Psychiatric Aspects of Headache Russell C. Packard, M.D. Naval Aerospace Medical Institute, Pensacola, Florida. Reprint requests to: Russell C. Packard, M.D., Neurology & Psychiatry Service, Naval Aerospace Medical Institute, Pensacola, Florida 32508. In the evaluation of the headache patient, we must deal not only with the symptom of headache but also with the patient. Physicians have long been aware that emotional factors play some part in the perception and reaction to pain, but we must constantly remind ourselves that pain, like disease, is not an abstraction with an existence outside a person; a person must feel it. The complaint is the balance between cause, sensation and reaction. The ancient Greeks and Romans were aware of this balance, and recognized that emotional factors can trigger headaches, particularly migraine. In the 1880s Breuer and Freud1 noticed that patients' complaints of headache often disappeared after an improved emotional equilibrium had been reached. Harold Wolff2 investigated psychiatric factors in headache and wrote: "Since the human animal prides himself on 'using his head', it is perhaps not without meaning that his head should be the source of so much discomfort." In that the head is commonly regarded as the portion of the body containing the organ controlling consciousness, memory, talent, intellecual activity, cognition and judgment, we begin to understand how the patient may use the headache complaint as a means of expressing anxiety. To the layman, the terms "head" and "brain" are often synonymous.3 Unfortunately, headache is a complex syndrome that may represent tissue damage, evidence of a psychophysiological disorder, a symbolic communication of distress, or a combination of these expressions. Frequently, a headache is a psychoneurotic expression, or a psychophysiologic resultant of tension or anxiety. It is often difficult to separate these different types, or determine to what extent emotional factors are involved. This difficulty leads us at once into the problems we face with the ambiguous and unsatisfactory terminology used in this field. Terms such as "psychogenic", "nervous", and "tension" headache have been used in different senses by different authors. For example, a number of general reviews and symposia dealing with the subject of psychogenic headache have left it either undefined or defined differently in each case.4-6 In 1976, I conducted a survey among physicians at the National Naval Medical Center, Bethesda, Maryland, asking them to define "psychogenic headache" as they tended to use the term. There were 105 responses. Table 1 summarizes the findings of the survey.7 Responses varied considerably with "tension headache" being the leading definition and "no organic basis", second. It seemed apparent from the literature and from this survey that the term "psychogenic headache" is neither precise nor diagnostic. As a result of this study, I recommended that "psychogenic headache" not be used to categorize patients unless the term is restricted to Category 5 of the Ad Hoc Committee's classification Table 1 Definitions of Psychogenic Headache Main Response Number Tension headache 23 No organic basis 19 Secondary to stress 18 Don't use term 12 Muscle contraction 7 Multiple responses* 7 Psychophysiological 4 Chronic 3 No physical or lab findings 3 Don't know 3 Conversion reaction 1 Malingering 1 Ad Hoc Committee-Category 5 1 Vascular or migraine 0 Cannot categorize 3 Total 105 *6
of 7 characterized by a combination of the first three categories listed.
of headache,8 which includes only those headaches having no peripheral pain-inducing mechanisms, such as conversion headache. I still recommend adherence to this terminology. For the purposes of this paper, I will approach the psychiatric aspects of headache by examining three main types of cases that can be identified with some certainty in the literature and from my own studies. The material dealing with them may be grouped accordingly as: 1. Common headaches, demonstrably occurring in relationship to personal stress. 2. Migraine, in which psychodynamic and personality factors have been described. 3. Cases of conversion headache. Common Headaches. Headaches demonstrably associated with emotional stress or tension are probably the most common types seen in medical practice. A major difficulty in discussing this group is that clinical reports frequently do not specify the end-mechanisms involved in the particular cases described. In general, these headaches may be regarded as mediated by local physiological changes that accompany a repressed affect. Some of these belong to the muscle contraction group; in others, the local mechanisms may be vascular or combined. Although the actual mechanism of a tension-induced headache is unknown, there is relatively good evidence that such headaches are related to psychological disturbances. Frequently, the fundamental psychic factors are unconscious, although most patients are aware of their anxiety. The headache may be the response of an inadequate personality to ordinary stress, or of an adequate personality to extraordinary stress. The key to the diagnosis of these common headaches is the usually clear correlation with environmental stress and anxiety. Migraine. Personality structure and life situations have been more intensively studied in migraine than in other forms of headache, probably because migraine is a fairly well defined syndrome in comparison to tension or conversion headache. As in other so-called "psychosomatic diseases" in which an attempt