Migraines and our Emotions: An Interview with Psychotherapist Nathan Feiles

Do you think your emotions and your migraine attacks may be related? Or do you find no connection? A few years back I sought out a migraine support group and attended a couple of sessions run by psychotherapist Nathan Feiles, who specializes in migraines and has put a lot of thought into the matter. I had since lost contact, but then we reconnected when I responded to his blog posts about emotions and migraines on Twitter. I was curious and interested in learning more. Nathan agreed to an interview. Below, we talk about emotions and emotional history in connection to migraine, therapy for migraine, some self-help tools, and much more.

You discuss at length in many of your articles about the mind-body connection with migraine. I’ve read that early childhood trauma can increase migraine risk, as well as risk for chronic pain in general. Have you found a stronger connection in terms of the mind-body connection in migraines as opposed to other illnesses? If so, why do you think this could be the case?

This is quite complicated, as it is difficult to quantify the mind-body connection. There certainly is literature to support the physiological impact of psychological, emotional, and relational distress (including childhood traumas). I've written in several articles about the biochemical response to emotion – using stress as an example, and how more cortisol is released when stressed. IBS [irritable bowel syndrome] is another area that sees significant movement based on emotional states. I'm sure one could make a case that other medically-unexplained physiological events could have at least a combination of emotion involved. However, there are many layers to this. For instance, a person would have to be medically "susceptible" (including with migraines) – why are certain people triggered by things that don't trigger other people? So the medical component of susceptibility is always there, but with the mind-body connection, the triggers can be many things and combinations, including emotional and relational patterns that reinforce an internal biochemical "setup" for the event. (Added stress = tension, tightening of muscles, releasing more chemicals internally – whatever else happens when a person responds to their emotional environment). I don't know if migraines are the number one mind-body issue (though a lot of people struggle with migraines), or if other illnesses could have a stronger connection (some believe that some forms of cancer have a mind-body connection).

You posit in “Migraines: The Silent Voice of Our Past,” that “emotional history (past and present) can be a significant factor with chronic migraines.” If a person with migraine is considering the possibility of a connection between their emotional history and their migraine attacks, are there any correlations that you or others have discovered that may indicate how strong a factor emotions may be in migraine attacks? For example:

  1. When the migraine attacks started, i.e. starting in infancy or childhood verses developing later in life.
  2. Childhood trauma.
  3. History of mental illness.
  4. Effectiveness of medications.
  5. Any other factors?

This is also quite complicated. With therapy, and anything related to a person's psychological, emotional, and relational history, it's different for every person. This is one of the reasons it's hard to fully prove mind-body connection – it isn't consistent from one person to the next. It isn't consistent how and why a person feels the way they feel, and therefore, how to treat it from one person to the next isn't consistent (which is why a good therapist has to learn how to respond to the person in front of them, and not just follow a blanket model). Therapy takes many different forms, and different therapies help different people. So, it's hard to have a study and say, "this is the percentage of emotional involvement for your migraines". But, what I can say from experience is that there is often significance to when the migraines started. And there is pretty strong research that shows the susceptibility increases for people who have had adverse childhood experiences, including various types of traumas (whether relational, or larger scale).

From my experience working with people in this area, I would say emotional dissociation (and repression, suppression) is a highly significant factor, as are patterns of internal emotional activation to present pseudo-repetitions of old traumas. Again, this plays out differently for each person. But, the difference is noticeable in how people start to feel when they reconnect to previously dissociated states and are better able to manage and work through emotional states without cutting these parts of themselves out. This includes shifting dynamics to make repetitions of harmful dynamics less likely.

If there is another area that stands out to me and has my interest, just based on patterns of observation – passive aggression, fear of conflict, and people-pleasing seem to be common traits in people who experience chronic migraines. This doesn't mean everyone who has migraines operates in this way, but I have noticed a general commonality in this area. I also wouldn't say these qualities alone are triggers, but I do wonder about the ripple effect here (what's being dissociated and bottled as part of this type of process).

To respond to the medications part of your question – not all medications work for everyone. But when people have tried "everything", and nothing is touching the migraines, and there is nothing visible medically, I would imagine this is a good indicator that there's more to look at. Emotional history may be a good place to look next.

Could you tell me a little bit about what you refer to as Migraine Therapy – what makes it different from other forms of therapy and what the patient could expect?

Migraine Therapy is the informal term I sometimes use to reference therapy for migraines. First, it's important to know that when people seek out "therapy", they are going to get the school of therapy that that therapist practices. There are many, many schools of therapy, and the combination I use is what I've found to be most effective in working with migraines.

The reason I called it Migraine Therapy is because it goes a bit beyond what general psychotherapy tends to do. I have had extensive training in contemporary psychoanalysis and comprehensive psychotherapy, also including years of working with cognitive-behavioral therapy, and trauma and neuroscience-based techniques. There are many schools of thought in the history of psychoanalysis alone (I find contemporary analysis to be more effective than classical), and I apply more "relational" approaches.

