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Munchausen's Syndrome Presenting as
Cluster Headache: Case Report
Posted August 2001


The patient was a 23-year-old female with typical symptoms of cluster headache that began shortly after a cervical trigger point injection for radicular pain.She underwent multiple hospitalizations, was frequently seen in outpatient offices,and was given a number of cluster and migraine medications. She became well versed in the textbook presentation of cluster headache.The patient displayed a very dramatic presentation of pain, but could be easily distracted from the pain.While it was suspected that she was using artificial tears to simulate tearing, this was not definitely confirmed.In addition, despite the patient claiming to have severe nausea and vomiting, actualvomiting was never witnessed by medical personnel.Antiemetics were unsuccessful in relieving her nausea.The patient craved attention, and was very persistent in attempting to be hospitalized.Psychological testing revealed weak coping mechanisms, depression, low frustration tolerance, and a low self esteem.


Factitious disorders are displayed by patients who actively seek to assume the sick role, without obvious secondary gains from feigning illness.If they do display ulterior motives, the disorder would most likely be termed malingering.The popular name for these factitious disorders with physical symptoms has become Munchausen's syndrome, labeled as such by Richard Asher.He based the name and syndrome on the German officer Karl Friedrich Hieronymus, Frieherr von Munchausen (1720-1797), well known for exaggerating his own adventures.With this disorder, there is a need to remain in the sick role, and these patients often are hospitalized multiple times for the feigned illness.In the following report, a young woman feigned cluster headache, which began after an injection for cervical pain.


The patient was a 23 year old white female with a 1 year history of right periorbital and temporal sharp pain, eye tearing, and nasal congestion. The attacks occurred 1 to 5 times per day, lasting 1 to 2 hours. She had associated nausea and vomiting. Neurological exam was always normal, with no pupillary abnormalities, and no skin changes. The symptoms began shortly after a right sided cervical trigger point injection for radicular pain. With the onset of the cluster headaches, the patient was admitted multiple times for prolonged hospitalizations, was seen in outpatient offices at least once per week, and was given numerous medications. Virtually every known cluster, migraine, and pain preventive medication was a failure. Within 2 months after the clusters began, she was very well versed in the textbook presentation of cluster headache. Narcotics provided the only benefit, and the patient did actively seek them out. Her presentation of the pain was often dramatic, but she could be easily distracted from the pain. She was caught several times manipulating and lying in order to obtain narcotics. While it was suspected that the patient was using artificial tears to simulate tearing, this was not able to be confirmed. Despite her description of nausea and vomiting, actual vomiting was never confirmed by medical personnel.Antiemetics were unsuccessful in alleviating her nausea. The patient was exceedingly dependent, but had little or no support from family or friends. Her hospitalizations were marked by a notable absence of visitors. Psychological testing revealed depression, denial of psychological problems, poor impulse control, low frustration tolerance, low self esteem, and a dependent personality. In addition, testing revealed weak coping mechanisms, social isolation, little experience of pleasure, and agitation. There was no evidence for distorted reality testing.

The patient craved attention, and was very persistent in her attempts to be hospitalized.She felt very comfortable in the sick role and described herself as an extremely severe chronic cluster patient. There was no obvious secondary gain other than increased attention, and the obtaining of narcotics.

The patient was followed in our headache clinic for two years.She cooperated with regular visits to the psychotherapist, but very minimal progress was made.After several years, the symptoms had not abated, and the patient was still very forceful in attempting to obtain hospitalization.She was subsequently lost to follow-up.


DSM-IV lists the following Factitious Disorders:

Factitious Disorder with Predominantly Psychological Signs and Symptoms
Factitious Disorder with Predominantly Physical Signs and Symptoms (Munchausen's Syndrome)
Factitious Disorder with Combined Psychological and Physical Signs and Symptoms
Factitious Disorder Not Otherwise Specified (NOS)

Factitious disorder must be distinguished from malingering.As with factitious disorder, patients who are malingering feign illness and produce physical or psychological symptoms.With malingering, there is a definite secondary gain such as money, evading the law, avoiding responsibility, etc.Patients with factitious disorder are assuming the sick role; malingerers have goals outside of this.In the past, patients with factitious disorders often became;hospital hoboes; however, as it is much more difficult to obtain admissions to the hospital in the past few years, and those admissions are for a short period of time, many of these patients bounce from outpatient clinic to outpatient clinic.Factitious disorder does not have to be limited to oneself; factitious disorder by proxy is the assumption of the sick role by feigning illness in another person or a child.

Most of the Munchausen patients fake physical symptoms, but with some patients it is primarily psychological symptoms that are feigned. The patients may actively take in toxic substances, place blood or other substances in their urine, overmedicate with drugs such as insulin, or produce home-grown thermometers that are pre-set.Some patients are more active in their feigning of illness than others.In the case presented here, the patient primarily complained of typical cluster symptoms, but she did have eye tearing that was felt to be feigned.No eye drops were ever found on her person.

Munchausen's syndrome is relatively rare, even among chronic pain patients.One study of 2,860 chronic pain patients identified 4 Munchausen patients, for a frequency of 0.14%.

Munchausen syndrome often begins in early adulthood, and as in the current case, it may begin after a hospitalization or a medical problem.While many of the patients are medical personnel, or are well versed in medical terminology, the young woman in this case did not have specific medical training.

Various psychodynamic scenarios have been described in patients with factitious disorder.Rejecting mothers, serious illness in a parent, and a history of childhood deprivation have been described. If the patient has been raised primarily by institutional personnel, this may make it more likely for the person to seek that type of care as an adult.Psychological testing may reveal a narcissistic personality, an inability to tolerate frustration, a poor sense of identity, but no evidence for a true formal thought disorder.