This is a highly interesting study from a methodological perspective, as its design, sample size, and data analysis grant it a high level of excellence. I commend the research team’s initiative in addressing suicidal behavior among individuals diagnosed with various types of headaches characterized by pain intensity and complexity (migraine, tension-type headache, post-traumatic headache, and trigeminal autonomic cephalalgia). The data obtained are clear and robust.

The experience of chronic pain entails significant suffering in people’s lives and constitutes a classic risk factor for suicidal behavior. It is essential to contribute to its understanding and raise awareness among medical professionals who, despite being experts in neurological aspects, may be unaware of the scope or characteristics of this psychological phenomenon. Suicidal behavior is linked to experiencing deep distress and despair, particularly when pain is perceived as irresolvable and inescapable. In their conclusions, the authors call for early diagnosis and more effective treatments, which would undoubtedly be highly beneficial for individuals with such diagnoses.

As a constructive counterpoint, and without detracting from the methodological and epidemiological quality of the study, it could be noted that certain terminology in the article reflects the absence of experts in suicidal behavior among the study’s authors and the references used. Perhaps it would be necessary to adopt more comprehensive and less reductionist or diagnosis-centered models. The language used in certain terms deviates from the new paradigms of psychological knowledge. This is the case with "completed suicide" or the term "risk of" in the title, which may lead to the establishment of simplistic and direct relationships when this is not the case. Suicidal behavior is behavior, and as such, it must be addressed accordingly. Behavior is functional and operant, not merely the direct result of an association with a diagnosis—though diagnosis may be an important factor, it is not causal. Everything is interconnected, especially when discussing decisions as complex and existential as ending one’s own life. The meaning of life, reasons for living, and the personal experience of difficulties are fundamental aspects to consider when examining death by suicide, beyond its association with a diagnosis, even in cases where the correlation is particularly strong. Scientific literature has already highlighted the need to move away from the "risk" paradigm in suicide, as it can be prevented but not predicted. Pain has a significant psychological component, and in my opinion, psychological approaches should be proposed for its management—especially in an article on suicidal behavior, where psychological therapy is also the treatment of choice.

In any case, I congratulate the authors for their sensitivity, for choosing this topic, and for their excellent work, which undoubtedly reinforces the role that pain plays in suicidal thoughts, particularly during episodes of moderate to severe pain, as highlighted in the article. Further research is essential to improve the quality of life for individuals with chronic pain.

Suicide is a major social and public health issue that causes the premature loss of thousands of lives each year and brings suffering to an even greater number of survivors. Certain groups, such as individuals with schizophrenia, depression, or substance use disorders involving alcohol and other drugs, are at a higher risk of developing suicidal thoughts and behaviors.

Like most health problems, suicide does not stem from a single cause nor is it solely attributable to individual factors. Age, gender, unwanted loneliness, unemployment, and easy access to means of suicide are some of the known determinants of suicidal behavior. There is also evidence indicating that individuals with certain chronic illnesses face a higher risk of dying by suicide.

A study recently published in JAMA Neurology investigated the association between different types of headaches and suicidal behavior. To do so, the authors conducted a case-control study using a large population-based registry to compare the incidence of fatal and non-fatal suicides among 119,486 individuals diagnosed with a headache disorder and 597,430 matched controls with similar characteristics in terms of age, sex, and other sociodemographic variables. Over the 15 years following diagnosis, a higher incidence of both fatal and non-fatal suicides was observed among individuals with headaches. The results also suggest that the incidence of suicidal behavior—both fatal and non-fatal—was higher in cases of more severe headaches, such as trigeminal autonomic cephalalgias or post-traumatic headaches. However, no differences were observed in the strength of the association between headaches and suicide based on age, social conditions, or sex.

The results of this study are particularly robust due to the large sample size and demonstrate a higher risk of suicide among those suffering from a chronic condition like headaches, which negatively impacts quality of life. In line with these findings, and as the study concludes, it is reasonable to consider that early and adequate treatment of headaches and other chronic illnesses could help reduce suicide mortality. Additionally, it would be advisable to incorporate suicide risk assessment and behavioral support into the follow-up care of individuals suffering from these disorders.