Headache is a disturbance affecting 90% of the population (1). The International Headache Society (IHS) has classified headaches as 14 main group and hundreds of sub-groups (2). Headaches emerging directly just as headache and has no relation with any disease are named as “primary headaches”. This class involves migraine, tension type headache (TTH) and cluster type headache. Migraine and TTH are most seen headache types (3). Secondary headaches’ prevalence is 10% and it secondarily seen during the any illness’ progress whose etiology is known such as brain vessel diseases, nervous system diseases, brain tumors, eye diseases, sinusitis, meningitis (4). Migraine has a nature that generally recurrent, frequently located on one-side, characterized with throbbing, and intolerance to the light and voice, and concomitant the presence of the nausea, worsening with the movement. Whereas TTH is a headache located bilaterally, characterized as repressive and astringent, not worsening with daily actions, not accompanied by nausea or vomiting, and there is no intolerance to the light or voice. The severity of headache in migraine is much more than TTH (1).
Community-based studies investigated the relation between psychiatric disease and headache (5) and the most relevant relation was reported to be between anxiety disorder and depressive disorder (6).
Studies have shown that the prevalence of the headache in patients with chronic schizophrenia is lesser than the normal population (7). The tendency of reduction in headache frequency in this group of patients might be explained by the less sensitivity to pain (8). Previous studies reported that the loss of pain sensation and the reduction of pain sensitivity were present (9-11). Although results of studies investigating the reduction of the pain sensation in schizophrenia are not convincing, four different kind of study types have provided data to support this argument; a) Clinical case reports that determine the reduced or no pain sensation in patients with schizophrenia during different kinds of painful medical situations (ruptured appendix, perforated bowel, peritonitis, etc.), b) Population-based studies that have shown the increased prevalence of reduction or loss of the pain sensation in schizophrenic patients who suffer from a painful medical condition, c) Population-based studies that defined the reduced prevalence of schizophrenia in patients who suffer from pain and d) Experimental studies have shown that the pain threshold is high in patients with schizophrenia (11).
There is not enough research in the literature regarding the presence of headache in patients with schizophrenia. In this study it was aimed to evaluate the prevalence and types of headache in schizophrenic patients and to compare the results with healthy controls and thus, to contribute to the literature.
Patients between 18 and 65 years old and who were diagnosed as schizophrenia according to DSM-IV-TR criteria in Recep Tayyip Erdogan University Training and Research Hospital outpatient clinic in 2011 and were being followed for at least two years, who signed the consent form and whose education and functioning levels were well-enough to fulfill the questionnaires were selected for the study. Control group was similar with the patient group in terms of age and gender. They were selected from workers in our hospital or from patients’ companion who had no psychiatric treatment or medical treatment history and gave informed consent to involve in the study. The members of the healthy volunteers had no neurological disease or treatment history. Furthermore, hospital file records of the control group were examined by us. All volunteers completed the study.
A hundred and one patients and 89 of healthy persons were included. Socio-demographic data form which was prepared by authors to evaluate the patient’s sociodemographic features and question the headache, structured clinical interview for DSM disorders type 1 (SCID-1), Scale for the Assessment of Negative Symptoms (SANS) and Scale for the Assessment of the Positive Symptoms (SAPS) were applied to the patients. Patients declaring headache at that time or in the past were consulted to the neurology clinic. Types and characteristics of the headache were evaluated by a neurologist. International Classification Headache Disorders-2004 version (ICH-2004) was used for evaluating the headache. Similarly, healthy controls who complained the headache were consulted to the neurology. All participants gave written informed consent. The study protocol was approved by the Ethics Committee of the Faculty of Medicine, University of Recep Tayyip Erdogan, Rize, Turkey.
Sociodemographic data form was prepared by authors to evaluate the patient’s socio-demographic features and question the headache.
The Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-1): SCID-1 is a structured clinical interview for Axis 1 type of psychiatric disorders. It has been developed by First et al. (12) Turkish version’s validity and reliability of SCID-I was validated by Corapcioglu et al. (13) and agreement percentage was 98.1% and its reliability coefficient (Cronbach alpha) was found as 0.86.
Scale for the Assessment of Negative Symptoms (SANS): SANS developed by Andreasen (14) and its Turkish version was validated and studied by Erkoc et al. (15). SANS consists of the five subscales; the flattening of the affect, impoverishment of thought, involuntariness (apathy, anhedonia), social withdrawal, and attention deficit.
Scale for the Assessment of Positive Symptoms (SAPS): SAPS developed by Andreasen (16) and validated and studied by Erkoc et al. (17). SAPS consist of five subscale containing hallucinations, delusions, bizarre behavior, positive formal thought disorder and inappropriate affect.
