Headache psychiatry: A structured narrative review and integrative framework.

Abstract

Headache disorders involve complex interactions between neurobiological, psychiatric, behavioral, and social factors. Despite robust evidence of psychiatric comorbidity and psychosocial influences, these dimensions remain inadequately integrated into clinical practice and conceptual models. This review synthesizes evidence linking psychiatric factors with headache disorders and proposes Headache Psychiatry as a unified, integrative framework, operationalized through the Psychocephalology model. We conducted a structured narrative review across PubMed, PsycINFO, and Web of Science (1990-2025), examining psychiatric comorbidity, emotion regulation, stress physiology, pain neuroscience, and psychosocial determinants in headache disorders. The Psychocephalology framework synthesizes findings across five interconnected domains: neurobiological mechanisms, pain-processing dynamics, emotion regulation, stress-behavioral factors, and social-contextual influences. Strong bidirectional associations exist between headache and depression, anxiety, trauma exposure, and sleep disturbance. Emotion dysregulation, catastrophizing, and maladaptive coping predict chronification and disability. Neural pain-emotion circuits show heightened activity in chronic migraine. Stress physiology, HPA axis dysregulation, and behavioral patterns are associated with chronic headache. Women experience disproportionate burden due to hormonal fluctuations, perinatal transitions, and role-related stress. Headache Psychiatry, operationalized through the Psychocephalology framework, offers a biopsychosocial model that bridges fragmented disciplines. Clinical implementation requires routine psychiatric screening, multidisciplinary teams, integrated behavioral-pharmacological treatments, and specialized attention to perinatal mental health. This approach enables personalized, context-sensitive care and may prevent transition from episodic to chronic headache.