Chronic migraine: when headache days outnumber the days without

“I don’t know any more when it doesn’t hurt. I used to count the attacks. Now I count the days without them — and every month there are fewer.”

People say a sentence like this quietly, almost apologetically, as if they were admitting something they shouldn’t. Behind it there is usually a long history: first a few attacks a year, then a few a month, then a stretch when the good and bad days merged into a single grey background of pain, from which only the worst attacks stand out. The person still goes to work, cooks, answers messages. Only they do all of it with a head that is almost never entirely quiet.

When the days with headache outnumber the days without, neurologists speak of chronic migraine. In this post I explain what the term means, why migraine becomes denser for some people and what happens to their inner world and their relationships along the way. Diagnosis and treatment belong with your doctor and neurologist. My part is what happens around the pain — and that is not a small part.

First things first: migraine is a disease of the brain

Before I write about stress and emotions, I need to say something that matters more with migraine than with most other topics: migraine is not a psychosomatic symptom. It is a neurological disease with a hereditary component, with well-described changes in how the brain and the trigeminal nervous system work, and with its own phases — from the early signs before an attack to the exhaustion after it. Studies of the global burden of disease rank it among the leading causes of years lived with disability, precisely in people’s most working years.

I stress this because people with migraine often hear the opposite: that they should relax a little, that it is “all in your head”, that it would pass if they worried less. Sentences like these are not only wrong but harmful. They steer people away from the doctor and load them with guilt for an illness they did not choose. When test results are clear and the pain still remains, the explanation can be different — I wrote about that in “The tests are normal, but it still hurts”: what therapy knows about psychosomatics. With migraine, however, a normal result does not mean there is no illness: migraine usually does not show up on a brain scan, and the doctor makes the diagnosis based on how the attacks are described.

So psychology does not explain why someone has migraine. But it can tell us a great deal about how the illness lives in a person’s everyday life — and sometimes about why the attacks become more frequent.

When migraine is called chronic

The International Classification of Headache Disorders defines chronic migraine quite precisely. A person has headache on at least 15 days a month, for more than three months in a row, and on at least eight of those days the headache has the features of migraine or responds to migraine medication. Everything below that line is episodic migraine — even when the attacks are frequent and severe.

Chronic migraine is not rare, but neither is it as common as you might think from how often it is mentioned. A systematic review of studies from different countries estimated that between 1.4 and 2.2 per cent of the population have chronic migraine. That is a smaller share of everyone with migraine, but also the group that carries a disproportionately large part of the burden: more lost working days, more visits to the doctor, and more often anxiety and depression too.

The threshold matters for a practical reason. Once a doctor recognises chronic migraine, the treatment plan changes too. That is why it is worth keeping a record of how many days a month you are in pain and what kind of pain it is — how to keep such a record is the subject of A migraine diary: why it works and how to keep one.

How episodic migraine becomes chronic

Nobody develops chronic migraine overnight. It is usually a gradual process that specialists call chronification: attacks become more frequent, there are fewer and fewer completely calm days between them, and one day the person realises they can no longer remember when they were last free of pain.

Research has described a range of factors linked to this. Some cannot be changed — sex, age, heredity. Others can: how often attacks occurred to begin with, poor or irregular sleep, obesity, a lot of caffeine, frequent use of painkillers, stressful life events, and anxiety and depression. It is important to understand that these are risk factors, not causes. Nobody gets chronic migraine because they worried too much. But when the nervous system is already oversensitive, long-lasting strain can lower the threshold for an attack even further.

One of these factors stands out in particular: frequent use of medication for acute attacks. In some people it can itself contribute to headaches becoming more frequent — a condition known as medication-overuse headache. Because the topic is delicate and has to be managed by a doctor, it has a post of its own.

And something people rarely hear: chronification is not necessarily a one-way street. An American population study that followed people with chronic migraine for two years found that in a substantial share of them the condition returned to the episodic form. Chronic migraine is serious, but it is not necessarily for life.