International Classification of Headache (ICH-2004): The first classification was done in 1988, the second version was reviewed and republished in 2004 (2).
The SPSS for Windows 18.0 program was used for analyses. Descriptive data was shown as mean±standard deviation for numerical variables, and as frequency and per cent for categorical variables. To compare groups Student’s t test and its non-parametrical equivalent, Mann Whitney U test were used. Chi-square and Fisher’s exact test were applied for categorical variables. P<0.05 were accepted as significant.
In this study, 101 schizophrenic patients and 89 healthy persons were included, and both groups were same in terms of age, education levels, and sex. Demographic features of groups were shown in Table 1.
The duration of illness of patients was changeable as from 2 years to 37 years, mean duration of illness was 15.68±9.52 years. Eighty six point one percent of patients have been taking their medicine regularly since at the beginning of the illness. The rest of the patients (13.1%) were not using their drugs regularly. While the percentage of the usage of single antipsychotic drug was 36.6%, the rest of the patients (63.4%), were using multiple antipsychotic drugs. The mean of the SAPS score 38.80±24.56, of the SANS score was 49.49±26.32.
Complaint of headache was reported by 38.6% of patients with schizophrenia, and by 37.1% of the controls. There were no difference in terms of the frequency of headache in two groups (p=0.828). When two groups were compared according to type of headaches, the difference was found as statistically significance (p=0.014). Whereas in both groups, the most prominent type of headache was TTH (31.7% of patients, 18% of controls), TTH was found significantly higher in patients than the controls (p=0.045). Migraine was detected in 11.2% of controls and in 2% of patients (p=0.02). Headache and its features related to the groups and their comparisons were shown in Table 2.
Twenty three point one percent (n=9) of 39 of patients and 3% of controls (n=33) who complained from the headache had never complained from the headache before. Schizophrenic patients were less complaining than controls and this difference was statistically significant (p=0.014).
Half of the females (n=19) and 31.7% of the males (n=20) who suffer from schizophrenia have complained from headache, but there were no statistically significant difference between males and females (p=0.106). In controls, headache was found in 46.3% of the females (n=19) and 29.2% of the males (n=14). Similarly there were no difference in terms of the frequency of headache between the males and the females (p=0.147).
Twenty one point one percent of schizophrenic women and 25% of men with schizophrenia and headache had never complained from the headache before. The difference in terms of the frequency between two sex was not significant (p=0.535).
No difference was noticed with antipsychotic treatment in terms of the severity and duration of the headache in 53.8% of patients with schizophrenia. Among the patients 33.3% (n=13) reported a reduction in the severity of the headache after the antipsychotic treatment, whereas 12.8% (n=5) expressed an increase in the severity of the headache.
In patient group, the mean of the SAPS score of patients who had headache was 46.43±21.81, whereas it was 34.00±25.14 for patients who did not have headache. Likewise, the mean of the SANS score of the patients who had headache was 58.84±23.40, while it was 43.61±26.52 for patients who did not have headache. Patients’ SAPS and SANS scores who had experienced headache was found significantly higher than patients who did not report a headache (p=0.01 and p=0.03 respectively).
Headache can be seen with the course of many psychiatric disorders. Especially this situation has been reported in a great deal of studies with mood disorders, anxiety disorders, somatoform disorders (5). There are a few studies regarding the frequency of the headache in patients with schizophrenia (8). In our study, we compared that the frequency of headache and related factors in patients with schizophrenia and healthy controls and we found that there was no difference in terms of the frequency of headache between two groups while the frequency of headache was higher in patients than controls. Related and limited studies have been reported that the frequency of headache is less in chronic schizophrenic patients than normal population (7). But in a recent study conducted by Krutzky et al. (8), the frequency of headache in patients with schizophrenia was reported as higher than normal population.
Schizophrenic patients have much more complained from the headache at the beginning of the illness (18). In contrary, chronic period of the illness is characterized by general apathy. Authors have explained this situation as decreased awareness or decreased sensitivity to pain (1,7). In this study we included the patients who had been following at least for 2 years because, the schizophrenic process can begin with somatic or hypochondriac symptoms in some cases. But, in our study, results did not support the hypothesis about the presence of decreased sensitivity to pain in chronic period of schizophrenia. For all that our results are compatible with Krutzky et al.’s report (8).
There are exacerbation and remission periods of progress in schizophrenia. Clinical researches have been reported that patients have complained different somatic complaints in different periods of the illness. These are varied from mild somatic complaints to somatic delusions (19,20). In the present study, we detected that the SAPS scores were higher in patients who complained from the headache. So, this high level may be related to the period of the illness or somatic symptoms related to the illness. Although the majority of patients have been taking their drugs regularly, the illness symptoms of those who have taken their medicine irregularly might contribute to this higher value.
