Psychological factors in chronic migraine

Psychological factors play a major role in migraines. This is not to say that migraine is a psychological disorder – we have good genetic and brain imaging studies confirming its strong biological underpinnings. The divide between biological and psychological is very artificial since we know that physical illness leads to psychological problems and the other way around. Stress is obviously one of the major triggers of migraines and we know that people with migraines are at least twice as likely to develop anxiety, depression, and other mental disorders. These are not cause-and-effect relationships because anxiety and depression can precede the onset of migraines. The connection is probably due to shared underlying problems with serotonin, dopamine, and other neurotransmitters.

We have strong evidence that addressing psychological factors involved in migraines through biofeedback, meditation, and cognitive therapy can lead to the reduction of migraine frequency, severity, and disability. Studies in chronic pain patients have shown that people with external locus of control (thinking that uncontrollable outside chance events are major contributors to pain) have more disability than people with internal locus of control (those who feel that their actions are contributing to pain and that active involvement in treatment can relieve pain).

Chronic migraine sufferers (defined as those with 15 or more headache days each month) are known to have greater disability than those with episodic migraines. In a recent study by researchers at the Yeshiva University and Albert Einstein College of Medicine, 90 chronic migraine patients were evaluated for psychological symptoms. Of these 90 patients, 85% were women, their mean age was 45, and half reported severe migraine-related disability. They were twice as likely to be depressed and to have external locus of control. The half with severe migraine-related disability were 3.5 times more likely to have anxiety and depression and were twice as likely to have a symptom described as catastrophizing. Catastrophizing is defined as having irrational thoughts about pain being uncontrollable, leading to disability, loss of a job, partner, ruined life, etc.

The good news is that many studies show that with cognitive therapy locus of control can be shifted from external to internal, catastrophizing can be reduced or eliminated, and disability diminished. This may not eliminate migraines or chronic pain, but can make you less anxious and depressed, and much more functional. Cost and access to therapy can be a problem, but studies suggest that even online therapy can be very effective.

Besides psychological approaches, regular aerobic exercise (stationary bike is easiest for migraine sufferers), certain supplements and prescription drugs can also help. Supplements that can relieve anxiety and depression include SAMe, omega-3 fatty acids (fish oil), methylfolate, and other. Some antidepressant medications relieve not only anxiety and depression, but also provide relief of migraines even when psychological factors are absent. These include so called SNRIs (duloxetine or Cymbalta, venlafaxin, or Effexor, and other) and tricyclics (amitriptyline, or Elavil, protriptyline, or Vivactil, and other). The most popular group of antidepressants, the SSRIs (fluoxetine, or Prozac, escitalopram, or Lexapro, and other) do help anxiety and depression, but have no pain or headache-relieving properties. Obviously, all drugs have potential side effects and for most patients it makes sense to try non-drug treatments first.