Why You Should Not Accept the “Stress” Diagnosis of Migraine

The doctor confirms what you suspected – you’re “stressed”, and that’s why you’re getting all these “headaches”. No worries, the exams will be over soon . . .

During the recent World Migraine Summit, I mentioned in my interview that we should be very cautious about accepting the “stress” diagnosis when it comes to migraine. This caused a few raised eyebrows, since “stress” is often at the top of the list for migraine triggers and reducing stress is a constant theme in migraine treatment. So what was I talking about?

First, I need to stress (no pun intended) that I am not saying that there is no relationship between stress and migraine. It’s pretty clear that there’s a connection – perhaps multiple connections.

But just what is the connection?

Migraine-Stress Link: Not so clear?

Stress does not equal Migraine!Today I spent some time again reviewing trials and papers related to migraine and stress. In spite of the fact that researchers can claim multiple clinical trials relating stress and migraine, there’s a danger in thinking that all these trials “prove” that stress “causes” migraine, or that stress “triggers” migraine attacks. Now we know that the “cause” of migraine is much more complex than stress. But neither can we jump to the conclusion that it’s “stress” that is triggering our attacks, even though that could be the case sometimes.

Let’s say that patients with more migraine experience more stress. Is the stress triggering the migraine, or is the migraine triggering the stress? Could be both!

Let’s say that more stress tends to precede a migraine attack. Why? Because the stress triggers the migraine attack? Or are there other factors going along with the stress that are actually triggering the attack (late nights, more coffee, irregular mealtimes)? It’s not an easy question.

Some of the studies include things as “stress” that you might not expect. For example, are hormonal changes “stress”?

How exactly do you decide what stress is, and how do you measure it? What if biological differences in the brain of a migraine patient actually make them more aware and more sensitive to stress (as this study suggested)? In other words, the same amount of stress in person A may trigger and attack in person B because person B’s brain is wired differently (they have migraine disease).

This might explain another study that found there weren’t as many stressful events before a migraine attack as you might think. Could it be that the same stresses are worse for the person who already has migraine – or that the early symptoms of migraine (before the headache begins) simply add to the stress?

Some researchers point to successful anti-stress lifestyle changes. More sleep, better eating habits, coping skills, exercise – but wait. Do these things help because they lower stress? Or is there another reason?

None of this proves, either way, the affect of stress on migraine. But it does suggest there could be a complex web of relationships – going both ways.

And it could very well be that the relationship comes from the disease, not the disease from the stress.

A couple of years ago a report made the headline – “proving” that stress caused headaches (the very fact that this made headlines may point to the doubts that many people still have!) (see “Proof” that Headaches are caused by Stress?). The large study showed that increased headache correlated with increased stress. People with more headaches were more stressed. Ya think?!

Dr. Todd A. Smitherman from the University of Mississippi says it well:

Problematically, the overwhelming majority of studies on stress as a headache trigger have relied on either retrospective or prospective patient reports of stress. What is needed are experimental studies that directly manipulate stress, measure resulting physiological changes, and try to link these changes to subsequent headache activity.

So we need to give people controlled amounts of stress to really see the relationship. Do you see why more studies haven’t been done?

Patients and Doctors Speak Out

Why is this such a problem? The problem is this – patients and doctors are missing important problems that could be solved because they are saying that it’s “just stress”.

Take for example this example from journalist Jo Waters, who was investigating the stress-diagnosis relationship (The doctor says you’re just stressed. But could it be more sinister?):

Some patients dismiss their symptoms as stress too … Jade Smith – another patient I’ve interviewed for the piece above – admits she put all her symptoms down to stress – even though she was in constant pain from head to toe. The problem was that she was going through a stressful time at work so stress seemed to be the obvious cause of all her ills. Later though when her symptoms of depression lifted she was still left in pain. When she mentioned it to her doctor he diagnosed fibromyalgia. [source]

Think of the pain that could have been saved!

Sadly, patients often miss the real diagnosis – and/or the most effective treatment – because they are putting their symptoms down as caused by stress.

AngelinaB commented here, saying her doctors kept telling her it was “stress” and “depression”. When she started keeping a diary, she found no relationship.

Winny said her doctors were missing her cancer diagnosis:

Have had the same thing happen to me with a cancer diagnosis. Not only was I stressed but I was deemed (literally) hysterically wanting a hysterectomy because I calmly and clearly stated something was “wrong” because of many many issues. I was told that I needed to take a “vacation” from gyno doctors for a couple of years. In 2 years I was in the kind of shape you could not mistake my problems.

Just take a vacation? Really?

And consider this patient who only found relief as a POW!

Neurologist Dr Giles Elrington from the National Migraine Centre in the UK has said:

If I had a pound (£) for every patient I see who is told their headache is down to stress, I’d be a rich man. Saying headaches are just down to stress won’t do. While stress, or the let-down period after stress, can trigger migraine attacks, it occurs in only 10 per cent of cases. The reality is that there are lots of other triggers, including dehydration, skipping meals, lack of sleep, disruptions to the body clock, poor posture and hormone changes — yet these are often overlooked.

A Balanced Response to Stress

So what do we do with all this information?

First, we do not accept the “it’s just stress” “take some time off” “wait until exams are over” “any problems in your marriage?” “calm down” “it’s your female emotions” “it’s just your personality” “try to cope better” diagnosis.

Instead, keep looking for other causes and triggers beyond stress.

AND ALSO consider behaviours that can reduce stress and help your body better handle stress – and give you other benefits. Absolutely – regular exercise, good sleep habits, a good diet, avoiding destructive thinking – these are almost certain to provide a benefit!

At the same time, chances are that you would still have migraine attacks if you lived on a beach (with excellent sunglasses) sipping coconut milk and listening to your favourite music all day. It’s not just stress.

Keep looking for other triggers, other causes, other treatments.

If your doctor keeps prescribing vacations after a 1 minute interview, find another doctor.

Is stress related to migraine? Of course. But if we overblow the relationship, we will miss some very serious problems that could be solved.

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