Ronald S. Kaiser, PhD, ABPP - Jefferson Headache Center, Thomas Jefferson University
The American Migraine Prevalence Study (Lipton et al, 2007), the largest study of migraine in America ever conducted, found that 12% of Americans have migraine, and 90% of them can’t function normally on days when they have migraine. 30% of them are bedridden on those days. Obviously, that level of impairment impacts quality of life as well as mood.
Working with migraine headache patients can be challenging, but it can also be one of the most rewarding therapeutic experiences that can occur for both the patient and the therapist – so long as each pursues the therapeutic process with the proper mindset. Because of the size of the migraine population, there has been considerable research to provide guidance for understanding and treating migraine patients.
Reviews of the literature (Kaiser et al, 2015, Kaiser et al, 2016), as well as clinical experience, provide principles for psychotherapeutic effectiveness in treating migraine patients.
- In almost every case, migraine is a neuro-biochemical disorder that may include pain, nausea, light and sound sensitivity, and fatigue. Various brain chemicals have been implicated in the migraine process including serotonin, norepinephrine, and calcitonin gene-related peptide (CGRP). Unlike many other types of pain patients whose pain is caused by structural damage (e.g., herniated or bulging discs, diabetic neuropathy), improved control over physiology can lead to lasting changes. Thus, migraine patients don’t have to assume that “living with the pain” is as good as it can get. Some individuals are currently disabled or otherwise impaired by their head pain, but it is important to be mindful of the fact that MIGRAINE PATIENTS CAN GET BETTER.
- The term, migraine, is not a description of the degree of impairment that the patient may be experiencing. Since most people have had headaches, some of which have been accurately or inaccurately described as migraine, there is a good chance that the therapist working with the migraine patient has had headaches him/herself. It is important to not assume that the patient’s experience is the same as that of the therapist. Listen to the patient’s description of pain and also ask about associated symptoms.
- Appropriately diagnosed migraine is neither a terminal illness nor the type of disorder that deteriorates organs, but it does negatively impact upon quality of life. Migraine can reduce or severely limit productivity at school or work, curtail social involvements, affect family relationships, and cause the patient to feel physically and emotionally drained even when overtly functioning in a successful manner.
- Migraine patients don’t wear badges such as casts, walkers, etc. Because they look “normal”, many have had to deal with the stigma of being seen as having weakness, hypochondriasis, drug-seeking behaviors, and secondary gains (Young et al, 2013). To cope with being stigmatized, patients may develop counterproductive coping strategies. McCrea et al (2013) found that such patients developed a dislike for interacting with others, while Waugh et al (2014) found that internalized stigma had a negative relationship with self-esteem and pain self-efficacy – even when controlling for depression. In many cases, stigmatizers have included medical and mental health professionals as well as family members, friends, and coworkers. Until proven otherwise, the patient may not trust your ability to be empathic.
- Without proper guidance, many headache patients develop their own coping strategies – with differing degrees of appropriateness and effectiveness. In some cases, they may overuse medications for pain in order to keep functioning. Some patients withdraw from normal activities for fear of aggravating their headaches, and they become physically and emotionally deconditioned and depressed. Others have mastered the art of being a migraine patient – treating the migraine as part of life, but not part of the definition of self.
For the therapist, there can be no better patient than a motivated headache patient. Regardless of the patient’s current means of coping, there usually is a history of success that can be called upon. There is the probability of getting better, and there usually are some bad habits that can be changed to reduce the centrality of the headache. When migraine patients feel they are being understood, they typically become willing allies in their treatment.
If the patient is getting appropriate medical treatment, the therapist is part of a treatment team. Long before integrated care became a buzzword, cooperation between physicians and mental health professionals was taking place in the field of headache medicine
There have been many psychological approaches to migraine treatment. Although some appear to be promising, such as acceptance and commitment therapy (ACT), mindfulness, neurofeedback, and yoga, there are four approaches that have attained an “A” rating from the U.S. Headache Consortium: relaxation training; thermal biofeedback plus relaxation training; EMG biofeedback; and cognitive-behavioral therapy (CBT) (Silberstein, 2000).
Because of its focus upon the thinking process as an agent of change, CBT is particularly well-suited to working with headache patients whose typically good cognitive functioning enables them to be active participants in their treatment plans (Kaiser & Weatherby, 2009). In addition, while both anxiety and depression significantly affect headache-related quality of life (HRQoL), catastrophizing has been found to be an independent and greater predictor of HRQol – as it intensifies the negative aspect of pain and exaggerates helplessness (Holroyd et al, 2007). Of course, a major focus of CBT is the reduction of catastrophic thinking.
The positive focus utilized in working with migraine patients has led to the widespread incorporation of positive psychology techniques in the treatment process. Goal-Achieving Psychotherapy (GAP), a unique offshoot of CBT and positive psychology, was developed, based upon strategies that have been successfully implemented to promote positive behavior change at the Jefferson Headache Center in Philadelphia (Kaiser, 2012).
Certain principles have emerged in our work that can be helpful in guiding the mental health professional in working with migraine patients.