There are some differences in the prevalence of the headache because of the diversity of the studies stem from different countries, societies, or ages. The lifetime prevalence of migraine in developed countries is about 13-16% (for men 7-9%, for women 13.5-25%) (21-28). The prevalence of the TTH type headache throughout the world is more than 46%. In a study, conducted in Turkey, the lifetime prevalence of the TTH in young population was found as 20.35 percent (29). In another study, in a psychiatry outpatient clinic, the prevalence of the headache was found 32.3% and 13.7% of them was found migraine, and 12.6% of them have TTH type as the most common headaches (30).
In our study, TTH type was the most common type in both groups (31.7% for patients, 18% for controls) whereas in patient group, TTH was found significantly higher than controls. Migraine type of headache was detected in 11.2% of controls while it was present in 2% of patients.
Krutzky et al. (8) reported that TTH was most prominent type of headache in schizophrenic patients and higher than controls, whereas migraine was higher in controls than patients. But their report for migraine ratio in patients was higher than in our report and it may be explained with social features.
In our study, the prevalence of TTH in controls was less than reported in literature. Considering that the control group was formed by persons who have never appealed to the psychiatry and thinking that the common togetherness of the headache and psychiatric disorders, there is a need to evaluate for this healthy group in terms of sub-threshold psychiatric disorders.
Twenty three point one percent (n=9) of 39 patients who had complained from the headache had never headache before. Three percent (n=1) of 33 controls who reported headache, had never complained. Schizophrenic patients were complaining less from headache than controls. These results were compatible with the results, conducted by Krutzky et al. (8).
Migraine and TTH, which are the most common types of headache, are much more seen in women than men. The prevalence of the migraine for women is about 15-18%, for men is 8-10%. Although TTH is not prominent like migraine, it is frequently seen in women (31). In the present study, even though statistically insignificant, the incidence of headache was found to be much more common in women than men in both the control and the patient groups, consistent with previous studies.
Fifty three point eight percent (n=21) of patients did declare that there was no difference in the severity and the duration of the headache with antipsychotic treatment, a reduction of the severity of the headache after usage of the antipsychotics was present in 33.3% of patients (n=13), and an increase in the severity of the headache with antipsychotic treatment was reported in 12.8% of patients (n=5). Some researches have been argued that antipsychotics have analgesic features and the differences in pain process in some schizophrenic patients may be related to this (32-35). In our study, 33.3% of patients who had headache reported that their severity and duration of pain decreased after using the antipsychotic medication can be explained with the analgesic effect of the antipsychotics. An increase in the severity of pain after antipsychotic medication might be related to the neurological adverse effect of the antipsychotics.
Recent study has several limitations. First, patient group was constituted from patients who were in the chronic phase and taking antipsychotic medication. Because of the confusing effect of these antipsychotics, further larger studies which will eliminate these confounding effects of the antipsychotics or compare the different periods of illness will provide us more comprehensive information. Second, because this study was carried out in one center and executed as cross-sectional, results of this study cannot be generalized. Nevertheless, results comparing the patients with the control group might be important for the other further studies.
In conclusion, this study showed that schizophrenic patients have headache as normal population has and patients less declare their headache than normal population. Further studies with larger samples of schizophrenic patients would present the importance of the issue and improve the quality of life in patients with schizophrenia contributing the analgesia.
1. Green MW. Headaches: psychiatric aspects. Neurol Clin 2011; 29:65-80.
2. Headache Classification Subcommittee of the International Headache Society. The International Classification of Headache Disorders: 2nd ed. Cephalalgia 2004; 24 (Suppl 1):9-160.
3. Lipton RB, Goadsby P, Silberstein SD. Classification and epidemiology of headache. Clin Cornerstone 1999; 1:1-10.
4. Siva A, Saip S. Akut Bas. Agrili Hastaya Yaklasim. In Siva A, Kaytaz A, (editors). Basagrilari, Basdonmeleri. Istanbul: Istanbul University, Cerrahpasa Faculty of Medicine, Continuous Medical Education Publications, 1998; 21-33. (Turkish)
5. Kroenke K, Price RK. Symptoms in the community: prevalence, classification, and psychiatric co morbidity. Arch Intern Med 1993; 153:2474-2480.
6. Mitsikostas DD, Thomas AM. Comorbidity of headache and depressive disorders. Cephalalgia 1999; 19:211-217.
7. Dworkin RH. Pain insensitivity in schizophrenia: a neglected phenomenon and some implications. Schizophr Bull 1994; 20:235-248.
8. Kuritzky A, Mazeh D, Levi A. Headache in schizophrenic patients: a controlled study. Cephalalgia 1999; 19:725-727.
9. Bonnot O, Anderson GM, Cohen D, Willer JC, Tordjman S. Are patients with schizophrenia insensitive to pain? A reconsideration of the question. Clin J Pain 2009; 25:244-252.
