Stress and migraines

In the past several posts, I talked about the important lifestyle factors and strategies of hydration, diet, sleep and exercise. In this post I will discuss the effects of stress.  Again these are basic lifestyle strategies that are appropriate for all headaches, but can be particularly important to migraineurs. In fact, stress is at the top of the list of migraine triggers.

Stress!  We all talk about it, we all have it from time to time, and it is a fact of life for all human beings.  What is stress? It is a normal reaction, psychologic and physiologic, to the everyday demands of life.  When your brain perceives a threat (stress), the body reacts with a fight-or-flight response, releasing hormones to increase the heart rate and blood pressure.  When the situation is over, most of the time, your body returns to a normal, calm state.   But sometimes, in our multitasking, overly stimulated world, the stress response button gets stuck in the ‘on’ position.  This may lead to a chronic stress state, which is not easily overcome by your body’s usual methods, and cause chronic headache.

For kids and teens, stress often occurs in the school setting, striving to achieve good grades, to be a part of the popular crowd, or to deal with being bullied. It can be related to sports achievement, trying to be the best player.   Or it can happen in the home setting, dealing with discord between parents or their siblings, or financial stressors, or even abuse.  If it seems that kids are more stressed out then they used to be, you are right. There has always been stress associated with growth, development, social and physical maturation.  But the impact of social media, cultural, environmental and financial stressors, has greatly increased the sources of stress for the average teen, and many of them are more stressed out.

Unfortunately, being under stress can lead to more headaches and migraines. For migraineurs, feeling stressed is a significant migraine trigger, both during the stressful time and afterwards, during the ‘letdown’ period after the stressors have past. Migraineurs need to be aware and be vigilant with their self-care, especially sleep, to help decrease the incidence of migraine.

Stress can also trigger tension-type or stress headaches. Many of us carry our cares and worries in our neck and shoulders. During stressful times, the trapezius and paracervical muscles (which encompass our heads) tense up around our heads, squeezing the occipital nerve in particular bilaterally, and triggering headache.  Relieving the pain involves getting these muscles to relax.

So learning to manage stress is an important aspect of self-care for everyone, especially people with headaches and migraines.  When I ask my teenage patients about how they manage their stress, the usual response is that they talk with friends and/or family, nap, play with a pet or watch Netflix.  I rarely hear that they exercise.  I never hear that they do meditation or relaxation exercises (cognitive-behavioral therapy or CBT).

Stress management has become one of the things I always ask my patients about now.  I start by saying that we all have stress in our lives, and if we don’t learn how to manage it, it can cause even more headaches than they already have. While doing ‘relaxing’ activities can be helpful in the moment, it’s not the same as ‘turning on the relaxation response’ (described in detail below), which is the key to managing stress.  It can be challenging to talk about this subject, hard to get the kids to listen and take action. But we can get creative and try.

I usually talk about the autonomic nervous system, and how it gets activated with stress and pain and is not under our voluntary control.  The activation of the ANS can be turned down by turning on the relaxation response.  This is an intentional activity meant to induce real relaxation, turn down the mind chatter, and improve focus.

There are a variety of ways to turn on the relaxation response, such as yoga, meditation, guided imagery, breath counting, Reiki, acupuncture/acupressure, progressive body scan, cognitive-behavioral techniques (CBT).  There are many ways to access these activities, such as with a therapist, in a wellness/health class at school, in a yoga class, or on YouTube videos, for example.  There are some great apps which can be helpful and give guidance, such as my favorite, Insight Timer (free! so many options! Kids/teens section! search by length of time!).

But how do you get a kid to do this?  It can be tough, since teens don’t feel they have a lot of time. We are not talking about spending 1 hour on a cushion contemplating the universe.  I always emphasize that 5-10 minutes is enough time to do an exercise, and everyone has that kind of time.  We talk about when to fit it into the day and what would it helpful for, such as just before bed to help with sleep, or in the library during study to help with focus and anxiety.  I urge them to find what they like (accented voice, music or not, etc.) and then bookmark what works for them in the app.  Doing a relaxation exercise frequently can help reset their stress response. Then when they do get stressed, it won’t be so intense.

Practice is important and works best when they are relaxed so they can be more effective at using the exercises when actually stressed.  I hear a lot of parents and kids say “it doesn’t work” when the kids are stressed. In reality, it is exceedingly difficult to engage in a new skill when your nervous system is on high alert. Practice allows children/teens to feel more adept at the exercises so that they can more easily engage appropriately in a tense/stressful moment.  The worst time to try out an app for the first time is when you really need it.

Trying to get kids to engage in a relaxation activity can be a hard sell.  It often takes more than 1 clinic visit, with me actually taking out my phone, showing them how to use the app and then having then download it for themselves. Oftentimes, their parent is also downloading it (and telling me they have been using it for themselves or in their classrooms).  If an app doesn’t work for them, then they can consider working with a trained therapist for 6-8 sessions of CBT training. There is often resistance about seeing a therapist; I always emphasize that they are going to learn coping and stress management skills, not to talk extensively about their ‘feelings’, which seems to make a bit more acceptable.  Some schools offer stress management classes for teens and parents. The pain psychologists in my hospital hold a monthly session with teens and parents to learn some CBT skills (Comfortability workshop).

In whatever way we can get our young people more in touch with how stress feels in their bodies, and how to manage it, the less it may affect them.  Again, I always say the best strategy is the one you like and the one you will actually do.  In the end, it will help them be more resilient, and have less headaches and migraines.

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