Migraine and anxiety: why they so often go together

“When it doesn’t hurt, I’m afraid it will start. When it hurts, I’m afraid it won’t stop. Sometimes I no longer know which is worse.”

Many people who live with migraine could say this sentence. There is no exaggeration in it and no “oversensitivity”. It is an accurate description of what it is like to live with an illness that arrives unannounced, takes a day or two and then leaves without saying when it will be back. The body learns that danger can be around any corner. And once the body has learned that, something else often wakes up too: anxiety.

Migraine and anxiety meet so often, in research and in life, that it cannot be a coincidence. In this post I will explain what we know about this link and what we don’t, why anxiety is not the cause of migraine — and why it is still worth taking seriously.

First, to be clear: migraine is not “nerves”

People with migraine hear this often, sometimes even from doctors: “You’re too tense, that’s why your head hurts.” It isn’t true. Migraine is a neurological disease with known mechanisms in the brain and nervous system, a strong hereditary component and precise diagnostic criteria. It is not a psychosomatic symptom, not an expression of suppressed emotions and not a character trait.

I need to say this at the start of a post about anxiety, because otherwise it is easy to misread. When I say migraine and anxiety are linked, I do not mean migraine is “really” anxiety. I mean they are two real problems that often occur together, reinforce each other and are both worth treating. Leave the diagnosis of migraine and its medication to your doctor or neurologist. The anxiety that comes with it, though, is an area where psychotherapy can help too.

How often they go together

The link is not new. In a well-known Swiss study that followed young adults in Zurich over several years (Merikangas et al., 1990), anxiety disorders were markedly more common in people with migraine than in others. Many studies in different countries have since confirmed this. A review of mental health conditions alongside migraine (Minen et al., 2016) summarises that anxiety disorders are two to five times more common in people with migraine than in the general population. The link is strongest with generalised anxiety disorder and panic disorder.

Even more interesting is how the two problems fall in time. In some studies, anxiety appeared before migraine in many people, not only after it. That matters, because it overturns the simple explanation that anxiety is just an understandable reaction to pain. If that were so, it would always come second. Because it doesn’t always, researchers conclude that the two share some of their roots.

Research shows a similar two-way link between migraine and depression, which I write about in Migraine and depression: a connection that has nothing to do with character. Here I will stay with anxiety.

Three paths that intertwine

So why do they go together? There is no single answer. Researchers describe at least three paths, which can intertwine in any one person.

Shared background. Migraine and anxiety disorders have something in common in their heredity and in how the brain regulates arousal, pain and sleep. Similar messenger systems in the brain play a role in both. That does not mean one illness is the other in disguise. It means some people have a nervous system that is more sensitive to both.

Anxiety as a consequence of migraine. Unpredictable, severe pain that takes away your plans is a real threat as far as the brain is concerned. The brain responds to threat with vigilance — scanning the body, looking for first signs, predicting. I described what happens in the brain during this in What happens in the brain during anxiety. With migraine, this vigilance has a fairly good reason. The problem starts when it no longer switches off.

Anxiety as a factor in migraine. Anxiety does not cause migraine on its own, but it can affect the conditions in which an attack arises more easily. Chronic tension, poorer sleep, an irregular rhythm — for many people with migraine these are among the known triggers. And so the circle closes.

How anxiety shows up with migraine

Anxiety alongside migraine does not always look like what people imagine anxiety to be. It is often quiet and very practical. A few forms that come up again and again:

• Constant body-scanning. Every tightness in the neck, every flicker of light, every yawn gets checked: is this the start? This vigilance uses up a huge amount of energy, even on pain-free days. The mechanism is related to the one I describe in Health anxiety: when every symptom means the worst.
• Avoidance. A person starts withdrawing from anything that might trigger an attack — concerts, travel, late dinners, sometimes work opportunities too. In the short term this brings relief; in the long term it narrows life. I explained why in Anxiety and avoidance: why avoiding helps you today and harms you tomorrow.
• Catastrophic thinking about pain. “What if it lasts three days? What if it hits me in the middle of a presentation?” Catastrophising is well researched in pain and is linked to how severely a person experiences it.
• Medication out of fear. Some people take a painkiller “just in case”, before it is clear an attack is coming. With migraine this is risky, because taking painkillers too often can make headaches worse. Agree with your doctor on when and how to take medication.

Fear of the next attack even has its own name in the professional literature — some authors describe it as a particular form of fear of illness (Peres et al., 2007). I look at it more closely in Fear of the next migraine attack: when anticipation becomes a burden.

When the symptoms get mixed up

For some people, migraine and anxiety also overlap in bodily sensations. During an aura or at the start of an attack there can be tingling, dizziness, nausea, visual disturbances. A panic attack brings similar sensations. Someone who has experienced both sometimes struggles to tell what is happening — and that uncertainty alone can heighten the fear.

Two things matter at the same time here. First: a panic attack in itself is not dangerous, even though it feels that way — I wrote about this in Why a panic attack is not dangerous, even when it feels like a heart attack. Second: new, different or unusual neurological symptoms — such as sudden weakness on one side of the body, difficulty speaking or “the worst headache of your life” — are not something to interpret yourself or calm with breathing. In that case call 112 (the emergency number in Slovenia) or see a doctor. Telling an aura from panic and from other causes is a job for a doctor, not for a blog post.

