What to do if you have persistent headaches

 

In recent decades, there has been an increase in the increase in anxiety of the population, an increase in stress factors (constant overwork, insufficient sleep, an increase in workload). Most people are not always psychologically prepared for such stressful situations. As a result, the majority of patients have, as a rule, serious problems of both somatic and mental nature.
In this regard, it is of natural interest to study a new in our country diagnostic category of “post-traumatic stress disorder” (PTSD), which is one of the most profound and persistent over time types of stress.
 It should be noted that PTSD is an unusual terminology for Russian science – this diagnosis appeared in Russian psychiatry only at the turn of the 21st century. As a result, in our country, quite a few works are devoted to the study of chronic PTSD, and many problems associated with the development of this condition remain unexplored. In particular, one of the important questions (both for the organization of assistance and for a general idea of the scale of the phenomenon) is at least an approximate estimate of the number of PTSD sufferers.

When analyzing the data cited by different authors, it becomes obvious that the frequency of PTSD varies significantly depending on the material studied, the use of diagnostic criteria, the characteristics of the surveyed population, and the research methods used. So, according to American authors, the prevalence of PTSD among the population is 8-9%. Russian researchers indicate that its frequency in the population ranges from 1 to 12% and varies depending on the frequency of accidents and traumatic situations within 48-80%. However, despite such significant discrepancies in the assessment of the prevalence of this condition in the population, most researchers agree that the prevalence of PTSD increases during tragic events that cover a large number of the population. Some authors believe that 61% of men and 49% of women experienced at least one traumatic event in their life, up to 25-48% experienced two or more psychological traumas. A further increase in mental disorders is predicted in response to trauma.

In addition, many researchers have drawn attention to a significant discrepancy between the prevalence of mental trauma and the incidence of PTSD – according to epidemiological data, the prevalence of trauma is much higher than the incidence of PTSD. According to several studies, in developed countries more than 80% of the population has ever experienced a serious injury, but the disorder was detected in less than 10% of cases. In this regard, the risk factors for the development of post-traumatic stress disorders are currently being studied. The role of biological, psychological, socio-psychological and other etiological and predisposing factors is investigated.

The risk factors for the development of PTSD include the characteristics of the stressor – its content, duration, severity, strength, suddenness of action, etc. A high risk factor for the development of PTSD is the multiple traumatic events to which a person is exposed. At the same time, further study of stress factors can reveal new significant characteristics of them.

A number of authors are of the opinion that the main factors influencing the development of PTSD are the personality traits of a person. It was revealed that extramorbid personality traits, its orientation, gender, age, life experience, resistance to stress, the presence of mental, psychosomatic disorders in the past, somatic diseases, craniocerebral trauma, injuries, and addictions play an important role in the development of the disorder. So, V. Ya. Semke points to the presence of special personality traits that develop as a result of a violation of the process of its formation, as an important internal condition that determines the subject’s ability to survive the trauma received. The point of view is also expressed that the development of PTSD is due to the susceptibility of some people to stress. So, T.A. When examining participants in local hostilities, Rodionova revealed changes in a number of clinical, laboratory and neurophysiological parameters reflecting the state of the central nervous system and autonomic regulation. According to the authors, these changes indicate differences in specific adaptation to stress in different individuals. A number of authors describe the influence of socio-psychological factors, including negative family relations, conditions of upbringing, leading to personality pathology in PTSD.

At the same time, it is believed that risk factors play a significant role only in certain individuals, and their influence cannot be extended to all patients with PTSD. The mechanism of these influences continues to be studied and refined. The role of internal and external risk factors is currently practically not disputed, however, a consensus on their significance has not been developed to date.

In addition, there is evidence that PTSD is characterized by specific psychobiological changes. For example, structural and functional imaging of the brain revealed a decrease in the volume of the hippocampus in patients with the disorder (although, according to some reports, this could already be before the disorder and was a marker of predisposition). In addition, important specific neurotransmitter changes have been found in PTSD. Thus, there is indirect evidence (from pharmacological data and pharmacotherapeutic studies) of dysfunction in mono-aminergic systems and direct evidence (based on the results of molecular studies) of dysfunction of g-aminobutyric acid receptors. Also, according to Yehuda et al., PTSD is characterized by a certain neuroendocrine profile, in which there is a decrease in the concentration of cortisol in the blood plasma (due to the induction of negative feedback along the hypothalamic-pituitary-adrenal axis). This model is further studied in animals.
Attention should be paid to the inconsistency of data concerning the state of the hypothalamic-pituitary-adrenal (HPA) system in conditions of PTSD. Some authors report an increased level of cortisol, while others report a decreased level of cortisol in conditions of PTSD.

