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Chronic Headache Associated With Increased Risk of Suicide Attempts Among Veterans


Results of a large retrospective cohort study showed veterans with chronic headache are at an increased risk of suicide attempts compared with those experiencing other forms of chronic pain.

US veterans suffering from chronic headache have a higher risk of suicide attempts (SA) compared with those with other chronic pain, according to results of a retrospective cohort study.

These findings, published in Journal of Pain Research, also showed women with chronic headache exhibited a higher risk of SA than men, while concurrent traumatic brain injury (TBI) compounded this risk, especially in men.

“Necessary suicide screening precautions should be taken for veterans with chronic headache disorders with or without concurrent TBI,” the authors wrote. “Even if chronic headache disorders are only a red flag, it is imperative for clinicians to attend to this as veterans typically speak more freely about headache than other symptoms, such as mental health issues.”

Previous studies have revealed risk of suicide is greater among those with neurological diseases, including stroke, multiple sclerosis, migraine, and epilepsy, “suggesting a complex interplay between the underlying dysfunctional nervous system, comorbid psychiatric disorders, and subjective experiences, such as hopelessness,” the researchers wrote.

Furthermore, chronic headache and TBI often involve a sense of helplessness and lack of agency, which mark key factors related to the development of suicidal ideation, they explained. Migraine-like headache is also the most common long-term sequalae of TBI.

To better understand the incidence of SA among veterans with chronic headache and other types of chronic pain, investigators assessed data from the Veteran Health Administration’s Corporate Data Warehouse—a national inpatient and outpatient administrative database collected between 2000 and 2010.

A total of 3,247,621 veterans with chronic head, neck, back, and other noncancer-related pain were included in the analysis. All individuals were between the ages of 18 and 95. The researchers collected demographic information, data on SA and TBI, and information on any diagnosed psychiatric comorbidity.

“Annual incidence rates of SA per 100,000 were calculated for each chronic pain condition from 2001 to 2010,” the authors wrote, while “multivariable Poisson regression was used to examine the association between chronic headache disorders and the number of SA in the entire cohort, male cohort, and female cohort.”

Of the individuals included, 14.19% had chronic headache, 14.9% had chronic neck pain, 59.3% had chronic back pain, and 60.28% had other types of chronic pain. The most common types of headache disorder identified were nonspecific headache diagnosis and migraine. Depression, posttraumatic stress disorder (PTSD), and adjustment disorder were the most frequently diagnosed psychiatric comorbid conditions.

Analyses revealed:

  • Veterans with chronic headaches had the highest annual incidence of SA (329 to 491 per 100,000) each year among all identified types of chronic pain conditions
  • Compared with other nonheadache chronic pain, chronic headache was associated with increased risk of SA (men's relative risk [RR], 1.48; 95% CI, 1.37-1.59; women's RR, 1.64; 95% CI, 1.28-2.09), after adjusting for demographic factors, TBI, and psychiatric comorbidities
  • The risk increased further when chronic headache was comorbid with TBI (men's RR, 2.82; 95% CI, 2.60-3.05; women's RR, 2.16; 95% CI, 1.67-2.78)
  • Men with anxiety alone and women with obsessive compulsive disorder alone have no association with SA risk, but when these conditions are concurrent with chronic headache, SA risk significantly increased
  • Chronic headache disorders were associated with an increased risk of SA, which was slightly higher in women (RR, 1.64; 95% CI, 1.28-2.09) than in men (RR, 1.48; 95% CI, 1.37-1.59)

These study findings are consistent with past research showing women tend to attempt suicide more frequently than men, although men tend to die via suicide more frequently than women. This is due in part to the fact men often select more lethal means of suicide (ie, firearm) than women (ie, drug overdose). Approximately 90% of SA using firearms result in death.

“In this cohort, men with chronic headache and TBI were almost 3 times more likely to have attempted suicide, whereas women were more than twice as likely to have attempted suicide,” researchers wrote. “It is possible that higher suicide risk attempt in men with chronic headache and TBI is attributed to the severity of TBI and pain, and/or poor executive functioning associated with TBI, whereas higher suicide risk in women with chronic headache alone is attributed to catastrophizing pain.”

Additional socioeconomic factors, sleep problems, and other health issues may contribute to this discrepancy.

Because not all SA are reported to health care providers it is likely the rate of SA in this study is lower than previously reported.

“At the biomolecular level, we postulate that the etiopathogenic mechanism of SA in this population is associated with chronic, exacerbated neuroinflammatory process associated with both chronic headache/migraine, TBI, and SA,” authors concluded.


Androulakis XM, Guo S, Zhang J, et al. Suicide attempts in US veterans with chronic headache disorders: a 10-year retrospective cohort study. J Pain Res. Published online August 24, 2021. doi:10.2147/JPR.S322432

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