Limbic Healing

Managing Migraine Through Limbic Healing


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Migraine is an episodic pain disorder with a pathophysiology that begins when the nervous system encounters an environment that exceeds its capacities. Presumably these triggering factors disrupt the homeostatic balance of the brain and lower the threshold of the nervous system to migraine. Electrical and neurochemical chaos ensues, resulting in disinhibition of sensory processing mechanisms in the brainstem. As the migraine progresses second and third order neurons are disinhibited such that sensory symptoms are amplified by central mechanisms. As the migraine progresses it has the potential to become an allodynic pain state. Significant in this process are inputs from the cortex, thalamus, hypothalamus, and limbic areas. The process of migraine follows a predictable progression that has been categorized into five stages: prodrome, aura, headache, resolution, and postdrome. With changes in central neuromodulation, the onset of premonitory symptoms occurs. Prodromal symptoms reflect disruption of homeostasis and foretell the oncoming headache. If the process continues, disinhibition of the occipital cortex produces a wave of spreading cortical depression and aura symptoms may arise.

With central disinhibition, second-order neurons in the nucleus caudalis may also become more sensitive to incoming sensory stimuli. Trigeminal inputs that typically produce no effect become amplified to the extent that they are perceived as unpleasant or even painful, a process that has been termed sensory wind-up. This may become the initial mild phase of headache or pre-headache muscle tenderness. As the process proceeds, meningeal perivascular inflammation can lead to further sensitization of first order trigeminal neurons and second and third-order neurons in the central nervous system. With the crescendo of central sensitization and autonomic activation, symptoms such as nausea and sensory hyperexcitability erupt. Uncontrolled, migraine eventually can become an acute allodynic pain state.

Yet, the migraine process does not end here. The Limbic System records each episode of migraine in terms of the situation as well as the emotional accompaniment to the assault on the system. From interviews with 80 patients at a headache center, the majority perceived their first migraine as traumatic. Some went “blind” due to an aura; others fled from the situation and sought comfort in a dark, cool, quiet room; a few believed they were dying from a brain tumor or hemorrhage. These pain memories are etched into the person’s consciousness, instilling dread and fear of the next attack, at the same time, feeling helpless and victimized by her own system. The Limbic System sets the stage for the individual’s perception of the meaning of migraine or any other phenomena that affects the person. Is migraine considered just a bad headache that goes away after sleep? Or is migraine foreseen as a bolt that strikes a person down, making her immobile? This differentiation resides in the Limbic System.
Anatomically, the Limbic System is situated juxtaposition to the structures responsible for migraine pathophysiology. The archipallium or primitive (reptilian) brain comprises the brainstem (medulla, pons, cerebellum, mesencephalon), the globus pallidus and the olfactory bulbs. The migraine generator is hypothesized to be in the brainstem and mid brain as well. The brainstem is largely responsible for self-preservation, instinctive reactions and commands which allow certain involuntary actions and the control of visceral functions, such as cardiac, pulmonary, and intestinal, that are necessary for the preservation of life.

In 1878, the French neurologist Paul Broca pinpointed the “limbic lobe” that forms a border around the brain stem, right underneath the cortex which consists of several nuclei of gray matter. The Limbic System commands certain behaviors that are necessary for survival and allows mammals to distinguish between pleasant and unpleasant sensations. Affective behaviors, such as inducing mothers to nurse and protect their young, are developed within this system. In addition, emotions like love, joy, hate, wrath, fright, passion, and sadness originate in the Limbic System. This area of the brain is also responsible for some aspects of personal identity and memory-related functions.

In other words, an emotional component accompanies each pain experience and a pain memory can elicit more pain. While pharmacology and modalities may take the edge off of pain, the person remembers the emotional response to that pain. Limbic healing, has been relegated to behavioral medicine and is an essential part of recovery regardless of the person’s response to medicine. Because migraine is a chronic disorder, stressful factors in the individual’s life can potentially express themselves as headaches regardless of pharmacological treatment. The migraineur needs to understand how to listen to her own body and respond with tools, like biofeedback to enable her system to return to homeostasis.

Steps toward Limbic Healing

1.    Education

Individuals with disabling headaches often have a physiologically sensitive nervous system. Change affects them physiologically and emotionally more than the average person. When the system feels threatened or overwhelmed, a disabling headache shuts it down. This neurological process occurs in a predictable fashion. Once the headache pattern is identified, the person learns to listen for somatic clues, like craving food, yawning, or lethargy, that tell her a migraine is on its way. By taking migraine-specific medicine early in the process, the efficacy of the drug is enhanced and the individual will be able to function without having to lose time at work, school, or recreation.

