Skip to main content Accessibility help
  • Print publication year: 2013
  • Online publication date: March 2013

Chapter 13 - Somatoform disorders and headache


This chapter focuses on the issues that arise when prescribing opioids and other controlled substances for chronic headache pain. The majority of headache patients who overuse or develop dependence on opioids and opioid-containing compounds suffer from migraine-type headaches. Tramadol withdrawal often includes symptoms not typically seen in pure opioid withdrawal, such as extreme anxiety, panic or paranoia, hallucinations, and feelings of numbness and tingling in extremities. Butorphanol, an opioid with partial mu-agonist effects, was first developed in injectable form and initially used in hospital settings mainly for post-operative and labor pain. The only barbiturate indicated specifically for the treatment of headache is butalbital, prescribed in the various combination medications. The care of cannabis-using patients may be managed best by coordinating their continuing headache care with an addiction specialist. It is well known that patients with physiologic dependence on caffeine routinely develop caffeine withdrawal headaches.

Related content

Powered by UNSILO


[1] LipchikGL, SmithermanTA, DonaldB.PenzienDB, HolroydKA.Basic principles and techniques of cognitive-behavioral therapies for comorbid psychiatric symptoms among headache patients. Headache 2006; 46 :S119–32.
[2] The International Headache Society. (Accessed May 28th 2012).
[3] FordCV, FolksDG.Conversion disorder: an overviewPsychosomatics 1985; 26: 371–83.
[4] LaneRD.Neural substrates of implicit and explicit emotional processes: a unifying framework for psychosomatic medicine. Psychosom Med. 2008; 70: 214–31.
[5] BarskyAJ, GoodsonJD, LaneRS, ClearyPDThe amplification of somatic symptomsPsychosom Medi 1988 50: 510–19.
[6] NakaoM, BarskyAJ.Clinical application of somatosensory amplification in psychosomatic medicine. Biopsychosoc Med 2007 9; 1: 17.
[7] DudduV, IsaacMK, ChaturvediSK.Somatization, somatosensory amplification, attribution styles and illness behavior: a review. Int Rev of Psychiatry 2006 18:1 25–33.
[8] American Psychiatric Association DSM -5 Development. (Accessed May 29 2012).
[9] SlaterE: Diagnosis of hysteria. BMJ 1965; 1: 1395–9.
[10] StoneJ, SmythR, CarsonA, et al. Systematic review of misdiagnosis of conversion symptoms and “hysteria.”BMJ 2005 29; 331: 989.
[11] LazareA.Current concepts in psychiatry. Conversion symptoms. N Engl J Med 1981 24;305:745–8.
[12] EngelGL.“Psychogenic” pain and the pain-prone patient. Am J Med 1959; 26: 899–918.
[13] Diagnostic and Statistical Manual of Mental Disorders, 4th edn Text Revision. APA, 2000.
[14] TooneBK.Disorders of hysterical conversion, In C Bass, ed. Somatization: Physical Symptoms and Psychological Illness. Boston, MA: Blackwell Scientific, 1990, pp 207–34.
[15] StoneJ, CarsonA, DuncanR, et al. Symptoms ‘unexplained by organic disease’ in 1144 new neurology out-patients: how often does the diagnosis change at follow-up? Brain. 2009; 132: 2878–88.
[16] EttingerAB, DevinskyO, WeisbrotDM, GoyalA, ShashikumarSHeadaches and other pain symptoms among patients with psychogenic non-epileptic seizures. Seizures 1999; 8: 424–6.
[17] KroenkeK.Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med 2007; 69: 881–8.
[18] StoneJ, ZemanA, SimonottoE, et al. FMRI in patients with motor conversion symptoms and controls with simulated weakness. Psychosom Med 2007; 69: 961–9.
[19] HinsonVK, WeinsteinS, BernardB, LeurgansSE, Goetz CG Single-blind clinical trial of psychotherapy for treatment of psychogenic movement disorders. Parkinsonism Rel Disord 2006; 12: 177–80.
[20] RuddyRHouse A. Psychosocial interventions for conversion disorder. Cochrane Database Syst Revi 2005 19;CD005331.
[21] PooleNA, WuerzA, AgrawalN.Abreaction for conversion disorder: systematic review with meta-analysis. Br J Psychiatry 2010; 197: 91–5.
[22] VerhaakPF, KerssensJJ, DekkerJ, SorbiMJ, BensingJMPrevalence of chronic benign pain disorder among adults: a review of the literaturePain 1998; 77: 231–9.
[23] FröhlichC, JacobiF, WittchenHU.DSM-IV pain disorder in the general population. An exploration of the structure and threshold of medically unexplained pain symptoms. Europ Arch Clin Psychiatry 2006; 256: 187–96.
[24] AdlerR, ZamboniP, HoferT, HemmelerW.How not to miss a somatic needle in a haystack of chronic pain. Journal of Psychosom Res 1997 42: 499–505.
[25] RoditiD, RobinsonME.The role of psychological interventions in the management of patients with chronic pain. Psychol Res Behav Managem 2011; 4: 41–9.
[26] American Academy of Pain Medicine (Accessed May 27, 2012).
[27] American Pain Society (Accessed May 27, 2012).
[28] PassikSD, WeinrebHJ.Managing chronic nonmalignant pain: Overcoming obstacles to the use of opioids. Adv Ther 2000; 17: 70–83.
