Hypnosis and Suggestion in the Treatment of Pain

“I FEEL LIKE I lose nearly a week out of my life every month. It’s like the pain is a monster, consuming me, starting with my head, crushing it in a vise. Taking the medication is like taking water, it just doesn’t help. I’m so miserable, I can’t stand this anymore!”

When she is not felled by the pain of a migraine, Helen is a charming, optimistic 34-year-old woman, married, with two young children, who writes a popular opinion column for one of the nation’s most widely read newspapers. Since the birth of her second child, five years ago, her menstrual cycle has included migraine headaches of increasing intensity.

“I’m afraid I’m going to lose my grip on my life. Not only am I useless during the four days of my monthly headache, but now I am beginning to anticipate those days, feeling increasingly anxious and irritable before the headache even begins. My kids are going to think I’m nuts! My husband is going to run out of patience with me. Please, can you help me?”

Helen’s case will be familiar to any clinician who treats patients with headache. What to do for Helen, and patients like her, is the subject of this chapter.

Though the etiology of headache is complex and varied (see Oleson & Bonica, 1990, for a full review of headache), here I am simplifying the problem by collapsing the many headache categories to the following few, which encompass most of the headaches likely to be treated by psychological methods: migraine headache, muscular tension headache, cluster headache, vascular headache, and posttraumatic headache.

Migraine headache is a frequent source of disabling pain, producing greater impact on social and work activities than all other headaches. Recent epidemiological studies suggest that between 15 and 30 percent of adults suffer from the blinding, disabling pain of migraine (Oleson & Bonica, 1990, p. 697).

The International Headache Society has adopted the categories “migraine with aura” and “migraine without aura” to indicate the two distinctive types of migraine, although there are other, specific varieties of migraine as well, e.g., hemiplegic, opthalmoplegic, basilar, retinal, and facial.

Although there is a widely held notion that migraine is a result of primarily psychological factors, this belief is not supported by the evidence, which suggests a strong genetic factor in over 50 percent of cases (Selby & Lance, 1960). In women (who comprise about 75 percent of migraine sufferers), hormonal changes associated with the menstrual cycle may be the predominant etiological factor (Oleson & Bonica, 1990, p. 699). Food allergy or food intolerance is also a major source of migraine attacks. Food rich in tyramine (e.g., aged cheese, pickled herrings, red wine) is particularly likely to induce migraine attack in those persons who are susceptible. Although psychological stress facilitates migraine attacks in individuals who are biologically predisposed, it does not seem to be a common primary cause of migraine.

Simply stated, the pain of migraine is essentially the result of over-dilation of vessels in the scalp, meninges, and brain. This over-dilation produces mechanical stretching stimulation of nociceptors that surround these blood vessels, thus producing pain. This is a vastly simplified description, and there is much still to be understood about the pathophysiology of migraine. Nevertheless, this description may be sufficient for clinicians who treat migraine patients with hypnosis and suggestion.

Migraine headache is characterized by pain that is almost always unilateral (which gives the syndrome its name, from the Greek, “hemi-kranios”), pulses with each heartbeat, can be of severe intensity, and may be associated with nausea and sensitivity to sensory stimulation (primarily by light and sound). Persons suffering a migraine attack are nearly always disabled, for a period ranging from four to seventy-two hours. In practical terms, when a person experiences a migraine attack, it is likely that he or she will be unable to work that day, and perhaps the day or two following as well. The patient’s family and social life is, of course, disrupted.

In migraine with aura (formerly called classic migraine), the pain is preceded (usually by less than an hour) by an aura that, though idiosyncratic, is often characterized by early visual symptoms, which may involve a sense of flickering or shimmering light and may be associated with a developing sense of tunnel vision. There may be other sensory symptoms, including various dysesthesias.

In migraine without aura (formerly called common migraine), the onset of pain is not preceded by such an aura. Compared to migraine with aura, there are also other differences in the quality of the pain. However, these differences are not pertinent to our purpose here, of learning how to treat migraine pain with hypnotic techniques.

There is a wide variety of medications used in the treatment of migraine, most commonly ergotamine, aspirin, sumatriptan, beta blockers, calcium-channel blockers, and non-steroidal anti-inflammatory drugs. Although medication is of substantial benefit for most migraine sufferers, in some cases it is not effective and in others the side effects are so troublesome that patients are not appropriately compliant to support their effective use.

Assuming the appropriate medical evaluation has been done and that medical solutions are inappropriate to the case (or that hypnotic treatment will be an adjunct to these medical treatments), I have found that using posthypnotic suggestions is useful in the treatment of pain, in general, and migraine pain, in particular. It has been my experience, and that of colleagues with whom I’ve consulted, that the only successful way to relieve a migraine is to prevent it. That is, once the migraine attack begins, sufficient physiological changes have occurred and the intensity of the pain is such that only medication can provide any relief at all. In fact, once the attack has reached a certain point, it is my experience that only substantial doses of opioid medications can bring relief to the patient.

Using hypnosis to prevent the attack, however, can offer an effective alternative to medications. I encourage the patient to construe the prodromal aura as a signal for two simultaneous events:

1. Reversal of the physiological process leading to the migraine—namely, the gradual reduction in dilation of the vessels involved.

2. A rest period that makes the first event possible.

Sometimes, of course, patients suffer from migraines without auras. Since the treatment described above depends upon the perception of the aura as a signal (a posthypnotic cue, if you will), I suggest to such patients that they, in fact, do have an aura but that they have not yet noticed it. While this may not be strictly true, it is a useful therapeutic conceit.

Another complication occurs when a patient tends to be awakened from sleep by onset of the painful migraine attack (as happened to Elaine, whom I discuss below). In this case, I suggest to the patient that the aura is there to warn her of the impending migraine, even while she is sleeping; as with other important signals that occur during sleep, she can be awakened by the signal of the aura. I suggest that the aura will awaken the patient and that she will then respond to the aura by initiating the hypnotic procedure, just as if the attack had occurred during a waking period.

