It is well known that the patient having a mild tension headache, which can be relieved by aspirin, is rarely seen by the physician for this condition. However, if the headache occurs daily, is present when the patient awakens, remains for most of the day and has been occurring for months or even years, the patient becomes an important therapeutic problem. These are the patients seen by the practicing physician because of the continuous headache, which does not usually respond to the common analgesic drugs.
In 1964, this type of headache was described by the author as being a major symptom in patients with depressive reactions. The presence of depression is often subtle and the diagnosis is often missed. Probably most physicians are able to recognize the classically depressed patient. This is the patient who walks into the office with a certain look of sadness, speech and movements are slow, exhibits little interest in anything, and sighs frequently. However, since the majority of depressed patients do not fit the classic mode, diagnosis will require some detective work on the part of the physician. The physician must obtain a thorough psychiatric history from the patient, which should include the patient's marital relations, occupation, social relationships, life stresses, personality traits, habits, methods of handling tense situations, and sexual problems. Two basic questions are often helpful in providing insight for a possible depression. First, inquiries should be made about family, personal history of prior depression, or if the patient had similar symptoms previously. Second, the patient should be questioned about the onset of his/her symptoms or any precipitating events.
The depressed patient often presents a wide variety of complaints that can be categorized as physical, emotional, and psychic. The physical complaints include chronic pain and headaches, sleep disturbances, severe insomnia and early awakening, appetite changes, anorexia and rapid weight loss, and a decrease in sexual activity, ranging at times to impotence in males and amenorrhea or frigidity in females. Emotional complaints include feeling "blue," anxiety, and rumination over the past, present, and future. Finally, psychic complaints may include such statements as "morning is the worst time of day," suicidal thoughts, and death wishes. A headache secondary to depression is usually considered a tension-type (muscle contraction) headache.
Tension-type (muscle contraction) headache is believed to be due to sustained and/or tightened muscle contraction of the scalp and neck muscles. Sustained voluntary contraction of skeletal muscles may cause pain after variable periods. The pain may intensify if compression of small vessels causes ischemia or accumulation of noxious metabolites occurs in the affected muscles. Although evidence regarding the cause of pain is conflicting, a recent study showed that voluntary contraction or decreased circulation in exercising temporalis muscle resulted in pain. A combination of exercise and ischemia markedly shortened the onset of pain.
An earlier study suggested that in susceptible persons contraction of skeletal muscles of the head, together with extracranial vasoconstriction caused by circulating constrictor agents, could produce tension-type (muscle contraction) headaches. The investigator believed that both responses occur concomitantly in anxiety-producing situations. In a later study, researchers observed increased blood flow to the scalp muscles during tension headache. However, this increased blood flow did not rule out decreased circulation, since metabolic demands may have exceeded the observed flow in actively contracting muscles.
Recent studies have questioned the role of muscle in tension headache. They argue that most patients do not manifest increased muscle activity during tension-type (muscle contraction) headache. However, the muscle model should not be dismissed and may be useful in a limited group of patients. The muscle contraction concept is still worthwhile, although evidence is conflicting. Increased muscle contraction and scalp muscle ischemia are probably essential to head pain, and central pain mechanisms may also lead to headache. Chronic tension-type (muscle contraction) headaches may conceal a serious emotional disorder, such as depression. The patient will present with a persistent and vague headache, for which no organic cause can be determined. For the patient, the physical symptoms are more socially acceptable than the anxiety or depressive symptoms; many patients are certain there is a somatic basis for their pain.
People with depressive illness may develop bodily symptoms, and conversely people with painful organic diseases tend to become depressed. It should be noted that too little attention is given to the depressive aspects of chronic pain and its treatment. The physical complaints dominate the situation so that the underlying depression tends to be overlooked. Certain details about the headache may indicate an underlying depression. These headaches usually appear at regular intervals in relation to daily life, occurring on weekends, Sundays, or holidays, and on the first days of vacation or after exams. The greatest incidence of "nervous-type" headache occurs from 4:00 p.m. to 8:00 p.m. and from 4:00 a.m. to 8:00 a.m. These are usually the periods of the greatest and sometimes the most silent family crises. This headache consists of a steady, nonpulsatile ache, often distributed in a band-like pattern around the head. It may be described as vise-like, a steady pressure, a weight, a soreness or a distinct cramp-like sensation. They follow no definite pattern as to location, although the occipital portion of the skull is frequently affected. Their duration is a distinguishing feature. A depressed person will describe his/her headache as lasting for years or throughout life. A depressive headache is usually dull and generalized, characteristically worse in the morning and in the evening.
In making the diagnosis of depressive headache, we must be certain to rule out organic causes. These include cervical arthritis, discogenic bony anomalies of the occipitocervical joints, basilar invagination, chronic mastoiditis, malocclusion of the temporomandibular joint and possibly a posterior fossa lesion in the brain.
The most popular biologic theories of depression hold that the disorder is associated with depletion of brain monoamine neurotransmitters such as serotonin and norepinephrine. Determining the most important substance in depression is controversial. Evidence is available to support both the norepinephrine and serotonin hypotheses. Other neurotransmitters, such as dopamine and endorphin, may also be involved in depression. The discovery of endogenous, opiate-like substances in the brain, the endorphins and enkephalins, has significantly advanced our understanding of pain.
The current treatment of tension-type (muscle contraction) headache often focuses on the underlying depression and includes the use of the antidepressant agent. Biofeedback also has been demonstrated as useful in the treatment of tension-type (muscle contraction) headaches. Some scientists have reported a reduction of the levels of depression in patients with tension-type (muscle contraction) headache following the use of biofeedback. However, in their work, the categorizing of the depression was unclear.
There may also be a relationship between depression and migraines. Researchers have reported a weak but significant relationship between migraine and depression. They noted a high correlation between depression and migraine in relation to weakness, sensory disturbance, difficulty with speech and loss of consciousness. They postulated about a possible subgroup of patients in whom depression and migraine are linked and who are characterized by the presence of those focal neurological signs previously mentioned.
It has been proposed that the antimigraine effect of amitriptyline is independent of its antidepressant effect, but it is undetermined if this effect is due to blocking of the re-uptake of serotonin and, to a lesser degree, norepinephrine at the nerve endings, or due to its anticholinergic, antihistaminic and antiserotonergic actions. Further investigation is warranted in this possible link.
In summary, depression is a widespread affliction that can be treated, but first it must be unmasked. The physician should be cognizant that although the headache may be secondary to depression, the pain is very, very real. The patient should be reassured that he/she can be helped but it is not going to happen immediately and it will require time and complete cooperation.
The tricyclic antidepressants, the selective serotonin re-uptake inhibitors, and the monoamine oxidase inhibitors are agents of choice in the treatment of headaches associated with depression. A physician must prescribe these drugs.