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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