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 Table of Contents  
LETTER TO THE EDITOR
Year : 2013  |  Volume : 27  |  Issue : 3  |  Page : 189-190

Coexisting fibromyalgia, depressive disorder, and tension headache: Chance finding or common pathology?


1 Assistant Professor, Department of Psychiatry, Subharti Medical College, Meerut, Uttar Pradesh, India
2 Associate Professor, Department of Psychiatry, Subharti Medical College, Meerut, Uttar Pradesh, India
3 DM Rheumatology & Immunology, Department of Rheumatology, Subharti Medical College, Meerut, Uttar Pradesh, India
4 Clinical Psychologist, Department of Psychiatry, Subharti Medical College, Meerut, Uttar Pradesh, India

Date of Web Publication7-Jan-2014

Correspondence Address:
Supriya Vaish
134, Ram Sadan, Opposite Anurag Cinema, Baghpat Road, Meerut-250 001, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-5333.124607

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How to cite this article:
Vaish S, Sharma S, Grover S, Bharti S. Coexisting fibromyalgia, depressive disorder, and tension headache: Chance finding or common pathology?. Indian J Pain 2013;27:189-90

How to cite this URL:
Vaish S, Sharma S, Grover S, Bharti S. Coexisting fibromyalgia, depressive disorder, and tension headache: Chance finding or common pathology?. Indian J Pain [serial online] 2013 [cited 2019 Nov 19];27:189-90. Available from: http://www.indianjpain.org/text.asp?2013/27/3/189/124607

Sir,

A 45-year-old-woman was admitted to our ward for a daily tension-type headache, it was not responding to usual pharmacological treatment. She had headache since 19 years which was bilateral constricting type, which initially was gradual, episodic, and mild to moderate in severity lasting for hours but later on became daily, intense and constrictive pain, generalized. It was not associated with aura, vomiting, ocular symptoms, phonophobia, and not worsened by exercise. The diagnosis of daily tension-type headache met the International Classification of Headache Disorders (IHCD)-II criteria. She also started reporting generalized weakness including the upper and lower limbs, lethargy, generalized musculoskeletal pain, tingling sensation, difficulty in walking and climbing, and difficulty in doing her routine household activities. She referred widespread pain, unusually severe above all joints and muscular pain which were painful on palpation without any sign of inflammation. Patient also complained of fatigue, memory difficulties, and depressive symptoms including low mood, anhedonia, poor concentration, decreased sleep and appetite, and hopelessness; which appeared following the plethora of pain symptoms. The patient's medical history reported hypothyroidism for which patient was on 50 mg of thyroxine daily and the current thyroid profile was within normal limits. There was no history of any other medical disorder. The patient underwent a brain and neck computed tomography (CT), a brain magnetic resonance imaging (MRI) which was normal. Since the headache could be a symptom of a systemic disease, we decided to perform several blood investigations including rheumatoid factors, complete blood counts, uric acid levels, and C-reactive protein which were all within normal limits. Antinuclear antibody (ANA) immunological tests showed negative results. In addition, the patient was examined by a rheumatologist, neurologist, and a psychiatrist; and she underwent a personality test, which emphasized a state of mixed anxiodepressive symptoms. The differential diagnosis excluded systemic diseases of connective tissue (systemic sclerosis, mixed connectivity, polymyositis, and systemic lupus erythematosus); therefore, the most probable diagnosis was primary chronic tension-type headache with fibromyalgia with moderate depressive episode. The diagnosis of fibromyalgia was made according to the American College of Rheumatology (ACR) criteria and calculating widespread pain index and symptom severity (SS) scale of by Wolfe et al. [1],[2] The patient had pain caused by digital palpation of the neck, shoulder, chest, hip, knee, and elbow regions. The patient is being treated with antidepressants, anxiolytics, and antiepileptic gamma-aminobutyric acid fascilitating or (GABA)ergic drugs with an improvement of the symptoms along with physiotherapy and progressive muscle relaxation exercises.

