Abstract
Introduction
Franz Kafka suffered from a particular variety of extremely severe headache attacks between 1913 and 1917. Several features of his pains and his behaviour during headaches seem to be indicative of cluster headache. This has not been discussed in the previous vast literature on Kafka, but appears to have some implications on his literature production.
Franz Kafka's headaches – a case report
On 16 September 1915 Franz Kafka writes in his diary (1):
‘Neuer Kopfschmerz noch unbekannter Art. Kurzer schmerzhafter Stich rechts über dem Auge. Vormittag zum erstenmal seitdem häufiger’
‘A new headache of a hitherto unknown type. A short stabbing pain over the right eye. This morning for the first time, more frequently since’
The diaries written by Kafka may be read as a continuous medical record. He notices very carefully all his symptoms during the years, and most common are notes on headaches and insomnia. Kafka was 26 years of age when he began to write his diary in 1909. We therefore do not know very much on his previous medical state, but in a letter from 1907 the symptom of headache is mentioned. At that time it was presumably manifesting as a rather mild form of so-called unclassified primary headache (perhaps migraine?). Otherwise headache is not mentioned in letters or in his diary until the autumn of 1911.
On 4 October 1911 Kafka writes:
‘Gestern vor dem Einschlafen hatte ich links oben im Kopf ein flackerndes kühles Flämmchen. Über meinem linken Auge hat sich eine Spannung schon eingebürgert’
‘Yesterday, before falling asleep, I had a flickering, cool little flame up in the left side of my head. A tension type sensation has already been present over my left eye’
Kafka also describes a ‘vertical pain in my head over the root of the nose, like a very sharp pressure in a wrinkle of my forehead’. On 9 October pain is felt like a knife ‘carving thin slices out of my brain’.
From New Year of 1913 and later on there is a most dramatic change in the pattern of his head pains. They are now described as terrible, being quite intolerable. In the middle of January 1914 he describes the pains in a letter to his fiancée Felice Bauer: ‘The headache has had its onset during the last two months, or perhaps from New Year of 1913’. The headache is felt as being extremely severe, ‘like a torture’. ‘Like a see-saw through my head’. ‘Like a nail through the temple’. ‘Headache down to unconsciousness’.
In December 1914 he still suffers from intolerable headaches and insomnia. Headaches appear on a periodic basis, sometimes being endurable, but on other occasions so intense that he feels to be ‘tortured by agonies like a martyr’. On September 1915 his headache is stated to occur over his right eye. The diary on 28 September 1915: ‘It is without meaning to complain. As an answer stabbing pain in my head’.
Kafka's headache attacks probably lasted for a few hours. Thus it is said in several notes that he suffered from headaches in the morning hours. Kafka did not use any analgesics against his headaches. On the contrary, he distrusted drugs and the medical profession and there are reasons to assume that the pain vanished spontaneously during the day.
In August 1917 Kafka had a severe haemoptysis and a diagnosis of lung tuberculosis was made. Thereafter there was a marked improvement of his headaches. Kafka says that his headaches and insomnia were as if being ‘washed away’. It is evident from letters and his diary that some headache and sleep troubles also occurred during his last years, in the beginning of the 1920s, but they were not as troublesome as during the crisis years 1913–1917.
Discussion
It is quite clear that Franz Kafka suffered from an extremely severe kind of repeated headaches. The symptoms are so vividly described that a diagnosis of cluster headache appears to be likely. This has not been observed in the vast literature on Kafka. There is, for example, no comment on his headache observations in September 1915 in the critical edition of Kafka's writings (1), nor in the recent comprehensive biography on Kafka by R. Stach (2), despite the fact it carefully deals with the critical years of 1910–1915 when he did have repeated head pains.
Franz Kafka suffered from severe headaches from about the age of 30. Cluster headache commonly develops in men at ages 20–45 years (3). Attacks of cluster headache are typically described as being knife-like, splitting or stabbing, and being of an excruciating intensity. ‘As severe as an attack of kidney stone’ or the like is a characteristic statement of patients. Max Brod, Kafka's close friend, refers in his biography (4) to Kafka's own description of his pains: they occur ‘in the same way as a glass window might feel it in the point where it breaks into pieces’. Franz Kafka's headaches were concentrated to a particular point in his head, and as was said in September 1915, they were localized to the right supra-orbital region.
