Psychotherapy

It is evident that certain conditions predispose to headache. The principal of these is having sufficient time to advert to certain uncomfortable feelings in or around the head. Few people who stop to think of what their head feelings are but will find there is some unusual sensation somewhere in or outside the head which if dwelt upon becomes emphasized into an ache. If the mind can be diverted it disappears. If there has been some injury of the head or some pathological conditions set up by congestion or anemia, the feelings may become emphasized and occupy the center of attention, and even after the injury has disappeared or the pathological condition been ameliorated some sensations remain which with advertence produce achy feelings of discomfort. This is the history of a great deal of the increase of headache in our time. There are, of course, real headaches due to definite pathological conditions, but the great majority of headaches complained of are the result of over-attention to certain sensations, some of them normal, some of them only slightly abnormal, which are emphasized by concentration of attention on them until they become a torment.

Two main classes of headaches come to the physician for treatment. One class is seen in patients who suffer from real and even acute pain that cannot be distracted by diversion of mind, that is usually worse when they try to sleep, as toothache is, and is evidently due to definite physical disturbance. In the second class are the many queer feelings about the head called headaches, though the patient suffers rather from annoyance than from pain. It is said that the Chinese in olden times put criminals to a lingering death by fastening them in such a way that a drop of water fell every minute on their heads. It was impossible to avoid the falling drop, and its constant recurrence became an awful torture. Any feeling that engrosses consciousness will be followed by the same sense of torment. The constant exercise of function of any nerve without rest is of itself physically disturbing to a serious degree. This must be realized with regard to many forms of headache which, though trivial in origin, are the source of bitter complaint.

Attention Headaches.—Professor Oppenheim, in his "Letters to Nervous Patients," has a paragraph with regard to headache that is worth recalling for the benefit of patients who suffer from low-grade headaches. Doubtless these were at the beginning real aches due to some local condition. They are now due merely to exaggeration of more or less normal feelings within the head which have come into the realm of the conscious because of the attention attracted to them when the intracranial affection was first noted. Professor Oppenheim says:

Your headache also I ascribe to this source. Originally it may have been a real headache, the result of your nervous shock. There is no one who has not at some time had a transient feeling of pain in the head or in some other part of the body, quite apart from those caused by injuries or painful diseases. Out of a thousand various kinds of causes I will mention only an extremely common one: the pains which result from straining muscles or nerves. Every sudden awkward movement may in this way cause pain in different parts of the body, but very specially so in nervous persons, in whom the mechanical excitability of the nerves—that is, their sensitiveness to pressure and strain—is usually exaggerated. As a rule, however, this pain is quite transient. But here again the law of which I have been already speaking comes into force: under the stimulating influence of introspection the tiny, perishable seed-grain of pain grows into the firm, strong, enduring tree of neuralgia or psychalgia.

The first condition for the successful treatment of headache, then, must include the recognition of the possibility of some rather simple pathological condition being exaggerated by over-attention to a disturbing affection, or of some affection, now past, having produced a suggestion that, in a mind given to introspection, continues to have influence even to the inveteration of sensations for which there is no longer a physical cause.

These patients insist that their medical status is that of real pain. Hysterical patients describe a sensation as if a nail were being driven into the forehead—the so-called clavus hystericus. In nervous people the sense of pressure increases from one of mere discomfort to a positive pain, as a consequence of attention to it. In most cases of headache, however, what is most needed is a distraction of the attention from the ailment. Over and over again I have found that when all remedies failed the deliberate search for an occupation of mind that would interest the patient during many hours of the day was the only thing that promised relief and in many cases the relief afforded was so complete that patients were effusive in their gratitude.

Power of Distraction .—The proof that these so-called headaches are really not aches is found in the comparative ease with which many of them may be suppressed. Almost any interesting occupation will make the sufferer forget them entirely and they will not return immediately after the occupation ceases, but usually only when the patient is alone and attention is once more directed to this symptom. These queer feelings about the head that are often raised to the dignity of headaches by attention and auto-suggestion may be distracted away completely. That they are not pain is shown by the fact that the ordinary remedies which ease pain so promptly often fail to relieve these or soon cease to have any effect on them.

