East Asian Arch Psychiatry 2014;24:10-5

Original Article

Association of Panic Disorder with Quality of

Life among Individuals with Headache

IJ Ratnani, BN Panchal, DS Tiwari, AU Vala

Abstract
Objective: To study the association of panic disorder with severity of anxiety symptoms and quality of
life among individuals presenting with headache.
Methods: This was a single-centre, cross-sectional, observational, questionnaire-based study performed
at the psychiatry outpatient department of a tertiary care hospital. Participants of both genders, aged
between 18 and 60 years, and having headache as a presenting complaint for at least 3 months were
evaluated for symptoms of panic disorder. The severity of headache was evaluated with the visual
analogue scale and that of anxiety disorder with the Hamilton Anxiety Rating Scale (HAM-A). The
quality of life was evaluated with the World Health Organization Quality of Life Scale brief version.
Proportions of participants were compared using Chi-square test, and scores by Mann-Whitney test or
Kruskal-Wallis test followed by Dunns post-hoc multiple comparisons.
Results: The frequency of panic disorder among patients with headache was 67%. Those with daily
headache and panic disorder (with or without agoraphobia) showed higher HAM-A score and poorer
quality of life than those with intermittent headache and without panic disorder, respectively.
Conclusions: Co-morbid panic disorder among patients with headache was associated with high anxiety
score and poor quality of life.
Key words: Anxiety; Headache; Panic disorder; Quality of life

18603
HAM-A

Mann-WhitneyKruskal-Wallis

HAM-A

Dr Imran Jahangirali Ratnani, MBBS, Department of Psychiatry, Government

Medical College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat,
India.
Dr Bharat Navinchandra Panchal, MD, Department of Psychiatry, Government
Medical College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat,
India.
Dr Deepak Sachchidanand Tiwari, MD, Department of Psychiatry, Government
Medical College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat,
India.
Dr Ashok Ukabhai Vala, MD, Department of Psychiatry, Government Medical
College and Sir Takhtasinhji General Hospital, Bhavnagar, Gujarat, India.
Address for correspondence: Dr Imran Jahangirali Ratnani, Room No. 133,
Department of Psychiatry, Government Medical College and Sir Takhtasinhji
General Hospital, Bhavnagar, Gujarat, India 364001.
Tel: (91) 9925056695; Fax: (91-278) 2422011; Email: drijratnani@gmail.com
Submitted: 16 September 2013; Accepted: 11 October 2013

10

Introduction
Headache is a common cause for medical consultation.1
Tension-type headache (TTH) is the most common cause for
primary headache (69%), followed by migraine headache
(16%).2 Headache often results in considerable disability
and poor quality of life.2 The present lifetime disability
attributable to migraine of 0.5 in terms of disabilityadjusted life years is equal to or more than that of several
other major chronic illnesses such as hypertension, breast
cancer, and rheumatoid arthritis.1 Psychiatric illnesses are
commonly associated with headache. The relationship of
anxiety disorders and depression with migraine has been
established in various studies.3-5 Anxiety is the commonest
2014 Hong Kong College of Psychiatrists

Panic Disorder and Quality of Life in Headache

co-morbidity affecting about 75% of patients6; its association

with migraine is stronger than that with depression,3 and the
presence of anxiety disorders is an independent risk factor
for depression in patients with migraine.4 Panic disorder
and phobia are the most common anxiety diagnoses
among migraineurs.7 There is paucity of clinical literature
concerning the association of anxiety disorders in relation
to headache.

At present, it is difficult to clinically distinguish
migraine from TTH, as the International Headache Societys
main definition of TTH allows an admixture of nausea,
photophobia, or phonophobia in various combinations,
although the appendix definition does not.2 This illustrates
the difficulty in distinguishing migraine from TTH.

Migraine is associated with anxiety, depression, and
poor quality of life.2 To our best knowledge, there is no
published evidence on the association of panic disorder
with severity of anxiety symptoms among patients with
headache. Thus, in the present study, we evaluated the
prevalence of panic disorder among patients with headache,
and the possible association of panic disorder with severity
of anxiety symptoms and quality of life in the patients with
headache.

