Headache and Heartache: The Case of Anna
Contributing Clinician: Daniel P. Kohen, MD
Daniel P. Kohen, M.D. is Professor of Pediatrics and Family Practice & Community Health, and Director of the Behavioral Pediatrics Program, University of Minnesota Medical School. Dr. Kohen is a Fellow of the American Academy of Pediatrics, the American Society of Clinical Hypnosis, and the Society for Clinical and Experimental Hypnosis. He has served 2 consecutive two-year terms as President of the American Board of Medical Hypnosis. Dr. Kohen is the co-author of the classic textbook Hypnosis and Hypnotherapy with Children and has published over 50 journal articles. He was the Distinguished Lecturer for the 45th Annual NESCH Workshop held on May 6-7, 2000 at the Newton-Wellesley Hospital, Newton, MA.
Chronic headaches since January 1998. No aura reported, no sensory phenomena reported.
Positive for familial lipidemia and hypercholesterolemia, as well as elevated liver function tests. MRI was normal; sleep-deprived EEG suggested “possible small seizures.” She had failed a series of medications trials, including Amitryptaline, Depakote and Tegretol, all of which produced troublesome drowsiness and no significant relief. She was on no medication at the time of her presentation. Her father suffered from migraine and familial lipidemia, which contributed to his death.
Family history is notable for the death of her father at her age 11, and for multiple deaths of extended family members within a 16-month period surrounding his death. Although Anna’s presenting complaint was of headache, she gave the overall general impression of being depressed; (she did not meet criteria for clinical depression.) The patient’s psychosocial history was otherwise normal: she was an average student, had friends, and was involved in extracurricular activities.
Anna reported two types of headache: a tension headache, which was constant @ 7-8/10, and bitemporal migraines twice a month, accompanied by nausea, flushing, pallor, dizziness, and fatigue. History of daily tension headaches during her 4th grade year. A variety of medications had been tried without success, and the headaches had remittted spontaneously. Just after her great-grandmother died (8/97), Anna “just kind of fell apart, saying she couldn’t cope,” said her mother. The chronic tension headache and intermittent migraines then began in 1/98. Noteworthy were migraines occurring on the date of her father’s birthday, the anniversary of his death, and on visiting a previous home. Assessment focused on the interlocked problems of Unresolved Grief and Chronic Migraine Headache.
In the 1st session, the idea of self-monitoring leading to self-regulation was introduced with a 1-12 scale for headache pain to be recorded each evening on a “headache calendar”. Positive expectations were introduced, with the suggestion (in the waking state) that “I was 100% certain I could help her to help herself, providing that she didn’t need the headaches for anything.”
I pointed to the file cabinet and asked her if she knew what was in there. She responded: "files, papers, books, etc." I agreed and added "Headaches are in there 'cause I collect them. If you miss them, and want them back, I'll give them back...but in the meantime you can send me all your past, present, and future headaches..." I smiled and said "I know it sounds weird, but just let yourself think about it."
I asked Anna to "tell me about your Dad?" She quietly shook her head no, but agreed when I gently suggested, " perhaps some other time, then?" Tears welled up and thereafter she spoke much less in the interview..
In the 2nd session two weeks later, she was taught to differentiate psychological distress from physical pain by asking her to create a 1-12 point “paying attention to it” scale for her headaches, to be used in addition to the pain intensity scale. Grief work was initiated by asking her which death (of the several family members she had lost) she wanted to discuss first. She discussed these losses in the order she chose, and she ended with her father’s death 3+ years ago. When asked if she thought that being sad and missing her Dad had anything to do with headaches, she said “yes” very definitively. She was then told that “sometimes people are very surprised. . . that after they have let difficult feelings out, like today, that . . . the feelings don’t have to come out ‘sideways’ . . . like through headaches or stomachaches.” While formal trance was not induced, she appeared to be in a trance-like state throughout the grief-work.
After appropriate education about hypnosis and biofeedback for the patient and her mother, Anna was taught how to enter trance. Using a combination of biofeedback measures and hypnotic suggestion, the patient created a visual image to gauge the intensity of her headache (a blue ruler with black letters). She was then asked to give the headache pain a color (red) and to determine the “color of no headache” (white).
Anna was then told various stories of what other children have done to reduce headache. These included an elevator metaphor ( "watching the numbers go down as the headache becomes less intense") and the story of the little girl “who didn’t like elevators who used a slide into a cool pool of water sometimes.” She was instructed to practice twice daily, with the self-induction of “imagining something fun,” and then reducing the intensity of the headache by using whatever images came to her mind. Anna was asked to make a note on her calendar when she practiced. She was also taught to use the Bioband peripheral temperature home device to monitor the hypnotically-amplified increase in blood flow to her extremities.
By the 4th visit one month later, she was remarkably improved; her headache ratings showed a 33% improvement over the visit two weeks earlier, both in pain intensity and in distress. She reported practicing for 20-30 minutes per night, and was using a variety of hypnotic images to visualize pain reduction. In a “waking suggestion” Dr. Kohen asked her to speculate about the future and when the next 1/3 improvement would occur and she said “two months”.
At the 5th visit two months later, Anna had shown no more improvement. The session was audiotaped at her request. She was asked to provide details about the imagery she was using to reduce headaches, and these details were integrated into a formal trance induction. Direct suggestions were offered that she would begin “paying attention to the tension and how tension goes away and the way that you do that”, being pleasantly surprised at how good she was getting at this, and how effective she was becoming . Additional suggestions for “being proud of what you have done for yourself,” for “the gift of your own imagination” and “being the boss of how you feel.”
The 6th visit took place about one month later, and the patient reported that she had had no headaches at all since the last visit (which had been at the two-month mark she had estimated to be headache free). She was taught to do rapid self-hypnosis as a “stress immunization” throughout the school day.
On the 7th visit 2.5 months later (12/99), she remained virtually headache free. The visit ended by asking Anna “How will you know when it’s the right time to stop coming for appointments?”
At the 8th and final visit, the patient continued headache free. When asked why she didn’t have any more headaches, she said matter-of-factly “because of self-hypnosis...I do it before I get a headache. . .I know when I’m gonna get one because I can feel it in the back of my eyes. . .” She was educated about aura. She reported that this aura occurs once a week, usually in the afternoon, but “I just do my self-hypnosis and it goes away. . .!” She reported that she was using self-hypnosis, the Bioband device, and the audiotape intermittently (i.e., PRN.) No further follow-up was scheduled.