The pathogenesis of the development of PTSD is not fully understood. Biological mechanisms, psychological, informational and others are considered. Among the variety of theories of the pathogenesis of PTSD, of interest is the modern psychosocial approach, according to which the model of response to mental trauma is multifactorial, therefore, it is necessary to take into account the role of various factors in the development of the response to stress. Biopsychosocial theories are promising.

Also, there is currently no consensus about the typical symptoms of post-traumatic stress disorder. The PTSD clinic is determined by a wide range of changes in both mental and somatic spheres. Most authors pay attention primarily to an altered state of consciousness and self-awareness (mental numbness or emotional anesthesia, a sense of detachment, depersonalization-derealization phenomena, amnesia). These phenomena are usually combined with intrusive (i.e. invading consciousness) symptomatology in the form of repetitive thoughts, images, dreams, illusions, experiences and overwhelming ideas. This also includes signs of increased mental sensitivity and avoidance of stimuli reminiscent of the stress experienced. Another sign of stress disorder is a persistent increase in anxiety. This is expressed in the difficulty of falling asleep and intermittent sleep, fearfulness, irritability, outbursts of anger, concentration disorders, mood swings.

Other authors also focus on general changes in the reactivity of the organism. Post-traumatic stress disorder is characterized by the appearance of persistent autonomic shifts in the form of thermoneuroses, psychogenic dyspnea, “stressful” gastritis, irritable bowel syndrome, idiopathic urticaria, as well as eating disorders, sexual dysfunctions and non-organic insomnia. It is believed that a prolonged stay in a state of PTSD leads to the development of somatic diseases, among which the most common are coronary heart disease, atherosclerosis, hypertension, carbohydrate metabolism disorders, and stroke.

According to A.L. Pushkareva et al. in the structure of complaints, which was analyzed according to the Giessen psychosomatic questionnaire, in patients with signs of PTSD, the largest proportion are complaints related to the state of the cardiovascular system (cardiac factor “C”), they account for 36% of all complaints; slightly fewer complaints are associated with the manifestation of nervous exhaustion (factor of exhaustion “I”), they account for 24.6%; complaints related to pains of various etiology and localization (pain factor “B”) account for 20.2%.

Among all the symptoms characteristic of PTSD, headache deserves special attention. The significance of this problem is determined by a significant decrease in the quality of life of patients due to the frequent chronicity of headache and the presence of associated neuropsychiatric disorders and the abuse of over-the-counter analgesics.

Very interesting data were obtained when conducting a comparative analysis of the prevalence of PTSD and chronic pain in patients. This gives grounds to some authors to believe that chronic pain is an independent disease with a primary process in the somatic sphere and secondary dysfunction in the peripheral and central nervous system with the participation of personality-psychological mechanisms. A.I. Fingers et al. it is believed that the combination of PTSD and chronic pain leads to an increase in both the intensity of pain and the manifestations of PTSD. Moreover, both processes are the product of a breakdown of the adaptive mechanisms of the nervous system.

The most common chronic headaches are tension headaches and post-traumatic headaches. Tension headache was characterized mainly by a bilateral character, more often in the evening hours and was provoked by a change in the weather. It also had a significantly shorter duration than post-traumatic pain. The leading provoking factors for tension headaches were complaints of similar pains in the close environment, and for the post-traumatic variant – physical strain and climbing stairs.

Discussing the possible mechanisms of the formation of chronic headache in patients, it should be noted that the information given in the modern literature made it possible to formulate the position that chronic pain develops and is maintained by a combination of biological, psychological and social factors. At the same time, the most significant risk factors for the transition of pain to a chronic state are psychological and social factors.

Many authors believe that chronic stress leads to depletion of the compensatory capabilities of the brain and the development of a state of “pre-illness”, in the formation of which dysfunction of nonspecific brain systems plays a significant role. Clinically, this manifests itself as a disintegration psychovegetative syndrome due to dysregulation of the limbicoreticular complex. These violations create the prerequisites for the development of pathology of the autonomic nervous system and deviations in the psychoemotional sphere of a person. As a result, one of the leading symptoms of dysfunction of the cerebral regulatory systems is headache.

