Migraine and pain catastrophising: what the research shows

“Again. Not again. This is going to last three days and I’m going to miss everything again.”

The thought arrives faster than the pain itself. The first flicker has barely appeared at the edge of your vision, you have barely felt the familiar tightening at the back of your head, and a whole film is already running: the cancelled meeting, your manager’s irritated look, the children hearing “Mum’s not well” yet again, the weekend that won’t happen. Before the attack has even peaked, you have already lived through its worst possible course in your head — and the next few as well.

In the psychology of pain this is called pain catastrophising. The word sounds accusatory, as if someone were exaggerating or making a mountain out of a molehill. That is not how it is meant, and in this post I will explain why. I will look at what research on catastrophising in migraine really shows, what it does not show, and what you can do with these thoughts — not so that the attacks disappear, but so that they don’t take more from you than the illness already does.

First things first: migraine is a disease of the brain

Before I write anything about thoughts and feelings, I need to say something that is essential with this topic. Migraine is a neurological disease, not a psychosomatic symptom. It has a strong hereditary component, its own diagnostic criteria and its own mechanisms in the brain and nervous system. It does not start because someone worries too much, and it does not go away because they start thinking differently.

How serious it is can be seen in one figure from the large Global Burden of Disease research: in 2018, Timothy Steiner and colleagues showed that among people under 50, migraine is the leading cause of years lived with disability — in women and in men alike. Not headache in general, but migraine specifically. This is not “a slightly worse headache”; how it differs from an ordinary headache is a topic in its own right.

That is why there is a clear division of labour. Diagnosis, medication for attacks and preventive treatment are decided by your doctor and neurologist. As a psychotherapist I give no advice here about medication. My contribution lies elsewhere: in what happens inside a person and between people when pain keeps coming back — in fear, anxiety, stress and relationships. Catastrophising is one of these pieces. It does not cause migraine. But it can strongly affect how a person bears it.

What pain catastrophising is

In everyday language, catastrophising means imagining the worst possible outcome. I wrote about this general pattern of anxious thinking in “What if …”: why the brain would rather predict a hundred disasters than one calm day, and you can also find a short explanation in the knowledge base under catastrophising.

In relation to pain, the term has a narrower, precisely researched meaning. In 1995 the Canadian psychologist Michael Sullivan and two colleagues published the Pain Catastrophizing Scale, which researchers still use today. They found that catastrophising about pain shows three faces, which intertwine with one another:

• Rumination — your thoughts keep returning to the pain. “I can’t stop thinking about how much it hurts.” I wrote more about why the mind goes round in circles in Rumination: the scientific name for spinning thoughts.
• Magnification — the pain and its consequences seem bigger and more dangerous. “What if it’s something worse this time?” “This is going to ruin my job.”
• Helplessness — the sense that nothing can be done about the pain. “Nothing helps. I just have to endure it.”

It matters what this scale measures: not how much someone hurts, but what goes on in their mind while it hurts. Two people can have an equally strong attack, yet one experiences it as a severe but passing nuisance and the other as proof that the illness is taking their life away. Both are suffering. But their suffering is not made of the same things.

What research on migraine shows

Catastrophising was first studied in back pain, after surgery and in other forms of chronic pain. A review published in 2009 by Phillip Quartana, Claudia Campbell and Robert Edwards sums up a consistent picture: people who catastrophise more strongly about pain experience it, on average, as more intense, are more disabled by it and carry more emotional distress. This holds across very different conditions, which suggests that it is not a feature of one diagnosis but a general way in which the mind responds to pain.

In migraine, one of the more important studies was led by Kenneth Holroyd and colleagues (2007). They looked at people with severe, frequent migraine and found that those who catastrophised more reported greater disability and poorer quality of life. The link was not simply a reflection of these people having more frequent attacks. Two people with the same frequency of attacks could therefore live very differently limited lives — and part of that difference lay in how they thought about the pain.

We need to read this carefully. Most of these studies are cross-sectional: they measure catastrophising and disability at the same time and find a connection. From that we cannot reliably conclude what is cause and what is effect. Very probably it runs both ways. Someone who has more severe and frequent attacks has more reasons for dark thoughts. And someone who has dark thoughts experiences an attack as worse. It is not “either–or”, but a circle.

That is exactly why catastrophising matters in therapy. I cannot change the frequency of attacks through conversation. But together with the person in front of me, I can change what happens in their thoughts and body when an attack comes — and that is the part of the circle within reach.