2.    Headache Diary

The headache pattern becomes apparent by recording and rating headaches. Because memory of pain is unreliable, an objective documentation of the frequency, intensity, and duration of headaches is a valuable tool for the individual to recognize how entrenched headaches are in her life. A diary also keeps track of the amount of medication, over-the-counter and prescription, required to stop the migraine process. By reviewing the diary during the follow-up visit, the physician communicates interest in the patient’s progress while at the same time evaluating the efficacy of the prescribed medication and the possible need for preventive medication.

3.    Migraine Threshold

The migraine threshold is the physiological point at which the neurological system becomes sufficiently threatened and the process of migraine is initiated. By recognizing this point, the migraineur can learn to balance risk factors for headache with protective behaviors to maintain or restore equilibrium. For those with menstrual migraine, for example, the monthly cycle is a period of vulnerability to migraine. During the menstrual period, she needs to eliminate caffeine, eat three meals a day, and go to sleep and awake on schedule. Exercise, relaxation, and recreation are important ways to bolster the migraine threshold.

4.    Thermal Biofeedback

Thermal biofeedback is one of the most effective strategies for controlling migraine. Through practice, the body is trained to cope with internal and external stress, with relaxation rather than the fight-or-flight response.

Finger temperature is a reliable indicator of how much stress the body is carrying. The average finger temperature is 85 degrees F. A finger temperature below 85 degrees F signifies that the body is holding a great deal of tension. Migraineurs typically have a finger temperature in the 70’s, which reflects an over-extended nervous system.

The goal of biofeedback is to warm the finger temperature to 96 degrees F by taking 10 minutes each day to relax in a comfortable chair with eyes closed, listening to soothing music or performing a visualization exercise. This is an opportunity for the individual to shed accumulated negativity that builds up through daily living.

5.    Sharing Experiences

The migraineur often feels alone and isolated. By the time she seeks medical consultation, the individual has failed self-management of migraine attacks and worries that the rest of her life will revolve around disabling headaches. She may feel weak and vulnerable. A migraine support group, either in person or over the internet, is a positive way to share experiences about headaches and treatment options, such as herbal remedies, massage, and transcutaneous electrical stimulation. Through the group, individuals are challenged to become responsible for their own health and try options for healing besides medication.

Limbic Language

1.    Can’t say “No.” Fear of rejection and abandonment
2.    Puts self last, questions self-worth
3.    No boundaries, much dependency
4.    Existential Crisis:

  • Who am I?
  • What am I doing here?
  • Where am I going?

5.    Self-parenting: neglected or abused as a child
6.    Lives up to others’ expectations. Does not make own goals.
7.    Conscientious
8.    Somaticizes stress and pain
9.    Sense of victimization: stuck in victim consciousness
10.    Denies stress and pain
11.    Distrustful of self
12.    Intuitive to others’ feelings
13.    Perceived trauma coincides with chronic daily headache or chronic pain
14.    Detail oriented
15.    Perfectionistic
16.    Worrier
17.    Afraid of anger

