The association between suicide and headache was robust across four types of headache: migraine, tension-type headache, post-traumatic headache, and trigeminal autonomic cephalalgia (which includes cluster headache), says lead author Holly Elser, MD, PhD, a neurology resident at Penn Medicine in Philadelphia.
“In particular, we find that patients diagnosed with tension-type headache — which is highly prevalent and typified by mild-to-moderate symptoms — experience elevated risk of attempted and completed suicide as compared with members of the general population without a diagnosis of headache,” says Dr. Elser.
Certain Kinds of Headaches Pose the Greatest Risk
A Danish population study followed over 119,000 people diagnosed with headaches and compared them with a control group of more than 597,000 individuals without headaches. Researchers followed people for 15 years and used diagnostic codes to track attempted suicide and death registries to identify completed suicide.
Investigators adjusted for factors that could influence the outcome, including age, sex, education level, income level, and coexisting health conditions.
Out of every 1,000 people with headache, 7.8 attempted suicide, and 2.1 out of every 1,000 completed suicide.
In the general population, 0.33 percent (3.3 out of 1,000) attempted suicide, and 0.15 percent (1.5 out of 1,000) completed suicide.
The risk for people diagnosed with post-traumatic headaches was the highest, with a 214 percent higher risk for attempted suicide compared with the general population.
Researchers also found that people diagnosed with headaches in emergency settings had a significantly higher risk of suicide attempts and completions. That suggests that the severity and complexity of a headache disorder might be crucial factors in suicide risk, they wrote.
“This study was not limited to only migraine, and the association of suicide with tension-type headache is an important addition to our understanding of the suicide risks of patients with headaches and chronic pain,” says Timothy Collins, MD, chief of the headache and pain division of the neurology department at Duke University School of Medicine in Durham, North Carolina. Dr. Collins was not part of the study.
Why Headaches Might Increase the Risk of Suicide
While the study did not examine why headache may increase suicide risk, there are several theories about the link, says Elser:
- There may be a complex, bidirectional association between headache and mental health disorders. The headaches may worsen in response to psychiatric symptoms, and worsening of headache can lead to feelings of hopelessness or demoralization, she says.
- Prior studies consistently demonstrate an association between chronic pain and suicide risk. Previous research has shown that the risk of death from suicide is double in people with chronic pain.
- There may be common underlying causes of headaches and psychiatric symptoms, including increased inflammation and changes in the release of serotonin, a neurotransmitter that plays a role in mood, sleep, and appetite.
“It is interesting that the use of opioids was higher in all headache groups versus the control group, despite evidence-based guidelines that opioids are not appropriate treatment for headaches, and research showing that chronic opioid therapy is associated with an increased risk of suicide,” says Collins.
Screening People With Headache for Depressive Symptoms and Suicidal Thoughts May Help People at Risk
“Screening and early recognition of depressive symptoms and suicidality may help to identify patients with headache who are at elevated suicide risk. Patients diagnosed with headache with comorbid psychiatric symptoms may benefit in particular from comanagement with behavioral health specialists,” says Elser.
Collins agrees that the most significant risk is the coexistence of depression, and that everyone with newly diagnosed headache disorders should be screened.
People With Headache Should Seek Treatment
People with headaches — newly diagnosed or not — should seek care with a specialist and should have screening for depression as part of their headache treatment, says Collins.
“There are so many headache-specific treatments that can be used to treat headaches. Most of the time, improved headaches with decreased pain significantly improves depressed mood,” he says.