has been made to establish a characteristic personality, a bewildering array of "personality profiles" has been described among the victims of migraine. In the 1930s, from detailed studies of personality and psychodynamics, the concept was developed that special personality characteristics were associated with migraine.9,10 These views were adopted by many and were propagated by the late Harold Wolff,11 who noticed the presence of rigid, ambitious, perfectionist personality types among migraine patients in whom headache would result from a variety of stresses. The observations of Fromm-Reichman,12 Selinsky,13 and others indicated that hostile impulses were basic to the neurotic conflicts in patients with migraine, and that these individuals rechanneled their hostilities in ambitious striving for success. If these aggressive energies were not handled successfully, attacks could erupt in a setting of unconscious hostile feelings associated with sustained resentment, anxiety, frustration, and energy depletion. There is evidence, however, that the relationship of suppressed anger to migraine is not entirely specific, and that, on occasion, other conflicts may precipitate the migraine attack. Friedman and Brenner14 reported in 1950 that while conflicts over hostility are frequently present in cases of migraine, this is not inevitably so. In 1958, Friedman15 claimed that no one personality type could describe all migraine patients, and in fact, the personality manifestations in migraine patients were extremely variable, and embraced a variety of emotional factors, most of which are unconscious. These include hostility, identification with a family figure, a wish to remain in a position of dependency, or a means to gain love, affection, or attention. He found little evidence of specificity of the precipitating psychodynamic factors, and concluded that not all patients with migraine are compulsive, perfectionistic or rigid. Nevertheless, these emotional and personality factors in migraine are important to determine when taking the patient's history because they may be helpful in treatment. For example, a migraineur who gets headaches only on weekends because he "loses his structure of the week," often can be helped by simply having him plan some weekend activities in advance, so he doesn't wake up Saturday morning with a headache to fill his "unplanned" day. Conversion headache. The bulk of the literature dealing with head pain as a conversion symptom consists largely of case reports describing the particular symbolism involved in individual patients.16-18 Conversion headache has generally been defined as a headache in which the prevailing disorder is a conversion reaction and a peripheral pain mechanism is nonexistent; but it is still open to question whether underlying local physiological changes are present in this disorder.19 Most of the cases described in the literature strongly suggest a central process with little in the way of significant local change. However, Boag20 feels that it is almost always possible, with close observation, to pick up some suggestive evidence for a local focus around which the symbolic tension has become elaborated. Within the limitations of a clinical situation, one is rarely in a position to obtain convincing evidence one way or the other with regard to local changes. It is possible for pain that began as a result of a local process to be prolonged (as a hysterical symptom) long after the local lesion has healed. This may explain some cases of persistent headache after head trauma (with or without litigation proceedings). From a review of the cases described in the literature, and from several cases I have reported
previously,21 one of the most striking features observed in the diagnosis of conversion headache is the delay in diagnosis. In many cases there is an initial feeling by the physician that emotional factors are playing a role in the headaches, but it is not until after several sessions and tests that the diagnosis becomes clear. One of the reasons for this delay is that a conversion headache does not stand out in any remarkable way from many other types of headache. Most headache patients have normal neurologic exams, laboratory studies, and emotional factors, which often play a large part in pathogenesis. Moreover, one seldom finds major abnormalities in the mental status of patients with a conversion reaction. Another problem in diagnosis is that the patient will often deny any disturbing emotional relationships or events in his life. This denial is what the conversion reaction is all about. Anxiety, instead of being consciously experienced, is converted into functional symptoms which usually symbolize an underlying mental conflict. This most likely explains why we don't know what is wrong with the patient initially, because he doesn't really know either, except that he has a headache. And if the symptom is good enough to fool him, it is usually adequate to fool his physician, too. The conversion mechanism, by allaying a deeper anxiety, may give way to a calm indifference in the patient's expression of his pain. This affectual indifference to the headache is perhaps the most frequent and suggestive finding in a conversion headache. Denial on the part of the patient of any emotional difficulty also occurs frequently with other headache patients, but it should not discourage the physician from a careful evaluation of the patient's life situation preceding and/or accompanying the onset of the headache. The coincidence of an acute emotional state