Gupta Ravi, Bhatia Manjeet S, Chhabra Vishal

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1 JPPS 2007; 4(1): ORIGINAL ARTICLE ABSTRACT CHRONIC DAILY HEADACHE: MEDICATION OVERUSE AND PSYCHIA CHIATRIC MORBIDITY Gupt Rvi, Bhti Mnjeet S, Chhbr Vishl Objectives: The objectives of the study were: (i) To ssess the frequency of different chronic dily hedches in ptients using ICHD-2 criteri (ii) To find out the frequency nd type of mediction overuse nd psychitric morbidity in chronic dily hedche subjects. Design: Cross sectionl observtionl study. Plce nd durtion of study: The study ws conducted in the psychitry outptient deprtment of teching medicl institution during Jnury to September Subjects nd Methods: Subjects suffering from chronic dily hedche were recruited from specilized hedche clinic in tertiry cre hospitl s Psychitry deprtment. The dignoses were mde ccording to ICHD-2. Mediction overuse ws defined ccording to ICHD-2 criteri nd psychitric illness ws dignosed following ICD-10 criteri in CDH ptients. In subjects fulfilling the criteri for mediction overuse, the culprit drug ws stopped immeditely nd prophylctic therpy ws strted. Results: Frequency of chronic dily hedche ws 37% in this smple. Femles outnumbered mles (1: 1.52) nd formed higher number of migrine cses (p=0.02). Tension Type Hedche (TTH) ws most frequent hedche (48.5%). According to ICHD-2 criteri, probble mediction overuse hedche could be dignosed in ll ptients, which precluded the dignosis of chronic migrine nd chronic TTH. Psychitric morbidity ws seen in 70.3% subjects nd mild to moderte depression ws the most common illness (53%). TTH subjects showed predisposition for nxiety disorders (OR= 6.41; p= 0.004). Conclusion: TTH is the most common subtype of CDH when ICHD-2 is followed. Mediction overuse is common in this group of ptients nd these probbly should be discontinued ccording to substnce dependence de-ddiction model for better complince, nd even more slowly in subjects with chronic migrine hedche. Psychitric morbidity is prevlent in CDH ptients nd requires specil ttention. Key words: Chronic Hedche, Psychitric morbidity, Tretment dherence, Anlgesic overuse. INTRODUCTION Chronic dily hedche (CDH) is defined s hedche tht occurs 15 dys or more month 1. It is one of the most common cuse of referrl to specilized centers with prevlence of pproximtely % in generl popultion 1-3 nd 50% in clinic s popultion 4. ICHD-2 5 clssifies primry dily hedches with their episodic vrints, which my be beneficil to the Gupt Rvi, MD, Deprtment of Psychitry, University College of Medicl Sciences nd GTB Hospitl, Shhdr, Delhi (Indi) Bhti Mnjeet S, MD, Deprtment of Psychitry, University College of Medicl Sciences nd GTB Hospitl, Shhdr, Delhi (Indi) D-1, Nrin Vihr, Delhi , Ph E-mil: mnbhti1@rediffmil.com Chhbr Vishl, DNB, Deprtment of Psychitry, University College of Medicl Sciences nd GTB Hospitl, Shhdr, Delhi (Indi) Correspondence: Dr. Mnjeet Singh Bhti reserch purpose, but for clinicl prctice grouping these ptients under single entity i.e., CDH is more sensible 1. Among primry CDH, the migrine or trnsformed migrine is more common thn the TTH in specilized clinics, while the opposite is seen in generl prctice 1. Other studies hve shown tht trnsformed migrine 3-4, 6 ws the most common dignosis in this group nd Tension Type hedche comprised only smll prt. This is n importnt clinicl group since these ptients suffer frequent bsenteeism nd poor qulity of life 7 in ddition to the higher prevlence of psychitric illnesses 1,4,8-9 nd mediction overuse 1,10. However, dt regrding prevlence of CDH in using ICHD-2 5 criteri for chronic primry hedches is scrce s most of the pst studies hd used Silberstein et l s criteri 11 for dignosis of chronic migrine. To our knowledge, there is only one report 12 tht exmined the prevlence of chronic migrine following ICHD-2. Inconsistencies regrding the definitions of CDH nd mediction overuse between these studies mke the results difficult to interpret en-mss nd thus results cn not be 19

