Tag Archives: migraines

Migraine Headaches

Migraine headaches can be debilitating, and, in some cases, chronic.  In this post, we will look at some of the symptoms of migraines, how they are diagnosed, and some common treatments for migraines.


Migraines are characterized by severe headaches that usually involve throbbing pain felt on one side of the head, and can be accompanied by symptoms such as nausea, vomiting, and/or sensitivity to light and sound.

Migraines are the third most prevalent illness in the world, and can interfere with an individual’s ability to work and complete day-to-day activities, especially for those suffering from chronic migraines.  Some studies have determined that healthcare and lost productivity costs associated with migraines may be as high as $36 billion annually.  Migraines can affect anyone—in the U.S. 18% of migraine sufferers are women, 6% are men, and 10% are children.  They are more common in individuals aged 25 to 55 and in those with family members that also suffer from migraines.[1]


Migraine symptoms, frequency, and length vary from person to person.  However, they usually have four stages:

Prodrome: This occurs one or two days before a migraine attack and can include mood changes, food cravings, neck stiffness, frequent yawning, increased thirst and urination, and constipation.

Aura: This stage can occur before or during a migraine attack.  Auras are usually  visual disturbances (flashes of light, wavy or zigzag vision, seeing spots or other shapes, or vision loss.  There can also be sensory (pins and needles, numbness or weakness on one side of the body, hearing noises), motor (jerking), or speech (difficulty speaking) disturbances.  While auras often occur 10 to 15 minutes before a headache, they can occur anywhere from a day to a few minutes before a migraine attack.  Typically, an aura goes away after the migraine attack, but in some cases, it lasts for a week or more afterwards (this is called persistent aura without infarction).

Migraine: The migraine itself consists of some or all of the following symptoms:

    • Pain on one or both sides of the head that often begins as a dull pain but becomes throbbing
    • Sensitivity to light, sound, odors, or sensations
    • Nausea and vomiting
    • Blurred vision
    • Dizziness and/or fainting
    • Migrainous stroke or migrainous infraction (in rare cases)

Post-drome: This stage follows a migraine and can include confusion, mental dullness, dizziness,  neck pain, and the need for more sleep.

A migraine can last anywhere from a few hours to several days, and there are several classifications of migraines, including:

  • Classic migraine – migraine with aura
  • Common migraine – migraine without aura
  • Chronic migraine – a headache occurring at least 15 days per month, for at least three months, eight of which have features of a migraine
  • Status migraine – (status migrainosus) a severe migraine attack that lasts for longer than 3 days


The exact causes of migraines are not clearly understood but involve abnormal brain activity, including (1) changes in the brain stem and its interactions with the trigeminal nerve and (2) imbalances in brain chemicals, including serotonin.  Migraines are most often triggered by:

  • Food and food additives (often salty or aged food, MSG, meats with nitrites, aspartame)
  • Skipping meals
  • Drink (alcohol, caffeine, caffeine withdrawal)
  • Sensory stimuli (bright or flashing lights, strong odors, loud noises)
  • Hormonal changes or hormone medication such as birth control
  • Certain other medications
  • Stress or anxiety
  • Strenuous exercise or other physical stress
  • Change in sleep patterns
  • Changes in weather


Migraines have been shown to co-occur with several other conditions[2], including:


There are a variety of options that doctors employ to both treat and prevent migraine attacks.

  • Pain-relieving medications (both over the counter and prescription)
  • Preventative medications (which can include antidepressants, blood pressure medications, and seizure medications)
  • Botox
  • Transcutaneous supraorbital nerve stimulation (t-SNS) (a headband-like device with attached electrodes)
  • Acupuncture
  • Biofeedback
  • Massage therapy
  • Cognitive behavioral therapy (CBT)
  • Herbs, vitamins, and minerals
  • Relaxation exercises
  • Sticking to a sleep schedule
  • Exercise
  • Avoidance of known triggers

Doctors also sometimes recommend keeping a headache diary, similar to a pain journal, which can help you track the frequency of your migraines and may help identify triggers.

These posts are for informative purposes only and should not be used as a substitute for consultation with and diagnosis by a medical professional.  If you are experiencing any of the symptoms described below and have yet to consult with a doctor, do not use this resource to self-diagnose.  Please contact your doctor immediately and schedule an appointment to be evaluated for your symptoms.


Cedars-Sinai, https://www.cedars-sinai.edu
Healthline, www.healthline.com
Mayo Clinic, www.mayoclinic.org
MedlinePlus, www.medlineplus.gov


[1] Migraine Research Foundation, About Migraine, http://migraineresearchfoundation.org/about-migraine/migraine-facts/

[2] Wang, Shuu-Jiun, et. al., Comorbidities of Migraine, Frontiers in Neurology, Aug. 23, 2010, http://journal.frontiersin.org/article/10.3389/fneur.2010.00016/full

[3] Id. (citing Von Korff M., et. al., Chronic spinal pain and physical-mental comorbidity in the United States: results from the national comorbidity survey replication, Pain 113, 331-330 (2005).