Shari: Neglected and abused as a child

Shari, a 32-year-old Caucasian divorced female with a 13-year-old daughter, walked into my office as if I were interviewing her for a job. Very business-like, sitting very erect, without any emotional expression on her face, I asked her why she was seeking treatment for her headaches at this time.
She said she had been working 80 hours a week as a dietician technician over the past four years and it dawned on her that she couldn’t do it anymore. I asked how she came to this decision. She explained that she had a home of her own, but three months ago, her father moved in after he had successfully completed a rehabilitation program for alcohol and drug addiction. Since then, she had been sharing her bed with her daughter, “just to keep her safe.” Also her daily headaches had become intolerable. She feared she would lose her job due to absenteeism and an inability to function as well as she had before.
She explained with a smile that she is the oldest of three children. Both parents were addicted to alcohol and drugs and she had parented her siblings as well as her parents. She tried to protect her siblings from her parents’ physical and sexual abuse, but that often resulted in becoming the target of abuse herself.
When I asked about the extent of sexual abuse, she spoke as if reassuring me, “It was only fondling.” I asked, “By both parents?” And she answered, “Yes.”
At age 6, she heard her mother telling someone over the phone that she and her children would not be around much longer. After the mother hung up the phone, Shari looked in the desk drawer and found a suicide letter. She telephoned her aunt who arrived at her home with a Department of Family Services social worker. She and her siblings were separated and put into different foster homes.
“Mom has been angry with me ever since because I prevented her from committing suicide.” I pointed out that she had also prevented the death of her siblings and herself. She responded with, “I never thought of that before.” Shari admitted she was very angry with her mother for “never loving me.” Despite her efforts over the past 32 years, her mother had always kept her at a distance, accusing her of lying, stealing, and other abhorrent behaviors. As I explained to Shari, this push-pull, come-here-stay-away relationship is not uncommon and is characteristic of an emotionally co-dependency where the mother projects onto her child everything the mother hates about herself, the mother’s “bad me.” Her mother did not see Shari as separate from herself and she needed Shari to continue being “bad” to maintain the illusion that her mother was “good.”
Once Shari realized that her turbulent relationship with her mother had nothing to do with misbehavior on her part, she was able to accept the idea that her mother would never treat her like a daughter. Instead, her mother wanted Shari to mother her, yet at the same time saw her as competition for the affection of Shari’s father.

How to let go?
Biofeedback is the door to the Healthy Self. Through the process of biofeedback, the body relaxes, dissolving tension; and the mind is turned off momentarily by picturing a symbol of the Healthy Self. Because the mind can hold only one thought at a time, intruding thoughts are blocked from the mind by visualizing the Healthy Self. Biofeedback freed Shari to receive new direction, information, or guidance. No longer was she confined to the thought loop that re-incriminated her for abuse. Th child within keeps asking, “What did I do to deserve this mistreatment? Maybe I asked for it. If I were a better daughter, my parents would not have mistreated me.” These misperceptions need to be replaced with affirmations verbalized to the child within, “I am lovable; I am worthwhile; I deserve health and harmony.”
At age 14, after several foster home placements, she ran away and lived on the streets until age 19, where she became pregnant and sought stability for the sake of her unborn child.

Shari had no memory of her childhood prior to age 6. Essentially, she had no childhood because she was put into a role of responsibility far beyond her years. Abuse produces terror in the victim. The 6-year-old Shari thought, “If I were a better daughter, my parents would not mistreat me this way. I must deserve this mistreatment. I must have done something bad. I must have asked for this.” These beliefs exist in the 6-year-old who lives within the adult Shari. Even though the 6-year-old wants to be loved, cherished, protected, and appreciated, she doesn’t feel she deserves it. The process of self-parenting identifies and stops the self-deprecating thoughts and replaces them with affirmations, such as, “You’re a special little girl. You’re lovable. You’re worthwhile. You deserve health and harmony.” Self-parenting is the process of affirming to the little girl within that she is safe, loved, and important. Shari had rejected the child within because she held her responsible for being abused. Now Shari is free to accept and nurture the child within which will lead to a most positive view of herself. These affirmations should be repeated often until the 6-year-old believes she is special, lovable, deserves health and harmony and feels safe and happy.

Her daughter had been diagnosed with autism, attention deficit disorder, and bipolar disorder. She attends public school, but has no friends and relies on Shari for companionship. Shari feels guilty that she passed on these imperfections to her daughter. Shari was advised to enroll her daughter in a special program that promotes socialization for autistic teenagers and to attend a class that explains autism as a non-inherited, neurological problem.

Romantically, she has been involved with abusive men until 2 years ago when she met Harry, never married and “afraid of commitment.” They have an emotionally comfortable relationship that is relatively stable, undemanding, and predictable.
Psychologically, Shari has been a survivor, burying her own wants and needs beneath a barrage of work. Now she has permission to live a life of her own choosing rather than please everyone around her.

Lisa and Family Secrets

I asked Lisa why she had chosen now to seek treatment. She said her father had died of lung cancer just three months before and she felt free to develop a life of her own. Her father had been well-liked and a respected surgeon in the community. His physical abuse of Lisa’s mother and older brother was a family secret. No one outside the immediate family knew and no one inside the family talked about it. “If we didn’t talk about it, it was less likely to happen again, but it always did. I could tell when Dad walked into the house whether he was angry or not. Many evenings I calmed him down before he hit Mom or my brother. I tried my best to protect them. When he beat them, I felt I had let them down.”