2 used in clinicl prctice. There is lso pucity of dt regrding prevlence of different psychitric illnesses nd type of mediction overuse in these ptients following ICHD-2 criteri. Hence, present study ws plnned to ddress these issues. SUBJECTS AND METHODS Subjects presenting with complints of hedche in the Psychitry outptient deprtment during six study months were screened for the presence of chronic dily hedche. The dignosis of hedche ws bsed upon history (see below), clinicl exmintion nd wherever required, lbortory investigtions. Those who suffered secondry hedche were excluded from the study. Informed consent ws tken from the subjects before inclusion into the study nd detils regrding their demogrphic dt were gthered. We recorded following dt for the dignosis of hedche: Time since onset, verge number of ttcks per month, verge number of dys for which ptients suffered pin in pst six months, chnge in the pin since onset (Frequency, durtion nd severity of episodes), lterlity (Unilterl, bilterl, chnging), loction (Temporl, frontl, occipitl, prietl, orbitl, generlized, neck), qulity (ching, pulsting/ throbbing, pressing, tightening, bnd like etc), durtion of episode, usul time of onset, precipitting nd relieving fctors, rdition of pin, premonitory symptoms, ssocited symptoms (phonophobi, nuse-vomiting, photophobi, red eye, lcrimtion, nsl blockde, worsening with exertion, dizziness, ptosis etc). Following this physicl exmintion ws crried out s described by Mongini 13. Few subjects were meeting criteri for more thn one primry hedche but, in those cses the hedche which ws fulfilling criteri for chronic ws kept s min dignosis nd the hedche which ws present intermittently before the onset of chronic hedche, ws dignosed s the co-morbid hedche. Hedches were dignosed bsed on ICHD-2 criteri. Mediction overuse hedche ws defined s intke of nlgesics more thn 15 times month for t lest 3 months i.e., criteri B of 8.2.3; nd for combintions nd ergotmine more thn 10 dys month for 3 months- i.e., criteri B of nd respectively. During the process of dt cquisition we encountered following problems in dignostic clssifiction: (i) Dignosis of Chronic Migrine (CM; ICHD 1.5.1) nd Chronic Tension Type Hedche (CTTH; ICHD 2.3) could not be mde becuse it requires bsence of Anlgesic overuse hedche (ICHD 8.2.3) (ii) Anlgesic overuse hedche could not be dignosed becuse study ws terminted t 6 weeks due to poor follow-up. (iii) New Dily Persistent Hedche (NDPH; ICHD 4.8) could not be dignosed becuse informtion gthered ws retrospective nd ll subjects were fulfilling the criteri B (Anlgesic overuse for > 15 dys month for > 3 months) of nlgesic overuse hedche (ICHD 8.2) t the time of dignosis. Due to these problems dignosis of (i) Migrine with ur with Probble Chronic Migrine with ur with Probble MOH, (ii) Migrine without ur with Probble Chronic Migrine without ur with Probble MOH, nd (iii) TTH with Probble Chronic Tension Type Hedche with Probble Mediction Overuse Hedche were mde 5,14. Though, for the ske of simplicity of presenttion, designtions like Migrine with ur, Migrine without ur nd TTH for ctegories (i), (ii) nd (iii) were used in this study respectively. Detils regrding behviorl symptoms were gthered from the ptient in the presence of relible informnt, who confirmed the history, nd dignosis ws mde ccording to ICD-10 criteri 15. We could not use ny structured interview schedule becuse most of the ptients could not spek English, nd Hindi version of the sme is not vilble, in ddition to resons discussed lter. During dignosis of psychitric morbidity it ws ssured tht these behviorl symptoms were not limited to hedche episodes nd they occurred independent to these episodes. If ny subject hd symptoms lsting for hedche episode only, dignosis of co-morbid psychitric disorder ws not mde. All the subjects were kept on the prophylctic drugs ccording to vilble literture 13,16 nd their bused medictions were stopped immeditely. It resulted in very high ttrition rte of subjects from the study, the resons for which re discussed lter. For sttisticl nlysis SPSS Version 11 for Windows ws used. For comprison of proportions (Ctegoricl dt), Chi-squre test with ctegory collpse nd Fisher exct test were pplied. For numericl vribles independent smple t test ws used nd logistic regression ws pplied to find out odds rtios (OR). RESULTS TS A totl of 245 subjects reported primry hedche out of whom 91 (37.14%) were suffering from chronic hedche. Femles were overrepresented in the smple compred to mles in rtio of 1: Men ge of subjects in the study ws yers (Rnge yers) nd there ws no significnt difference (t=0.23; P= 0.81) between ge of mle nd femle subjects (34.29 vs 33.80). In ptients with chronic dily hedche group, gender significntly ffected (p=0.002) the frequency of hedche s migrine with or without ur ws more frequent mong femles while TTH hd opposite trend. Overll, TTH ws the most common dignosis followed by migrine without ur. Mediction overuse ws present in ll CDH subjects, but due to poor follow up, study ws terminted premturely nd dignosis of Probble Mediction Overuse Hedche ws mde. 20

