Psychological factors are known to play a role in pediatric headache. We know that stress is the #1 trigger for migraine for people of all ages. We also know that stress is a contributor/cause of tension-type headaches (stress headaches). And finally we know that patients with constant/chronic headache often have increased pain and decreased functioning when there is increased stress or psychological symptoms.
As providers, it would be helpful to understand more about the issue and appropriate ways to help. For this post, I have help in discussing the impact of psychological factors for kids and teens with headache from one of our Pain Psychologists, Sarah Nelson PhD. Sarah works both in our Multidisciplinary Headache Clinic and Chronic Pain Clinic and has considerable practical knowledge, academic training and research, in the area of pain and the pediatric/adolescent brain. Welcome Sarah!
What are the common psychological issues associated with headache?
SN: A number of psychological concerns are common in youth who experience headaches. First and foremost, as a pain psychologist, I make sure to assure all of my patients that even when they are experiencing psychological symptoms, this does not mean that pain is not real. Unfortunately, because psychological complaints are so common to chronic pain, generalist providers, who may not be knowledgeable on the diagnosis and treatment of chronic pain, can infer to patients that their pain is “all in their head.” This could not be further from the truth.
The biological aspect of pain is generally categorized as over-activity or over-excitement in the nervous system. In addition to an over-active nervous system, our patients frequently experience symptoms of anxiety and depression. The psychological symptoms of anxiety can encompass many experiences, and often include fear about pain and pain catastrophizing. It is very important to assess and to address these issues in treatment.
- Fear of pain (algophobia) is the abnormal and persistent fear of pain that is far more powerful than that perceived by the usual person. The patients worry excessively about why they have pain, what the pain means, if the pain will get better, and what will happen if it does not get better. (“I find it difficult to calm my body down when having pain”).
- Pain catastrophizing is the tendency to describe a pain experience in more exaggerated terms than the average person, to ruminate on it more, and/or to feel more helpless about the experience. (“I worry all of the time that this pain will never end”).
With respect to depression, many youth with headaches experience decreased mood associated with decreased physical and social activity. It can be very depressing for a child/adolescent to miss out on enjoyed activities and have to play “catch-up” in school or with friends. Outside of anxiety or depression, high levels of stress have been found to be significantly common in youth with headaches and can often interact with pain on a neurological level. Stress can serve to excite the nervous system and intensify pain.
How do these issues affect the coping and functioning of our patients with chronic headache?
SN: Coping with pain, outside of psychological function, can be a significant barrier for youth, especially with it comes to engaging in physical and social activity. Many youth perceive pain to be harmful or dangerous (understandably so), which causes them to minimize activity and stay home/rest. The presence of anxiety or depression along with pain often compounds the issue and makes it significantly more difficult to foster healthy engagement in activities and/or recommended treatment. For example, many youth with headaches struggle to engage in physical therapy due to the significant discomfort that they feel. Some even perceive that their pain gets worse when engaging in these exercises.
Coping with pain involves:
- engaging in healthy distraction (e.g., playing a game),
- cognitive strategies (e.g., focusing on how increased pain with activity is expected and is a sign that the body is doing what it is supposed to with exercise),
- or relaxation strategies (e.g., breathing to keep the nervous system calm and decreased any over-excitability).
However, engaging in these adaptive coping strategies while doing a painful activity, such as physical therapy or school attendance, takes practice and it can often be helpful to work with a pain psychologist to help.
Often there is resistance to accepting psychological help, especially among teenagers. What are the particular barriers? How can we best overcome these barriers to help our patients function and cope in a healthy way, and avoid disability?
SN: As mentioned above, many of our patients have the unfortunate experience of being told that their pain is “all in their head”, that they “just need to get therapy”, etc. This is an incorrect assumption and can often lead towards resistance to pain psychology’s involvement in their care. By agreeing to see a psychologist, this does not mean that the pain is not real and actually means that one is willing to learn strategies to cope with their pain more effectively.
As a pain psychologist, when I encounter resistance to psychological care, my first goal is to educate the patient on the role of behavioral coping strategies to modulate pain responses. Research shows us that by changing behavior and thoughts, new brain pathways can be created which can pave the way for sustained wellness and lack of disability.
Aside from the misconceptions about psychology’s role in pain coping, many individuals may have had negative prior experiences with therapists who do not understand their unique needs. To this, I often recommend focusing first and foremost on finding a therapist that they feel comfortable and connected with. Connecting with a therapist is a crucial part of creating a “therapeutic alliance”, which means feeling like you and your therapist are part of the same team. The therapeutic alliance has been shown to have significant importance in enabling the patient to gain positive outcomes from therapy.
Before entering into any new therapy experience, patients can think about the type of person with whom they may connect well. They can identify their specific preferences (someone young or more mature, male or female, etc) and use that as a jumping off point. It is important for the patient to have a say in the selection, rather than deferring to parental preference.
We will continue this conversation in our next post, stay tuned.