Migraine at work: how to talk about it — and how much to say

“Another headache?”

A colleague said it in passing, by the coffee machine, with a smile. She didn’t mean anything by it. But the person she said it to had spent the last hour in a meeting with a curtain over one eye, a lump of nausea in his throat and a single thought: just let me get to the end. He answered: “No, no, I’m just a bit tired.” And went back to his computer, where for the next two hours he read the same paragraph over and over.

This scene is one of the most common I hear when people talk about migraine. Not an attack at home, in a dark room, but an attack at work — where you can’t lie down, where people are watching and where you feel you have to justify your pain. In this post I look at a question people with migraine carry around for years: whether to tell anyone at work, whom, and how much. I am leaving the legal details aside. What interests me is what happens inside a person and between people.

First: migraine is a disease of the brain

Before we talk about how to tell people about migraine, it needs to be said clearly what migraine is. Migraine is a neurological disease — not a psychosomatic symptom, not a personality trait and not a sign that someone copes badly with stress. It is a disorder of brain function with its own biology, its own phases and its own diagnostic criteria. The diagnosis is made by a doctor, a neurologist if needed, and only they can judge which treatment is right for you. I won’t be giving any advice on medication in this post.

Why do I stress this in a post about work? Because the workplace is exactly where it is hardest. If migraine is “just a headache”, then the person who goes home because of it is weak or unreliable. If it is a disease, then going home is a reasonable decision. How you see migraine yourself will strongly shape how you talk about it with others.

By current estimates, roughly one in seven people worldwide has migraine. The Global Burden of Disease study found that migraine is the second leading cause of years lived with disability — and among women aged 15 to 49, the very first. These are precisely the years when people build careers, change jobs and look after small children. So migraine is not a rare exception in the office. In almost every larger team there is someone who knows what it is like when the world starts breaking into zigzag lines.

An invisible illness at work

Migraine is invisible in two ways. Between attacks a person is completely well — working, laughing, turning up to the team-building day. During an attack they often hide: close the door, dim the screen, go quiet. So colleagues see two pictures that don’t match. Yesterday she was perfectly fine; today she isn’t here.

Research on migraine in the workplace keeps repeating one finding: most of the loss does not come from absence but from the days when people come to work despite an attack and work at reduced capacity. This is called presenteeism. The person is at their desk, but half of them is in pain, nausea and the fear that someone will notice. Such a day is often more costly than a day at home would have been — for the company and for them.

Then there is stigma. An American study on the stigma of migraine found that people with chronic migraine reported more stigma than people with episodic migraine, and even more than people with epilepsy. Stigma here doesn’t necessarily mean someone openly humiliates you. It means small remarks like “another headache?”, the look you get when you leave early, and a quiet assumption that you could try a bit harder.

Why it is so hard to say

When I talk with people about why they keep quiet about migraine at work, I never hear just one reason. Usually several pile up:

• Fear of being seen as unreliable. Especially in workplaces that prize availability, admitting that an illness occasionally switches you off can feel like admitting you’re not good enough.
• The experience of not being believed. Many people heard as children, or in previous jobs, that they were “exaggerating”. After a few reactions like that, a person learns that silence is safer.
• Their own shame. Sometimes the harshest judge isn’t the boss but an inner voice saying you ought to be able to cope.
• Unpredictability. It is hard to explain something you don’t fully understand yourself: you don’t know when the next attack will come, how long it will last or how bad it will be.

In many of the people I meet, migraine overlaps with high demands on themselves. On the outside they have everything under control; inside, every lapse feels like a personal failure. If you recognise yourself in this, you may find the post High-functioning anxiety useful. And if you feel that your worth is tightly tied to how much you get done, that is the subject of Worth only as much as you get done. Migraine tests that belief regularly — and every attack confirms it again unless you look at it up close.

