Headache is a very common symptom for neurosis. According to our data, 58% of patients with neurosis complain of headaches, in particular, 60.2% of people suffering from neurasthenia, and 64.3% – with hysteria. Headache in 10% of patients with neurasthenia and 7% hysteria is the main complaint. Relatively less, this symptom is observed in obsessive-compulsive disorder .
In the figurative expression of W. Schulte (1955), “every patient suffers from his own headache.” If this is true for headaches in general, this is even more true in cases of neurotic cephalgia, the complexity of the differential diagnosis of which is due to the diversity of their pathophysiological mechanisms.
For clinical and therapeutic purposes, we have proposed the following classification of neurotic headaches:
1) headache with the primary participation of neuromuscular mechanisms;
2) headache with the primary participation of neurovascular mechanisms;
3) headache without significantly pronounced neuromuscular and neurovascular disorders (such as psychalgia ).
The basis for this classification was the data obtained from a multilateral examination of 450 patients who were treated in the neurosis clinic for persistent cephalgic syndrome.
In the clinic of neurosis, patients with a headache with the predominant participation of neuromuscular and neurovascular mechanisms are more common. In various forms of neurosis, all three types of headache are observed. It can only be noted that muscular and vascular headache is relatively more common in patients with neurasthenia, and of the type of psychalgia in patients with hysteria.
Neurotic headache with predominant participation of neuromuscular mechanisms. This type of headache is manifested by the sensation of external pressure, tightening, tension (“helmet”, “cap”, “helmet”, “hoop” on the head, neck in the “corset”).
These vivid descriptions of pain always reflect its main character. As an example, we cite the statements of patients: “A tight rubber cap is put on the head”; “The head is squeezed, the brain is tightly in the skull box, I want to rip it off and release the brain,” etc. In 2 cases with typical muscular pain, the patients experienced the sensation of a nail hammered into the back of the head. Complaints of soreness of the scalp, feeling of numbness, etc., are typical: “The head is cold, the sensation is as if ice was laid on the crown and the back of the head.”
The pain is constant with periodic reinforcements. In most cases, it begins in the morning, decreases slightly by the middle of the day and intensifies again by the end of the day. Its localization is different: unilateral, bilateral, in any part of the head, but more often in the region of the neck and neck (53 of 75 patients). Often the pain is perceived as deep. Headache is sometimes accompanied by dizziness, nausea and vomiting.
Characteristic is the combination of the above painful and emotional disorders – anxiety and fear. The latter often acquires a specific plot. Most often it is the fear of insanity, stroke.
Usually there is a clear link between the exacerbation of pain and the occurrence or increase in fear; pain increases with emotional stress, for example, in connection with conversations in which stressful circumstances are affected, with cooling of the head. Therefore, patients are wary of hypothermia, in connection with which almost at any time of the year they wear a hat, a warm scarf.
To differentiate the neuromuscular headache with neurosis should be primarily from the secondary cephalgia with eye diseases, paranasal sinuses, cervical vertebrae, the state after head injuries, etc. In these forms of headache, the brightness of the description of pain, which is typical for neurosis, is absent, as well as the frequency of combination with emotional disorders.
Neurotic headache with the primary participation of neurovascular mechanisms. For patients with neuroses with a headache of this type, pulsating pains are characteristic (“pulsating in the head”, “knocking at the temples”, etc.). For example, one patient, during an attack, was trembling, crying, screaming that she was “straining the temporal vessel” and that “he would burst now.” Another patient told with fear that he was feeling a pulse; at one of the moments, it seemed to him that something burst in his temple, and he decided “that this is the temporal artery,” and called the doctor.
A colorful, extremely exaggerated description of a headache is typical mainly for patients with hysteria. Sometimes in patients with the type of headache in question, the so-called hysterical nail symptom occurs. This sensation is not constant, it arises at the time of exacerbation of pain, its localization often corresponds to certain vascular basins – the temporal, occipital arteries, etc. One patient during the exacerbation of pain lay quite still, could not turn her head, and then said in a quiet voice that she “pulses, everything is strained, the brain is pierced by a sharp arrow, as if a nail was inserted into the back of the head.”
Neurotic headache with the predominant participation of neurovascular mechanisms, as a rule, does not occur immediately, but several weeks or even months after the development of neurosis. An obvious dependence of pain on the dynamics of traumatic circumstances is revealed. A sharp increase in headache coincides with the exacerbation of a conflict situation.
