J Headache Pain (2008) 9:397–400

DOI 10.1007/s10194-008-0069-z

BRIEF REPORT

Obsessive compulsive disorder and migraine: case report,

Received: 23 May 2008 / Accepted: 31 August 2008 / Published online: 19 September 2008
Ó Springer-Verlag 2008

Abstract Psychiatric disorders, notably mood and anxi- comorbidities most described in these patients [1–3]. The
ety disorders, are frequently associated with migraine and literature also indicates that psychiatric comorbidity is even
chronic daily headaches. The obsessive–compulsive dis- higher in transformed migraine and chronic daily head-
order (OCD) is included in the spectrum of anxiety aches, particularly in the presence of analgesic abuse [2].
disorders and may be a comorbid condition in headache The connection between psychiatric disorders and head-
patients. However, little information has been reported in ache syndromes is not fully understood, but this issue has
the literature about this association. This is an important been extensively debated in the literature. Regardless of the
issue as OCD may contribute to the development or mechanism of comorbidity, psychiatric conditions may
maintenance of treatment-resistant chronic headaches. In influence patient’s outcome and selection of headache
this paper, we describe a young female patient with treatment [1–3].
refractory chronic migraine and OCD. Considerations on It is worth mentioning that the bulk of this knowledge
diagnosis, management and treatment of these comorbid derives from studies performed with an adult migraine
conditions are presented. population. Some studies also investigated psychiatric and
behavioral problems in childhood and adolescence [4–6].
Keywords Migraine
Chronic daily headache
For instance, Guidetti et al. [4] have found that anxiety and
Obsessive–compulsive disorder
Psychiatric comorbidity depression symptoms were associated with migraine in
children and adolescents, but not with tension-type head-
aches, a finding that is in line with studies in adults.
Introduction Notably, there is also some support in the literature to
suggest that medication overuse and psychiatric comor-
Psychiatric disorders are frequently found in migraine. bidity are risk factors for the development of chronic
Mood and anxiety disorders are the psychiatric headaches in adolescents, as occurs in adult population
[7, 8]. By contrast, other studies showed that, despite
behavioral symptomatology in children with headaches,
most of these symptoms were subclinical and did not
L. P. B. Vasconcelos
M. C. Silva
E. A. C. Costa
qualify children for psychiatric diagnosis [5, 6]. Further-
A. A. da Silva Júnior
R. S. Gómez
A. L. Teixeira more, similar levels of behavioral and emotional symptoms
Headache Clinic, University Hospital, School of Medicine, were reported in young tension-type headache and
Federal University of Minas Gerais (UFMG),
migraine patients [5].
Belo Horizonte, Brazil
Obsessive–compulsive disorder (OCD) belongs to
A. L. Teixeira (&) the anxiety spectrum disorders and may be a comorbid
Departamento de Clı́nica Médica, Faculdade de Medicina, condition in patients with migraine. OCD seems to occur at
Federal University of Minas Gerais (UFMG),
higher frequency in patients with migraine than in the
Av. Alfredo Balena, 190. Santa Efigênia, Belo Horizonte,
MG 30130-100, Brazil general population, but little information regarding this
e-mail: [email protected] association is available [9].

