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2014 Hong Kong College of Psychiatrists

East Asian Arch Psychiatry 2014;24:10-5 Original Article

10

Association of Panic Disorder with Quality ofLife among Individuals with Headache

IJ Ratnani, BN Panchal, DS Tiwari, AU Vala

Abstract

Objective: To study the association of panic disorder with severity of anxiety symptoms and quality oflife among individuals presenting with headache.Methods:This was a single-centre, cross-sectional, observational, questionnaire-based study performedat the psychiatry outpatient department of a tertiary care hospital. Participants of both genders, agedbetween 18 and 60 years, and having headache as a presenting complaint for at least 3 months wereevaluated for symptoms of panic disorder. The severity of headache was evaluated with the visualanalogue scale and that of anxiety disorder with the Hamilton Anxiety Rating Scale (HAM-A). Thequality of life was evaluated with the World Health Organization Quality of Life Scale brief version.

Proportions of participants were compared using Chi-square test, and scores by Mann-Whitney test orKruskal-Wallis test followed by Dunns post-hoc multiple comparisons.Results:The frequency of panic disorder among patients with headache was 67%. Those with dailyheadache and panic disorder (with or without agoraphobia) showed higher HAM-A score and poorerquality of life than those with intermittent headache and without panic disorder, respectively.Conclusions:Co-morbid panic disorder among patients with headache was associated with high anxietyscore and poor quality of life.

Key words:Anxiety; Headache; Panic disorder; Quality of life

18603HAM-AMann-WhitneyKruskal-WallisHAM-A

Dr Imran Jahangirali Ratnani, MBBS, Department of Psychiatry, Government

Medical College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat,

India.

Dr Bharat Navinchandra Panchal, MD, Department of Psychiatry, Government

Medical College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat,

India.

Dr Deepak Sachchidanand Tiwari, MD, Department of Psychiatry, Government

Medical College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat,

India.

Dr Ashok Ukabhai Vala, MD, Department of Psychiatry, Government Medical

College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat, India.

Address for correspondence:Dr Imran Jahangirali Ratnani, Room No. 133,

Department of Psychiatry, Government Medical College and Sir Takhtasinhji

General Hospital, Bhavnagar, Gujarat, India 364001.

Tel: (91) 9925056695; Fax: (91-278) 2422011; Email: drijratnani@gmail.com

Submitted: 16 September 2013; Accepted: 11 October 2013

Introduction

Headache is a common cause for medical consultation.1Tension-type headache (TTH) is the most common cause forprimary headache (69%), followed by migraine headache(16%).2 Headache often results in considerable disabilityand poor quality of life.2 The present lifetime disabilityattributable to migraine of 0.5 in terms of disability-adjusted life years is equal to or more than that of severalother major chronic illnesses such as hypertension, breastcancer, and rheumatoid arthritis.1Psychiatric illnesses arecommonly associated with headache. The relationship ofanxiety disorders and depression with migraine has been

established in various studies.3-5

Anxiety is the commonest

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Panic Disorder and Quality of Life in Headache

East Asian Arch Psychiatry 2014, Vol 24, No.1 11

25 years of experience in the subject. Hamilton AnxietyRating Scale (HAM-A), a 14-item observer-rated scale,was used to assess the severity of the anxiety symptoms.10The participants were asked to complete the 26-item WorldHealth Organization Quality of Life Scale brief version(WHOQOL-BREF) which is a self-rating questionnaire forassessment of the quality of life in the domains of physicalhealth, psychological health, social relationship, andenvironment.11

Qualitative data were expressed as percentages andquantitative data were expressed as median interquartilerange. The statistical analysis was done with GraphPadInStat version 3.06 (San Diego, California, US). Proportionsof participants were compared by using Chi-square testwhile scores of VAS, HAM-A, and WHOQOL-BREF werecompared by using Mann-Whitney test or Kruskal-Wallistest followed by Dunns post-hoc multiple comparisons. A pvalue of < 0.05 was considered statistically signicant.

