Psychological factors and headache

Ronald S Kaiser PhD (Dr. Kaiser of Thomas Jefferson University has no relevant financial relationships to disclose.)
Jennifer Kengeter PsyD (

Dr. Kengeter of Thomas Jefferson University has no relevant financial relationships to disclose.

Natalie Chaykin MA (

Ms. Chaykin of Widener University has no relevant financial relationships to disclose.

Daniel Cohn MS (

Mr. Cohn of LaSalle University has no relevant financial relationships to disclose.

Stephen D Silberstein MD, editor. (

Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, receives honorariums from Allergan, Avanir Pharmaceuticals, Curelator, Depomed, Dr. Reddy's Laboratories, eNeura,  INSYS Therapeutics, Lilly USA, Supernus Pharmacerticals,  Thernica and Trigemina for consulting. He is also the  principal investigator for a clinical trials conducted by Alder Biopharmaceuticals, Amgen, electroCore Medical, Lily USA and Teva.

Originally released April 22, 1994; last updated March 14, 2019; expires March 14, 2022


Psychological factors and their role in headache have been known for centuries and possibly millennia. In the past, it was believed that headache was caused by psychological factors; however, it is now recognized that headache is a complex biomedical disorder in which psychological factors can play a contributory, maintaining, and/or reactive role. The authors describe the interaction of psychophysiological factors with headache syndromes, the evidence for genetic and environmental factors, and novel forms of nonpharmacologic therapies for the headache patient with psychological accompaniments. This update highlights research on psychological factors in headache-related disability and advances in cognitive behavioral treatments for headache.

Key points


• Although headache is almost always a biochemical disorder, psychological factors often play a contributory role in headache onset and/or a reactive role in headache maintenance.


• There is a high level of comorbidity between headache and psychiatric disorders such as depression and anxiety.


• Because headache has a major impact on quality of life, psychological interventions such as psychotherapy and biofeedback are not only useful adjuncts to medication therapy, but also permit patients to be actively involved in managing their lifestyles.

Historical note and terminology

The relationship between psychological factors and headaches has been observed for hundreds of years. The ancient Greeks and Romans were aware that emotional distress often triggered headaches, particularly migraine headaches. In 1743, Junkerius wrote that the primary cause of migraine is anger, especially when it is tacit and suppressed. In the 1880s, Breuer and Freud reported that many patients headache complaints disappeared after a cathartic experience or a state of improved emotional equilibrium had been reached (Breuer and Freud 1955).

The term "psychogenic" headache was introduced in the 1930s, when the field of psychosomatic medicine was developing. Psychogenic headache was considered to be "symbolic distress" relative to head function rather than distress originating in psychophysiologic mechanisms (Kolb 1959). Weiss and English stated that psychogenic headaches were "reflex headaches" in that they were caused by conscious or unconscious emotional stress (Weiss and English 1943). Headache improvement was noted following emotional releases (Kolb 1959).

Harold G Wolff, in summarizing his research regarding psychological factors in headache, wrote, "Since the human animal prides himself on 'using his head' it is perhaps not without meaning that his head should be the source of so much discomfort...the vast majority of discomforts and pains of the head...are accompaniments of resentments and dissatisfactions" (Wolff 1963). Because the head is commonly regarded as the portion of the body that controls consciousness, memory, talent, intellectual activity, cognition, and judgment, we begin to understand how the patient may use the complaint of headache as a means of expressing anxiety. To the lay person, the terms "head" and "brain" are often synonymous (Kolb 1959).

In the past, the terminology used by clinicians to describe psychological or psychogenic headache has often been vague and inadequate (Boag 1968). In a survey conducted among physicians at a large medical center, numerous definitions were given for the term "psychogenic headache," with tension headaches, headaches with no organic basis, and headaches secondary to stress being the most frequent (Packard 1976). Over time headache has been determined to be a medical rather than purely psychological disorder. It has been suggested that the term "psychogenic headache" should not be used, or used only when a peripheral pain-inducing mechanism is nonexistent (Packard 1976). However, this often causes conflict when one tries to determine whether a patient's headache pain is "real" or "not real" (Packard 1983). The patient's headache or complaint of head pain must always be approached as real. The emergence of the biopsychosocial model changed our view of headache incorporating the biological, psychological, and social variables that impact headache (Andrasik et al 2005).