123
398 J Headache Pain (2008) 9:397–400

In this paper, we report a young female patient with use of acute relief medications was clearly a way to
migraine presenting also a comorbid OCD. This associa- attenuate excessive worries and the recurrent negative
tion had relevant implications for the headache treatment thoughts about her condition. No significant improvement
and prognosis which are discussed. of headache was observed. She was interviewed by a
psychiatrist who performed the diagnosis of OCD accord-
ing to DSM-IV criteria [12] based on a structured interview
Case report (Mini International Neuropsychiatric Interview, M.I.N.I.)
[13]. A neuropsychological evaluation, including Rey
A 14-year-old white female patient was referred to our Auditory Verbal Learning test, Stroop test, verbal fluency
service to be evaluated for a severe daily headache which test and Trail Making test (parts A and B), was also per-
was refractory to diverse non-steroidal anti-inflammatory formed. She exhibited only an increased time of execution
drugs (NSAIDs), triptans and ergotamine. In her first of Trail Making test’s part B, a task aimed at measuring
evaluation, the patient reported a disabling daily headache visual attention and concentration. This result indicates
with frequent episodes of exacerbation started 1 year abnormality in the mental processing speed for executing
before. These episodes were characterized by frontal tasks which require the ability to make alternate conceptual
throbbing headaches along with nausea, vomiting, photo- changes (require also the ability to maintain alert states) as
phobia and phonophobia. Such exacerbation episodes used has been previously reported for young migraineurs [14].
to occur 10 days per month and could not be relieved with Despite the institution of cognitive–behavior therapy for
any analgesic medication. The patient habitually abused OCD and the maintenance of the drug therapy for
NSAIDs and triptans in a daily pattern to relieve pain and migraine, the patient evolved with poor clinical response
avoid exacerbations of headache. Headache episodes star- and persistence of headache. After 6 months of follow-up,
ted when she was 12 years old and became more frequent with no significant improvement, she quit our service and
in the year before consultation. her treatment was discontinued.
On examination, the patient demonstrated excessive
worry about her condition and gave a detailed description
of her pain. She also reported that she could not ‘‘stop Discussion
thinking’’ about the possibility of a severe disease leading
to her pain and described that she was ‘‘continuously The connection between psychiatric disorders and
worried and alert’’ to the emergence of severe crisis of migraine and/or CDH has been extensively described in
headache. In addition, she reported intrusive thoughts the literature [1–3, 9, 15]. The incidence of psychiatric
about the fear of doing harm to others as a consequence of disorders may reach up to 90% of patients with CDH [9,
her acts that lead to mental compulsions. She also exhibited 16]. A great body of evidence even suggests that the
worries about symmetry. She had experienced these adequate treatment of psychiatric comorbidity determines
symptoms as mildly distressful since she was 10 years old. a significant improvement of the quality of life of head-
Her neurological examination was unrevealing as well as ache patients [3, 9, 17–20].
neuroimaging and routine laboratory tests. Thus, according The association between migraine and/or CDH and
to the reviewed criteria of the ICHD II [10], the patient psychiatric disorders seems to be not merely incidental [9,
fulfilled the criteria for chronic migraine in association to 17]. There is much debate on the possible causal rela-
analgesic medication overuse. tionship between migraine and psychiatric disorders [15].
The patient and her mother were informed about the Many authors believe that there is a common physiopath-
possible nature of the headache and that analgesic overuse ological pathway for both entities in which the
could have impact on its evolution. A weaning treatment serotoninergic system may be involved [1–3].
with corticosteroids, restricted use of analgesics and The OCD is characterized by intrusive and recurrent
headache prophylaxis with flunarizine were prescribed. obsessive thoughts and repetitive behaviors that are
Flunarizine was chosen as the patient had not been treated engaged to relieve the anxiety caused by the obsessive
before with a single-drug regimen for migraine prophylaxis thoughts. The OCD is classified under the group of anxiety
and is the treatment of choice for migraine prophylaxis disorders and its association with migraine and/or CDH has
[11]. A structured pain calendar was offered to the patient, been also described [9, 15, 17, 18]. It is worth mentioning
so she could make a detailed description of her headache that patients with migraine are five times more susceptible
and indicate the days of severe pain during 1 month period. to suffer from OCD [9, 16].
After 6 weeks the patient returned with a complex In the present case report, our patient exhibited chronic
headache report along with a series of charts. She reiterated migraine with analgesic medication overuse and OCD. She
the obsessive thoughts about her pain. Besides, the daily was refractory to any treatment proposed. In this context,