Chronic Pain and Anxiety Disorders

Chronic pain by itself is often debilitating, and the struggle to obtain a correct diagnosis, effective pain management, and ongoing treatment can be stressful and overwhelming.  As we discussed in a previous post, depression often co-occurs with chronic pain, and can further complicate treatment.  The same is true of anxiety disorders.

Chronic Pain Disorders Associated with the Co-Occurrence of Anxiety

Like depression, anxiety is more likely to co-occur with certain conditions, such as:

It is no secret that physicians and dentists have stressful and demanding careers.  One Cardiff University study showed that of 2,000 British doctors, at various stages of their careers, 60% had experienced mental illness.[1]  Often practitioners ignore or fight through both chronic pain and anxiety and show up to work, to the point of endangering themselves or others before acknowledging their disability or seeking adequate treatment.

While anxiety alone can result in an inability to practice, either indefinitely or in the short-term, it is also quite common in those suffering from chronic pain to experience an anxiety disorder.  Anxiety disorders are also the most common type of psychiatric disorders in the United States, with 19 million adults affected.[2]

Chronic Pain and Anxiety—Worse Together

Facing a long-term or permanent disability can be anxiety provoking for a physician, who must (1) face giving up a career he or she invested so much time and financial resources to establish; (2) seek a correct diagnosis, course of treatment, and adequate pain management; and (3) often struggle with adapting to the loss of a previously enjoyed quality of life.  Conversely, chronic pain is also common in people with anxiety disorders,[3]  with up to 70% of people with certain medical conditions (including hypertension, diabetes, and arthritis) had an anxiety disorder first.[4]

Regardless of whether anxiety or chronic pain came first, individuals suffering from anxiety can experience pain that is particularly intense and hard to treat.[5]  In a 2013 study, 45% of 250 patients who had moderate to severe chronic joint or back pain screened positive for at least one of the common anxiety disorders (generalized anxiety, social anxiety, PTSD, OCD).  Further, those that had an anxiety disorder reported significantly worse pain and health-related quality of life than their counterparts without anxiety.[6]

Symptoms of Anxiety[7]

There are several anxiety disorders and, while the below list is by no means exhaustive, sufferers of anxiety often exhibit the following symptoms:

Generalized Anxiety Disorder

  • Difficulty controlling worry
  • Restlessness, feeling wound-up or on edge, irritability, muscle tension
  • Being easily fatigued and problems with sleep
  • Difficulty concentrating or having their minds go blank

Panic Disorder

  • Sudden and repeated attacks of intense fear
  • Feelings of being out of control during a panic attack
  • Intense worries about when the next attack will happen
  • Avoidance of places where panic attacks have occurred in the past

Social Anxiety Disorder

  • Feeling highly anxious about being around other people (including having a hard time talking to them, blushing, sweating, trembling, or feeling sick to your stomach)
  • Feeling self-conscious in front of others and worried about feeling humiliated, embarrassed or rejected, or fearful of offending others
  • Worrying before an event and/or avoiding places where there are other people
  • Having a hard time making and keeping friends

Post-Traumatic Stress Disorder

  • Flashbacks, bad dreams, difficulty sleeping, frightening thoughts, angry outbursts
  • Avoiding places, events, objects, thoughts, or feelings that are reminders of the traumatic experience and trouble remembering key features of the traumatic event
  • Being easily startled and feeling tense or “on edge”
  • Negative feelings about oneself or the world, and distorted feelings like guilt or blame
  • Loss of interest in enjoyable activities

Obsessive Compulsive Disorder

  • Fear of germs or contamination
  • Unwanted or forbidden thoughts, including aggressive thoughts towards others or self
  • Having things symmetrical or in perfect order; excessive clearing and/or hand washing; ordering and arranging things in a precise way; repeatedly checking on things; compulsive counting

Treatments for Anxiety

Some of the treatments that have been successful in addressing anxiety in those with chronic pain include:

  • Cognitive-behavioral therapy (CBT)
  • Psychodynamic therapy (talk therapy)
  • Support groups
  • Relaxation or meditation training
  • Alternative treatments, such as acupuncture and hypnosis
  • Exercise
  • Medication

Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.

[1] Michael Brooks, Why doctors’ mental health should be a concern for us all, NewStatesmen, April 11, 2016, http://www.newstatesman.com/politics/health/2016/04/why-doctors-mental-health-should-be-concern-us-all

[2] What are Anxiety Disorders?, Global Medical Education, https://www.gmeded.com/gme-info-graphics/what-are-anxiety-disorders

[3] Chronic Pain, Anxiety and Depression Association of America, April, 2016, https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain

[4] Global Medical Education, Supra.

