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Stress and chronic headache

  • c. besta m ilan italy

Abstract and Figures

The aims of this study were to assess how stress affects chronic headaches, and in particular to determine whether events play a role in the transformation of an episodic headache into a chronic form. A population of 267 Italian patients with chronic headache (headache present on average more than 15 days per month) was studied. Our results confirm a triggering role of stress on headache. We also found that episodic headache (migraine in most patients, 74.1%) preceded the development of a chronic form in about 90% cases. Among these patients, in 44.8% a stressful event correlated with the transformation. Analysis of these events revealed that minor events played a greater role than major life events, suggesting that patients with transformed headache are characterised by a different way of reacting to stress.
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It is a matter of clinical experience that psychological fac-
tors, in particular stress, can exert notable effects on prima-
ry headaches. Several studies have shown that stress is one
of the most common trigger factors for headache, both in
migraine and in tension-type headache [1–5]. It is reason-
able, therefore, that stress may exert effects on the clinical
evolution of these headaches. For example, stressful events
may increase headache frequency or promote transforma-
tion of an episodic headache into a chronic form. A chronic
headache is one present on average more than 15 days per
month [6]. A transformed headache is an originally episod-
ic headache that developed into a chronic one.
A stressful event is an environmental situation or psy-
chological trauma that compromises or threatens wellbeing.
Several models have been proposed to explain how stress
can influence headache. More recent theories do not consid-
er stress as a purely exogenous factor but recognise that
stressful events can induce objective biological and psycho-
logical changes.
Stress acts on the body via the endocrine system, auto-
nomic nervous system and immune system [7–9]. These
systems act as biological integrators in the body, function-
ing to maintain homeostasis. In turn they are influenced by
such factors as genetic makeup or constitution, psychobio-
logical imprinting and the external environment (the sum of
physical, emotional and social stimuli). Stressful events
affect the brain through inputs from the cortex, subcortical
regions, and sensory organs, and from the endocrine system,
provoking reactions mediated, principally, by the hypothal-
amo-hypophyseal-adrenal axis (CRH) and by the locus
coeruleus (norepinephrine). The effects of these multifari-
ous hormonal and neurotransmitter changes vary with the
duration of the stressful stimulus. Prolonged and repeated
exposure to stressful stimuli may lead to permanent func-
tional changes and even to anatomical damage, and can thus
assume the role of a pathogenetic agent or illness precursor.
J Headache Pain (2000) 1:S49–S52
© Springer-Verlag 2000
Stress and chronic headache
D. D’Amico G. Libro C. Peccarisi
G. Bussone ()
C. Besta National Neurological Institute
Via Celoria 11, I-20133 Milan, Italy
Tel.: +39-02-2394264
Fax: +39-02-70638067
The affiliations of the other authors are
listed at the end of the article
Domenico D’Amico
Giuseppe Libro
Maria Pia Prudenzano
Cesare Peccarisi
Mario Guazzelli
Giuliano Relja
Francomichele Puca
Sergio Genco
Ferdinando Maggioni
Giuseppe Nappi
Anna Pia Verri
Rosanna Cerbo
Gennaro Bussone
Abstract The aims of this study
were to assess how stress affects
chronic headaches, and in particular
to determine whether events play a
role in the transformation of an
episodic headache into a chronic
form. A population of 267 Italian
patients with chronic headache
(headache present on average more
than 15 days per month) was stud-
ied. Our results confirm a triggering
role of stress on headache. We also
found that episodic headache
(migraine in most patients, 74.1%)
preceded the development of a
chronic form in about 90% cases.
Among these patients, in 44.8% a
stressful event correlated with the
transformation. Analysis of these
events revealed that minor events
played a greater role than major life
events, suggesting that patients with
transformed headache are charac-
terised by a different way of reacting
to stress.
Key words Chronic headache
Stress Life events Trigger factor
Migraine Transformation of
Prolonged stress has been shown to induce functional lesions
in the nerve terminals within the hypothalamus and locus
coeruleus in animals [10]. Prolonged glucocorticoid secretion
(as occurs in chronic stress) may be responsible for loss of
hippocampal dendrites or neurons in humans [11].