Written informed consent was obtained from every

participant. Prior approval for the study was obtained fromthe local ethics committee.

Results

These 100 participants (24 males and 76 females) weredivided into 3 groups according to severity of their anxietysymptoms and were assessed by HAM-A. HAM-A scoresof 17 were classied as mild, 18-24 as mild to moderate,

and 25 as moderate to severe. Table 112shows demographicvariables of these participants. The frequency of panicdisorder among the patients presenting with headache

was 67%; PA was noted in 23% of subjects and PoA in44% of subjects. Severity of anxiety symptoms did notdiffer with various demographic variables including age,gender, residence, religion, marital status, education, socio-economic status, tobacco use, severity, characteristic andduration of headache, as well as history and family historyof headache or psychiatric consultations. Participants withpanic disorder had signicantly higher HAM-A score

(p < 0.0001) and poor quality of life in all domains ofWHOQOL-BREF except in the social relationship domain.The HAM-A score and quality of life in subjects with PAdid not differ signicantly from those with PoA (Table

2). Besides, those with daily headache had signicantly

higher HAM-A score (p = 0.04) and poor quality of life inthe psychological health domain of WHOQOL-BREF (p =0.04) than those with intermittent headache (Table 3). Thosewith high HAM-A scores had poor quality of life in all thedomains of WHOQOL-BREF (p < 0.0001). Among all thedomains, the psychological health domain score reducedsignicantly as anxiety score increased (Table 4).

Discussion

Psychiatric disorders such as anxiety disorders anddepression are more common among patients with recurrent

headache than in the general population.3,13A majority of

co-morbidity affecting about 75% of patients6; its associationwith migraine is stronger than that with depression,3and thepresence of anxiety disorders is an independent risk factorfor depression in patients with migraine.4 Panic disorderand phobia are the most common anxiety diagnosesamong migraineurs.7There is paucity of clinical literatureconcerning the association of anxiety disorders in relationto headache. At present, it is difcult to clinically distinguish

migraine from TTH, as the International Headache Societysmain denition of TTH allows an admixture of nausea,

photophobia, or phonophobia in various combinations,although the appendix denition does not.2This illustratesthe difculty in distinguishing migraine from TTH.

Migraine is associated with anxiety, depression, andpoor quality of life.2 To our best knowledge, there is nopublished evidence on the association of panic disorderwith severity of anxiety symptoms among patients withheadache. Thus, in the present study, we evaluated the

prevalence of panic disorder among patients with headache,and the possible association of panic disorder with severityof anxiety symptoms and quality of life in the patients withheadache.

Methods

A total of 100 consecutive patients of both genders between18 and 60 years, and having headache as a presentingcomplaint for at least 3 months were recruited from thepsychiatry outpatient department of a tertiary care hospitalfrom April 2012 to July 2012. Patients with severe mental

illnesses including schizophrenia, bipolar mood disorder,cognitive impairment, chronic disabling illnesses, negativesymptoms, dementia, and poor attention, as well as thoseunable to give verbal replies were excluded from the study.Patients on antidepressant, antipsychotic or antianxietymedications in the last 2 months were also excluded. Causesfor secondary headache involving organic aetiologieslike systemic infection, head injury, vascular disorders,subarachnoid haemorrhage and brain tumours were ruledout with clinical examination. Participants were interviewed by the principalinvestigator on demographic variables like age, gender,residence, religion, marital status, education, socio-

economical status, and tobacco use. Duration andcharacteristics of headache (dull aching, throbbing or mixed)were recorded. The visual analogue scale (VAS) was usedfor recording the severity of headache using self-rating on ascale of 0 to 10.8History and family history of headache orany other psychiatric consultation were recorded. Participants were interviewed for the symptoms ofanxiety disorders like panic disorder, agoraphobia and forthe diagnosis of panic disorder with agoraphobia (PA) andpanic disorder without agoraphobia (PoA) using clinician-administered interview as per the DSM-IV-TR criteria.9The diagnosis was conrmed by a consultant psychiatrist

holding a master degree in psychiatry and with more than

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IJ Ratnani, BN Panchal, DS Tiwari, et al

