Stress and migraine: why the attack often comes only after the pressure

“All year I wait for my holiday. And then on the first day I’m lying in a dark room with a bucket next to the bed.”

I hear this sentence, in one version or another, more often than you might think. Sometimes it is the first day of a holiday, sometimes the Saturday after a week with a project deadline, sometimes the evening after a viva, a house move or a funeral, when everything has finally been taken care of. Throughout the pressure, the person held up. The body worked, the mind was clear, tasks were closed one after another. But when the pressure eased, the migraine arrived.

People often experience this as an injustice, or even as proof that something is wrong with them: “I can’t even rest properly.” In this article I would like to explain why an attack so often comes after stress rather than during it, what the research says about it, and where psychological work has a place — not instead of the doctor, but alongside them.

First things first: migraine is a brain disorder, not “just stress”

Before I write about stress, I need to say something people with migraine would like to hear more often than “it’s just stress”: migraine is not a psychosomatic symptom, and it is not the result of someone “worrying too much”. It is a neurological disease with a strong hereditary component. In migraine, the brain is more sensitive to change — in the body’s internal environment and in the outside world — and responds to it with a chain of events involving the hypothalamus, the brainstem and the trigeminal nervous system. An attack has its own phases, from the first warning signs to the tail end, and it is not simply a “bad headache”.

Global burden of disease estimates have for years ranked migraine second among the causes of years lived with disability, and first among young women. This is not an illness anyone invents to get out of their obligations.

So why write about stress at all? Because stress affects migraine — not as its cause, but as one of the factors that can open the door to an attack in a brain that is already sensitive. What else can trigger an attack, and what is merely folklore, I have explained in Migraine triggers: what really sets off an attack and what we have made up. Here I will focus only on stress, because it has some peculiarities that other triggers don’t.

A migraine diagnosis is made by a doctor — your GP and, where needed, a neurologist. Medication, both for attacks and for prevention, is in their hands too. You won’t find any recommendations about medication in this article. My contribution is the other part of the story: how stress, anxiety and relationships affect life with migraine, and what you can do about it yourself or in therapy.

What the research shows: the attack after the let-down

When you ask people with migraine what triggers their attacks, stress sits at the top of the list in most studies. In one of the largest clinical studies of triggers, carried out by Leslie Kelman, stress was the most frequently reported trigger, ahead of hormonal changes, skipped meals and the weather.

More interesting, though, is when the attack comes. In 2014 Richard Lipton and colleagues published a study in which people with migraine kept an electronic diary for three months and rated their stress every day. They found that an attack was not most likely on the day of greatest stress, but when stress dropped. When stress was lower on one day than on the day before, the odds of an attack in the following six hours were almost twice as high. The effect was more pronounced when the drop was larger.

The study was small and needs to be read with caution. But it confirmed something people with migraine have known for a long time and that neurologists call the “let-down headache”: the weekend migraine, the first day of the holiday, the evening after the exam.

Why after the pressure?

Science does not yet have a definitive answer. There are several explanations, which don’t exclude one another, and it is only fair to say that they are hypotheses.

The migraine brain dislikes change. One of the common threads in migraine research is that the brains of people with migraine are particularly sensitive to departures from balance — in sleep, meals, hormones, light. Stress is a state the body adapts to, to some extent. The sudden end of stress is just as much a change for such a system as its beginning.

During stress, the body stays on standby. During prolonged pressure, the body’s coping systems are active — from stress hormones such as cortisol to the autonomic nervous system. One hypothesis is that some of these systems even have a short-term protective effect against pain, and that it is their decline at the end of the pressure that opens a window of vulnerability.

Stress rarely comes alone. When the week is demanding, people usually sleep less and more irregularly, skip meals, drink more coffee, sit longer in front of a screen and hold more tension in their shoulders and jaw. When the pressure eases, all of this flips: on Saturday you sleep longer, coffee comes later, breakfast is at eleven. An attack we put down to “relaxing” may in fact be the result of a whole series of changes at once.

Sleep matters particularly here, because stress shortens and fragments it, and short sleep in turn makes you more sensitive to stress — I describe how this happens in Sleep and emotion: why everything hurts more after a bad night.