Lack of Distractions .—The apartment hotel system has multiplied the victims of headaches. When a woman has nothing in the world to do except get her clothes fitted and attend to what she calls her "social duties," it is no wonder that her head bothers her. Blood is constantly going to the brain and interchange of nutritive elements is taking place, yet there is no real function of cells and no consumption of material, or at least function is so slight that consumption of material must be trivial. There is no reason why these women should get up in the morning. Their breakfast is brought to their rooms, and some of them do not get around until eleven o'clock. Women used to have a morning occupation in going out to market or else in planning the household day with housekeepers, but of course there is no more of that. In olden times, too, many of them had religious practices. Now women are likely to be unemployed until the afternoon, which must be occupied at most with so-called social duties that may be done if one wishes to do them, but that may be put off for many reasons and there are constantly recurring reasons for not making any special exertion. Also, the rooms these women live in must be kept at a high temperature because the poorer the air that we breathe the higher must be its temperature for comfort, while stimulating fresh air may be quite low in temperature and yet produce only a brisk reaction instead of chilly feelings.

Children used to be the best possible remedy for these non-occupation headaches, but either there are no children any more or there are but one or two and these are largely cared for by bonnes at home and by various schools once they have reached the age of three. The old idea that children should not leave home until six put upon the mother the burden of their early education, but since the coming of the kindergarten she is relieved of responsibility of this and the mother of one or two children might now almost as well be childless as far as any serious occupation from care of her children is concerned.

If patients are told all this bluntly there will be a vigorous protest from most of them, for to them their pains are very real. It must not be forgotten that a pain in the mind is often worse than in the body. Some of these women save themselves from having their unused mental faculties disturb them from very lack of something to do, by becoming interested in charities, in clubs, in social movements of various kinds, in art and in literature. It is not to these that I refer. On the contrary, if women have nothing else to do I would insist that they find some cause or movement in which they may become deeply interested. Their interest will save them from self-annoyance, though it may not exactly add to the gayety of nations in its effect upon other people. As a physician, however, I am only interested for the moment in the good of particular patients.

Source of Pain.—I would not be understood as saying that all headaches are not real aches nor pains in the most literal sense of the word, for some of them are agonizing tortures. With regard to all headaches, however, even the most genuine variety, there are certain considerations that are of value from the standpoint of psychotherapeutics. The most important of these is assurance as to the source or location of the pain. Most people think that it is the brain itself that is suffering pain and not a little of their suffering is due to the fact that they dread the effect of such pain upon the cerebral tissues and its possible consequences upon their mental state. These people will be much relieved to be told at once that the brain tissue itself is not sensitive, that when exposed it may be touched with impunity without causing any pain. It is the structures surrounding the brain that are sensitive. As a rule the lesion that causes pain is not progressive and all dreads with regard to serious after effects may be put aside.

Pressure Headaches.—It is important to insist on the fact that, as a rule, headaches and pains in the head are not due to the brain, but to extraneous structures within the skull. It is true that brain tumors, gliomatous and cystic and, above all, the overgrowth of the pituitary body in acromegaly give rise to agonizing pains. The cause of these headaches is undoubtedly pressure. It is not the pressure upon the brain tissue itself, however, that is the underlying cause of the pain, but pressure upon the sensitive structures connected with the brain. The same thing is true with regard to congestive headaches. Pain is produced not because vascular congestion presses on sensitive brain tissues, for we have no reason to think that any such exist, but because the congested brain exerts pressure upon sensitive filaments in its integuments. Neuralgia may be unbearable and yet it is borne with more equanimity, and less dread of results, because it is felt to be in a comparatively unimportant structure. One of the most serious elements in severe headache is the fear of lasting results in the brain tissues, that may lead to disturbance of mentality or to injury affecting mental processes. Patients find their pain much more bearable as soon as they are assured that headaches do not lead to mental disturbances and that, as a rule, even the growth of a tumor does not disturb mentality.

In the relation of the brain to the intellectual faculties that are so closely associated with it, we must remember that direct connection between the two has not been demonstrated and that the relations of the brain and the mind are almost as mysterious as they ever were. There are some who still think that the frontal convolutions are especially concerned in carrying out mental operations. All that we know about them in pathology, however, is that they are the silent convolutions. When a lesion occurs in other portions of the brain we see the effect of it practically always without delay, in some way, either in the sensory or motor functions of the body. Large lesions in the frontal region, however, often give no sign. Large tumors have been found pushing frontal convolutions from their ordinary positions without any noticeable effect upon the individual.

Hard Study and Headache.—It is worth while to impart this knowledge to patients who suffer from headaches, because it at once improves their outlook on life. I have known hard students—men who had spent twenty or thirty years in work at a special subject—live in constant dread that sometime their minds would give way because they frequently suffered from headaches, or at least from some uncomfortable sensations in their heads, which they feared as a portent of ultimate mental breakdown. The assurance that such a thing is utterly unlikely and quite apart from the physician's ordinary experience, not only relieved their anxiety and made their headaches more bearable, but in a dozen of cases in my note-books the headache has gradually disappeared as certain habits of life were corrected and modified, as their habits of eating were varied, as bodily functions were controlled and as diversions of mind were introduced into lives that had before been too unvaried for healthy functions.

