If you are a person living with migraine AND a mental health condition, you are not alone.
Migraine and chronic daily headaches are common in people who suffer from anxiety disorders. Common symptoms of anxiety, like excessive worry, fear and irritability, can play off of migraine symptoms. We worry about when the next attack will come, what will trigger it, and feel helpless and frustrated about the unpredictability of migraine and how it is affecting our lives. And, when you don’t know when the next attack is coming, it can cause a great deal of migraine anxiety. It is estimated up to 60% of migraine patients also have anxiety.
People with both an anxiety disorder and migraine have an increased likelihood of experiencing major depression. And the more migraine days you have, the higher your risk of developing anxiety and/or depression.
People with migraine are about five times more likely to develop depression than someone without migraine, and it is estimated 40% of people living with migraine have some level of depression. It is logical when you’re living with a chronic disease like migraine, which is affecting your life significantly, that you’re going to feel sad or down about how it’s affecting your life.
Many other mental health conditions affect those living with migraine more than the rest of the population. Bipolar disorder, panic attacks, substance abuse disorders, and phobias have all been highly correlated with migraine (that is, people have been found to have both conditions, but there is no evidence to prove one causes the other). Recent research also suggests that people with migraine are more likely to have posttraumatic stress disorder (PTSD) than the general population.
Migraine attacks can start before mental health issues emerge. If you have been diagnosed with migraine, implementing a pro-active mental health management plan can be a good idea.
Signs of Anxiety
Physical: panic attacks, hot and cold flushes, racing heart, tightening of the chest, quick breathing, restlessness, feeling tense, wound up and edgy
Psychological: excessive fear, worry, catastrophising (thinking things are worse than they are), or obsessive thinking
Behavioural: avoidance of situations that make you feel anxious which can impact on study, work or social life
Anxiety First Aid
Slow your breathing
Stay in the present by grounding yourself – use one of your five senses (e.g. Feel the grass beneath your seat, feel your back against the chair, fix your eyes on one thing in front of you)
Challenge your self-talk – it’s trying to tell you that there’s danger so try to engage your rational mind to come up with a more helpful thought
Self-compassion – be kind to yourself. You are not a failure and you are not weak. You have anxiety and it can be treated.
Managing migraine related mental health issues
The use of therapy for chronic pain has evolved significantly over the last few decades. Initially there was behavioural therapy, then the inclusion of cognitive therapy principles, and most recently the successful addition of acceptance and mindfulness based approaches. Recognising this advancement and the abundance of supporting evidence, leading international pain organisations are now beginning to endorse and recommend cognitive and behavioural psychological approaches alongside medication as the first line treatment approach for headache disorders, including migraine (Penzien, Rains, & Andrasik, 2002).
Below are some of the most widely used approaches for chronic pain and migraine management. There are also other approaches which have been found to be beneficial, this includes self hypnosis and others. Like all migraine treatment options, you need to find what works for you.
The best way to learn how to use these really important tools to assist with chronic pain is to see a registered psychologist in your area. See your GP and you may be able to access a Mental Health Care Plan (MHCP) that allows 10 visits in a calendar year that attracts a Medicare rebate. There may still be an out of pocket fee so do your research.
To get initial feedback on your levels of anxiety and depression visit the K10 checklist at Beyond Blue: https://www.beyondblue.org.au/the-facts/anxiety-and-depression-checklist-k10
Important to note: these strategies work by giving people living with migraine skills they can use, which is empowering for you as it allows you to become an active participant in the management of your condition.
Mindfulness Based Cognitive Behavioural Therapy (MBCT)
MBCT has a wealth of evidence to support its effectiveness in people with intractable pain such as those living with migraine. It combines traditional cognitive and behavioural approaches with the more recent mindfulness concepts of being in the here and now.
MBCT involves steps like: moving out of automatic pain habits, challenging negative thinking styles, using our breath as an anchor, learning to stay present, active acceptance, seeing thoughts as just thoughts, and last but not least, self-care (Day, 2017). These all assist with pain management as well as anxiety and depression.
We all have things that bring us into the moment – perhaps a beautiful sunset or the first mouthful of an amazing meal. Mindfulness is about stretching out those moments of present focused awareness by training our minds to come back to whatever is happening right now. This assists with pain by focusing ONLY in the present instead of jumping to conclusions about the past (how bad it’s been) or the future (if I miss work again….). This is often described as shifting out of the “doing” mode and into the “being” mode, or switching out of autopilot.
Negative thoughts drive negative feelings, which can sensitise our nervous systems and increase our pain. Thinking very negatively about pain, or what we call ‘pain catastrophising’, is one of the strongest predictors that short-term acute pain will become longer-term persistent pain. Mindfulness meditation can reduce the burden of these negative thoughts because it changes our relationship to thinking itself. We start to see thoughts as just ‘mental events’ rather than facts, which lessens their impact. In other words, we don’t as easily buy into the negative story around our pain. This is especially important in overcoming the upsetting emotional impacts of pain and disability, such as depression and anxiety (Pain Health, 2019).