123
J Headache Pain (2008) 9:397–400 399

many factors may be involved in therapeutic failure and There is considerable evidence suggesting a role for atyp-
some considerations must be done. First of all, the lack of ical antipsychotics, such as olanzapine, in augmentation
adhesion to treatment and the failed attempts to withdrawn therapy for OCD and there have been several anecdotal
analgesic overuse may be considered relevant factors of reports of their efficacy in the management of refractory
therapeutic failure. It is already defined that analgesic migraine [24].
overuse is important to establish and maintain chronic We decided to use flunarizine in the present case as it
headaches [21]. Furthermore, the presence of obsessive presents great efficiency and safeness in the prophylaxis of
thoughts and her compulsion to take analgesics suggest that children and adolescents with migraine and the risks for
OCD may be a contributing condition to the chronic and exacerbating obsessive–compulsive symptoms are very
refractory migraine in this patient. Anxiety disorders may low [11, 25]. The cognitive–behavioral therapy (CBT) is
play an important role in peripheral and central mecha- considered one-first line treatment of OCD, notably in
nisms of pain sensitization which contributes to the children and adolescents [17, 26]. CBT is based on cog-
evolution to chronic headaches [18, 19]. The headache nitive restructuration and patient education for solving
sensitization becomes even more evident if we consider problems. The active participation of the patient in CBT is
that patients with psychiatric comorbidity usually overuse of great value in improving adhesion and efficacy of the
analgesics or other relief medications at a higher fre- concomitant treatment for headache and psychiatric
quency. Besides medication overuse, 40% of these patients comorbidity [19]. Despite the institution of a combined
do not return to consultations and 50% do not take pre- therapy and the special attention offered by our team, the
scribed headache prophylactic drugs [17]. patient maintained poor response to treatment. Maybe this
The management of patients with headache and could be explained by the lack of adherence to the treat-
psychiatric comorbidity is quite difficult and there are ment. On follow-up the patient frequently missed sessions
no established protocols to treat both conditions of psychotherapy and many times resisted to use flunari-
simultaneously. Merely prescribing a medication without zine. It is worth mentioning that even when careful
demanding an active participation of the patient may lead integrative approach is employed with patients with head-
to frustrating results. The establishment of a good doctor– ache and psychiatric comorbidity, unfavorable outcomes
patient relationship and the education of the patients and may occur [17].
their relatives are of extreme importance for a successful As the association between headache and psychiatric
therapy [9, 17–20]. The combination of drug therapy and disorders seems to be frequent and impact on the outcome,
psychotherapy may be a very effective approach for OCD it is essential to look for psychiatric symptoms in all
and migraine. Regarding the relevant role of social and patients with headache, notably those with refractory to
familiar contexts in children’s and adolescents’ headaches, treatment [9, 16]. Simple questions about sadness symp-
family counseling may be recommended for increasing toms, unwillingness, irritability and anxiety and the
compliance to treatment [7]. observation of clinical signs such as obsessive thoughts
In respect to the drug therapy, it may be started with a must be a routine. Some screening instruments, such as
conventional migraine treatment which includes immediate PRIME-MD, were designed to detect psychiatric comor-
relief medications and prophylactic drugs. Withdrawal bidity in patients in the general practice. They are more
from medication overuse when clinically present must frequently used by researches, but they might be used and
always be attempted. Beta blockers, flunarizine and topi- incorporated in the headache clinics [16].
ramate must be used with caution because they can worsen In conclusion, OCD must be considered as a factor
psychiatric symptoms [3, 18, 19]. There is even one single contributing to headache treatment resistance. Its screen-
case report of OCD induced by topiramate [22]. However, ing, as in the other psychiatric disorders, is of extreme
controlled studies are necessary to confirm this observa- importance for the better management and treatment of
tion. Valproate could be an option for chronic migraine headache patients.
prophylaxis, but it should be used with caution in female
adolescents taking into account its significant potential to Conflict of interest None.
induce weight gain. The serotonin selective reuptake
inhibitors (SSRIs) antidepressants are effective to treat
OCD, but they are not effective in migraine treatment [3, References
18] and may even exacerbate it [20]. Besides that, SSRIs
must be used with caution in children and adolescents since 1. Juang KD, Wang SJ, Fuh JL et al (2000) Comorbity of depression
and anxiety disorders in chronic daily headache and its subtypes.
many undesirable side effects may appear such as suicidal Headache 40:818–823
behavior [23]. Clormipramine may be effective for both 2. Radat F, Swendsen J (2005) Psychiatric comorbidy in migraine: a
headache and OCD and can be indicated in such cases [20]. review. Cephalalgia 25:165–178

