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Psychosomatics 49:502-510, November-December 2008
doi: 10.1176/appi.psy.49.6.502
© 2008 Academy of Psychosomatic Medicine
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Migraine Predicts Self-Reported Muscle Tension in Patients With Major Depressive Disorder

Ching-I Hung, M.D., Chia-Yih Liu, M.D., Jane-Jane Chen, R.N., and Shuu-Jiun Wang, M.D.

Received November 27, 2006; revised March 29, 2007; accepted April 5, 2007. From the Dept. of Psychiatry, Chang Gung Memorial Hospital, and Chang Gung University College of Medicine; The Nursing Department, Taipei Veterans General Hospital; the Neurological Institute, Taipei Veterans General Hospital, and the National Yang-Ming University School of Medicine, Taipei, Taiwan. Send correspondence and reprint requests to Shuu-Jiun Wang M.D., The Neurological Institute, Taipei Veterans General Hospital, 201 Shi-Pai Rd., Section 2, Taipei, 112, Taiwan. e-mail: sjwang{at}vghtpe.gov.tw
© 2008 The Academy of Psychosomatic Medicine


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
BACKGROUND/OBJECTIVE: The aim of this study was to identify factors related to muscle tension in patients with major depressive disorder (MDD) with comorbid anxiety and migraine. METHOD: Consecutive psychiatric outpatients with MDD were enrolled. Self-reported muscle tension (SMT) during the previous week was evaluated with a 0–10 scale. RESULTS: Of 135 participants with MDD, 63 (46.7%) had migraine. Multiple-regression analyses showed that migraine and headache intensity were two major independent factors related to SMT. CONCLUSION: Further studies on musculoskeletal symptoms in MDD should not neglect the impact of migraine.


  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 
Depression and musculoskeletal symptoms are closely related. For example, it has been reported that depressive symptoms and chronic musculoskeletal pain at baseline are mutually predictive of each other at 8-year follow-up.1 It has also been observed that nonspecific musculoskeletal symptoms are common in patients with depression2,3 and that they have a negative impact on the remission of depression.4

Headache and musculoskeletal symptoms are closely related.5 Previous studies have reported a positive association between headache and musculoskeletal discomfort in the upper body.5 Muscular factors have long been considered to be important in tension-type headache (TTH).6 Migraine, which was previously considered to be a type of vascular headache, has also been found to be associated with several musculoskeletal symptoms, such as muscle tightness or soreness in the neck, shoulders, or back.5,7–10

Migraine, the most commonly studied type of headache associated with depression,11–14 and is not uncommon in patients with major depressive disorder (MDD).15–19 However, previous studies of somatic symptoms in patients with MDD have rarely focused on the impact of migraine. Moreover, few studies have examined depression, anxiety, migraine, and musculoskeletal symptoms at once.20

The DSM–IV-TR21 lists muscle tension as one criterion for the diagnosis of generalized anxiety disorder (GAD). For several reasons, this study focused on self-reported muscle tension (SMT) in patients with MDD. Increased muscle tension is related to some painful symptoms.22 Von Knorring et al. reported that at least some aches and pains in patients with depressive disorders are related to increased muscle tension.23 Therefore, increased muscle tension might be one of the important factors related to general musculoskeletal discomfort or pain in MDD. However, previous studies investigating somatic symptoms in patients with MDD have rarely focused on this symptom. The factors related to self-reported muscle tension in MDD patients have never been systematically studied.

Our previous study demonstrated that migraine had negative impacts on physical dimensions of quality of life, especially on bodily pain.16 Increased muscle tension might be related to some aches or pains in patients with depression.22,23 Moreover, migraine and headache severity were associated with musculoskeletal symptoms such as muscle tightness or soreness.5–10 Therefore, we hypothesized that migraine and headache intensity might be important factors related to SMT in depression patients. To test this hypothesis, we simultaneously investigated the impact of migraine, comorbid anxiety, and headache intensity on SMT in patients with MDD because of the close relationship among depression, anxiety, migraine, and musculoskeletal symptoms.


