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Headache associated with psychiatric disorders: Classification and etiology
A. DIXON WEATHERHEAD, M.D.
Headache associated with psychiatric disorders: Classification and etiology ABSTRACT: The term "psychogenic headache" should be restricted to headaches that reflect an underlying psychiatric disorder. Four types of such headaches may be recognized: muscle contraction headaches, conversion headaches, psychotic head pain, and vascular headaches. Although migraine does not completely fit the definition of psychogenic headache, it may have a psychogenic basis and it may coexist with muscle contraction headache in some patients. The fact that headache often has a psychological cause or component has become so well recognized that the term "psychogenic headache" is now in danger of becoming a psychiatric wastebasket. The term has come to be used to describe any type of headache for which no organic cause can be found. "Functional headache" is a synonym, and other terms used include "psychological headache," "psychophysiologic headache," and "psychosomatic headache." Sometimes patients and physicians alike speak of "tension headaches," "nervous headaches," and "sick headaches," presumably all
psychogenic in origin. The term "psychogenic headache" is also used by some physicians to describe migraine and vascular types of headache in which alterations in blood flow result from acute or chronic psychological stress. Psychogenic headache may also refer to the headache of conversion reactions, depression, schizophrenia, or hypochondriasis. Headache following trauma, with no clinical evidence of actual tissue damage, may also be called functional or psychogenic or may be referred to as a posttraumatic headache. It is obvious that when one term can indicate so many different
Dr. Weatherhead is a staffpsychiatrist at the Cleveland Clinic. Reprint requests to him there, The Clinic Center, 9500 Euclid Avenue, Cleveland, OB 44106. &JZ
causes, its meaning becomes diluted. The purpose of this paper is to clarify the picture by classifying psychogenic headaches in the context of the psychiatric disorders in which they most often appear. We will also consider the psychological factors that may be significant in the etiology of some other types of headache. What is a psychogenic headache? A useful definition of psychogenic headache is head pain that arises in the absence of a peripheral pain-inducing mechanism and without demonstrable organic cause. Just as
important to the definition is the qualification that the headache constitutes a major symptom of an underlying psychiatric disorder.
While it is true to say that headaches, like pain elsewhere in the body, always have an affective component, the above definition rules out headaches that occur in psychiatrically healthy individuals after an emotionally stressful experience. True psychogenic headache, then, reflects an underlying psychiatric disorder. PSYCHOSOMATICS
The definition also excludes muscle-contraction types of headache, which result from overuse of the posterior cervical and suboccipital muscles, as might occur at the end of a period of prolonged muscle tension. Similarly, this definition also excludes the muscle contraction type of headache that results from local irritation of the neck and scalp muscles, as occurs in cervical arthritis, eye strain, temporomandibular joint disease, or referred dental pain.
What causes psychogenic beadacbe? Any classification of psychogenic headache must take into account not only the various stresses that produce it but the fact that individuals cope with anxiety by utilizing different psychological mechanisms. Some patients resort to conversion of anxiety into a somatic symptom such as headache. In this instance, if the conversion is complete, anxiety is not present clinically. Thus, the headache is not associated with increased neuromuscular tension or muscle contraction. In some depressed patients in whom the usual vegetative and psychological manifestations of depression are not overtly evident, the depression is converted into a somatic symptom: headache. Such headaches are often referred to as "depressive equivalents." Many classifications have been used to help in the diagnosis of headache that is a prominent symptom of an underlying psychiatric disorder. In 1962, the Ad Hoc Committee on the Classification of Headache,· chaired by Arnold P. Friedman, developed a classification that is still used extensively. Essentially, psychogenic headaches were placed in two categories.
