Chronic daily headache: stress and impact on the quality of life

Cefaléia crônica diária: estresse e impacto sobre a qualidade de vida

ARTICLES

Chronic daily headache: stress and impact on the quality of life

Cefaléia crônica diária: estresse e impacto sobre a qualidade de vida

José Carlos Busto Galego^I; Avelina Maria Moraes^II; José Antonio Cordeiro^III; Waldir Antonio Tognola^I

^IPh.D., Professor, Clinical Neurology, Medical School of São José do Rio Preto

^IIPsychologist

^IIIPhD, Professor, Epidemiology Departament, Medical School of São José do Rio Preto

ABSTRACT

OBJECTIVE: To evaluate the stress presence and its influence in the quality of life of patients with chronic daily headache (CDH).

METHOD: A hundred patients with at least 18 years old, with primary headache with duration greater than 4 hours a day, and frequency of 15 or more days monthly for at least three months were studied. Lipp's Inventory of Stress Symptoms and the Medical Outcomes Study Short Form (SF-36) were used.

RESULTS: Stress was observed in 90% of the patients; nearly half of them was in the phase almost exhaustion. Patients with stress when compared with the ones with no stress presented significantly lower scores in all the domains of SF-36; except in physical functioning. The resistance phase presented scores significantly higher than almost exhaustion; except for bodily pain.

CONCLUSION: The majority of the patients presented stress with significant reduction in their quality of life. Consequently, the stress could be related with both the development and the maintenance of CDH.

Key words: chronic daily headache, stress, quality of life.

RESUMO

OBJETIVO: Avaliar a presença de estresse e sua influência na qualidade de vida dos pacientes com cefaléia crônica diária (CCD).

MÉTODO: Foram estudados 100 pacientes com idade mínima de 18 anos, apresentando cefaléia primária com duração maior que 4 horas e freqüência de 15 ou mais dias por mês, há pelo menos três meses. Foram aplicados o Inventário de Sintomas de Estresse de Lipp e o Questionário SF-36 de Pesquisa em Saúde (SF-36).

RESULTADOS: Estresse foi observado em 90% dos pacientes; aproximadamente metade deles estava na fase de quase exaustão. Pacientes com estresse comparados àqueles sem estresse, apresentaram pontuações significativamente menores em todas as escalas do SF-36; exceto em capacidade funcional. A fase de resistência apresentou pontuações significativamente maiores que quase exaustão; exceto para dor corporal.

CONCLUSÃO: A grande maioria dos pacientes apresentou estresse com redução significativa na qualidade de vida. Consequentemente, o estresse poderia estar relacionado tanto no desenvolvimento como na manutenção da CCD.

Palavras-chave: cefaléia crônica diária, estresse, qualidade de vida.

The term chronic daily headache (CDH) comprises a group of headaches that manifests in 15 or more days a month, lasting more than 4 hours, including the headaches associated with the excessive use of medication¹. The prevalence in the general population ranges from 3 to 5%, and women are the most affected^2-4. Several factors are related with CDH development: abnormal profile of the personality; stress; the excessive use of symptomatic medication; arterial hypertension; the use of contraceptives or estrogen replacement and traumatic life events⁵. Excessive use of medication is considered the main progression factor for the CDH stage⁶, however, the stress is mentioned as one of the most frequent factors in precipitating and worsening headache episodes^7,8. Stress represents the tension sensation, anguish and discomfort that an individual can experiment. Those sensations would be consequence of important emotional events and or physical and mental disorders. Basically, stress development depends on both the interpretation of the triggering factors and the coping strategies. The personality characteristics can also determine the individual’s answer to stress⁹. At first, Selye proposed the stress development into three phases: alert, resistance and exhaustion. Due to the fact that the resistance phase is very extensive, Lipp et al.¹⁰ proposed a fourth phase of stress development namely the almost exhaustion. Therefore in Lipp's model, the stress could develop in the following way: alert phase, resistance, almost exhaustion and exhaustion.

Headache is a subjective complaint that in its primary form is not detected by specific examinations; moreover, it does not increase the mortality. Impairments associated with headaches were considered less significant than those attributed to the systemic chronic diseases. However, patients with chronic headaches complain about significant well-being impairment with damage in their quality of life¹¹. Most studies have reported the consequences of migraine in the quality of life^12-17; few reported the quality of life of patients with CDH^18-22. When compared to the general population, the patients with CDH present significant reduction in all SF-36 domains²². Besides daily headache, other factors such as depression, anxiety and stress can affect the quality of life of patients with CDH.

The objective of this study was to evaluate the stress presence and its influence in the quality of life of patients with CDH.

METHOD

A hundred patients, both sexes, at least 18 years old were prospectively studied. They were assisted at the headache inpatient unit of Hospital de Base, São José do Rio Preto, SP. The inclusion criterion was the presence of primary headache, with duration greater than 4 hours a day and frequency of 15 or more days monthly for at least three months. The patients were admitted in the study consecutively, after their informed and free consent term on the research objectives. This project was approved by the Committee of Ethics in Research of Medical School, São José do Rio Preto, SP.