Whom, how much and when

First, something I think matters: the decision whether to tell is yours. There is no rule that you must talk about your illness, and no rule that you must keep quiet about it. There is only the question of what serves you better in your particular setting.

It helps not to see disclosure as all or nothing. Between “nobody knows” and “everybody knows everything” there are many steps. You can tell only what people need to know to understand you in the moment of an attack. You can tell more to one person you trust. You can tell your manager that you have a diagnosed condition which occasionally affects your day, without going into details.

As for timing, one rule is almost always useful: don’t talk about migraine for the first time in the middle of an attack. That is when you are in the worst position — in pain, lost for words, perhaps nauseous. A conversation you prepare on a calm day is different from one you force out at the door as you’re leaving. People who have heard an explanation before they see you pale and wordless respond differently from those who see you like that for the first time.

It also helps to know exactly what you want to convey. People in such conversations often say too much about the pain and too little about what they need. Your manager doesn’t need to know how your left temple feels. They need to know what will happen when you have an attack and how the work will carry on.

What such a conversation might sound like

A conversation with a manager might go something like this (composite, not a real person):

“I’d like to tell you something it’s good for you to know. I have migraine — diagnosed. Most of the time it doesn’t get in the way, but a few times a month I get an attack when I can’t look at a screen for a few hours.”
“Oh. I didn’t know. Is that what happened last week when you left after lunch?”
“Yes. I was apologising as if I’d done something wrong. I’d rather we agreed in advance: if I feel an attack coming, I’ll send you a short message, hand anything urgent to Maja and finish it the next day.”
“That actually makes it easier for me. At least I know what’s going on.”

Something important happens in this conversation. The person doesn’t ask for pity and doesn’t apologise. She states a fact, connects it to the work and offers a plan. The manager gets what managers need most: predictability. And interestingly, she doesn’t have to convince him that migraine is serious. It is enough for him to understand how things will go.

Of course, not every conversation ends like that. Sometimes the response is cold or mocking. Then it helps to separate two things: how the other person reacted, and whether your decision to tell was wrong. A cold response says something about the setting. It doesn’t say your illness isn’t real.

Small agreements that make a big difference

Once the conversation has happened, there is often room for practical adjustments. I don’t mean rights and procedures, but arrangements you can make with the people around you. Some are so small that nobody even notices:

• a desk where light doesn’t fall straight into your eyes, or the option to dim it,
• regular screen breaks and regular meals, even on packed days,
• a quiet spot where you can withdraw for half an hour when you notice the first signs,
• an agreement on who takes over urgent tasks when you leave,
• some flexibility over the start of the working day if your attacks often come in the morning.

It helps to know what sets off your attacks and how they unfold. People who keep notes often discover that their attacks at work are not random — that they are linked, for example, to a skipped lunch or a week of less sleep. I describe how to keep such a record in A migraine diary. Notes are valuable both at the doctor’s and in a conversation with your manager, because they move the conversation from feelings to patterns.

Stress at work and the attack that comes on Friday evening

Many people with migraine know an odd pattern: they hold out all week under pressure, and the attack arrives on Friday evening or on the first day of a holiday. This is not imagination. In some people, attacks are triggered not by the peak of stress but by its drop — the moment the tension lets go. I explain why in Stress and migraine.

Stress doesn’t cause migraine. Migraine is a disease of the brain that a person would have even in the calmest job in the world. But for many, stress is one of the factors that affects how often attacks come. This is where psychological work has its place. Prolonged tension without breaks — what we call chronic stress — keeps the body in a state of readiness that is hard to step out of.

Among non-drug approaches to migraine, relaxation techniques, biofeedback and cognitive behavioural approaches have the strongest support. They don’t replace treatment from a doctor, but they can complement it. One of the best-studied techniques is progressive muscle relaxation, which you can practise at home and later use in a shortened form during the working day.