and the appearance of headache are suggestive, especially if the connection between the psychological event and the symptom is unrecognized by the patient. For example, a man who presents with a history of daily headaches that started at the time his wife delivered their first child, deserves further evaluation into his feelings about that situation, even though he sees no apparent connection between his headache and the event. A relative or close friend may clarify many confusing areas in this instance, whereas further direct questioning of the patient may not be of benefit. The patient must be allowed to tell his own story at his own rate. Another helpful sign in diagnosis is a bizarre or unusual description of the symptoms that do not resemble the usual headache syndromes, such as, "It feels like an ax dropping on my head." A key mechanism in the development of a conversion headache may be the patient's identification with the symptoms of a person with whom he has a close relationship. This identification is commonly with a person who has recently died.22-23 Headaches have also developed following the suicide of someone close to the patient who had shot himself in the head.4 It is well for the doctor to ask himself what purpose the symptoms play in the life of the patient. Sometimes a leading question about how the patient would live his life if he were not having headaches opens up areas for further exploration. One should consider whether the patient is emotionally immature. Although today the diagnosis of conversion reaction is not thought synonymous with "hysterical personality," it seems that many sufferers have such a personality makeup.24 It may also occur in other settings, however, such as obsessive-compulsive neurosis or depression. Psychological testing may often help to confirm the clinical findings. TREATMENT The physician who undertakes the treatment of headaches of emotional origin should allow an unusual amount of time and an extra measure of patience. A thorough examination is essential in all cases to rule out the "real problems" that may present in a bizarre fashion, and it may in itself give clues to the diagnosis. As a rule, patients must be convinced that the cause is not an organic ailment, because usually they are convinced that it definitely is organic. It must always be kept in mind that the laity still look upon neurosis as shameful, while organic ills bear no stigma. In the treatment of the chronic headache patient, or the patient refractory to any treatment, a psychiatric evaluation or psychotherapy should be part of the structured plan of management, but unfortunately this aspect of therapy is often neglected. For these patients, a supportive doctor-patient relationship is the key to treatment. The physician should limit himself to supportive therapy, guidance, counseling, and situational insight unless he is well trained in psychiatry. If the patient requires in-depth or long-term therapy, it should be done by the psychiatrist. In many cases, assurance that the headache itself is not the result of serious organic disease may be the most satisfactory solution to the problem. It is clear that there are many patients in whom a headache is a relatively nondisabling symptom, and who are either unwilling or unable to contemplate the necessary changes in their life pattern necessary for relief of their symptoms; for them, formal psychotherapy is not a useful approach. However, symptomatic management and drug treatment will be all the more effective if the physician guides himself by paying due attention to the personality of the patient and the life situation in which headaches tend to occur. For those patients in whom headache is severe, recurrent, disabling and resistent to pharmacologic treatment, psychotherapy is indicated. In well-motivated patients, this may be quite helpful. In the less motivated, it is important to remember that the greatest obstacle for the therapist to overcome will be
the relative positive gain that the patient receives from his symptoms. The chronic headache patient generally "needs" his symptoms for some reason, whether they provide a relief of stress, or an escape mechanism for avoiding unpleasant realities. In the case of the conversion reaction, the effort of the psychotherapist must be to modify the communicative process so that the patient can speak directly of his underlying stress. REFERENCES 1.
Breuer J, Freud S: Case Histories in the Complete Psychological Works of Sigmund Freud, Studies on Hysteria, Vol. 2, J. Strachey (ed.), London, The Hogarth Press, pp 23, 302, 1955.
2.
Wolff HG (ed:) Cranial pain sensitive structure, in Headache and Other Head Pain, 2nd ed., New York, Oxford University Press, pp 59-97, 1963.
3.
Kolb LC: Psychiatric and psychogenic factors in headache, in Friedman AP, Merritt HH (eds.): Headache, Diagnosis and Treatment, Philadelphia, F.A. Davis Co., pp 259-289, 1959.
4.
Rosenbaum M: Symposium: psychogenic headache. Cincinnati J Med 28:7-16, 1947.
5.
Warpman B: Psychogenic aspects of headache, symposium. J Clin Psychopathol 10:3-20, 1949.
6.
Kolb LC: Psychiatric aspects of the treatment of headache. Neurology 13:34, 1963.
7.
Packard RC: What is psychogenic headache? Headache 16:20-23, 1976.
8.
Ad Hoc Committee on Classification of Headache; special report. JAMA 179:717-718, 1962.
9.
Touraine GA, Draper G: The migrainous patient; a constitutional study. J Nerv Ment Dis 80:1-23, 1934.
10.
Knopf O: Preliminary report on personality studies in thirty migraine patients. J Nerv Ment Dis 82:270-285, 1935.
11.