Lisa went away to college, but a phone call from her mother brought her back home. “Mom sounded so depressed, I was afraid she’d commit suicide. She couldn’t take the beatings. She said it was much worse after I left. I had to go home to protect Mom and keep her from committing suicide. That occurred 17 years ago. With her Dad gone, she no longer has to defend her mother, but she has to re-learn how to live her own life.
Memories of painful events may be held in muscles throughout the body as reminders never to make that mistake again. These memories are meant to be protective, as lessons learned not to be forgotten will not be repeated. When these muscles become dysfunctional, such as with fibromyalgia, the memories need to be identified and released one at a time.

Cosensitization:  When the Migrainous Nervous System Spills into Other Symptoms

Pamela is an 18-year-old single Caucasian female who dropped out of school during her junior year in high school due to disabling headaches. She was schooled at home her junior and senior years by an itinerant teacher. She was not permitted to graduate with her class, but earned a GED. She sought treatment for headaches because she wanted to attend college in three months.
The process of transformation from episodic to daily headaches occurs in one-fifth of migraineurs,  but its pathophysiology is unknown. The clinical differences between patients with episodic migraine and chronic headache are vast. Those with daily headaches not only have continuous headaches, they also have various associated symptoms that shift from autonomic and gastrointestinal in episodic migraine to musculoskeletal and psychological symptoms in chronic headaches.

Pamela may be classified as a Stage 4 headache patient (see Appendix A). In terms of the neurological pervasiveness of headaches transforming from episodic to daily, Pamela’s nervous system is failing to return to its normal baseline. Instead, her system is in a constant disruptive state, meaning that besides headaches, other neurological symptoms surface such as other aches and pains, sleep disturbance, anxiety, and depression. Staging a patient identifies his or her treatment needs and the degree to which various symptoms are complicating the diagnosis and management strategy. Patients are rated as Stage 1, 2, 3, or 4, depending on their answers to five questions, which address five factors that measure the level of cosensitization between the neurological complaint of headache and other medical problems. The five questions include: 1. Frequency of headaches; 2. Effectiveness of medication; 3. Medical problems other than headaches; 4. Impact of headaches on life; 5. Number of days per month that the patient feels normal.

The Stage 4 patient has daily headaches which are nonresponsive to medication. Other medical problems, such as fibromyalgia, irritable bowel syndrome, anxiety, or depression are also bothering Pamela. The impact of headaches on her life is severe; in fact, she states, “My life revolves around headaches.” She never feels normal and has a hard time remembering what normal is.
Cosensitization can be explained by the nervous system’s response to a painful stimulus. Consider muscular tightness in the scalp. Impulses traverse from the scalp over A-delta fibers through the brainstem into the trigeminal nucleus caudalis and up the ascending pathway to the thalamus where the tightness is felt as throbbing pain. This is the somatosensory aspect of pain perception that is fast, discriminative, and exact, pinpointing the location and instituting action to avoid tissue damage. At the same time, impulses from the scalp travel over C fibers through the brainstem into the trigeminal nucleus caudalis and up the ascending pathway to the limbic lobe of the brain. The limbic system is responsible for encoding the affective component of pain perception and holds the memory of the feelings associated with pain. Learned pain behavior is headquartered there. This information is recorded much slower than the somatosensory, but the message to the rest of the body is, “The world is a dangerous place. Be alert. Watch for other threats in the environment.” With acute pain, the person takes an aspirin, lies down, and the headache stops in 30 minutes. The impulses over the descending pathway calms the body, “The threat has passed. The headache is under control. Go about your daily activities without further worry.”
But if the headache does not respond to medication and the pain incapacitates the person, the impulses over the descending pathway pushes the body to further defensive maneuvers. Hypervigilance ensues and eventually the body cannot let down or relax and other markers of being overly stressed appear, such as fatigue, irritability, restlessness, lack of motivation, fearfulness, and desperation.
Medication treats the somatosensory response to pain whereas behavioral approaches are necessary to heal the limbic reaction. Limbic language, such as, “Headaches are ruining my life,” is a predictor that behavioral methods as well as pharmacological intervention will be required for effective control of disabling headaches.

