Stress and migraine

What studies show

• Self-report. 79.7% of 1,207 clinic patients named stress (Kelman 2007). The 2021 review prefers the term risk factor, because self-report is limited by recall bias and false attribution (Stubberud 2021).
• Daily diaries. Using a measure of how unusual each day was, stress had the highest odds ratio for attacks, 1.30 (95% CI 1.14 to 1.46), and departures from a person’s usual pattern mattered most (Turner 2019, reported in Stubberud 2021).
• Long-term data. In a study of more than 5,000 people, headache days rose 4.3% for each 10-point rise on a 0 to 100 stress scale (Schramm 2015, reported in Stubberud 2021).
• Causation. The review concludes that a causal relationship remains unclear. Establishing one needs assumptions, such as stable exposure and stable effect, that daily life rarely meets.
• Forecasting. A model using perceived stress predicted next-day headache with an AUC of 0.65, and another model did only slightly better than chance (0.56). The review says drug treatment based on forecasts should be used only if future models are highly accurate (Stubberud 2021).

Let-down attacks

Let-down means an attack that starts after stress falls, for example at the start of a weekend or holiday.

In one prospective study, 17 people kept electronic diaries for about 3 months, recording 110 attacks. A fall in stress from one evening to the next was linked to attacks. On the Perceived Stress Scale the odds ratio was 2.49 (95% CI 1.24 to 5.02) over 12 hours and 1.63 (1.01 to 2.64) over 24 hours. Stress level itself was generally not linked (Lipton 2014).

The sample was small, 16 of the 17 were women, the results were unadjusted apart from models controlling for stress level, and the study was funded by a drug company. Other evidence is mixed: two other studies support a let-down effect and two do not. In a later analysis of stress patterns, most attacks fell in a flat group, about a quarter in a trigger group and the rest in a let-down group. No patient had more than 90% of attacks in the trigger or let-down group (Stubberud 2021).

Which comes first

Stress may be a symptom as well as a cause. The American Migraine Foundation lists mood changes, including irritability and stress, in the prodrome. Lipton’s authors say a fall in stress may be a marker of an impending attack. They raise the possibility that it is part of the attack itself, but consider that unlikely. Frequent attacks are also a source of stress: in one case-control study, chronic migraine was linked to more perceived stress, while episodic migraine was not after adjusting for depression and anxiety (Stubberud 2021).

Mechanism

Not established. Findings are mostly from mice or small human studies, and findings on the autonomic nervous system and the stress-hormone (HPA) axis conflict (Stubberud 2021).

How to check it in your diary

1. Rate stress at the same time each evening, as the Lipton study did. A rating made after an attack starts may be affected by the attack.
2. Look at change. Compare each evening with the one before.
3. Mark transitions: the end of a deadline, the first day of a holiday, the weekend.
4. Count stressful days with no attack. Without them a link cannot be judged.

For the general method, see how to test a suspected trigger.

Treatment options

Stress-oriented treatment is chosen with a clinician. The 2021 review reports Grade A evidence for relaxation, cognitive behavioural therapy and biofeedback in migraine prevention, citing an American Headache Society statement from 2019. In a trial of 127 adults, a coping programme did better than advice to avoid triggers (Martin 2014).