Migraine and Mental Health Guide

Living with chronic migraine takes a toll on our physical and emotional health. Unfortunately, we tend to focus on our physical health, often ignoring our emotional needs. Chronic illness impacts our entire life, and it’s imperative that our emotional health is also a priority. It is important to understand the connection that living with chronic disease can have on emotional well-being. People with migraine have a reported two-to-four-fold increase in lifetime risk of developing major depressive disorder.(1)

The stress of dealing with chronic illness creates understandable emotional impact and mental pressure. Having symptoms dismissed as “in your head” can lead to feeling frustrated and unheard. Not being believed can cause anger and disappointment. Coping with disabling pain and symptoms with ineffective medical care can lead to emotions of fear and sadness, leading  to depression and anxiety. Living with chronic disease can create many losses, such as employment, relationships, financial instability, dreams and expectations. These losses can create grief and feelings of denial, guilt, anger and sadness.

Below is a “toolbox” of coping and resilience strategies. Feel free to use what works, leave what doesn’t and even add new tools.

Emotional Distress Tolerance

Activity - Find an activity you can do that requires thought and concentration.

• Solving word puzzles, reading, writing in a journal, crafting, playing an instrument, etc.

Contributing - Do something that focuses on another person.

• Ask a friend about their day, make a gift for someone, send a card to a friend, volunteer at your own pace.

Comparisons - Put your situation in perspective by comparing it to a more painful or distressing time.

• Realize how resilient you are and think about a time when you got  through a difficult period. You have survived 100% of your worst days.

Emotions - Do something to create a new emotion that competes with your distressing emotion.

• Sad? Watch a funny movie. Anxious? Practice deep breathing.

Pushing Away - Block a painful or upsetting situation from your mind by using techniques such as guided imagery.

• Imagine putting your painful thoughts in a box, taping it shut and throwing it away.
• Delay harmful urges for one hour, if it doesn’t pass, another hour.
• Give your negative thoughts a name, imagine it, draw it and throw it out; or talk to it and tell it how it makes you feel.

Thoughts - Shift your thoughts to something neutral.

• Starting with the letter “A,” name all objects that start with “A” and go through the whole alphabet.
• Count specific objects in your surroundings.

Sensations - Find a safe physical sensation to distract you from your distressing emotion.

• Take a cool shower. Get a massage. Put an ice cube on your wrist. Taste a favorite dish or something sour or spicy. Sit under a weighted blanket. Pet a furry friend.

Maintenance or Comfort Care

Noticing

• Identify your triggers - keeping a journal is a useful tool. 
• Be a detective - if I had noticed this five minutes earlier, what would I have done?
• Note what you want to see more of in your life.
• Make your migraine concrete and separate from self. Give it a name, what would it look like?

Practice self-care

• Find moments of peace and joy. 
• Reward yourself for utilizing coping skills.
• Take time to do things you enjoy.
• Make self-care a priority. Self-care should be given the same importance as other priorities in your life.
• Set short and long-term self-care goals. Make self-care a habit.
• Set boundaries to protect your self-care. You don’t need a major obligation or excuse to say “no” to others. Your self-care is as important as anyone else’s.
• A few minutes of self-care is better than no self-care.
• Keep up with self-care even when you are feeling better.
• Practice gentle movement when you can, such as taking a walk, swimming or stretching.

Practice gratitude

• Write five  things you are grateful for and remember the simple things, like a friend who gave you a ride to the doctor’s office, a chat with a neighbor, waking up to a sunny day.

Challenge Negative Automatic Thoughts

• Write down the negative thought and then one alternate positive thought.
• Look for that stinking thinking and challenge it!
• Separate the migraine attack from emotional distress.
  • Note examples of high distress/mild attack days and vice versa.
  • Rate attack and emotional distress separately in a record.

Reach Out

• Add a support group or supportive friend to your team.

Self-empathy

• If you wouldn’t say it to a friend, don’t say it to yourself!
• Remind yourself of at least one positive attribute about yourself each day.
• Give yourself the permission to grieve the feelings of loss that often come with chronic migraine disease.

Spirituality

Faith, religion and spirituality are important aspects of many people’s lives and can be utilized as a coping skill.

• Reach out to your pastor, rabbi, etc. for support.
• Engage in activity that helps you feel closer to your higher power, such as taking a walk in nature, reading a Bible or daily meditation, or utilizing prayer.

Affirm What Is Positive

• Often we easily affirm what is negative.Take time to affirm what is positive around you. Maybe it is a comfortable room or retreat, a compassionate doctor, a helpful support group, a furry friend, a book or new coping skill.
• Create a “good stuff” journal.

