Conversion Headache

Russell C. Packard, M.D.

From the Department of Neurology, Naval Aerospace Medical Institute, Pensacola, FL 32508.

Reprint requests to: Dr. Russell C. Packard, M.D., 5225 Carmel Heights Dr., Pensacola, Florida 32504.

Accepted for Publication: January 25, 1980

The opinions expressed herein are solely those of the author and do not necessarily represent the views of the Department of
the Navy or the Bureau of Medicine and Surgery.

SYNOPSIS

The literature pertaining to conversion headache is briefly reviewed and problems with definition are
discussed. There is often confusion about the concept of "psychogenic" headache and whether or not there are
underlying local physiological changes present in cases of conversion headache. For the purposes of this paper
conversion headache is defined as a headache in which the prevailing clinical disorder is a conversion reaction
and a peripheral pain mechanism is not present.

A case will be described to provide a clinical description of the disorder and to demonstrate some of the
features that can be helpful in establishing the diagnosis.

Discussion considers factors important in the pathogenesis and diagnosis of conversion headache, such as
the significance of symbolization, secondary gain, and other features associated with the conversion reaction.

(Headache 20:266-268, 1980)

For centuries man has used ache or pain to refer not only to his perception of unpleasant sensations, but also to his
psychologic and emotional stress. The significance of symbolization becomes apparent as the physician understands that the
patient may use the headache complaint as a means of expressing anxiety over the head portion of the body. The head is
commonly regarded as the portion of the body wherein resides the organ for consciousness, memory, talent, intellectual
activity, cognition, and judgment. To the layman the terms "head" and "brain" are often synonymous.1
The bulk of the literature dealing with head pain as a conversion symptom consists largely of case reports describing the
particular symbolism involved in individual patients.2-6 It has also been described in discussions of psychogenic headache7-9
but the term psychogenic headache has not been generally precise nor diagnostic.10
Conversion headache has generally been defined as a headache in which the prevailing disorder is a conversion reaction
and a peripheral pain mechanism is non-existent, which is in accordance with the definition proposed by the Ad Hoc
Committee on Classification of Headache.11 This definition will be adhered to in this paper, but it is still an open question
whether any underlying local physiological changes are present in the conversion headache.12
Most of the cases described in the literature strongly suggest a central process with little in the way of significant local
change. However, Boag feels that it is almost always possible, with close observation, to pick up some suggestive evidence
for a local focus around which the symbolic tension has become elaborated.8 Within the limitations of a clinical situation in
which psychological information is elicited, one is rarely in a position to obtain convincing evidence one way or the other with
regard to local changes. It is quite possible for pain which began as a result of a local process, to be prolonged as a hysterical
symptom, long after the physical problem has healed. This may explain some cases of persistent headache after trauma, with
or without litigation proceedings.

To provide a clinical description of the disorder and to demonstrate some of the features which can be helpful in
establishing the diagnosis, several cases will be briefly described:

Example 1. A 20-year-old Navy jet mechanic was admitted to the hospital with a three month history of a "constant
squeezing tense pain," which was worse than anything he had ever had before. He had seen several doctors and had
multiple medications prescribed without the slightest relief. He was referred to the hospital with orders for admission from his
base. When asked about his expectations of what the hospital might be able to do for him, he said; "I hope I can get my head
back together." (In my experience, this is a very unusual response - in evaluating over 100 patients hospitalized with
headache it has been extremely unusual if they didn't want to get rid of their pain first and foremost). He said his symptoms
became worse with prolonged standing and were completely relieved by lying down for 15 minutes. During the neurologic
examination he held his head and insisted on lying down, but frequently smiled and joked with the examiner. Despite normal
strength on
his exam, he complained of right-sided weakness, and on the sensory examination he felt "a 1% difference" in vibration and
pinprick on the right, compared to the left. All other examinations were normal.

During his hospital stay he never requested pain medication, but he continually requested a change in duty station,
because he felt it was the only thing which would help relieve his headache. This prompted further exploration of his feelings
about his work and significant past history. At first his explanations for wanting to leave his base were vague; he mainly felt
that he "wasn't getting anywhere there."

Of significance was that his father had had headaches so severe that he had to miss work and lie in bed without moving
his head. He would refuse to go to the doctor so the patient's mother had to take care of him. His father died four years prior
to the patients admission and his mother had remarried three months prior to the onset of the patient's headaches. He said
with a trace of disgust, that his stepfather was "an OK guy," but he no longer wished to visit with his mother or return home
anymore.

During the initial interviews the patient insisted on only talking while he was lying in bed. He appeared surprised when the
examiner suggested to him how similar his behavior resembled what he had said about his father. After this session, the
patient wanted to try and sit up in the doctor's office and began to show improvement.

It is apparent in this case that the patient had identified with his father's symptoms, but was totally unaware of this. He felt
abandoned and alone when his mother had remarried and displaced many of these feelings onto his job, where he no longer
felt he was getting anywhere, or being noticed.

DISCUSSION

One of the most striking features observed in cases of conversion headache is the delay in diagnosis. In many cases there
is an initial feeling that emotional factors are playing a major role in the headaches, but it is not until after several sessions and
tests that the diagnosis becomes clear. This should not be taken to mean that the diagnosis cannot be made initially, or that
others have not made the diagnosis quickly, but from my experience and from cases described in the literature, the diagnosis
is seldom easy.

