Abstract
There are a significant number of famous people who suffered from frequent headaches during their lifetime while also exerting an influence of some kind on politics or the course of history. One such person was Anneliese Marie Frank, the German-born Jewish teenager better known as Anne Frank, who was forced into hiding during World War II. When she turned 13, she received a diary as a present, named it ‘Kitty’ and started to record her experiences and feelings. She kept the diary during her period in hiding, describing her daily life, including the feeling of isolation, her fear of being discovered, her admiration for her father and her opinion about women's role in society, as well as the discovery of her own sexuality. She sometimes reported a headache that disturbed her tremendously. The ‘bad’ to ‘terrifying’ and ‘pounding’ headache attacks, which were accompanied by vomiting and during which she felt like screaming to be left alone, matched the International Headache Society criteria for probable migraine, whereas the ‘more frequent headaches’ described by Anne's father are more likely to have been tension-type headaches than headaches secondary to ocular or other disorders.
Anneliese Marie Frank (12 June 1929 to March 1945) was a German-born Jew who wrote a diary while in hiding with her family and four other Jewish people during the German occupation of the Netherlands in World War II. During the period from June 1942 until August 1944, when Anne Frank wrote her diary (originally in Dutch), she described her daily life, including the feeling of isolation, her fear of discovery, her admiration for her father and her opinions about women's role in society, as well as her discovery of her own sexuality. Anne Frank's writings include tales, fables, essays and even an unfinished novel (1). It was her diary, though, that reached millions of people around the globe and made her famous. While she had little influence as a literary writer, she certainly made a major contribution in terms of keeping alive the memory of the horrors of the Holocaust, recording both brilliantly and dramatically the events that took place during World War II. It is this achievement that makes her book one of the most valuable historical documents produced to date. To our knowledge, this is the first study of Anne Frank's headaches in medical literature.
Below are a number of quotations from some episodes written by Anne. Although Anne Frank was German, she was brought up in Holland, so her diary was written in Dutch. We have therefore endeavored, in translating the following extracts from Dutch, to preserve their originality (2, 3).
Saturday, 3 October 1942
‘Yesterday Mother and I had another run-in and she really kicked up a fuss … (En ik had al zo'n verschrikkelijke hoofdpijn) and I already had such an awful headache.'
Monday, 2 November 1942
‘Bep stayed with us Friday evening. It was fun, but she didn't sleep very well because she'd drunk some wine. For the rest, there's nothing special to report. (Gisteren had ik erge hoofdpijn en ben vroeg naar bed gegaan.) I had an awful headache yesterday and went to bed early. PS. ‘I forgot to mention the important news that I'm probably going to get my period soon. I can tell because I keep finding a whitish smear in my panties, and Mother predicted it would start soon.'
Saturday, 30 January 1943
‘I am seething with rage, yet I can't show it … I'd like to scream, stamp my foot, … ' ‘I'd like to scream at Mother, Margot, the van Daans, Dussel and father too: Leave me alone, let me have at least one night when I don't cry myself to sleep with my eyes burning and my head pounding! (en m'n hoofd bonst!).'
Monday, 26 July 1943
‘The first warning siren went off in the morning while we were at breakfast, but we paid no attention, because it only meant that the planes were crossing the coast. (Want ik had erge hoofdpijn.) I had a terrible headache, so I lay down for an hour after breakfast and then went to the office at around two.’
Friday, 19 May 1944
‘I felt rotten yesterday. (Overgeven [en dat bij Anne!], hoofdpijn, buikpijn, wat je je maar in kunt denken.) Vomiting [and this happened to Anne!], headache, stomach ache and anything else you can imagine).’
Discussion
We know very little about Anne Frank's diseases. According to her biography (4), Anne was considered a child who had fragile health. She was even given an affectionate nickname, ‘The Little Delicate One’. During her first months of life, she used to cry in a moving way, and night after night would keep her parents awake with her episodes of diarrhoea and attacks of what was apparently belly ache. Otto Frank, her father, had to spend many nights beside her bed trying to calm her down and massaging her belly. Clearly, Anne was affected by diseases that are common to all children. However, she probably also suffered from rheumatic fever as well as from some kind of deformity of her shoulder joint, which she even used to scare people with, by dislocating her shoulder at will (4, 5).
It is very likely that Anne's first reference to a headache was in one of her letters during her summer vacations in 1941:
‘For the first time I felt well when I woke up this morning, apart from a little headache and belly pain.’
During her period of isolation, Anne frequently showed signs of fever and had cold shivers. However, the main cause of her pain was apparently her eye problem (myopia, according to Anne Frank herself in June 1943), which was also believed to be responsible for her headaches (4). Miep Gies, considered the ‘Guardian Angel’ of the eight Jewish people in hiding with Anne, wrote in her book Anne Frank remembered (6) about her concerns for Anne's health. She reported that Otto Frank had told her that his daughter was suffering from frequent headaches. Anne needed to see an eye doctor, but her parents were afraid she might get arrested, so she had to accept the situation.