What happens to life when it hurts almost every day

With episodic migraine, a person has their own life between attacks. With chronic migraine, the pain moves from the exception into the background. That changes far more than a schedule.

First, time changes. People start living in units of “today is a good day” and “today isn’t”. They stop making plans two months ahead because they don’t know what their head will be like that day. Concert tickets stay in the drawer because “we’ll see”. Life becomes a collection of conditional promises.

Then attention changes. If you have often experienced an attack beginning with a slight pressure behind the eye, you start watching for slight pressures. That is understandable — and exhausting. An inner radar that constantly scans for the first signs never rests. When that radar paints the worst possible outcome at every sign, we speak of catastrophising, which is well researched in people with pain and linked to greater suffering at the same intensity of pain.

And self-image changes. People describe no longer recognising themselves: once they were the ones who organised the trips, now they are the ones who cancel them. This is not laziness and not a lack of willpower. It is a loss, and like every loss it brings sadness, anger and sometimes numbness. It is no coincidence that long-lasting pain is so often intertwined with low mood — I wrote about how depression shows itself in the body in Depression and the body: pain, fatigue and digestion.

Stress, anxiety and mood: what is cause and what is consequence

With stress and migraine, we often get the direction of the arrow wrong. It is true that stress can trigger an attack and that long-lasting strain is linked to attacks becoming more frequent. But the reverse is also true: chronic pain is in itself one of the heaviest stressors we know. If you have a headache twenty days a month, you are dealing almost every day with pain, uncertainty, cancelled commitments and the feeling that you can’t manage as much as others.

The body responds to such chronic stress with constant readiness — tense muscles, shallow breathing, poorer sleep. I described a similar mechanism for insomnia in Hyperarousal: why chronic insomnia is not a sleep problem but an arousal problem. With migraine, this readiness meets a brain that is already sensitive to change. The result is a loop in which pain causes tension, and tension smooths the way for the next pain.

Anxiety and depression are more common in people with migraine than in people without it, and more common still in the chronic form. This link is not proof that anyone “gave themselves” migraine through anxiety. But it does show that it makes sense to look after both at once: the illness with a neurologist, and the emotional burden where there is room for it.

Relationships around chronic pain

Chronic migraine never hurts only one person. It also changes the rhythm of a family, a partnership and friendships.

A partner learns to read a face and turns the lights off before anyone asks. Children learn to be quiet. Friends stop inviting because they have been turned down so many times. Each of these responses starts as an expression of care. Over time, though, they can harden into roles: one is “the ill one”, the other “the one who copes”. In roles like these it is hard to remain a couple. We know a similar dynamic from burnout — I described it in Burnout and relationships: what happens to a couple when one partner gives out.

Something quieter often happens as well. A person with chronic migraine starts hiding the pain, because they don’t want to be a burden or because they are tired of explaining. On the outside they seem fine; in reality they spend an enormous amount of energy on appearing fine. And when it seems to them that the people closest to them don’t understand, loneliness joins in too.

This is where a conversation that isn’t only about symptoms shows its value. Here is how such a conversation in a session might sound (composite, not a real person):

“What makes me angriest is that he thinks I decide every day whether I’ll come along.”
“What do you think he sees when you stay at home?”
“That I couldn’t manage again. That I’m leaving him alone again.”
“And what do you see?”
“That I held out at work all week so I wouldn’t lose my job. There was nothing left for him.”

At a moment like this, pain is no longer only a medical question but also a question of how a couple shares out energy that is scarcer than it used to be. Relational family therapy, in which I am training, pays particular attention to exactly these patterns: how one person’s illness reshapes everyone’s relationships.

What psychotherapy can contribute

Psychotherapy does not cure migraine. But it can make living with it easier — and for some people it also affects how often attacks come. Psychological approaches to migraine are not an alternative to medical treatment but a complement to it, which professional guidelines recommend as part of comprehensive care.