Lazarus and Folkman proposed the transactional model
of stress which focuses on cognitive aspects [12]. They dis-
tinguished two types of evaluation of stressful events: pri-
mary evaluation, whether an event is interpreted to be sig-
nificant to the person’s wellbeing; and secondary evalua-
tion, whether the person has the resources available to
respond successfully to the event. If an event is judged to be
a threat, then a coping response is required; unsuccessful
attempts at coping lead to physiologic arousal and eventual-
ly to pain (for example, through muscle tension).
Patients and methods
The aims of the study were to determine to what extent stress
adversely affected chronic headache, to identify patients whose
chronic headache had developed from an episodic form, and to
investigate whether stress played a role in that transformation.
The study was conducted on out-patients recruited consecu-
tively at the main Italian headache centres. Inclusion criteria were
chronic headache (pain for 15 or more days per month for at least
six months) and age between 18 and 65 years. A total of 267
patients were enrolled. Patients were interviewed individually and
data were entered directly onto a computer form that had been
designed for the study. Stressful events reported by patients were
classified according to Paykel et al.’s life events scale [13] and
grouped into 10 activity areas, as reported in the Italian translation
of the scale [14]: work, education, finances, health, bereavement,
migration, courtship and cohabitation, legal concerns, family and
social issues, and marriage
Of the 267 chronic headache patients enrolled, only 28 had
chronic headache from onset. In the remaining 239 (89.5%)
cases, the headache had developed from an episodic
headache. In 177 (74.1%) of 239 patients, the initial
headache was migraine, and in 34 (14.2%) the headache
was tension type (Table 1).
Regarding stress as a headache aggravating factor, we
found that 120 (44.9%) patients reported a deterioration of
their chronic headache following a stressful event.
Among the 239 patients in whom an originally episodic
headache had become chronic, stress was reported to be a
trigger for the episodic headache in 87 (36.4%) cases.
Furthermore, 107 (44.8%) of these patients indicated that a
stressful event correlated with the passage from episodic to
chronic headache (Table 2). Stressful events were due to
health problems in 35.6% of cases, family and social prob-
lems in 17% of cases, marriage in 13.6%, bereavement in
13.6%, and work in 11.4%. Less frequently, legal concerns,
education, courtship and cohabitation, finances and migra-
tion-related problems were mentioned (Fig. 1).
We conducted a further analysis to determine whether
major stressful events, such as serious illness or loss of
job, had greater effect than minor events on headaches.
Table 1 Initial headache diagnosis in 267 chronic headache patients
Diagnosis at onset Patients, n (%)
Chronic headache 28 (10.5)
Episodic headache 239 (89.5)
Migraine 177 (74.1)a
Migraine + tension-type headache 5 (2.1)a
Tension-type headache 34 (14.2)a
Not classifiable headache 23 (9.6)a
Total 267 (100)
a Percent of 239 patients initially diagnosed with episodic headache
Table 2 Presence of life events associated in time with the transformation of headache from an episodic to a chronic form
Chronic headache patients with an episodic headache at onset Patients, n (%)
With presence of life events 107 (44.8)
With absence of life events 132 (55.2)
Total 239 (100.0)
Minor events were those related to the following areas of
Paykel et al.’s scale: courtship and cohabitation, marriage,
education, family/social; and paraphysiological health
problems (e.g. menopause, birth of a child, use of oral con-
traceptives) and non-serious work problems (stressful rela-
tionships and work conditions). Major problems were
bereavement, financial troubles, legal concerns, and
migration from Paykel et al.’s activity areas, and serious
illness or work problems (e.g. change or loss of job and
Of the patients in whom chronic headache had devel-
oped from episodic headache, 154 (64.4%) reported that a
minor stressful event coincided with this change, while
only 85 (35.6%) indicated that a major event coincided
with the change (Fig. 1).