East Asian Arch Psychiatry 2014, Vol 24, No.112

Table 1. Demographic variables according to severity of anxiety symptoms based on Hamilton Anxiety Rating Scale

scores.*

Characteristics Mild

(n = 33)

Mild to

moderate

(n = 24)

Moderate to

severe

(n = 43)

p Value

Age (years) 34 (20-58) 32 (21-40) 35 (19-54) 0.55

GenderMale (n = 24)Female (n = 76)

1122

618

736

0.22

ResidenceRural / town (n = 53)Urban (n = 47)

2013

1014

2320

0.36

ReligionHindu (n = 79)Muslim (n = 21)

294

195

3112

0.24

Marital statusMarried (n = 94)

Unmarried (n = 6)

30

3

23

1

41

2

0.65

EducationIlliterate (n = 37)Primary (n = 43)Post-primary (n = 20)

1014

9

1194

1620

7

0.64

Socio-economic status

1-2 (n = 62) 3 (n = 38)

1914

1410

2914

0.62

Tobacco useYes (n = 31)No (n = 69)

1320

420

1429

0.17

Headache characteristicDull aching (n = 31)Throbbing (n = 51)Mixed (n = 18)

822

3

813

3

151612

0.08

Visual analogue scale 5 (3-9) 7 (3-9) 7 (1-10) 0.63

Duration of headache (months) 12 (3-120) 30 (4-240) 18 (3-240) 0.08

Panic disorderWith agoraphobia (n = 23)Without agoraphobia (n = 44)No panic disorder (n = 33)

24

27

218

4

1922

2

< 0.0001

History of headache or any other psychiatric illnessesYes (n = 25)

No (n = 75)

6

27

6

18

13

30

0.48

Family history of headache or any other psychiatric illnessesYes (n = 23)No (n = 77)

429

717

1231

0.19

* Data are shown as No. of patients or median (interquartile range). Calculated by Chi-square test or Kruskal-Wallis test with Dunns post-hoc multiple comparisons. Based on Kuppuswamys Socioeconomic Status Scale score.12

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East Asian Arch Psychiatry 2014, Vol 24, No.114

participants in this study were women (76%). Accordingto a prospective study,14women were 4 times more likelyto develop migraine in comparison with men. Unlike thatfor migraine, the female-to-male ratio for TTH is 5:4,suggesting that the prevalence of TTH is slightly higher inwomen than in men.15Our nding suggested that the severity

of anxiety symptoms did not differ with demographicvariables of age, gender, residence, religion, education, andsocio-economical status. Similar ndings were reported in

an earlier study by Mercante et al.16

In contrast to data from an earlier study16 thatheadache intensity was higher among patients withanxiety disorder compared with the controls, the severityof headache was not associated with severity of anxietysymptoms in this study. This difference may be attributed tocross-cultural variation, the subjective nature in expressingpain severity, and the poor reliability of the self-rating VASused for assessing the severity of pain. In the present study,the severity of anxiety symptoms was independent of the

characteristics of headache like dull aching, throbbing, ormixed headache. Patients complaining of daily headache showedhigher scores for anxiety symptoms and poorer scores forquality of life in the psychological health domain than thosewith intermittent headache. This nding is in accordance to

data from earlier studies16,17which found that the symptomsof depression and anxiety disorders were more commonin chronic than episodic migraine and TTH. Patients withchronic daily headache are likely to show poor quality oflife across all the 8 domains of the self-administered 36-itemShort Form questionnaire used to measure health-related

functions, except that of physical functioning.18-20

Patientswith chronic migraine have higher rate of anxiety disordersand are twice as likely to report anxiety disorders than thosewith episodic migraine.21,22Recent data23,24also showed thatco-morbid anxiety disorders and depression have a role inthe progression of episodic migraine to chronic migraine. In this study, the frequency of panic disorders inpatients with headache was 67%, while frequencies of PAand PoA were 23% and 44%, respectively. The frequencyof panic disorder among individuals with headache variedfrom 4.5 to 27% in earlier studies.25,26 The diagnosis ofpanic disorder was made with the help of DSM-IV-TR,which allows diagnosis of panic disorder in less frequent