Three groups of approaches are the best researched:

• Relaxation techniques. For example progressive muscle relaxation or breathing exercises, which with regular practice lower overall tension.
• Biofeedback. You see on a screen what is happening to your muscle tension or skin temperature, and you learn to influence it.
• Cognitive behavioural therapy. It helps you recognise the thoughts and habits that amplify pain and build a more flexible way of handling attacks.

One of the more convincing studies in this field included children and adolescents with chronic migraine. They all received the same medical treatment; half also had cognitive behavioural therapy, while the other half received only education about headache. The therapy group had noticeably fewer headache days at the end of the study and at later follow-up. This does not mean that therapy replaced medical treatment — it means that the two together worked better than treatment without therapy.

Therapy also has room for what research does not always measure: grief over what has been lost, anger at your own body, relationships that have changed under the weight of the illness. Once this is spoken, some of the tension eases in a way no scale can capture.

It also matters that therapy does not become one more obligation that leaves you feeling like a failure. If relaxation “doesn’t work” in the first week, that is no proof you are doing something wrong. The effects usually show after weeks of regular practice and are more modest than we would like — but they are real.

Exercise: a plan for a bad day

You do this exercise on a good day — or at least on a day when your head allows you to write. Its purpose is not to prevent an attack but to make sure a bad day brings less additional suffering.

1. Write down what remains essential on a bad day. Three things at most. Everything else can wait, even if it won’t feel that way in the moment.
2. Prepare a sentence for cancelling. Short, without apologising: “I’m having a migraine day today, I’ll be in touch tomorrow.” Save it on your phone so you don’t have to compose it with an aching head.
3. Agree on it with one person. Whom you will tell that it is a bad day, and what helps you then — silence, a darkened room, someone who takes the children out.
4. Write down separately what your doctor has advised. How to manage an attack and when to seek help should be what you agreed with your doctor — not something you invent in the middle of the pain.
5. Add one small thing that counts. Something you can manage even on a bad day that tells you life has not stopped completely: a message to a friend, a song, five minutes on the balcony.

The plan does not take the pain away. But it takes away some of the pain’s power over your decisions. On a bad day you don’t need to think — you just open the page.

Where this post does not apply

I want to be careful here, because with migraine it is possible to go wrong in both directions.

Not every daily headache is chronic migraine. Frequent headaches can have other causes, and some of them need prompt medical assessment. If your headache changes, is suddenly different from usual, comes with new neurological signs or a fever, or is the worst of your life, see a doctor straight away or call 112 (the emergency number in Slovenia). A doctor diagnoses chronic migraine, not a post on the internet.

Psychotherapy is not a substitute for a neurologist. Options for preventive treatment are wider today than a decade ago, and many people who have resigned themselves to daily pain have never had the chance to try them. If your headache is followed only by your GP and it is not improving, talk to them about a referral to a neurologist. I described how the path to a specialist works here in Referral, waiting list or self-funded: how you actually get help here.

Stress is not always the key. For some people attacks become more frequent without any noticeable psychological reason — because of hormonal changes, other illnesses, medication or simply the course of the disease. Searching for an emotional cause behind every attack can become a new form of self-blame. Psychological work makes sense when it helps you live, not when it becomes one more proof that you are “doing it wrong”.

What to remember

• Chronic migraine means headache on at least 15 days a month for more than three months, with at least eight of those days having migraine features.
• Migraine is a neurological disease, not a psychosomatic symptom; diagnosis and treatment are led by your doctor and neurologist.
• Poor sleep, anxiety, strain and frequent use of medication are risk factors for attacks becoming more frequent — not a matter of blame.
• Chronification is not necessarily permanent: in a substantial share of people the condition returns to the episodic form.
• Relaxation, biofeedback and cognitive behavioural approaches complement treatment, and psychotherapy is also a space for the burden the illness brings into your life and relationships.