Psychophysiological disorders of the musculoskeletal system can easily blend with actual physical problems or with the symbolic
ex-pressions of conversion neurosis. In many cases it is difficult to make a differential diagnosis, particularly when pain is the primary symptom.
Hypnosis may at times be useful in deciding whether pain is organic or functional. Organic pain tends to recur more quickly after hypnotic treatment than does pain of functional origin. This rule does not hold where there is strong secondary gain, where the underlying psychody-namic conflict is particularly strong, or where repeated sessions of trance have increased the effectiveness of hypnosis. Used with due respect for other signs and symptoms, however, such observations may help in establishing the diagnosis.
Headache
This widespread disorder may arise from a variety of causes, emotional or physical, sometimes far removed from that place where the pain is felt. The brain itself is free of pain fibers, except around the blood vessels, so that most headache is of extracranial origin. Intra-cranial causes of headache, such as brain tumors or expanding intra-cranial masses, act through traction or strain on the coverings of the
brain or the blood vessels. Migraine headache is probably caused by a contraction of cerebral blood vessels followed by an overdilation that produces pain. It may respond to medications that cause vasocon-striction, such as ergotamine preparations. Extracranial causes of
headache include temporal arteritis, eye strain, pain from the sinus cavities, and pain originating in other structures of the head and neck.
The most frequent cause of headache, however, is " t e n s i o n , "
resulting in muscular pain. The pain of tension headache generally occurs in the occipital region and the forehead, though it may present in any part of the head. It most likely arises from prolonged contraction of muscle—the neck muscles, the muscles of the j a w s , or the muscles of the forehead and scalp.
Many times the headache can be associated with some definite area of identifiable stress, such as crisis in a marriage, unpleasantness with persons at work, or particular problems with children. One woman had headache of uncertain origin, having had a thorough neurological examination without any organic cause being identified. We asked her to keep a diary that would record for each day the presence or absence of headache, its intensity, its relation to her menstrual cycle, the
presence of edema on a one-to-four scale of increasing intensity, and any important emotional interaction that occurred during the day.
After keeping the diary 2 weeks, she reported only one headache.
Inquiry revealed that she had awakened with the headache the morning
that her ex-husband was to come to take their 8-year-old son for a visit.
The night before the headache she had dreamed that she was pursued by someone who was going to take her child away, and there was nowhere to escape from him. Only after her feelings about her
ex-husband had been explored did she reveal the depth and complication of her difficult relations with her present marriage partner. The use of hypnosis was postponed until she more thoroughly understood the emotional origin of her headache.
Hypnosis may be helpful for headache of either functional or organic origin, but it should be used only when there is relative certainty that there is no serious organic etiology to be treated. If the headaches are on a functional basis, the underlying conflict should be identified, if possible, and treated in addition to seeking symptomatic relief of pain.
Our hypnotic suggestions follow the formula, " Y o u r headaches will become less intense, less in number, less in frequency, and will become less debilitating. They will diminish in intensity until you are ready to give them u p . " It is important to note the permissive cast of the suggestion that the headaches will diminish "until you are ready to give them up." This permits the patient to retain the headache, perhaps in a diminished form, if it is serving a necessary function in his
unconscious conflict.
T h e suggestion is always given that the patient will be able to have a "normal headache" but that this type of headache will " p a s s away normally." This is to prevent the hypnotic suggestions from interfering with headache that might arise from other causes. Usually a self-hypnosis procedure also is employed. The patient is told, while in trance, that should a headache begin he or she will be able to stop it by putting his or her right hand on the abdomen, closing the eyes, and giving himself or herself suggestions for pain relief similar to those that
have been given during treatment sessions.
In a study of 48 patients, Schlutter, Golden, and Blume (1980) found no significant difference in pain relief in hypnosis compared with fontalis electromyographic feedback, and biofeedback combined with Jacobson progressive relaxation. Hypnosis alone was as effective as biofeedback, and biofeedback combined with relaxation was equally effective. Drummond (1981) has reviewed 10 years of literature of
hypnosis in the treatment of headache.
The usual duration for treatment of recurrent headache by hyp-nosis is about 3 months (weekly visits), and the success rate seems comparable to that for inhibiting the smoking habit.