SAN DIEGO—Stress is a fact of life. More than 40 years of data have established the relationship between stress and migraine. Biobehavioral treatments such as relaxation training, biofeedback, and cognitive behavioral therapy may help to modify patients’ response to stress and reduce the likelihood of a migraine attack, according to an overview presented at the 58th Annual Scientific Meeting of the American Headache Society.
“It can be difficut or impossible to change many factors in our life that create stress, but we can modify how we think about and react to them. That is what we help our patients do using biobehavioral treatments such as cognitive behavioral therapy,” said Dawn Buse, PhD, Director of Behavioral Medicine at Montefiore Headache Center and Associate Professor of Neurology at Albert Einstein College of Medicine in New York. For example, neurologists can teach patients better coping strategies, reduce catastrophizing, encourage the use of social support, and create healthy lifestyle behaviors and other potentially protective factors.Triggers and Protective Factors
Stress can play many roles in migraine. It can exacerbate migraine attack frequency or be a premonitory feature, prognostic factor, or a consequence of an attack. In addition, stress can be a risk factor for the onset of migraine and is a common trigger.
In a study by Kelman of 1,750 patients diagnosed with migraine, 76% of the participants reported having triggers. Nine percent of patients experienced triggers very frequently, 27% experienced triggers frequently, and 40% of patients encountered triggers occasionally. In addition, 80% of respondents reported stress as a trigger for migraine, making it the most common trigger. In a study by Wöber et al published in 2007 in Cephalalgia, “stress in private life” and “psychic tension” were associated with an increased risk of migraine attacks. A study published in the European Journal of Pain in 2014 reported strong associations between migraine and job stress, which researchers defined as low job control, high job demands, and low social support.
Other data suggest that migraine attacks may result from a combination of triggers, rather than from one trigger. A study of the association between stress and menstruation in migraine published in the International Journal of Women’s Health in 2014 included 307 participants with migraine without aura. Participants kept a headache diary for 14 months. The data suggested that women were more susceptible to stress in the premenstrual period. The researchers also found a statistically significant relationship between alcohol and migraine attacks only during stressful periods.
Martin and colleagues conducted three studies comparing people with migraine or tension-type headache and controls without headache. Participants attempted to solve difficult anagrams for 35 minutes while receiving negative feedback. They found that the stress condition was associated with increased head pain, compared with controls.
Sleep duration may have a relationship with stress. Data published in Pain in 2012 suggested that two consecutive days of high stress levels or low sleep were strongly predictive of headache. In contrast, two consecutive days of low stress or adequate sleep were considered protective factors that may help raise the headache attack threshold. Information like this may help give patients a sense of control, said Dr. Buse.
Two Types of Stressors
Investigators generally categorize stressors as daily hassles or major life events. According to research published in 1992 in Pain, people with recurrent headache experience more hassles than controls do. Daily hassles are also associated with an increased frequency of headache attacks.
Adverse childhood experiences such as emotional neglect, emotional abuse, sexual abuse, and other forms of abuse are considered major life events and appear comorbid with migraine incidence and attack frequency. Data published in Neurology showed that people who experienced more types of traumatic events in early childhood were more likely to have a higher frequency of severe headache, including chronic migraine.
Appraisal and Self-Efficacy
Years of research support the thesis that modifiable factors such as appraisal and self-efficacy influence migraine, said Dr. Buse. Studies have found that people with tension-type headache appraise stressful life events more negatively than controls do. This result raises the possibility that appraising stressful events less negatively could reduce headache pain or frequency.
People with tension-type headache also perceive themselves as having less control (ie, low self-efficacy). Self-efficacy helps to moderate the impact of stressful events on headache. According to a 1984 electromyography biofeedback study published in the Journal of Consulting and Clinical Psychology, a greater sense of self-efficacy resulted in a reduction in headache.
Coping and Social Support
Improving their coping skills and seeking greater social support also may benefit patients with headache. Migraineurs may respond to stress with more wishful thinking, self-criticism, social withdrawal, and catastrophizing, compared with controls. A study published in the Journal of Behavioral Sciences reported that patients with tension-type headache practiced less effective coping strategies, were more likely to blame themselves, and made less use of social support than did controls. Researchers also found that people with migraine tend to engage in catastrophizing while thinking about their condition.