The diagnosis of the type or types of the present headaches was made according to The International Classification of Headache Disorders, 2^nd Edition²³.

In the selected patients, Lipp's Inventory of Stress Symptoms for Adults (ISSL)²⁴ was applied to observe the presence and the stress level; the Medical Outcomes Study Short Form (SF-36) ²⁵, to evaluate the quality of life.

ISSL, a research instrument, validated by Lipp and Guevara in 1994²⁶, is used to evaluate if the patient has stress, in which phase is (alert, resistance, almost exhaustion or exhaustion) and if the symptoms indicate physical or psychological stress.

SF-36, a generic questionnaire, translated and validated for the Portuguese language²⁷ is used to evaluate the quality of life related to health. It has 36 items that include 8 domains: physical functioning, role physical, bodily pain, general health, vitality, social functioning, role emotional and mental health. Each SF-36 domain presents a final score ranging from 0 to 100. Zero indicates the worst life quality related to the health and 100 the best.

Patients with chronic organic diseases were not included in the study. In the statistical analysis, comparisons of two means were performed by the test t and medians were compared by Mood’s Median Test. The level of significance 0.05 was adopted.

RESULTS

At the first consultation, the patients’ mean age was 38.8 years with an 11.7 standard deviation, ranging from18 to 73 years. Figure 1 shows the distribution according to gender and the patients’ age groups with CDH. Women were the majority in this group (87%). The mean duration of CDH was 4.0 years with standard deviation of 5.6 years, varying between three months and 30 years of duration.

Applying the criteria of the second edition of the International Classification of Headaches, 17 different types of diagnosis were necessary to classify all the 100 patients with CDH. Table 1 shows the distribution of the different types of diagnosis obtained.

The stress presence, the stress phase and the type of the predominant symptom (psychological or physical) were observed in the patients through ISSL. Stress was found in 90% of the patients. The distribution of the patients' stress phases is showed in Figure 2. Among those that presented stress, the prevalence of symptoms in 94.5% was psychological; in 3.3% physical, and in 2.2% combined symptoms.

Table 2 shows the comparison of SF-36 scores among the patients with CDH who presented and did not present stress. The patients with stress presented scores significantly lower in all SF-36 domain (test t for two samples), except for the physical functioning domain.

Stress phases were compared with the scores in the eight domains of the SF-36 obtained by the patients. This comparison was made between the resistance, almost exhaustion and exhaustion phases since only two patients were found in the alert phase of stress (Fig 3).

DISCUSSION

Primary chronic headaches as migraine and tension-type headache are frequently associated to the psychological stress^7,8. In relation to CDH, Galego et al.²⁸ found the emotional stress as the main precipitating factor (75%) of headache to transformed migraine. Stress is also mentioned as a development factor for CDH⁶.

In our study, stress was observed in 90% of the patients, and the great majority (94.5%) presented the symptoms of psychological stress. This suggests that the anxiety symptoms, tension, distress, insomnia, difficulties with the memory, excessive concern, emotional instability and relaxing difficulties are frequent in patients with CDH.

According to the distribution of stress phases, approximately half (51.1%) of the patients was in the phase of almost exhaustion. In that phase, the patients although presenting some distress and other symptoms, they are still able to work, but with some limitation²⁹.

Comparing SF-36 scores among patients with CDH presenting stress and the ones without stress; except for the domain physical functioning, the first presented scores significantly lower in all the domains. This may indicate the stress negative influence on the quality of life of the patients with CDH.

We also compared the stress phases with the scores obtained by the patients in each of the SF-36 domains. Except for the bodily pain domain, the patients have presented scores significantly higher in the resistance phase than those in the phase of almost exhaustion. However, the patients in the exhaustion phase, except for role physical, have not presented significant differences comparing with those in the resistance phase.

Compared to the resistance phase, the patients in the exhaustion phase should also present an inferior quality of life, this is what is expected. Due to its own definition, in exhaustion phase there is a lack of resistance with psychological and physical exhaustion and, consequently, some diseases can appear²⁹. In this phase, the individual may become anergic with no satisfactorily answer to negative or positive environmental stimuli. This may suggest that in the exhaustion phase of the stress, the SF-36 questionnaire could be less sensitive in measuring the life quality with fewer reliable results.

In our study the great majority of patients presented stress with significant reduction in their quality of life. Consequently, the stress could be considered as a factor either in the development and maintenance of daily or almost daily headaches. Therefore, identifying the presence and the stress level of patients with CDH can provide important information for the therapeutic approaches.

Received 5 July 2007. Accepted 14 September 2007.

