Date of Award


Degree Name

Doctor of Physiotherapy Research

Schools and Centres


First Supervisor

Professor Benedict Wand


Headache is the most common pain problem reported by people with schizophrenia, with 12 month prevalence rates of around 50%. Despite this little research has been conducted into the characteristics, impact and management of headaches in this population. There is evidence to support the efficacy of physiotherapy treatment of cervicogenic headache and tension type headache and determining the prevalence, impact and current management of these types of headache was of particular interest.

A pilot study was first undertaken to identify and refine an appropriate headache questionnaire, develop an algorithm to use for classification of headache and test the repeatability and reliability of using the algorithm to classify headache types. A previously validated questionnaire was identified and slightly modified for the mental health population. A two part algorithm, which utilized information from the questionnaire, was designed to classify headaches into cervicogenic (CGH), migraine (MH) or tension type (TTH) headache against the International Classification of Headache Disorder criteria. Participants whose headache characteristics did not enable them to be classified into one of these three categories were coded as Other Headache (OH) type. A convenience sample of 12 chronic headache suffers not currently receiving care for their headache completed the questionnaire on two occasions, separated by 6-weeks. On each occasion two independent reviewers used the algorithm to characterise the headache type. The algorithm was shown to have high inter rater reliability (weighted-κ=.827) and moderate test re-test reliability (weighted-κ=.636).

A cross-sectional observational cohort study of people with schizophrenia or schizoaffective disorder was then undertaken to determine the prevalence, characteristics, impact and management of headache in this population. Using the validated headache questionnaire, data was collected about headache prevalence and characteristics from 100 consecutive people diagnosed with schizophrenia or schizoaffective disorder. Headaches were classified using the algorithm by two independent reviewers and any disagreement settled by consensus. Clinical information, demographic data and information on current management of headache was collected and questions from the SF-36 questionnaire were included to assess quality of life.

Males made up 66% of the sample cohort. The mean age of participants was 38.8 years and on average participants had been diagnosed with schizophrenia or schizoaffective disorder for 14.6 years. The most common comorbid physical illness was diabetes. All participants were taking antipsychotic medication, with 66/100 people taking some form of medication that listed headache as a common or very common side effect.

Twelve month prevalence of headache (57%) was slightly higher than in the general population (46%). The two reviewers demonstrated excellent agreement on headache classification (weighted-κ=.85). Prevalence of CGH (5%) and MH (18%) were comparable to the general population and TTH had a much lower prevalence (16%) than that found in the general population (42%). OH was the most prevalent (19%).

When considering the whole population we found no evidence of a relationship between mental health clinical characteristics and the presence of headache. The presence of any headache was not related to inpatient/outpatient status (OR=2.07, 95% CI [0.92-4.68]), length of time from diagnosis of mental illness (OR=0.99, 95% CI [0.95-1.03])) or taking medication with a side effect of headache (OR=0.94, 95% CI [0.40-2.19]). Similarly, there was no relationship between clinical status and the individual specific headache types. These data suggest that the specific headache types are independent of the mental health problem. We did find an association between OH type and medication use (OR=0.32, 95% CI [0.11-0.90]) and inpatient/outpatient status (OR=5.76, 95% CI [1.74-19.07]), suggesting those whose headache is not classifiable using International Headache Society (IHS) criteria might be suffering from headache which is secondary to their mental health problems.

A similar analysis was undertaken utilising only data from the headache population. These data suggest that there is a relationship between age and CGH (OR=1.14, 95% CI [1.01–1.29]), medication use and MH (OR=6.14, 95% CI [1.24-30.44]) and inpatient/outpatient status and TTH (OR=0.28, 95% CI [0.08-0.95]) when considering only those people who suffer from headache. The quality of life of headache sufferers in this cohort was lower than seen in healthy populations. Importantly, the frequency of headache was shown to be negatively correlated with Social Functioning (ρ=-.44, p<.001), Bodily Pain (r=-.44, p<.001) and Role Physical (ρ=-.32, p=.01), suggesting that headache may contribute to the reduced quality of life experienced by people with mental health problems. It was evident that very few people were receiving appropriate treatment for their headache. No participant with MH had been prescribed migraine specific medication and physiotherapy was not included in the management of headache of any participant with CHG or TTH. It is recommended that better education is provided for both patients and mental health workers about headache and its management as well as the role of physiotherapy in managing the physical health and mental wellbeing of people accessing mental health services.

Files over 3MB may be slow to open. For best results, right-click and select "save as..."