Why this is not “exaggerating”

When I mention catastrophising to people with migraine, I often see them close up. I understand why. Many have spent years hearing that they “bring the migraine on themselves”, that they are “too sensitive”, that they should “think a little less”. The word catastrophising can sound like a professional term for the same accusation.

So let me be clear: catastrophising is not a character flaw, and it is not proof that the pain isn’t real. It is an understandable response of a nervous system that has already learnt, many times over, how bad things can get. If you have already spent three days in a dark room several times, if an attack has made you miss an important event or vomit in the toilets at work, then your thought “this is going to be awful again” is not made up. It is based on experience.

The brain is built to learn from pain. When something hurts repeatedly, it starts looking for warning signs in advance, takes them more seriously and answers them with alarm. This is a protective mechanism. The problem is not that you have it, but that it can switch on even when it no longer helps — and itself become a source of suffering added on top of the pain. If you would like to read more about how pain and emotion travel along the same pathways, there is an explanation in the knowledge base under pain and emotion.

At the same time, it is important to distinguish migraine from bodily complaints where the test results stay normal and there is no explanation. That is a different story, which I wrote about in “The tests are normal, but it still hurts”. Migraine has a name and a diagnosis. With migraine, catastrophising is not about whether the pain is “real”, but about what the mind does with pain that is real.

How a thought amplifies suffering

Pain psychologists have long described how fear of pain and avoidance can weave their way into everyday life. In 2000, Johan Vlaeyen and Steven Linton described what is known as the fear-avoidance model. It was developed for back pain, not migraine, but its logic applies more widely: someone who experiences pain as a threat starts to avoid it, and through avoidance their life shrinks, their body weakens and their fear grows.

With migraine, the circle might look like this. A first sign appears. A thought immediately declares it the start of a catastrophe. The body responds with a stress reaction: the muscles in the neck and shoulders tense, breathing becomes shallow, the heart speeds up. Attention narrows to the head and every throb seems louder. When the attack passes, the memory of how bad it was remains — and at the next sign the alarm goes off even faster. In between, the person begins giving things up because “what if it starts”.

That last part, the fear between attacks, is so important that I have given it its own post: Fear of the next migraine attack: when anticipation becomes a burden. Here I focus on the moment of pain itself and the thoughts that come with it.

How it sounds in conversation

Catastrophising often hides in perfectly ordinary sentences. This is how part of a conversation in a session might sound (composite, not a real person):

“It started again yesterday. In the middle of my child’s school performance. I knew straight away that it was over.”
“What was over?”
“The day. The week. It’s always like that. When it starts, everything goes to pieces.”
“And yesterday? What happened next?”
She thinks. “I took the medicine my neurologist prescribed and went to sit in the car. After two hours it eased off. In the evening I was tired, but I was at home with them.”
“So yesterday’s attack turned out differently from what the thought told you at the beginning.”
“Yes … But the next one might be worse.”
“It might. Do you notice how quickly the thought jumped ahead?”

In this conversation I am not trying to convince anyone that migraine isn’t bad. Nor am I denying that the next attack could be worse. We are noticing something else: how, at the first sign, the thought already knows how everything will end, and how often that forecast doesn’t come true in full. This doesn’t give the person less migraine. But it does give them a little more space between the attack and the story about it.

What helps: from noticing to responding

The good news from the review by Quartana and colleagues is that catastrophising can change. It is not a fixed personality trait. In chronic pain it decreases with psychological approaches, most thoroughly researched among them cognitive behavioural therapy. I wrote about how these approaches are used in migraine, and how biofeedback joins them, in Biofeedback and cognitive behavioural approaches to migraine: what we know and what we don’t. Here I will highlight only a few things that concern the thoughts themselves.

First: a thought is not a forecast. “It’s going to last three days again” is a sentence the mind produces. It may be true, it may not. When you notice it as a sentence rather than a fact, its power lessens. This is called cognitive defusion, and I have written a post about it: How to notice a thought instead of following it.

Second: helplessness is often inaccurate. Most people with migraine have something that helps at least a little — medication prescribed by their doctor, a dark room, something cool on the forehead, rest, getting away from screens. When you write these down, the thought “nothing helps” meets evidence to the contrary. Not so that you can talk yourself into anything, but so that you see the whole picture.