A Stage 4 headache patient like Pamela requires interdisciplinary care. At the Headache Care Center, the Intensive Program is a one-week outpatient treatment program designed for Stage 4 headache patients. They are encouraged to attend the program with a support person who will be part of treatment, especially during group meetings with other patients and their significant others. They have daily appointments with a physician, psychologist, physical therapist, and nurse. The focus is identifying and restructuring learned pain behaviors. As documented in the pain literature, limbically augmented pain syndrome (LAPS),  reflects a person’s previous experience and the situation in which the pain stimulus occurred determines the augmented response. In addition, the perceptual filter through which the person judges her present circumstances needs to be clarified and shifted toward a healthier view of herself and a less threatening vision of the world. These are the goals of behavioral interventions such as education, thermal biofeedback, and cognitive behavioral therapy. The five days of intense treatment are orchestrated to return Pamela to Stage 1 where headaches may occur 4 or less times a month, are responsive to medication, and she feels normal and can function most of the time.

Pamela needs to understand that she has a very sensitive nervous system with an inherited migraine threshold lower than the average person. This threshold can be reinforced by avoiding migraine triggers, such as caffeine, and by living a scheduled lifestyle of routine mealtimes, sleep and wake times. Also self-nurturing activities, like exercise, humor, recreation, and biofeedback, can raise the threshold. A headache diary or calendar (see Appendix B) can help pinpoint triggers and events that appear to make her more vulnerable to headaches.
Another important factor in appreciating this highly sensitive nervous system is to recognize the positive characteristics of her migrainous personality. She is conscientious, detail-oriented, and picks up the feelings of others, especially her Mom’s anxiety and fear. She does this automatically without realizing she is doing this. She is creative; she loves to style and sew her own clothes. She tends to put herself last and she has difficulty saying no to the demands of others. This is the first step in seeing something positive about herself. Up to now, she has considered herself weak and a failure.

Thermal Biofeedback
Thermal biofeedback is a tool used to turn down the volume of her nervous system. For the past two years, she has awoken with a headache. Yet each night she prays it will go away, but it hasn’t. Her system feels nothing but headache. Yet there are other feelings that are being drowned out by headaches.

Thermal biofeedback is a vehicle for getting in touch with her body again. By training her body to warm her fingers to 96 degrees F, she has to learn to breathe slowly and deeply from the abdomen. She redirects blood flow to the fingers and toes. In her mind she focuses on an image of her healthy self. For over two years her only thought was “I am sick.” She couldn’t see the healthy side of herself. She receives a finger thermometer and a relaxation/visualization CD-ROM to practice at least twice a day. She also records her finger temperature before and after listening to the ten-minute relaxation exercise. The average finger temperature is 85 degrees F. Migraineurs often have a finger temperature in the 70’s which reflects the level of stress they are carrying.

Cognitive Behavioral Therapy
Cognitive Behavioral Therapy unravels the web she has woven in an attempt to adapt and survive. The term somatization implies that she has used chronic headaches to avoid problems associated with life, but in reality she is doing the best she can. Her body is expressing itself through persistent, continuous, disabling headaches as a call for help, but she does not know what to do to escape from this trap. Cognitive behavioral therapy helps her find the path to a life of her own.

Her history takes us along a trail that must be retraced to guide her from Stage 4 of intractable headaches with multiple physical complaints, depression and anxiety to Stage 1 where she can begin college in a few months.

Day 1 of the Intensive Program
A review of the psychological system begins with two questions:

1. Why are you seeking treatment for headaches at this time? This elicits her goal and predicts success in the program. Pamela’s response, “I want to begin college in three months,” indicated that she is invested in the treatment process. If she had said, “My mother is tired of my lying around the house,” another goal would have had to be generated before she started the program.
2. What else was happening at the time your headaches increased in frequency? This reveals psychological milestones that the patient rarely associates with fueling headache frequency. The significant events that will be resolved with cognitive behavioral therapy were:

  1. Age 16, headaches forced Pamela to drop out of high school
  2. Age 14, bout with depression
  3. Age 8, painful GI symptoms.

Pamela is angry with herself for being trapped in this predicament. She doesn’t know how it happened. The three major issues to address are grounded in a fear of abandonment

  1. Codependency between herself and her mother
  2. No father or other male in her life
  3. Her friends apparently don’t care about her and her health.

Pamela is instructed to write three letters to express anger, disappointment, and fear: 1. To her best friend, why doesn’t she return her phone calls; 2. To her deceased father, why did he leave her before she got to know him (age 15 months); 3. To her mother, why doesn’t she have a life of her own? These letters bring into awareness powerful feelings that Pamela has been harboring for a long time without realizing they were there. This releases a buildup of negativity that has been denied, but growing and produces a sense of relief and lightness.