This study has confirmed the hypothesis that stress has a
negative influence on headache. Specifically, we found that
stress leads to a worsening of chronic headaches and acts as
a trigger of episodic headache attacks before they transform
into chronic headaches. We also found that in almost 90% of
cases the chronic headache was originally episodic in
nature, but at some point transformed into a chronic form.
Furthermore, in most cases the original episodic headache
was migraine. These findings are in accord with previous
studies [15, 16], one of which [15] first proposed the term
“transformed” to refer to migraine that had become chronic.
Our data, in addition, indicate the existence of a relation
between stress and this transformation process: stressful
events were associated in time with the transformation of
the headache in 44.8% of patients.
Patients with headache may either be more exposed to
stressful psychosocial stimuli, or have reduced ability to tol-
erate stress. Published findings regarding the former
hypothesis are not clear cut. For example, Invernizzi et al.
[17] reported more stressful life events in a group of prima-
ry headache patients than in healthy controls. However,
when the diagnostic categories were considered it emerged
that the significant difference was due entirely to patients
with migraine, while patients with chronic headaches
(“mixed” and “daily” headaches) did not differ from con-
trols. De Benedictis and Lorenzetti [18] studied patients
with recurrent headache (average frequency, 16 days
(SD=10) per month) and found that those with chronic ten-
sion-type headache and “mixed” headache were more
exposed to stressful events than controls or migraine
patients. Here, however, the significant differences per-
tained to “daily hassles” – small problems of daily life – and
not major life events.
The second idea, that patients whose headaches have
0 10 20 30 40 50 60 70
Family and social
Major event
Minor event
Percent of patients
Fig. 1 Life events and transformation
from episodic to chronic headache
become chronic cope poorly with stress, seems more likely
from published work. Holm et al. [19] found that patients
with tension chronic-type headache judged stressful events
more negatively than controls and this difference was more
evident for daily hassles. Furthermore, these patients adopted
less efficient coping strategies, using mainly avoidance behav-
iour and self criticism, while seeking less social support.
Martin and Theunissen [20] found no difference between high
frequency migraineurs, tension-type headache patients and
controls as regards frequency and importance of life events.
However, there were significant differences on measures of
social support: patients could count on fewer people for emo-
tional and social support, and these were less useful.
Our findings also indicate that minor events (which we
call daily hassles) play a greater role in transforming
headache than major events (as we defined them), suggest-
ing that patients with transformed headache are charac-
terised, not by greater exposure to major stressful events,
but by a different way of reacting to stress.
M.P. Prudenzano F. Puca S. Genco
Neurological Clinic I,
University of Bari, Bari, Italy
M. Guazzelli
Psychiatric Clinic,
University of Pisa, Pisa, Italy
F. Maggioni
Neurological Clinic,
University of Padua, Padua, Italy
G. Nappi A.P. Verri
IRCCS Mondino,
University of Pavia, Pavia, Italy
R. Cerbo
Department of Neurological Sciences
University of Rome La Sapienza, Rome, Italy
G. Relja
Ospedale Maggiore, Trieste, Italy
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... normal (18.5-25), overweight (25)(26)(27)(28)(29)(30), class I obesity (30-35), class II obesity (>35) and class III obesity (40+) [14] and Asia pacific guidelines [15] as underweight <18.5, normal (18.5-22.99), overweight (23-24.99), ...
... The effects of these multifarious hormonal and neurotransmitter changes vary with the duration of the stressful stimulus. Prolonged and repeated exposure to stressful stimuli may lead to permanent functional changes and even to anatomical damage, and can thus assume the role of a pathogenetic agent or illness precursor for the development of headache [28]. In this study there was no significant association found between stress and obesity as p> 0.005. ...