Third: you can let your body go, even when your head hurts. Tension in the shoulders, a clenched jaw and held breath don’t cause migraine, but they can make an attack even more unpleasant. A slow out-breath or deliberately relaxing the muscles are small acts that tell the nervous system it is not in mortal danger. For a start, the knowledge base has an exercise called breathing with a longer out-breath.

Fourth: you don’t fight your thoughts, you answer them. The goal is not positive thinking. “This attack will be mild” is just as much a forecast you cannot guarantee. A balanced, truthful sentence helps more: “This is an attack. I’ve had them before and they have passed. I’ll do what helps me.”

In relational family therapy, in which I am training, we also look at where a person learnt how to respond to pain. Someone grew up with a parent who expected the worst with every illness. Someone else learnt that their distress was a burden at home, so they had to carry it alone and in silence. Catastrophising often has this family layer too — and when a person recognises it, the thought “everything will be ruined” can reveal itself as an old, learnt voice rather than the truth about the present.

Exercise: three questions at the first sign

You can do this exercise today, first in your mind and then during your next attack. It does not replace medication or the plan you have agreed with your doctor — it runs alongside it.

1. First do what has been agreed. If your doctor has prescribed medication for attacks and told you when to take it, follow those instructions. This exercise is not instead of that.
2. Catch the thought and write it down or say it out loud. What did your mind tell you in the first few seconds? For example: “The whole weekend is ruined again.” Add a prefix to it: “I’m noticing the thought that …”
3. Ask yourself three questions. What do I actually know right now? How did my last few attacks end — were they all equally bad? What has helped me at least a little in the past?
4. Breathe out slowly three times in a row. Make each out-breath longer than the in-breath. With each out-breath, drop your shoulders and unclench your jaw.
5. Tell yourself one balanced sentence. Not “it won’t be bad”, but “This is an attack. I don’t yet know how it will go. I’ll look after myself as best I can.” After the attack, write down what actually happened.

The last step, the note after the attack, matters more than it seems. Memory of pain is biased: the worst moments imprint more strongly than the whole course. Over time, your notes will show you a fairer picture than the one memory carries.

Where this explanation doesn’t apply

Because I am writing about thoughts, it may seem that a person is at least partly to blame for their migraine troubles. So I want to say clearly where this story stops.

Catastrophising does not explain migraine. A person who handles their thoughts superbly can still have frequent, severe attacks. If attacks become more frequent, change or feel different from usual, that is a reason to see a doctor, not to work on your thoughts.

Not every dark thought is catastrophising. If someone has truly severe, frequent migraine that has cost them their job or narrowed their life, their sadness is real. Grieving for what the illness has taken is not a thinking error. I wrote about this in Loss of health: when a diagnosis changes your whole future.

When pain is new or different, caution is not catastrophising. A sudden, extremely severe headache, a headache with neurological symptoms you don’t recognise, or a headache after a blow to the head needs immediate medical help. In an emergency, call 112 (in Slovenia). Here, worry is in the right place.

When worry about your health overshadows everything else. If the fear is attached not only to attacks but to every bodily sensation that you read as a sign of serious illness, this may be health anxiety — a different topic, which I wrote about in Health anxiety: when every symptom means the worst.

And one last boundary: if despair or thoughts that life is not worth living take over alongside migraine, that is not something an exercise can solve. Talk to your doctor, or in Slovenia call the crisis line Klic v duševni stiski on 01 520 99 00 (from 7 pm to 7 am) or the Samaritans helpline on 116 123 (every day, 24 hours).

What you can do in therapy

Psychotherapy does not treat migraine. But it can be a place where you look at what happens around it. In a session we can explore together what your mind tells you at the first sign, where those words come from and how they affect your day, your relationships and your decisions. We can look at how the people close to you react to attacks and how those reactions intertwine with your thoughts. And we can find ways of bearing the pain with a little less struggle. I also work with English-speaking clients in Ljubljana.

It is best when psychological work takes place alongside treatment from your doctor or neurologist, not instead of it. The people who fare best are those for whom the two complement each other: medication and neurological care for the disease, psychological work for what the disease stirs up in the person and their relationships.

What to remember

• Migraine is a neurological disease. Catastrophising does not cause it — but it does shape how much suffering and disability an attack brings.
• Pain catastrophising has three faces: rumination, magnification and helplessness.
• Research on migraine links it to greater disability and poorer quality of life, though the link most likely runs both ways.
• Catastrophising is not a character flaw but a learnt protective response — and because it is learnt, it can change.
• Psychological work complements treatment from your doctor and neurologist; it never replaces it.