With relational therapy, I keep a closer eye on the emotional and relational patterns, "enactments" (repetitions of life patterns) that present in the room, as well as the areas of emotional dissociation, while also working within a general therapy frame (meaning, we talk about the person's life, and all that comes up in daily life, but we also acknowledge the patterns that repeat in real time and tend to be problematic in some way for the person's life – locating where the dissociated emotion is, for example).

A person can expect to talk about anything and everything they want. It's their therapy. While I'm here as a supportive person in their life, my ear is also always looking out for patterns and connections that could be problematic in terms of dissociation, and repetitions that can lead to physiological events. When something comes up that seems like it could use some further understanding and exploration, as related to each person's migraines, I help focus there with each person.

What also makes Migraine Therapy a bit different is that I sub-focus with people on identifying triggers with them, and helping them to adjust to identified triggers (with CBT-based work), and at times using relaxation, mindfulness, and meditative techniques, as needed. It's really a combination of a migraine therapy and migraine-based coaching.

I also incorporate what is known in the trauma world as "bottom-up" therapy, where at times we go through the experience of emotion and affect to get to the deeper layers, rather than always starting from the mind.

This is all a bit of the theory, but generally, what a person should expect is just to come in and be themselves, bring in any emotions, talk about whatever they would like, and I do my part to listen for the links and connections to migraines. They will have my support as they go through life with migraines – dealing with people not understanding (often, family and friends), as well as the daily fear of trigger and the impact of this on life, and all that comes with migraines – they will have my support, as well as working further to bring relief.

What sorts of improvements have you seen in your practice when a patient pursues therapy for migraine? What is the success rate in patients being able to reduce either severity or frequency? Are there any cases in which migraine attacks cease to occur? And is there a point where you ever feel like you have dug deep enough and the root of the migraines are not emotional?

It always depends. I have seen significant improvement as people work through various emotional points from their histories (it's rarely just one event from history, but rather a series of events and patterns, which are different for everyone). I don't look for the migraines to cease completely – I think that would be unrealistic. But what becomes notable is people saying things like, "I haven't really had a migraine in the last few weeks... I usually get them once a week", or something to this effect. People start noticing more space in between attacks, and even people with chronic daily migraine have often noticed more space without headaches in their weeks. Without realizing it, people sometimes have gone from several attacks per month to maybe one per month. It's a process, so it's not just waking up one morning and the migraines are gone – rather it's a process where things shift as you go.

As far as figuring out if the root is not actually emotional – I don't believe that there is necessarily "one" root for most people (unless their triggers are very cut and dry). I think there is most likely a biological susceptibility for most people (though people without migraines in their family history do suffer from them as well sometimes), and from there, when they are primed emotionally, this can trigger that susceptibility. But, there are also many concrete triggers that are important to figure out as well. Many times in the therapy, people start to make connections to triggers they'd never realized before, and this only adds to the benefit of self-reflection in this process. Unless something shows up on a medical test (including hormonally), it's otherwise hard to say definitively to someone that emotional-relational process isn't involved, if they are still experiencing chronic migraines after significant medical effort. Some people function on a high level of stress at all times, and many don't realize how this impacts them emotionally and bio-chemically (the mind-body connection). It can sometimes take a while for people to break through some long standing patterns that could well be reinforcing migraine environment. That being said, if over time I saw nothing changing, and if we've been through a lot of work, with little benefit, then it would be worth considering with the individual if this route is useful to continue with. But also keep in mind that I don't advocate for this therapy to be the only treatment a person is receiving. I believe in a team approach with migraines, with this therapy being one of the parts of that team.

In, “Migraines: ‘No On Understands!’” you talk about the toll migraine can take on relationships and other aspects of a person’s life. I would imagine most people would benefit from some sort of therapy after years of dealing with migraine, at the very least to deal with the emotional hardship that can occur. How are you able to determine whether or not the emotions feed into the migraines or the migraines feed into the emotions? Does it matter in terms of the healing process?

The first thing to acknowledge in this question, is that it's not necessarily one or the other, it's more likely to be both. Emotions can feed migraines and migraines can feed emotions. For example, a person may be stressed at work, and the stress of their work ends up triggering a migraine, and they have to go home. Now, they become angry and resentful about having migraines, and more stressed that they can't be at work during this particularly busy time. Now they are even more primed emotionally to re-trigger. So it can very much be a vicious cycle. It doesn't so much matter the direction the cycle is moving, in terms of treatment. Part of the treatment is learning how people respond to emotional states, and well as to external life, day-to-day events. The hope is to learn how to internally (and externally) respond to and manage the significant parts of the cycle, including working through emotionally – rather than acting out or acting in emotionally.