Signs of Depression
You may be depressed if, for more than two weeks, you’ve felt sad, down or miserable most of the time, or have lost interest or pleasure in usual activities, and have also experienced several of the signs and symptoms across at least three of the categories below. It’s important to remember that we all experience some of these symptoms from time to time, and it may not necessarily mean you’re depressed. Equally, not everyone who is experiencing depression will have all of these symptoms.
Behaviour: not going out anymore, not getting things done at work/school, withdrawing from close family and friends, relying on alcohol and sedatives, not doing usual enjoyable activities, unable to concentrate
Feelings: overwhelmed, guilty, irritable, frustrated, lacking in confidence, unhappy, indecisive, disappointed, miserable, sad
Thoughts: ‘I’m a failure’, ‘It’s my fault’, ‘Nothing good ever happens to me’, ‘I’m worthless’, ‘Life’s not worth living’, ‘People would be better off without me’
Physical: tired all the time, sick and run down, headaches and muscle pains, churning gut, sleep problems, loss or change of appetite, significant weight loss or gain
Depression First Aid
re-engage in an activity that you used to get pleasure from
talk to a trusted friend
increase nutrition and/or exercise
see your GP
Pain with less distress
Exciting research using brain scanning technology like functional magnetic resonance imaging (fMRI) is beginning to shed light on patterns of activity in the brain when a person is in pain and when they are meditating. It looks like people are still aware of the sensory aspects of pain during mindfulness meditation but they experience it as less unpleasant since it does not activate as many of the brain networks related to memory, emotion and self-referential thought. In more technical terms, this relates to a decoupling of sensory-discriminative and cognitive-evaluative brain networks. In other words, meditation trains your brain to experience pain with less distress (Pain Health, 2019).
Acceptance and Commitment therapy (ACT)
Similarly ACT has some helpful strategies that are very useful for pain management. These strategies include:
Mindfulness – paying attention to the present moment, whatever that holds for us. See above or website below for more information.
Acceptance – to let go of the emotional fight of wanting things to be different and accept what is in the here and now (and the past). This is very different to liking it or giving up. We can feel like we’re locked in a fierce battle with our pain and just want to get rid of it. While this is completely understandable, it can make us more frustrated, anxious or depressed when we can’t control the pain. Mindfulness is about accepting what is here right now as best we can, including pain, so that we can soften and be more receptive to what happens next. This is very different from being resigned to a life of pain. Mindfulness is all about curiosity and what some people call ‘beginner’s mind’. Research shows that people who learn how to accept their pain respond better to various treatments and have better overall pain outcomes (Pain Health, 2019).
Values – knowing clearly what our values are and living in accordance with them can assist pain, depression and anxiety by assisting us to live a rich, full and valuable life with some sense of mastery over the things that are important to us. This can happen even though we feel out of control with our pain.
Cognitive defusion – is about getting some distance or unhooking from unhelpful thoughts. Sometimes we get so caught up in our thoughts relating to pain, anxiety or low mood that it’s difficult to see things clearly – for what they really are. So this strategy can assist us to make the world a little clearer again by letting go of unhelpful thoughts and the intense emotions they create.
Again, a registered psychologist is the best place to start, so do your research. Make sure the person or practice you choose has undergone ACT training. A very useful website is by Dr Russ Harris at www.actmindfully.net.au.
Relaxation, including guided visual imagery, deep abdominal breathing, progressive muscle relaxation and mindfulness, are all excellent treatments for people living with migraine. There are many apps and websites available. Mindfulness is not technically a relaxation strategy (it has other benefits) however if you were to do a mindful breathing exercise before bed you are likely to feel the benefits of relaxation.
Relaxation is very important for coping with pain because pain is not only stressful in itself, but stress exacerbates and maintains pain. Relaxation is very helpful in calming down your nervous system, which often becomes ‘sensitised’ when pain persists for a long time. Relaxation also boosts your body’s natural pain modifiers, such as endogenous endorphins, or “feel good” hormones.
We can’t always change or minimise the stress that happens around us (or sometimes we can!) so changing our ways of reacting by managing our thoughts differently to reduce our stress can be very helpful. Other proven stress busters might include setting tighter boundaries with work or certain people in your life, more assertive communication including saying NO more often, greater levels of self compassion and/or more exercise each week.
To combat feelings of isolation and loneliness we need to reach out – to family, friends and professionals – tell them what you need from them. This support system is incredibly important when depression and /or anxiety are present however just having coffee with a friend and talking about everyday activities is also vital for a sense of connectedness. If you are feeling unwell (either migraine, anxiety, depression or all three), remember there are different types of support available – some common ones are physical/practical (transport to appointments, meals made), emotional (a listening ear) or financial. Of course if we can manage our migraine more effectively, we can experience more engagement in life and “give back” in personal relationships when you can. Usually all that is required from our personal support network is “thank you”.
Beyond Blue: https://www.beyondblue.org.au/
Black Dog Institute: https://www.blackdoginstitute.org.au
ACT Mindfully: https://www.actmindfully.com.au
Centre for Clinical Interventions workbooks: https://www.cci.health.wa.gov.au/Resources/Looking-After-Yourself
Head to Health: https://headtohealth.gov.au/