Although I have not always succeeded in helping patients relieve other kinds of headaches, all my migraine patients have benefited from hypnotic treatment. Six-month follow-up on twenty-six of my patients revealed that fifteen reported successfully averting migraine attacks each time they experienced an aura, eight had been successful with two episodes of failure each, and three reported success when the headache began while awake but failed completely when the headache occurred during sleep.

Elaine, a married mother of two children who owns her own business, was referred by her neurologist for treatment. She has suffered for five years, since the birth of her second child, from migraines that are associated with her menstrual period. Menstruation-related migraines are the most common of migraine. (Elaine’s case is reminiscent of Helen’s, described at the opening of the chapter.) Various medications have been tried, but none with success. When she develops a migraine, she is disabled for about three days. Almost completely unable to function, she remains virtually bedridden for the duration of the attack.

The intake interview was occupied by the usual history-taking and discussion of the problem and how it affects the patient. Because she was highly motivated and her headaches seemed to be uncomplicated by psychological issues, Elaine seemed to be a good candidate for psychological treatment—that is, she had headaches that disabled her and she wanted to be rid of them. In my judgment, Elaine also had realistic and healthy expectations about the role of psychological treatment, including hypnosis.

The first treatment visit involved no particular explanations or discussion, just a fairly rapid initiation of the hypnotic induction. I do not remember, and my notes do not reveal, what kind of induction I used. This, of course, does not matter to this discussion, since the induction can be independent of the therapeutic suggestions offered.

You are about to begin a very interesting process of learning how to use your mind’s capacity to work toward the greater health and well-being of your body.…

In the future, whenever you begin noticing the sensations of the aura, that will be the signal for your body to react in the following way:

When you first notice the sensations of the aura, you will stop whatever it is that you are doing [examples were given here, based on the activities she might be engaged in, including driving her car, working at her desk, etc.], you will find a place to sit back or lie back comfortably. After you are sitting or lying down, take a very deep, very satisfying breath and … hold it … hold it for a moment. Now, continuing to hold your breath, roll your eyes up as far as they will go, and just hold them there. Then, as you let your breath all the way out, without moving your eyeballs, allow your eyelids to close. Now … just allow yourself to sink deeply down into this experience of comfort and relaxation.

Whenever you do this … whenever you rest back, on a sofa, or a bed, or a chair … and take a deep, satisfying breath … and whenever you then roll your eyeballs up, as far as they will go, and, holding them there, slowly lower your lids … letting your breath all the way out, and relaxing your eyeballs … whenever you do this, you’ll find yourself suddenly and pleasantly recreating the experience you are having right now, here with me.

With your eyes closed, breathing comfortably, allowing yourself to become more and more absorbed by the comfort of your inner experience, you prepare your body to reverse the process of the headache. You will begin to notice that you see an image in your mind … an image of swollen blood vessels that are now very gently beginning to relax, beginning to reduce the swelling.…

Just watch carefully as the blood vessels begin to relax, to reduce that dilation, to promote normal blood flow throughout your body. Continue to breathe comfortably, and just watch the vessels continue to relax.…

You may find that, after a while, you drift into restful, restorative sleep … or you may find that, after twenty minutes or so, you find yourself sitting up, alert, relaxed, and noticing that the aura has gone away.…

By taking this time, by allowing your body to relax, you will be helping those blood vessels to reduce in size, and to reverse the process of the headache. You will not need to have any headache at all.…

But it is very, very important that … each time you notice the aura, this is the signal for you to automatically begin the process of reducing the dilation of your blood vessels. Always, and without fail, if you notice the aura, you will stop what you are doing, and follow the suggestions I have given to you.

This hypnotic treatment was followed by several minutes of coaching Elaine, so she could practice developing what amounts to a self-hypnotic experience. For example, I would ask Elaine to take a deep breath, hold it, roll her eyeballs up, as high as she could, slowly lower her lids … and then follow her inclinations. I would then observe her behavior, adding supportive suggestions to guide her into an experience that could be practically repeated whenever she developed an aura.

I could see that Elaine was able to produce an effective hypnotic experience in this way, based on my observation of her rapid relaxation and her ability to carry out posthypnotic suggestions. A few days later I saw her again to confirm that she could still produce the hypnotic experience. However, because the entire purpose of this treatment is to reduce pain, there was as yet no way to know if she would be successful. Since I wanted her to have an optimal chance to experience success, we made an appointment to meet at about the time that she would otherwise expect, given her menstrual cycle, to be experiencing migraine attacks.

At that next appointment, about two weeks later, Elaine indicated that she had awakened the previous morning, earlier than usual, with the sense that she was having a prodromal aura. She initiated the self-hypnotic treatment we had established for her and experienced much the same feelings as she did in my office. She did not have an attack.

At follow-up of one, two and three months, Elaine reported that she was continuing to avert the migraine attacks. However, seven months later she called to make another appointment, because she had had an attack the day before. At the subsequent meeting, she indicated that she had awakened several days before with an aura and had done what she had learned to do, but had, nonetheless, been unpleasantly surprised by the onset of a painful migraine attack about half an hour later. That attack had kept her bedridden for the day. She was feeling very discouraged, wondering if the hypnotic effect had “worn off.”

Upon more detailed discussion, it turned out that Elaine had probably gone back to sleep after awakening, and had not really followed through with the hypnotic procedure. I used hypnotic suggestions to reestablish in her mind what the hypnotic experience was like, and reminded her of the importance of going through the procedure entirely each and every time she thought she was having an aura.

Three weeks later, Elaine called to say she had successfully averted an attack. At follow-up three months later, she continued to be successful, and had not had another migraine.

Matt, an accountant, had begun experiencing migraine headaches about two years previously. He had also suffered with them in late childhood and adolescence, but with auras, and they had abated when he was 20. Then, over 30 years later, they had begun to recur, this time without auras. Over the course of the past two years, his neurologist had tried several combinations of medication, but to no avail. About twice a month, with no obvious precipitant, Matt was laid low by severe head pain and photophobia. Matt and his neurologist were interested in the possibility that hypnotic treatment might relieve his symptoms.

