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The Neuropsychiatry of Headache
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Book description

Whilst the vast majority of headaches are minor ailments, some patients develop chronic symptoms that have psychiatric dimensions. These symptoms can be immensely challenging to manage and can have a serious impact on the patient's quality of life. The relationship between headache and psychiatric disease is often rationalized as cause and effect; however, the interplay between the two is complex. Management of each of the co-morbid disorders affects the other one in positive and/or negative ways. The Neuropsychiatry of Headache details the current concepts of various headache conditions and the psychiatric syndromes; topics covered include migraine, mood disorders, medication overuse and personality disorders. Headache specialists, neurologists, psychiatrists, neuropsychiatrists and neuropsychologists will find this an invaluable resource for understanding and co-managing these conditions.

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  • Chapter 7 - Drug dependence in headache patients
    pp 63-74
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    This chapter focuses on the psychiatric comorbidities of migraine and other headache disorders. Anxiety disorders have been found to be significantly associated with migraine in both clinical and community-based studies. Patients with migraine and tension-type headache exhibit psychiatric illnesses at a disproportionately higher rate than individuals with no history of recurrent headache. Unidirectional causal models suggest that an index disease increases the risk of the comorbid disorder. Psychiatric comorbidities can influence the frequency and severity of migraine, and impact disease prognosis, treatment, and clinical outcomes. Some psychiatric comorbidity, including depression and anxiety, has been associated with increasing migraine attack frequency, or progression from episodic to chronic migraine. Rates of psychiatric comorbidity are even higher among persons with more frequent headache. The high rates of psychiatric comorbidity with migraine highlights the importance for healthcare professionals (HCPs) to maintain diagnostic vigilance and provide appropriate treatment or referrals when necessary.
  • Chapter 8 - The neuropsychiatry ofpsychosis and headache
    pp 75-94
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    This chapter presents information on the background, diagnosis, clinical features, pathophysiology, forms, and precipitating factors of migraine. There are three major approaches to the treatment of migraines. It is often useful to view a migraine as a low threshold for the development of headache. There are three major approaches to the treatment of migraines: non-medication therapies; acute treatment; preventive treatment. Evidence-based guidelines support the use of cognitive behavior therapy. Most preventive agents for migraine are associated with weight gain, and this side effect, along with memory loss and depression, are the most common reasons for rejecting a particular agent. The Food and Drug Administration (FDA) in the United States issued an alert in 2006 that there would be a life-threatening risk when triptans were used in individuals taking selective serotonin reuptake inhibitors and selective serotonin/norepinephrine inhibitors.
  • Chapter 9 - Chronic daily headache
    pp 95-105
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    Tension-type headache (TTH) is the most common form of headache in the general population. The phenotypic features of TTH are non-specific and may be seen with an assortment of secondary headache conditions, which are linked mechanistically to an identifiable structural or physiological disorder. One recent study of psychiatric comorbidity in patients with migraine, TTH, and migraine plus TTH revealed significant differences in the rate of occurrence of depression, with the combined group being of highest risk. TTH is typically managed mainly through administration of medication during acute episodes. Simple analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), and combination agents are most commonly recommended. Aspirin is more effective than placebo and comparable to the efficacy of acetaminophen in the relief of acute TTH. The prognosis is generally favorable, with limited disability during headache occurrences and age-related improvement or resolution of episodes later in life.
  • Chapter 10 - Stress management
    pp 106-118
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    The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) classifies mood disorders as major depressive disorder, dysthymic disorder, bipolar I disorder, bipolar II disorder, and cyclothymic disorder, on the basis of the types of mood episodes present in the patient's history. The association between headaches and mood disorders has been demonstrated for many years across various cultures. Suicide is attempted more often when a patient has comorbid mood disorder and headache than when he or she has either alone. Suicidal intent is inversely correlated with quality of life. The treatment of depression is broadly divided into psychopharmacological and psychological therapies. The United States Food and Drug administration (USFDA) has approved the use of fluoxetine, sertraline, paroxetine, citalopram, escitalopram, and vilazodone for the treatment of major depressive disorder. Several treatments that are effective for mood disorders also are efficacious in headache treatment.
  • Chapter 11 - Working with personality andpersonality disorders in the headache patient
    pp 119-130
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    This chapter describes the major anxiety disorders and their associations with headache, the increased burden of comorbid anxiety and headache, the mechanisms hypothesized to explain the connection between anxiety and headache, and the behavioral treatments and strategies for managing anxiety and headache. Anxiety disorders are a separate category of psychiatric disorders in The Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR), which contains six major anxiety disorders, namely generalized anxiety disorder (GAD), panic disorder, specific phobias, social anxiety disorder, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD). Anxiety disorders and primary headache are commonly occurring conditions, both independently and as co-occurring conditions. The presence of anxiety and anxiety disorders in individuals with headache negatively impacts quality of life, functioning, and response to headache treatment. Effective management of headache necessitates understanding, identifying, and addressing anxiety, anxiety-related disorders, and their underlying factors that are related to headache.
  • Chapter 12 - Complementary and alternative medicine (CAM) approaches to headache
    pp 131-148
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    Primary headache disorders are among the most prevalent conditions affecting various populations worldwide. Personality traits and psychiatric disorders are important comorbid and possibly causal conditions in migraine and mediators of stress impact on migraine or tension-type headache. These include neuroticism, anxiety, panic disorder, depression, and post-traumatic stress disorders. Post-traumatic stress disorder (PTSD) is a well-recognized risk for and modulator of headache. Peterlin and colleagues evaluate the relative frequency of PTSD in episodic migraine (EM), chronic daily headache (CDH), and the impact on headache-related disability. The goal of behavioral management for stress must be to improve headache frequency and severity and to improve quality of life by increasing patient self-knowledge, disease knowledge, and sense of control and self-efficacy. The role of stress as a modifier or trigger of headache should be actively evaluated in all patients with recurrent or chronic headache disorders.
  • Chapter 13 - Somatoform disorders and headache
    pp 149-163
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    This chapter focuses on the issues that arise when prescribing opioids and other controlled substances for chronic headache pain. The majority of headache patients who overuse or develop dependence on opioids and opioid-containing compounds suffer from migraine-type headaches. Tramadol withdrawal often includes symptoms not typically seen in pure opioid withdrawal, such as extreme anxiety, panic or paranoia, hallucinations, and feelings of numbness and tingling in extremities. Butorphanol, an opioid with partial mu-agonist effects, was first developed in injectable form and initially used in hospital settings mainly for post-operative and labor pain. The only barbiturate indicated specifically for the treatment of headache is butalbital, prescribed in the various combination medications. The care of cannabis-using patients may be managed best by coordinating their continuing headache care with an addiction specialist. It is well known that patients with physiologic dependence on caffeine routinely develop caffeine withdrawal headaches.


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