  METHOD

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
RESULTS
 DISCUSSION
 REFERENCES
 
This study was part of a project titled The Impact of Headache and Somatic Symptoms on MDD: II. We aimed to identify independent factors related to SMT in patients with MDD that included anxiety and migraine. The project was approved by the Institutional Review Board of the Chang Gung Memorial Hospital. We conducted this study in the general-psychiatric clinics of the Chang Gung Memorial Hospital from January 2004 to January 2005. Study participants were recruited from consecutive outpatients age 18 to 65 years, who had not taken antidepressants, other psychotropic drugs (including benzodiazepines), or muscle relaxants within the previous 2 weeks. This study did not exclude those who had used analgesics in the previous 2 weeks because this might have excluded patients with headache. Screening included an interview by a board-certified psychiatrist using the Structured Clinical Interview for DSM–IV-TR Axis I disorders.24 Patients who met the DSM–IV-TR criteria for MDD and had experienced a major depressive episode (MDE) were enrolled.21 To prevent the effects of somatic symptoms from being confounded by those of other medical conditions, substance abuse, or psychotic symptoms, we established the following exclusion criteria: 1) a history of substance dependence or abuse without full remission in the previous month; 2) psychotic symptoms, catatonic features, or severe psychomotor retardation, with obvious difficulty being interviewed; and 3) chronic medical diseases, such as hypertension, diabetes mellitus, and other medical diseases, except for headache. Written informed consent was obtained from all subjects before study enrollment.

Assessment of Psychiatric Comorbidity and Severity of Depression
All patients were assessed with the 17-item Hamilton Rating Scale for Depression (Ham–D).25 Psychiatrists who were blind to the diagnosis of headache, SMT data, and Ham–D results used the Structured Clinical Interview24 to evaluate seven anxiety comorbidities: panic disorder, agoraphobia, social phobia, specific phobia, posttraumatic stress disorder (PTSD), obsessive-compulsive disorder (OCD), and GAD. It should be noted that the Structured Clinical Interview can diagnose the lifetime prevalence of all anxiety disorders except GAD, which can be diagnosed by current prevalence (the past 6 months).24 Anxiety comorbidities were divided into the current episode, partial remission, full remission, and previous history on the basis of the Structured Clinical Interview.24 Anxiety comorbidities in a current episode or partial remission were used in further statistical analysis because these participants had active anxiety symptoms.

Moreover, the course of depression was clearly characterized. Chronic depression was defined as chronic MDD for more than 2 years, dysthymic disorder plus current MDE, or previous MDD without full remission plus current MDE with a total course of more than 2 years.26

Assessment of Headache
Headache Diagnosis
All patients completed a structured Headache Intake form, which was designed to meet the operational criteria of the International Classification of Headache Disorders, 2nd Edition (ICHD–2)27 for both clinical and research use. The form emphasized the collection of information needed to classify migraine and other types of headache. Questions regarding the frequency, intensity, features, aura, locations, duration, and precipitating factors of headache, as well as the amount and frequency of use of drugs taken for pain were included. An experienced headache specialist, who was masked to the results of psychiatric evaluations, interviewed all patients after they completed the Headache Intake form and made the headache diagnoses on the basis of the ICHD–2.27

Headache Severity Assessment
Subjects evaluated their average headache intensity during the previous week by use of an 11-point (0–10) scale, with 0 representing "no headache" and 10 representing "headache as severe as I can imagine."

Assessment of Self-Reported Muscle Tension and Bodily Pain
The participants reported the average muscle tension in six body parts (head, neck, shoulders, back, upper limbs, and lower limbs) during the previous week by use of an 11-point (0–10) scale, with 0 representing absence of muscle tension and 10 representing "muscle tension as extreme as I can imagine." Subjects were instructed that the evaluation was focused on their muscle tension, not their pain. They were also requested to report which body part was the most bothersome because of muscle tension.

In a pilot study, test–retest reliability was evaluated in 36 psychiatric outpatients with stable depression during a 1-week interval. The Pearson correlation coefficients of the SMT scores ranged from 0.70 to 0.82 (all p<0.01) for different body parts.

For understanding the relationship between SMT and bodily pain (BP), we measured the correlation of SMT and the BP subscale of the Short-Form 36 (SF–36).28,29 The SF–36 questionnaire is a widely used generic questionnaire, with eight subscales for assessing health-related quality of life during the previous month. Lower scores on the subscales indicate poorer quality of life.28 The Taiwan version of the SF–36 shows good validity and reliability.29 The "acute" version of the SF–36, which evaluates quality of life during the previous week with the same items as the SF–36, was used in the study to be compatible with the severity of SMT, depression, and headache during the previous week.

