**1. Introduction**

The International Association for the Study of Pain defines pain as: "An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage". This allows considering it as a singular psychophysical perception due to factors that may vary both interpersonally and individually in the same person over time and according to their physical, psychological, and social circumstances [1].

Tension-type headache, as defined by the latest revision of the International Headache Society (IHS), is a pathological disorder that fulfills the criteria of an essential pain without an organic basis or underlying structural damage [2]. It is the most common type of headache and is one of the most prevalent diseases globally, being the second in terms of global disease burden [3].

**Citation:** Romero-Godoy, R.; Romero-Godoy, S.R.; Romero-Acebal, M.; Gutiérrez-Bedmar, M. Psychiatric Comorbidity and Emotional Dysregulation in Chronic Tension-Type Headache: A Case-Control Study. *J. Clin. Med.* **2022**, *11*, 5090. https://doi.org/ 10.3390/jcm11175090

Academic Editors: Markus W. Hollmann, Casandra I. Montoro Aguilar and Carmen María Galvez Sánchez

Received: 18 July 2022 Accepted: 25 August 2022 Published: 30 August 2022

**Publisher's Note:** MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

**Copyright:** © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/).

According IHS criteria, Chronic tension-type headache (CTTH) occurs with a frequency of more than 15 days a month or more than 180 days a year and persisting for more than 3 months [2]. It has been estimated that CTTH affects 2–3% of the general population [4], and it causes a significant functional limitation as well as a major impact on the quality of life [5–9].

CTTH is commonly associated with comorbidity of anxiety and depression [10–15]. Anxiety and depression are common neuropsychiatric disorders in our society, as well as in chronic pain pathologies [16], and their diagnostic clinical criteria are defined according to the Diagnostic and Statistical Manual of Mental Disorders (DSM V) [17]. Their prevalence in the Spanish population, according to the National Institute of Statistics (INE), are estimated to be 5.3% for depression and 5.8% for anxiety [18]. They are generally associated with emotional expression disorders and, at the same time, involve a disturbance in the processing and regulation of negative thinking material [19]; a reduction of negative thought material inhibition with less use of cognitive reappraisal and greater use of expressive suppression [7,20], as well as a greater faculty for rumination and difficulty in removing non-relevant negative thoughts from memory [21–23], have both been observed in subjects with high levels of depression. The rumination of negative thoughts generates a state of permanent tension that can contribute to the genesis of tension-type headaches. Thus, high levels of repetitive negative thinking have been associated not only with an emotional regulation deficit but also with the presence of tension headaches [23]. This situation may stay and become chronic, setting up a functional disturbance known as catastrophizing pain, that may persist even following the disappearance of the triggering factors [24].

The objective of our study was to evaluate the association of anxiety, depression, and positive and negative traits of affectivity and emotional management with patients with CTTH without a previous diagnosis of psychopathological disorder or consumption of psychotropic drugs or abuse of analgesics in order to consider a baseline situation without these influences, understand their conditions, and establish the most appropriate therapies for them.

#### **2. Materials and Methods**

#### *2.1. Study Design and Participants Selection*

The design of the present study was a case-control study. Forty subjects with a diagnosis of CTTH and another forty healthy controls (HC) with no headache were included. Cases were recruited from the Neurology Department of the Virgen de la Victoria University Hospital in Malaga (Spain). The CTTH diagnosis was made by a neurologist skilled in headaches, following International Classification of Headache Disorders criteria. Psychometric and socio-demographic data were collected by a clinical neuropsychologist.

Following a convenience-sampling method, controls were recruited among relatives or friends of patients who attended other departments of the same hospital for reasons other than neurological diseases. Controls were evaluated by a clinical interview with the clinical neurologist and neuropsychologist to avoid inter-observer error. Those who had any other illness or chronic disease, including any type of headache, were excluded.

The inclusion criteria for subjects with CTTH and HC were as follows: age between 20–69 years, with normal cognitive capacity for understanding and performing the neuropsychological tests as well as being informed and helped by the neuropsychologist.

Participants were excluded if they met any of the following criteria: having more than one type of headache (such as chronic tension-type headache and migraine), another chronic pain disease, chronic consumption of psychopharmacological and/or analgesic medication or taking any type of them at least 72 h prior to data collection, and clinical diagnosis or recognition of any neuropsychological disorder.

Cases in this study were incident cases since the Neurology Department of the Virgen de la Victoria University Hospital is a reference center for these pathologies, and all cases included were for the first time evaluated and diagnosed with CTTH.

The Ethics Committee of the University of Malaga approved this study (code number: S1033; date: 14 June 2010).
