Outcomes For Chronic Headache Patients

Psychosocial Factors Are Not Instrumental  

For decades, studies focusing on personality and psychological profiles of those with migraine have dominated journals. The end result suggests that depression and anxiety is increased among migraineurs,1 and a strong correlation between pathological personality and migraine.2 

I was intrigued and bemused by a recent study demonstrating that those with migraine (n=162) compared to controls (n=140) were less optimistic and more pessimistic, and confirmed higher levels of anxiety and depression (yet again!). Pessimism and anxiety predicted migraine, whilst optimism was inversely associated migraine related disability.3

This is hardly ground breaking research, but it is interesting to note that another study investigating personality profiles of 124 patients with migraine and 77 controls found that of all the (many) personality traits assessed, anxiety and depression were the primary psychological aspects of migraine.4 However, whilst anxiety and depression was twice that of controls, they were not the personality trait facets primarily influencing migraine.,4 i.e. not inherent in the ‘migraine personality’.

Sensitisation of the trigemino cervical nucleus is the underlying disorder in Migraine, indeed Primary Headache and chronicity in headache generally.5-10 Research demonstrates that biopsychosocial factors are not the main factors responsible for central hyper-excitability i.e., spinal cord hyper-excitability appears to not be affected, at least significantly, by psychological factors.11

Despite this context, debate continues as to whether psychological distress precedes and causes chronic pain or, conversely, psychological distress is a consequence of chronic pain.12

Interestingly, a recent study has questioned the role of early attention to biopsychosocial factors in low back pain. Two hundred and two patients underwent:

i) treatment for acute low back pain

and either a

ii) session comprising information on pain and biopsychosocial contributors plus self-management techniques, such as remaining active and pacing


iii)  a placebo education (active listening, without information or advice) session.

The authors concluded… ‘Adding 2 hours of patient education to recommended first-line care for patients with acute low back pain did not improve pain outcomes. Clinical guideline recommendations to provide complex and intensive support to high-risk patients with acute low back pain may have been premature.’13

Recognising extrapolation from acute lower back pain to chronic headache may be tenuous, the literature14 (and clinical experience) suggests that it is detrimental to focus on psychosocial factors in chronic headache; changing patients’ pain by identifying and successful intervention of relevant biomedical sources is the most powerful instrument in effecting changes in psychosocial environments.15  

The evidence suggests that psychosocial factors are not instrumental in the outcomes of chronic headache patients. Therefore, whilst it is recognised that psychological, behavioural, and lifestyle factors may influence a physical disorder in chronic headache patients at various times,16 identifying and managing relevant biomedical disorders should be, and is the focus, thus ensuring the provision of a committed service.12

Here’s to changing psychosocial situations ‘bottom up’ by raising the awareness of (and addressing) noxious cervical afferents!


  1. Minen MT, Begasse De Dhaem O, Kroon Van Diest A, et al. Migraine and its psychiatric comorbidities. J Neurol Neurosurg Psychiatry. Jul 2016;87(7):741-749.
  2. Davis RE, Smitherman TA, Baskin SM. Personality traits, personality disorders, and migraine: a review. Neurol Sci. May 2013;34 Suppl 1:S7-10.
  3. Peres MFP, Oliveira AB, Mercante JP, et al. Optimism, Pessimism, and Migraine: A Cross-Sectional, Population-Based Study. Headache. Feb 2019;59(2):205-214.
  4. Muscogiuri G, Dimaggio L, Giani L, Mariani C, Pantoni L, Lovati C. Personality traits in migraineurs: a case-control study by personality inventory for DSM-5 (PID-5). Neurol Sci. Jun 2018;39(Suppl 1):129-130.
  5. Milanov I, Bogdanova D. Trigemino-cervical reflex in patients with headache. Cephalalgia. Feb 2003;23(1):35-38.
  6. Nardone R, Ausserer H, Bratti A, et al. Trigemino-cervical reflex abnormalities in patients with migraine and cluster headache. Headache. Apr 2008;48(4):578-585.
  7. Katsarava Z, Lehnerdt G, Duda B, Ellrich J, Diener HC, Kaube H. Sensitization of trigeminal nociception specific for migraine but not pain of sinusitis. Neurology. Nov 12 2002;59(9):1450-1453.
  8. Katsarava Z, Giffin N, Diener HC, Kaube H. Abnormal habituation of ‘nociceptive’ blink reflex in migraine–evidence for increased excitability of trigeminal nociception. Cephalalgia. Oct 2003;23(8):814-819.
  9. Kaube H, Katsarava Z, Przywara S, Drepper J, Ellrich J, Diener HC. Acute migraine headache: possible sensitization of neurons in the spinal trigeminal nucleus? Neurology. Apr 23 2002;58(8):1234-1238.
  10. Sandrini G, Proietti Cecchini A, Milanov I, Tassorelli C, Buzzi MG, Nappi G. Electrophysiological evidence for trigeminal neuron sensitization in patients with migraine. Neurosci Lett. Jan 14 2002;317(3):135-138.
  11. Sterling M, Hodkinson E, Pettiford C, Souvlis T, Curatolo M. Psychologic factors are related to some sensory pain thresholds but not nociceptive flexion reflex threshold in chronic whiplash. Clin J Pain. Feb 2008;24(2):124-130.
  12. Bogduk N. Whiplash can have lesions. Pain Res Manag. Autumn 2006;11(3):155.
  13. Traeger AC, Lee H, Hubscher M, et al. Effect of Intensive Patient Education vs Placebo Patient Education on Outcomes in Patients With Acute Low Back Pain: A Randomized Clinical Trial. JAMA neurology. Nov 5 2018.
  14. Probyn K, Bowers H, Caldwell F, et al. Prognostic factors for chronic headache: A systematic review. Neurology. Jul 18 2017;89(3):291-301.
  15. Wallis BJ, Lord SM, Bogduk N. Resolution of psychological distress of whiplash patients following treatment by radiofrequency neurotomy: a randomised, double-blind, placebo-controlled trial. Pain. Oct 1997;73(1):15-22.
  16. Pikoff HB. Psychological mislabeling of chronic pain: lessons from migraine in the 20th century. Pain management. Mar 2017;7(2):127-132.

Until next time

If you are new to Watson Headache®, welcome to the Watson Headache® Approach, an evidence-informed practice when considering the role of the neck in Cervicogenic and Primary Headache.

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