Intake revealed his circumstances to be within normal range, with nothing catching my eye. I suggested that we make four appointments to initiate hypnotic treatment. Matt expressed some ambivalence about this. On the one hand, he very much wanted to be free of the headaches; on the other, he was wary about the prospect of being hypnotized. He feared that this would mean surrendering his will to me. I attempted to put his fears at ease by discussing my understanding of hypnosis and how it alleviated pain—all without surrendering one’s will.

Several days later, I reminded Matt that we were going to use the power of his imagination to affect the physiological process that led to a migraine attack. Although Matt was very clear that he did not experience any prodromal warning of the headache, I suggested to him while he was hypnotized that, while he did not have the kind of aura common to many migraine sufferers, his body was sending him a warning of a more subtle kind. I didn’t know what form the warning took, but, I suggested, if he would allow himself to become very absorbed, now, by the process of his imagination, he might begin to remember a signal, however subtle, that had been associated with migraine onset in the recent past.

… take a moment, as I stop talking, and allow yourself to focus deep, deep down within you, to that awareness of yourself that feels most right, most true to you. Allow yourself to become completely absorbed in the sense that you can be aware of your body and its needs.

Now, from this place, allow yourself to remember back to the most recent headache. Remember back, minutes before that last headache. What sensation can you become aware of that signals to you that you were about to have a headache?

After several minutes, Matt was unable to report any significant awareness. I then suggested that he allow himself to remember back to the headache before that one, and the one before that, to discover what might be common to the antecedent conditions of each headache. With continuing support and encouragement, Matt finally reported that he had a vague sense of smelling something metallic. He could not be more specific than that—just a vague metallic smell.

That’s right. Something about the process that creates each headache also inexplicably produces a metallic smell for you. So I want you to know that, in the future, whenever you become aware of that same metallic smell, you will know that this smell is a signal for you to stop what you are doing as soon as possible, and to do the following.

I then gave Matt the same suggestions for developing a self-hypnotic experience for the purpose of averting the headache that I’d given Elaine. I repeated the suggestions, gave other posthypnotic suggestions for the purpose of evaluating his responsiveness, and then asked him to terminate the hypnotic experience.

Our appointment time was now at an end. If his headache frequency could be predicted from his recent history, it was likely that he would again suffer a migraine attack within ten days. I thought further practice would be helpful to insure success, so we made an appointment for three days hence.

At the second treatment appointment I asked Matt to imagine, for a moment, that he was beginning to experience the metallic smell and then to follow his inclinations. After a brief clarifying discussion (because he didn’t understand exactly what I meant—he felt odd just closing his eyes and ignoring me, he said), he took a deep breath, held it for several seconds, he rolled his eyes up, and, releasing his breath, closed his eyes and appeared to become quiescent and relaxed.

After two or three minutes, I asked him what he was aware of. He replied that he was feeling deeply comfortable and was observing with curiosity his blood vessels, looking for some that might seem swollen but not finding any.

I asked him to end the hypnotic experience and to find himself feeling alert and awake and well. As we repeated this process three times over the next half-hour, I became more and more confident of Matt’s responsiveness to the hypnotic treatment.

We then made an appointment that I thought would take place about when his headache would be predicted to occur. I also encouraged him to call me if he experienced anything out of the ordinary between now and then.

As it turned out, he did not have a headache, or any signal of one, by the next week, so he telephoned to discuss changing the appointment. We agreed to meet four days hence. Two days later, Matt called and told me, with some excitement, that about an hour earlier he had noticed the same metallic smell he’d talked about in my office. At that signal he had stopped his work and gone through the hypnotic procedure; he had developed a slight nauseated feeling but no headache. And he was now feeling fine.

Because he seemed to be doing well, we canceled the appointment and agreed to meet two weeks later. Doing so allowed us to confront a common complication in the treatment of migraines.

It turned out that, about five days after our telephone conversation about the apparent averted migraine, Matt was returning to his office from lunch and thought he noticed the metallic smell. He wasn’t sure, though, and waited to see if it became more apparent. By the time he’d reached his office, he was no longer aware of the smell sensation and began work at his desk. About 15 minutes later, he suddenly experienced a full-blown migraine attack. As instructed, he took the oral medication he’d tried previously and lay down in his darkened office. The headache continued to build, however, and disabled him for the remainder of that day and most of the next.

As I listened to Matt’s report, I was reminded that this is one of the greatest obstacles to patients’ reliable use of hypnosis to avert migraines. The patient isn’t certain that he or she is actually experiencing an aura and so ignores whatever had been noticed and continues to work, only to be surprised by the onset of a migraine later. Or, sometimes, particularly in patients whose work lives are very intense, the patient will notice the aura but, because of the press of work, develop a version of denial or put off cessation of work “for just a few minutes.” In fact, it is the subsequent onset of the full-blown migraine that causes them to stop working.

In Matt’s case, and in others of this type, I patiently but emphatically insist that the headache can only be averted by swift and timely response to the prodromal sign. Sometimes I remind them of Hobson’s choice in this context: If they mistakenly think they are experiencing an aura but aren’t, they will have unnecessarily stopped work for a while; however, if they mistakenly think they are not experiencing an aura, they will have unnecessarily lost at least a day of work to the subsequent headache. When nothing else has been persuasive, this last characterization often reveals to the patient the wisdom of acting swiftly and decisively, even if he or she is not certain that what is being experienced is a true aura.

Given the severity of migraine pain and the inexorable development of an attack once it has begun, it is a source of some mystification to me that this hypnotic treatment of migraine is so often effective. Even though other headache syndromes may not be so severe, they are not also quite as amenable to successful hypnotic intervention.

This is the most common headache type. Muscular tension headache is caused primarily by ischemia and fatigue of scalp muscles held under tension (either by poor posture—including “posture” of the mandible—or psychological stress or both). Because psychological tension is so often associated with this syndrome, the name “tension headache” conveys many people’s belief that the tension is psychological rather than muscular. However, in my experience, patients who suffer regularly from muscle tension headaches may best be treated by physical interventions.