For your everyday life, the main point is this: the problem isn’t necessarily that you “don’t know how to rest”. Perhaps the problem is how abruptly you switch from one state to the other.

Chronic stress: when the alarm never quite goes quiet

The let-down headache is only one part of the story. The other is long-lasting, chronic stress, which doesn’t end on Friday but goes on for months: an ill parent, an insecure job, debt, a relationship falling apart. Studies in which people with headaches track their stress and sleep every day show that both are linked to the intensity and frequency of headaches. Chronic stress doesn’t cause migraine, but it can lower the threshold at which an attack is set off.

In the people I know, this often shows up as life on permanent standby. On the outside they come across as composed and reliable; inside, they are always one step ahead of the next problem. I wrote about what it looks like when you have everything under control on the outside while an alarm rings inside in High-functioning anxiety. With migraine, this way of living carries an extra cost: the body never reaches a calm point from which it could take in change without resistance.

What is important to understand is that chronic stress is not a question of character or weakness. It is the body’s response to circumstances in which it is hard to be any different. How anxiety and stress play out in the brain, and why the body reacts before you even think, I explained in What happens in the brain during anxiety.

When migraine itself becomes the stress

The link between stress and migraine is not one-way. Migraine is itself a source of stress — and a big one. Cancelled plans, lost working days, guilt towards your children and partner, the fear that an attack will land on a friend’s wedding day. People with frequent attacks often begin to live “around” the migraine: they don’t make plans, because they don’t know whether they will be up to it on the day.

And so a circle forms. Stress lowers the threshold for an attack, the attack brings new stress, and the fear of the next attack keeps up a constant tension. The way we think about pain plays an important part in this circle. When thoughts revolve around the worst — “it’ll last three days again”, “I won’t cope”, “this will never end” — psychologists speak of catastrophising. Research on chronic pain shows that catastrophising is linked to greater disability and a harsher experience of pain. This doesn’t mean you are imagining the pain. It means that on top of pain that is real, there is added suffering that can be reduced.

Migraine in the family: who carries what

As a therapist in training in relational family therapy, I also look at migraine through relationships. Migraine doesn’t happen to just one person. It happens to a family, a partnership, a team at work. Someone has to take over the children, cancel the visit, explain to the boss. And unspoken feelings quickly gather around this: guilt in the person having the attack, tiredness or quiet anger in the person who takes over.

Stress in a relationship is one of the most common forms of chronic stress there is. And because tension at home is often exactly the kind we can’t simply “put down”, an attack may come after an argument or — just as often — after making up, when the tension finally releases. A conversation might go something like this (a composite, not a real person):

“Again? We’d only just agreed to go to my parents’ on Saturday.”
“You think I choose it? I tried all week to make sure Saturday would be calm.”
“I know. It’s just that sometimes I feel the migraine runs our life.”
“I feel that every day.”

Nobody in a conversation like this is being unkind. Both are worn out by the same thing; each just carries it from a different side. In therapy we don’t look for someone to blame; we help the partners see the migraine again as a shared “opponent” rather than something standing between them. Often just saying out loud “I feel that every day” changes the tone at home.

Was it really stress? When the “trigger” is already part of the attack

Here is a section that somewhat undercuts my own argument, and it is right that I write it. A migraine attack often begins hours or even a day before the pain, in what is called the premonitory, or prodromal, phase. It can bring irritability, tiredness, yawning, difficulty concentrating, cravings for particular foods and sensitivity to light. A study by Giffin and colleagues, in which people recorded their observations in real time in an electronic diary, showed that many were able to predict an attack on the basis of these signs.

What does this mean for stress? That the feeling “I’m tense today and everything gets on my nerves” is sometimes already part of the attack, not its cause. Someone who has a tense argument with their partner and wakes up with a migraine the next morning will easily see the argument as the trigger. Perhaps it was. But perhaps the tension and irritability were the first sign of an attack that had already begun. The same goes for the craving for chocolate that people often list among their triggers.