Headaches that had been primarily considered psychogenic have historically met the criteria for somatoform disorders. Somatoform disorders were characterized by physical symptoms for which no known organic findings or physiologic mechanisms could be identified and for which there was a strong presumption that the symptoms were linked to psychological factors (American Psychiatric Association 2000). A somatoform disorder is different from a malingering or factitious disorder, in that a patient intentionally produces symptoms for the purpose of a specific gain. In the DSM-4-TR, somatoform disorders were subdivided into conversion disorder (loss of physical functioning that suggests a physical disorder), hypochondriasis (preoccupation with or the belief that one has a serious disease in spite of evidence to the contrary), somatization disorder (recurrent and multiple somatic complaints, often including headache), and somatoform pain disorder (preoccupation with pain without organic pathology). The publication of the American Psychiatric Association s Diagnostic and Statistical Manual-5 has resulted in substantial modifications to the conceptualization of somatization. The DSM-5 has removed the subdivisions of somatoform disorders and has categorized them under the umbrella term somatic symptom disorder (SSD). Another change to the DSM-5 criteria is that a diagnosis of somatic symptom disorder allows for symptoms that have a medical explanation. Thus, a cancer patient experiencing disproportionate and excessive thoughts, feelings, and behaviors related to their illness may qualify for a diagnosis of somatic symptom disorder (American Psychiatric Association 2013). This consolidation of disorders was developed in part to facilitate use in nonpsychiatric settings. Thus, headache patients overly focused on headache symptoms could now be diagnosed with somatic symptom disorder, in addition to those patients whose headaches are obviously exacerbated or aggravated by psychological factors (American Psychiatric Association 2000).

In 2013 the International Classification of Headache Disorders, 3rd edition, was released by the International Headache Society (Headache Classification Subcommittee of the International Headache Society 2013). Included was the heading of “12. Headache attributed to psychiatric disorder,” along with subheadings “12.1 Headache attributed to somatization disorder” and “12.2 Headache attributed to psychotic disorder.” When a headache disorder develops for the first time in close temporal association to a psychiatric disorder, it may be coded as a secondary headache that is attributable to that psychiatric disorder.

Secondary headache is defined as headaches that occur as a result of head traumas, whiplash, neck conditions, or rhinosinusitis and resolve in the majority of cases. However, in some cases, these headaches remain chronic. A study found that in those cases that remain chronic, the patients had significantly higher levels of psychological distress and neuroticism (Kristoffersen et al 2018). Psychological distress was measured by the Hopkins Symptom Checklist-25. Neuroticism was defined as neurotic personality traits and symptoms of moodiness, nervousness, being easily irritated, lack of endurance, and feelings of guilt and worry, as measured by the Eysenck Personality Questionnaire.

When a preexisting headache syndrome is worsened in association with a psychiatric disorder, the patient can be diagnosed either with the preexisting headache disorder, or as a headache attributed to the psychiatric disorder. The particular diagnosis of headache attributed to psychiatric disorder becomes definite only when headache resolves or improves after effective treatment or resolution of the psychiatric disorder. Criteria for these coded diagnoses are now available:

12.1 Headache attributed to somatization disorder


A. Headache, no typical characteristics known, fulfilling criterion C
B. Presence of somatization disorder fulfilling DSM-IV criteria:


1. History of many physical complaints beginning before the age of 30 that occur over a period of several years and result in treatment being sought and significant impairment in social, occupational, or other important areas of functioning


2. At least 4 pain symptoms, 2 nonpain gastrointestinal symptoms, 1 sexual or reproductive symptom, and 1 pseudoneurologic symptom


3. After appropriate investigation, each of these symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance or medication; or, if there is a related medical condition, the complaints or impairment are in excess of what would be expected from the history, examination or laboratory findings


C. Headache is not attributed to another cause

12.2 Headache attributed to psychotic disorder


A. Headache, no typical characteristics known, fulfilling criteria C-E
B. Delusional belief about the presence and etiology of headache occurring in the context of delusional disorder, schizophrenia, major depressive episode with psychotic features or other psychiatric disorder fulfilling DSM-IV criteria
C. Headache only occurs when delusional
D. Headache resolves when delusions remit
E. Headache is not attributed to another cause


In the meantime, it must be recognized that there is an interplay between medical and psychological factors that makes it difficult to confidently identify pure psychogenic headaches.

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