WHAT IS PSYCHOGENIC HEADACHE ? Russell C. Packard, M.D. The opinions expressed herein are solely those of the author and do not necessarily represent the views of the Department of the Navy or the Bureau of Medicine and Surgery. Submitted for publication-6/2/75 Revision accepted-10/8/75 SYNOPSIS The purpose of this study was to explore the question of "What is psychogenic headache?" The literature was reviewed and a survey was conducted among physicians at the National Naval Medical Center in Bethesda, Maryland, asking them to define psychogenic headache. There were 105 responses, representing a wide consensus of opinion about definition. From the literature and data from this survey it is concluded that the term "psychogenic headache" is not precise nor diagnostic. A definition is proposed based on criteria of the American Medical Association Ad Hoc Commitee on Classification of Headache. EMOTIONAL FACTORS play some part in all perception and reaction to pain or discomfort. Psychogenic headache is an interesting challenge in evaluation and therapy. References to this common manifestation of distress appeared in the 1880's. Breuer and Freud1 recognized the entity when they noticed that patients headache often disappeared after an improved emotional equilibrium had been reached. Psychogenic headache was discussed in the 1930's. Psychoanalytic case reports2 dealt with mechanisms of migraine headache. A classic3 and frequently quoted paper dealt also with the etiology of eight cases of migraine. The developing field of psychosomatic medicine included studies of headache4,5 but the attention given to headache was surprisingly modest compared to other psychosomatic syndromes. Wolff and his coworker6 investigated psychological factors in headache. He 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 .... the vast majority of discomforts and pains of the head .... are accompaniments of resentments and dissatisfactions." Kolb7, in Friedman and Merritt's Headache; Diagnosis and Treatment, defined psychogenic headache as, "symbolic distress relative to head function rather than distress originating in psychophysiologic mechanisms." He considered migraine as a "neurovascular head manifestation of a widespread bodily response which occurs episodically in individuals predisposed by their particular personality development and their genetic and constitutional endowments." A number of general reviews and symposia dealt with the subject of psychogenic headache, but left it either undefined, or defined differently in each case.8-12 One generally noted definition is summarized13 in the Handbook of Clinical Neurology as "a broad general term used in referring to those types of headache in which psychological factors appear to play a significant etiological role." How do physicians tend to use such a term? "Oh, the headache is psychogenic," what does this mean? The purpose of this study is to explore these questions further and to propose a definition which might be more meaningful. METHOD A survey was made among physicians at the National Naval Medical Center, Bethesda, Maryland. They were asked to define psychogenic headache and to give their specialty. Responses were categorized according to the major theme of each answer. Sixty-seven percent were obvious with answers such as: "I think it means tension headache." Twenty-six percent were more involved, but one
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-Categ. 5 1 Vascular or Migraine 0 Cannot Categorize 3 Total 105 * 6 of 7 characterized by a combination of the first three categories listed.
main theme could still be found, such as: "It could mean tension or muscle contraction headache but I think it means a headache with no organic basis." In this case "no organic basis" was recorded. Five percent of answers were detailed and multiple and had to be listed as such. Two percent could not be categorized: one because I could not read it, and one defined by a psychiatrists as "the type that is sent to us." The other was defined as "a headache from the heels up." RESULTS There were 105 responses which represented 41% of the staff. Table I summarizes the findings of the survey. It was not always clear what secondary to, or precipitated by, stress meant. Specific stresses mentioned varied from "a severe crisis", to "normal stress of everyday living", but most often the headache was said simply to be precipitated by, or following stress, Eighty-seven percent of those who answered the survey either use the term psychogenic headache or had thoughts about it. Ten of 12 physicians who said that they did not use the term, guessed what it might mean, seven were of the opinion that it was probably a tension headache and 3 felt that it had no physical or organic basis. Responses given according to specialty are given in Table 2. All specialties were represented except Obstetrics and Gynecology. Over half of the physicians were internists, surgeons, and psychiatrists. Muscle contraction or tension headache was
Specialty Int. Med. Surgery Psychiatry Radiology Neurology ENT Eye Peds. Derm. Neurogurg. Phys. Med. Path. Anesthesia GP
* MC-T
MC-T 8 7 5 5 3 2 2 2 0 0 0 0 0 0 34
TABLE 2 Responses by Specialty Don't Use/ NOB** 2°Stress Don't Know 8 4 5 5 2 4 3 1 0 2 2 0 2 2 0 2 2 2 2 1 0 0 1 1 0 3 1 0 1 2 1 2 0 0 2 0 0 1 0 0 0 0 25 18 15
= muscle contraction-tension
**
NOB = no organic basis
Other 3 2 2 I 2 0 1 1 0 0 0 0 0 1 13
Total Responses 28 20 11 10 9 8 6 5 4 3 3 2 1 1 105
15. 16. 17. 18.