Wolff HG: Personality features and reactions of subjects with migraine. Arch Neurol Psychiat 37:895-921, 1937.
12.
Fromm-Reichmann F: Contribution to the psychogenesis of migraine. Psychoanal Rev 24:26-29, 1937.
13.
Selinsky H: Psychologic study of the migrainous syndrome. Bull NY Acad Med 15:757-763, 1939.
14.
Friedman AP, Brenner C: Psychological mechanisms in chronic headache. Ass Res Nerv Dis Proc 29:605-608, 1950.
15.
Friedman AP: The mechanism and treatment of migraine and tension headache. Mississippi V Mad J 80:141-146, 1958.
16.
Rangell L: Psychiatric aspects of pain. Psychosomatic Med 15:22-37, 1953.
17.
Forrer GR: Hallucinated headache. Psychosomatics 3:120-128, 1962.
18.
Aring CD: Emotion-induced headache. Postgrad Mad 56:191-195, 1974.
19.
Alexander F: Emotional Factors in Cardiovascular Disturbances in Psychosomatic Medicine, New York, W.W. Norton, pp 155-157, 1950.
20.
Boag TF: Psychogenic headache, in Vinken PJ, Bruyn GW (eds.): Handbook of Clinical Neurology, Vol. 5. Amsterdam, North Holland Publishing Co. pp 247-256, 1968.
21.
Packard RC: Conversion headache. Presented at the Annual Meeting, American Association for the Study of Headache, Dallas, Texas. June 26, 1976.
22.
Brenner C, Friedman AP, Cartar S: Psychosom Med 11:53-56, 1949.
23.
Friedman AM, Kaplan HI: Comprehensive Textbook of Psychiatry. Baltimore, Williams & Wilkins Co., p 882, 1967. p 882, 1967.
24.
Kolb LC: Modern Clinical Psychiatry, 8th ed. Philadelphia, W.B. Saunders Co., p 413, 1973.
DISCUSSION Lee Kudrow, M.D., Encino, California: Thank you, Dr. Packard - it's not easy to talk intelligently, as you have, about conversion cephalgia, an unknown entity. We have approximately 200 patients with this disorder; and have helped six. The majority of our patients with conversion cephalgia have had the disorder for many years, unlike Dr. Packard's younger population, where pain is only of a few months' duration. The diagnostic characteristics of conversion are: essentially equal distribution between males and females; daily, severe, constant, unremitting headaches; and social and occupational incapacitation. There's usually a peculiar relationship between the spouses, that is, the spouse is often too supportive constantly doling out the medication, making all the appointments, and doing most other things for the patient, who is virtually an invalid. Recently, during our first group therapy session consisting of patients with conversion cephalgia, a very interesting finding came out. We learned that of the ten patients who participated, each had grown up with a sick relative; a parent, an aunt, or a grandparent. Also, each patient had a history of prolonged sickness throughout childhood. Leonard Lovshin, M.D., Cleveland, Ohio: The fact that you have helped only about six patients out of 200, Dr. Kudrow, makes me feel that, yes, we're talking about the same headache, all right. Jack J. Pinsky, M.D., Duarte, California: I think a crucial factor here, when you talk about chronicity and various types of headaches, is that part of the difficulty lies in the descriptive terms. Definition of the word "acute" means to the patient and to the physician that the end is in sight. The words "chronic" and "intractable" always mean that there is no end in sight - for either the patient or the physician. This is very important, because the real problem that must be addressed is how to get the patients into psychological treatment. (Whether they're treated by a clinical psychologist or by a psychiatrist is beside the point, even though I'm related to the medical profession.) A competent treater must work in true teamwork with the physician who's also involved in the medical care of the patient, where the schism usually occurs. The fact is that the physician who refers the patient for psychiatric or psychologic treatment actually holds the key to whether or not that patient is going to stay in therapy. There's a big difference between a patient who is sent for treatment and a patient who chooses to go for treatment. John R. Graham, M.D., Boston, Massachusetts: There's a line in Dr. Packard's excellent presentation that is a good one to remember: that if the symptom is good enough to fool the patient, it is very likely to fool the doctor, too. I think it is important
for doctors to remember the first half of that remark, because even though we discover later that this is a conversion symptom, we're apt to have a feeling of hostility or antipathy toward the patient, for having fooled the doctor and himself as well. If we can look upon such a patient as being unaware of the mechanisms that have brought about his illness, we can perhaps have a more genial and kindly approach to dealing with his problem. The second point is the importance of dealing with these patients during their teens or early years and not have them go on for 30 years with their headache. That's the time when they can be treated, if recognized and handled properly. The attitude of the doctor also is affected by what kind of a goal he is setting for himself. I would be inclined to disagree, Dr. Kudrow, that your patients have not been helped. I suspect that you have given them the best help that can be given to such patients. You supported them, carried them