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Background: Many factors are involved in the prognosis and outcome of Chronic Migraine and Medication Overuse Headache (CM+MOH), and their understanding is a topic of interest. It is well known that CM+MOH patients experience increased psychiatric comorbidity, such as anxiety, depression, or personality disorders. Other psychological factors still need to be explored. The present study is aimed to evaluate whether early life traumatic experiences, stressful life events, and alexithymia can be associated with CM+MOH. Methods: Three hundred and thirty-one individuals were recruited for this study. They belonged to one of the two following groups: CM+MOH (N = 179; 79% females, Age: 45.2 ± 9.8) and episodic migraine (EM) (N = 152; 81% females; Age: 40.7 ± 11.0). Diagnosis was operationally defined according to the International Classification of Headache Disorders 3rd edition (ICHD-IIIβ). Data on early life (physical and emotional) traumatic experiences, recent stressful events and alexithymia were collected by means of the Childhood Trauma Questionnaire, the Stressful life-events Questionnaire, and the Toronto Alexithymia Scale (TAS-20), respectively. Results: Data showed a higher prevalence of emotional (χ² = 6.99; d.f. = 1; p = 0.006) and physical (χ² = 6.18; d.f. = 1; p = 0.009) childhood trauma and of current stressful events of important impact (χ² = 4.42; d.f. = 1; p = 0.025) in CM+MOH patients than in EM ones. CM+MOH patients were characterized by higher difficulties in a specific alexithymic trait (Factor 1 subscale of TAS-20) [F (1, 326) = 6.76, p = 0.01, η p ² = 0.02] when compared to the EM group. The role of these factors was confirmed in a multivariate analysis, which showed an association of CM+MOH with emotional (OR 2.655; 95% CI 1.153-6.115, p = 0.022) or physical trauma (OR 2.763; 95% CI 1.322-5.771, p = 0.007), and a high score at the Factor 1 (OR 1.039; 95% CI 1.002-1.078, p = 0.040). Conclusions: Our findings demonstrated a clear relationship between CM+MOH and life traumas, stressful events, and alexithymia. These observations have a relevant role in multiple fields of related to chronic headache: from the management to the nosographic framing.
New daily persistent headache is described as an enigmatic condition with daily headache from onset. It has posed challenges diagnostically and therapeutically. Methods: We conducted a study of patients referred to headache services based in Central and North-East London, United Kingdom, meeting the International Classificaiton of Headache Disorders – 3 criteria for New daily persistent headache. Information on demographics, phenotype and treatment responses were collected. The syndrome of the daily headache was also classified according any other ICHD-3-defined syndrome. Results: Of 162 patients, females comprised 68.5% with median age of onset 35 years. The daily headache experienced was chronic migraine in 89.7% and tension-type headache in 8.8%. Thunderclap-onset New daily persistent headache occurred in 14.8%. More than one headache syndrome was experienced in 15.4%, including cough, hypnic, sexual and stabbing headache. All aura types were experienced, most commonly brainstem aura in 39%. Prior headache was reported 53.7%. A persisting sub-form was present in 51.2%, relapsing remitting in 12.3% and 14.0% reported improvement; 19.8% were lost to follow-up. Only 11.1% reported an antecedent trigger. The most common premorbid disorders were psychiatric in 35.7%. A fifth improved on preventative medication, most commonly amitriptyline, propranolol and topiramate. Conclusion: Our cohort of New daily persistent headache is consistent with a mode of onset of migraine and tension-type headache which occurs in predisposed individuals.
Primary headache can be seen as a failure to adapt to environmental demands. From an interoception point of view, every change in sensation, which is not in line with predictions, can cause a surprise, produce feelings, emotions, a perception of distress, a headache and initiate pain behaviour. Social stress is a stress which arises from interactions with people, social situations, social roles and could be important part of an overall psycho-psychical burden. A common form of social stress is stress in the workplace. Our predictions originate from our beliefs, which in turn depend on the knowledge we obtain during our lives. Our personality, in combination with the social situation, is important in producing distress and related headaches. From a cognitive neuroscience perception, such headaches are produced in the process of inference and depend on both sensations and predictions through interoception. Thus, headaches from a biopsychosocial view can be considered as behaviour responses to stresses including social stress.
Migraine has been known from the time of ancient Greco-Roman medicine. It has been studied by physicians throughout the ages, and many eminent physicians and scientists have themselves suffered from it.