Statistical Analysis
All statistical analyses were performed with SPSS for Windows 10.0 software. Pearson correlation was used to test the relationships of SMT, headache intensity, Ham–D scores, scores on the BP subscale, and age. The Student t-test with Bonferroni correction (statistical significance: p<0.008) was used to test the difference in SMT between subjects with or without different comorbidities. Multiple linear-regression analyses were used to determine the factors that were independently associated with SMT in MDD patients. Forward selection was used to prevent multicollinearity. The dependent variable was the severity of SMT in each body part. The 15 independent variables were age, gender, Ham–D score, headache intensity, chronic depression, migraine, TTH group, and anxiety comorbidities, including panic disorder, agoraphobia, OCD, social phobia, specific phobia, PTSD, GAD, and any anxiety comorbidity.

In testing the impact of migraine, a multivariate analysis of variance with the general linear model was used to investigate the impact of migraine on SMT in each body part, after controlling for age, gender, and the severity of depression (Ham–D score). The estimated difference in SMT score due to migraine was calculated for each body part. In all statistical analyses except the Student t-test with Bonferroni correction, a p value of <0.05 was considered statistically significant.


  RESULTS

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
DISCUSSION
 REFERENCES
 
Subjects
During the study period, 148 consecutive patients (37 men, 111 women) met our study criteria; however, 13 patients (3 men, 10 women; 8.8%) refused participation; 135 patients (91.2%; 34 men, 101 women; mean age 30.2 [standard deviation {SD}: 8.4 years]; mean Ham–D score: 23.4 [4.5]; mean headache intensity: 5.2 [3.4]; mean BP score: 49.0 [23.3]) agreed to participate in our study. Among them, 26 subjects (19.3%) had used analgesics, such as acetaminophen or nonsteroidal anti-inflammatory drugs in the previous 2 weeks.

The mean [SD] severity of SMT was the following: in the head, 5.4 [2.9]; neck, 6.4 [2.9]; shoulders, 6.5 [2.9]; back, 4.9 [3.0]; upper limbs, 4.1 [2.9]; and lower limbs, 4.3 [2.9], respectively. The SMT score was ≥5 in the head for 65.9% of the subjects (N=89), neck: 76.3% (N=103), shoulders: 78.5% (N=106), back: 60.0% (N=81), upper limbs: 48.9% (N=66), and lower limbs: 52.6% (N=71). Overall, 87.4% of subjects (N=118) had at least one body part with an SMT score ≥5.

There was no significant difference between men and women in age (men/women: 32.2 [8.4] years versus 29.5 [8.3] years), Ham–D score (men/women: 22.8 [3.7] versus 23.6 [4.8]), headache intensity (men/women: 4.4 [2.9] versus 5.4 [3.5]), or SMT in all six body parts (all p values >0.05).

Diagnosis of Headache and Psychiatric Comorbidity
Among 135 participants, 63 (46.7%) had migraine (including 51 without aura and 12 both with and without aura). Among 63 subjects with migraine, 4 subjects (6.3%) had chronic migraine, and 4 had probable chronic migraine with medication-overuse headache. Those subjects who did not meet the criteria for migraine included 18 (13.3%) with probable migraine without aura, 3 (2.2%) with chronic TTH, 4 (3.0%) with infrequent episodic TTH, 20 (14.8%) with frequent episodic TTH, 6 (4.4%) with probable episodic TTH, 7 (5.2%) with headache not otherwise classified, and 1 with headache unspecified; 13 subjects (9.6%) reported no headache. Subjects with chronic, infrequent episodic, frequent episodic, or probable episodic TTH were categorized as the TTH group (N=33; 24.4%). Compared with subjects without migraine, subjects with migraine had higher average headache intensity during the previous week (6.7 [3.2] versus 3.8 [2.9]; p <0.01). However, the TTH group had less average headache intensity than the non-TTH group (4.2 [2.9] versus 5.5 [3.5]; p=0.049).

The percentages of lifetime anxiety comorbidities were 17.8% (N=24) for panic disorder, 16.3% (N=22) for agoraphobia, 31.1% (N=42) for social phobia, 26.7% (N=36) for specific phobia, 12.6% (N=17) for OCD, 9.6% (N=13) for PTSD, and 3.7% (N=5) for GAD. The frequencies of comorbid anxiety disorders with a current episode or partial remission in the past month are shown in Table 1.


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TABLE 1. Severity of Self-Reported Muscle Tension (mean [standard deviation])a in Different Areas of the Body in the Comorbid Group Versus the Non-Comorbid Groupb



Difference in SMT Between Groups With and Without Comorbidity
The differences in SMT in relation to the presence or absence of various comorbid disorders are shown in Table 1. A trend toward higher SMT scores was noted in subjects with comorbid anxiety disorders or chronic depression; however, after Bonferroni correction, most of the differences were not significant. Of note, the differences in SMT scores for all body parts, after Bonferroni correction (Table 1), were significant between those with and those without migraine. The TTH group had lower SMT scores than the non-TTH group. There was no difference in SMT in the six body parts in relation to comorbid panic disorder, specific phobia, OCD, PTSD, or GAD.