For example, some years ago my dentist inquired if I had headaches. I did, with almost daily regularity, but had not really paid attention to them. (I had assumed them to be a function of the psychological tension I experienced while working at a pain clinic.) He evaluated my “bite” and concluded that the headaches were a result of chronic tension created by a very subtle malocclusion (Fricton, 1982, p. 25). A very brief and painless correction of the occlusion was accompanied by an abrupt cessation of the headaches.

More recently, I began to suffer frequent and severe muscle tension headaches and consulted a physical medicine specialist, who concluded that normal wear and tear on the cervical spine, in association with less than perfect spinal posture, resulting in pressure on cervical nerves, was precipitating these headaches. I was taught exercises to strengthen the appropriate muscles and others to correct my posture; gradually, these headaches improved. Occasionally, when I fail to keep up with the daily exercise regimen, I am presented with a headache to remind me to be more conscientious.

Although hypnosis can certainly be helpful with reducing the pain of muscle tension headache, it is only ameliorative, not curative. It is similar in its degree of amelioration to medication—aspirin, for example. However, some minutes or hours later, the pain will have returned, because the underlying cause for the pain has not been altered. Physical treatment, as discussed above, is essential for successful treatment. Although suggestions for relaxation might be adjunctively useful, it is my experience that physical treatments are the speediest and most effective means for reducing muscle tension.

Consequently, when patients seek treatment from me for this headache, I am most likely to refer them to a physical medicine specialist for treatment. I explained that this is far more likely to lead to a satisfactory outcome than hypnotic treatment; such corrective physical treatment is likely to cure, rather than palliate symptoms. There are exceptions, but as a rule such headaches can only be successfully treated by physical attention to the source of muscular tension.

Occasionally, but equally importantly, it is the case that the primary source of the muscle tension is emotional conflict, not poor posture. When this is so, it is appropriate to attend to the conflict’s source and the patient’s way of coping with it.

Durkin, a stenographer, had suffered from headaches since high school. His physician referred him to me after trying a variety of unsuccessful medical treatments.

As is always the case, I wanted to know about the source of Durkin’s tension. A hypothesis occurred to me several minutes into the intake interview. Durkin was a very small man, only slightly over four feet tall. He lived alone. According to him, he had no friends, and was not close to his family. He enjoyed his work, though he complained that typewriters were too large, the keys spaced too far apart for comfort. He also complained, as an aside, that furniture was generally too large. He wondered why people tolerated such uncomfortably oversized furniture. He expressed these complaints with a perfectly straight face, with no apparent ironic intent.

It became clear, as our conversation continued, that Durkin found the world to be an intimidating place, fraught with physical discomfort and the risk of physical danger. My hypothesis was that much, if not all, of his tension (both emotional and physical) was a function of living with this constant sense of threat.

Durkin’s physician had already told him that hypnotic treatment would be effective for him, so that is what Durkin expected from me. We arranged to begin such treatment the following day.

When we met the next day, Durkin reported that, as usual, he had a headache. He rated the intensity as 6 (out of 10), and rated it affectively as 8. Following hypnotic induction, I suggested to Durkin that his musculature would begin to relax very deeply, and that the pain would naturally reduce as his muscles relaxed. I spent some time repeating these suggestions and went to some effort to convey the deep level of relaxation I hoped he would experience. While hypnotized, he reported that he felt very relaxed, that he had no pain, and that he felt very well.

The problem, of course, involved extending the relief beyond the duration of the treatment appointment. How, I wondered, might I enable Durkin to feel safe enough in the world to maintain a reduced level of muscular tension? Unable to arrive at a satisfactory solution, I asked Durkin for his opinion:¹

Durkin, as you continue to rest very deeply, and remain very comfortable, I’d like to ask that the muscles of your voice become independent and active, so that you can talk with me even though you remain very, very relaxed.

Allow the muscles of your voice to begin now to become independently active, so that the muscles of your breathing … and of your larynx … and your jaw … and your tongue … and your lips … all of the muscles of your voice can now become independent and active. And you can tell me, now, what are you aware of right now?

“That’s fine. Now, Durkin, I want you to imagine that you can speak from the very deepest, wisest part of you, and you can tell me: What do you need to feel this kind of comfort all of the time?”

“That’s fine, but let’s just imagine that, deep within you, in that part of you that does sometimes surprise you with what you know … let’s imagine that you can hear a voice from deep within you. Even if you think you don’t know, just listen to that voice, and tell me what you hear.”

At this point, Durkin began to cry, very quietly. I remained in contact with him by making supportive, empathic statements, by expressing my interest in his feelings, and by expressing my gratitude for his willingness to talk with me about this painful subject. As I heard myself commenting aloud to Durkin about his courage, I began to formulate a plan for enabling him to feel less tense more of the time. After all, Durkin was being courageous by openly discussing with me a deeply painful topic (and one that I doubt he had ever spoken about before, with anyone).

I began gently to suggest to Durkin how important it was that he recognize his courage. I reminded him, too, that courage does not mean not being afraid. Because little time was left at this visit, I suggested to Durkin that he allow himself to think about his courage in the context of recognizing how frequently he was afraid but continued to function anyway. And I suggested that we could talk about this again. After giving him further suggestions for feeling less tense, for being less critical of himself, and for being curious about what we might accomplish at the next visit, we ended the hypnotic experience.

Three days later, Durkin arrived with what seemed to me a little less of the pugnacious quality in his demeanor than I had noticed previously. He said that he had a headache but that it was not “too bad.” He rated it with an intensity of 4 and affectively as 1. Responding to a posthypnotic cue, Durkin developed a hypnotic state and began to relax.

We resumed the conversation of a few days previously. I asked Durkin if he had had an opportunity to think about courage. He said that he had not, really, but that he did like what I had said about it before, that is, about his being courageous. We continued to discuss courage, and fear, and threat, and the fact that courage depended upon both threat and fear, and so on.