In addition, during her period of isolation, Anne reported instances of anxiety and sadness and took ‘valerian root’. As she wrote in her diary on 16 September 1943:
‘I've been taking valerian every day to fight the anxiety and depression, but it does not stop me from being even more miserable the next day.'
In her diary, Anne wrote about some episodes of her headaches, and her descriptions suggest that they were disabling pains. She even used terms like ‘awful’, ‘terrible’ and ‘pounding’ and also mentioned that there was some vomiting associated with the headaches.
According to Anne's biography, her headache attacks were attributed to eye problems (probably myopia). Several eye disorders can cause headache (7), but the most frequent ones, such as uncorrected or miscorrected refractive errors, can cause eye pain and/or mild headache (8). Anne, however, reported episodic and disabling headache.
What type of headache(s) might Anne Frank have had? Migraine is the most frequent disabling primary headache. Attacks are moderate or severe, unilaterally located and disabling and worsen with physical activity. The pain is pulsating (‘throbbing’, ‘pounding’) and usually associated with nausea (with possible vomiting), photophobia and phonophobia. Attacks may last from 4 to 72 h when not treated or treated ineffectively (7). Tension-type headache has a pressing (non-pulsating) quality and is of mild or moderate intensity (7). Thus, it does not produce disabling pain, but only disturbs the patient when it becomes frequent or chronic, its persistence being more disturbing than its intensity.
Anne mentioned three painful episodes as very strong, even using the term ‘pounding’ for certain attacks, and there was vomiting associated with another episode, although she did not give any details about the pain. Bearing in mind that she was a teenager and that migraine usually begins with prepuberty, we have to consider probable migraine as the most likely diagnosis, but the ‘more frequent headaches’ described by Anne's father are more likely to have been tension-type headache.
Why is it that in 2 years Anne reported only a few headache attacks? She may have suffered other headache episodes but not reported them. Moreover, her father, Otto Frank, once told Miep Gies that Anne was suffering from headaches. Initially, Anne wrote her diary strictly for herself in an unpretentious way. Then, in March 1944, she listened to a radio broadcast from London of an appeal from a member of the Dutch government in exile. He hoped that after the war he could collect eyewitness accounts of the suffering of the Dutch people during the German occupation. As an example, he specifically mentioned letters and diaries (2). Impressed by this speech, Anne decided to reorganize her diary and suppressed or extended some information. Thus, she probably did not report her headaches in the belief that these details were not important for her new purpose in keeping the diary.
If Anne Frank's prodigious life had not been so brutally and prematurely interrupted by the absurd and tragic Nazi ideology, she might have been a prolific writer and an important activist, and more details of her headaches would have become known.
Afterword
On the morning of 4 August 1944, after nearly 25 months in hiding, Anne Frank's group was betrayed (somebody, maybe an employee, must have told the authorities), arrested and transported to Westerbork, a transit camp in the Netherlands. On 3 September they were deported on what was to be the last transport from Westerbork to Auschwitz. On 28 October, Anne and her sister Margot were transported from Auschwitz to Bergen-Belsen (Germany).
In March 1945, a typhus epidemic spread through the camp, killing several prisoners, among them Anne and Margot Frank. This is believed to have occurred a few weeks before the camp was set free by British troops.
Otto Frank, the only survivor, was freed from Auschwitz by the Russian Army in 1945, remarried in 1953 and died on 19 August 1980, at the age of 91. He devoted the latter part of his life to keeping Anne Frank's memory alive and sharing the message of his daughter's diary with the rest of the world.
Anne Frank has departed this world, but her diary survived the war and was found by Miep Gies. The first edition in Dutch appeared in 1947, and since then the diary has been published in more than 60 languages all over the world!
‘I don't want to live like Mother, Mrs Van Daan and all the other women who simply do their work and are then forgotten. I need to have something besides a husband and children to devote myself to! I want to be useful or bring enjoyment to all people, even those I've never met. I want to go on living even after my death!' Anneliese Marie Frank
Postscript
Miep Gies is still alive and is 97 years old. We were unable to contact her.
Acknowledgements
The authors thank the following: Professor Gerardus Jozef Maria Huiskamp (the Netherlands) and Mr Osvaldo Eustáquio de Almeida (Brazil), respectively, for translation of part of Anne Frank's Diary from Dutch and for translation of this paper to English; Mrs Anna Maria Kuhne (Switzerland); Dr Ariovaldo Alberto Silva Júnior (Brazil); Dr Mauro Eduardo Jurno (Brazil); Dr Elza Magalhães (Brazil); and Dr Abouch Krymchantowski (Brazil) for their constructive comments.