The first of these was "Muscle Contraction Headache." It is described as "an ache or sensations of tightness, pressure, or constriction, widely varied in intensity, frequency, and duration, sometimes long-lasting and commonly suboccipital. It is associated with sustained contraction of skeletal muscles in the absence of permanent structural change, usually as part of the individual's reaction during life stress. The ambiguous and unsatisfactory terms 'tension,' 'psychogenic,' and 'nervous' headache
Some psychiotrists consider
lllleonscious conjlict cellte";"g Oil aggressive drives to be the """" clIIISe ofthe VtlScultu clulllges IlCcomJHlllying migrtline. refer largely to this group."· The secOnd category of psychogenic headache described by the Ad Hoc Committee was "Headache of Delusional, Conversion, or Hypochondriacal States." This category included "headaches of illnesses in which the prevailing clinical disorder is a delusional or a conversion reaction and a peripheral pain mechanism is nonexistent. Closely allied are the hypochondriacal reactions in which the peripheral disturbances relevant to headache are minimal. These have also been called 'psychogenic headaches.' '" The Ad Hoc Committee also described "the so-called chronic posttraumatic headache," which could result from any of several mechanisms described in the categories just given.' Subsequent attempts to classify psychogenic headache have been
concerned mostly with muscle contraction headaches. Various types of depression have been thought by some to be the underlying psychiatric disorder in psychogenic headache.2-6 Anxiety and tension states have also been proposed as the basis of such headaches. 7 The source of the anxiety may be the patient's inability to adequately express feelings of resentment and hostility, which are then turned in on the self and appear somatically as a muscle contraction headache or as a vascular type of headache. Some psychiatrists consider unconscious conflict centering on the patient's difficulty in coping with his aggressive drives to be the main cause of the psychophysiologic vascular changes accompanying migraine.8• IO Similarly, environmental factors causing emotional stress may trigger an increase in anxiety with any or all of its somatic manifestations, including headache. The most frequently encountered psychiatric disorders in patients with psychogenic headache are the psychoneuroses.· Neuroses by definition are "suboptimal adaptations to biodynamic stress and conftict,"11 or, more simply, less than ideal ways of dealing with anxiety. Anxiety is the basis of all neuroses. It is an equal partner with depression in the most frequently encountered depressive reactions and it is converted into somatic symptoms in conversion reactions. The major psychogenic headaches that are not of psychoneurotic origin are those associated with psychotic depressive states such as manic-depressive depression and psychotic middle-life depression.t 'In DSM III, these are classified as "Atypical Affective Disorders," "Anxiety Disorders," or "Somatoform DiSOrders." tin DSM III, these are classified under "Affective DiSOrders. "
(continued) OCTOBERI~'VOL21'NOIO
833
Psychogenic headache
From the work of Kashiwagi and associates,6 Cassidy and associates,'2 Diamond and Baltes,3 and Ziegler,13 it is apparent that the incidence of headache in manicdepressive patients is higher than the incidence in control patients with medical illnesses. Kashiwagi and associates6 found that 39 of 100 headache patients they studied had a diagnosis of manic-depressive psychosis. Eleven patients had "secondary depression." Thirty-one had muscle contraction headaches, although only seven of these patients were diagnosed as having anxiety neurosis. In 15 patients a diagnosis of hysteria had been made. Kashiwagi and associates did not find any patients with schizophrenia in the study group, which may underscore the fact that the incidence of headache in schizophrenia is low, a finding that has been noted by Friedman and Frazier.'4 The headache of delusional states, referred to in the Ad Hoc Committee'S classification,' is less of a headache and more of a somatic delusion, i.e., a head pain that has a delusional basis. A
dasslftcadon There is often considerable overlap
lient clinical features of each of these types of headache are given below. Muscle contraction headaches. These are more appropriately called tension headaches so as to emphasize their etiology and to differentiate them from muscle contraction headaches resulting from local irritation. As the name implies, the headaches are associated with increased muscular tension and affect particularly the muscles of the neck, suboccipital region, frontal and temporal regions, scalp, and jaw. The patient most often describes the headache as a pressure sensation or a dull ache that may be continuous. Muscle-contraction types of headache occur in patients of all
