Sign Up for a Free Account
  • Updated 12.20.2023
  • Released 04.22.1994
  • Expires For CME 12.20.2026

Psychological factors and headache



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, 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 patient with headache and 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 or a reactive role in headache maintenance.

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

• It is hypothesized that psychiatric comorbidity is a risk factor for medication overuse, causing worsening headache frequency or chronic headaches.

• 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 (19).

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 (61). Weiss and English stated that psychogenic headaches were "reflex headaches" in that they were caused by conscious or unconscious emotional stress (115). Headache improvement was noted following emotional releases (61).

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" (117). 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 layperson, the terms "head" and "brain" are often synonymous (61).

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 (09).

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 (07). 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 (DSM-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 (08). 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 (07).

In 2013 the International Classification of Headache Disorders, 3rd edition, was released by the International Headache Society (53). 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 (64). 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 four pain symptoms, two non-pain gastrointestinal symptoms, one sexual or reproductive symptom, and one 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 patients with headache disorder co-occurring with psychiatric disorders without any evidence of causal connection, both headache and a separate psychiatric diagnosis should be made (53). 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.

This is an article preview.
Start a Free Account
to access the full version.

  • Nearly 3,000 illustrations, including video clips of neurologic disorders.

  • Every article is reviewed by our esteemed Editorial Board for accuracy and currency.

  • Full spectrum of neurology in 1,200 comprehensive articles.

  • Listen to MedLink on the go with Audio versions of each article.

Questions or Comment?

MedLink®, LLC

3525 Del Mar Heights Rd, Ste 304
San Diego, CA 92130-2122

Toll Free (U.S. + Canada): 800-452-2400

US Number: +1-619-640-4660



ISSN: 2831-9125