25 years of experience in the subject. Hamilton Anxiety

Rating Scale (HAM-A), a 14-item observer-rated scale,
was used to assess the severity of the anxiety symptoms.10
The participants were asked to complete the 26-item World
Health Organization Quality of Life Scale brief version
(WHOQOL-BREF) which is a self-rating questionnaire for
assessment of the quality of life in the domains of physical
health, psychological health, social relationship, and
environment.11

Qualitative data were expressed as percentages and
quantitative data were expressed as median interquartile
range. The statistical analysis was done with GraphPad
InStat version 3.06 (San Diego, California, US). Proportions
of participants were compared by using Chi-square test
while scores of VAS, HAM-A, and WHOQOL-BREF were
compared by using Mann-Whitney test or Kruskal-Wallis
test followed by Dunns post-hoc multiple comparisons. A p
value of < 0.05 was considered statistically significant.

Written informed consent was obtained from every
participant. Prior approval for the study was obtained from
the local ethics committee.

Methods

These 100 participants (24 males and 76 females) were

divided into 3 groups according to severity of their anxiety
symptoms and were assessed by HAM-A. HAM-A scores
of 17 were classified as mild, 18-24 as mild to moderate,
and 25 as moderate to severe. Table 112 shows demographic
variables of these participants. The frequency of panic
disorder among the patients presenting with headache
was 67%; PA was noted in 23% of subjects and PoA in
44% of subjects. Severity of anxiety symptoms did not
differ with various demographic variables including age,
gender, residence, religion, marital status, education, socioeconomic status, tobacco use, severity, characteristic and
duration of headache, as well as history and family history
of headache or psychiatric consultations. Participants with
panic disorder had significantly higher HAM-A score
(p < 0.0001) and poor quality of life in all domains of
WHOQOL-BREF except in the social relationship domain.
The HAM-A score and quality of life in subjects with PA
did not differ significantly from those with PoA (Table
2). Besides, those with daily headache had significantly
higher HAM-A score (p = 0.04) and poor quality of life in
the psychological health domain of WHOQOL-BREF (p =
0.04) than those with intermittent headache (Table 3). Those
with high HAM-A scores had poor quality of life in all the
domains of WHOQOL-BREF (p < 0.0001). Among all the
domains, the psychological health domain score reduced
significantly as anxiety score increased (Table 4).

A total of 100 consecutive patients of both genders between

18 and 60 years, and having headache as a presenting
complaint for at least 3 months were recruited from the
psychiatry outpatient department of a tertiary care hospital
from April 2012 to July 2012. Patients with severe mental
illnesses including schizophrenia, bipolar mood disorder,
cognitive impairment, chronic disabling illnesses, negative
symptoms, dementia, and poor attention, as well as those
unable to give verbal replies were excluded from the study.
Patients on antidepressant, antipsychotic or antianxiety
medications in the last 2 months were also excluded. Causes
for secondary headache involving organic aetiologies
like systemic infection, head injury, vascular disorders,
subarachnoid haemorrhage and brain tumours were ruled
out with clinical examination.

Participants were interviewed by the principal
investigator on demographic variables like age, gender,
residence, religion, marital status, education, socioeconomical status, and tobacco use. Duration and
characteristics of headache (dull aching, throbbing or mixed)
were recorded. The visual analogue scale (VAS) was used
for recording the severity of headache using self-rating on a
scale of 0 to 10.8 History and family history of headache or
any other psychiatric consultation were recorded.

