Headache Strongly Linked to Attempted, Completed Suicide

Headache, including migraine, tension-type, trigeminal autonomic cephalalgia (TAC), and posttraumatic stress headache are significantly associated with both attempted and completed suicide, results of a large study suggested.

The risk for attempted and completed suicide was more than threefold higher for individuals with posttraumatic headache and about twofold higher for those with TAC than their counterparts without headache.

Even those with tension-type headache, one of the milder headache types, carried nearly a twofold increased risk for attempted suicide vs the comparison group with no headache.

First author Holly Elser, MD, MPH, PhD, a resident physician in the Department of Neurology at the University of Pennsylvania, Philadelphia, told Medscape Medical News that the findings were “quite striking” and underscore the importance of screening for suicide risk even in patients with mild headache.

The findings were published online on February 3 in JAMA Neurology.

Common, Disabling 

With an estimated global lifetime prevalence of 67%, headache disorders are a leading cause of productivity loss, work absences, and short-term disability.

The mechanisms linking headache disorders to suicide remain unclear for several reasons, the investigators noted.

First, the relationship between headache and psychiatric comorbidities may be complex and bidirectional, with psychiatric symptoms potentially exacerbating headache severity and frequency, the investigators noted.

Secondly, research has shown a consistent link between chronic pain and suicidality, even after adjusting for comorbid psychiatric conditions. Finally, disruptions in serotonergic pathways and increased production of inflammatory cytokines may contribute to both headache disorders and psychiatric symptoms, suggesting a shared biological basis.

Previous research has also shown that headaches are often comorbid with psychiatric disorders, including mood and anxiety disorders, somatoform disorders, and substance use disorders.

But, despite “plausible mechanisms” the link between suicidality and headache remains unclear. Even cluster headache, often colloquially known as “suicide headache” due to its excruciating pain, have little empirical evidence supporting a direct link to suicidality.

However, the investigators pointed out that data from the United States Cluster Headache Survey revealed that over 55% of respondents experienced suicidal thoughts and 2% had attempted suicide.

The investigators noted that most of the research examining the relationship between headache and suicidality has primarily focused on migraine.

To examine the link between suicidality by headache type, investigators analyzed data from multiple Danish population-based medical and administrative registries from 1995 to 2020.

Together, the databases represent an estimated population size of 7.9 million individuals.

The Danish National Patient Registry (DNPR) was used to gather diagnostic codes for first diagnosis of migraine, tension-type headache, TAC and posttraumatic headache from inpatient hospitalizations, emergency department visits, and outpatient specialty visits.

The headache cohort which included 119,486 individuals was matched on a 5:1 basis with 597,430 individuals without headache. The median age in both groups was 40 years and 69.5% were women. Median follow-up time was about 8.7 years.

Information on attempted suicide came from the DNPR and the Danish Psychiatric Central Register, which contains information on psychiatric emergency department contacts, psychiatric hospitalizations, and outpatient visits. Data on completed suicides came from the Danish Register of Causes of Death.

Participants were followed from the index date until attempted or completed suicide, death from other causes, emigration, or until December of 2020.

After adjusting for potential confounders including chronic physical diseases and comorbid psychiatric disorders, results showed that overall, individuals with headache were twice as likely to attempt suicide (adjusted hazard ratios [aHR], 2.04; 95% CI, 1.84-2.27) and 1.4 times as likely to die by suicide (aHR, 1.40; 95% CI, 1.17-1.68) compared with those with no headache.

In addition, the researchers found that the risks for attempted and completed suicide differed by headache type. Posttraumatic headache had the greatest risk for attempted suicide (aHR, 3.14; 95% CI, 1.81-5.47) and completed suicide (aHR, 3.22; 95% CI, 1.40-7.40).

It was followed by TAC, which was associated with more than double the risk for completed suicide (aHR, 2.40; 95% CI, 1.23-4.66). Even tension-type headache, a milder headache disorder, carried a significantly increased risk for attempted suicide (aHR, 1.91; 95% CI, 1.63-2.24).

Individuals who were first diagnosed with headache in an inpatient or emergency department setting had a greater risk for suicide attempt than those diagnosed in an outpatient setting.

Specifically:

• Those diagnosed in an inpatient setting had 2.70 times higher risk for attempting suicide (HR, 2.70; 95% CI, 2.27-3.20).
• Those diagnosed in an outpatient setting had 1.57 times higher risk (HR, 1.57; 95% CI, 1.34-1.84).
• Those diagnosed in the emergency department had 2.27 times higher risk (HR, 2.27; 95% CI, 1.74-2.96).

For completed suicide, the risk was also highest for those diagnosed in an inpatient setting:

• Inpatient setting: 1.80 times higher risk (HR, 1.80; 95% CI, 1.38-2.36).
• Outpatient setting: 1.18 times higher risk, but the CI includes 1, meaning the result is less certain (HR, 1.18; 95% CI, 0.89-1.57).
• Emergency department: 0.99 times the risk, meaning no significant difference from the baseline (HR, 0.99; 95% CI, 0.58-1.70).

The study’s findings, said Elser, highlight the need for screening and early detection of depressive symptoms and suicidal thoughts in patients with headache, which could help detect those at increased risk for suicide, aid in identifying patients with headache, who face an increased risk for suicide.

“Patients diagnosed with headache with comorbid psychiatric symptoms may benefit in particular from comanagement with behavioral health specialists,” she added.

Not ‘Just Headaches’

In an interview with Medscape Medical News, Fred Cohen, MD, an assistant professor of medicine and neurology at the Icahn School of Medicine at Mount Sinai Hospital, New York City, shared his perspective on the findings. Cohen, who was not involved in the study agreed with Elser’s point and incorporated screening into his practice.

“As part of my routine at every new patient appointment, I conduct screenings for depression and suicide risk. If a patient responds affirmatively to any of these questions, I make sure they get connected to the mental health resources they need,” Cohen said.

At least one of his patients per week screens positive for depression, he noted.

“Primary headaches, including migraine and trigeminal autonomic cephalalgias, are a significant source of disability and suffering,” said Cohen, adding that migraine, in particular, is the leading cause of disability worldwide among women aged 18-50 years. “These conditions are often misunderstood and dismissed as ‘just headaches,’ when in reality, they are much more complex and debilitating.”

Given that depression and anxiety are common co-occurring conditions with primary headache disorders, he said, “depression screenings should be standard practice when evaluating patients with headaches.”

The study’s limitations include dependence on diagnosis codes, which are prone to misclassification, and lack of information about headache chronicity and severity, which could have affected the findings.

There was no information provided about study funding. Elser and Cohen reported no relevant financial relationships.