l
OCTOBER 1980· VOL 21 • NO 10
A Classification of Psychogenic Headaches Muscle contraction headaches
I
Anxiety causes increased neuromuscular tension, as in Anxiety reactions Reactive (exogenous) depression
Conversion headaches
DeW
not only between the different types of psychogenic headache but also between the psychiatric disorders where headache is a major symptom. For this reason, it is often difficult to be diagnostically precise. However, the Table provides a classification of psychogenic headaches that may help in the differential diagnosis of this disorder.'s The four main types of psychogenic headache are muscle contraction headaches, conversion headaches, psychotic head pain, and vascular headaches. The sa-
ages, and the setting is usually an anxiety reaction or a reactive depression. Indeed, the headache may be accompanied by other clinical manifestations of anxiety and depression, and the patient may be able to relate the headache to external stress or internal conflict. Conversion headaches. These occur in certain persons, usually young women, who are faced with an emotionally stressful situation that they can neither solve immediately nor shelve. The anxiety resulting from this experience is repressed and re-emerges as a somatic symptom that may symbolically represent the precipitating conflict. The headache provides the patient with secondary gains in the form of attention derived from others, sym-
I
Anxiety or depreSSion is somatized, as ConversIon reactions DepressIve equivalents
In
Psychotic head pain As in Manic-depressive depression. where headache accompanies other depressive symptoms Psychotic middle life depression, which is often associated with hypochondriasis . Schizophrenic reactions. where the headache may be delusional in ongin
Vascular headaches
r
Changes in cerebral artery blood flow are precipitated by psychological stress, as in ClaSSIC migraine Migraine equivalents J
839
Psychogenic headache
pathy, and sometimes compensation. If the conversion of the anxiety is complete, the headache may be dramatically described and yet not appear to cause the patient any obvious distress. Indeed, such patients exhibit Janet'sl6 characteristic "la belle indifference." When depression is converted into a somatic symptom such as headache, the symptom may be less dramatically described. The key point is that the headache occurs within an aura of depression, although other manifestations of depression may be hard to pinpoint. Psychotic head pain. This form of headache is usually easy to diagnose, as it occurs in a setting of unipolar depressed manic depression, in persons with psychotic middle-life depression or, rarely, in schizophrenic individuals with somatic delusions referable to the head. The history is important in diagnosis. The patient may have had manic or depressive reactions in the past (bipolar disease), or may give a history of previous psychotic depressions (unipolar disease). The headache is often accompanied by diurnal mood variation, sleep disturbance, and other manifestations of endogenous depression. In psychotic middle-life depression, the patient's age (45 to 60), sex
REFERENCES 1. Ad Hoc Committee on Classification of Headache: Classification of headache. JAMA 171:717-718,1962. 2. Diamond S: Depressive headache. Headache 4:255-258, 1964. 3. Diamond S, Banes BJ: Chronic tension headache-treated with amitriptyline-a doubleblind study. Headache 11:110-116,1971. 4. Dalessio OJ: Some reflections on the etiologic role of depression in head pain. Headache 8:28-31, 1968. 5. Diamond S, Dalessio 0: The Practicing Physician's Approach to Headache, ed 2. Baltimore, Williams & Wilkins, 1978, pp 94-103. 6. Kashiwagi T, McClure IN Jr, Wetzel RD, et al: Headache and psychiatric disorders. Dis
840
(females more often than males), and premorbid personality (obsessive-compulsive type) help to identify the psychogenic origin of the headache. Frequently, the patient also has the clinical findings of agitation and/or hypochondriasis. Hypochondriacal delusions referable to the head or brain may be the most prominent symptoms of an involutional depression. The delusions often have a bizarre and depressive quality. In schizophrenic reactions, headache or head pain is uncommon and may be delusional in origin. Headache may occur transiently in a schizophrenic patient after electroconvulsive therapy, but this head pain has no special identifying characteristics. Vascular headaches. These include all types of migraine headache, such as classical, common, and variant migraine. Such headaches are thought to be psychophysiologic in nature. A psychologic stress ofone type or another in a predisposed individual causes an alteration in cerebral blood flow, which in turn leads to other intracerebral changes, as described by Edmeads,17 and to the development of a migraine or vascular type of headache. It is true that vascular headaches