SYNOPSISA group of chronic headache sufferers (migraine and tension-type headache) was compared with twoindividually matched control groups of nonheadache subjects in terms of life event stress, and the stressmoderating factors of coping skills and social support. The headache group did not differ from the controlgroups on the measures of life event stress or coping but significant differences arose on the measure ofsocial support with the headache group achieving lower scores than the control groups. The findings wereinterpreted as suggesting that clinicians and researchers should pay more attention to social aspects ofheadaches, and that interventions aimed at teaching headache sufferers to mobilize social support shouldbe considered as components of treatment packages.
SYNOPSIS This study investigated the role of stress in recurrent tension headache. Although recurrent tension headache sufferers (N=117) and matched headache-free controls (N=174) reported similar numbers and types of stressful life events, headache sufferers reported a greater number of chronic everyday stresses or daily hassles than did controls. Recurrent tension headache sufferers also appraised the stressful events they experienced more negatively than did controls, and employed less effective coping strategies in their efforts to manage stressful events. When the potential impact of a stressful event was ambiguous, recurrent headache sufferers appraised this event more negatively and themselves as having less control over the event than did headache-free controls. In their coping efforts, recurrent tension headache sufferers also placed greater reliance on the relatively ineffective coping strategies of avoidance and self-blame, and made less use of social support than did controls. These findings suggest that research on the role of stress in tensionheadaches should focus not on the occurrence of major stressful life events, but on the recurrent headache sufferer's cognitive appraisals of stressful events and efforts to cope with stress.
SYNOPSIS 1161 college students were surveyed to provide information about headache prevalence. Virtually all students reported experiencing some headache pain. Females reported headaches that were more frequent, more painful, and of longer duration than males. Information regarding suspected causes, onset characteristics, presence of migraineous symptoms, and nature and localization of experienced pain was also collected. The significance and implications of these findings, as well as suggestions for future research, are discussed.
This study investigated the role of major stressful life events vs. minor life events (i.e., daily hassles) in the persistence of primary headache. It was hypothesized that chronic headache patients (n = 83) would be characterized not so much by exposure to a continued surfeit of inherently major life events as by a tendency to appraise cognitively and emotionally any ongoing microstressor or daily hassle as being more arousing or impactful than headache-free controls (n = 51). As predicted, chronic headache patients reported a significantly higher frequency (P < 0.01) and density (P < 0.01) of daily hassles, but not of major life events, than controls. Furthermore, minor life events were significantly correlated with headache frequency (P < 0.001) and density (P < 0.001) but not with gender, age and headache history. In terms of item content, health-related hassles (e.g., trouble relaxing) were perceived as being the most stressful. Significant differences between headache subgroups (chronic tension-type headache, migraine, mixed headache) were found, with tension-type and mixed headache sufferers reporting a higher incidence and density of daily hassles than migrainous patients. It was concluded that daily hassles were significantly associated with the persistence of headache and might be a better life event approach to chronic headache than major stressful events.
SYNOPSIS 630 (39%) of 1600 patients seen in a Headache Clinic over a three year period had chronic daily headaches (CDH). In 78% of these CDH patients, the daily headaches evolved out of a prior history of episodic migraine; these patients we designate as having “transformed” or “evolutive” migraine. The other 12% had migraine headaches which were daily from the start. Patients with transformed migraine, in contrast to those with daily headaches from the start, have a significantly higher incidence of positive family history of migraine, menstrual aggravation of migraine, identifiable trigger factors, associated G.I. and neurological symptoms, and early morning awakening with headache. The CDH group in general over-used symptomatic medication and exhibited abnormalities on behavioral scale testing. Withdrawal of daily symptomatic medication, institution of a low tyramine low caffeine diet, initiation of prophylactic anti-migraine therapy, and biofeedback and behavioral therapy, gave worthwhile improvement in 76% of chronic daily headache patients. Factors which promote “evolution” of migraine from intermittent to chronic daily occurrence are not well-defined but may include medication abuse, medication withdrawal, and psychiatric disturbances.