Why Is a Psychologist Interested in Migraine?

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My lab at Yeshiva University and Albert Einstein College of Medicine has one goal: To harness behavior change to improve the lives of people with migraine.

But I'm not a neurologist or pain physician. In fact, I'm not a physician at all. I'm a psychologist. So why is a psychologist so interested in migraine?

Not Just Anxiety and Depression

When I meet people and tell them what I do, many of them assume that I'm trying to find ways to treat anxiety and depression in people with migraine. And that is certainly important. People with migraine have about 3-5 times higher odds of having an anxiety disorder, and 2 times higher odds of having depression than other people.

Understanding how to help people with migraine reduce anxiety and depression is important, because they interfere with quality of life and can generally make you even more miserable than you would have been with migraine alone. But it is a myth that people with migraine who have comorbid anxiety or depression can't improve, or that you need to treat the psychiatric symptoms before you can make meaningful gains in migraine management.

In fact, we have shown that people with comorbid anxiety or depressive disorders can make just as large, if not larger, gains in migraine management.

So, I will let you in on a secret: I'm not all that interested in anxiety and depression in people with migraine. In fact, I think there are much more interesting reasons psychologists should be interested in migraine. And if more psychologists got interested in migraine, we could help improve not just the lives of people with migraine, but help everyone lead happier, healthier lives.

Migraine as a Model of Episodic Diseases

Migraine is a model disease for episodic symptoms impacting behavior, and then behavior reciprocally impacting those symptoms.

All episodes must be triggered by something. Episodes happen because something changes, in your body, in your brain, or in your environment. People have been trying to figure out what triggers migraine attacks for hundreds of years. But triggers are tricky.

Just because something happens before a migraine attack doesn't mean it caused the attack. It could be that your brain is already in the throes of a migraine attack, and you just haven't felt the pain yet. Or that something else, like hormone dysregulation or lack of sleep, caused both the perceived trigger and the migraine attack, separately. As we develop better models for understanding migraine triggers, we will better understand how to study episodic conditions across the board.

Because migraine attacks occur so frequently in people with migraine (~1 in 10 people with migraine have 15 or more headache days per month), this gives people with migraine a lot of opportunities to start to develop habits, patterns, and beliefs related to migraine attacks. Some of these habits, patterns and beliefs are adaptive and help people with migraine better manage their disease.

But some are likely maladaptive, increasing distress without reducing disease burden. Psychological work and research can help us understand how to shape adaptive habits, patterns and beliefs in response to episodic migraine attacks.

There are many episodic diseases, such as asthma and epilepsy. Understanding the psychology around how people with migraine relate to these episodic symptoms, and how that impacts their management, can help us uncover more about how people manage episodic symptoms across conditions

Migraine as a Model of the Need for Routine

People with migraine have brains that are more responsive to lifestyle disruptions like stress, poor quality sleep, skipping meals, and drinking alcohol.

Here's the thing. It's not good for anyone to have high chronic stress. Poor sleep quality is associated with all sorts of negative health indicators. Eating small frequent meals is often helpful, and unplanned skipping of meals has negative consequences for most people.

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And binge drinking (which is the amount of alcohol that has empirically demonstrated a relationship with next-day migraine) is a major health and societal problem, regardless of whether or not one has migraine.

So it's not good for anybody to live with chronic stress. Or to skip sleep. It's not good for anybody to skip meals. Or binge drink. And as we develop interventions that can help people with migraine lead happier lives, we will likely be developing interventions that could help all of us live happier, healthier lives.

Marginalization of People in Pain

When I first got interested in health psychology, I knew I wanted to work with chronic pain. Because people with chronic pain are so often marginalized in the medical community. What physician wants to treat patients who come in each visit and say, "Sorry, Doc, I'm still in pain."

This is a very difficult situation. It can make both the patient and provider feel hopeless and powerless to change this outcome. This is bad for patient care. Who wants to see a doctor who feels hopeless to treat them? Or worse, who blames them for their own symptoms?

The psychological community needs to step up and help our colleagues who treat migraine and chronically painful conditions understand how our own health systems are set up in ways that marginalize chronic pain patients. That people with migraine are unfairly considered to be fragile complainers, overstating their burden to get out of responsibilities.

That people with cancer pain are unfairly stigmatized if they require opioids for pain relief. That people with a racialized minority status experience even greater stress that leads to health disparities seen across chronically painful conditions.

Psychosocial research can help medical communities who treat chronic pain patients to understand their social contexts, and make sure that our clinics are not contributing to this marginalization and stigma.