The International Classification of Headache Disorders 2nd Edition

Headache Attributed to Psychiatric Disorder

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12. Headache Attributed to Psychiatric Disorder

12.1 Headache attributed to somatisation disorder

    1. Headache attributed to psychotic disorder

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.


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.

12.1 Headache attributed to somatisation disorder

Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criterion C

B. Presence of somatisation disorder fulfilling DSM-IV criteria:

1. history of many physical complaints beginning before age 30 that occur over a period of several years and result in treatment being sought and/or in significant impairment in social, occupational or other important areas of functioning

2. at least four pain symptoms, two non-pain gastrointestinal symptoms, one sexual or reproductive symptom and one pseudoneurological symptom

3. after appropriate investigation, each of these symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance or medication; or, if there is a related medical condition, the complaints or impairment are in excess of what would be expected from the history, examination or laboratory findings

C. Headache is not attributed to another cause


Somatisation disorder, as defined in DSM-IV, is a polysymptomatic disorder characterised by multiple recurring pains and gastrointestinal, sexual and pseudoneurological symptoms occurring for a period of years with onset before age 30. These symptoms are, by definition, considered to be somatoform: that is, they are complaints of physical symptoms suggestive of, but not fully explained by, a medical condition or the direct effect(s) of a substance. In the United States, it is found predominantly in women, in whom the lifetime risk is estimated to be 2.0%, with a female/male ratio of approximately 10:1. This ratio is not as large in some other cultures (eg, in Greeks and Puerto Ricans).

It should be noted that the symptom requirement laid out in DSM-IV is quite extensive: a minimum of eight somatoform symptoms must have occurred over the patient’s lifetime, each one severe enough to result in the seeking of medical help or the taking of a medication (prescribed or over-the-counter), or to affect the person’s functioning (eg, causing missed days at work). DSM-IV has set such a high threshold in order to reduce false positives, most particularly the possibility that the “unexplained” symptoms are in fact part of a complex and as yet undiagnosed medical condition with variable symptom presentation such as multiple sclerosis or systemic lupus erythematosus. Somatoform disorders with fewer than eight symptoms are diagnosed in DSM-IV as Undifferentiated somatoform disorder. Because of the difficulty and uncertainty associated with this diagnosis, A12.6 Headache attributed to undifferentiated somatoform disorder is included only in the appendix.

To ascertain whether headache is part of the presentation of somatisation disorder, it is important to ask whether the patient has a history of multiple somatic complaints, since at any one time the patient may be focused on one particular complaint. Consider the following case scenario (from Yutzy, 2003):

A 35-year-old woman presented with a complaint of extreme headaches, “like a knife being stuck through the back of my head into my eye,” as well as other headaches virtually every day. After medical and neurological examinations failed to suggest any specific aetiology for either headache, it was important to take a careful history of past symptoms. In this case, the woman also reported a history of other pains, including abdominal pain associated at times with nausea and vomiting, periods of constipation followed by diarrhoea which had resulted in investigation for gallbladder and peptic ulcer disease with no significant findings, and pain “in all of my joints” but particularly in her knees and her back that she said had been diagnosed as degenerative arthritis at age 27 years yet no deformities had developed since. She had had menstrual problems since menarche, with pain that put her to bed and excessive flow with “big blue clots”, which had resolved only after hysterectomy two years earlier at age 33 years. The mother of four, she reported a long history of sexual problems including pain with intercourse. She had been told that she had a “tipped uterus”. Throughout her life, she was seldom orgasmic and had not enjoyed sex “for years”. She reported episodes of blurred vision with “spots” in front of her eyes, which caused her to stop work, and other episodes when she just could not hear anything, “like someone put their hands over my ears.” She also reported periods of uncontrollable shaking and a feeling that she was losing control of her body, for which she had been investigated for seizures. She reported that, at times, she had feared having some serious medical disease but “with all the work-ups I have had, I am sure they would have found something by now.”