A most notable feature of conversion headache is that it does not stand out in any remarkable way from many other types
of headache. Most headache patients have normal neurological exams and laboratory studies, and emotional factors which
often play a large part in pathogenesis. Also, one seldom finds major abnormalities in the mental status of patients with a
conversion reaction.

So how do we diagnose this problem? Or why is it that we so seldom make the diagnosis? I believe the key lies in the
history obtained during the first interview. Although at times we can say that the physician does not take an adequate history, I
believe in many cases an adequate attempt is made to discover what the patients life is like and in a passive or angry way the
patient initially denies any disturbing emotional relationships or events in his life.

This initial denial occurs frequently and is what the conversion reaction is all about. Anxiety, instead of being consciously
experienced, is converted into functional symptoms that usually symbolize the underlying mental conflict. This most likely
provides the basis for why we don't know what is wrong with the patient initially, because he doesn't really know either, except
that he has the most common symptom afflicting man, the headache. And if the symbolism is good enough to fool him, it is
usually adequate enough to fool his physician as well. The conversion mechanism, relieving anxiety to some extent, probably
also explains the patients relative calm, or indifference, about his symptom. This affectual indifference to the headache is
perhaps the most frequent and suggestive finding for a conversion headache.

The denial on the part of the patient of any emotional difficulty also occurs frequently with other headache patients, but it
should not discourage us from a careful evaluation of the patients situation preceding and/or accompanying, the onset of the
headache. The coincidence of an acute emotional state and the appearance of headache is suggestive, especially if the
connection between the psychological event and the symptom is unrecognized by the patient. A relative or close friend may
clarify many confusing areas in this instance, whereas further direct questioning of the patient will probably be of no further
benefit. He must essentially be allowed to tell his own story, at his own rate. Often a bizarre or unusual account of the
symptoms may be presented that does not resemble the usual headache syndromes, such as, "it feels like an ax dropping on
my head."

A key mechanism in the development of the conversion headache may be the patients identification with symptoms of a
person with whom he has a close relationship. This identification is commonly with a person who has recently died.13,14 Cases
of conversion headache have developed following the suicide of someone close to the patient, who had shot himself in the
head.3
It is important for the doctor to ask himself what purpose the symptoms play in the life of the patient. In many instances,
the patient is incapacitated for social activity or employment by his headache, which helps differentiate the conversion
headache from the muscle contraction headache. This secondary gain, even if fairly apparent, may be misleading. In the case
presented, it would have been quite easy to blame the military for the patients difficulties, especially if his understanding
physician would have felt the same way.

One should also consider whether the patient is

emotionally immature. Even though today the diagnosis of a conversion reaction is not thought synonymous with "hysterical
personality," it seems that many sufferers have such a personality make-up.15 It may also occur in other settings, such as
obsessive-compulsive neurosis or depression.

A thorough examination is essential in all cases to rule out the "real problems" that may present in a bizarre fashion, and in
itself, it may give clues to the diagnosis. As a rule, patients must be convinced that the cause is not an organic ailment
because they are usually convinced that it definitely is. It must always be kept in mind that the laity still look upon neurosis as
shameful, and on organic ills as bearing no stigma. Psychological testing may help to confirm the clinical findings.16
In summary, we may begin by stating that conversion headache is usually not an easy diagnosis to make. It is seldom
diagnosed in the initial evaluation because of a vague and sometimes inadequate history, subtle symbolism, and no major
abnormalities in the mental status. It is important then to think about this disorder and make further observations which
suggest its presence. There may be a satisfied indifference, often despite bitter complaining, bizarre or unusual symptoms
sometimes described in a dramatic manner, exaggerated complaints of pain, early passive or angry denial of any emotional
difficulties, or a headache, sometimes chronic, which has not responded to any medications.17 A possible precipitating event,
not recognized by the patient is also important, and one should consider the gains for the patient, an immature personality,
and possible psychological testing to help confirm the clinical impression.18

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3. Rosenbaum M: Symposium; psychogenic headache. Cincinn J Med 28:7-16, 1947.

4. Rangell L: Psychiatric aspects of pain. Psychosom Med 15:22-37, 1953.

5. Seidenberg R: Psychosexual headache. Psych Quart 21:351-360, 1947.

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7. Moench LG: Headache. Chicago, Year Book Publishers. pp 196-208, 1951.

8. Boag T J: Psychogenic headache in Vinken PJ and Bruyn GW (eds): Handbook of Clinical Neurology, vol. 5.
Amsterdam, North Holland Publishing Co., pp 247-256, 1968.

9. Aring CD: Emotion induced headache. Postgrad Med 56:191-195, 1974.

10. Packard RC: What is psychogenic headache? Headache 16:20-23, 1976.

11. Ad Hoc Committee on Classification of Headache: special report. J Amer Med Assoc 179:717-718, 1962.

12. Alexander F: Emotional factors in cardiovascular disturbances in psychosomatic medicine. New York, W.W. Norton
and Co., pp 155-157, 1950.

13. Brenner C, Friedman AP and Carter S: Psychosom Med 11: 53-56, 1949.

14. Friedman AM and Kaplan HI: Comprehensive textbook of psychiatry. Baltimore, The William and Wilkins Co., p 882,
1967.

15. Kolb LC: Modern clinical psychiatry, 8th ed. Philadelphia, W.B. Saunders Co., p 413, 1973.

16. Harrison RH: Psychological testing in headache: a review. Headache 14:177-185, 1975.

17. Kudrow L: The enigma of conversion cephalgia. Headache Update 2:7, 1977.

18. Packard RC: Psychiatric aspects of headache. Headache 19:168-172, 1979.