TABLE 3 Location and Type of Pain Circumferential, frontal to occipital Continuous, dull; post. occipital Localized frontally and bitemporal Holocephalic Dull frontal; not greater than 24 hours Ill-defined, poorly localized pain Primarily frontal Primarily occipital Pain in the front half of the head Occipital muscle contraction pain Occipital Diffuse-usually a squeezing pressure pain around the head Localized in temporal and cervical muscles Pain about the neck, occiput and temples, often throbbing with the pulse. Associated with muscle tension and spasm in the neck and back Frontal or occipital throbbing Band-like tightening A midline tense ache in the head
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
TABLE 4 Treatment of Psychogenic Headache A tranquilizer works better than aspirin May respond to mild analgesics Valium better than aspirin Responds to aspirin or placebo Relieved by sleep, relaxation training, and muscle relaxants Requires removal from the stressful situation Relieved by non-narcotic analgesics Partially relieved by mild analgesics May respond better to fiorinal and sleep, than aspirin Self-limited, relieved by sleep Is without significant response to medications. Usually easily treated Never completely goes away Occasionally may require psychotherapy
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
the leading definition with "no organic basis" second. Eighteen responders in this survey gave a brief description of the pain (Table 3). There was no unanimity about whether the headache should be occipital or frontal, continuous or throbbing. Fourteen responses mentioned treatment (Table 4). Thoughts about treatment varied widely. One mentioned that the patient may require psychotherapy. DISCUSSION No conclusions can be reached about location, type of pain or responses to treatment of psychogenic headache, but different and conflicting ideas about this entity have been expressed. From a review of the literature and the results of this survey, it is apparent that the term "psychogenic headache" is not precise nor diagnostic. Headache is a symptom which occurs in different contexts. Attempts at classification and definition are therefore difficult. A generally accepted classification is that proposed by the American Medical Association Ad Hoc Committee on Classification of Headache14 because it is based on objective and measurable factors of pain mechanisms. The first five categories of this classification represent the major common clinical disorders. Psychogenic headache is not one of these categories, but this doesn't prevent the term from being used. Moreover, only 13% of physicians said they did not use the term, or did not know what it meant. In this classification, psychogenic headache is referred to twice, once related to muscle contraction headache, and once to headache of delusional, conversion, or hypochondriacal states. Emotional factors appear to be the most frequent precipitants of headache. A headache may represent a symptom of tissue damage, evidence of a psychophysiological disorder, a symbolic communication of distress, or a combination of these expressions. Frequently, headache is a psychoneurotic expression, or a psychophysiologic resultant of tension or anxiety. It is often difficult to separate these different types. I propose that "psychogenic headache" not be used to categorize patients. The terms, "Muscle contraction headache", or "headache of delusional, conversion, or hypochondriacal states" are more specific. However, since psychogenic headache is used by many physicians, I propose that the term be restricted to Category 5 of the Ad Hoc Committee's
classification of headache which includes headaches without a peripheral pain inducing mechanism. REFERENCES 1.
Bruer, J. And Freud, S.: Case Histories in the Complete Psychological Works of Sigmund Freud, Studies on Hysteria, Vol. 2, J. Strachey, Editor, London, The Hogarth Press, pp 23 and 302, 1955.
2.
Guthiel, E.: Analysis of a Case of Migraine. Psychoanal. Rev. 21:272-276, 1934.
3.
Fromm-Reichmann, F.: Contribution to the Psychogenesis of Migraine. Psychoanal. Rev. 24:26-29, 1937.
4.
Dunbar, F.: Illness Syndromes in Emotions and Bodily Changes, 4th Edition. New York, Columbia University Press, pp. 122-124, 1954.
5.
Weiss, F. and English, O.S.: Chapter Three Psychosomatic Medicine. Philadelphia, W.B. Saunders Co., pp 83-84, 1957.
6.
Wolff, H.G., ed.: Cranial Pain Sensitive Structures in Headache and Other Head Pain, 2nd Edition. New York, Oxford University Press, pp. 59-97, 1963.
7.