For the next 16 weeks, Durkin and I met weekly for hypnotic conversations about courage. He continued to report general relief from his headaches, though he occasionally suffered from them. He also reported that he was more confident now and that I had been right in the first place about his courage. He had decided that he was, in fact, a very courageous person.

At one-month, three-month, and six-month follow-up meetings, Durkin’s improvement seemed stable. He no longer complained of headaches, though he acknowledged that he sometimes had them.

Durkin’s treatment illustrates the fact that sometimes pain can be a symptom of a more fundamental psychological problem. In Durkin’s case, chronic anxiety seemed to result in chronic muscle tension, which resulted in headache pain. It was not possible, of course, to make Durkin taller. And it was not possible to change the way people responded to his short stature. It was possible, though, to facilitate a change in Durkin’s attitude toward himself. Although Durkin’s case demonstrates the dramatic improvement that can sometimes occur in otherwise intractable headaches, not every case has such satisfying results.

In summary, while most muscle tension problems are likely to be physically based, in some cases unresolved emotional conflict may need our attention. Artfulness may be required to orient the patient toward emotional aspects of the problem, especially if the patient tends to somaticize—and thereby to avoid awareness of emotional issues.

Cluster headache, like migraine headache, can result in very severe, even disabling pain. Cluster headache is unilateral, intense, accompanied by autonomic phenomena (e.g., lacrimation, rhinitis, rhinorrhea)² and forehead sweating, all on the side of the head experiencing the pain. The pain usually comes without warning and lasts between 15 minutes and three hours. What constitutes the “cluster” is the frequency of the headaches—they tend to occur in clusters, separated by intervals free of headache (except for the variant called “chronic,” which is not associated with headache-free intervals). The clusters vary from one attack within two days up to eight per day. In contrast to the case with migraine, most cluster headache sufferers are male. Again, unlike migraine sufferers, there seems to be no familial factor in the incidence of cluster headache. The etiology of this syndrome remains unknown (Oleson & Bonica, 1990, p. 717).

Pharmacological treatments have been reported to be effective. Ergotamine is commonly used to treat the acute attack, and a variety of medications has successfully been used to prevent attacks. I know of no literature reporting the use of hypnosis in treatment of this syndrome. However, I have treated four patients with cluster headache. In each case, I was struck by the patient’s anxiety over the anticipated onset of the next painful attack, as well as associated anxiety that there would be no effective treatment. (All patients, of course, had already undergone medical evaluation, without finding effective treatment for their headaches.)

As with all recurrent pain syndromes, hypnotic treatment of cluster headache requires that the patient be able to utilize training in self-hypnosis and to respond to suggestions for analgesia during an attack. Two of the four patients in my practice actually experienced a reduction in frequency so that after three years the attacks did not recur. (It is possible that this reflects a natural course of the syndrome; it is unclear what, if any, role hypnosis may have played beyond facilitating analgesia during an attack.) The other two patients experienced variable success in diminishing the pain, but neither was free of attacks five years after treatment.

Mick, an engineer, had been referred to me by his neurologist after a lengthy and largely unsatisfactory trial of medications. His history was unremarkable, except that he had been troubled by severe headaches for nearly five years. His headaches tended to cluster in a one-to-three day period and recurred about every ten days. Significantly, he sometimes noticed a “bad” smell (“like burning rubber”) in the minutes preceding the onset of a headache. Sometimes Mick benefitted from the medications and was able to continue working, and sometimes no medication could relieve the intense, debilitating pain on the right side of his head and face.

Mick agreed to see me out of desperation, with no real confidence or hope that I would be able to help. Understanding that the headaches were physical in origin, he was pessimistic about obtaining help from psychological treatments.³ Consequently, much of the latter half of the intake appointment was taken up by my discussion of the treatment plan I thought would help. I confirmed for him that his headaches were physical in origin, and that, while psychological stress might conceivably contribute to the onset or intensity, it was probably not really a significant factor in his condition. I talked with him about the interface between mind and body and the psychological dimensions of the experience of pain. I suggested that his engineering education might facilitate the treatment I had in mind, since I expected to depend on the “executive control center” in his brain to exert influence on the “peripheral operations,” including the receiving and processing of pain messages.

Mick seemed intrigued by this discussion and agreed to my recommendation that we plan to meet four times in the subsequent two weeks, using psychological methods to exert influence on his pain experience.

Still not using the word “hypnosis,” at our next meeting I reminded Mick that our goal was to “re-engineer” the information about his headache pain, so that, even if the physical condition continued to exist, he would not have to suffer so severely with the pain. In the context of this discussion, I reminded him of mundane examples of mind-body interactions, including vasodilation of the subcutaneous facial vessels when he experienced embarrassment. He seemed interested and open to the possibilities I was suggesting.

I felt confident that Mick would be able to respond to my suggestions if he could be satisfied that they were reasonable. I continued:

So, Mick, I think we’ve accomplished enough by this discussion this morning, so let’s now find a way to access the executive control center in your brain, so that the next time a headache comes you won’t have to feel it so strongly. Is that OK with you?

Mick indicated his assent, adding that he’d be very grateful if we could just “turn down the volume by half” on his headache intensity.

As you continue to sit comfortably in that chair, why not just let your eyelids close so that you can hear me from deeper within yourself?

I continued the hypnotic induction, and within a few minutes Mick was resting quietly. After eliciting his responses to various suggestions, I was confident that he was experiencing a satisfactory level of hypnotic absorption. I then began to offer the following therapeutic suggestions:

You have now begun a process of altering your nervous system in ways that can make an important difference to your future health and comfort. I am now going to talk with you about some specific changes you can expect.

Although you may notice a general level of comfort and relaxation throughout the remainder of the day, you may also notice a very subtle shift in your awareness of your body.

For some time now, you have learned that the terrible pain in your head and face can come at any time, without warning. Now, though, you can expect that this will change.

From now on, whenever you have the slightest inkling that pain may be on its way, you will notice a curious tingling that begins at the top of your head and very quickly spreads throughout your head and face, creating a sense of peculiar comfort.