If a person is unable to attend therapy (either due to cost or other factors) is there anything they could do themselves to address a possible emotional factor with their migraines? Are there any resources you would recommend? Try tracking moods daily (including any mood changes during the course of each day). Track when the migraines occur, and what you were feeling in the 24-48 hours prior to the migraines as well. Any emotional states can be labeled as part of tracking this – happy, sad, anxious, nervous, fear, stressed, depressed, vulnerable, inferior/small/discounted, grandiose/superior, in control, ordered, disorganized, etc. To go a step further, consider labeling any correlations. For example – stressed – children talking back; or angry – spouse yelled at me; scared – spouse is drinking again; happy – did well at work, no stresses at home. It takes a lot of dedication to track emotional states, but it would be a good start to see the shifts and correlations surrounding when migraines occur for you.

You discuss the possibility in “Migraines: Personality Inhibition” that repressed emotions, whether it be sexual or emotional, can lead to migraine in some individuals. Do you consider these emotional repressions triggers or a direct cause of migraine?

This is very complicated. Once again, nothing can be proven, otherwise the answer about migraines would finally be solved – we only can go with observations of patterns. Dissociated, repressed, and suppressed emotions and states don't simply disappear. If a person is afraid to be angry because of the consequences of anger, they either dissociate from it, or repress or suppress the emotion. But where does the anger go? Some people fear conflict and sit with the emotions of frustration, aggravation, and have no outlet for these emotions. They end up acting in. When a child learns that showing certain emotions isn't safe, they learn to shut them off from being seen from the outside, and essentially bottle everything up. The overflow for each person is different. But I think it's both – I think it builds the internal migraine environment, and sets the scene for a trigger to more effectively trigger a migraine, and sometimes there can be an actual emotional repetition (or enactment) that can in itself push someone over the threshold for an attack. Cutting off parts of ourselves emotionally (whether it's anger, sadness, sexuality, assertiveness, etc.) can lead to many different possibilities, including physiological responses (though I focus more on migraines, physiological symptoms can present in a variety of ways).

You mention in “Migraine Therapy — More Effective Than Medication?” that “a lot of patients often come to me for help when they’ve exhausted every conventional and alternative approach to migraines they can think of.” Does part of Migraine Therapy include working with patients to help determine if they have actually tried everything?

I have had many patients tell me in their first sessions that they have "tried everything." They then often verbally tell me a list of the various treatments and medications they have tried. I help people with the emotional component of migraines, as well as offering support, and help to manage and figure out the struggle of migraines together. I do ask people what they've tried, and require them to seek medical support from a neurologist since I do not treat migraines from a medical perspective. In general, I look for what we are missing in the migraine picture, and this could include areas they have not tried. I will at times suggest or discuss adding another approach if it seems it could be useful. However, whether or not there are other things they haven't tried, I don't believe this changes the relevance of emotions and relational patterns that can be involved as part of the total migraine picture.

Many people with migraine report that family members, friends and even doctors dismiss their migraines as emotional, saying things like, “It’s all in your head,” or “You’re just stressed.” In the article, “Why the ‘Migraine Personality’ is Total Bunk,” Anna Eidt writes: “Believing that our fixed personality has somehow directly caused us pain; that migraine is somehow intrinsically a part of who we are can lead to shame, hopelessness, and self-blame on top of the already difficult mix of emotions involved in living with disabling migraine attacks, and that’s just not helpful.” With this dialog in mind, how do we remain open to the possibility of an emotional factor in migraine without contributing to the stigma that migraine carries?

It's not all in anyone's head. The pain and the entire experience of a migraine is very real. There is nothing imagined or fictional about being in tremendous pain, having trouble seeing, feeling numb, confusion, vomiting, seeing visual patterns, aural/visual sensitivity, and more. I have had my own history with debilitating migraines, and it would infuriate me when someone would say it's all in my head, or suggest that I'm doing something to cause them. That being said, our emotional and relational patterns are not imagined or fictional, either. The patterns we developed when growing up in this world, based on the various events that shaped our lives, have an impact on who we are, how we respond to scenarios, events, other people, internally, externally, etc. It's very important to remember – we don't have control over these patterns until we become aware and start to shift them. Before we're aware of them, we continue to re-enact whatever our emotional life patterns are, at times to our own detriment. But this is very different than "doing this to ourselves." It's one thing to say, "I know if I drink this wine, I could trigger a migraine", and then drink it anyway. It's another thing to unconsciously repeat emotional life patterns that have been instilled for many years, that may work against us. This is very unintentional and not even in awareness. Saying it's all in someone's head is a very ignorant and insulting stance to take about somatization.

The migraine puzzle is multi-faceted and complicated. It's very individual – most people don't seem to have the exact same migraine experience, including presentations, triggers, or history. The idea is to figure out and work on as much of each person's total migraine puzzle as possible. Emotions and emotional/relational history are one part of this puzzle (I believe it to generally be a significant piece of the pie)... but not the entirety.

You can learn more about Nathan and his work with migraine patients at his website.

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