Reprinted with permission from ACHE (American Council for Headache Education)
People with chronic headache sometimes react angrily to friends or doctors who suggest they are just under too much stress - and with reason, since there’s often an implication that the headaches are a psychological rather than a medical issue. In fact, chronic headache is unlikely to be caused by stress alone, yet stress can contribute significantly to making headaches worse. In addition to all the other hassles of modern life, people with severe or chronic headache have to deal with the stress of being in pain. Approaches that help to reduce the stress associated with chronic headache can also help control the headaches themselves.
Chronic Headache, Chronic Stress
With episodic migraine, individuals can often identify how different stressors affect their headache pattern. A given person might recognize that headaches tend to follow a hectic week at work, a quarrel with a family member, or an important social occasion. There are also physical stresses that can trigger an attack, such as changes in weather, missed meals or too much alcohol. Because both the headaches and the stresses are infrequent, it’s relatively easy to see the connection.
For people with daily or near-daily headache, it’s often much harder to be aware of stress, because their stress may be nearly constant. The biggest stress in chronic headache is having chronic headache. Pain is itself a major stressor, physically and mentally. Pain can make the normal stresses of daily living all the worse. Holding down a job, raising a family, dealing with relationships, and just getting around in a complex world become very problematic with an every-present headache that is on the verge of intensifying. The stress is the product of the headache, but the stress then contributes to the severity of the headache in a vicious cycle of pain- increased stress - increased pain.
What Do We Mean by “Stress”?
Stress has become a catch-all term for negative moods and emotions ranging from mild anxiety to frantic worry to severe depression. The implication often present is that stress is “psychological” and thereby imaginary. But the stress response is a group of physical and biochemical events, just as headache is.
Everyone knows what a sudden, heart-pounding scare feels like. Your body reacts immediately to the threat presented by a car swerving into your lane, or just by an unexpected loud noise. These emergency reactions are an easy to-identify form of stress. A more chronic or long-term example would be the serious illness of a family member. Stress is best defined as a threat or expectation of future harm. Some stresses are immediate and obvious (the risk of a car accident); others are subtle or lasting (the fear of losing the family member).
While the stress response is physical and “real”, the perception of a threat is subjective and individual. An event that is threatening to one person may not be so to everyone. For someone prone to severe headaches, a change in the weather or a sudden sensation in the head may be a threat - the threat of another bad headache. Some people misinterpret bodily sensations as symptoms of an impending attack. In both instances, a panicked, stressed response might well increase the probability of an attack.
Some people make the distinction between “good stress” and “bad stress.” Good stress is a manageable challenge - perhaps a tough deadline at work or the task of organizing a big event. People with headache may become more vulnerable if they miss meals or sleep during a busy period, but otherwise this “good stress” doesn’t have a negative impact. Bad stress, in contrast, involves a sense that things are out of control and you are unable to manage. People who underestimate their coping skills are more likely to feel overwhelmed. By its nature, a high-frequency headache condition is likely to make someone feel as though things are out of control. For people with frequent severe headache, the threat of pain can make everyday challenges and responsibilities - the so-called “good stresses” - almost overwhelming.
Controlling the Stress Response
Given that the person with high-frequency headache is under stress, there are useful approaches to managing the stress response to reduce feelings of anxiety, panic or helplessness. There are four basic aspects to the stress response: cognitive (thoughts and evaluations about your situation), emotional (associated feelings), physical (“emergency” bodily reactions), and behavioral (actions taken in response to your thoughts and feelings). These aspects are interrelated.
Cognitive/Emotional – Cognitive therapy helps people recognize and change thinking patterns that contribute to panicked or helpless feelings as well as headache susceptibility. Techniques aim at providing patients with a set of problem-solving skills that can be used in a wide range of headache -prone situations. For example, some people respond by expecting the worst whenever they are exposed to a headache trigger or feel a sudden twinge of pain. (“Why me? I can’t believe I’m getting another migraine. It’s no use.”) Using cognitive therapy approaches, people learn to “challenge” their fears, substituting more rational thoughts and accurately interpreting perceived danger signals.
Behavioral – People who feel stressed may attempt to manage their anxiety with alcohol, prescription tranquilizers and pain medications, or drugs of abuse. These substances have only a short-term effect in relieving stress and ultimately may contribute to anxiety or depression. Treating any drug or alcohol misuse is important for long-term stress management. Chronic headache sufferers may also overuse headache medicines when alarmed by warning signs or fears of an attack. Daily or near-daily use of pain relief medicines can result in a drug rebound headache that returns as each dose wears off. Finally, people who feel overwhelmed often neglect good self-care practices like getting exercise, regular sleep and eating regular meals. Aerobic exercise is one of the best stress relievers available, and it may also help headache.
Physical – Biofeedback trains people to recognize and reduce physical tension in the body. Similarly, progressive muscle relaxation, deep breathing and other forms of relaxation therapy offer techniques for relieving physical tension and bringing body and mind into a more relaxed state. (See Summer 1998 issue of Headache.) Prescription medications can also be effective in relieving anxiety and depression associated with chronic pain and chronic stress.
There are many headache patients with a wide variety of headache types who successfully manage the normal stress of life as well as the stress of a headache condition. Stress is most problematic for individuals with high-frequency headaches who feel overwhelmed and become fatalistic or despairing about their lack of control. There is no magic cure for someone who is in such a high-stress situation, but a step-by-step approach that includes medication, behavioral and other non-drug approaches often yields good results over time.
Published on the Help For Headaches Web Site