3 Tble 1 Generl Chrcteristics of the study smple. S. No. Vrible Mle (N= 36) Femle (N= 55) Totl (N=91) 1. Principl Hedches* TTH # 27 (75%) 21 (33.2%) 48 (52.7%) 6 (16.7%) 18 (32.7%) 24 (26.4%) p= MA $ 3 (8.3%) 16 (29.1%) 19 (20.9%) 2. Principl Hedches** TTH # 27 (75%) 21 (38.2%) 48 (52.7%) 3 (8.3%) 3 (5.5%) 6 (6.6%) MA $ 2 (5.6%) 3 (5.5%) 5 (5.5%) MO + TTH 2 (5.6%) 10 (18.2%) 12 (13.2%) MO + Unspecified 1 (2.8%) 5 (9.1%) 6 (6.6%) MA + TTH 1 (2.8%) 7 (12.7%) 8 (8.8%) MA + Unspecified nil 6 (10.9%) 6 (6.6%) 3. Psychitric illness Absent 10 (27.8%) 17 (30.9%) 27 (29.7%) Depression with Somtoform 19 (52.8%) 29 (52.7%) 48 (52.7%) 0.91 Anxiety Disorders 7 (19.4%) 9 (16.4%) 16 (17.6%) * Following ICHD-2 criteri limited to different episodes. ** Following ICHD-2 criteri pplicble to single episodes. Chi-squre test could not be pplied becuse of smll expected frequencies in more thn 20% of cells. # TTH with probble chronic TTH with probble Migrine without ur with probble chronic MO with probble MOH. $ Migrine with ur with probble chronic MA with probble MOH. Co-morbid hedches re shown in Fig. 1. Few subjects in TTH group lso hd TTH s comorbid hedche becuse in these cses Episodic TTH ws present well before the onset of Probble CTTH. Fig. 1: Co-morbid Hedches in different Primry CDH Groups As result of brupt discontinution from overused nlgesics, the entire smple ws lost to follow up by the end of six weeks. Figure 2 shows tht MA ptients were first to lost to follow up, while TTH subjects were the lst. Also notble is the finding tht substntil number of subjects were lost to follow-up by the end of first week (i.e., strt of prophylctic drugs nd withdrwl from overused mediction). Psychitric morbidity ws seen in 70.3 % subjects. Gender did not ffect occurrence of psychitric morbidity (P= 0.91). Subjects with TTH were more likely to suffer from nxiety disorders (OR= 6.41; p= 0.004), while nlysis for depression did not rech sttisticl significnce (OR= 1.76; p= 0.244). 21

4 Fig. 2: Tble 2 Distribution of psychitric morbidity in different Primry Hedche Groups $ DISCUSSION SION CDH subjects lost t weekly follow-up fter cute withdrwl from overused mediction S. Psychitric Hedche Type Totl morbidity TTH* Migrine # 1 Absent (20.8%) (39.5%) 2. Depression nd (54.2%) (51.2%) P= Somtoform 0.05 Disorders 3. Anxiety Disorders (25%) (9.3%) Totl * Episodic Frequent/Infrequent TTH with probble chronic TTH with probble MOH # includes Migrine with ur with Probble Chronic Migrine with/ without ur with Probble MOH; Migrine without ur with Probble Migrine with/without ur with Probble MOH. $ Criteri followed in clinicl context. Prevlence of CDH nd loss t follow-up In present study 37% subjects ttending specil clinic suffered from CDH. Nerly similr figure hs been reported by Chkrvrty 4 in the Indin popultion in specilty clinic. These ptients comprise substntil number nd should be given due concern. Like present study, higher number of femle subjects (72% 3, 83% 4, 65% 6 nd 73% 17 in chronic dily hedche group s whole nd lso in migrine subgroup) hs been reported 3-4. In this study ll the subjects were lost to follow up t six weeks. Similr results hve been reported from Indin popultion nd cceptnce of hedche s prt of life; chnge of doctors nd wy out to lternte forms of therpy were implied s the custive fctors 4 in those studies. Another reson for this could be sudden discontinution of overused mediction which usully results in rebound hedche. Abrupt discontinution hs been tried previously 18, but in tht study use of NSAID drug other thn the one overused ws llowed to mximum of two times week. Despite this only 52% were retined till the end of tht study 18. In present study MA hd the poorest complince to the prophylctic therpy while the TTH subjects were the lst. We could not find ny other study tht reported similr or contrdictory findings. These findings on retrospect mke one to think of hving different pproch to stopping the overused mediction. The possibility of grdul tpering of overused drugs ccompnied with explining the purpose of tking such step to the ptients my help in getting better complince nd retention in the study. Frequency of primry y hedches ccording to ICHD-2: -2: In this study TTH ws most common type of primry CDH followed by Migrine. This observtion does not mtch with previous reports tht describe high prevlence of trnsformed migrine- e.g., 55% 3, 82% 4, 87% 6. Definition of chronic hedche tht ws followed in previous studies influenced the prevlence of migrine s they used Siberstein et l s criteri 11,19 tht re different from ICHD-2 criteri 5 for Chronic Migrine in three wys- : (i) they rely on the pst history of episodic migrine (ii) ll 15 or more episodes in month need not to fulfill criteri for migrine (iii) nd lstly, decrese in the severity of hedche is llowed. Recently, Bigl et l 12 reported tht ICHD-2 criteri for migrine