do in fact have a peripheral paininducing mechanism and do occur in the absence of a clinically manifest underlying psychiatric disorder. Thus, vascular headaches do not strictly fit into the definition of psychogenic headache previously given. These headaches are nevertheless included in this classification for the sake of completeness and because combinations of vascular headache and muscle contraction headache are observed to coexist in some ·patients. Some vascular headaches are precipitated by anxiety and emotional stress, and it is in this setting that the combination of vascular headache and muscle contraction headache is most often observed. Also, the personality of the patient with vascular headaches is frequently of the obsessive-compulsive type, a fact that has led to much speculation and research. Vascular headaches are usually easy to recognize, although atypical types of migraine may present diagnostic problems. In summary, use of this simplified classification of psychogenic headaches can aid in earlier identification of the associated psychiatric disorders. This in tum facilitates more appropriate and effective treatment. 0
Nerv Sys/33:659-663, 1972. 7. Marlin MJ, Rome HP, Swenson WM: Headache 1:184-217,1967. 8. Wolff HG: Personality features and reactions of subjects with migraine. Arch Neurol and Psychiatry 37:895-921, 1937. 9. Fromm·Reichmann F: Contribution to the psychogenesis ot migraine. Psychoanal Rev 24:26-33, 1937. 10. Selinsky H: Psychologic sfudies of the mi· grainous syndrome. Bull NY Acad Med 15:757-763. 1939. 1t. Masserman JH: Principles of Dynamic Psychiatry. Philadelphia, WB Saunders, 1947, p286. 12. Cassidy WL, Flanagan NB, Spellman M, et al: Clinical obServations in manic depressive dis·
ease. A quantitative study of 100 manic depressive patients and 50 medically sick con· trols. JAMA 184:1535-1546,1957. Ziegler OK: Headache syndromes: Problems of definition. Psychosomatics 20:443-447, t979. Friedman AP, Frazier SH: Preliminary obSer· vations of the psychiatric evaluation of treated chronic headache patients. Head· ache 3:378-380, 1972. Weatherhead AD: Psychogenic headache. Headache 20:47-54,1980. Janet P: The Major Symptoms of Hysteria. ed 2. New York, Macmillan, 1920, pp 160-163. Edmeads J: Vascular headaches and the era· nial circulation-another look. Headache 11:127-132,1979.
t3.
t 4.
15. 16. 17.
PSYCHOSOMATICS
Headache associated with psychiatric disorders: Classification and etiology ABSTRACT: The term "psychogenic headache" should be restricted to headaches that reflect an underlying psychiatric disorder. Four types of such headaches may be recognized: muscle contraction headaches, conversion headaches, psychotic head pain, and vascular headaches. Although migraine does not completely fit the definition of psychogenic headache, it may have a psychogenic basis and it may coexist with muscle contraction headache in some patients. The fact that headache often has a psychological cause or component has become so well recognized that the term "psychogenic headache" is now in danger of becoming a psychiatric wastebasket. The term has come to be used to describe any type of headache for which no organic cause can be found. "Functional headache" is a synonym, and other terms used include "psychological headache," "psychophysiologic headache," and "psychosomatic headache." Sometimes patients and physicians alike speak of "tension headaches," "nervous headaches," and "sick headaches," presumably all
psychogenic in origin. The term "psychogenic headache" is also used by some physicians to describe migraine and vascular types of headache in which alterations in blood flow result from acute or chronic psychological stress. Psychogenic headache may also refer to the headache of conversion reactions, depression, schizophrenia, or hypochondriasis. Headache following trauma, with no clinical evidence of actual tissue damage, may also be called functional or psychogenic or may be referred to as a posttraumatic headache. It is obvious that when one term can indicate so many different
Dr. Weatherhead is a staffpsychiatrist at the Cleveland Clinic. Reprint requests to him there, The Clinic Center, 9500 Euclid Avenue, Cleveland, OB 44106. &JZ
causes, its meaning becomes diluted. The purpose of this paper is to clarify the picture by classifying psychogenic headaches in the context of the psychiatric disorders in which they most often appear. We will also consider the psychological factors that may be significant in the etiology of some other types of headache. What is a psychogenic headache? A useful definition of psychogenic headache is head pain that arises in the absence of a peripheral pain-inducing mechanism and without demonstrable organic cause. Just as
important to the definition is the qualification that the headache constitutes a major symptom of an underlying psychiatric disorder.
