Migraine and Catastrophizing Philip C. O’Carroll, MD - Director, Neurobehavioral Medicine, Neuroscience Center, Newport Beach, California

“There is nothing good or bad but thinking makes it so”……..William Shakespeare (Hamlet)

Introduction

Migraine, in its “pure culture” is an episodic, phasic disorder.[1] Its pathophysiology is increasingly understood and the insights gained have lead to potent medicines. However, the chronic headache sufferer still presents the clinician with a daunting challenge. Of the estimated 26 million Americans who suffer from migraine, as many as 6 to 8 million suffer from “chronic migraine.”[2] For these patients treatment has failed. They frequent headache clinics and emergency rooms in a desperate attempt for a “fix”. There are multiple onramps to the chronic headache highway but behavioral factors play a huge role. Physiology is hijacked by emotional and cognitive factors. Amongst these, catastrophizing plays a crucial role.

What is catastrophizing?

Sullivan conceives of catastrophizing as “an exaggerated negative mental set brought to bear during actual or anticipated pain experience” [3]. It leads to magnification, rumination, helplessness and increased attention to pain. A growing literature shows that the tendency to catastrophize contributes to more intense pain and emotional distress.[4] In the last two decades it has risen to the status of one of the most important psychological predictors of the pain experience. It predicts disability better than any other disease related variable or pain.[5] In addition, catastrophizing has been associated with increased pain behavior, increased use of health services, longer duration of hospital stay and increased use of analgesic medication.[6]

Catastrophizing and the headache sufferer

Pain is not merely nociception; there is a powerful affective emotional and cognitive component which can amplify the pain experience. Catastrophizing is merely one facet of anxiety and anxiety is the most common comorbid condition in the migraine sufferer. Anxiety is associated with the tendency to overemphasize the probability of a catastrophic outcome. Unfortunately no pain disorder lends itself to catastrophizing more than migraine. Its unpredictable, capricious nature inevitably leads to anticipation and dread which are the main factors leading to the ritualistic, habitual use of analgesics. (“If I can just take my medicine, I can prevent the migraine from hell!”). Since the work of Kudrow in the 1980’s, much emphasis has been placed on the role of analgesic rebound in the chronification process.[7] But, we need to go one step further and understand the role of anxiety/catastrophizing as the primary cause of habitual analgesic usage.[8] It is a curious phenomenon that the connection between migraine and catastrophizing has not been explored more thoroughly. One study by Holroyd has dealt with the issue.[9] He evaluated 232 frequent headache sufferers for comorbid psychiatric diagnoses. He recorded anxiety, depression and catastrophizing scales. Catastrophizing predicted functionality and quality of life across every measure, independent of migraine characteristics and psychological variables (This finding has also been substantiated in studies on fibromyalgia and other painful conditions such as rheumatoid arthritis).[6]

How does catastrophizing lead to increased pain perception?

Anxiety and pain are Siamese twins. The positive relationship between anxiety and pain is a common experience in the clinical setting.[10] Anxious patients are more likely to increase their attentional focus on pain. This may lead them to preferentially process pain-related information and to interpret even ambiguous or non-painful sensations as being painful.[11] By engaging in cognitive activity that amplifies pain signals, central neural mechanisms may become more sensitized to yield a chronic hyperalgesic state.[12] Furthermore, the relationship between catastrophizing and central nociceptive mechanisms is bidirectional leading to a self-sustaining, self-tuning process that contributes to the chronicity of many pain states. This “cognitive distortion” is a key element in understanding this baffling pain disorder.[13]

On a more peripheral level, a recent study shows that increased catastrophizing about pain triggers increased stimulation of pro-inflammatory processes, a reaction that could explain differences in how individuals are affected by pain.[14] Those who catastrophize the most were the ones with the highest level of increase in IL6 (Interleukin 6). Clearly, cognitive and emotional negative responses to pain seem to be driving the inflammatory response.

