia among patients with migraine and with TTH were high and comparable; however, it was significantly more prevalent in migraine patients compared to healthy controls. Rates of other psychiatric morbidities like panic disorders, obsessive compulsive disorder and generalized anxiety disorder were comparable amongst all the three groups. Similar observations were made in other studies. [4],[6],[7],[39],[40]

The use of WHOQOL-BREF was appropriate for our setting as its domains show less floor or ceiling effect than the SF-36 scale, availability of well-validated Hindi (local language) version and its use in other chronic physical illnesses. [28],[41] Both the headache groups had significantly poor quality of life in comparison to headache free control group in all four domains (physical domain, psychological domain, social relationship domain, environmental domain) similar to the observations in other studies. [16],[17],[42] However, no statically significant difference could be found between the two headache groups. Studies comparing quality of life between subjects with migraine and TTH have shown varied results. Van Suijlekom et al. using SF-36 found low scores for social and physical functioning in patients with migraine compared to patients with TTH [43] whereas Solomon et al. using SF-12 found poor health and social functioning in patients with TTH compared to migraine patients. [44] Our study cohort was drawn from tertiary care hospital where patients having severe headache report for treatment thus resulting in both the groups having equally poor quality of life. These findings emphasize the need for routine assessment of quality of life patients with primary headache syndromes.

The mean score of HIT-6 were 56.73 ± 7.49 in migraine patients and 54 ± 8.60 in TTH patients which translated into category of substantial impact and some impact respectively. Sixty percent of subjects with migraine and 47.7% with TTH had very severe to substantial impact on functioning. However, the difference between the two groups was not significant. Similar to these observations, Shin et al. in their study found 68% of migraine patients having an impact of moderate-to-severe degree on functioning. [19] In a population-based study, Ouinekh et al. found 89% of migraine patients and 43% other episodic headache patients had severe to substantial impact on functioning. [18] However, we did not find any statistical differences in the disability between migraine and TTH patients. Our study is based in the specialized clinic of tertiary care hospital in an urban setting and that may explain some of these differences. However, the findings of our study cannot be generalized due to some limitations such as cross-sectional design, small sample size and clinic-based sample.


1Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population-a prevalence study. J Clin Epidemiol 1999;44:1147-57.
2Manzoni GC, Stovner LJ. Epidemiology of headache. Handbook Clin Neurol 2010;97:3-22.
3Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher A, et al. The global burden of headache: A documentation of headache prevalence and disability worldwide. Cephalalgia 2007;273:193-210.
4Puca F. Psychological and social stressors and psychiatric comorbidity in patients with migraine without aura from headache centers in Italy: A comparison with tension-type headache patients. J Headache Pain 2000;1:17-25.
5Puca F, Guazzelli M, Sciruicchio V, Libro G, Sarchielli P, Russo S, et al. Psychiatric disorders in chronic daily headache: Detection by means of the SCID interview. J Headache Pain 2000;1:Suppl: 33-7.
6Mongini F, Rota E, Deregibus A, Ferrero L, Migliaretti G, Cavallo F, et al. Accompanying symptoms and psychiatric comorbidity in migraine and tension-type headache patients. J Psychosom Res 2006;61:447-51.
7Verri AP, Projetti Cecchini A, Galli C, Granella F, Sandrini G, Nappi G. Psychiatric co-morbidity in chronic daily headache. Cephalagia 1998;18 Suppl 21:45-9.
8Corchs F, Mercante JP, Vera Z, Guendler VZ, Vieira DS, Masruha MR, et al. Phobias, other psychiatric comorbidities and chronic migraine. Arq Neuropsiquiatr 2006;64:950-3.
9Guidetti V, Galli F, Fabrizi P, Giannantoni AS, Napoli L, Bruni O, et al. Headache and psychiatric co-morbidity: Clinical aspects and outcome in an 8-years follow up study. Cephalagia 1998;18:455-62.
10Penzien D, Peatfield R, Lipchik GL. Headaches in Patients with Coexisting Psychiatric Disease. In: Olesen J, Goadsby PJ, Ramadan NM, Tfelt-Hansen P, Welsch K, editors. The Headaches. 3 rd ed. Philadelphia: Lippincott Williams and Wilkins; 2006. p. 1117-24.
11Lake AE 3 rd . Behavioral and nonpharmacologic treatments of headache. Med Clin North Am 2001;85:1055-75.
12Lipchik GL, Rains J. Psychiatric and psychologic factors in headache. In: Loder E, Marcus DA, editors. Migraine in Women. Hamilton: Decker; 2004. p. 14 4-64.
13Lipchik GL, Penzien DB. Psychiatric comorbidities in patients with headache. Sem Pain Med 2004;2:93-105.
14The WHOQOL Group, 1994a Available from: [Last accessed o n 2014 Mar 28].
15Autret A, Roux S, Rimbaux-Lepage S, Valade D, Debiais S. West Migraine Study Group. Psychopathology and quality of life burden in chronic daily headache: Influence of migraine symptoms. J Headache Pain 2010;11:247-53.
16Lipton RB, Liberman JN, Kolodner KB, Bigal ME, Dowson A, Stewart WF. Migraine headache disability and health-related quality-of-life: A population-based case-control study from England. Cephalalgia 2003;23:441-50.
17Simic S, Slankamenac P, Kopitoviæ A, Jovin Z, Banic-Horvat S. Quality of life research in patients suffering from tension type headache. Med Pregl 2008;61:215-21.
18Nachit-Ouinekh F, Dartigues JF, Henry P, Becg JP, Chastan G, Lemaire N, et al. Use of the headache impact test (HIT-6) in general practice: Relationship with quality of life and severity. Eur J Neurol 2005;12:189-93.
19Shin HE, Park JW, Kim YI, Lee KS. Headache Impact Test-6 (HIT-6) scores for migraine patients: Their relation to disability as measured from a headache diary. J Clin Neurol 2008;4:158-63.
20Rao GN, Kulkarni GB, Gururaj G, Rajesh K, Subbakrishna DK, Steiner TJ, et al. The burden of headache disorders in India: Methodology and questionnaire validation for a community based survey in Karnataka State. J Headache Pain 2012;13:543-50.
21Khess R, Kumar S, Basu S, Akhtar S. Psychiatric aspects of headache: Initial experience from a newly established headache clinic. Hong Kong J Psychiatry 2000;10:4-6.
22Sharma H, Shah S. Psychiatric comorbidity of headache in a medical relief camp in a rural area. Indian J Psychiatry 2006;48:185-8.
23Sharma K, Remanan R, Singh S. Quality of life and psychiatric comorbidity in Indian migraine patients: A headache clinic sample. Neurol India 2013;61:355-9.
24Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders. 2 nd edition. Cephalalgia 2004;24 Suppl 1:9-160.
25Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiller E, et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): The development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998;59 Suppl 20:22-33.
26Skevington SM, Lotfy M, O′Connell KA. WHOQOL Group. The World Health Organization′s WHOQOL-BREF quality of life assessment: Psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual Life Res 2004;13:299-310.
27Chiu WT, Huang SJ, Hwang HF, Tsauo JY, Chen CF, Tsai SH, et al. Use of the WHOQOL-BREF for evaluating persons with traumatic brain injury. J Neurotrauma 2006;23:1609-20.
28Khanna S, Pal H, Pandey RM, Handa R. The relationship between disease activity and quality of life in systemic lupus erythematosus. Rheumatology (Oxford) 2004;43:1536-40.
29Bayliss MS, Dewey JE, Dunlap I, Batenhorst AS, Cady R, Diamond ML, et al. A study of the feasibility of Internet administration of a computerized health survey: The headache impact test (HIT). Qual Life Res 2003;12:953-61.
30Kosinski M, Bayliss MS, Bjorner JB, Ware JE Jr, Garber WH, Batenhorst A, et al. A six-item short-form survey for measuring headache impact: The HIT-6. Qual Life Res 2003;12:963-74.
31Ware JE Jr, Bjorner JB, Kosinski M. Practical implications of item response theory and computerized adaptive testing: A brief summary of ongoing studies of widely used headache impact scales. Med Care 2000;38 9 Suppl:1173-82.
32Pryse-Phillips W. Evaluating migraine disability: The headache impact test instrument in context. Can J Neurol Sci 2002;29 Suppl 2:S11-5.
33Juang KD, Wang SJ, Fuh JL, Lu SR, Su TP. Comorbidity of depressive and anxiety disorders in chronic daily headache and its subtypes. Headache 2000;40:818-23.
34Serrano-Dueñas M. Chronic tension-type headache and depression. Rev Neurol 2000;30:822-6.
35Saunders K, Merikangas K, Low NC, Von Korff M, Kessler RC. Impact of comorbidity on headache related disability. Neurology 2008;70:538-47.
36Mitisikostas DD, Thomas AM. Comorbidity of headache and depressive disorder. Cephalagia 1999;19:211-7.
37Marazziti D, Toni C, Pedri S, Bonuccelli U, Pavese N, Nuti A, et al. Headache, panic disorder and depression: Comorbidity or a spectrum? Neuropsychobiology 1995;31:125-9.
38Von Korff M, Simon G. The relationship between pain and depression. Br J Psychiatry 1996:101-8.
39Guillem E, Pelissolo A, Lepine JP. Mental disorders and migraine: Epidemiologic studies. Encephale 1999;25:436-42.
40Breslau N, Schultz LR, Stewart WF, Lipton R, Welch KM. Headache types and panic disorder: Directionality and specificity. Neurology 2001;56:350-54.
41Stewart WF, Lipton RB, Simon D, Von Korff M, Liberman J. Reliability of an illness severity measure for headache in a population sample of migraine sufferers. Cephalalgia 1998;18:44-51.
42Terwindt GM, Ferrari MD, Tijhuis M, Groenen SM, Picavet HS, Launer LJ. The impact of migraine on quality of life in the general population The GEM study. Neurology 2000;55:624-9.
43Van Suijlekom HA, Lame I, Stomp-van den Berg SG, Kessels AG, Weber WE. Quality of life of patients with cervicogenic headache: A comparison with control subjects and patients with migraine or tension-type headache. Headache 2003;43:1034-41.
44Solomon GD. Quality-of-life assessment in patients with headache. Pharmacoeconomics 1994;6:34-41.