123
400 J Headache Pain (2008) 9:397–400

3. Torelli P, Lambru G, Manzoni GC (2006) Psychiatric comor- 15. Sareen J, Jacobi F, Cox BJ et al (2006) Disability and poor
bidity and headache: clinical and therapeutical aspects. Neurol quality of life associated with comorbid anxiety disorders and
Sci 27:S73–S76 physical conditions. Arch Intern Med 166:2109–2116
4. Guidetti V, Galli FT, Fabrizi P et al (1998) Headache and 16. Maizels M, Smitherman TA, Penzien DB (2006) A review of
psychiatric comorbidity: clinical aspects and outcomes in an screening tools for psychiatric comorbidity in headache patients.
8-year follow-up study. Cephalalgia 18:455–462 Headache 46(Suppl 3):S98–S109
5. Mazzone L, Vitiello B, Incorpora G, Mazzone D (2005) Behav- 17. Baskin SM (2007) Managing the ‘‘difficult’’ headache patient.
ioural and temperamental characteristics of children and Neurol Sci 28:S78–S83
adolescents suffering from primary headache. Cephalalgia 18. Savarese M, Guazzelli M, Prudenzano MP et al (2005) Tertiary
26:194–201 treatment for psychiatric comorbidity in headache patients.
6. Pakalnis A, Gibson J, Colvin A (2005) Comorbidity of psychi- J Headache Pain 6:231–233
atric and behavioral disorders in pediatric migraine. Headache 19. Lipchik GL, Smitherman TA, Penzien DB et al (2006) Basic
45:590–596 principles and techniques of cognitive-behavioral therapies for
7. Pakalnis A, Butz C, Splaingard D, Kring D, Fong J (2007) comorbid psychiatric symptoms among headache patients.
Emotional problems and prevalence of medication overuse in Headache 46(Suppl 3):S119–S132
pediatric chronic daily headache. J Child Neurol 22:1356–1359 20. Griffith JL, Razavi M (2006) Pharmacological management of
8. Wang SJ, Fuh JL, Lu SR, Juang KD (2007) Outcomes and pre- mood and anxiety disorders in headache patients. Headache
dictors of chronic daily headache in adolescents: a 2-year 46(Suppl 3):S133–S141
longitudinal study. Neurology 68:591–596 21. Bigal ME, Rapoport AM, Sheftell FD et al (2004) Transformed
9. Baskin SM, Lipchik GL, Smitherman TA (2006) Mood and migraine and medication overuse in a tertiary headache center—
anxiety disorders in chronic headache. Headache 46(Suppl 3): clinical characteristics and treatment outcomes. Cephalalgia
S76–S87 24:483–490
10. Headache Classification Subcommittee of the IHS (2004) The 22. Thuile J, Even C, Guelfi JD (2006) Topiramate may induce
International Classification of Headache Disorders, 2nd edn. obsessive-compulsive disorder. Psychiatry Clin Neurosci
Cephalalgia 24 (Suppl 1):8–160 60(3):394
11. Lewis D, Ashwal S, Hershey A et al (2004) Practice parameter: 23. Cohen D (2007) Should the use of selective serotonin reuptake
pharmacological treatment of migraine headache in children and inhibitors in child and adolescent depression be banned? Psy-
adolescents: report of the American Academy of Neurology chother Psychosom 76:5–14
Quality Standards Subcommittee and the Practice Committee of 24. Silberstein SD, Peres MF, Hopkins MM et al (2002) Olanzapine
the Child Neurology Society. Neurology 63(12):2215–2224 in the treatment of refractory migraine and chronic daily head-
12. American Psychiatric Association (2000) Diagnostic and statis- ache. Headache 42:515–518
tical manual of mental disorders, 4th edn. American Psychiatric 25. Boccia G, Del Giucce E, Crrisanti AF et al (2006) Functional
Association, Washington, DC gastrointestinal disorders in migrainous children: efficacy of
13. Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, flunarizine. Cephalalgia 26(10):1214–1219
Weiller E, Hergueta T, Baker R, Dunbar GC (1998) The Mini- 26. O’Kearney RT, Anstey KJ, Von Sanden C (2006) Behavioural
International Neuropsychiatric Interview (M.I.N.I.): the develop- and cognitive behavioural therapy for obsessive compulsive
ment and validation of a structured diagnostic psychiatric interview disorder in children and adolescents. Cochrane Database Syst
for DSM-IV and ICD-10. J Clin Psychiatry 59(Suppl 20): Rev 18(4):CD004856
22–33
14. Riva D, Aggio F, Vago C et al (2006) Cognitive and behavioural
effects of migraine in childhood and adolescence. Cephalalgia
26:596–603

123