Headache . . . is NOT a Mental Illness

I know of no other disease that has such a stigma as headache disorders.  I suspect that the major reason is there has always always been a mystery around headache causes, that it was assumed to be a mental health issue. But another, and more cynical, reason I am sure is the fact that women suffer from it more than men.  We understand why and it has more to do with the constant rising and falling of estrogen than any mental weakness.

But if you think back to the Victorian age, or further, you would have noticed that women missed more functions than men due to being in bed with a “sick headache.”  The male dominated society (at the time) quickly assumed that the difference had to do with mental toughness.  This stigma quickly got translated into the notions of “stress headaches” or “tension headaches.”

The fact that I have a headache clinic makes many of my social friends assume that that I am a psychologist.  Years ago I left a major headache center (MHNI in Ann Arbor) to work in primary medical care in a slum outside of Cairo, Egypt.  All of my belongings got left in Cyprus (a long story). I started to find some of the unusual headache syndromes in this slum, such as CPH.  I had only worked in headache disorders for about four years at that time so (unlike now) I needed my headache textbooks to help me navigate treatment protocols. I put in a request to our humanitarian organization to send down my headache text books. The next thing I know, the organization was setting up an appointment for me to see a psychiatrist back in the US because they had heard rumors that I was suffering from a lot of headaches.

What brings this to mind at this time are several things.

First of all, I had two patients encounters that, I would say, sent me some frustrations related to this stereotype.   In the first case, it was a patient whom I’ve been seeing for about a year and a half with a post-traumatic headache disorder.  This 52 year old man had never had headaches in his life. Then, about 18 months ago, he was struck in the back of the head with a 80 lb metal object at work and knocked unconscious.  He immediately awaken with a severe headache right where he was hit.  He had a CT scan, which was normal, and later a MRI, which too was normal.

The man continued having the same headache up until the present time.  Post-traumatic headaches have been well documented.  The International Headache Society declares that it is reasonable to consider a post traumatic headache for any headache that comes on within 2 weeks of a head or neck injury.  This man was typical.  More recent studies are showing that as many as 30% of people with such injuries, or sometimes even minor injuries, are left with this aftermath, sometimes for years.  Of course the head scans are always normal. A normal scan means nothing.

I was treating this man for post-traumatic headaches.  Then L and I sent him for an independent evaluation with a neurologist (a neurologist with no headache training). The neurologist declared that his headaches had nothing to do with the injury because his scans were normal and that his headaches were a emotional response to life stresses.  I sensed a great injustice in his case as now his headaches are being denied as a work-related injury and they have completely changed the man’s life.

The second event was a new migraine patient that I saw.  She has suffered for headaches in a typical way, from her teen years. But they are getting worse as she approaches menopause. This is also a typical pattern.  I was 100% sure she had migraine as she met all the criteria.  I spent 90 minutes going over her case with her, and a very detailed treatment plan.

A month later, I saw her back.  She told me that she had done nothing on the plan because she saw her primary physician back after seeing me.  He put his hand on her back and said he could tell that she was tense and that she carried her tension in her neck and head. Therefore all her headaches were “tension-stress headaches.”  He put her on Prozac.  Prozac is a very poor migraine preventative medication. However, she choose to believe his  idea rather than mine.  I regret that because I want her to be well.

In the International Headache Society’s diagnostic criteria for headache, “Tension Headache” no longer exist.  There is a headache type, which headache clinics in American rarely use, called, “Tension-type Headaches.”  I was around when this definition was created.  Basically it was felt at the time that the research of the 1980s was showing that the headaches we use to call “Tension Headaches” were NOT simply caused by tension, therefore (we still didn’t know what to call them) we would use the term “Tension-type Headaches.”

Can stress cause headaches?  Never. But, to make myself clear, it can worsen them. It is exactly the same for asthma or diabetes. Does stress cause asthma or diabetes?  Never.  However, a really stressful day can exacerbate a asthma attack or increase someone’s blood sugars.

If you are prone to headaches from a well-known (at least well-known among headache specialist and researchers) genetic predisposition  or trauma,  and you have a really crappy day (or week, or month or year) the headaches can get worse. There is place for behavioral therapy to help in the over all treatment of headaches.  A lot of people need mental health treatment BECAUSE they have headaches so often.

We all have stress.  We all can have our mental health problems, some far more serious than others. But headache is NOT a mental health disease in itself.  When it is treated as a mental health disease . . . patients rarely get well.