Whenever you develop that odd sense of smell, for instance, that has signaled, in the past, that a headache was on the way, … whenever you notice the smell … you will also notice that curious tingling sensation, spreading from the top of your head, all over your head and face, leaving you with a very deep sense of comfort and well-being.

You can recreate the sense of comfort you feel right now, as well. Anytime you want to feel as you do right now … quiet, restful, relaxed, comfortable … all you have to do is to rest back, in a chair, or sofa, or bed … and take a very deep, satisfying breath, and hold it … hold it for a moment. And then, when you let it all the way out, you can let your eyelids close, and notice how quickly, and how automatically, these feelings of comfort and well-being wash over you … just like water in a hot tub.

For reasons that may seem mysterious, at first, you will have the opportunity to discover that you are a man who used to have headaches, but now that has begun to change.

After repeating these suggestions and making other suggestions intended to increase his confidence in his ability to reduce his headaches, I suggested that he would soon awaken, feeling alert and refreshed. This he did. I then gave him an audiotape of the hypnotic treatment he had just experienced and asked him to listen to the tape twice a day, once in the morning and once in the evening, for the next several days. By providing such a tape I was giving Mick the opportunity to practice the development of his hypnotic skills, as well as to benefit from hearing the therapeutic suggestions repeatedly. By the time we next met, I assumed, he would have had an occasion to experience a headache and perhaps to experience a reduction of the pain.

Five days later, when Mick came for his next appointment, he announced that he had had one very intense headache the day after the treatment, but that the pain had lasted only a few minutes, which was far shorter than usual. He was very curious about this phenomenon and about the fact that he had had no other headaches since.

I suggested to Mick that perhaps he had already begun to experience the initial results of his effort to retrain his nervous system and that our work today would reinforce those results. We then did hypnotic work, which largely repeated the suggestions that I had given him previously, but also included suggestions intended to reinforce the therapeutic gains he had apparently already made.

We continued this work at two subsequent treatment appointments, one week apart. Mick reported a brief, very painful headache on two occasions—but again, the brevity of the headache was a new and, to him, very pleasing development.

At follow-up one month later, Mick told me much the same—that he would occasionally have brief, intense headaches, but they would not last long, and did not seem to come in clusters anymore.

Because he seemed to be so much improved, and because his improvement seemed stable, I recommended that we not meet again for six months, unless he needed to see me earlier. At six-month follow-up, Mick reported that he continued to listen to the audiotape, but only about once a week, “to keep it fresh.” He also reported that he experienced headaches about once every ten days, as they had before, but that they lasted only a few minutes. The brevity of his headaches made them more tolerable, and he felt satisfied that he could continue to tolerate them at this level. He also expressed optimism that his increasing confidence in his hypnotic skills might provide even more substantial improvement over time. This did not prove to be the case, however, at least within the next year. I saw Mick twice, at six-month intervals, and his headaches remained stable, occurring about once every two weeks—but only once and for only a few minutes, without causing disability.

Although Mick’s case demonstrates the dramatic improvement that can sometimes occur in otherwise intractable headaches, this is not always the case.

Vascular headache differs from migraine headache in that, although the primary source of pain for both seems to be the dilation of vessels in the scalp and within the brain, vascular headaches are almost never as intense as migraine headaches and are not usually accompanied by the other migraine phenomena, such as photophobia, nausea, and so on. Unlike tension headache, vascular headache pain pulses with the heart beat and intensifies if the patient bends over (altering blood pressure within the head). Etiology of vascular headache is variable; three major sources are hormonal (associated with the menstrual cycle), food allergy or intolerance, and muscle tension. Evaluation of the etiology is important, obviously, to determine if relief may be found, for example, in avoiding certain foods, undertaking hormonal therapy, or pursuing physical therapy. Headache medications, such as aspirin, are normally quite effective. Hypnotic treatment can be valuable in those cases where analgesic medications are not effective. The patient may respond well to hypnotic suggestions not unlike those for migraine headache, namely, suggestions for reducing dilation of the vessels to a normal, comfortable level.

Carolyn was referred by her mother, a pediatrician colleague of mine. Carolyn had developed intensely painful vascular headaches about six months earlier. Like many migraine headaches, Carolyn’s vascular headaches were associated with her menstrual cycle. Hormone treatment had been ruled out by Carolyn’s physician. Carolyn’s headache would develop gradually, over a period of about an hour, and was only partially responsive to aspirin. The headache would typically last throughout the day, rendering her fairly miserable and disabled.

I saw Carolyn in the company of her mother for the initial part of the intake interview. During this conversation, I saw that Carolyn and her mother seemed to agree about the nature and character of the headaches, and I did not see any evidence of psychological problems in either Carolyn or in her relationship with her mother. It seemed to me that, in this case, since physical remedies did not seem helpful, hypnosis would be a very good option.

A few days later, Carolyn arrived for her first treatment appointment. She had no questions about the treatment, although she seemed a bit anxious about it. After some preliminary conversation, in which I reminded her of the rationale I had described to her and her mother, we began a hypnotic induction. Carolyn had seemed to relax substantially during our conversation and was now able to respond readily to the suggestions for deep relaxation and dissociation that were a part of the induction.

Adolescents have an understandable enthusiasm for independence; as a consequence, I tend to use suggestions that are intended to be congruent with that enthusiasm. In this case, I also provided a number of suggestions and comments that were intended to draw Carolyn’s attention to her ability to control her experience, to resist any suggestion that did not appeal to her, and to exert her own initiative whenever she wished to do so.

After establishing a secure context in which to create the treatment suggestions, I then reminded Carolyn that treatment would involve two goals:

1. Carolyn would use hypnosis to reduce the pain of headaches when they occurred.

2. Carolyn would use hypnosis to reduce the onset of future headaches by physiologically altering her body’s response to the hormones that were now producing the headache response.

The following is an excerpt of what I told Carolyn as part of achieving the first goal:

Carolyn, because you are learning a new way to use the power of your nervous system, you can change the way you feel your headaches. In the future, if you begin to feel the headache beginning to grow, all you have to do is to use your newfound power.