along, interpreted their symptoms, and you have set a goal of support which may keep them going, and without which they might get into much more serious trouble. So the doctor has to set his sights on limited goals and recognize that by living with the problem of these adult patients, he may be doing a lot to help. Seymour Diamond, M.D., Chicago, illinois: I agree with Dr. Graham completely. Many patients come in with their charts, and I see no improvement, and I wonder why they come back again. The answer is because somebody is fulfilling a need for them to see somebody. It's very important that anybody treating pain of any kind see the patient at frequent intervals. You just can't write a consultation and then send them away, because you're not giving them service when you do. Gleb G. Bourianoff, M.D., Houston, Texas: Discussion of psychogenic headache always includes the statement that organic pathology must be ruled out and the patient reassured that nothing is physically wrong. However, it is sometimes very difficult, no matter how many tests you do, to reassure the patient that nothing is physically wrong. Also, in doing the organic workup, speed is helpful. The patient shouldn't be put through a long-drawn-out evaluation but rather should be evaluated promptly. Do whatever tests you're going to do, and present the findings - it shortens the time of anxiety.
of 7 characterized by a combination of the first three categories listed.
of headache,8 which includes only those headaches having no peripheral pain-inducing mechanisms, such as conversion headache. I still recommend adherence to this terminology. For the purposes of this paper, I will approach the psychiatric aspects of headache by examining three main types of cases that can be identified with some certainty in the literature and from my own studies. The material dealing with them may be grouped accordingly as: 1. Common headaches, demonstrably occurring in relationship to personal stress. 2. Migraine, in which psychodynamic and personality factors have been described. 3. Cases of conversion headache. Common Headaches. Headaches demonstrably associated with emotional stress or tension are probably the most common types seen in medical practice. A major difficulty in discussing this group is that clinical reports frequently do not specify the end-mechanisms involved in the particular cases described. In general, these headaches may be regarded as mediated by local physiological changes that accompany a repressed affect. Some of these belong to the muscle contraction group; in others, the local mechanisms may be vascular or combined. Although the actual mechanism of a tension-induced headache is unknown, there is relatively good evidence that such headaches are related to psychological disturbances. Frequently, the fundamental psychic factors are unconscious, although most patients are aware of their anxiety. The headache may be the response of an inadequate personality to ordinary stress, or of an adequate personality to extraordinary stress. The key to the diagnosis of these common headaches is the usually clear correlation with environmental stress and anxiety. Migraine. Personality structure and life situations have been more intensively studied in migraine than in other forms of headache, probably because migraine is a fairly well defined syndrome in comparison to tension or conversion headache. As in other so-called "psychosomatic diseases" in which an attempt has been made to establish a characteristic personality, a bewildering array of "personality profiles" has been described among the victims of migraine. In the 1930s, from detailed studies of personality and psychodynamics, the concept was developed that special personality characteristics were associated with migraine.9,10 These views were adopted by many and were propagated by the late Harold Wolff,11 who noticed the presence of rigid, ambitious, perfectionist personality types among migraine patients in whom headache would result from a variety of stresses. The observations of Fromm-Reichman,12 Selinsky,13 and others indicated that hostile impulses were basic to the neurotic conflicts in patients with migraine, and that these individuals rechanneled their hostilities in ambitious striving for success. If these aggressive energies were not handled successfully, attacks could erupt in a setting of unconscious hostile feelings associated with sustained resentment, anxiety, frustration, and energy depletion. There is evidence, however, that the relationship of suppressed anger to migraine is not entirely specific, and that, on occasion, other conflicts may precipitate the migraine attack. Friedman and Brenner14 reported in 1950 that while conflicts over hostility are frequently present in cases of migraine, this is not inevitably so. In 1958, Friedman15 claimed that no one personality type could describe all migraine patients, and in fact, the personality manifestations in migraine patients were extremely variable, and embraced a variety of emotional factors, most of which are unconscious. These include hostility, identification with a family figure, a wish to remain in a position of dependency, or a means to gain love, affection, or attention. He found little evidence of