Implications for treatment

“If you are distressed by anything, the pain is not due to the thing itself, but your estimate of it; and this you have the power to revoke at any moment”………Marcus Aurelius (Meditations).

Any physician who treats the chronic headache patient must be aware of the emotional and cognitive issues responsible for the transition from episodic to chronic, daily pain. It is not sufficient to simply “detox” these patients; unless the underlying sensitized, catastrophizing state is dealt with, it is inevitable that the patient will once again fall into the same trap. A simple catastrophizing scale should be part of every headache intake process. Non-pharmaceutical treatment in the form of cognitive behavioral therapy (CBT) should be part of every treatment regimen.

Medications have the ability to dampen limbic/amygdala activity, the so called “bottom-up approach” but there is also a “top-down” approach using CBT.[15] Studies show that CBT can have long-lasting effects in these patients, leading to reductions in catastrophizing which in turn is associated with reduction in chronic pain.[16,17] This is good news for the headache physician, often frustrated in their attempts to deal with these patients; catastrophizing is treatable and does not have the immutable character associated with personality traits/disorders.

Conclusion

Catastrophizing and migraine go hand in hand. No other disorder lends itself to dreading and anticipatory anxiety than one with maddening unpredictability (and indeed maddening predictability, as in the case of menstrual migraine). It is fair to say that under these circumstances, one would be foolish not to catastrophize.

It is not sufficient to detox the analgesic rebounding patient, it is vital that we address the full dimensions of pain, treating the whole patient and not simply their inflamed blood vessels. These patients live with the proverbial “sword of Damocles” hanging over their heads, in a perpetual state of readiness for the worst. In the words of Martin Teicher, “to a brain so tuned even Paradise would hold its share of dangers.”

References

1. Haut, Bigal, Lipton: Chronic disorders with episodic manifestations: focus on epilepsy and migraine Lancet Neurology, Feb 2006;vol 5:148-157

2. Rothrock: Migraine “Chronification” Headache, Jan 2008;vol 48,1:181-182

3. Sullivan, et al: The Pain Catastrophizing Scale, development and validation Psychol Assess 1995;9:253-259

4. Sullivan, et al: Theoretical perspectives on the relation between catastrophizing and pain The Clinical Journal of Pain 2001;17:52-64

5. Keefe, et al: Pain-coping skills training in the management of osteoarthitic knee pain; a comparative study Behav Ther 1991;21:41-62

6. Gracely, et al: Pain-catastrophizing and neural responses to pain among persons with fibromyalgia Brain 2004;127:835-845

7. Kudrow: Paradoxical effects of frequent analgesic use Adv Neurol 1982;33:335-341

8. Turner, et al: Strategies for coping with chronic low back pain: relationship to pain and disability Pain, 1986;24:355-364

9. Holroyd, et al: Impaired functioning and quality of life in severe migraine: the role of catastrophizing and associated symptoms Cephalgia, 2007;27(10);1156-1165

10. Melzac 1973: The puzzle of pain New York Basic Books

11 Edward, et al: Catastrophizing predicts changes in thermal pain response after resolution of acute dental pain The Journal of Pain, 2004; Vol 5 Issue 3:164-170

12 Ploghaus, et al: Exacerbation of pain by anxiety is associated with activity in a hippocampal network The Journal of Neuroscience, 2001;21(24):9896-9903

13 Beck: Cognitive therapy of depression (Guilford, New York 1979)

14 Edwards, et al: Catastrophizing triggers the inflammatory response Presented at American Academy of Pain Medicine 2009 (In Publication)

15 DeRubis, et al: Cognitive Therapy versus medication for depression: treatment outcomes and neural mechanisms. Nature Neuroscience, 2008;9(10):788-796

16 Koyama, et al: The subjective experience of pain: where expectations become reality PNAS, 2005;102(36):12950-12955

17 Price, et al: Psychological and neural mechanisms of the affective dimensions of pain Science 2000;288:1769-1772

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