Rhythm matters too. Weeks when you work late, skip meals and then “switch everything off” on Friday are, for many people with migraine, the riskiest. Not because you’re doing something wrong, but because a migraine brain tolerates big swings poorly. A steadier pace — including in how you rest — is often more protective than even the best weekend of recovery.

Exercise: prepare your sentence

You can do this exercise today, in ten minutes. You need a sheet of paper and a bit of quiet.

1. Write down what happens at work when you feel an attack coming. Concretely: when you notice it, what you can no longer do first, how much time you have before you need to leave or withdraw.
2. Write down what you fear most about telling. That they’ll think you’re weak? That you won’t get the project? That they’ll talk behind your back? A fear you write down is easier to weigh up.
3. Choose one person and one level of disclosure. Not everyone at once. Your manager, the colleague you share an office with, or someone who trusts you.
4. Write three sentences: what you have (the name or a description), what happens during an attack, and what you suggest. No more. Read them out loud.
5. Choose a calm moment and have the conversation then, not in the middle of an attack. Afterwards, note down how it went — even if it wasn’t ideal.

The exercise isn’t meant to persuade you that you must tell. It is meant to give you words that are ready when you decide to — and to make sure the decision is made by you, not by fear.

A plan has one more advantage: it reduces anticipatory anxiety. When you know what you’ll do when an attack comes, you don’t have to wait for it in constant tension. Many people with migraine carry a quiet fear of the next attack — and it is sometimes this fear that steals the most from pain-free days.

Where my argument doesn’t hold

This whole post rests on the assumption that disclosure can be helpful. But it isn’t always.

The setting isn’t always safe. If you work somewhere weakness is punished, where people are spoken about mockingly, or where you sense the information could be used against you, caution is reasonable. Silence in such a setting isn’t shame but protection. In that case the question may be wider than migraine: is this a workplace you want to stay in?

A conversation doesn’t replace treatment. If you have so many attacks that your job is falling apart, the answer isn’t just better disclosure but, first, a doctor and a neurologist. Migraine can be treated better today than decades ago — but not without a diagnosis. Psychological work comes alongside, not instead.

Sometimes the problem isn’t migraine. If you notice that, on top of migraine, work is getting harder and harder — that you have no drive, can’t get yourself going in the morning, can’t see the point — something else may be there too. Migraine and depression often appear together. How to work when you can’t is the subject of Depression and work.

There is no single right decision. One person will find relief in telling; another will prefer to keep their privacy and manage attacks in their own way. Both can be a mature decision.

Where psychotherapy can help

Psychotherapy doesn’t cure migraine. But it can help with everything that builds up around it. At work, this often means:

• Fear of an attack that pushes you to cancel meetings, trips or opportunities before anything has happened. Avoidance calms you in the short term but narrows your life in the long run — see Anxiety and avoidance.
• Catastrophic thoughts at the first signs: “Now everything will fall apart, I’ll ruin it all again.” Research shows that catastrophising is linked to greater disability with pain — and that it can be changed.
• Your relationship with work and with yourself. Who are you when you can’t cope? When did you learn that you are loved only when you are useful?
• Relationships. Migraine doesn’t affect only you, but also the people you work and live with.

In relational family therapy, in which I am training, we are also interested in what a person brings with them from their family of origin. It isn’t unusual for our attitude to illness to follow the way our family received illness. If the rule at home was “don’t make a fuss”, telling people at work will be harder too. Once you recognise that, you have more choice. I also work with English-speaking clients, in person in Ljubljana.

What to remember

• Migraine is a neurological disease, not a psychosomatic symptom and not a weakness. Diagnosis and treatment belong with a doctor.
• Disclosure at work is not all or nothing — you can tell different people different things and change your decision.
• Don’t talk about migraine for the first time during an attack. Prepare three sentences: what you have, what happens, and what you suggest.
• An attack plan prepared in advance reduces both confusion in the team and your own fear of the next attack.
• Psychological work doesn’t treat migraine, but it can ease the fear, catastrophic thoughts and pressure you carry around it.