specificity of the precipitating psychodynamic factors, and concluded that not all patients with migraine are compulsive, perfectionistic or rigid. Nevertheless, these emotional and personality factors in migraine are important to determine when taking the patient's history because they may be helpful in treatment. For example, a migraineur who gets headaches only on weekends because he "loses his structure of the week," often can be helped by simply having him plan some weekend activities in advance, so he doesn't wake up Saturday morning with a headache to fill his "unplanned" day. Conversion headache. The bulk of the literature dealing with head pain as a conversion symptom consists largely of case reports describing the particular symbolism involved in individual patients.16-18 Conversion headache has generally been defined as a headache in which the prevailing disorder is a conversion reaction and a peripheral pain mechanism is nonexistent; but it is still open to question whether underlying local physiological changes are present in this disorder.19 Most of the cases described in the literature strongly suggest a central process with little in the way of significant local change. However, Boag20 feels that it is almost always possible, with close observation, to pick up some suggestive evidence for a local focus around which the symbolic tension has become elaborated. Within the limitations of a clinical situation, one is rarely in a position to obtain convincing evidence one way or the other with regard to local changes. It is possible for pain that began as a result of a local process to be prolonged (as a hysterical symptom) long after the local lesion has healed. This may explain some cases of persistent headache after head trauma (with or without litigation proceedings). From a review of the cases described in the literature, and from several cases I have reported
previously,21 one of the most striking features observed in the diagnosis of conversion headache is the delay in diagnosis. In many cases there is an initial feeling by the physician that emotional factors are playing a role in the headaches, but it is not until after several sessions and tests that the diagnosis becomes clear. One of the reasons for this delay is that a conversion headache does not stand out in any remarkable way from many other types of headache. Most headache patients have normal neurologic exams, laboratory studies, and emotional factors, which often play a large part in pathogenesis. Moreover, one seldom finds major abnormalities in the mental status of patients with a conversion reaction. Another problem in diagnosis is that the patient will often deny any disturbing emotional relationships or events in his life. This denial is what the conversion reaction is all about. Anxiety, instead of being consciously experienced, is converted into functional symptoms which usually symbolize an underlying mental conflict. This most likely explains why we don't know what is wrong with the patient initially, because he doesn't really know either, except that he has a headache. And if the symptom is good enough to fool him, it is usually adequate to fool his physician, too. The conversion mechanism, by allaying a deeper anxiety, may give way to a calm indifference in the patient's expression of his pain. This affectual indifference to the headache is perhaps the most frequent and suggestive finding in a conversion headache. Denial on the part of the patient of any emotional difficulty also occurs frequently with other headache patients, but it should not discourage the physician from a careful evaluation of the patient's life situation preceding and/or accompanying the onset of the headache. The coincidence of an acute emotional state and the appearance of headache are suggestive, especially if the connection between the psychological event and the symptom is unrecognized by the patient. For example, a man who presents with a history of daily headaches that started at the time his wife delivered their first child, deserves further evaluation into his feelings about that situation, even though he sees no apparent connection between his headache and the event. A relative or close friend may clarify many confusing areas in this instance, whereas further direct questioning of the patient may not be of benefit. The patient must be allowed to tell his own story at his own rate. Another helpful sign in diagnosis is a bizarre or unusual description of the symptoms that do not resemble the usual headache syndromes, such as, "It feels like an ax dropping on my head." A key mechanism in the development of a conversion headache may be the patient's identification with the symptoms of a person with whom he has a close relationship. This identification is commonly with a person who has recently died.22-23 Headaches have also developed following the suicide of someone close to the patient who had shot himself in the head.4 It is well for the doctor to ask himself what purpose the symptoms play in the life of the patient. Sometimes a leading question about how the patient would live his life if he were not having headaches opens up areas for further exploration. One should consider whether the patient is emotionally immature. Although