The Mindful Migraine

A doctor I met on LinkedIn sent me a PDF of a book suggesting it might help me with my migraines; “Hidden from view: a clinician’s guide to psychophysiologic disorders” by doctors Allan Abbass and Howard Schubiner (2018).  As the title suggests, I think it was designed for people who are treating patients, rather than patient-readers.  As the book was long and my time was short, I did a naughty thing – instead of reading it all, I did a word search for “migraine” and just read those pages… oops… (but it seemed to give me a good overview, regardless.)

Whilst the book seemed to take it for granted that the reader knew what psychophysiologic disorders (PPD) were, I guessed it was the way mental health issues might influence physical health. 

[I looked it up, and according to the PPD Association: “Psychophysiologic Disorders (PPD) is the clinical term for mindbody symptoms, meaning symptoms that are caused by neural pathways that develop in response to stress, trauma, and repressed emotions.”]

[Out of curiosity, the landing page of the PPD Association, above, had a short test for you to self-screen whether your pain might be a result of your emotional wellbeing (past and present).  All it said in reply to my test result was the higher the number the more likely PPD is your issue – I scored 7 out of 12 which doesn’t sound super-convincing to me… I stand by the fact that migraine IS influenced by stress and negative emotions, but is not always ONLY that – I’m sure fluctuating hormones remain an issue for me, for example, which is a physical not emotional issue.]

The authors note that psychological factors often play a role in why and when people get sick, and whether or not treatment options will work (p.2).  The “D” in the title suggests to me that this is more than normal psychological factors like anxiety about your illness… it implies it is next level anxiety… and yet the more of the book I read, the smaller the potential underlying ‘trauma’ needed to be.

The authors were blunt (and biased?); most chronic pain is due to PPD.  They specifically give the example of migraine – “only a very small proportion have a structural disorder to account for the symptoms” (p.9). 

[My sore-eye has been tested several times; there is nothing physically wrong with it.  The MRIs on my brain that I’ve had over the years reveal that, again, there is nothing structurally wrong with my brain… but again, my hormonal issues ARE physical rather than psychological… so I’m not yet ready to say that my pain is “ALL in my head.”]

The authors also discuss the notion that pain is “learnt” – AND pain is remembered.  An old / prior neural pathway becomes easily activated under stress.  Migraine is used as an example; you may have a genetic predisposition which is then activated by environmental stresses (19).

Apparently, patients who had “adverse” events in their childhood are more likely to present with PPD because the patient has exaggerated fight-or-flight signals; their alarm system is easily triggered.  Fibromyalgia, IBS (irritable bowel syndrome) and migraines, were all listed as potential problems stemming from these difficult events.  The authors suggest a strong overlap here with PTSD-styled events.  The issues they list include; abandonment, neglect, divorce, bullying, and significant sibling rivalry.  The authors even suggest parents with high expectations can create resentment and self-esteem issues (24-5). 

[I’m going to jump in and say my childhood was happy, but it is possible that watching my mother have migraines led to a learnt behavior… maybe… and maybe my low-self-esteem (which was not my parent’s fault) might also be at play… maybe.]

Something that was interesting was this: “Pain and other symptoms can be conditioned responses to stimuli such as changes in the weather, foods, light, sounds, and many other things.  Some researchers now recommend learning to defuse triggers to migraine headaches rather than avoiding them […] Avoiding triggers can lead to increased fear and helplessness” (p.52). 

It was similar to a previous book review (here) which noted that you can’t beat anxiety by trying to be less anxious or avoiding everyone and everything.  

Without knowing the details, I’m pretty sure that a lot of phobias are addressed through gradual desensitization.  Scared of spiders?  Let’s say the word out loud a few times, then look at a picture, then see one in a box from waaaaaay back here, then take a step closer…

Scared that bright lights will cause a migraine?  Yes, that’s why I walk the dogs at dawn and joke about turning into a vampire… More recently however, I have been making a concerted effort to sit outside on sunny days.  I tell myself I need the Vitamin D.  Strangely, by making a deliberate “appointment” with sunshine, I’m getting less stressed about it, and… no migraine. 

As the authors write, addressing your triggers with confidence means their power as triggers wanes (52-3).

The authors talk about how anxiety and negative emotions can be hidden.  They use the case study of a middle-aged woman with migraine and IBS who is sitting calmly in her doctor’s office, with no visible muscle tension (p90).  But when the doctor asks her to give an example of when she last got a migraine, she mentions it was when she was yelling at her husband, and then felt guilty for being a bad wife.  The authors determine that this patient has repressed emotions – her unconscious anxiety is not being “discharged” and it moves into her muscles.

The leap to this conclusion was whiplash fast.  So was the next part where the doctor was able to get her to recognize the link.  It was almost miraculous how quickly the case study resolved itself.  I could almost imagine the conversation: “See how when you’re stressed you convert your frustration at him, to frustration with yourself, and then your emotions are turned into physical symptoms?  Yes?  So, try not to hold onto those negative feelings too long, and stop the transfer of negative emotions to your body.  Voila!  My job is done.”

The book does then conclude that once patients see the links between psychological and physical concerns, Cognitive Behavioral Therapy can be recommended.  They advocate expressing emotions (talking or journalling), facing fears and phobias, reducing stress in a patient’s life and so on (165).

It was all a bit over my head, but I do accept the underlying idea that sometimes pain is more than just physical… and, the more we know the more we grow.

My LinkedIn friend gave me a second book which was very similar to the first; “Psychophysiological disorders: trauma informed, interprofessional diagnosis and treatment” by Clarke, Schubiner, Clark-Smith and Abbass (2019).  With shared authors, much of the content was very similar.  Again, PPD included issues such as IBS, complex regional pain syndrome (CRPS), fibromyalgia, postural orthostatic tachycardia syndrome (POTS), myofascial pain syndrome, irritable bladder syndrome, and migraine.

The only additional information was a reference to a 2014 test in which migraine patients got better after taking a placebo, apparently indicating “expectations play a powerful role in responses to noxious stimuli” (approx.p63).

There was also a suggestion for what next. 

The authors say that you should try these three things:

1. Become confident in the diagnosis of PPD (really, truly confident).

2. Change your relationship with your pain and with yourself in a positive way.

3. Be patient.

And then they roll it all up noting: “Remember, you aren’t consciously causing your pain and you have the capacity first to reduce and then to eliminate your pain.  Continue the work and over time you will see the changes you want to see.  Persistence will pay off, so get to work!” (approx.p263).

I guess it’s up to you – and your healthcare team – to decide whether your migraines are the result of structural issues (hormonal imbalances or a pinched nerve in your neck etc) or whether they are the result of sub-conscious retained traumas… or a combination of both.

Take care taking care, Linda xx

[PS – Disclaimer – I’m not a doctor, and my summary of the above books comes from a lay-person’s perspective.  Always speak to a health care provider before making any changes to your treatment program.]