Participants were interviewed for the symptoms of
anxiety disorders like panic disorder, agoraphobia and for
the diagnosis of panic disorder with agoraphobia (PA) and
panic disorder without agoraphobia (PoA) using clinicianadministered interview as per the DSM-IV-TR criteria.9
The diagnosis was confirmed by a consultant psychiatrist
holding a master degree in psychiatry and with more than
East Asian Arch Psychiatry 2014, Vol 24, No.1

Results

Discussion
Psychiatric disorders such as anxiety disorders and
depression are more common among patients with recurrent
headache than in the general population.3,13 A majority of
11

IJ Ratnani, BN Panchal, DS Tiwari, et al

Table 1. Demographic variables according to severity of anxiety symptoms based on Hamilton Anxiety Rating Scale
scores.*
Characteristics
Age (years)
Gender
Male (n = 24)
Female (n = 76)
Residence
Rural / town (n = 53)
Urban (n = 47)
Religion
Hindu (n = 79)
Muslim (n = 21)
Marital status
Married (n = 94)
Unmarried (n = 6)
Education
Illiterate (n = 37)
Primary (n = 43)
Post-primary (n = 20)
Socio-economic status
1-2 (n = 62)
3 (n = 38)
Tobacco use
Yes (n = 31)
No (n = 69)
Headache characteristic
Dull aching (n = 31)
Throbbing (n = 51)
Mixed (n = 18)
Visual analogue scale
Duration of headache (months)
Panic disorder
With agoraphobia (n = 23)
Without agoraphobia (n = 44)
No panic disorder (n = 33)
History of headache or any other psychiatric illnesses
Yes (n = 25)
No (n = 75)
Family history of headache or any other psychiatric illnesses
Yes (n = 23)
No (n = 77)

Mild
(n = 33)

Mild to
moderate
(n = 24)

Moderate to p Value
severe
(n = 43)

34 (20-58)

32 (21-40)

35 (19-54)

11
22

6
18

7
36

20
13

10
14

23
20

29
4

19
5

31
12

30
3

23
1

41
2

10
14
9

11
9
4

16
20
7

19
14

14
10

29
14

13
20

4
20

14
29

8
22
3
5 (3-9)
12 (3-120)

8
13
3
7 (3-9)
30 (4-240)

15
16
12
7 (1-10)
18 (3-240)

2
4
27

2
18
4

19
22
2

6
27

6
18

13
30

4
29

7
17

12
31

0.55
0.22

0.36
0.24
0.65
0.64

0.62
0.17
0.08

0.63
0.08
< 0.0001

0.48
0.19

Data are shown as No. of patients or median (interquartile range).

Calculated by Chi-square test or Kruskal-Wallis test with Dunns post-hoc multiple comparisons.

Based on Kuppuswamys Socioeconomic Status Scale score.12

*

12

East Asian Arch Psychiatry 2014, Vol 24, No.1

Panic Disorder and Quality of Life in Headache

Table 2. Association of panic disorder with the severity of headache, anxiety, and quality of life.*
Item

Panic disorder with

agoraphobia
(n = 23)

VAS (severity of headache)

HAM-A (anxiety)
WHOQOL-BREF (quality of life)
Physical health
Psychological health
Social relationship
Environment

7 (1-10)
28 (13-41)
50
45.83
66.66
50

Panic disorder
without
agoraphobia
(n = 44)

6.5 (3-10)
24.4 (9-41)

(28.5-78.5)
(29.1-66.6)
(16.6-83.3)
(21.9-65.6)

50
50
66.66
53.13

(39.2-85.7)
(33.3-83.3)
(33.3-83.3)
(21.8-68.7)

No panic disorder
(n = 33)
6 (3-9)
14 (2-29)
60.71 (35.7-75.0)
62.5 (41.6-83.3)
66.66 (33.3-100)
62.5 (12.5-100)

p Value

0.98
< 0.0001
0.002
< 0.0001
0.09
0.0003

Abbreviations: VAS = visual analogue scale; HAM-A = Hamilton Anxiety Rating Scale; and WHOQOL-BREF = World Health
Organization Quality of Life Scale brief version.
*
Data are shown in median (interquartile range). All the groups were compared by Kruskal-Wallis test followed by Dunns post-hoc
multiple comparisons.

p < 0.05 in comparison with other groups.