Kolb, L.C.: Psychiatric and Psychogenic Factors in Headache in Friedman, A.P. and Merritt, H.H.: Headache Diagnosis and Treatment. Philadelphia, F.A. Davis Co., pp 259-289, 1959.
8.
Draper, P.A.: Chronic Headache. J. Nerv. Mental Dis. 37:26, 1938.
9.
Rosenbaum, M.: Symposium; Psychogenic Headache. Cincinnati J Med. 28:7-16, 1947.
10.
Karpman, B., ed.: Psychogenic Aspects of Headache, Symposium. J. Clin. Psychopathol. 10:3-20, 1949.
11.
Alexander, F.: Emotional Factors in Cardiovascular Distrubances in Psychosomatic Medicine. New York, W.W. Norton and Co., pp 155-157, 1950.
12.
Kolb, L.C.: Psychiatric Aspects of the Treatment of Headache. Neurology 13:34, 1963.
13.
Boag, T.J.: Psychogenic Headache in Vinken, P.J. and Bruyn, G.W., (eds.): Handbook of Clinical Neurology, Vol. 5. Amsterdam, North Holland Publishing Co., p. 248, 1968.
14.
Ad Hoc Committee on Classification of Headache; special report. J Amer. Med Assoc. 179:717-718, 1962. Reprint requests to: Russell C. Packard, LCDR MC USN Department of Neurology National Naval Medical Center Bethesda, Maryland 20014
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-Categ. 5 1 Vascular or Migraine 0 Cannot Categorize 3 Total 105 * 6 of 7 characterized by a combination of the first three categories listed.
main theme could still be found, such as: "It could mean tension or muscle contraction headache but I think it means a headache with no organic basis." In this case "no organic basis" was recorded. Five percent of answers were detailed and multiple and had to be listed as such. Two percent could not be categorized: one because I could not read it, and one defined by a psychiatrists as "the type that is sent to us." The other was defined as "a headache from the heels up." RESULTS There were 105 responses which represented 41% of the staff. Table I summarizes the findings of the survey. It was not always clear what secondary to, or precipitated by, stress meant. Specific stresses mentioned varied from "a severe crisis", to "normal stress of everyday living", but most often the headache was said simply to be precipitated by, or following stress, Eighty-seven percent of those who answered the survey either use the term psychogenic headache or had thoughts about it. Ten of 12 physicians who said that they did not use the term, guessed what it might mean, seven were of the opinion that it was probably a tension headache and 3 felt that it had no physical or organic basis. Responses given according to specialty are given in Table 2. All specialties were represented except Obstetrics and Gynecology. Over half of the physicians were internists, surgeons, and psychiatrists. Muscle contraction or tension headache was
Specialty Int. Med. Surgery Psychiatry Radiology Neurology ENT Eye Peds. Derm. Neurogurg. Phys. Med. Path. Anesthesia GP
* MC-T
MC-T 8 7 5 5 3 2 2 2 0 0 0 0 0 0 34
TABLE 2 Responses by Specialty Don't Use/ NOB** 2°Stress Don't Know 8 4 5 5 2 4 3 1 0 2 2 0 2 2 0 2 2 2 2 1 0 0 1 1 0 3 1 0 1 2 1 2 0 0 2 0 0 1 0 0 0 0 25 18 15
= muscle contraction-tension
**
NOB = no organic basis
Other 3 2 2 I 2 0 1 1 0 0 0 0 0 1 13
Total Responses 28 20 11 10 9 8 6 5 4 3 3 2 1 1 105
15. 16. 17. 18.
TABLE 3 Location and Type of Pain Circumferential, frontal to occipital Continuous, dull; post. occipital Localized frontally and bitemporal Holocephalic Dull frontal; not greater than 24 hours Ill-defined, poorly localized pain Primarily frontal Primarily occipital Pain in the front half of the head Occipital muscle contraction pain Occipital Diffuse-usually a squeezing pressure pain around the head Localized in temporal and cervical muscles Pain about the neck, occiput and temples, often throbbing with the pulse. Associated with muscle tension and spasm in the neck and back Frontal or occipital throbbing Band-like tightening A midline tense ache in the head
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
TABLE 4 Treatment of Psychogenic Headache A tranquilizer works better than aspirin May respond to mild analgesics Valium better than aspirin Responds to aspirin or placebo Relieved by sleep, relaxation training, and muscle relaxants Requires removal from the stressful situation Relieved by non-narcotic analgesics Partially relieved by mild analgesics May respond better to fiorinal and sleep, than aspirin Self-limited, relieved by sleep Is without significant response to medications. Usually easily treated Never completely goes away Occasionally may require psychotherapy
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14.
