April 30, 2007 -- Young adolescents with chronic daily headache (CDH), particularly those who have migraines with aura, are at 6 times greater risk for suicide than their headache-free peers, new research suggests.

"Teens with chronic daily headache should be screened for psychiatric disorders so they can get the treatment and help they need," said study author Shuu-Jiun Wang, MD, in a statement from the American Academy of Neurology.

The community-based study conducted by investigators at the Taipei Veterans General Hospital and National Yang-Ming University School of Medicine in Taipei, Taiwan, included 7900 adolescents aged 12 to 14 years from 5 schools in Taipei.

The study is published in the May 1 issue of Neurology.

Major Depression, Panic Disorders Common Comorbidities

Students were surveyed and those who reported frequent headaches were referred to a neurologist for diagnosis of headache subtype. A total of 122 subjects with CDH were identified.

CDH was defined as 15 or more headache days per month for more than 3 months, with each headache lasting 2 hours or more daily.

Following diagnosis of CDH subtype, a psychiatrist, who was blinded to students' subtype status, screened subjects for current comorbid psychiatric disorders including depression and various types of anxiety disorders using the Mini-International Neuropsychiatric Interview-Kid (MINI-Kid) for children and adolescents.

Adolescents were also screened for current suicide risk using the MINI Suicidality Module. Subjects were considered at high suicide risk if they had a score of 10 or greater. A total of 121 individuals completed the in-person interviews.

Almost half of subjects had at least 1 psychiatric disorder. Major depression (21%) and panic disorder (19%) were the 2 most frequent diagnoses. Investigators also found 20% of subjects were at high risk for suicide.

According to Dr. Wang, these numbers are much higher than those in recently reported data among Taiwan's general teen population.

Aura Is an Issue

Individuals with migraine headaches were 3.5 times more likely to have a psychiatric disorder than those without migraine. In addition, the investigators found those who had migraine with aura were at even greater risk for psychiatric disorders and higher suicide risk.

According to the authors, the study's revelation that migraine with aura is linked to higher risk for psychiatric comorbidities and suicide risk is notable.

"Intriguingly, migraine with aura has seldom been raised as an issue in patients with CDH since most headache experts believe that patients with chronic migraine usually have migraine without aura," they write.

Of the total study group, 81 (67%) had migraine or probable migraine and, of these, 67 (55%) had migraine without aura and 14 (12%) had migraine with and without aura.

Unexpected Finding

Age and sex effects were also associated with increased risk for depressive disorders, but not anxiety disorders. Female subjects were more likely to have major depression than male participants (26% vs 7%). They were also much more likely than their male counterparts to have any type of depressive disorder (37% vs 10%).

The study also showed subjects with major depression or any depressive disorders were older than those without any type of depression.

Adolescents with psychiatric comorbidities did not consult clinicians more frequently or take more days of sick leave than those without psychiatric conditions.

This unexpected finding, the authors note, may result from ignorance among study subjects and their parents of psychiatric problems. As a result, clinicians need to screen for psychiatric comorbidity when assessing their young CDH patients, the authors comment.

Neurology. 2007;68:1468-1473.

Clinical Context

Study Highlights

• Surveys were conducted of adolescents aged 12 to 14 years from 5 public schools (n = 7900) of whom 122 were diagnosed with CDH by neurologists.
• CDH diagnosis was defined as at least 15 headache days per month for more than 3 months, with each headache lasting an average of 2 hours or more daily.
• A senior board-certified psychiatrist conducted face-to-face interviews of the adolescents using the structured MINI-Kid, which follows Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, and International Classification of Diseases, 10th Revision, criteria.
• The MINI Suicidality Module was used to rate the current suicide risk.
• The following items were included and each given weighted scores: adolescents were asked if in the past month they had wished they were dead, wanted to hurt themselves, thought about killing themselves, thought about a way to kill themselves, or tried to kill themselves.
• Suicide risk was classified as low (score, 0 - 5), moderate (score, 6 - 9), and high (score, ≥ 10) and subjects were divided into 2 groups: with high current suicide risk (score, ≥ 10 ) or without high risk (score, ≤ 9).
• Those with suicide risk were referred for further evaluation and treatment.
• A control group was not included.
• 121 subjects (90 girls; mean age, 13.8 years) completed the psychiatric interview.
• 67% had migraine or probable migraine; of these, 55% had migraine without aura and 12% had migraine both with and without aura.
• 47% had at least 1 psychiatric comorbidity (depression or anxiety).
• Major depression (21%) and panic disorder (19%) were the most frequent psychiatric diagnoses.
• Girls had higher frequencies of at least 1 comorbidity (52% vs 32%; P = .055), and frequency of major depression was 26% in girls and 7% in boys ( P = .02).
• Frequency of depressive disorders was 37% in girls and 10% in boys (odds ratio [OR], 3.8; P = .005).
• Those with major depression or any depressive disorder were older.
• Age and sex effects were not seen for anxiety disorders.
• Headache frequency and duration and presence of medication overuse were not associated with depressive or anxiety disorders.
• The presence of migraine increased the risk for depression and anxiety (OR, 3.5 for ≥ psychiatric comorbidity; OR, 4.6 for major depression; OR, 3.8 for any anxiety disorder; OR, 6.6 for panic disorder; and OR 3.3, for obsessive compulsive disorder).
• The mean suicidal score was 4.8, and 20% of those with CDH were rated with a high suicide score ≥ 10).
• Those with high suicide score were more likely to be girls and to have major depression (OR, 3.0), anxiety (OR, 4.1), and migraine (OR, 4.3).
• After controlling for age, sex, major depression, and anxiety, migraine with aura remained as a predictor of suicidality (OR, 7.8).
• Mean total days of sick leave, health problems, and headache leave did not differ between those with and without psychiatric comorbidity.

Pearls for Practice

• About half of young adolescents with CDH have a psychiatric comorbidity, and major depression and panic disorder are the most common diagnoses, with female sex predicting depression risk.
• Suicide risk is increased in adolescents with CDH, with migraine with aura being a strong predictor of risk.

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