Chronic headache is not only a consequence of direct effects on the brain and its membranes of the trauma factor. This is also the influence of factors of general chronic intoxication, autointoxication, infectious-allergic burden, which leads to changes in the immune status, homeostasis in general. In this regard, V.M. Myakotnykh believes that the predominance of the combined, combined nature of headache with various pathophysiological mechanisms of its occurrence is also manifested in the atypical clinical picture of a number of symptoms accompanying severe headache. For example, he observed in many patients the onset or a sharp increase in headache in an upright position, when trying to move the head. In addition, the author does not exclude the role of post-traumatic cerebral arachnoiditis in the development of cerebrospinal fluid dynamics leading to headaches. Special mention should be made of the so-called vertebrogenic headache. V.M. The pulp associates it with the presence of cervical osteochondrosis due to minor craniocerebral injuries.

The author also tried to establish what role craniocerebral trauma plays in the origin of headaches, and what role is played by the concomitant chronic psychoemotional stress of a combat situation. With the help of a comparative analysis of the phenomenon of headache in representatives of the observed groups of patients, he revealed that patients with the consequences of traumatic brain injury were bothered by the headache significantly more often (p <0.05) than those who had suffered chronic psychoemotional stress. In the course of long-term observation of patients, he became convinced that primary post-traumatic cephalalgias in the long-term period of TBI have already a mixed development mechanism, combining tension headaches, vascular cephalalgias and pain associated with impaired CSF dynamics.

T.I. Larikov and G.M. Cherevikova, after analyzing the data of different authors, it is believed that both for traumatic brain injury and for chronic stress, neural and neurotransmitter systems become targets, with a decrease in the rate of local cerebral blood flow and morphological changes characteristic of a hypoxic state. In this case, trauma, realized through the development of neurodynamic disorders, acts as an aggravating factor.

M.A. Sherman found a significant predominance of difficult-to-correct depressive disorders in the case when cephalalgia takes the leading place in the clinical picture of PTSD. This allowed them to suggest the decisive importance of these emotional and personality disorders in the dysfunction of the central nociceptive mechanisms of the brain of patients with the formation, as a consequence, of tension headache.

Tesnaya vzaimosvyaz’ depressivnykh rasstroystv s khronicheskoy bol’yu otrazhena v rabotakh ryada avtorov. Tak, Dzh. Myurrey podcherkivayet, chto pri khronicheskoy boli nado prezhde vsego iskat’ depressiyu i, naprotiv, po dannym S.N. Mosolova, u 60% bol’nykh depressiyey obnaruzhivayutsya khronicheskiye bolevyye sindromy. Na znachimost’ nekotorykh psikhologicheskikh faktorov v razvitii khronicheskoy boli ukazyvayut i drugiye avtory. Schitayetsya, chto dominiruyushchim mekhanizmom formirovaniya khronicheskoy boli yavlyayetsya dezintegratsiya protsessov provedeniya i kontrolya boli na urovne tserebral’nykh struktur. Poetomu osnovnym otlichiyem khronicheskoy boli ot ostroy yavlyayetsya ne vremennoy faktor, a yeye dopolnitel’nyye neyrofiziologicheskiye mekhanizmy, dezadaptivnoye znacheniye dlya organizma i vozrastaniye vliyaniya psikhologicheskikh faktorov (lichnostnyye izmeneniya kognitivno-emotsional’nogo, povedencheskogo i sotsial’nogo soderzhaniya). Eti biopsikhosotsial’nyye sostavlyayushchiye khronicheskoy boli vzaimodeystvuyut i vliyayut drug na druga.Ещёvolume_up964 / 5000

The close relationship of depressive disorders with chronic pain is reflected in the works of a number of authors. Thus, J. Murray emphasizes that in chronic pain one must first of all look for depression and, on the contrary, according to S.N. Mosolov, 60% of patients with depression have chronic pain syndromes. Other authors also point out the importance of some psychological factors in the development of chronic pain. It is believed that the dominant mechanism for the formation of chronic pain is the disintegration of the processes of pain conduction and control at the level of cerebral structures. Therefore, the main difference between chronic pain and acute pain is not a temporal factor, but its additional neurophysiological mechanisms, maladaptive significance for the body and an increase in the influence of psychological factors (personality changes in cognitive-emotional, behavioral and social content). These biopsychosocial constituents of chronic pain interact and influence each other.

