Psychiatric Comorbidities and Environmental Triggers in Patients with Chronic Daily Headache: A Lifestyle Study

  • Fakhrudin Faizi PhD Candidate in Pain Research and Management, Behavioral Sciences Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
  • Abbas Tavallaee Associated Professor of Psychiatry, Behavioral Sciences Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
  • Aboulfazl Rahimi PhD, Assistant Professor, Faculty of Nursing, Baqiyatallah University of Medical Sciences, Tehran, Iran.
  • Masoud Saghafinia Associated Professor, Pain Fellowship at Trauma Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran.
Comorbidity, Headache, Life Style, Psychiatry, Trigger


Objective: Patients with chronic daily headache (CDH) suffer from several significant psychiatric comorbidities and have unhealthy lifestyle. We aimed at studying psychiatric comorbidities, environmental triggers, lifestyle factors, and intensity of CDH in patients referred by the department of neurology from 2011 to 2014.

Method: Through medical and psychiatric interviews and using 0 to 10 visual analogue scale (VAS), we assessed patients with CDH, using a checklist, to elicit psychiatric comorbidities, intensity of CDH, environmental factors, and lifestyle derangement.

Results: We interviewed 413 (age 16-80 years, mean 40 +/- 14.0) out of 548 patients; 312 (75.5%) were married, and 282 (68.1%) were female. Environmental triggers (374, 90.6%) were the most common cause of CDH, while 214 (51.8%) had no compliance to recommended nutrition. Exercise avoidance (201, 48.7%) was the less prevalent lifestyle factor. Of the patients, 372 (90.1%) were stressed and 162 (39.2%) had obsessive-compulsive disorder (OCD), which were the most and less prevalent psychiatric comorbidities, respectively. Intensity of pain was moderate to severe (mean score = 7.1+/- 1.9), while females reported higher VAS scores (p<0.02). Patients with previous history of psychotherapy reported higher score of VAS (p<0.001). Those patients living with a person suffering from head pain reported more VAS score (p<0.003).

Conclusion: Notable psychiatric comorbidities were found in patients with CDH, many of which are modifiable such as environmental triggers and unhealthy lifestyle. In heavily populated cities, these factors may double the burden of the CDH by precipitating new or exacerbating previous psychiatric comorbidities. We, thus, suggest conducting more studies on this subject.


Ashina S, Lipton RB, Bigal ME. Treatment of comorbidities of chronic daily headache. Curr Treat Options Neurol 2008; 10: 36-43.

Heckman BD, Merrill JC, Anderson T. Race, psychiatric comorbidity, and headache characteristics in patients in headache subspecialty treatment clinics. Ethn Health 2013; 18: 34-52.

Turner DP, Houle TT. Psychological evaluation of a primary headache patient. Pain Manag 2013; 3: 19-25.

Juang KD, Wang SJ, Fuh JL, Lu SR, Su TP. Comorbidity of depressive and anxiety disorders in chronic daily headache and its subtypes. Headache 2000; 40: 818-823.

Liang X, Ying G, Huang Q, Wang J, Li N, Tan G, et al. Characteristics of primary stabbing headache in a tertiary neurological clinic in China. Pain Med 2014; 15: 871-875.

Kunkler PE, Zhang L, Pellman JJ, Oxford GS, Hurley JH. Sensitization of the trigeminovascular system following environmental irritant exposure. Cephalalgia 2015; 35: 1192-1201.

Moschiano F, D'Amico D, Ramusino MC, Micieli G. The role of diet and lifestyle in adolescents with headache: a review. Neurol Sci 2013; 34 Suppl 1: S187-190.

Freedom T, Evans R. Headache and Sleep. Headache 2013; 53: 1358-1366.

Holzhammer J, Wober C. [Alimentary trigger factors that provoke migraine and tension-type headache]. Schmerz 2006; 20: 151-159.

El-Sherbiny NA, Masoud M, Shalaby NM, Shehata HS. Prevalence of primary headache disorders in Fayoum Governorate, Egypt. J Headache Pain 2015; 16: 85.

Albers L, Ziebarth S, von Kries R. [Modifiable risk factors for primary headache. A systematic review]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2014; 57: 952-960.

Mawer C. Air pollution in Iran. Bmj 2014; 348: g1586.

Hosseinpoor AR, Forouzanfar MH, Yunesian M, Asghari F, Naieni KH, Farhood D. Air pollution and hospitalization due to angina pectoris in Tehran, Iran: a time-series study. Environ Res 2005; 99: 126-131.

Asghari A, Saed F, Dibajnia P. Psychometric properties of the Depression Anxiety Stress Scales-21 (DASS-21) in a non-clinical Iranian sample. Int J Psychol 2008; 2: 82-102.