Day 2 of Intensive Program
When Pamela was 16, her mother was having problems at work and was afraid of losing her job. This distress was absorbed by Pamela, increasing her headaches and forcing her to drop out of school. Codependency is often a real problem between parent and child with disabling headaches. On the one hand, the parent usually has migraine and feels guilty about passing on the genetic predisposition to the child. The parent knows firsthand the fear and anxiety over when the next attack will occur and tries to protect the child from the disbelieving reactions of authority figures, friends, and family when she cannot function due to a headache. Also the parent and child share a sensitive nervous system that tends to be intuitive and understanding. Often the parent seeks emotional support from the child because the spouse over the years may have become unsympathetic to the disabling headaches. The child usually absorbs the parent’s anxiety, which triggers a bad headache. An unconscious see-saw emotional bond forms where the parent feels good when the child is sick and bad when the child is healthy. The parent believes he or she is doing everything possible to help the child when in reality the parent is keeping the child in the patient/sick role. Even though the parent cannot be confronted directly about this relationship, the child can be advised about how to develop his or her own life.
This includes sleeping in her own bed, not the parent’s, during a headache; saying no to suggestions about staying home with a headache; doing routine tasks on her own rather than allowing the parent to do them for her. The child can be alerted to the automatic acceptance of the parent’s negative feelings and can be trained how to reject these feelings behaviorally.

Neither Pamela nor her mother had outside interests. Both were encouraged to plan and engage in activities with others. At first the mother hesitated because Pamela might not be able to follow through with the plans. But with Pamela going away to college, the mother was advised to begin to construct a life of her own to counteract the natural empty nest syndrome. In short, the mother was given permission to hand over to Pamela the responsibility for her own health. This was a relief to the mother because despite her efforts, she had failed to help Pamela manage disabling headaches.

Day 3 of Intensive Program
At age 14 when Pamela was beginning high school as a freshman, her mother thought she would provide Pamela with a sister surrogate by inviting Mia, a foreign exchange student from Sweden to live with them and accompany Pamela to school. She was petite, blonde, and vivacious. By comparison, Pamela felt huge, ugly, and dull. Mia formed a close relationship with Pamela’s mother, triggering recurring fears of abandonment in Pamela which she did not understand. She felt unwanted, unnoticed, and believed that her mother would be happy if she were never born. Her anger, directed inward, looked like depression, but in truth she hated herself.

Negative conversations with oneself are usually unconscious and automatic. Look in the mirror and what do you say to yourself in your mind. Common comments are, “My nose is too big”; “I’m getting wrinkles”; “I have too many freckles.” Those prone to depression say more desperate statements to themselves, such as, “You’re no good”; “You don’t deserve to live”; “You’d be better off dead.” The first step in correcting negative self-talk is to record the number of times in one minute that a person insults herself. Awareness is important to reverse this self-deprecating barrage of insults. The next step is to replace the negative remark with a positive affirmation. Because individuals prone to headaches are often perfectionistic, an effective affirmation is: I forgive myself for being imperfect. Pamela was instructed to put this affirmation on note paper and attach it on all the mirrors in the house, on the refrigerator, above her bed, anywhere she spent a lot of time. When she catches herself saying something critical to herself, she was instructed to reply instead with the affirmation. Like a mantra, the affirmation should be repeated often, at least every minute. This process reverses self-loathing over time. It is a challenge to undo years of automatic, negative, self-abusing remarks, but with diligence it is possible.

Day 4 of Intensive Program
At age 8, Pamela had the first attack of a medical problem she described as GI problems. Her mother explained that Pamela’s father had suffered from Crohn’s disease and died when Pamela was 15 months old of colon cancer.  She believed that Pamela had inherited his GI problems. It did not occur to her that these GI complaints could be an abdominal migraine, inherited from her.
Prior to these GI problems, Pamela did not hear much about her father. She found out that her parents never married and her mother’s explanation about Pamela’s inheriting her GI system from her father sounded like it would be fatal. This was a milestone in emotional development creating in Pamela the thought that she was a continuation of a line of people who had a beginning and an early end. And she would probably die of colon cancer like her father. These perceptions and emotions were never discussed. Her mother was still angry over Pamela’s father never marrying her, but Pamela perceived only her mother’s anger, which she assumed was due to her physical problems. She felt like a burden and hid whatever she could from her mother.