The relationship of some psychological factors with the development of chronic headache in patients is also indicated by E.V. Mikhailov. According to her data, there is a strong positive relationship between personal anxiety and the level of depression, as well as personal anxiety and subjective pain.

However, analyzing the literature data, it becomes obvious that in most cases it is impossible to clearly distinguish between psychosomatic and somatopsychic influences. So, the team of authors, on the basis of the study, concludes that long-term cephalalgia significantly enhances personal disharmony in patients. When using the Leonhard characterological questionnaire, excitable and unbalanced types of accentuation were significantly more frequent in the group of patients with post-traumatic headache. In the group with tension headache, statistically significant sharpening was revealed according to the “emotiveness” and “hyperthymic” scales. It is interesting to note that in this group, the severity of accentuation increased with age.

Thus, it is necessary to take into account when selecting an individually oriented therapy for this pathology. In addition, the formed concept of chronic pain as an independent pathological process leading to changes in the entire body, was the basis for the development of an integrated approach to its treatment.

From the point of view of complex impact, first of all, attempts to treat PTSD attract attention. In the work of V.D. Troshina et al. it is indicated that the basis of pathogenetic therapy should be the elimination of the pathological system formed in the central nervous system. This is possible by destabilizing it, weakening connections within the system, and reducing the number of its parts. In all cases, the elimination of the pathological system is carried out by their own sanogenetic mechanisms. According to the authors, therapeutic measures should be aimed at strengthening these sanogenetic mechanisms and the development of plastic processes. Activation of antisystems is also considered an important link in therapy. In this regard, the researchers assume the effectiveness of acupuncture, alternative medicine, physiotherapy, since they act precisely through the stimulation of the corresponding antisystems. Not only antisystems, but also ordinary physiological systems with the creation of a positive dominant can suppress the activity of the pathological system or limit its action.

          T.G. Pogodina offers her own treatment system based on the following principles:

1. Early onset – this should take into account the ultimate goal of therapy, that is, from the very beginning, treatment should be restorative.

2. Continuous step-by-step and successive application of medical and psychological measures in a certain sequence, depending on the nature of the disorder and real possibilities. The principle manifests itself in a consistent change in the methods of treatment and rehabilitation and organizational forms of service. Long-term dynamic observation is necessary.

3. Individualization of the treatment program: the appointment of methods, means of restorative therapy, depending on age, personality characteristics, general condition, nature of treatment.

4. Integrativeness – that is, the unity of psychosocial and biological methods of influence.

5. Optimizing your lifestyle.        

In general, various groups of drugs are used for the drug treatment of PTSD: tricyclic antidepressants, MAO inhibitors, selective serotonin reuptake inhibitors (SIRS), benzodiazenines, sedative antipsychotics, drugs that affect adrenergic innervation, normotimics.

More specific recommendations for the treatment of PTSD are given by T.I. Larikova and G.M. Cherevikova. They have obtained very interesting results in the treatment of PTSD with daily intravenous drips of Cerebrolysin. The choice of the drug was dictated by the fact that, according to research, it increases the efficiency of energy metabolism in the brain, protects neurons from damage as a result of ischemia, trauma, exposure to free radicals and neurotoxins. In addition, the drug has neurotrophic activity similar to the action of natural growth factors of nerve tissue. As a result of the treatment, the patients’ health in general improved. In particular, asthenic complaints (headache, fatigue, disturbance of attention and memory) were expressed much less frequently, sleep improved. Based on these data, the authors come to the conclusion that psychopharmacological therapy has an independent meaning, eliminating the most acute symptoms of PTSD, facilitates psychotherapy and contributes to the success of rehabilitation measures.  At the same time, the authors warn against the use of benzodiazepine tranquilizers for the correction of stress disorders, which are widely used in clinical practice. According to some reports, these drugs suppress the active adaptation of the body. In addition, it is not always taken into account that the use of benzodiazepine drugs should be limited in this contingent due to a tendency to addictive behavior, as well as the situational use of alcohol, drugs, and other psychoactive substances.

