Thursday, March 15, 2012

An Ugly Truth: Headache and Suicide Attempts

Headache Pain While news media have been abuzz about an “epidemic” of drug overdoses and deaths, a far more numerous and potentially greater threat to public health may be suicide attempts associated with unrelieved chronic pain. Recently reported research confirms a disturbing link between recurrent headache and attempted suicides that should be of great concern to healthcare providers, as well as to patients and their loved ones.

Naomi Breslau, PhD, from Michigan State University College of Human Medicine, East Lansing, Michigan, and colleagues observe that previous cross-sectional studies have reported an increased risk of suicide attempt in persons with migraine headache, which was independent of psychiatric comorbidity. To further examine this risk using a more rigorous research design, they conducted a prospective cohort study among 3 groups of persons: 1) those with diagnosed migraine, 2) persons with non-migraine headache of comparable severity and disability, and 3) a control group of persons with no history of severe headache.

From a pool of 4,765 persons randomly screened in the community (Detroit, Michigan area), the researchers arrived at a final sample of 1,186 respondents with full assessments via face-to-face interviews: 1) migraine (N = 496), 2) non-migraine severe headaches (N = 151), and 3) controls (N = 539). All participants were interviewed at baseline in 1997 and reassessed 2 years later, in 1999. On average, the age of the study population was 40 years, 79% were female, and 74% were white. Overall, 5.6% had at least one suicide attempt prior to the start of the observation period: 9.1% migraine, 5.3% severe headache, and 2.6% controls (however, the difference between migraine and severe headache groups was not statistically significant).

During the 2-year followup period, persons with migraine or severe headache were at least 4 times more likely to attempt suicide than controls. The odds ratio in migraineurs — adjusted for sex, psychiatric disorder, and previous history of suicide attempt at baseline — was 4.43 (95% Confidence Interval [CI] 1.93, 10.2). Persons with non-migraine headache of comparable intensity and disability also had a greatly increased likelihood of suicide attempt as compared with controls: odds ratio, adjusted for the same covariates, was 6.20 (95% CI 2.40, 16.0). [Due to the wide, overlapping CIs the difference between the 2 odds ratio estimates was not statistically significant.]

The likelihood of suicide attempt was not influenced by alcohol- or drug-use disorder, or by migraine with or without aura. However, the average pain intensity score of persons who attempted suicide during the follow-up period was significantly higher than in persons who did not attempt suicide: mean 7.58 (Standard Deviation [SD] = 2.75) on a 0-to-10 scale compared with 5.18 (SD = 3.70), respectively. Essentially, the risk of suicide attempt increased by 17% with each 1 point rise on the pain-intensity scale; or, in other terms, an increase in pain score of 1 SD unit raised the odds of suicide-attempt by 79% (OR = 1.79).

The researchers conclude that their study provides strong confirmation of previous reports on the increased risk of suicide attempts associated with migraine and other headache of comparable severity and disability. Pain severity appears to be a most important etiological factor in this association — more so than co-occurring depression or anxiety disorder, or other factors; therefore, pain-relieving strategies may be of primary importance in these patients.

COMMENTARY: This study — funded by the Headache Research Center at the U.S. National Institutes of Health — was of reasonably good quality and adequately powered to produce reliable outcomes. Curiously, it took the researchers well over a decade to publish their findings, and they make no mention of reasons for the delay. Expectedly, incidences of suicide attempts would be at least comparable, and probably greater, today.

It might be considered whether the interview process itself, asking questions about suicide, might have in some way influenced subsequent suicide ideation and actual attempts during the 2-year followup period, but this was not discussed by the researchers. Nor do they report on multiple suicide attempts by the same individuals or successful suicides, other than to note that 7% of initial study participants were lost at followup (1.3% died or were too ill and 5.7% refused or could not be located).

The researchers do note that in unadjusted data a history of past suicide attempt, prior to the study period, increased by more than 2-fold the likelihood of a new attempt during the 2-year follow-up interval. Also, females were more likely to attempt suicide, but this was not significantly greater statistically than in males.

Overall, about a quarter (26.2%) of participants had a lifetime history of depression, anxiety, or both, but these influences were contolled in the adjusted data. The researchers do not report how long participants had suffered migraine or severe headache, or the frequency of attacks, and whether these factors might have influenced suicide attempts.

So, this study leaves some questions unanswered, but it should not diminish concerns about relatively high incidences of suicide attempts, and potentially successful suicide, in patients with chronic pain conditions, including headache. Some authors have inexplicably denied the life-threatening nature of chronic pain, claiming these are largely “nonprogressive, nonfatal” conditions [discussed in UPDATE here]. Along with that, they have created fallacious arguments to exaggerate the risks of strong medications — such as opioids in treating chronic noncancer pain — and completely ignore rising suicide rates among affected patients with pain.

Suicide in the United States might be considered a national crisis; in 2009 alone there were nearly 37,000 deaths due to intentional self-harm/suicide [see government data here]. This is more than twice the 15,000 deaths attributed to opioid-analgesic overdose, which the U.S. Centers for Disease Control and Prevention and other agencies have called an “epidemic” [discussed in UPDATE here]. Suicide attempts are even far more numerous, and their possible association with chronic pain has been discussed in prior UPDATES [here] and [here].

In 2009 there were approximately 120,000 suicide attempts by women and 78,000 by men of all ages, and incidence rates had been increasing by double-digit percentages from prior years. Government agencies and anti-opioid proponents have attempted to attribute the crisis to alcohol and drug abuse, as well as the more liberal prescribing of analgesics and other psychotropic medications. Rarely, do they take into account as a potential influence the escalating rates of chronic pain and its mismanagement.

Other reports have more clearly depicted a connection between chronic pain and suicide. Writing in a special supplement to the journal Pain Medicine, Martin D. Cheatle, PhD, observes that numerous comorbid conditions that pose risks for suicide are prevalent in people living with chronic pain [Cheatle 2011]. The true numbers of failed attempts and successful suicides are unknown and may never be determined, he says; yet, “risk factors for suicidal ideation are so high in the chronic pain population that it must be assumed that some proportion of those who die of drug overdoses might have intended to end their lives, not just temporarily relieve their pain.”

During the two-year observation period of this present study by Breslau et al. [2012], the absolute risk (beyond that in the control group) of suicide attempt attributable to migraine was 7.4%, and 8.6% in persons with severe headache. It is a reminder that chronic headache pain — whether due to migraine or other severe, recurrent forms — may be an independent risk factor for attempted suicide, and one must assume that some of those attempts will be tragically successful. Furthermore, the research suggests that comorbid psychiatric conditions and substance abuse may play relatively minor roles at most. The vital message seems to be that recurring headache of any type must be taken very serously and aggressively treated by whatever therapy works best for individual patients.

> Breslau N, Schultz L, Lipton R, et al. Migraine Headaches and Suicide Attempt. Headache: The Journal of Head and Face Pain. 2012(Mar); online ahead of print [
abstract here].
> Cheatle MD. Depression, Chronic Pain, and Suicide by Overdose: On the Edge. Pain Medicine. 2011(Jun);12(Suppl s2):S43-S48 [
abstract here].

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