Dr. José Carlos Busto Galego - Rua Professor Nelson I. Bento Lutaif 145 - 15091-550 São José do Rio Preto SP - Brasil. E-mail: [e-mail]

Department of Neurological Sciences, Medical School of São José do Rio Preto, São José do Rio Preto SP, Brazil

• 1. Silberstein SD, Lipton RB, Solomon S, Mathew NT. Classification of daily and near-daily headaches: Proposed revisions to the IHS criteria. Headache 1994;34:1-7.
• 2. Scher AI, Stewart WF, Liberman J, Lipton RB. Prevalence of frequent headache in a population sample. Headache 1998;38:497-506.
• 3. Castillo J, Muñoz P, Guitera V, Pascual J. Epidemiology of chronic daily headache in the general population. Headache 1999;39:190-196.
• 4. Lanteri-Minet M, Auray JP, EI Hasnaoui A, Dartigues JF, et al. Prevalence and description of chronic daily headache in the general population in France. Pain 2003;102:143-149.
• 5. Mathew NT, Stubits E, Nigam MR. Transformation of episodic migraine into daily headache: analysis of factors. Headache 1982;22:66-68.
• 6. Mathew NT. Transformed migraine, analgesic rebound, and other chronic daily headaches. Neurol Clin 1997;15:167-186.
• 7. Rasmussen BK. Migraine and tension-type headache in a general population: precipitating factors, female hormones, sleep pattern and relation to lifestyle. Pain 1993;53:65-72.
• 8. Spierings EL, Ranke AH, Honkoop PC. Precipitating and aggravating factors of migraine versus tensio-type headache. Headache 2001;41:554-558.
• 9. Stronks DL, Tulen JH, Pepplinkhuizen L, et al. Personality traits and psychological reactions to mental stress of female migraine patients. Cephalalgia 1999;19:566-574.
• 10. Lipp MN. O modelo quadrifásico do stress. In Lipp MN (org). Mecanismos neuropsicofisiológicos do Stress: teoria e aplicações clínicas. São Paulo: Casa do Psicólogo, 2003: 17-21.
• 11. Solomon GD, Skobieranda FG, Gragg LA. Quality of life and well-being of headache patients: measurement by the medical outcomes study instrument. Headache 1993;33:351-358.
• 12. Osterhaus JT, Towsend RJ. The quality of life of migraineurs: a cross sectional profile. Cephalalgia 1991;11(Supl 11):S103-S104.
• 13. Dahlof C, Dimenas E. Migraine patients experience poorer subjective well-being/ quality of life even between attacks. Cephalalgia 1995;15:31-36.
• 14. Michel P, Dartigues JF, Lindoulsi A, Henry P. Loss of productivity and quality of life in migraine sufferers among French workers: results from the GAZEL cohort. Headache 1997;37:71-78.
• 15. Terwindt GM, Ferrari MD, Tijhuis M, Groenen SM, Picavet HS, Launer LJ. The impact of migraine on quality of life in the general population. The GEM study. Neurology 2000;55:624-629.
• 16. Lipton RB, Stewart WF, Sawyer MB, Edmeads JG. Clinical utility of an instrument assessing migraine disability: the migraine disability assessment (MIDAS) questionnaire. Headache 2001;41:854-861.
• 17. Lipton RB, Bigal ME, Kolodner K, Stewart WF, Liberman JN, Steiner TJ. The family impact of migraine: population-based studies in the USA and UK. Cephalalgia 2003;23:429-440.
• 18. Solomon GD, Skobieranda FG, Gragg LA. Does quality of life differ among headaches diagnoses? Analysis using the medical outcome study instrument. Headache 1994;34:143-147.
• 19. Cavallini A, Micieli G. Bussone G, Rossi F, Nappi G. Headache and quality of life. Headache 1995;35:29-35.
• 20. Monzon MJ, Lainez MJ. Quality of life in migraine and chronic daily headache. Cephalalgia 1998;18:638-643.
• 21. Meletiche DM, Lofland JH, Young WB. Quality of life: differences between patients with episodic and transformed migraine. Headache 2001;41:573-578.
• 22. Guitera V, Muñoz P, Castillo J, Pascual J. Quality of life in chronic daily headache: a study in general population. Neurology 2002;58:1062-1065.
• 23. Classification Committee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgia and facial pain. Second Edition. Cephalalgia 2004;(Supl 1):S1-S160.
• 24. Lipp MN. Manual do inventário de sintomas de stress para adultos de Lipp (ISSL). São Paulo: Casa do Psicólogo; 2000.
• 25. Ware JE Jr, Sherbourne CD. The MOS 36-item Short-Form Health survey (SF-36): I. Conceptual framework and item selection. Med Care 1992;30:473-483.
• 26. Lipp MN, Guevara AJ. Validação empírica do inventário de sintomas de stress. Estudos de Psicologia 1994;11:42-49.
• 27. Ciconelli RM, Ferraz MB, Santos W, Meinão I, Quaresma MR. Tradução para a língua portuguesa e validação do questionário SF-36. Rev Bras Reumatol 1999;39:143-150.
• 28. Galego JC, Cipullo JP, Cordeiro JA, Tognola WA. Clinical features of episodic migraine and transformed migraine: a comparative study. Arq Neuropsiquiatr 2002;60:912-916.
• 29. Lipp MN. O modelo quadrifásico do stress. In Lipp MN (org). Mecanismos neuropsicofisiológicos do stress: teoria e aplicações clínicas. São Paulo: Casa do Psicólogo, 2003:17-21.

Publication Dates

• Publication in this collection
  07 Mar 2008
• Date of issue
  Dec 2007

History

• Accepted
  14 Sept 2007
• Received
  05 July 2007