Whenever you feel a headache beginning to grow, stop whatever you are doing, find a safe and comfortable place to sit or lie down, and let yourself imagine the blood vessels in your head as they automatically begin very slowly, very gently to reduce in size.

As you watch your blood vessels very slowly, very gently begin to shrink … ever so slightly … you can also notice how deeply relaxed you begin to feel. You will begin to feel the same kind of deep absorption and deep comfort that you are feeling right now.

Even though I will not be with you, even though you will be controlling this process all by yourself, you can remember the sound of my voice, you can remember that you have learned this process with me, and you can feel increasingly confident that you can do this all by yourself.

As you continue to experience the changes in your body … as you continue to become older and more grown up … you may sometimes be surprised at some of the changes you notice.

You body will continue to change in healthy ways as you grow older, and your body will continue to accept the changes that are occurring in more comfortable ways. Just as you sometimes feel aches in joints, from the growth of your bones, so you have also felt headaches from the new hormones that your body is producing.

But these headaches are like the growth pains of your joints. They are only temporary. Just as you have adjusted to the growth of your bones, so you are already beginning to adjust to the new hormones. Even if you had not come to see me, you would have noticed, after a while, that your headaches became less and less frequent, and bothered you less and less.

In the weeks and months ahead, your body is adjusting to the hormones that you are producing, and your blood vessels will soon be more comfortable. Soon your blood vessels will respond in more and more comfortable ways to the hormones that flow through them. Soon there will be nothing to bother you. Soon you will have no more headaches of the kind you have been having.

We all have headaches, from time to time, and that’s OK. You have had headaches before, and perhaps you will again, from time to time, for various reasons. But these headaches are almost at an end now.

I will be very surprised if you call me next week and say that you no longer have these headaches. I will be very surprised if you call me in, say, a month, to tell me that you are not having these headaches. But, Carolyn, I will not be surprised if you and I talk in, say, six months, and you tell me that you no longer have these headaches. I will not be surprised to learn, in a few months, that it is even difficult for you to remember what these headaches were like. Because they will soon be a part of your past … not your present, and not your future. Like so many of the changes you have experienced as you grow up, these headaches will just be a part of your past … of your growing up.

After the treatment, I recommended to Carolyn that we meet once a month for the next few months, to reinforce the treatment, and to monitor her progress.

One month later, Carolyn reported that she had had a headache the week before and that it had not been any different from previous headaches. She wondered if the treatment was working. I told Carolyn that it not was surprising that she had had another headache, because these changes do not usually occur so swiftly, but that we would know more in a few months. I also used hypnotic suggestions to reinforce the suggestions I had given her previously and made an audiotape of the suggestions, which I instructed Carolyn to listen to anytime that she felt the need to do so.

One month later, Carolyn reported that she had had her usual headache, except that she thought it was less intense than it had been before—a 3 instead of an 8. She reported the affective component was 1 (it had been 7 initially). She also reported that she had listened to the tape twice, in the evening, about a week before the headache. I again used hypnotic suggestions to reinforce the work we had already done, recommended that she continue to listen to the audiotape whenever she felt inclined to do so, and arranged a meeting a month later.

On the next visit, the fourth treatment visit, Carolyn reported that she had thought she was about to get a headache the previous week, but that it did not develop; except for that, she had not really thought about her headaches lately. I used hypnotic suggestions in the way I had done previously, reinforcing earlier suggestions.

At the fifth month, Carolyn again reported that she had thought she was about to get a headache on a couple of occasions, but that she did not. I told her that I thought it was unnecessary for me to use hypnotic treatment with her again, since it seemed that she had the situation well under control. I reminded her to listen to the tape anytime she wished to, if it seemed useful to keep a headache at bay, and recommended that she call me if she had any questions. Otherwise, I would meet with her in three months to hear how well she was doing.

I did not hear from Carolyn during the three-month interval, and she told me at the follow-up visit that she had forgotten about the tape, had forgotten about her headache—had even forgotten about the appointment until her mother reminded her a few days before. I asked Carolyn to telephone me anytime she had a question, and to be sure to call me in six months to let me know how well she was doing.

At one-year follow-up, Carolyn continued to be free of the vascular headaches, though she occasionally had what sounded like ordinary muscle contraction headaches.

One of the misconceptions about hypnotic treatment is that, once effective it will continue be effective. Unfortunately, this is not the case, which is why follow-up visits are essential to long-term therapeutic benefit. Follow-up contact with patients provides an opportunity to monitor their condition (they might not call if pain recurs); moreover, it provides ongoing reinforcement of the initial treatment.

Carolyn’s case is instructive because it clearly reveals that, even in cases in which the presumed cause of the painful condition persists, hypnotic treatment can be of value. Her case also illustrates that the value may not be instantaneous. It is important that we persist in our treatment, if it seems reasonable to do so, even when relief does not occur quickly.

Following a concussion, some patients experience persistent headache. While there is no correlation between severity of the original injury and occurrence of posttraumatic headache, there is a relationship between severity of injury and duration of the symptoms (Oleson & Bonica, 1990, p. 720). The etiology of this headache is not yet understood.

This headache syndrome is also ordinarily responsive to medication. However, in some cases, medication has little or no effect. In such cases, hypnotic treatment may be helpful.

As in all pain syndromes, we must properly evaluate the patient, determining, among other things, the meaning of the pain to the patient. In my experience, posttraumatic headache seems more often fraught with meaning than are other headaches. In some cases, the patient has not yet had an opportunity to discuss the meaning of the original injury. Doing so often facilitates resolution of the syndrome. In cases where the injury raises the issue of blame or culpability in the patient’s mind, discussion of this issue may result in substantial relief of anxiety or guilt, which may in turn result in reduced intensity and/or bothersomeness of the headache. In cases of persistent posttraumatic headache following mild injuries, issues of unresolved anger (at victimization), avoidant reactions, and/or need for compensation may play a significant role in the effectiveness of pain treatment, and should be evaluated (Pepping, personal communication, 1995).