today the diagnosis of conversion reaction is not thought synonymous with "hysterical personality," it seems that many sufferers have such a personality makeup.24 It may also occur in other settings, however, such as obsessive-compulsive neurosis or depression. Psychological testing may often help to confirm the clinical findings. TREATMENT The physician who undertakes the treatment of headaches of emotional origin should allow an unusual amount of time and an extra measure of patience. A thorough examination is essential in all cases to rule out the "real problems" that may present in a bizarre fashion, and it may in itself give clues to the diagnosis. As a rule, patients must be convinced that the cause is not an organic ailment, because usually they are convinced that it definitely is organic. It must always be kept in mind that the laity still look upon neurosis as shameful, while organic ills bear no stigma. In the treatment of the chronic headache patient, or the patient refractory to any treatment, a psychiatric evaluation or psychotherapy should be part of the structured plan of management, but unfortunately this aspect of therapy is often neglected. For these patients, a supportive doctor-patient relationship is the key to treatment. The physician should limit himself to supportive therapy, guidance, counseling, and situational insight unless he is well trained in psychiatry. If the patient requires in-depth or long-term therapy, it should be done by the psychiatrist. In many cases, assurance that the headache itself is not the result of serious organic disease may be the most satisfactory solution to the problem. It is clear that there are many patients in whom a headache is a relatively nondisabling symptom, and who are either unwilling or unable to contemplate the necessary changes in their life pattern necessary for relief of their symptoms; for them, formal psychotherapy is not a useful approach. However, symptomatic management and drug treatment will be all the more effective if the physician guides himself by paying due attention to the personality of the patient and the life situation in which headaches tend to occur. For those patients in whom headache is severe, recurrent, disabling and resistent to pharmacologic treatment, psychotherapy is indicated. In well-motivated patients, this may be quite helpful. In the less motivated, it is important to remember that the greatest obstacle for the therapist to overcome will be
the relative positive gain that the patient receives from his symptoms. The chronic headache patient generally "needs" his symptoms for some reason, whether they provide a relief of stress, or an escape mechanism for avoiding unpleasant realities. In the case of the conversion reaction, the effort of the psychotherapist must be to modify the communicative process so that the patient can speak directly of his underlying stress. REFERENCES 1.
Breuer J, Freud S: Case Histories in the Complete Psychological Works of Sigmund Freud, Studies on Hysteria, Vol. 2, J. Strachey (ed.), London, The Hogarth Press, pp 23, 302, 1955.
2.
Wolff HG (ed:) Cranial pain sensitive structure, in Headache and Other Head Pain, 2nd ed., New York, Oxford University Press, pp 59-97, 1963.
3.
Kolb LC: Psychiatric and psychogenic factors in headache, in Friedman AP, Merritt HH (eds.): Headache, Diagnosis and Treatment, Philadelphia, F.A. Davis Co., pp 259-289, 1959.
4.
Rosenbaum M: Symposium: psychogenic headache. Cincinnati J Med 28:7-16, 1947.
5.
Warpman B: Psychogenic aspects of headache, symposium. J Clin Psychopathol 10:3-20, 1949.
6.
Kolb LC: Psychiatric aspects of the treatment of headache. Neurology 13:34, 1963.
7.
Packard RC: What is psychogenic headache? Headache 16:20-23, 1976.
8.
Ad Hoc Committee on Classification of Headache; special report. JAMA 179:717-718, 1962.
9.
Touraine GA, Draper G: The migrainous patient; a constitutional study. J Nerv Ment Dis 80:1-23, 1934.
10.
Knopf O: Preliminary report on personality studies in thirty migraine patients. J Nerv Ment Dis 82:270-285, 1935.
11.
Wolff HG: Personality features and reactions of subjects with migraine. Arch Neurol Psychiat 37:895-921, 1937.
12.
Fromm-Reichmann F: Contribution to the psychogenesis of migraine. Psychoanal Rev 24:26-29, 1937.
13.
Selinsky H: Psychologic study of the migrainous syndrome. Bull NY Acad Med 15:757-763, 1939.
14.
Friedman AP, Brenner C: Psychological mechanisms in chronic headache. Ass Res Nerv Dis Proc 29:605-608, 1950.
15.
Friedman AP: The mechanism and treatment of migraine and tension headache. Mississippi V Mad J 80:141-146, 1958.
16.
Rangell L: Psychiatric aspects of pain. Psychosomatic Med 15:22-37, 1953.
17.
Forrer GR: Hallucinated headache. Psychosomatics 3:120-128, 1962.
18.
Aring CD: Emotion-induced headache. Postgrad Mad 56:191-195, 1974.
19.
Alexander F: Emotional Factors in Cardiovascular Disturbances in Psychosomatic Medicine, New York, W.W. Norton, pp 155-157, 1950.
20.
Boag TF: Psychogenic headache, in Vinken PJ, Bruyn GW (eds.): Handbook of Clinical Neurology, Vol. 5. Amsterdam, North Holland Publishing Co. pp 247-256, 1968.
21.
Packard RC: Conversion headache. Presented at the Annual Meeting, American Association for the Study of Headache, Dallas, Texas. June 26, 1976.