[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection

[6] Health Behavior News Service, part of the Center for Advancing Health, Chronic pain sufferers likely to have anxiety, ScienceDaily, May 8, 2013, https://www.sciencedaily.com/releases/2013/05/130508213112.htm

[7] Definitions according to National Institute of Mental Health: https://www.nimh.nih.gov/index.shtml

Chronic Pain and Depression

Chronic pain is often difficult to diagnose and treat.  Consequently, those who suffer from chronic pain typically must also deal with a significant amount of stress, due to repeated failed treatments, numerous medical appointments, interruption of work and enjoyable activities, and the inability of their friends or family to understand their physical limitations.  This can, in turn, cause or worsen depression.  When depression occurs alongside chronic pain, it can make dealing with and treating the pain even harder.

Chronic Pain Disorders Associated with the Co-Occurrence of Depression

While mental health conditions, including depression, can often be disabling in and of themselves, they are unfortunately also quite common in those suffering from chronic pain.  Depression is more likely to co-occur with certain conditions, such as:

  • Back Pain
  • Neck Pain
  • Joint Pain
  • Arthritis
  • Migraines
  • Fibromyalgia

Studies show that rates of depression are high in residents and medical students (15%-30%) than rates in the general population, and the risk of depression continues throughout a physician’s career.[1]  According to a British study, 60% of dentists reported being anxious, tense, or depressed.

Dentists, doctors, and other medical professionals place extreme amounts of pressure on themselves because the stakes of their professions are so high.  In addition to perfectionism and self-criticism, other predictors of depression in doctors include:  lack of sleep, stressful interactions with patients and staff, dealing with death, constant responsibility, loneliness, and making mistakes.[2]

Often practitioners work through both chronic pain and psychiatric disorders for some time before acknowledging their disability or seeking adequate treatment.  In the case of depression, this can be due in part to the social stigma that surrounds it.  For all of these reasons, depression may go undiagnosed or seem less of an immediate concern to those suffering from chronic pain.  However, if you are experiencing symptoms of depression and chronic pain, studies show that it is important to treat both, because chronic pain can become much more difficulty to treat if the depression is allowed to progress unchecked.

Chronic Pain and Depression—Worse Together

Facing a long-term or permanent disability can trigger depression—this is especially understandable for doctors or dentists who have put years into medical school and establishing their careers, only to become disabled and have to step away from a profession that has become a significant part of their identity. Depression can also precede chronic pain.  For example, several studies have examined the link between depression before the onset of back-pain.[3]

Regardless of which came first, together they are formidable to treat.  Major depression is thought to be four times greater in people with chronic back pain than those in the general population, and studies show that individuals suffering from both chronic back pain and depression experienced a greater degree of impairment than those with either depression or back pain alone.[4]

Treatments for Depression

Focusing solely on pain management can prevent both the patient’s and treating physician’s ability to recognize that a psychiatric disorder is also present.  Yet, even with correct diagnoses, both issues can be difficult to treat together.[5]  For instance, those who suffer from both chronic pain and mental illnesses can have a lower pain threshold as well as increased sensitivity to medication side-effects.[6]  Some treatments that have proved successful in addressing depression in those with chronic pain include:

  • Cognitive-behavioral therapy (CBT)
  • Psychodynamic therapy (talk therapy)
  • Relaxation or meditation training
  • Acupuncture
  • Hypnosis
  • Exercise
  • Medication

Symptoms of Depression

  • Little interest or pleasure in doing things
  • Feeling down, depressed, or hopeless
  • Trouble falling asleep or sleeping too much
  • Feeling tired or having little energy
  • Poor appetite or overeating
  • Trouble concentrating
  • Feeling bad about yourself, or that you are a failure or have let yourself or others down
  • Thoughts that you would be better off dead, or hurting yourself in some way

Chronic pain sufferers who recognize any of the above-referenced symptoms in themselves should talk to their doctor to address these serious issues.


[1] Robert P. Bright, MD, Depression and suicide among physicians, Current Psychiatry, April 10, 2011.

[2] Id.

[3] William W. Deardorff, PHD, ABPP, Depression Can Lead to Chronic Back Pain, Spine-health.com, Oct. 15, 2004, http://www.spine-health.com/conditions/depression/depression-can-lead-chronic-back-pain.

[4] William W. Deardorff, PhD, ABPP, Depression and Chronic Back Pain, Spine-health.com, Oct. 15, 2004, http://www.spine-health.com/conditions/depression/depression-and-chronic-back-pain.

[5] Celeste Robb-Nicholson, M.D., The pain-anxiety-depression connection, Harvard Health Publications, http://www.health.harvard.edu/healthbeat/the-pain-anxiety-depression-connection.

[6] Anxiety and Depression Association of America, Chronic Pain,  https://www.adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/chronic-pain.