In cases where there is amnesia as well as posttraumatic headache associated with the initial injury, patients sometimes seek hypnotherapeutic treatment to “find out what really happened” to cause the injury. Some practitioners then lead patients through reconstructive experiences, which they construe as a reliable memory of the events leading up to the initial injury. Sometimes patients feel pain relief subsequent to this procedure. However, one needs to bear in mind that this procedure is more likely to result in credible confabulation rather than reliable memory. This point may become crucial in any case in which legal action is likely to take place.

Tanya was referred to me by her neurologist one year after an auto accident in which she suffered a mild concussion. Since then she had suffered from constant, unremitting headache. Various medications and physical therapy had been tried, with no significant relief of the headache.

At her initial visit, Tanya rated the intensity of her pain at 7 and the affective component at 10, meaning that the pain was as bothersome as she could imagine a pain to be. Since such a rating is very unusual. I wondered how much of the pain and suffering was related to the accident and what that meant to Tanya and how much was related to actual noxious stimulation. When I asked what it was about her pain that was bothersome to her, Tanya was not very responsive. She said she did not know why it bothered her, it just did.

Tanya had already learned from her neurologist that the etiology of posttraumatic headache is unknown, although it is frequently associated with the kind of head injury she had sustained. However, usually such a headache resolves by one year after injury. In Tanya’s case, of course, it had not.

Following the intake interview and review of her records, I decided that it was reasonable to use hypnotic treatment for Tanya’s pain. If nothing else, such treatment might have diagnostic value, as long as there was a substantial psychological component to her pain and suffering. I explained the rationale for using hypnosis, and Tanya was eager to begin. We scheduled for four treatment appointments over the next two weeks.

Because the pain was constant and distracting, the hypnotic induction incorporated the experience of the headache:

… Imagine that you can feel yourself inside the pain … let your mind focus very clearly, very steadily on the pain. And as you continue to hear the sound of my voice, notice that my voice seems to come almost from within the very center of the pain.…

… Continue to hear the sound of my voice, coming from the very center of your head, of your mind, of your awareness.…

… Allow yourself to become more and more absorbed by the comfort of my voice, by the gentle certainty that, for right now, everything is just fine … knowing that there is nothing you have to do right now … no obligations … no commitments … nothing you have to do right now, but hear the sound of my voice, and notice how easily it surrounds you, with a greater and greater sense of comfort and well-being.…

Once Tanya responded to these suggestions, and once she verbally responded to questions about how she was feeling (“My head isn’t hurting”), I offered suggestions for future headache relief. Among these suggestions were the following:

… You were seriously injured in the accident. Now, however, your injuries have healed. You no longer need to feel pain in your head, because the injury to your head has healed very well.…

… You can enjoy discovering how easily you waken each morning, and notice how well you feel. You might even be surprised, sometimes, to notice that … you feel well … you feel comfortable.… It’s almost as though you’ve forgotten all about the headache.…

When the treatment ended, Tanya reported that she was surprised how well she felt, that she had no headache at all. She seemed delighted by this result. I reminded her that we had three more appointments and said that we might know better what she needed in the future when we met again in a few days.

At the next treatment appointment, Tanya reported that the headache had returned within an hour or two of our previous appointment and that it remained unchanged, as though the treatment had never occurred. I used a posthypnotic suggestion to recreate the hypnotic experience, and Tanya responded well. Following suggestions for comfort and well-being, she reported feeling well again, with no headache. I reinforced the suggestions previously made and added further suggestions about continuing comfort and about there being no need for further headaches. I also instructed her in the use of self-hypnotic suggestions, in the event that the headache returned.

This pattern continued for the next two treatment appointments: Tanya felt well during the treatment but soon after the headache returned, remaining unabated until the next treatment.

At the fourth treatment appointment, I began to take more seriously my initial hypothesis that a significant component of Tanya’s pain and suffering related to the auto accident, her injury, and what this might mean. Though we had discussed this issue in the initial intake interview, and though Tanya had expressed no particular concerns about this issue, I thought that further exploration might be productive.

I asked Tanya for her understanding of what was happening with respect to her headaches. Although Tanya was generally articulate, she responded quite minimally to these questions, as she had initially. She did not know why she had the headaches, and she did not know why the headaches did not respond better to the treatment. “But there must be a good reason,” she said.

During the intake interview, Tanya had told me that her best friend had been driving the car at the time of the accident and had been killed. When pressed, Tanya had little to say about what she felt about this, except to say that she was sad about her friend’s death.

Now, however, while hypnotized, Tanya responded more fully to questions about the accident. She felt enraged at her friend for having the accident. “If she weren’t dead already, I could kill her, I’m so mad at her!” Tanya was angry that her friend’s poor driving had resulted in this terrible loss to Tanya and in her almost being killed.

Using fantasy, I involved Tanya in a conversation with her friend about her feelings. Tanya took to this conversation very readily, engaging in animated conversation with her friend, expressing her anger about her friend’s poor driving. Suddenly, Tanya stopped speaking and began to cry, at first very softly, then with greater and greater energy, until she was sobbing. She seemed to be experiencing, for the first time since the accident, a cathartic release of her feelings of grief and loss.

I supported Tanya in her emotional release and, when appropriate, attempted to facilitate a more peaceful resolution to her feelings toward her friend.

After several minutes, Tanya said, “I think my hateful feelings have been giving me these headaches.”

I agreed that this might be true. If so, I said, “You have now found a healthy way to express your feelings, and you don’t need to keep them inside your head anymore.”

It is always difficult to know how to attribute symptomatic change. Maybe Tanya’s headaches would have resolved anyway, given the time since the accident. Curiously, though, she left the office free of her headaches and remained so at one-, three-, and six-month follow-up visits.

Tanya’s case demonstrates the sometimes complex nature of headache pain and the importance of remaining flexible in our treatment plan. Clearly, suggestions for direct reduction of the pain were not useful. As is often true in such cases, substantial, lasting pain relief came only when the emotional underpinnings of the pain were addressed.