Migraine and Anxiety: An Interview with Psychologist Brooke Pellegrino
Recently we shared a video describing a panic attack that occurred when I was afraid of getting a severe migraine attack in public. Many community members commented that they, too, have dealt with anxiety either associated with or in addition to their migraine attacks. So how common is anxiety in those who have migraine? And when does it warrant treatment? Below, Dr. Brooke Pellegrino of the Hartford Healthcare Headache Center answers these questions and more in a conversation* on the relationship between migraine and anxiety.
Working with migraine patients
Could you tell me a little about your practice at the headache center? How did you become interested in working with migraine patients? What is a frustration of working with people with migraine, and what is a joy?
My role at the Hartford Healthcare Headache Center is to provide non-medication treatments for headache. This sometimes means targeting the headache directly and other times means targeting the comorbid condition. There are several evidence-based non-medication approaches to treating headache directly, including trigger identification and management, relaxation, stress management, and biofeedback. At other times, treating the comorbid condition of depression, anxiety, or sleep disturbance can also be effective at improving headache.
I first became interested in working with migraine patients in graduate school under the advisement of Todd Smitherman, PhD. My involvement in the field of headache first began as research and then developed more into clinical practice. I am currently involved in research as well as clinical practice as a Clinical Health Psychologist at the Hartford Healthcare Headache Center.
I think sometimes the biggest frustration about working with patients with migraine is that they often feel helpless that they can do anything to control their pain or disability. Part of what I do is to try to increase the amount of control that the person feels over their migraine symptoms and related disability. In addition, it is often difficult to see how much migraine has taken away from a person’s life. So, another goal of treatment is often getting patients their lives back, which means beginning to engage in activities that they used to as much as possible despite their pain.
A joy of working with migraine patients and the team I work with at the Hartford Healthcare Headache Center is getting to help patients with migraine and see them improve. Migraine has such a large impact on people’s lives, on our healthcare system, and on the economy, so it is nice to be able to help reduce that burden in whatever way I can.
Anxiety statistics and types
There is a lot of talk about depression in the migraine community as a co-morbid condition, but I feel like gets forgotten, though it is common. Do you have any statistics on the percentage of patients with depression and migraine verses an anxiety disorder and migraine? What have you observed in your practice?
About 25% of people with migraine suffer from depression and about 50% suffer from anxiety (American Migraine Foundation, 2016). Anxiety disorders are two to five times more common in migraineurs than in the general population (Breslau 1998). And often, patients suffer from both depression and anxiety. I would say these statistics are consistent with what I see in my practice. As you probably know, both the relationship between “migraine and anxiety” and “migraine and depression” is bi-directional. Sometimes the migraine comes first and people develop anxiety about getting another migraine. Even with negative brain imaging, still migraine can be scary. People often do not know what is happening to them and worry that there may be a more significant neurological cause for their migraine. In addition, people worry about what they will miss out on if they have a migraine. People become afraid to make plans in fear that they will have a migraine and will have to cancel those plans. This is just one way in which fear of migraine can start to chip away at a person’s life. In other cases, migraine can occur subsequent to anxiety. I see both directional relationships consistently in my practice.
What types of anxiety disorders do you most often see in the people you treat with migraine?
In my practice, I see a lot of patients with Generalized Anxiety Disorder, PTSD, and also health-related anxiety about their migraines. More rarely, I see patients with Panic Disorder, Social Anxiety Disorder, or OCD even though these have shown to be strongly linked to migraine (Baskin, Lipchik, & Smitherman, 2006). I also see a lot of people, not with history of anxiety, per se, but who are going through stressful life events (e.g., a new job) and have noticed an exacerbation in their previously infrequent migraines. Although most people do not experience migraine when stress is at its highest, people often experience migraine when stress begins to decline (stress let-down).
Even if patients do not have a pre-existing anxiety disorder, they may sometimes develop a pattern of anxiety as a result of their migraines.
Migraine and anxiety
Could you tell me a bit about the relationship between anxiety disorders and migraine?
From a pathophysiological standpoint, serotonergic dysfunction, dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, and hormonal influence are thought to play a role in both anxiety and migraine (Smitherman, Kolivas, and Bailey, 2012) and both anxiety and migraine have been associated with a higher frequency of the S allele in a study of the 5HTTLPR (serotonin-transporter-linked polymorphic region), implying a shared genetic predisposition to both disorders (Gonda et al., 2007). You can find out more about the underlying pathophysiology of migraine and anxiety by reading a great review article by Minen et al., 2016 entitled Migraine and its psychiatric comorbidities.
In my experience with frequently recurring migraine attacks, it seems natural to feel anxious about the next attack you know is coming sooner or later. How do you recommend a person with migraine assess if their anxiety is a problem that could benefit from working with a therapist?
One of the main ways to assess if the level of anxiety merits treatment is to determine impairment in social, occupational, or other important areas of functioning. If someone has anxiety about the next migraine attack but it does not prevent them from going about their normal activity and they do not spend a lot of time worrying about it, then they might not need to seek treatment. However, if worrying about the next migraine prevents a person from engaging in their normal activities, limits their home, work, or social life, or if they spend a lot of time thinking about when their next migraine might occur, it might be time for them to seek treatment. Another thing I see in practice in patients with anxiety (specifically health-related anxiety) is often fear of medical treatment. Sometimes when the physicians in my practice prescribe medication, patients immediately go home and look up the side effects online. Side effects (or fear of side effects), even if rarely reported, can sometimes prevent patients from trying a medication or from taking it long enough for it to have a significant effect. Treating anxiety in migraineurs is associated with improved quality of life, adherence to a migraine treatment plan, and effectiveness of migraine treatment (Baskin, Lipchik, & Smitherman, 2006).
*Dr. Brooke Pellegrino's answers submitted via email April 1, 2017
Can you tell when a migraine attack is coming?