- Any patient with chronic and/or debilitating migraine needs to be under the care of a knowledgeable and supportive physician who has done an appropriate evaluation to determine whether we are dealing with a primary migraine disorder or whether the patient’s pain is secondary to a medical condition that has to be addressed differently.
- As with any therapy patient, a comprehensive history should be taken to determine whether, instead of dealing with a primarily medical disorder, we are dealing with a symptom of a complicated psychological issue that requires special attention - such as past trauma or severe psychopathology such as a delusional disorder or dissociation.
- Because migraine patients often have a history of being misunderstood, marginalized, and stigmatized, therapeutic empathy is particularly important in working with this population.
- Migraine-oriented treatment needs to be positive, forward looking, and active. Homework assignments provide a system for measuring progress.
- While CBT is an effective treatment modality, it is important to not just address negative thoughts and irrational statements, but also to quickly get the patient into a positive mindset by addressing what can go right.
- Research is quite clear in reflecting the fact that positive change and progress in three main areas - health and fitness, intellectual functioning, and social functioning - is associated with achievement and happiness (Achor, 2010). Working on improving one’s body, mind, and character is incompatible with spending an inordinate amount of time focusing upon one’s pain. Goals for improvement need to be realistic and individually designed to maximize chances for success.
- Incorporating techniques such as biofeedback, meditation, and yoga can aid the patient in gaining a sense of control over seemingly involuntary aspects of physiology. Techniques that can help regulate physiology may have the added side-effect of helping migraine patients reduce or wean from their medications over time.
- Speaking of medications, it is important for the therapist working with migraine patients to be aware of the range of effective preventive and abortive medications that utilized to treat migraine as well as being knowledgeable of guidelines for their use. Conversely, it important to recognize which medications should not be used. Because we are not trying to promote the notion of indefinitely living with pain, headache physicians discourage excessive use of pain medications, especially opioids. Even the daily use of over-the-counter analgesics can cause changes in physiology that interfere with the potential for effective headache control.
- It is not accidental that a physical and socially bonding activity has evolved as a centerpiece of the migraine awareness movement. Now taking place in several cities, Miles for Migrainerun/walk events enable migraine patients, family members, health care professionals, and other supporters to live the message that migraine needs to be confronted proactively rather than reacted to in a passive manner. It is part of good mental health treatment for the therapist to encourage patients to participate in such physical activities at a level consistent with their abilities. In addition, monies raised from Miles for Migraine events support research and public awareness of migraine – enabling patients and their supporter to be actively involved in reducing the stigma of migraine and ultimately achieving control over the disease.
Despite all the progress that has been made, migraine is a stubborn disorder that does not always respond to appropriate medical treatment. Treating migraine is a process. Neither the patient nor the therapist can expect it to follow the type of predictable course that people have learned to expect from a bout with the flu or the recovery following a surgical procedure. Patience is required, and sometimes it is required for a pretty long time. Being active, however, reduces the centrality of the migraine in the patient’s life. Progress in making positive changes that affect body, mind, and character provide the evidence that change can occur – as can the recognition that, once the bad stuff has been ruled out, we are working on a potentially solvable problem. The therapist’s role includes being a cheerleader for change because, indeed, MIGRAINE PATIENTS CAN GET BETTER.
Achor, S. (2010). The happiness advantage. New York: Crown.
Holroyd, K., Drew, J., Cottrell, C., Romanek, K., & Heh, V. (2007). Impaired functioning and quality of life in severe migraine: The role of catastrophizing and associated symptoms. Cephalalgia, 27(10), 1156-65.
Kaiser, R. (2012). Goal-achieving psychotherapy. Retrieved from wwww.thementalhealthgym.com/goal-achieving-psychotherapy.
Kaiser, R., Kurzyna, A., & Mooreville, M. (in press). Psychological factors and headache. Medlink Neurology.
Kaiser, R., Mooreville, M., & Kannan, K. (2015) Psychological interventions for the management of chronic pain: A review of current evidence. Current Pain and Headache Reports, 9, 43. doi: 10.107/s11916-015-0517-9.
Kaiser R, & Weatherby S. (2009). Psychology in headache management. In: Kernick D, Goadsby PJ (eds). Headache: A practical manual. Oxford: Oxford University Press, 248-251.
Lipton,R., Stewart, W., Diamond, S., Diamond,M., & Reed, M. (2001). Prevalence and burden of migraine in the United States: Data from the American migraine study II. Headache, 61, 646-657.
McCrea, S, Kaiser, R., & Young, W. (2014) The relationship between personality factors and perceptions of stigma in chronic and episodic migraine patients. Headache, 54, :59.
Silberstein, S. (2000) Practice parameter: Evidence-based guidelines for migraine headache (an evidenced-based review): Report of the quality standards subcommittee of the American Academy of Neurology. Neurology, 55(6), 754-762.
Waugh, O., Byrne, D., & Nicholas, M. (2014). Internalized stigma in people living with chronic pain. The Journal of Pain, 15(5), 1-10.
Young, W., Park, J., Tian, I., & Kempner, J. (2013). The stigma of migraine. Plos One. Retrieved from dxdoi.org/10.1371/journal.poneoo54074
Published August 30, 2016