Table 3. Association of frequency of headache with severity of headache, anxiety, and quality of life.*
Item

VAS (severity of headache)

HAM-A (anxiety)
WHOQOL-BREF (quality of life)
Physical health
Psychological health
Social relationship
Environment

Intermittent (n = 43)
5 (1-10)
19 (2-40)

57.14
54.16
66.66
56.25

(39.3-75)
(33.3-83.3)
(16.7-100)
(21.9-100)

Daily (n = 57)

p Value

53.57 (28.6-85.7)
50 (29.2-75)
66.66 (25-91.7)
50 (12.5-84.4)

0.07
0.04
0.13
0.14

7 (3-10)
25 (6-41)

0.06
0.04

Abbreviations: VAS = visual analogue scale; HAM-A = Hamilton Anxiety Rating Scale; and WHOQOL-BREF = World Health
Organization Quality of Life Scale brief version.
*
Data are shown in median (interquartile range). All the groups were compared by Mann Whitney U test.

p < 0.05 in comparison with other groups.

Table 4. Association of severity of anxiety (based on Hamilton Anxiety Rating Scale) with quality of life.*
Item
WHOQOL-BREF
Physical health
Psychological health
Social relationship
Environment

Mild (n = 33)

60.71 (46.4-75)
62.5 (41.7-83.3)
66.67 (33.3-100)
62.5 (31.3-100)

Mild to moderate
(n = 24)

Moderate to severe
(n = 43)

p Value

53.57
54.16
66.67
56.25

46.43
45.83
58.33
46.88

0.002
< 0.0001
0.09
0.0003

(42.9-85.7)
(33.3-70.8)
(50-83.3)
(28.1-71.9)

(28.6-64.3)
(29.2-83.3)
(16.67-83.3)
(12.5-65.6)

Abbreviation: WHOQOL-BREF = World Health Organization Quality of Life Scale brief version.
*
Data are shown in median (interquartile range). All the groups were compared by Kruskal-Wallis test followed by Dunns post-hoc
multiple comparisons.

p < 0.05 in comparison with other groups.

Anxiety score was significantly higher compared with other groups.

East Asian Arch Psychiatry 2014, Vol 24, No.1

13

IJ Ratnani, BN Panchal, DS Tiwari, et al

participants in this study were women (76%). According

to a prospective study,14 women were 4 times more likely
to develop migraine in comparison with men. Unlike that
for migraine, the female-to-male ratio for TTH is 5:4,
suggesting that the prevalence of TTH is slightly higher in
women than in men.15 Our finding suggested that the severity
of anxiety symptoms did not differ with demographic
variables of age, gender, residence, religion, education, and
socio-economical status. Similar findings were reported in
an earlier study by Mercante et al.16

In contrast to data from an earlier study16 that
headache intensity was higher among patients with
anxiety disorder compared with the controls, the severity
of headache was not associated with severity of anxiety
symptoms in this study. This difference may be attributed to
cross-cultural variation, the subjective nature in expressing
pain severity, and the poor reliability of the self-rating VAS
used for assessing the severity of pain. In the present study,
the severity of anxiety symptoms was independent of the
characteristics of headache like dull aching, throbbing, or
mixed headache.

Patients complaining of daily headache showed
higher scores for anxiety symptoms and poorer scores for
quality of life in the psychological health domain than those
with intermittent headache. This finding is in accordance to
data from earlier studies16,17 which found that the symptoms
of depression and anxiety disorders were more common
in chronic than episodic migraine and TTH. Patients with
chronic daily headache are likely to show poor quality of
life across all the 8 domains of the self-administered 36-item
Short Form questionnaire used to measure health-related
functions, except that of physical functioning.18-20 Patients
with chronic migraine have higher rate of anxiety disorders
and are twice as likely to report anxiety disorders than those
with episodic migraine.21,22 Recent data23,24 also showed that
co-morbid anxiety disorders and depression have a role in
the progression of episodic migraine to chronic migraine.