So it is wise to treat every “I know what set it off” with some caution. A more accurate picture only comes from systematic recording — a diary in which, over several months, you note your attacks, sleep, meals, stress and how you felt the day before an attack. Only when a pattern repeats several times can you say with some confidence that it is a trigger and not chance or an early sign.

And one more limit: not every migraine is linked to stress. For some people the connection is very clear; for others it is barely there. Attacks can come in the calmest periods and stay away in the hardest. If someone tells you that you would “cure” your migraine if you worried less, they are loading you with guilt for an illness you didn’t choose.

What helps alongside medication

Psychological approaches to migraine are not a substitute for medication, but they are part of professional bodies’ recommendations for preventing attacks. The three best researched are relaxation techniques (for example progressive muscle relaxation), biofeedback, in which a device helps you learn to regulate your body’s responses, and cognitive behavioural approaches, which work with thoughts and behaviour around stress and pain. Research reviews show that these approaches can reduce how often attacks occur, and the effect is greater when people learn them with guidance and practise them regularly. I have described in more detail which relaxation techniques have the strongest evidence and how to learn them in What helps with migraine besides medication: relaxation techniques with evidence.

In therapy, we also often work on questions that no protocol fully captures. Why is it so hard for me to say no? Why do I keep going until I drop? Who taught me that rest only comes once everything is done? These patterns often come from the family you grew up in, and they shape how you respond to stress — and therefore how abrupt the transitions between pressure and rest become.

Exercise: a soft landing after a demanding period

If you notice that an attack often comes once the pressure is over, try what I call a “soft landing”. The aim is not to give up rest, but to make the transition from tension to rest more gradual. Don’t start the exercise on the day after the deadline, but a few days before.

1. Mark the landing in your calendar. When you know a demanding period is coming to an end (a deadline, an exam, a move), write down the day the pressure will ease. Simply knowing when it will happen helps you not to experience it as a sudden drop.
2. Keep your rhythm on the first free day too. Get up no more than an hour later than usual, eat at similar times and have your coffee at your usual time. Let your body experience the first day off as much like yesterday as possible.
3. Let tension down during the week. On each day before the pressure ends, take ten minutes for progressive muscle relaxation or for breathing with a longer out-breath. That way stress doesn’t fall from the top all at once, but comes down step by step.
4. Plan the last day of pressure a little lighter. If at all possible, don’t end the last day with the hardest task. Give yourself half an hour to “step out”: clear your desk, write down what is left, go for a walk.
5. Write down what happened. After each demanding period, note in your diary whether an attack came, when, and what the transition was like. After a few months you will see whether the soft landing helps you — and if it doesn’t, you haven’t done yourself any harm.

The exercise won’t prevent every attack. But it can help rest stop feeling dangerous.

Where the limits are, and when to see a doctor

Everything I have written applies to people whose migraine has already been diagnosed. If you have headaches and aren’t sure what they are, see your GP first. Headaches can have many causes, and not every headache that comes after stress is a migraine.

See a doctor too if your headaches change — if they become more frequent or different, or if medication no longer helps as it used to. Taking painkillers often can itself cause headaches, and this needs to be assessed by a doctor. Call 112 (the emergency number in Slovenia) straight away if you are suddenly hit by the worst headache of your life, if a headache comes with confusion, weakness, or problems with speech or vision that you don’t recognise from before, or if it appears after a blow to the head.

And one more limit, which concerns me: psychotherapy doesn’t cure migraine. But it can help with how you live with it — with the stress you carry, the fear of the next attack, the relationships that migraine puts under strain. That is no small thing. For many people, this is exactly the part that takes the most life from them.

What to remember

• Migraine is a neurological disease, not a psychosomatic symptom. Stress doesn’t cause it, but in a sensitive brain it can trigger an attack.
• The attack often comes not at the height of stress but when stress eases — Lipton and colleagues found almost twice the odds of an attack after a drop in stress.
• What looks like a trigger may already be the start of the attack: irritability and tension also belong to the premonitory phase.
• Relaxation, biofeedback and cognitive behavioural approaches are part of the recommendations for preventing attacks — alongside treatment from your doctor.
• Migraine happens to relationships too. Talking about guilt and taking over is often as important as talking about triggers.