attacks. As the patients were recruited from the tertiary carepsychiatry outpatient department, which is the specialisedreferral centre in the area, the patients with more severesymptoms were more likely to be referred by othermedical professionals in this study compared with previousstudies25,26 on general population in general medicalsetting. In our study, women represented more than threequarters (76%) of the study population, whereas anotherstudy9revealed that they were 2 to 3 times more likely tosuffer from panic disorder than men. These could be theprobable reasons for higher frequency of panic disorder inour study. The only published Indian study,27 performed

in a rural camp, showed a 14.5% frequency of PA. In this

study, patients with panic disorders (PA and PoA) showedhigher anxiety symptoms and poorer quality of life in mostdomains (except in the social relationship domain) of theWHOQOL-BREF than those without panic disorders.Perhaps the structure of questions in the WHOQOL-BREFmay explain this nding; there are only 3 questions in

the WHOQOL-BREF for evaluating the quality of life inthe social relationship domain, while there are 7, 6, and 8questions for evaluating the physical health, psychologicalhealth, and environmental domains, respectively. Theseverity of anxiety symptoms and quality of life did notdiffer signicantly among patients with PA or PoA. These

ndings are in accordance with data from earlier studies.13,16One population-based study28 showed that panic disorderwas strongly associated with migraine (odds ratio [OR] =3.7; 95% condence interval, 2.2-6.2 in severe headache

disorders vs. OR = 3.0; 95% condence interval, 1.5-5.8 in

non-headache controls). In this study, patients with severe anxiety symptoms

showed poorer quality of life across all domains. Otherstudies9,16,29 have demonstrated that patients with anxietydisorders are likely to have severe disability. A community-based longitudinal study13 found thatindividuals with a history of migraine attack are likely toexperience an episode of anxiety disorder or depressionon follow-up. This nding suggests that depression, panic

disorder, and migraine have a common predisposition andare not merely psychological consequences of headache.Another longitudinal study3showed that anxiety disordersmay precede migraine, and depression may follow it. Causalrelationship between anxiety disorders and headache needs

to be investigated further. Since anxiety disorders frequentlycoexist with headache, we recommend screening for anxietydisorders in patients with headache so as to facilitate theirearly identication and early treatment.

Limitations

Although this is the rst study to examine the association

of panic disorder with severity of anxiety symptoms andquality of life among participants with headache, it hasseveral limitations such as recruiting subjects from a singlecentre, an open-label study, and a small sample size. Asparticipants were recruited from the psychiatry outpatient

department of a tertiary care hospital, they did not representthe general population. Being a cross-sectional study,cause-effect relationship for headache and anxiety disorderscannot be established. As such, prospective cohort studiesto examine such association are recommended.

Conclusions

This study showed that there was high frequency of panicdisorder among patients with headache. Patients with severeanxiety symptoms had poorer quality of life. Patients withdaily headache showed more severe anxiety symptoms and

poorer quality of life than those with intermittent headache.

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East Asian Arch Psychiatry 2014, Vol 24, No.1 15

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Patients with panic disorders (PA and PoA) showed higherscores for anxiety symptoms and poorer quality of life thanthose without.

Declaration

The authors declared no source of nancial support and

conict of interest in this study.

Acknowledgements

We would like to thank Prof Mukesh Samani, Head ofDepartment of Psychiatry, P. D. U. Medical College, Rajkot,Gujarat, India for guidance about applying World HealthOrganisation Quality of Life (WHOQOL-BREF) scale,as well as Dr Divyesh R. Mandavia, Tutor, Department ofPharmacology, Government Medical College, Bhavnagar,Gujarat, India for guidance in statistical analysis, manuscriptpreparation, editing, and review.

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