| IHS | Diagnosis | ICD-10 |
|---|---|---|
| 12 | HEADACHE ATTRIBUTED TO PSYCHIATRIC DISORDER | R51 |
| Coded elsewhere | Headache attributed to substance-dependence, abuse or withdrawal, headache attributed to acute intoxication and headache attributed to medication overuse are all coded under 8. Headache attributed to a substance or its withdrawal . | |
General comment
Primary or secondary headache or both?
When a new headache occurs for the first time in close temporal relation to a psychiatric disorder, it is coded as a secondary headache attributed to that disorder. This is also true if the headache has the characteristics of migraine, tension-type headache or cluster headache. When a pre-existing primary headache is made worse in close temporal relation to a psychiatric disorder, there are two possibilities, and judgment is required. The patient can either be given only the diagnosis of the pre-existing primary headache or be given both this diagnosis and the diagnosis of headache attributed to the psychiatric disorder. Factors that support adding the latter diagnosis are: a very close temporal relation to the psychiatric disorder, a marked worsening of the pre-existing headache, very good evidence that the psychiatric disorder can aggravate the primary headache and, finally, improvement or resolution of the headache after relief from the psychiatric disorder.
Definite, probable or chronic?
A diagnosis of Headache attributed to psychiatric disorder usually becomes definite only when the headache resolves or greatly improves after effective treatment or spontaneous remission of the psychiatric disorder. If this disorder cannot be treated effectively or does not remit spontaneously, or when there has been insufficient time for this to happen, a diagnosis of Headache probably attributed to psychiatric disorder is usually applied.
Chronic headache attributed to and persisting after resolution of a psychiatric disorder has not yet been described.
Introduction
Overall, there is very limited evidence supporting psychiatric causes of headache. Thus, the only diagnostic categories included in this classification are those rare cases in which a headache occurs in the context of a psychiatric condition that is known to be symptomatically manifested by headache (eg, a patient who reports a headache associated with the delusion that a metal plate has been surreptitiously inserted into his or her head, or headache that is a manifestation of somatisation disorder). The vast majority of headaches that occur in association with psychiatric disorders are not causally related to them but instead represent comorbidity (perhaps reflecting a common biological substrate). Headache has been reported to be comorbid with a number of psychiatric disorders, including major depressive disorder, dysthymic disorder, panic disorder, generalised anxiety disorder, somatoform disorders and adjustment disorders. In such cases, both a primary headache diagnosis and the comorbid psychiatric diagnosis should be made.
However, clinical experience suggests that, in some cases, headache occurring exclusively during some common psychiatric disorders such as major depressive disorder, panic disorder, generalised anxiety disorder and undifferentiated somatoform disorder may best be considered as attributed to these disorders. To encourage further research into this area, criteria for headaches attributed to these psychiatric disorders have been included in the appendix.
A headache diagnosis should heighten the clinician's index of suspicion for major depressive disorder, panic disorder and generalised anxiety disorder, and vice-versa. Furthermore, evidence suggests that the presence of a comorbid psychiatric disorder tends to worsen the course of migraine and/or tension-type headache by increasing the frequency and severity of headache and making it less responsive to treatment. Thus, identification and treatment of any comorbid psychiatric condition is important for the proper management of the headache. In children and adolescents, primary headache disorders (migraine, episodic tension-type and especially chronic tension-type headache) are often comorbid with psychiatric disorder. Sleep disorder, separation-anxiety disorder, school phobia, adjustment disorder and other disorders usually first diagnosed in infancy, childhood or adolescence (particularly attention-deficit/hyperactivity disorder [ADHD]), conduct disorder, learning disorder, enuresis, encopresis, tic) should be carefully looked for and treated if found, considering their negative burden in disability and prognosis of paediatric headache.
To ascertain whether a headache should be attributed to a psychiatric disorder, it is clearly important first to determine whether or not there is a psychiatric disorder present with the headache. Optimally, this entails conducting a psychiatric evaluation for the presence of a psychiatric disorder. At a minimum, however, it is important to inquire about commonly co-morbid psychiatric symptoms such as generalised anxiety, panic attacks and depression.