Levin M. The International Classification of Headache Disorders, (ICHD III)–Changes and Challenges. Headache: The Journal of Head and Face Pain 2013; 53: 1383-1395.

Lichtenstein AH, Appel LJ, Brands M, Carnethon M, Daniels S, Franch HA, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation 2006; 114: 82-96.

Jafarian S, Gorouhi F, Salimi S, Lotfi J. Low-dose gabapentin in treatment of high-altitude headache. Cephalalgia 2007; 27: 1274-1277.

Moschiano F, Messina P, D'Amico D, Grazzi L, Frediani F, Casucci G, et al. Headache, eating and sleeping behaviors and lifestyle factors in preadolescents and adolescents: preliminary results from an Italian population study. Neurol Sci 2012; 33 Suppl 1: S87-90.

Wober C, Holzhammer J, Zeitlhofer J, Wessely P, Wober-Bingol C. Trigger factors of migraine and tension-type headache: experience and knowledge of the patients. J Headache Pain 2006; 7: 188-195.

Tajadini H, Zangiabadi N, Divsalar K, Safizadeh H, Esmaili Z, Rafiei H. Effect of Prayer on Intensity of Migraine Headache: A Randomized Clinical Trial. J Evid Based Complementary Altern Med 2016.

Tellez-Zenteno JF, Garcia-Ramos G, Zermeno-Pohls F, Velazquez A. Demographic, clinical and comorbidity data in a large sample of 1,147 patients with migraine in Mexico City. J Headache Pain 2005; 6: 128-134.

Cuvellier JC. [Management of chronic daily headache in children and adolescents]. RevNeurol(Paris) 2009; 165: 521-531.

Rasmussen BK. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain 1993; 53: 65-72.

Dzoljic E, Sipetic S, Vlajinac H, Marinkovic J, Brzakovic B, Pokrajac M, et al. Prevalence of menstrually related migraine and nonmigraine primary headache in female students of Belgrade University. Headache 2002; 42: 185-193.

Celentano DD, Linet MS, Stewart WF. Gender differences in the experience of headache. Soc Sci Med 1990; 30: 1289-1295.

Schur EA, Noonan C, Buchwald D, Goldberg J, Afari N. A twin study of depression and migraine: evidence for a shared genetic vulnerability. Headache 2009; 49: 1493-1502.

Guthrie E, Creed F, Dawson D, Tomenson B. A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterology 1991; 100: 450-457.

Whitehead WE, Winget C, Fedoravicius AS, Wooley S, Blackwell B. Learned illness behavior in patients with irritable bowel syndrome and peptic ulcer. Dig Dis Sci 1982; 27: 202-208.

Turk DC, Flor H, Rudy TE. Pain and families. I. Etiology, maintenance, and psychosocial impact. Pain 1987; 30: 3-27.

Katsarava Z, Dzagnidze A, Kukava M, Mirvelashvili E, Djibuti M, Janelidze M, et al. Primary headache disorders in the Republic of Georgia: prevalence and risk factors. Neurology 2009; 73: 1796-1803.

Satoh K, Masaoka Y, Kasai H, Satoh H, Tsukada S, Seino T, et al. Amygdala Response During Anticipatory Anxiety in Patients with Tension-type Headache. The Showa University Journal of Medical Sciences 2015; 27: 39-48.

Westergaard ML, Glumer C, Hansen EH, Jensen RH. Medication overuse, healthy lifestyle behaviour and stress in chronic headache: Results from a population-based representative survey. Cephalalgia 2016; 36: 15-28.

Nash JM. Stress and primary headache in adolescents: do those with migraine but not tension-type headache experience increased stress? Cephalalgia 2011; 31: 771-773.

Hauge AW, Kirchmann M, Olesen J. Trigger factors in migraine with aura. Cephalalgia 2010; 30: 346-353.

Abma TA, Baur V. Seeking connections, creating movement: the power of altruistic action. Health Care Anal 2014; 22: 366-384.

Vodonos A, Novack V, Zlotnik Y, Ifergane G. Ambient air pollution, weather and daily emergency department visits for headache. Cephalalgia 2015; 35: 1085-1091.

Theeler BJ, Kenney K, Prokhorenko OA, Fideli US, Campbell W, Erickson JC. Headache triggers in the US military. Headache 2010; 50: 790-794.

Pathak V, Tripathi BD, Mishra Vk. Evaluation of traffic noise pollution and attitudes of exposed individuals in working place. Atmospheric Environment 2008; 42: 3892-3898.

Chen SP, Fuh JL, Lirng JF, Chang FC, Wang SJ. Recurrent primary thunderclap headache and benign CNS angiopathy: spectra of the same disorder? Neurology 2006; 67: 2164-2169.

