David Godot, Psy.D.

Psychological Treatment for Migraines

November 25, 2012 • Mental Health

There is no single underlying cause of chronic headache pain, but rather a constellation of contributing factors. There is a genetic component, so a family history of migraine headaches does predispose you to also have migraine headaches. But even if your identical twin has migraines, there is still only about a 50% chance that you will have them as well. Hormones also play a role: women of child-bearing age are two to three times more likely than men to experience migraine headaches, and the headaches often ease up after menopause. Nerve tissue inflammation, skeletal problems, muscle tension, and dietary intolerances can all contribute.

But there are also psychological factors. Chronic pain has a strong, cyclical relationship with anxiety and depression. The experience of chronic pain causes anxiety and depression, and these heightened emotional states exacerbate the pain symptoms. On top of that, most chronic pain patients are surprised to learn that certain personality types are more likely to experience chronic pain.

Medications, injections, and surgeries have limited effectiveness in managing chronic headache pain, because they attempt to address the symptom without paying any attention to the underlying causes.

Headaches are complex, and require holistic treatment

I spent a year training at the Diamond Headache Clinic’s inpatient unit in Chicago, which provides treatment for the most severe, chronic, and intractable headache cases. While mild cases can often be managed reasonably well with medications, more severe cases require a variety of treatment modalities that work synergistically. These include medication, dietary adjustments, physical therapy, massage therapy, chiropractics, acupuncture, biofeedback, hypnosis, and psychotherapy. The types of treatment used are often selected based on the specific types of headaches you are experiencing and the way that the symptoms present. Migraine headaches with aura, for example, call for a different treatment approach than tension headaches or cluster headaches.

Pain perception is a psychological phenomenon

Most chronic pain sufferers assume that since pain is a physical condition, there is nothing that a psychologist could do for them other than to help them process the feelings of frustration of being ill. But it turns out that pain is not as strictly physiological as you might think.

To begin with, no matter what part of the body feels hurt, the pain itself actually takes place within the brain. The nerve endings that register pain throughout your body simply send signals back to the brain, which processes the signals and decides how much pain sensation it should produce in response. The amount of pain that results is not necessarily related to the amount of nerve damage or activation, but is instead regulated by context, emotional state, beliefs and social expectations about pain experience, and the amount and type of attention the pain is given.

Additionally, there are no pain receptors in the brain itself — no tissue has been damaged in the moments leading up to a headache. Instead, the part of the brain which creates pain has been activated for some other reason. It is very significant that fMRI studies have shown that “painful” emotional experiences such rejection and loss share the same neurological circuitry as physical pain. That is why sufferers of chronic pain are more prone to psychological distress, and those experiencing psychological pain are more likely to develop chronic physical pain. So in many cases, part of the chronic headache pain is a physical manifestation of psychological turmoil.

Has your doctor recommended therapy?

There are many different types of psychological interventions that may be helpful, depending on the nature of your headaches. After a thorough psychological assessment, I develop an individualized treatment plan that may include any combination of the following:

  • Cognitive Behavioral Therapy (CBT)
    • Behavior plays an important role in headache management. By optimizing diet, exercise, sleep, stress management and other behavioral aspects of headache management, we can help to create a relaxed physical state that encourages natural healing.
    • Identifying external triggers for headaches is another important part of psychological treatment. By managing these triggers more effectively, we can reduce headache frequency.
    • Cognitive restructuring provides tools to help you process pain differently in order to increase your ability to tolerate pain comfortably.
  • Biofeedback – By providing you with real-time feedback of unconscious physiological processes like heart rate and skin temperature, you can actually gain the ability to willfully change your physical state, replacing stress and inflammation with cool relaxation.
  • Mindfulness – By cultivating your ability to recognize and manage thoughts and feelings, mindfulness-based treatment strategies can be especially helpful for people suffering from emotional disruptions related to chronic pain.
  • Hypnosis – This powerful psychological tool can make it much easier to introduce new behaviors, new ways of thinking and feeling, and to directly modify physical processes. I have seen many patients respond extremely well to treatment which incorporates hypnosis into the psychotherapy.
  • Visualization – By creating new internal representations of pain processes we can change their meaning, and this changes the way that pain is dealt with at the neurological level.
  • Psychodynamic Psychotherapy – It is very common for unconscious psychological processes to contribute to chronic pain. For example, I have worked with many patients who first began experiencing severe migraines within one year of a traumatic experience or a major loss. By examining and resolving the psychological conflicts that prevent direct processing of these experiences, we can eliminate the need for somatic representation of painful emotions.

Studies have shown that even very straightforward forms of psychotherapy can be quite effective for relieving chronic headache pain, with most patients being able to return to work and go back to living normal, happy lives after treatment. In my experience, the key to successful treatment of headache pain is developing a clear picture of what is happening for you as an individual, and addressing the root causes using a customized, targeted treatment program.