During the worst attacks the intensity of pain in cluster headache is excruciating (5). Patients are unable to lie down during headaches and they typically sit in a chair or walk about. The high intensity of Kafka's headaches is, among others, specifically mentioned in another letter to Felice Bauer on 21 March 1915. He says that during morning attacks he ‘literally’ sits and sways his head ‘to and fro in my hands’. This kind of behaviour is characteristic of many patients with cluster headache.
The tendency of cluster headache patients to develop suicidal behaviour was described by Bayard Taylor Horton in his very first paper on the syndrome (6). The pain of his patients ‘was so severe that several of them had to be constantly watched for fear of suicide’. Indeed, Kafka considered his personal situation so desperate that thoughts of committing suicide were common during these years, as appears from the diary.
Periods of cluster headache attacks often occur with a seasonal rhythm, with a peak frequency during the spring and autumn (7). Kafka suffered from autumnal headaches and these were of very severe pain intensity. The age at onset, the extremely high intensity of the headache attacks, his behaviour during headaches, the character, localization and temporal pattern of pains may in our opinion speak in favour of a diagnosis of cluster headache. For several reasons it is much less likely that he suffered from migraine, trigeminal neuralgia or supra-orbital neuralgia.
In Kafka's diaries there is admittedly no mention of such associated symptoms of cluster headache as redness of the eye, tearing or stuffiness of the nostril. Therefore, it may be said that Kafka's diary notes on his headaches do not completely fulfil all the specified criteria of cluster headache according to the International Headache Society (5), but with this diagnostic reservation it may also be mentioned that, in about 3% of patients, attacks of cluster headache are never accompanied by these autonomic features, although the headaches are quite typical in all other respects (3, 8, 9). It does not seem very important or necessary to describe such minor local symptoms in detail in a private diary.
That Kafka seems to have suffered from a particular variety of extremely severe headaches apparently provides some new insights into his literature production in the middle of the 1910s.
In the diary and in his literature fantasies of torture-like pains are common during the years of 1913–1917. Kafka feels as if being stuck by knifes and needles, or penetrated by arrows: ‘I am consisting of needles that are forced in me’. He indulges in fancies on how to best force a knife through his neck, ‘between the neck and the chin’.
In the short story In der Strafkolonie from October 1914 he describes in detail a torture machinery with needles that are penetrating victims sentenced to death. Josef K. (in Der Prozess) is executed with a butcher's knife, his guards are tortured for hours with whips, Gregor Samsa (the beetle in Die Verwandlung) is tortured to death by his father; homicides by means of knifes, and bleeding ulcers are common in other short stories. In the literature on Kafka such pain descriptions have often been confused with sadism or masochism. In Kafka's works before 1913 there are, however, no such feelings of severe pains: they are not to be found in the short stories in his youth, in his first book from 1912 (Betrachtung), in Das Urteil (his breakthrough short story written in September 1912), or in the novel Der Verschollene (named ‘Amerika’ by Max Brod). Nor are torture-like descriptions of pain to be found after August 1917, in the novel Das Schloss or in his last short stories. Thus, after 1917 the pain fantasies are as being ‘washed away’, we find no such dramatic descriptions as being killed by guillotine during the French revolution, being crushed and cut into pieces by a butcher or by a train, tormenting a horse with sharp spurs, being draggled, bleeding by a necklace, through a building and thrown out on a roof as a strip of meat.
We suggest that Kafka sought to familiarize with some even more severe pain conditions, in order to try to endure his own headaches, i.e. a kind of desperate coping behaviour; the suffering of the prisoner in the torture machine was in any case still more severe than his own complaints.
‘Physical pain is the only real, incontrovertible truth’ can be read in a letter of Franz Kafka in 1922. He could at that time with some retrospective irony describe himself as a ‘headache specialist’. However, in the beginning of the century Horton's headache (cluster headache) was still an unknown medical entity. A physician that he visited in 1916 made a diagnosis of ‘extreme neurosis’ and recommended rest, healthful diet and promenades.