22.
Brenner C, Friedman AP, Cartar S: Psychosom Med 11:53-56, 1949.
23.
Friedman AM, Kaplan HI: Comprehensive Textbook of Psychiatry. Baltimore, Williams & Wilkins Co., p 882, 1967. p 882, 1967.
24.
Kolb LC: Modern Clinical Psychiatry, 8th ed. Philadelphia, W.B. Saunders Co., p 413, 1973.
DISCUSSION Lee Kudrow, M.D., Encino, California: Thank you, Dr. Packard - it's not easy to talk intelligently, as you have, about conversion cephalgia, an unknown entity. We have approximately 200 patients with this disorder; and have helped six. The majority of our patients with conversion cephalgia have had the disorder for many years, unlike Dr. Packard's younger population, where pain is only of a few months' duration. The diagnostic characteristics of conversion are: essentially equal distribution between males and females; daily, severe, constant, unremitting headaches; and social and occupational incapacitation. There's usually a peculiar relationship between the spouses, that is, the spouse is often too supportive constantly doling out the medication, making all the appointments, and doing most other things for the patient, who is virtually an invalid. Recently, during our first group therapy session consisting of patients with conversion cephalgia, a very interesting finding came out. We learned that of the ten patients who participated, each had grown up with a sick relative; a parent, an aunt, or a grandparent. Also, each patient had a history of prolonged sickness throughout childhood. Leonard Lovshin, M.D., Cleveland, Ohio: The fact that you have helped only about six patients out of 200, Dr. Kudrow, makes me feel that, yes, we're talking about the same headache, all right. Jack J. Pinsky, M.D., Duarte, California: I think a crucial factor here, when you talk about chronicity and various types of headaches, is that part of the difficulty lies in the descriptive terms. Definition of the word "acute" means to the patient and to the physician that the end is in sight. The words "chronic" and "intractable" always mean that there is no end in sight - for either the patient or the physician. This is very important, because the real problem that must be addressed is how to get the patients into psychological treatment. (Whether they're treated by a clinical psychologist or by a psychiatrist is beside the point, even though I'm related to the medical profession.) A competent treater must work in true teamwork with the physician who's also involved in the medical care of the patient, where the schism usually occurs. The fact is that the physician who refers the patient for psychiatric or psychologic treatment actually holds the key to whether or not that patient is going to stay in therapy. There's a big difference between a patient who is sent for treatment and a patient who chooses to go for treatment. John R. Graham, M.D., Boston, Massachusetts: There's a line in Dr. Packard's excellent presentation that is a good one to remember: that if the symptom is good enough to fool the patient, it is very likely to fool the doctor, too. I think it is important
for doctors to remember the first half of that remark, because even though we discover later that this is a conversion symptom, we're apt to have a feeling of hostility or antipathy toward the patient, for having fooled the doctor and himself as well. If we can look upon such a patient as being unaware of the mechanisms that have brought about his illness, we can perhaps have a more genial and kindly approach to dealing with his problem. The second point is the importance of dealing with these patients during their teens or early years and not have them go on for 30 years with their headache. That's the time when they can be treated, if recognized and handled properly. The attitude of the doctor also is affected by what kind of a goal he is setting for himself. I would be inclined to disagree, Dr. Kudrow, that your patients have not been helped. I suspect that you have given them the best help that can be given to such patients. You supported them, carried them along, interpreted their symptoms, and you have set a goal of support which may keep them going, and without which they might get into much more serious trouble. So the doctor has to set his sights on limited goals and recognize that by living with the problem of these adult patients, he may be doing a lot to help. Seymour Diamond, M.D., Chicago, illinois: I agree with Dr. Graham completely. Many patients come in with their charts, and I see no improvement, and I wonder why they come back again. The answer is because somebody is fulfilling a need for them to see somebody. It's very important that anybody treating pain of any kind see the patient at frequent intervals. You just can't write a consultation and then send them away, because you're not giving them service when you do. Gleb G. Bourianoff, M.D., Houston, Texas: Discussion of psychogenic headache always includes the statement that organic pathology must be ruled out and the patient reassured that nothing is physically wrong. However, it is sometimes very difficult, no matter how many tests you do, to reassure the patient that nothing is physically wrong. Also, in doing the organic workup, speed is helpful. The patient shouldn't be put through a long-drawn-out evaluation but rather should be evaluated promptly. Do whatever tests you're going to do, and present the findings - it shortens the time of anxiety.