In this study, the frequency of panic disorders in
patients with headache was 67%, while frequencies of PA
and PoA were 23% and 44%, respectively. The frequency
of panic disorder among individuals with headache varied
from 4.5 to 27% in earlier studies.25,26 The diagnosis of
panic disorder was made with the help of DSM-IV-TR,
which allows diagnosis of panic disorder in less frequent
attacks. As the patients were recruited from the tertiary care
psychiatry outpatient department, which is the specialised
referral centre in the area, the patients with more severe
symptoms were more likely to be referred by other
medical professionals in this study compared with previous
studies25,26 on general population in general medical
setting. In our study, women represented more than three
quarters (76%) of the study population, whereas another
study9 revealed that they were 2 to 3 times more likely to
suffer from panic disorder than men. These could be the
probable reasons for higher frequency of panic disorder in
our study. The only published Indian study,27 performed
in a rural camp, showed a 14.5% frequency of PA. In this
14

study, patients with panic disorders (PA and PoA) showed

higher anxiety symptoms and poorer quality of life in most
domains (except in the social relationship domain) of the
WHOQOL-BREF than those without panic disorders.
Perhaps the structure of questions in the WHOQOL-BREF
may explain this finding; there are only 3 questions in
the WHOQOL-BREF for evaluating the quality of life in
the social relationship domain, while there are 7, 6, and 8
questions for evaluating the physical health, psychological
health, and environmental domains, respectively. The
severity of anxiety symptoms and quality of life did not
differ significantly among patients with PA or PoA. These
findings are in accordance with data from earlier studies.13,16
One population-based study28 showed that panic disorder
was strongly associated with migraine (odds ratio [OR] =
3.7; 95% confidence interval, 2.2-6.2 in severe headache
disorders vs. OR = 3.0; 95% confidence interval, 1.5-5.8 in
non-headache controls).

In this study, patients with severe anxiety symptoms
showed poorer quality of life across all domains. Other
studies9,16,29 have demonstrated that patients with anxiety
disorders are likely to have severe disability.

A community-based longitudinal study13 found that
individuals with a history of migraine attack are likely to
experience an episode of anxiety disorder or depression
on follow-up. This finding suggests that depression, panic
disorder, and migraine have a common predisposition and
are not merely psychological consequences of headache.
Another longitudinal study3 showed that anxiety disorders
may precede migraine, and depression may follow it. Causal
relationship between anxiety disorders and headache needs
to be investigated further. Since anxiety disorders frequently
coexist with headache, we recommend screening for anxiety
disorders in patients with headache so as to facilitate their
early identification and early treatment.

Limitations
Although this is the first study to examine the association
of panic disorder with severity of anxiety symptoms and
quality of life among participants with headache, it has
several limitations such as recruiting subjects from a single
centre, an open-label study, and a small sample size. As
participants were recruited from the psychiatry outpatient
department of a tertiary care hospital, they did not represent
the general population. Being a cross-sectional study,
cause-effect relationship for headache and anxiety disorders
cannot be established. As such, prospective cohort studies
to examine such association are recommended.

Conclusions
This study showed that there was high frequency of panic
disorder among patients with headache. Patients with severe
anxiety symptoms had poorer quality of life. Patients with
daily headache showed more severe anxiety symptoms and
poorer quality of life than those with intermittent headache.
East Asian Arch Psychiatry 2014, Vol 24, No.1

Panic Disorder and Quality of Life in Headache

Patients with panic disorders (PA and PoA) showed higher

scores for anxiety symptoms and poorer quality of life than
those without.

Declaration
The authors declared no source of financial support and
conflict of interest in this study.

Acknowledgements
We would like to thank Prof Mukesh Samani, Head of
Department of Psychiatry, P. D. U. Medical College, Rajkot,
Gujarat, India for guidance about applying World Health
Organisation Quality of Life (WHOQOL-BREF) scale,
as well as Dr Divyesh R. Mandavia, Tutor, Department of
Pharmacology, Government Medical College, Bhavnagar,
Gujarat, India for guidance in statistical analysis, manuscript
preparation, editing, and review.

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