Correlation Among Self-Reported Muscle Tension, Depression Severity, Intensity of Headache, Score on the Bodily Pain Subscale, and Age
The correlation coefficients among the SMT score, Ham–D score, headache intensity, BP scores on the SF–36, and age are shown in Table 2. The headache intensity and Ham–D score were correlated with the SMT score. All correlation coefficients between the SMT score and headache intensity were higher than those between the SMT score and Ham–D score or age. Moreover, all SMT scores in the six body parts had a moderately negative correlation with the scores of the BP subscale. Age was only slightly correlated with SMT in the back and upper limbs. The correlation coefficient between headache intensity and Ham–D score was 0.25, between headache intensity and BP subscale: –0.42, and Ham–D score and BP subscale: –0.33 (p<0.01).


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TABLE 2. Pearson Correlation Coefficients for Severity of Self-Reported Muscle Tension in Six Body Areas and Severity of Depression, Headache Intensity, and Agea,b



The SMT scores for different body parts were intercorrelated (coefficients ranged from 0.86 to 0.42; all p values <0.01). The correlation coefficient was 0.86 between SMT scores in the neck and shoulders, followed by upper limbs and lower limbs (0.79), neck and back (0.64), and shoulders and back (0.62). The internal consistency of the SMT scores in the six body parts was 0.88 (Cronbach alpha).

Independent Factors Associated With SMT in Six Body Parts
Table 3 shows the independent factors associated by multiple linear regression with SMT in the six body parts being reported. Migraine and headache intensity were more important predictors of SMT than chronic depression, anxiety disorders, or the severity of depression (Ham–D score). In fact, migraine was independently associated with SMT in five of the six body parts and had the highest adjusted R2 change in four body parts: neck, shoulders, back, and lower limbs. In contrast, Ham–D score was associated in multiple-regression analyses with only SMT in upper and lower limbs.


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TABLE 3. Independent Factors Related to Self-Reported Muscle Tension in Body Areas of 135 Outpatients With Major Depressive Disordera,b,c



Impact of Migraine on SMT
The impact of migraine on SMT, after controlling for age, gender, and severity of depression, is shown in Table 4. Compared with those without migraine, patients with migraine had significantly increased SMT, ranging from 1.48 to 2.72 points, in all six body parts. This model found that migraine alone accounted for 17%–28% of the SMT variance in different body parts.


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TABLE 4. Results of Estimated Difference in Severity of Self-Reported Muscle Tension, With Migraine as the Main Factor, After Controlling for Age, Gender, and Severity of Depressiona




  DISCUSSION

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
REFERENCES
 
The study results demonstrated that migraine comorbidity was associated with increased SMT in different body parts in patients with depression. This association was independent of age, gender, depression severity, or other anxiety comorbidities. Previous studies have reported a link between migraine (or headache) and musculoskeletal symptoms,7–10,30–32 but have never reported this association in patients with MDD. Mongini et al. reported that anxiety or combined anxiety-and-depression in patients with episodic migraine increased the level of muscle tenderness in the head and neck and might foster the development of chronic migraine.20 Moreover, Peres et al.33 reported that depression predicted fibromyalgia, which has symptoms of general muscle tension or soreness, in patients with transformed migraine.

Our study demonstrated that migraine in patients with MDD was related to increased muscle tension. Our study and the other two studies demonstrated an interesting interaction among depression, anxiety, migraine, muscle tenderness or tension, and pain.

In addition to migraine, headache intensity was independently correlated with SMT in patients with depression; this also confirms the findings of a previous study.30 Our regression models showed that headache intensity was even more important than depression severity (by Ham–D score) or anxiety disorders in relation to SMT.

Most of our subjects (87.4%) had at least one body part with at least a moderate intensity of SMT (score: ≥5). More than half of our patients reported a muscle tension score ≥5 in all reported body parts except upper limbs. The SMT scores negatively correlated with the scores of the BP subscale of the SF–36 (Table 2). On that subscale,28 a lower score on the SF–36 indicates a poorer quality of life, and, in contrast, a higher SMT score indicates increased muscle tension. Therefore, in patients with MDD, increased muscle tension was related to poorer quality of life on the BP subscale.