re too restrictive nd result in multiple dignostic entities specilly the CTTH long with CM. CM without TTH could not be found even in single cse 6 while pure chronic migrine cses mde little number when ICHD-2 ws followed 12. Moreover, it is known tht chronic migrineurs lose typicl fetures nd cquire TTH like picture 14 nd chronic nlgesic or ergot use lso contributes to chnges in presenttion of episodic migrine to TTH 14. Monzini et l 20 reported tht lmost ll the migrine subjects lost pulsting qulity, cquired bilterl loction nd mild-moderte intensity when it becme chronic. Therefore, mny of the chronic migrine subjects tht lost migrinous chrcter in present study were spuriously dignosed s TTH sufferers. In ddition, recruitment bis s subjects were enrolled from the Hedche Clinic of Tertiry cre Psychitry deprtment could hve lso contributed to higher prevlence of CTTH. In this study, NDPH ws no dignosed becuse of the retrospective dt nlysis nd the mediction overuse, while it hs been reported in other studies 6. In ddition, NDPH in itself does not hve ny prticulr chrc- 22

5 teristics, nd different primry hedches e.g., Migrine nd TTH cn be kept under this rubric 6 provided they fulfill the durtion criteri of NDPH. Mediction overuse: Anlgesic overuse ws found in ll subjects (100%) in the present study. On the contrry, previous reports describe nlgesic overuse in 34% 3, 43% 4, nd 82% 6 chronic dily hedche subjects only. This difference could be secondry to definition of overuse s previous 3-4,6 studies followed Silberstein et l s 19 criteri tht require more number of dys month thn IHS criteri nd specifies minimum mount of the drug in question. Chkrvrty 4 reported nlgesic overuse only in migrine group nd he could not find single cse of mediction overuse in TTH group, contrry to findings of this study. It is possible tht difference in hedche definition s explined bove long with difference in the popultion led to these results. Most of the ptients were suffering from psychitric illness nd were working on dily wges; both the fctors in ddition to cheper nd esy vilbility of cute tretment drugs 4 could hve promoted mediction overuse. Moreover, hedche ws described s most significnt predictor for drug overuse 21. Pttern of mediction overuse ws lso dependent on the type of hedche. TTH subjects used simple nlgesics while migrine subjects consumed combintion of nlgesics or nlgesics with ergot. This pttern demonstrtes prescription prctices since combined nlgesics/ ergot re usully prescribed to migrine subjects nd simple nlgesics to TTH, s well s vilbility of drug, s overuse of Over-The-Counter drugs is more common compred to prescribed medicines 3-4. Psychitric illness: Present study reports prevlence of psychitric illness in CDH subjects to be 70%. Previous studies using SCID (Structured Clinicl Interview for DSM IV) nd MINI (Mini Interntionl Neuropsychitric Interview) for Axis I disorder demonstrted prevlence of 90% nd 78% respectively, while one study 9 tht used only HADRS (Hospitl Anxiety nd Depression rting scle) reported prevlence of 42%. Only vilble Indin study 4 tht ws bsed on clinicl exmintion using DSM IV criteri showed prevlence of nerly 50%. Differences cn be ttributed to the use of structured interviews in the bove mentioned studies s structured interviews hve limited vlidity nd re sensitive for more severe illnesses only 24. Possibility of spurious ptients response on these interviews cn not be ruled out s rewording of the question is not llowed 24, ignoring whether ptient hd understood the question or not. On the other hnd, HADRS detects only cseness nd not the individul dignosis 9. Although subjects in the present study were recruited from psychitry OPD, even then it did not influence the prevlence of psychitric illness since they were ttending hedche clinic with primry complint of hedche rther thn psychitric illness. In this study, psychitric illness ws less common in migrine group compred to TTH group. TTH nd Migrine hedche subjects hd nerly comprble prevlence of depression while nxiety disorders were more common mong TTH subjects. Similr results hve been reported in the pst 4. It cn be further substntited by biochemicl findings s lredy reported in the literture showing the decresed pltelet serotonin, up regultion of 5HT 2A receptors in CDH subjects 10 nd serotonin bnormlities in depression. Limittions of the study: This ws retrospective, recll bsed study conducted in tertiry cre centre. Therefore, possibility of recll bis cn t be ruled out but to limited extent only, s most of the subjects with chronic hedche tend to remember hedche chrcteristics. 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