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Headache





In spite of the improvement in the general health of the community,
due to more hygienic living, more healthy food and better ventilation,
headache, instead of decreasing, has increased to a great degree. Any
number of headache cures are advertised in the daily papers, in the
street cars, on the signboards, even in medical journals, and besides
these nearly every druggist has his own special preparation for
headache, so it would seem as though literally many millions of doses
of these headache cures must be taken every week. It would seem as
though there must be some special unhygienic factor at work to produce
headaches at a time when all other pathological conditions are being
reduced in number and severity.

A study of the patients who are especially affected by headache seems
to furnish evidence as to the special factor that has led to the
increase of the affection. It occurs much more frequently in women
than in men. It is complained of particularly by those who have less
regular occupation, and the notable increase has come with the
opportunity for leisure on the part of large numbers of the community
due to the growth of wealth.

A feeling of discomfort in the head to which much attention is paid
will become such a painful condition as to deserve the name of ache,
if it develops in those who have no serious occupation in life and no
interests that demand peremptory attention. With the noise of many
children around them in the olden times women suffered comparatively
little from headaches. Most of our grandmothers scarcely knew what it
was to have a headache. Now most business men are likely to say the
same thing. Very rarely do they suffer from headache. When they do,
there is some specific reason and when this is removed the headache
disappears. There are many women of leisure who have regular headaches
for which they must have some remedy at hand or the pain becomes
intolerable, but there are few women strenuously occupied with
business affairs or with interests in which their attention is
absorbed who find themselves under any such necessity.

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 Buelow, 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 Buelow 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.

With regard to anemic headaches, especially those which occur in
persons who are very much run down in weight, the most important
element of treatment is to bring about an increase in weight. This can
be accomplished much better through the mind than in any other way.
Appetite is a function of the will, and patients should have an
increase of diet dictated to them and then be persuaded to follow
that. I have seen many a headache disappear among teachers, and
religious workers particularly simply as the result of this measure.

As regards headaches for which no definite cause can be found mental
treatment is the only efficient remedy. Practically nothing but a
change of mental attitude towards the affection and its underlying
causes, whether these be neurotic or psychic, will bring about
relief, and each patient is a problem quite distinct from any other.

There is no pretense that this use of mental healing for headache is
new or even modern. Many stories show that in olden times headaches
were often relieved by this means, and that suggestion was looked upon
as an important element in the treatment for their relief. In the
chapter on Great Physicians in Psychotherapy the quotation from Plato
with regard to Socrates curing the headache of his young friend
Charmides illustrates this very well.

In the old stories of Greek medicine there are a number of references
to headaches cured by suggestion or at least by mental influence. Miss
Hamilton, in her book on "Incubation," [Footnote 40] tells the story
of Agestratos and his headaches and how they were cured at Epidaurus.
Agestratos had a combination of headache and insomnia, the description
of the ailments having a strangely modern air. Just as soon as he came
to the Temple at Epidaurus he fell asleep and had a dream. The God of
Medicine, AEsculapius, whose cult was practiced assiduously at
Epidaurus, came to him in his sleep and promised him the cure of his
headache and at the same time taught him wrestling and advised its
practice. When day came he departed cured, and continued to practice
wrestling. Not long after he competed at the Nemean Games and was
victor in the racing. The suggestion that his headache would get
better had come to him and at the same time he had been given a
suggestion that provided him with occupation of mind and body. Many of
the people who suffer from persistent headaches need this advice more
than anything else. Probably every physician has had the experience of
headaches being cured by some interesting exercise, especially if
taken in the open air. The important factor is the change of mental
attitude, though changes in exercise, diet, amount of sleep and the
like are helpful auxiliaries.

[Footnote 40: London, 1906.]





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