Migraine is linked to a number of psychiatric conditions including depression, anxiety, bipolar disorder, panic disorder and post traumatic stress disorder. People with anxiety and depression are also more likely to progress to chronic migraine. In fact, 54% of people who have more than 15 migraine days a month are affected by a psychiatric condition compared to 34% of those with less than 15 migraine attacks a month. 

Although doctors aren’t entirely sure why the connection exists, Dr. Steven Baskin, Co-director of Behavioral Medicine Services at The New England Institute for Neurology and Headache in Stamford, CT, says there are a number of factors that link these two conditions. These include:

  • The cumulative impact of genetics, childhood adverse events and recent stress
  • Neurotransmitters such as serotonin, norepinephrine and dopamine 
  • Hormones such as estrogen
  • Dysregulation in the brain stem 

It can be sometimes hard for people with migraine to find support for psychiatric illness because many doctors still not know about the connection. Dr. Baskin says that for a long time if a patient told their primary doctor they had a headache and were feeling down the doctor would either treat the depression or the headache and assume the other condition would likewise  improve. 

“You need to treat both because there are lots of costs to having anxiety and depression and lots of costs to having migraine,” he said. “We have to get beyond is it psychiatric or is it neurologic? The reality is that it’s still the brain  and the circuitry is very complex and involves all kinds of phenomena from pain to sleep, and it can be modified by medicines or by other interventions.” 

Preventive Medications Alongside Psychological Interventions

Dr. Baskin says that newer CGRP-targeting therapies are more well-tolerated for people with anxiety. Older medications may have caused side effects such as increased heartbeat or shortness of breath that felt like they were activating the stress response. Some, including fremanezumab (Ajovy) were shown to improve mood. Drugs like these along with Mindfulness-Based Stress Reduction, Cognitive Behavioral Therapy and other relaxation-based therapies, which may help people calm down their reaction to a migraine, can improve quality of life.  

“You want to have an ability to feel like you can control your headache, and part of that is via medicine and part of it is a psychological process,” Dr. Baskin said. “ You feel that you can manage the emotional reactivity to the pain and other stressors in your life. And also in the presence of a significant headache disorder, you can function.”

He says using Mindfulness-Based Stress Reduction can help people with migraine learn to pay attention with openness or flexibility even when what is happening is not positive. This may happen when someone begins to experience prodrome symptoms. Instead of panicking, and thinking about past migraines and what is going to happen next, they can stop to do some relaxation exercises. 

This can also help reduce overuse of medication, which Dr. Baskin says people with both psychiatric conditions and migraine are more prone toward. This can occur because of something called avoidance learning which is performing certain behaviors to prevent negative outcomes. 

It can happen when someone feels a sensation that they assume may be a prodrome or the beginning of a migraine, but they don’t know for sure if it will progress to a full-blown attack. They have a sense of panic because they don’t have time for a migraine so they take a migraine preventive. 

“If you take a medicine preemptively, and then you don’t get the migraine, well, would you have gotten the migraine or not? Avoidance learning leads to these fearful appraisals of pain that prompt the avoidance of anything related to the pain, it can lead to increased sensitivity to pain, it can lead to medication overuse headaches,” said Dr. Baskin. 

Instead he says using Mindfulness-Based Stress Reduction  or other relaxation techniques can help a person break the cycle. Working with a therapist, people with migraine can learn to pay attention with openness and curiosity and choose alternatives. 

How to Get Help

 Dr. Baskin encourages people with migraine to advocate for themselves even if they have to try a few times. 

“The field is expanding and there’s a lot more acceptance and there are a lot more people doing these, short term psychological interventions that are fairly specific for migraine,” he said.

He also encourages practitioners who are working with Cognitive Behavioral therapy to learn how to work with migraine so there are more options for patients. 

“A lot of cognitive behavioral therapies that we do as psychologists or mental health clinicians can be adapted to treat headache,” he said.