[29] FishbainDA, ColeB, LewisJ, RosomoffHL, RosomoffRSWhat percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based reviewPain Med 2008; 9: 444–59.
[30] GourlayDL, HeitHA, AlmahreziA.Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med 2005; 6: 107–12.
[31] McCleaneG.Antidepressants as analgesics. CNS Drugs 2008; 22: 139–56.
[32] JacksonJL, ShimeallW, SessumsL, et al. Tricyclic antidepressants and headaches: systematic review and meta-analysis. BMJ 2010; 20: c5222.
[33] SmithermanTA, WaltersAB, MaizelsM, PenzienDBThe use of antidepressants for headache prophylaxisCNS Neurosci therape 2011; 17: 462–9.
[34] AdelmanLC, AdelmanJU, Von SeggernR, MannixLKVenlafaxine extended release (XR) for the prophylaxis of migraine and tension-type headache: A retrospective study in a clinical setting. Headache 2000; 40: 572–80.
[35] BellinghamGA, PengPWDuloxetine: a review of its pharmacology and use in chronic pain management. Reg Anesth Pain Medi 2010; 35: 294–303.
[36] D’AmicoD.Antiepileptic drugs in the prophylaxis of migraine, chronic headache forms and cluster headache: a review of their efficacy and tolerability. Neurol Scie 2007; 28: S188–97.
[37] National Center for Complementary and Alternative Medicine Bethesda (MD): National Institutes of Health; 2011 updated 2011 Jun 20; cited 2010 Dec 20.
[38] BarnesPM, BloomB, NahinRLComplementary and alternative medicine use among adults and children: United States, 2007. Nat Hlth Stati Rep 2008; 10: 1–23.
[39] WellsRE, BertischSM, BuettnerC, PhillipsRS, McCarthyEPComplementary and alternative medicine use among adults with migraines/severe headachesHeadache, 2011; 51: 1087–97.
[40] SöderbergEI, CarlssonJY, Stener-VictorinE, DahlöfCSubjective well-being in patients with chronic tension-type headache: effect of acupuncture, physical training, and relaxation training. Clin J Pain 2011; 27: 448–56.
[41] EscobarJI, ManuP, MatthewsD, LaneT, SwartzM, CaninoGMedically unexplained physical symptoms, somatization disorder and abridged somatization: studies with the Diagnostic Interview Schedule. Psychiatric Dev 1989; 7(3):235–45.
[42] RadatF, MilowskaD, ValadeD. Headaches secondary to psychiatric disorders (HSPD): a retrospective study of 87 patientsHeadache 2011; 51: 789–95.
[43] KatoK, SullivanPF, Pedersen NL Latent class analysis of functional somatic symptoms in a population-based sample of twins. J Psychosom Res 2010; 68: 447–53.
[44] KronkeK, SpitzerRL, WilliamsJBW, et al. Physical symptoms in primary care: predictors of psychiatric disorders and functional impairment. Arch Fam Med 1994; 3: 774–9.
[45] SmithGR, Jr., MonsonRA, RayDC.Psychiatric consultation in somatization disorder. A randomized controlled study. N Engl J Med 1986; 314: 1407–13.
[46] CreedF, BarskyA. A systematic review of the epidemiology of somatization disorder and hypochondriasis. J Psychosom Res 2004; 56: 391–408.
[47] GreevenA, van BalkomAJ, VisserS, et al. Cognitive behavior therapy and paroxetine in the treatment of hypochondriasis: arandomized controlled trial. The Am J Psychiatry 2007; 164: 91–9.
[48] WalkerJ, VincentN, FurerP, CoxB, KjernistedK Treatment preference in hypochondriasis. J Behav Ther Expe Psychiatry 1999; 30: 251–8.
[49] ThomsonAB, Page LA Psychotherapies for hypochondriasis. Cochrane Database Syst Rev 2007; 17:CD006520.
[50] KanaanRA, Wessely SC Factitious disorders in neurology: an analysis of reported casesPsychosomatics 2010; 51: 47–54.
[51] SolomonS, LiptonRBHeadaches and face pains as a manifestation of Munchausen syndromeHeadache 1999; 39: 45–50.
[52] ReichP, GottfriedLA.Factitious disorders in a teaching hospital. Ann Intern Med 1983; 99: 240–7.
[53] KwanP, LynchS, DavyA.Munchausen’s syndrome with concurrent neurological and psychiatric presentationsJ Roy Soc Med 1997; 90: 83–5.
[54] YassaR.Munchausen’s syndrome: a successfully treated case. Psychosomatics 1978; 19: 242–3.
[55] RogersRDevelopment of a new classificatory model of malingeringBull Am Acade Psychiatry Law 1990; 18: 323–33.
[56] BerryTR, NelsonNWDSM V and malingering : a modest proposal. Psychol Injury Law 2010; 3, 295–303.
[57] FishbainDA, CutlerR, RosomoffHL, RosomoffRSChronic pain disability exaggeration/malingering and submaximal effort research. Clin J Pain 1999; 15: 244–74.
[58] GreveKW, OrdJS, BianchiniKJ, CurtisKLPrevalence of malingering in patients with chronic pain referred for psychologic evaluation in a medico-legal contextArch Phys Med Rehab 2009; 90: 1117–26.
[59] MaizelsM, SmithermanTA, PenzienDB. A review of screening tools for psychiatric comorbidity in headache patientsHeadache 2006; 46 :S98–109.
[60] GoldbergD, GaskL, O’DowdT.The treatment of somatization: teaching techniques of reattribution. J Psychosom Res 1989; 33: 689–95.
[61] SumathipalaA.What is the evidence for the efficacy of treatments for somatoform disorders? A critical review of previous intervention studies. Psychosom Med 2007; 69: 889–900.