the leading definition with "no organic basis" second. Eighteen responders in this survey gave a brief description of the pain (Table 3). There was no unanimity about whether the headache should be occipital or frontal, continuous or throbbing. Fourteen responses mentioned treatment (Table 4). Thoughts about treatment varied widely. One mentioned that the patient may require psychotherapy. DISCUSSION No conclusions can be reached about location, type of pain or responses to treatment of psychogenic headache, but different and conflicting ideas about this entity have been expressed. From a review of the literature and the results of this survey, it is apparent that the term "psychogenic headache" is not precise nor diagnostic. Headache is a symptom which occurs in different contexts. Attempts at classification and definition are therefore difficult. A generally accepted classification is that proposed by the American Medical Association Ad Hoc Committee on Classification of Headache14 because it is based on objective and measurable factors of pain mechanisms. The first five categories of this classification represent the major common clinical disorders. Psychogenic headache is not one of these categories, but this doesn't prevent the term from being used. Moreover, only 13% of physicians said they did not use the term, or did not know what it meant. In this classification, psychogenic headache is referred to twice, once related to muscle contraction headache, and once to headache of delusional, conversion, or hypochondriacal states. Emotional factors appear to be the most frequent precipitants of headache. A headache may represent a symptom of tissue damage, evidence of a psychophysiological disorder, a symbolic communication of distress, or a combination of these expressions. Frequently, headache is a psychoneurotic expression, or a psychophysiologic resultant of tension or anxiety. It is often difficult to separate these different types. I propose that "psychogenic headache" not be used to categorize patients. The terms, "Muscle contraction headache", or "headache of delusional, conversion, or hypochondriacal states" are more specific. However, since psychogenic headache is used by many physicians, I propose that the term be restricted to Category 5 of the Ad Hoc Committee's
classification of headache which includes headaches without a peripheral pain inducing mechanism. REFERENCES 1.
Bruer, J. And Freud, S.: Case Histories in the Complete Psychological Works of Sigmund Freud, Studies on Hysteria, Vol. 2, J. Strachey, Editor, London, The Hogarth Press, pp 23 and 302, 1955.
2.
Guthiel, E.: Analysis of a Case of Migraine. Psychoanal. Rev. 21:272-276, 1934.
3.
Fromm-Reichmann, F.: Contribution to the Psychogenesis of Migraine. Psychoanal. Rev. 24:26-29, 1937.
4.
Dunbar, F.: Illness Syndromes in Emotions and Bodily Changes, 4th Edition. New York, Columbia University Press, pp. 122-124, 1954.
5.
Weiss, F. and English, O.S.: Chapter Three Psychosomatic Medicine. Philadelphia, W.B. Saunders Co., pp 83-84, 1957.
6.
Wolff, H.G., ed.: Cranial Pain Sensitive Structures in Headache and Other Head Pain, 2nd Edition. New York, Oxford University Press, pp. 59-97, 1963.
7.
Kolb, L.C.: Psychiatric and Psychogenic Factors in Headache in Friedman, A.P. and Merritt, H.H.: Headache Diagnosis and Treatment. Philadelphia, F.A. Davis Co., pp 259-289, 1959.
8.
Draper, P.A.: Chronic Headache. J. Nerv. Mental Dis. 37:26, 1938.
9.
Rosenbaum, M.: Symposium; Psychogenic Headache. Cincinnati J Med. 28:7-16, 1947.
10.
Karpman, B., ed.: Psychogenic Aspects of Headache, Symposium. J. Clin. Psychopathol. 10:3-20, 1949.
11.
Alexander, F.: Emotional Factors in Cardiovascular Distrubances in Psychosomatic Medicine. New York, W.W. Norton and Co., pp 155-157, 1950.
12.
Kolb, L.C.: Psychiatric Aspects of the Treatment of Headache. Neurology 13:34, 1963.
13.
Boag, T.J.: Psychogenic Headache in Vinken, P.J. and Bruyn, G.W., (eds.): Handbook of Clinical Neurology, Vol. 5. Amsterdam, North Holland Publishing Co., p. 248, 1968.
14.
Ad Hoc Committee on Classification of Headache; special report. J Amer. Med Assoc. 179:717-718, 1962. Reprint requests to: Russell C. Packard, LCDR MC USN Department of Neurology National Naval Medical Center Bethesda, Maryland 20014