Once a doctor has explained what is what, though, that alone can be a great relief. Many people describe their fear dropping as soon as they understood their symptoms.

What this does to relationships

Because I work as a family therapist in training, I am always interested in how a problem is shared out between people. In a family, migraine with anxiety often settles into one of two patterns.

In the first, those close to the person take on the role of guardians. You make sure the children aren’t too loud, that nobody suggests a trip that would be “too much”. Out of love, a protective belt is built around the person with migraine — but it can unintentionally strengthen avoidance, and with it the anxiety.

In the second, those close stop believing. After the tenth cancelled lunch comes tiredness, then doubt, then a quiet reproach. The person with migraine senses this and starts hiding how they feel. And tension left unspoken is exactly what does not need adding.

Here is an example of a conversation in which these two patterns meet (composed, not a real person):

“You’re not coming to the seaside with us again?”
“I don’t know. What if it hits me there? Three hours’ drive, the heat, the sun …”
“It didn’t hit you last year.”
“Last year I was lucky.”
“Or maybe it wasn’t only luck. What would you need to be able to come — even if it does hit you?”

The last question moves the conversation. It does not deny the migraine and does not demand that the fear disappear. It asks how it might be possible to live with both.

In relational family therapy, in which I am training, we are interested not only in the individual but also in what place fear holds in the family. Sometimes the whole system carries the fear of an attack: a partner who doesn’t dare suggest a trip, a child who learns to be quiet, a parent who once lived through the same thing with their own mother’s migraine. When these patterns are put into words, the load is shared differently. The person with migraine is no longer the only one who has to make sure nothing happens — and those close to them are no longer helpless onlookers or silent critics, but people who know what they can do when an attack really comes.

What helps

The good news is that approaches for migraine and for anxiety overlap in many ways. Meta-analyses show that relaxation techniques, biofeedback and cognitive behavioural approaches reduce the frequency of migraine attacks (Nestoriuc & Martin, 2007). Cognitive behavioural therapy is at the same time one of the best-researched approaches for anxiety disorders. I summarised what research shows when comparing psychotherapy and medication for anxiety in Therapy or medication for anxiety: what the research shows.

It matters that everyone helping you knows about both problems. Tell your neurologist that you also have anxiety, and your therapist how you treat your migraine. For the doctor this is important when choosing medication; in therapy it shapes how we approach avoidance: with migraine, some caution is reasonable, while some may already be anxiety. Telling one from the other is a task best done together.

With anxiety alongside migraine, one of the key steps is re-examining avoidance. It is not about forcing yourself into situations that really do trigger attacks. It is about looking at which things you avoid because of a proven trigger and which because of a fear that has spread. Often the second group turns out to be much bigger than the first. It helps to rate your distress in each situation, for example with a distress scale, and to return to things gradually, from easier to harder.

Exercise: signal or alarm?

You can do this exercise today. It helps you tell useful caution from anxiety that has grown too big. Take a sheet of paper and give yourself twenty minutes.

1. Write down what you avoid because of migraine. Everything that comes to mind: things you no longer do, places you don’t go, plans you don’t make.
2. Next to each item, write how you know it triggers an attack. Did your diary show it? Has it happened several times? Or is it only a “what if”?
3. Split the list in two. On one side put the items you have experience or evidence for — these are signals. On the other, those driven mainly by fear — these are alarms.
4. Choose the alarm that frightens you least. Think about how you could try it with a safety net: medication with you, a plan for leaving, a person who knows.
5. Try it and write down what happened. Not only whether an attack came, but also how you felt before and after. This note is information for the next step.

If the list of alarms seems long and fear is narrowing your life more than the migraine itself, that is a good reason to seek help. Anxiety can be treated, even when its origin is entirely understandable.

Where this explanation falls short

I don’t want this post to sound as if everything about migraine is connected to anxiety. It isn’t. Many people with migraine have no anxiety disorder at all, and their caution is entirely proportionate. For them, looking for anxiety would only mean one more unnecessary doubt about themselves.

Nor are fewer attacks guaranteed if anxiety goes down. Psychological work can help with frequency and with how severely you experience attacks, but it cannot remove the neurological basis of the disease. If attacks are frequent or severe, the first port of call is a neurologist, not a psychotherapist.

And finally: anxiety can also be severe enough to need more than exercises and conversation. If it stops you working, sleeping or being with people, talk to your GP or a psychiatrist. And if thoughts that nothing makes sense any more appear, call the Klic v duševni stiski helpline on 01 520 99 00 in Slovenia (7 pm to 7 am) or the Samarijan helpline on 116 123 in Slovenia (every day, 24 hours). In an emergency, call 112.

What to remember

• Migraine is a neurological disease. Anxiety does not cause it, but often goes with it.
• Anxiety disorders are several times more common in people with migraine than in others; the link runs both ways and has a shared background too.
• Anxiety alongside migraine often shows up as body-scanning, avoidance and fear of the next attack.
• Cognitive behavioural approaches and relaxation help both; diagnosis and medication stay with your doctor.
• Tell signals (proven triggers) from alarms (fear that has spread) — and gradually return to the things fear has taken.