I do not think that I have ever seen a case, and I have been closely in touch with hard students for over twenty years, where I felt that the cause of a headache was mental overwork. I have known men who at the age of seventy or over have taken but four or five hours of sleep and who have worked at their favorite subjects for the better part of half a century. They never complained of headaches. Of course, there are others whose physical and mental power is less and who cannot be expected to stand a strain that for large-minded men is only the normal exercise of function. It has not been the mental work that they were doing, however, that was the source of whatever central nervous disturbance was to be found in lesser minds, but worry and anxiety and dread over what they were doing, anxiety as to what they were going to do that constituted the real pathological agents at work.

Local Conditions .—A striking case that impresses patients much more than the physician's declaration and is more likely to be remembered and is therefore of psychotherapeutic value, is that of Von Bülow, the German musician. He suffered for many years from excruciating headaches. They were so severe as almost to drive him crazy. His only relief was morphine and he and his friends lived in the midst of no little dread that sometime or other either the pain or the process which caused it would bring about a deterioration of mentality. After his death an autopsy was made. It was found to be a small nerve fiber pinched by a scar in the dura as a consequence of an injury received when Von Bülow was very young. Many other stories of this kind have been told.

It must not be forgotten that in many cases the pain is not within the skull itself or at least its cause is not and other sources should be carefully looked for. The connection of the eyes with headache has been so well worked out, owing to the initiative of S. Weir Mitchell, that nothing more need be said of it. One feature perhaps deserves to be mentioned. While strain of accommodation is a frequent source of headache and is at once looked for by ophthalmologists, there seems no doubt that some headaches, much fewer than accommodation cephalalgias, are due to muscle difficulties, that is, a lack of balance among the external muscles of the eye, whose full pathological significance has perhaps not yet been worked out. Headaches are frequently due to sinus troubles, especially to disturbances in the frontal sinus and to intranasal difficulties. These must be eliminated before the patient can be helped. Sometimes these nasal and sinus difficulties are signs of a deeper constitutional disturbance, due to lack of fresh air and exercise and are relieved promptly by the establishment of hygienic habits.

Congestion Headaches.—Some headaches require changes of habit and persuasion of the necessity for arranging the day's work so as to give proper intervals for relaxation. Much experience with persons whose absorption in their work causes them to miss a meal or delay taking it for seven or eight hours from the last time of eating has shown me that this disturbance of the routine of vegetative life is particularly likely to be followed by headache. This headache is not a mere dull ache and is much more than a sense of discomfort; it is often an excruciatingly painful condition that usually does not come on until toward the end of the day and then may seriously disturb sleep. An interesting thing about this class of headaches is that nearly always they are increased by lying down. Often only a faint preliminary symptom of it is apparent when the patients go to bed, though they may be wakened after two or three hours of disturbed slumber by a headache that prevents further sleep, and pass the remainder of the night in painful wakefulness.

Usually it becomes impossible to continue lying down. The head must be raised and much relief is afforded by sitting up. The headache does not disappear at once but it will gradually pass away and sleep may be resumed after a half an hour of sitting up, though the sleeper will have to be in a sitting posture. Older people get up and sit in an arm-chair. I have found that placing a chair with a rather long back beneath the mattress, the mattress slanting along the chair back at an angle of about forty-five degrees and then an arrangement of three or four pillows above that, will enable these patients to get to sleep better than anything else. The ordinary remedies for headache afford some relief, but even very large doses of the coal-tar products will not relieve the pain entirely unless some arrangement is made for keeping the head quite high and immovable.

The headache is evidently due to congestion. The reason for it is perhaps the failure of the blood to be recalled from the brain to do its usual physiological work at the digestive tract, with a consequent distention of arterioles in the brain so that a little later they do not react to prevent congestion. Usually with the headache there is some digestive disturbance, a feeling of unrest, flatulency with perhaps acid eructations. Accordingly the headache is often attributed to digestive disturbance. But both would rather seem to be effects of the same cause—the failure to supply the digestive apparatus with the proper amount of material to work on at the time when it expects it, while the mental absorption naturally attracts blood to the head. We know from delicate experiments made in physiological laboratories that at times of mental work there is an appreciably larger amount of blood in the head. A proof of the connection between the lack of a meal and the headache seems to be the fact that with most people even a glass of milk and a cracker, taken at the time when the meal is normally eaten, is sufficient to prevent the otherwise inevitable headache.

