Academic journal article Indian Journal of Psychiatry

Mix Headache: A Valid Clinical Entity?

Academic journal article Indian Journal of Psychiatry

Mix Headache: A Valid Clinical Entity?

Article excerpt

Byline: Tapas. Aich, Uttam. Gupta, Sandip. Subedi

Background: Chronic daily headache (CDH) patients respond better with a combination of anti-migraine and anti-stress medications, irrespective of clinical diagnosis of chronic migraine (CM) or chronic tension-type headache (CTTH). Hypothesis: "CDH: Mix headache" type is a valid clinical entity. Materials and Methods: A total of 70 participants fulfilling the diagnosis of "primary CDH," aged between 15 and 55 years were taken up for the present study. All these patients were subdivided into either CM or CTTH, based on the predominance of symptom profiles in these patients, in confirmation with the International Headache Society guidelines (International Classification of Headache Disorders-2, 2004). Schedules for clinical assessment in neuropsychiatry (SCAN) were applied to these patients to collect information about any mental or behavioral symptoms present at the time of the study. Psychiatric comorbidity was confirmed according to the International Classification of Diseases (ICD)-10. Results: Forty-eight (68.6%) patients could be differentiated into CM and rest 22 (31.4%) patients were given a diagnosis of CTTH. SCAN and ICD-10 diagnosis revealed the presence of comorbid anxiety and depressive illness in 47 (67.2%) patients. Thirty-four of them belonged to CM (MH) group and the rest 13 had CTTH. Discussion: We propose that these 47 (67.2%) patients of CDH form our special category of "CDH - mix headache" subtype. Thus, 14 (20%) patients constitute "CDH - migraine" subtype and rest 9 (12.8%) patients have a diagnosis of "CDH - tension headache" subtype. Conclusion: Findings of the present study validate the concept of "mix headache" and explains the clinical observation that chronic daily headache (CDH) patients responds better with a combination of anti-migraine and anti-stress medications.


Chronic daily headache (CDH) is defined as a headache without underlying lesions and without symptoms of a disease that might be causing this chronic headache, occurring on more than 15 days a month for more than 3 months and lasting for more than 4 h/day if untreated. The classification of CDH is controversial even although the criteria proposed by Silberstein and Lipton (criteria) in 1994 and 1996 have been widely used.[1],[2]

The second edition of the international classification of headache disorders (ICHD-II) did not comprise any CDH category as such but provided criteria for all four types of CDH: chronic migraine (CM), chronic tension-type headache, (CTTH), new daily-persistent headache, and hemicrania continua (HC). CM is said to be the most common of the CDHs.[2],[3],[4]

Numerous attempts to relate migraine and TTH have been made in the past.[4],[5],[6],[7] Clinically, it has been observed that many patients with migraine or TTH over time can "transform" from episodic headache into a daily or near-daily headache pattern wherein the two headache types appear intimately interrelated.

It is a common clinical observation that "CDH" patients clinically respond better with a combination of anti-migraine and anti-stress medications, rather than responding either to anti-migraine or anti-stress treatment alone, irrespective of clinical diagnosis of CM or chronic tension-type headache CTTH).

This clinical experience has led us to postulate a hypothesis that "CDH: Mixed type" is a valid clinical entity. The present study conceptualized to explore and validate this clinically and diagnostically less explored the region in CDH.

Materials and Methods

The study was conducted at the headache clinic run by the Department of Psychiatry, Universal College of Medical Science, Teaching Hospital, Bhairahawa, Nepal. It is a descriptive study in nature with a cross-sectional design for which we did purposive sampling technique according to certain inclusion and exclusion criteria.

The sample was recruited from Headache clinic run by the Department of Psychiatry; in UCMS Teaching Hospital from August 2011 to January 2012 (approximately 6 months). …

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