Why add a mental health professional to your treatment team?

There is a fear in the chronic migraine community as in most chronic illness communities, that going to a mental health professional or receiving a referral to one, means that the physical illness is “all in their head” or a symptom of a mental health issue. This fear and stigma prevents people from caring for their emotional well-being. The need to add a mental health professional is important because living with chronic migraine takes a toll not only on physical health, but on mental health as well.

Reaching out to a mental health professional  can help you learn new coping skills. Learning how to better communicate and  advocate  for your needs. A mental health professional can also be a great partner and advocate in your care.

There are many conditions that may be a focus of therapeutic attention related to living with chronic migraine, such as social exclusion or rejection, inaccessibility to health care, target of adverse discrimination, etc. There are also symptoms of clinical significance that may be assessed by your provider, such as a clinical depressive condition, trauma or stress-related condition.

Self-Assessment from the American Psychiatric Association

*The following assessment is not to take the place of a mental health assessment by a qualified mental health professional*

Depression (2)

Five or more of the following symptoms have been present during the same two-week period; at least one symptom is depressed mood or loss of interest or pleasure. Symptoms cause clinically significant distress or impairment in social, occupational or other areas of functioning. The disturbance is not better accounted for by Adjustment Disorder with Depressive Symptoms in which the stressor is a general medical condition.

• Depressed mood most of the day, nearly every day (in children or adolescents, can be irritable mood)
• Diminished interest or pleasure in all or almost all activities most of the day, nearly every day
• Significant weight loss (when not dieting) or weight gain, or decrease or increase in appetite nearly every day
• Insomnia or hypersomnia
• Psychomotor agitation (feeling restless) or retardation (feeling slowed down)
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt, nearly every day
• Diminished ability to think or concentrate, or indecisiveness
• Recurrent thoughts of death (not just fear of dying), suicidal ideation, suicide attempt or plan.

Note - Responses to a significant loss (i.e., serious medical illness or disability) may include feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss which may resemble a depressive episode. Although such symptoms may be understandable or appropriate to a loss, the presence of a major depressive episode should be considered. This decision requires the exercise of clinical judgment.

Anxiety

* Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities. The anxiety or worry cause clinically significant distress or impairment in social, occupational or other areas of functioning. The person finds it difficult to control the worry. The anxiety or worry are associated with three or more of the following. The disturbance is not better accounted for by Adjustment Disorder with Anxiety in which the stressor is a general medical condition.

• Restlessness or feeling keyed up or on edge
• Easily fatigued
• Difficulty concentrating
• Irritability
• Muscle tension
• Sleep disturbance

Warning signs of suicide include:

• Suicidal thoughts, talking or writing about death
• Giving away important possessions
• Talking about feeling like a burden to other people
• Increased use of alcohol or drugs
• Reckless behavior
• Extreme social withdrawal or isolation
• Making calls or visits to others to say goodbye
• Thoughts of hopelessness (that things will never get better in the future)

If you have been having suicidal ideation, please reach out for help from a trusted professional or crisis hotline. 

• United States: National Suicide Prevention Hotline, 1-800-273-8255
• United Kingdom: Samaritans (https://www.samaritans.org/). Samaritans Helpline can be reached at 116 123.
• Australia: Lifeline (https://www.lifeline.org.au/) is a 24-hour nationwide service that provides access to crisis support, suicide prevention and mental health support services. It can be reached at 13 11 14. They also offer an online chat service.
• Denmark: Livslinien (https://www.livslinien.dk) offers telephone support 11am-4am on 70 201 201, or online chat.
• Germany: Telefonseelsorge (https://www.telefonseelsorge.de/), 24/7, and no cost: 0800 111 0 111 (Protestant), 0800 111 0 222 (Catholic), 0800 111 0 333 (for children and youth).
• India: Samaritans Mumbai (http://www.samaritansmumbai.com) — +91 8422984528, +91 8422984529, +91 8422984530 — 3 pm to 9 pm, all days, samaritans.helpline@gmail.com.
• Ireland: Samaritans (https://www.samaritans.org/)
• Italy: Servizio per la Prevenzione del Suicidio (SPS) (http://www.prevenireilsuicidio.it/).
• New Zealand: Lifeline Aotearoa (https://www.lifeline.org.nz). Call 09 5222 999 if you live within Auckland or 0800 543 354 for those outside of Auckland.
• Spain: Teléfono de la Esperanza (http://www.telefonodelaesperanza.org) 717 003 717.

References

1. Amoozegar F. Depression comorbidity in migraine. Int Rev Psychiatry. 2017;6:1-12.

2. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Written by

Jeannette Rotondi, MSW, LSW, CCTP, CGCS