Adelman JU, Adelman RD. Current options for the prevention and treatment of migraine. Clin Ther 2001; 23: 772-788; discussion 771.

Stansfeld SA, Haines MM, Burr M, Berry B, Lercher P. A Review of Environmental Noise and Mental Health. Noise Health 2000; 2: 1-8.

Aaseth K, Grande RB, Kvaerner KJ, Gulbrandsen P, Lundqvist C, Russell MB. Prevalence of secondary chronic headaches in a population-based sample of 30-44-year-old persons. The Akershus study of chronic headache. Cephalalgia 2008; 28: 705-713.

Kristoffersen ES, Straand J, Russell MB, Lundqvist C. Feasibility of a brief intervention for medication-overuse headache in primary care--a pilot study. BMC Res Notes 2014; 7: 165.

Oshinaike O, Ojo O. Primary headache disorders at a tertiary health facility in Lagos, Nigeria: prevalence and consultation patterns. 2014; 2014: 782915.

Ayzenberg I, Katsarava Z, Sborowski A, Chernysh M, Osipova V, Tabeeva G, et al. The prevalence of primary headache disorders in Russia: a countrywide survey. Cephalalgia 2012; 32: 373-381.

Karakurum Goksel B, Coskun O, Ucler S, Karatas M, Ozge A, Ozkan S. Use of complementary and alternative medicine by a sample of Turkish primary headache patients. Agri 2014; 26: 1-7.

Yoon MS, Katsarava Z, Obermann M, Fritsche G, Oezyurt M, Kaesewinkel K, et al. Prevalence of primary headaches in Germany: results of the German Headache Consortium Study. J Headache Pain 2012; 13: 215-223.

Gaul C, Doorn C, Webering N, Dlugaj N, Katsarava Z, Diener H, et al. Clinical outcome of a headache-specific multidisciplinary treatment program and adherence to treatment recommendations in a tertiary headache center: an observational study. J Headache Pain 2011; 12: 475–483.

Trainor A, Miner J. Pain treatment and relief among patients with primary headache subtypes in the ED. Am J Emerg Med 2008; 26: 1029-1034.

Friedman BW, Hochberg ML, Esses D, Grosberg BM, Rothberg D, Bernstein B, et al. Recurrence of primary headache disorders after emergency department discharge: frequency and predictors of poor pain and functional outcomes. Ann Emerg Med 2008; 52: 696-704.

Liu R, Yu S, He M, Zhao G, Yang X, Qiao X, et al. Health-care utilization for primary headache disorders in China: a population-based door-to-door survey. J Headache Pain 2013; 14: 47.

Stang PE, Von Korff M. The diagnosis of headache in primary care: factors in the agreement of clinical and standardized diagnoses. Headache 1994; 34: 138-142.

Bahrami P, Zebardast H, Zibaei M, Mohammadzadeh M, Zabandan N. Prevalence and characteristics of headache in Khoramabad, Iran. Pain Physician 2012; 15: 327-332.

Atasoy HT, Unal AE, Atasoy N, Emre U, Sumer M. Low income and education levels may cause medication overuse and chronicity in migraine patients. Headache 2005; 45: 25-31.

Black AK, Fulwiler JC, Smitherman TA. The role of fear of pain in headache. Headache 2015; 55: 669-679.

Albers L, Heinen F, Landgraf M, Straube A, Blum B, Filippopulos F, et al. Headache cessation by an educational intervention in grammar schools: a cluster randomized trial. Eur J Neurol 2015; 22: 270-276, e222.

Overath CH, Darabaneanu S, Evers MC, Gerber WD, Graf M, Keller A, et al. Does an aerobic endurance programme have an influence on information processing in migraineurs? J Headache Pain 2014; 15: 11.

Baillie LE, Gabriele JM, Penzien DB. A systematic review of behavioral headache interventions with an aerobic exercise component. Headache 2014; 54: 40-53.

Naddafi K, Hassanvand MS, Yunesian M, Momeniha F, Nabizadeh R, Faridi S, et al. Health impact assessment of air pollution in megacity of Tehran, Iran. Iranian J Environ Health Sci Eng 2012; 9: 28.

Nazari F, Eghbali M. Migraine and its relationship with dietary habits in women. Iran J Nurs Midwifery Res 2012; 17: S65-71.

Kafeshani O, Sarrafzadegan N, Nouri F, Mohammadifard N. Major dietary patterns in Iranian adolescents: Isfahan Healthy Heart Program, Iran. ARYA Atheroscler 2015; 11: 61-68.

How to Cite
Faizi F, Tavallaee A, Rahimi A, Saghafinia M. Psychiatric Comorbidities and Environmental Triggers in Patients with Chronic Daily Headache: A Lifestyle Study. Iran J Psychiatry. 12(1):29-35.
Original Article(s)