Why does comorbidity of migraine in patients with MDD indicate increased SMT? Biologically, patients with migraine are considered to be in an abnormal sensory state—allodynia—which is related to neurophysiological sensitization.34 For example, neck stiffness, a common premonitory symptom of migraine, may be simply a form of allodynia in combination with subtle overactivity of muscles associated with segmental nocifensive activation.34 Moreover, previous studies reported significant tendon/muscle tenderness in the neck and shoulder before, during, and after migraine attacks.10,35 A connection between sympathetic nervous system dysfunction and musculoskeletal pain has been hypothesized to relate to abnormal sympathetic activation of muscle spindles.36

Our findings have several clinical implications: 1) Previous studies usually attributed the somatic discomforts of MDD to old age, female gender, culture, low socioeconomic status, or anxiety.37 Our findings imply that previous studies for somatic symptoms, which emphasized only severity of depression or anxiety comorbidity in MDD patients, might be incomplete. 2) Previous studies in headache patients reported a relationship of headache and upper-body musculoskeletal discomfort.5 Our results demonstrated a possibility that the impact of headache might also involve other body parts. However, another possible mechanism, which should not be neglected, is the idea that psychological or autonomic arousal due to depression might lead to increased perception of somatic symptoms, such as headache and increased SMT in the upper and other parts of the body.38 3) Muscle tension has long been considered one of the important features of TTH.6 Our results demonstrated that migraine might actually be more related to increased self-reported muscle tension than tension-type headache among patients with MDD. However, these findings need more supporting studies.

There are several issues worthy of further study in the future. Our results raise interesting questions, that is: 1) whether prophylactic migraine treatment can simultaneously decrease SMT as well as musculoskeletal or painful symptoms; 2) whether MDD subjects with migraine represent a distinct subgroup that needs specific treatment; and 3) what the interrelationships are among muscle tension, muscle soreness, and pain in patients with MDD. Finally, our study was limited to MDD patients with a current depressive episode. Epidemiological studies in the general population are needed to examine the relationships of depression, migraine, anxiety, and muscle tension.

Our study has several methodological issues or limitations. 1) Lack of a control group in this study precluded any comparisons of the severity and clinical significance of SMT between MDD and nondepressed patients. 2) The focus was on migraine because of its significant impact on depression, as reported in our study and previous studies.13,16 The combined-headache types, for example, migraine combined with TTH, were not analyzed in this study because of difficulty in diagnosis. The TTH group had lower average headache intensity and SMT scores than the non-TTH group, partly because the non-TTH group included subjects with migraine. 3) Subjects with the symptoms of GAD during a major depressive episode were not diagnosed as having GAD in our study because anxiety is considered to be a symptom of depression according to the hierarchy rule of DSM–IV-TR.21 The Structured Clinical Interview only diagnosed patients with current GAD, not the lifetime prevalence of GAD. Moreover, nearly half of our subjects (45.9%) had chronic depression. These three circumstances might partially explain the lower frequency of GAD in our study (3.7%). The lower frequency reduced its impact on SMT, although muscle tension is a criterion of GAD. 4) The frequency of migraine in our study (46.7%) was similar to Fasmer’s (46%) and our studies (48.3%), but higher than in some previous studies (23.9% and 31.0%).15,16,39,40 The questionnaire for headache requested subjects to report any headaches, even mild or infrequent headache. This might be the reason why only 9.6% of the study subjects were free of headache. The existence of Berkson’s bias, which stresses the importance of comorbidity of other illnesses in clinic-based study patients, should be considered as another reason for the high frequencies of migraine, other headache, and SMT. 5) A 0–10 scale was used in this study for evaluating SMT because a) numerical scales used in pain measurement have demonstrated reliability and validity and ease of administration and scoring;41,42 and b) SMT (like pain) is also a subjective discomfort. Our method had an acceptable test–retest reliability and internal consistency. Moreover, SMT was moderately correlated with scores on the BP subscale—more evidence of its validity. However, the biological mechanism of muscle tension, which might include several complex physiological mechanisms,43 is not well known. Self-report data might be partially affected by psychological factors. An objective measure of SMT is needed in future studies.

In conclusion, our study demonstrated that the presence of migraine and increased headache intensity were the two important independent predictors of increased SMT in patients with depression. However, this study result needs further research support because of the limited number of studies on this topic. Further studies on musculoskeletal discomfort or painful symptoms in MDD patients should not neglect the impact of migraine.


  ACKNOWLEDGMENTS

 
This study was supported in part by National Science Council grants NSC 93-2314-B-182A-200 and NSC 94-2314-B-182A-207.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 METHOD
 RESULTS
 DISCUSSION
 REFERENCES
 

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