The sensation of pulsation is especially pronounced during a headache aggravation. The pain is often constant, rarely paroxysmal. The pain is localized in the temporal areas on both sides or only on one side, less often in the occipital, frontal areas, or is perceived as diffuse. Often, palpation can determine the increased pulsation of the temporal arteries. Sometimes a headache is accompanied by autonomic disorders (nausea, dizziness). There is no relationship between the occurrence of headache and the time of day.
It is necessary to differentiate the headache of the neurovascular type with neurosis from migraine, especially its atypical variants. In case of neurosis, psychogenic conditioning of both the disease as a whole and the headache symptom is always revealed. Psychogenic factors often contribute to the onset of migraine attacks, but there is still no permanent connection. In classic forms of migraine, there are usually no particular difficulties in recognizing the disease. Moreover, very often the sick and do not go to the doctor, as headache attacks, as a rule, are not so frequent, and between attacks, these people feel completely healthy.
The presence of a family predisposition to migraine, the onset of attacks at a young age, precursors of headache (aura, nausea, vomiting, etc.), frequent localization of pain in the right or left half of the head are in such cases sufficiently solid differential diagnostic criteria.
However, considerable difficulties may arise in the diagnosis of some atypically occurring weighted variants of migraine. For such patients, a constant, often very intense headache, localized mainly in the temporal and occipital areas. Against this background, there are frequent, sometimes up to several times a week, headaches, accompanied by nausea and vomiting, which both the patients themselves and, in some cases, the doctors do not associate with the previous migraine.
Diagnostic difficulties are aggravated by the fact that long-term persistent headache leads to secondary neuroticization of patients, and therefore they present a host of other neurotic complaints ( insomnia , irritability, tearfulness, reduced mental performance, etc.).
The marked weighted atypical migraine variants are most often observed in the following cases:
1) when psychogeny joins the migraine;
2) in women in premenopausal and menopausal periods;
3) in patients with migraine after head injuries, especially after repeated injuries.
Clinically, these patients show signs of severe vegetative-vascular dystonia, primarily in the form of fluctuations in blood pressure in the direction of both increasing and decreasing. In the future, in many patients with a tendency to arterial hypertension, hypertensive disease occurs, and in patients with a tendency to arterial hypotension, there are pronounced hypotonic states, which are particularly difficult in the presence of regional cerebral vascular disorders. The latter are established on the basis of a significant increase or decrease in retinal pressure.
The course of the disease takes a particularly unfavorable character under the influence of psycho-traumatic situations that continue for a long time (family, sex, production).With a superficial approach in these cases, the most diverse types of pathology are diagnosed – from hysteria to a brain tumor.Only a thorough examination of patients and in-depth analysis of clinical and laboratory data help to clarify the diagnosis and the selection of adequate treatment.
Neurotic headache type psychalgia .Patients have difficulty in describing the nature of the headache, often they can not precisely localize it, there are no significant dynamics and progression .As in general with neurotic pain, the situational conditionality of the symptom is especially pronounced here.The intensity of the pain does not change when taking various analgesics and even drugs.
Some authors believe that a genuine psychogenic headache ( psychalgia ) is more likely to be an illusion, hallucination, it only worries the patient “mentally”, it doesn’t feel physical pain and that it is true that psychogenic headache occurs in the mentally ill and much less often with neurosis.
A peculiar variant of psychogenic headache associated with the attention stress describes J. Nick (1959). He observed it in children, youths and adults. In all cases, the headache occurs due to the tension of attention and disappears some time after the cessation of intellectual effort. The pain is often moderate, but difficult to tolerate, as it deprives the patient of the ability to work. It is not associated with visual tension and can be observed in the blind. The pain does not depend on mental fatigue, as it occurs at the very beginning of mental work, for example, when reading. The level of intelligence also does not matter.
Most often, pain occurs in cases where the intellectual effort is directed to an important activity for the patient (for example, work on a diploma). Sometimes a headache occurs only when studying an unloved subject, such as mathematics. Curious remark of the author that lazy people have a strong immunity to headaches associated with the stress of attention. The author considers this headache as a symptom of psycho-affective tension. However, due to the fact that no objective changes associated with the pain can be established, in his opinion, the symptom is purely subjective.