Whenever some such simple explanation as this for a headache is found and the patient made to realize its truth on his own observation, the significance of the headache at once dwindles and it becomes much easier to bear it. Before the very real pains of it were emphasized by the dread of the consequences that would result from it. If it was really a brain ache patients would find it hard to understand how under its influence even serious changes might not take place in the brain. This is only a rational suggestion, but it is mental healing of the best kind.

Many of the aches which are spoken of as headaches are really forms of tenderness associated with the integuments of the skull. Certain of the muscles particularly are likely to suffer from achy feelings which are spoken of as headaches. This is true of certain feelings of discomfort in the frontal region and also of those that occur on the occipital region. External applications of many kinds relieve headaches in these regions, particularly in the frontal region. It is easy to understand that such applications do not affect the contents of the skull.

Some Occipital Aches.—Occasionally I have found that people who complained of a sense of weight at the back of the head, with some muscular tenderness, were sleeping on pillows that were too high. They were over-exerting these muscles and this gave a sense of fatigue, which when much attention was paid to it, became such an ache or at least discomfort as is often found in the occupation neuroses. I have seen schemata according to which headache complained of at the top of the head meant digestive disturbance, headache in the anterior portion of the head was referred to the eyes or the brain, and headache at the back of the head spinal exhaustion or severe neurasthenia, but these are at most very uncertain and I do not think that the tabulation of cases justifies any such diagram of absolute causes and effect. Usually there is some local condition that calls particular attention to a special part of the head and then the attention being concentrated complaint is made of that part.

Local Head Discomfort.—Usually a headache, accompanied by a localized sense of pressure or weight or constriction, occurs in highly neurotic people or those inclined to think much of themselves and whose attention becomes concentrated on some part. At all times we have sensations streaming up to our consciousness from every portion of the body and anyone who wants to think about them, or a particular set of them, can make them sources of considerable discomfort by concentration of attention. Sometimes there are special conditions that predispose to these localized sensory disturbances. I have known tight hats to produce such effects. It is sometimes surprising how tightly hats are worn. Nervous people are prone to overdo everything, and they overdo the pulling down of their hats. At times the wearing of a heavy hat will be the root of the trouble. I have known nervous men accustomed to wearing high hats all their lives who began to complain of headache when they were in the midst of busy worries and troubles of late life, find considerable relief by abandoning their high hats.

Toxic Headaches.—There are headaches that are due to the taking of stimulants, as is well known from common experience. The mistake is often made, however, of thinking that only alcoholic stimulation will cause a severe headache. Tea and coffee headaches may be quite as severe. Whenever people complain much of headache it is important to revise their dietary as to the consumption of tea and coffee. Of course, the headaches following alcoholic stimulation are usually recognized as such, though occasionally a man accustomed to taking much alcohol without any such after effects is surprised in the midst of the worry incident to business stresses to find that he is having headaches. These are due to the combination of stimulants and congestion consequent upon an excess of alcohol with the increased brain work that is demanded, or even with the same amount of brain work from a tired brain. Gradually stopping the alcohol will do more to relieve these headaches than anything else. To advise the sudden stoppage of regular quantities of spirits that have been taken for some time, will sometimes produce an anemic headache and defeat the purpose of the advice.

When for some other reason tea or coffee or alcoholic stimulants are suddenly omitted after they have been taken to excess for some time, patients' complain of a headache. Some of this is probably imaginary, or at least is due to the idea that their craving for the stimulant, whatever it may be, must have a local manifestation, and the head sensation is exaggerated as a consequence. Tea and coffee cravings may here give more trouble than the longing for alcohol. Sometimes there may be a real disturbance of the circulation from the lack of the heart stimulant to which the system is accustomed and therefore an uncomfortable feeling in the head from brain anemia. This can be overcome by not cutting off the stimulant, whatever it may be, all at once, but by bringing about its gradual cessation. These patients, however, are very prone, even with the best of good will in the matter, to deceive themselves and find an excuse for not having their favorite tipple, be it tea or coffee or alcohol, taken from them, so that they readily create symptoms by auto-suggestion.

Direct Mental Treatment.—For both congestive and anemic headaches mental treatment is important. For those suffering from the congestive kind the physicians's business is not so much the cure of any one attack of headache (for this can be accomplished by various now rather familiar anodyne drugs as a rule), but the discovery and removal of the cause for the recurring attacks. These will be found in some habit of the patient which must be corrected. Drugs are seldom needed for the underlying condition which occasions the headache, for when it is due to such organic affections as brain tumors or other intracranial lesions, drugs can accomplish very little. In less serious conditions benefit may be obtained by having the patient change his attitude towards certain important details of his life, such as eating, sleeping, attention to business or to study and the like, so as to prevent the mistakes of daily habit that predispose to headache.