As was evident after a complete medical history, the headaches were part of a much more involved syndrome. This woman had had multiple physical complaints with onset before age 30 that had no adequate medical explanation, were severe enough to cause her to seek medical attention and affected a variety of organ systems meeting the DSM-IV criteria for Somatization disorder (ie, at least four pain symptoms [headaches, abdominal pain, back pain and knee pain], at least two non-pain gastrointestinal symptoms [nausea, vomiting, diarrhoea and constipation], at least one sexual or reproductive symptom [pain on intercourse, excessive menstrual flow, loss of sexual enjoyment] and at least one pseudoneurological symptom [muffled hearing, uncontrollable shaking, blurred vision, spots in visual field]). Thus, her headaches would be correctly diagnosed as 12.1 Headache attributed to somatisation disorder.

12.2 Headache attributed to psychotic disorder

Previously used terms:

Delusional headache
Diagnostic criteria:

A. Headache, no typical characteristics known, fulfilling criteria C-E

B. Delusional belief about the presence and/or aetiology of headache1 occurring in the context of delusional disorder, schizophrenia, major depressive episode with psychotic features, manic episode with psychotic features or other psychotic disorder fulfilling DSM-IV criteria

C. Headache occurs only when delusional

D. Headache resolves when delusions remit

E. Headache is not attributed to another cause


1. For example, a patient’s false conviction that he or she has a brain tumour or intracranial mass giving rise to headache, which would fulfil DSM-IV criteria for Delusional disorder, somatic type.


Delusions, as defined in DSM-IV, are false fixed beliefs based on incorrect inference about reality that are firmly held despite obvious proof to the contrary. Delusions, like any firmly-held belief, can be about virtually anything. In 12.2 Headache attributed to psychotic disorder, the delusion specifically involves the presence of headache. In some instances, the delusion may involve a false belief that a serious medical condition (eg, brain tumour) is present and is the cause of the headache, despite repeated and appropriate authoritative reassurance that no such medical condition is present. In other cases, the content of the delusion may be more bizarre: for example, a delusion that a transmitter has been surgically implanted into one’s head and that the transmitter is the cause of the headache.

Delusional headache is apparently very rare and no empirical data are available about this condition.

Bibliography and reference

Curioso EP, Young WB, Shecter AL, Kaiser R. Psychiatric comorbidity predicts outcome in chronic daily headache patients. Neurology 1999; 52 (Suppl 2): A471.
Canestri P, Galli F, Guidetti V, Tomaciello A. Chronic Daily Headache in children and adolescents: a two years follow-up. Cephalalgia 2001;21: 288.
Guidetti V, Galli F, Fabrizi P, Napoli L, Giannantoni AS, Bruni O, Trillo S. Headache and psychiatric comorbidity: clinical aspects and outcome in an 8-year follow-up study. Cephalalgia 1998;18:455-62.
Lake A. Behavioral and nonpharmacologic treatments of headache. Med Clin North Am 2001; 85(4):1055-75.
Marazzitti D, Toni C, Pedri S, Bonucelli U et al. Prevalence of headache syndromes in panic disorder. Int Clin Psychopharmacol 1999; 14(4):247-251.
Mitsikostas DD, Thomas AM. Comorbidity of headache and depressive disorders. Cephalalgia 1999; 19(4):211-217.
Pakalnis A, Greenberg G, Drake ME, Paolich J. Pediatric migraine prophylaxis with divalproex. J Child Neurol 2001; 16(10):731-4.
Radat F, Sakh D, Lutz G, el Amrani M, Ferreri M, Bousser MG. Psychiatric comorbidity is related to headache induced by chronic substance use in migraineurs. Headache 1999; 39(7):477-80.
Radat F, Psychopathology and headache. Rev Neurol 2000; 156 (Suppl 4):4S62-7.
Yutzy S. Somatoform disorders. In: Tasman A, Kay J, Lieberman JA. Psychiatry, 2nd ed. Chichester: John Wiley and Sons 2003: 1419-1420.


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