While it is true to say that headaches, like pain elsewhere in the body, always have an affective component, the above definition rules out headaches that occur in psychiatrically healthy individuals after an emotionally stressful experience. True psychogenic headache, then, reflects an underlying psychiatric disorder. PSYCHOSOMATICS
The definition also excludes muscle-contraction types of headache, which result from overuse of the posterior cervical and suboccipital muscles, as might occur at the end of a period of prolonged muscle tension. Similarly, this definition also excludes the muscle contraction type of headache that results from local irritation of the neck and scalp muscles, as occurs in cervical arthritis, eye strain, temporomandibular joint disease, or referred dental pain.
What causes psychogenic beadacbe? Any classification of psychogenic headache must take into account not only the various stresses that produce it but the fact that individuals cope with anxiety by utilizing different psychological mechanisms. Some patients resort to conversion of anxiety into a somatic symptom such as headache. In this instance, if the conversion is complete, anxiety is not present clinically. Thus, the headache is not associated with increased neuromuscular tension or muscle contraction. In some depressed patients in whom the usual vegetative and psychological manifestations of depression are not overtly evident, the depression is converted into a somatic symptom: headache. Such headaches are often referred to as "depressive equivalents." Many classifications have been used to help in the diagnosis of headache that is a prominent symptom of an underlying psychiatric disorder. In 1962, the Ad Hoc Committee on the Classification of Headache,· chaired by Arnold P. Friedman, developed a classification that is still used extensively. Essentially, psychogenic headaches were placed in two categories.
The first of these was "Muscle Contraction Headache." It is described as "an ache or sensations of tightness, pressure, or constriction, widely varied in intensity, frequency, and duration, sometimes long-lasting and commonly suboccipital. It is associated with sustained contraction of skeletal muscles in the absence of permanent structural change, usually as part of the individual's reaction during life stress. The ambiguous and unsatisfactory terms 'tension,' 'psychogenic,' and 'nervous' headache
Some psychiotrists consider
lllleonscious conjlict cellte";"g Oil aggressive drives to be the """" clIIISe ofthe VtlScultu clulllges IlCcomJHlllying migrtline. refer largely to this group."· The secOnd category of psychogenic headache described by the Ad Hoc Committee was "Headache of Delusional, Conversion, or Hypochondriacal States." This category included "headaches of illnesses in which the prevailing clinical disorder is a delusional or a conversion reaction and a peripheral pain mechanism is nonexistent. Closely allied are the hypochondriacal reactions in which the peripheral disturbances relevant to headache are minimal. These have also been called 'psychogenic headaches.' '" The Ad Hoc Committee also described "the so-called chronic posttraumatic headache," which could result from any of several mechanisms described in the categories just given.' Subsequent attempts to classify psychogenic headache have been
concerned mostly with muscle contraction headaches. Various types of depression have been thought by some to be the underlying psychiatric disorder in psychogenic headache.2-6 Anxiety and tension states have also been proposed as the basis of such headaches. 7 The source of the anxiety may be the patient's inability to adequately express feelings of resentment and hostility, which are then turned in on the self and appear somatically as a muscle contraction headache or as a vascular type of headache. Some psychiatrists consider unconscious conflict centering on the patient's difficulty in coping with his aggressive drives to be the main cause of the psychophysiologic vascular changes accompanying migraine.8• IO Similarly, environmental factors causing emotional stress may trigger an increase in anxiety with any or all of its somatic manifestations, including headache. The most frequently encountered psychiatric disorders in patients with psychogenic headache are the psychoneuroses.· Neuroses by definition are "suboptimal adaptations to biodynamic stress and conftict,"11 or, more simply, less than ideal ways of dealing with anxiety. Anxiety is the basis of all neuroses. It is an equal partner with depression in the most frequently encountered depressive reactions and it is converted into somatic symptoms in conversion reactions. The major psychogenic headaches that are not of psychoneurotic origin are those associated with psychotic depressive states such as manic-depressive depression and psychotic middle-life depression.t 'In DSM III, these are classified as "Atypical Affective Disorders," "Anxiety Disorders," or "Somatoform DiSOrders." tin DSM III, these are classified under "Affective DiSOrders. "