10. Raffard S, Bayard S, Capdevielle D, Garcia F, Boulenger JP, Gely-Nargeot MC. Lack of insight in schizophrenia: a review. Encephale 2008; 34:511-516.
11. Potvin S, Marchand S. Hypoalgesia in schizophrenia is in dependent of anti psychotic drugs: a systematic quantitative review of experimental studies. Pain 2008; 138:70-78.
12. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I). Washington DC: American Psychiatric Press; 1996.
13. Corapcioglu A, Aydemir O, Yildiz M, Esen A, Koroglu E. Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I), Clinical Version. Ankara: Hekimler Yayin Birligi, 1999. (Turkish)
14. Andreasen NC. Scale for the Assessment of Negative Symptoms (SANS). Iowa City: IA University of Iowa, 1983.
15. Erkoc S, Arkonac O, Ataklİ C, Ozmen E. Reliability and validity of negative symptoms rating scale. Düşünen Adam Journal of Psychiatry and Neurological Sciences. 1991; 4:16-19. (Turkish)
16. Andreasen NC: Scale for the Assessment of Positive Symptoms (SAPS). Iowa City, IA, University of Iowa, 1984.
17. Erkoc S, Arkonas O, Atakli C, Ozmen E. Validity and reliability of Scale for the Assessment of Positive Symptoms. Düşünen Adam Journal of Psychiatry and Neurological Sciences. 1991; 4:20-24. (Turkish)
18. Grebb JA, Cancro R. Schizophrenia: Clinical Features. Kaplan HI, Sadock BJ, (editors). In Comprehensive Textbook of Psychiatry. Baltimore: Williams and Wilkins; 1989.
19. Lipowski ZJ. Somatization: the concept and its clinical application. Am J Psychiatry 1988; 145:1358-1368.
20. Oner R, Tugcu H, Ozsan HH. Somatization in patients with schizophrenia. Turkiye Klinikleri Journal of 2002; 3:1-5. (Turkish)
21. Breslau N, Davis GC, Andreski P. Migraine, psychiatric disorders, and suicide attempts: an epidemiologic study of young adults. Psychiatry Res 1991; 37:11-23.
22. Edmeads J, Findlay H, Tugwell P, Pryse-Phillips W, Nelson RF, Murray TJ. Impact of migraine and tension-type headache on life style, consulting behavior, and medication use: a Canadian population survey. Can J Neurol Sci 1993; 20:131-137.
23. Rasmussen BK. Epidemiology of headache. Cephalagia 1995; 15:45-68.
24. Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population-a prevalence study. J Clin Epidemiol 1991; 44:1147-1157.
25. Steward WF, Schetcher A, Rasmussen BK. Migraine prevalence. A review of population-based studies. Neurology 1994; 44:17-23.
26. Boru UT, Kocer A, Luleci A, Sur H, Tutkan H, Atli H. Prevalence and characteristics of migraine in women of reproductive age in Istanbul, Turkey: a population based survey. Tohoku J Exp Med 2005; 206:51-59.
27. Wang SJ, Fuh JL, Lu SR, Juang KD. Chronic daily headache in adolescents: prevalence, impact, and medication overuse. Neurology 2006; 66:193-197.
28. Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton RB, Scher AI, Steiner TJ, Zwart JA. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 2007; 27:193-210.
29. Key FN, Donmez S, Tuzun U. Epidemiological and clinical characteristics with psychosocial aspects of tension-type headache in Turkish college students. Cephalalgia 2004; 24:669-674.
30. Kocer E, Degirmenci Y, Kocer A, Ataoglu A. The frequency of headache in Turkish patients with psychiatric disorders. New Symposium 2010; 48:132-138.
31. Saip S. Primer basagrilari. In Siva A, Saip S, Kaynak D, (editors). Norolog Olmayanlar Icin Noroloji. Istanbul: Istanbul University Cerrahpasa Faculty of Medicine, Continuous Medical Education Publications 2005; 35-62. (Turkish)
32. Kocher R. Psychopharmaceuticals in chronic pain. Schweiz Med Wochenschr 1981; 111:1946-1954.
33. Jakubaschk J, Boker W. Disorders of pain perception in schizophrenia. Arch Neurol Psychiatr 1991; 142:55-76.
34. Guieu R, Samuelian JC, Coulouvrat H. Objective evaluation of pain perception in patients with schizophrenia. Br J Psychiatry 1994; 164:253-255.
35. Jochum T, Letzsch A, Greiner W, Wagner G, Sauer H, Bär KJ. Influence of antipsychotic medication on pain perception in schizophrenia. Psychiatry Res 2006; 142:151-156.