  Very favorable results have been obtained in the treatment of PTSD with Betaserc. The authors used it to treat vestibular disorders that accompany PTSD. However, along with a decrease in vestibulopathy and an improvement in the general condition, by the end of the first week of treatment, a decrease in headache was also noted. In addition, the authors found that patients tended to decrease anxiety about their condition. This is a very important result, given the data on the relationship between anxiety-depressive symptoms and the development of chronic pain syndrome.

Another group of authors conducted a study of the therapeutic effect of Pantogam active in patients with traumatic brain injury and PTSD. As a result, it was shown that this drug causes a significant improvement in neurological and cognitive status, there was a decrease in the effect of pain on behavioral activity. Also, the use of Pantogam active in complex treatment made it possible to reduce the level of anxiety, reducing emotional problems in the daily life of veterans. On this basis, the authors come to the conclusion that an integrated approach to treatment makes it possible to achieve a long-term stabilization of the positive effect of treatment, and significantly improve the quality of life of patients.

A lot of works are devoted to non-drug methods of treating PTSD. So, N.L. Bundalo has developed the author’s integrative program of psychotherapy for chronic PTSD, which is a modified version of transactional analysis. As a result, high clinical efficacy of psychotherapy for PTSD by the proposed method was revealed – recovery was achieved in 57.6 + 4.3% of cases, and improvement in 37.1 + 4.2% of patients.

Very interesting data are cited by V.G. Zilov and I.A. Minenko. They studied various non-drug treatments for PTSD. As a result, it was revealed that the most effective was the combination of the following effects: homeopathy, manual therapy, Scenar therapy, psychotherapy. The effectiveness of treatment using this scheme reached 87.8%.

EAT. Mikhailova believes that the best effect in the treatment of cephalgia in combatants can be achieved only with the help of a differentiated individual approach. In case of tension headaches, she recommends giving preference to Ericksonian hypnosis as a method of significantly more significant reduction of anxiety-depressive disorders. In chronic post-traumatic headache in patients, correction of anxiety with anxiolytics is indicated and Ericksonian trances should be avoided. With a similar type of headache among combatants in Afghanistan, the author recommends NLP as a method for reducing depressive disorders, improving the quality of life and forming an active life position. It is recommended to assist psychotherapy with medication to reduce anxiety.

To test the effectiveness of psychotherapeutic correction of chronic headache V.Ya. Yakunin et al. the patients were randomly assigned to 3 groups, in which they received: standard drug therapy; a combination of standard drug therapy and neuro-linguistic programming (NLP); combination of standard drug therapy and Ericksonian hypnosis). The results of the work carried out have confirmed the effectiveness of the use of psychotherapy for headaches by reducing the level of depression and personal anxiety, as well as the expediency of using psychotherapeutic techniques and techniques from various methods and directions for the treatment of this pathology (taking into account comorbid burden).

At the same time, E.J.F.L. Olivier believes that because little is known about the natural course of illnesses caused by severe trauma, it is difficult for clinicians to select a treatment for a particular patient and even to predict the outcome. So, S. Solomon et al. carried out an inventory of existing treatments. They found only 6 controlled studies of non-drug treatments, predominantly exposure therapy. Reliable data on the use of promising forms of treatment such as behavioral therapy are insufficient for a meaningful meta-analysis. Moreover, in some cases, the treatment can induce unwanted side effects. Thus, R. Pitman et al. describe 6 cases of worsening depression, resumption of alcohol abuse and relapse of panic symptoms.

Thus, the analysis of the literature made it possible to establish that post-traumatic stress disorder is a very significant modern problem due to the unstable social and political situation. One of the most serious manifestations of PTSD is the chronic headache that most combatants suffer from. This not only worsens their quality of life. But it also leads to a change in the psychoemotional state, drug abuse, and is also fraught with alcoholism or drug addiction. Currently, there is no consensus regarding the mechanisms of the formation of chronic headaches. A variety of theories and the participation of many factors are discussed, but the data obtained are very contradictory. As a result, there is no unified view of the treatment of chronic headaches in PTSD. The use of both various drugs and non-drug therapies is recommended, but the results are extremely heterogeneous. This highlights the need for further, in-depth study of PTSD and chronic headaches.

ATTENTION: This article is posted for informational purposes only and is not a basis for self-diagnosis. We remind you that it is necessary to solve the problem of the occurrence of chronic headache in a comprehensive manner, taking into account an individual approach to each patient. For the localization and treatment of this disease. you urgently need to go to a medical institution to see a neurologist.