Day 5 of Intensive Program

Pamela has not had a headache for the past two days. She feels like a new person with the hope that indeed she can attend college and achieve a degree.
In cognitive behavioral therapy, the fear of abandonment was openly discussed with Pamela. She was advised that this theme will probably be a challenge for her throughout her lifetime, but now that she is aware of it, she can recognize its influence and not be surprised at her own reactions and the tendency to reject others before they abandon her. She was encouraged to contact her college roommate and begin the formation of a relationship before the beginning of school.
From Pamela’s viewpoint, she has learned from two years of chronic headaches that she is strong and that she needs to value those times when she is headache free. Even though she has difficulty believing that the daily headaches will not return, she is hopeful she can return to the active lifestyle of an 18-year-old.

Pamela’s is a story of a very sensitive nervous system, characteristic of a migraineur, gone awry. At age 8, with a maternal history of migraine, an astute clinician may have identified the gastrointestinal symptoms as a migraine equivalent or abdominal migraine. But because her father had a history of Crohn’s disease, the mother attributed the problem to the father’s disorder, not her own and she failed to seek medical consultation. Depression at age 14 too was explained away as characteristic of a moody teenager who had PMS symptoms. In actuality, the irritability, sleeping too much, lethargy, and feeling blue could have been partially attributed to the premonitory phase or prodrome of the migraine process.

As migraine progresses over 10 years or more, the pervasiveness of the migrainous neurological disruption spills over into other bodily complaints such as fibromyalgia, sleep disturbance, anxiety, depression, and gastrointestinal upset. In the process, disabling headaches become more frequent and intense, eventually interfering with the person’s ability to function. This has been categorized as Stage 4 of migraine.

From the medical perspective, it is easier to prevent a person’s progression to Stage 4 than it is to treat migraine. Stage 4 is essentially a chronic pain syndrome that requires interdisciplinary care. But Pamela was ready to win her life back through an intense analysis of her psychological milestones that had fueled chronic headaches and to learn techniques for balancing her sensitive nervous system.

Appendix A


1.    How many days per month do you have headaches?
Stage 1: 1 or 2
Stage 2: 3 to 8
Stage 3: 10 to 14
Stage 4: 15 or more

2.    Does the medicine you take for headaches, stop them?
Stage 1: Yes, most of the time
Stage 2: Rely on medicine to get through the day.
Stage 3: Takes the edge off but the headache is still there
Stage 4: Nothing works

3.    Do you have physical problems other than headaches?
Stage 1: No, I’m healthy
Stage 2: At times, I feel down, jittery, irritable, and anxious with upset stomach
Stage 3: Some aches and pains; bloating; and I feel depressed.
Stage 4: Yes, depression, fibromyalgia, insomnia, IBS, weight problem; I’m falling apart.

4.    How do your headaches interfere with your life?
Stage 1: They’re a nuisance that slows me down
Stage 2: I struggle through them and force myself to go on.
Stage 3: I’m missing work, family and social functions a lot
Stage 4: My life revolves around headaches

5.    How many days per month do you feel normal?
Stage 1: 25, most of the time
Stage 2: 15, half the time
Stage 3: 5 to 10.
Stage 4:  Zero

Appendix B

Name: _______________________
Headache Diary

Directions:  Please fill in the blank Headache Calendar below with the month and dates.  Record your headaches on the calendar as they occur circling the appropriate identifiers.  Then use the Headache Diary below to track the effects of treatment.

















Kathleen Farmer, PsyD
Headache Care Center, Springfield, MO
Published on July 24, 2013


Dr. Farmer is a psychologist, administrator of the Headache Care Center and Vice President of Education for the Primary Care Network, which is an organization of over 177,000 clinicians linked via the internet. A diplomate of the American Academy of Pain Management, she is the co-author of Managing Migraine: A Healthcare Professional’s Guide to Collaborative Migraine Care and Managing Migraine: A Patient’s Guide to Successful Migraine Care; The Adherence Principle: Empowering the Healthy Self and the patient education book, Headache Free. She has conducted research in the nonpharmacological treatment of disabling headaches, with special interest in pediatric migraine and cognitive efficiency associated with migraine. She speaks extensively about the therapeutic value of biofeedback for the treatment of chronic disorders and pain.