Fibromyalgia is a complex condition that is characterized by chronic widespread pain and multiple other symptoms, and may coexist and/or overlap with other conditions that may involve central sensitivity, including chronic fatigue syndrome; also psychiatric disorder like depressive disorders, anxiety disorders. The pathophysiology of fibromyalgia remains uncertain, but is believed to be partly the result of central systems affecting afferent processing as well as impaired endogenous pain-inhibitory systems. [3] In our case, the daily tension-type headache certainly was possibly a symptom of fibromyalgic syndrome, the symptomatology often overlaps between the two, the origin of pain is regarded as 'central'; indeed, the same neurotransmitters (serotonin, glutamate, P substance, and calcitonin gene-related peptide (CGRP)) and receptors that are involved. [4],[5] If the pathogenetic hypothesis is the same, and thus the pharmacological treatment is common. Antidepressants (selective serotonin reuptake inhibitors (SSRI)), antiepileptics, and anxiolytics are used in both cases, and likewise are useful muscle relaxation techniques. In our opinion, fibromyalgia should be always considered, especially in women as a differential diagnosis especially in cases of chronic headache.

The mutual comorbidity between headache and fibromyalgia reserves much attention, in view of common pathophysiological basis [6] and problems connected with therapeutical approach. [7] Moreover, patients with fibromyalgia also frequently suffer from emotional distress and/or psychiatric disorders. [8],[9],[10],[11] There are many common features between the pathologies of psychiatric disorders like depression, fibromyalgia, and chronic tension type headache. Are they coexisting disorders or simply a casual co-occurrence needs to be thoroughly explored which would pave way for better management of the patients who suffer from these disorders individually or comorbidly.

 
  References Top

1.Wolfe F, Smythe HA, Yunus MB, Bennett RM, Bombardier C, Goldenberg DL, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Report of the multicentre criteria committee. Arthritis Rheum 1990;33:160-72.  Back to cited text no. 1
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2.Wolfe F. New American College of Rheumatology criteria for fibromyalgia: A twenty-year journey. Arthritis Care Res (Hoboken) 2010;62:583-4.  Back to cited text no. 2
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3.Smith HS, Barkin RL. Fibromyalgia syndrome: A discussion of the syndrome and pharmacotherapy. Am J Ther 2010;17:418-39.  Back to cited text no. 3
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4.Leistad RB, Nilsen KB, Stovner LJ, Westgaard RH, Rø M, Sand T. Similarities in stress physiology among patients with chronic pain and headache disorders: Evidence for a common pathophysiological mechanism? J Headache Pain 2008;9:165-75.   Back to cited text no. 4
    
5.Bradley LA. Pathophysiology of fibromyalgia. Am J Med 2009;122:S22-30.  Back to cited text no. 5
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6.de Tommaso M, Federici A, Santostasi R, Calabrese R, Vecchio E, Lapadula G, et al. Laser evoked potentials habituation in fibromyalgia. J Pain 2011;12:116-24.   Back to cited text no. 6
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7.de Tommaso M, Sardaro M, Vecchio E, Serpino C, Stasi M, Ranieri M. Central sensitisation phenomena in primary headaches: Overview of a preventive therapeutic approach. CNS Neurol Disord Drug Targets 2008;7:524-35.  Back to cited text no. 7
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8.de Tommaso M, Federici A, Serpino C, Vecchio E, Franco G, Sardaro M, et al. Clinical features of headache patients with fibromyalgia comorbidity. J Headache Pain 2011;12:629-38.  Back to cited text no. 8
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9.Stifano G, Colantuono S, Carusi V, La Marra F, Marra A, Granata M. A case of tension-type headache in fibromyalgia. J Headache Pain 2010;11:367-68.   Back to cited text no. 9
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10.Epstein SA, Kay G, Clauw D, Heaton R, Klein D, Krupp L, et al. Psychiatric disorders in patients with fibromyalgia. A multicenter investigation. Psychosomatics 1999;40:57-63.  Back to cited text no. 10
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11.Thieme K, Turk DC, Flor H. Comorbid depression and anxiety in fibromyalgia syndrome: Relationship to somatic and psychosocial variables. Psychosom Med 2004;66:837-44.  Back to cited text no. 11
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