(continued) OCTOBERI~'VOL21'NOIO
833
Psychogenic headache
From the work of Kashiwagi and associates,6 Cassidy and associates,'2 Diamond and Baltes,3 and Ziegler,13 it is apparent that the incidence of headache in manicdepressive patients is higher than the incidence in control patients with medical illnesses. Kashiwagi and associates6 found that 39 of 100 headache patients they studied had a diagnosis of manic-depressive psychosis. Eleven patients had "secondary depression." Thirty-one had muscle contraction headaches, although only seven of these patients were diagnosed as having anxiety neurosis. In 15 patients a diagnosis of hysteria had been made. Kashiwagi and associates did not find any patients with schizophrenia in the study group, which may underscore the fact that the incidence of headache in schizophrenia is low, a finding that has been noted by Friedman and Frazier.'4 The headache of delusional states, referred to in the Ad Hoc Committee'S classification,' is less of a headache and more of a somatic delusion, i.e., a head pain that has a delusional basis. A
dasslftcadon There is often considerable overlap
lient clinical features of each of these types of headache are given below. Muscle contraction headaches. These are more appropriately called tension headaches so as to emphasize their etiology and to differentiate them from muscle contraction headaches resulting from local irritation. As the name implies, the headaches are associated with increased muscular tension and affect particularly the muscles of the neck, suboccipital region, frontal and temporal regions, scalp, and jaw. The patient most often describes the headache as a pressure sensation or a dull ache that may be continuous. Muscle-contraction types of headache occur in patients of all
l
OCTOBER 1980· VOL 21 • NO 10
A Classification of Psychogenic Headaches Muscle contraction headaches
I
Anxiety causes increased neuromuscular tension, as in Anxiety reactions Reactive (exogenous) depression
Conversion headaches
DeW
not only between the different types of psychogenic headache but also between the psychiatric disorders where headache is a major symptom. For this reason, it is often difficult to be diagnostically precise. However, the Table provides a classification of psychogenic headaches that may help in the differential diagnosis of this disorder.'s The four main types of psychogenic headache are muscle contraction headaches, conversion headaches, psychotic head pain, and vascular headaches. The sa-
ages, and the setting is usually an anxiety reaction or a reactive depression. Indeed, the headache may be accompanied by other clinical manifestations of anxiety and depression, and the patient may be able to relate the headache to external stress or internal conflict. Conversion headaches. These occur in certain persons, usually young women, who are faced with an emotionally stressful situation that they can neither solve immediately nor shelve. The anxiety resulting from this experience is repressed and re-emerges as a somatic symptom that may symbolically represent the precipitating conflict. The headache provides the patient with secondary gains in the form of attention derived from others, sym-
I
Anxiety or depreSSion is somatized, as ConversIon reactions DepressIve equivalents
In
Psychotic head pain As in Manic-depressive depression. where headache accompanies other depressive symptoms Psychotic middle life depression, which is often associated with hypochondriasis . Schizophrenic reactions. where the headache may be delusional in ongin
Vascular headaches
r
Changes in cerebral artery blood flow are precipitated by psychological stress, as in ClaSSIC migraine Migraine equivalents J
839
Psychogenic headache
pathy, and sometimes compensation. If the conversion of the anxiety is complete, the headache may be dramatically described and yet not appear to cause the patient any obvious distress. Indeed, such patients exhibit Janet'sl6 characteristic "la belle indifference." When depression is converted into a somatic symptom such as headache, the symptom may be less dramatically described. The key point is that the headache occurs within an aura of depression, although other manifestations of depression may be hard to pinpoint. Psychotic head pain. This form of headache is usually easy to diagnose, as it occurs in a setting of unipolar depressed manic depression, in persons with psychotic middle-life depression or, rarely, in schizophrenic individuals with somatic delusions referable to the head. The history is important in diagnosis. The patient may have had manic or depressive reactions in the past (bipolar disease), or may give a history of previous psychotic depressions (unipolar disease). The headache is often accompanied by diurnal mood variation, sleep disturbance, and other manifestations of endogenous depression. In psychotic middle-life depression, the patient's age (45 to 60), sex
