According to the American Migraine Foundation, 50 to 60 percent of those with Migraine also live with an anxiety disorder. Even if we don’t have an anxiety disorder we can experience anxiety as a symptom of a Migraine attack. The symptoms of anxiety disorders can have a negative impact on Migraine management. Untreated, these symptoms can lead to:
Increased frequency and severity of Migraine attacks
Increased risk of progression to chronic Migraine
Treatment resistance in which potentially helpful treatments fail
Anxiety is a heightened state of alertness. Every bodily function responds to these changes. The physical sensations associated with anxiety may include:
- Shortness of breath
- Increased heart rate
- Chest tightness
- Sensation of throat closing
- Double vision
- Difficulty thinking
- Cold hands and feet
Elements of anxiety affecting Migraine
1. Hypervigilance occurs when there is a heightened state of awareness in which we scan the environment for potential threats. This constant state of “high alert” perpetuates non-stop anxiety that can leave us feeling exhausted, but unable to relax. It’s easy to get caught up in hypervigilance. After all, Migraine management involves paying attention to many different factors: trigger avoidance, treatment compliance, stress management, sleep hygiene, nutrition, hydration, plus making in-the-moment acute treatment decisions. All that focus on Migraine can become all-consuming to the point that we see danger everywhere.
2. Self-fulfilling prophecies can easily occur. Whatever we look for, we’re likely to find. When we try to avoid every possible trigger, the world feels like a dangerous minefield. When we assume, without testing it out, that something is a trigger, we are likely to attribute the next Migraine attack to that trigger. Hypervigilance leads to these self-fulfilling prophecies that may or may not be true. It puts us at greater risk of attacks.
3. Catastrophizing then sets in. With danger surrounding us, we become consumed with fear. We may fear a worsening of attacks that do not respond to treatment. We may even begin to think that no one believes us. Distraction techniques become more difficult to employ, increasing our attention to negative outcome potentials.
4. Avoidance is the natural response to anxiety. Unfortunately, that instinct actually worsens our anxious feelings. The more we avoid, the more we believe that our behavior is protecting us from bad outcomes, the more we try to avoid. In terms of Migraine management, this avoidance can lead us to an unnecessary restriction of activities. We may also begin pre-treating to avoid a potential Migraine attack, increasing our risk of medication overuse which can lead to a worsening of attack frequency and severity.
5. Reinforcement is powerful at maintaining anxiety. We find what we look for. We prevent what we avoid. Fear is a powerful tool for survival. Trying to interrupt these impulses is no easy task.
Factors of Migraine management affecting anxiety
1. Keeping a Migraine diary can become anxiety-provoking. Trying to document every detail may backfire, leaving us with a mountain of unpleasant feelings:
fear that we might forget to record an attack or miss important details
self-blame and shame for not avoiding a known trigger
depression when viewing the recorded details of each attack
We can lose ourselves in the details, forgetting the purpose of tracking. The purpose of tracking our attacks is twofold: identify triggers and assess the effectiveness of our treatment plan. Not everyone needs to track every single symptom or every possible trigger. If your Migraine diary is stressing you out, it’s not fulfilling its purpose. Simplify tracking by using a tracking app, asking a loved one to document your attacks, or using a scaled-down tracking tool.
2. Trigger avoidance doesn’t have to be complicated or stressful. New research on triggers is yielding some surprising results. Much of what we have assumed about food and environmental triggers is proving either incorrect or over-emphasized. Migraine doctors are moving away from telling patients to avoid a long list of potential triggers. Instead, they are encouraging patients to focus on a few basics because these factors have been shown to have a greater impact on Migraine attack frequency and severity.
Migraine specialist Larry Newman, M.D., developed an acronym to help doctors and patients remember these basics. Remember SEEDS when making lifestyle choices to manage Migraine:
- SLEEP – consistent, healthy sleep hygiene
- EXERCISE – daily Migraine-friendly exercise
- EATING – regular healthy meals
- DIARY – simple tracking of attack frequency and severity
- STRESS – healthy stress management
Amaal Starling, MD shares this about SEEDS, “Nonpharmacological treatment options and lifestyle changes are important and proven to be effective in clinical studies in migraine. A good mnemonic is SEEDS: Sleep hygiene, Exercise, Eating healthy, keeping a headache Diary, and Stress management. These are the SEEDS for success in headache management.”
No shame in asking for help
If anxiety is complicating your migraine treatment, don’t try to resolve it alone. Ask your doctor for a referral to a behavioral health provider. Acute pharmaceutical treatment alone carries risks of dependency. It also treats symptoms rather than addressing the underlying causes of anxiety. Psychotherapy is essential to treat the emotional, cognitive, and behavioral habits that maintain anxiety. Asking for help could make all the difference in Migraine treatment success.
1 Asmundson G, Norton P, & Norton G. (1999). Beyond pain. Clinical Psychology Review, 19(1), 97-119. doi: 10.1016/S0272-7358(98)00034-8.
2 Email interview with Amaal Starling, MD on August 17, 2017.
3 Hamm A, & Weike A. (2005). The neuropsychology of fear learning and fear regulation. International Journal of Psychophysiology, 57(1), 5-14. doi: 10.1016/j.ijpsycho.2005.01.006.
4 Lucchetti G, Oliveira A, Mercante J, et al (2012). Anxiety and Fear-Avoidance in Musculoskeletal Pain. Current Pain and Headache Reports, 16(5), 399-406. doi: 10. 10.1007/s11916-012-0286-7.
5 Matatko N, Ruppert M, Zierz S, et al (2009). Fear-avoidance and Endurance-related Responses to Pain in Migraine. European Journal of Pain, 13(S1), S273c-S274. Doi: 10.1016/S1090-3801(09)60974-5.
6 Nicholas, M, Asghari A, Sharpe L, et al. (2014). Cognitive exposure versus avoidance in patients with chronic pain: Adherence matters. European Journal of Pain, 18(3), 424-437. doi: 10.1002/j.1532-2149.2013.00383.x
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Headache disorders counselor and advocate Tammy Rome maintains a private practice specializing in treating clients with Migraine and other headache disorders. She also volunteers as vice chair of the American Headache and Migraine Association and as president of The Cluster Headache Support Group. You can read more of Tammy’s work on her website and follow her on Facebook, Twitter, StumbleUpon, Pinterest, LinkedIn, and Google+.