REFERENCES 1. Ad Hoc Committee on Classification of Headache: Classification of headache. JAMA 171:717-718,1962. 2. Diamond S: Depressive headache. Headache 4:255-258, 1964. 3. Diamond S, Banes BJ: Chronic tension headache-treated with amitriptyline-a doubleblind study. Headache 11:110-116,1971. 4. Dalessio OJ: Some reflections on the etiologic role of depression in head pain. Headache 8:28-31, 1968. 5. Diamond S, Dalessio 0: The Practicing Physician's Approach to Headache, ed 2. Baltimore, Williams & Wilkins, 1978, pp 94-103. 6. Kashiwagi T, McClure IN Jr, Wetzel RD, et al: Headache and psychiatric disorders. Dis
840
(females more often than males), and premorbid personality (obsessive-compulsive type) help to identify the psychogenic origin of the headache. Frequently, the patient also has the clinical findings of agitation and/or hypochondriasis. Hypochondriacal delusions referable to the head or brain may be the most prominent symptoms of an involutional depression. The delusions often have a bizarre and depressive quality. In schizophrenic reactions, headache or head pain is uncommon and may be delusional in origin. Headache may occur transiently in a schizophrenic patient after electroconvulsive therapy, but this head pain has no special identifying characteristics. Vascular headaches. These include all types of migraine headache, such as classical, common, and variant migraine. Such headaches are thought to be psychophysiologic in nature. A psychologic stress ofone type or another in a predisposed individual causes an alteration in cerebral blood flow, which in turn leads to other intracerebral changes, as described by Edmeads,17 and to the development of a migraine or vascular type of headache. It is true that vascular headaches
do in fact have a peripheral paininducing mechanism and do occur in the absence of a clinically manifest underlying psychiatric disorder. Thus, vascular headaches do not strictly fit into the definition of psychogenic headache previously given. These headaches are nevertheless included in this classification for the sake of completeness and because combinations of vascular headache and muscle contraction headache are observed to coexist in some ·patients. Some vascular headaches are precipitated by anxiety and emotional stress, and it is in this setting that the combination of vascular headache and muscle contraction headache is most often observed. Also, the personality of the patient with vascular headaches is frequently of the obsessive-compulsive type, a fact that has led to much speculation and research. Vascular headaches are usually easy to recognize, although atypical types of migraine may present diagnostic problems. In summary, use of this simplified classification of psychogenic headaches can aid in earlier identification of the associated psychiatric disorders. This in tum facilitates more appropriate and effective treatment. 0
Nerv Sys/33:659-663, 1972. 7. Marlin MJ, Rome HP, Swenson WM: Headache 1:184-217,1967. 8. Wolff HG: Personality features and reactions of subjects with migraine. Arch Neurol and Psychiatry 37:895-921, 1937. 9. Fromm·Reichmann F: Contribution to the psychogenesis ot migraine. Psychoanal Rev 24:26-33, 1937. 10. Selinsky H: Psychologic sfudies of the mi· grainous syndrome. Bull NY Acad Med 15:757-763. 1939. 1t. Masserman JH: Principles of Dynamic Psychiatry. Philadelphia, WB Saunders, 1947, p286. 12. Cassidy WL, Flanagan NB, Spellman M, et al: Clinical obServations in manic depressive dis·
ease. A quantitative study of 100 manic depressive patients and 50 medically sick con· trols. JAMA 184:1535-1546,1957. Ziegler OK: Headache syndromes: Problems of definition. Psychosomatics 20:443-447, t979. Friedman AP, Frazier SH: Preliminary obSer· vations of the psychiatric evaluation of treated chronic headache patients. Head· ache 3:378-380, 1972. Weatherhead AD: Psychogenic headache. Headache 20:47-54,1980. Janet P: The Major Symptoms of Hysteria. ed 2. New York, Macmillan, 1920, pp 160-163. Edmeads J: Vascular headaches and the era· nial circulation-another look. Headache 11:127-132,1979.
t3.
t 4.
15. 16. 17.
PSYCHOSOMATICS