The Relationship Between Migraine and Stress: Clinical Assessment, Behavioral Interventions, and an Integrated Approach to Management

Bozhenko N.L.,Bozhenko M.I.,Bozhenko O.B.

Main
Publications
The Relationship Between Migraine and Stress: Clinical Assessment, Behavioral Interventions, and an Integrated Approach to Management

October 26, 2026

Bozhenko N.L.

Bozhenko M.I.

Bozhenko O.B.

УДК: УДК 616.857-06:616.8-008.615.1]-036-07-08

DOI: DOI: 10.32471/umj.1680-3051.281820

Keywords :

cognitive behavioral therapy,

Resume

The Relationship Between Migraine and Stress: Clinical Assessment, Behavioral Interventions, and an Integrated Approach to ManagementAbstract. Migraine is often dismissed as a condition affecting «fussy women», yet it is a serious neurological disorder influenced by biological predisposition, sensory processing, behavioral factors, and the environment. Patients frequently attribute their attacks to stress. Migraine and stress have a bidirectional relationship, making it difficult to establish causal links between psychological stress and attack onset. Attributing headache primarily to stress may lead to misdiagnosis and, even when migraine has been correctly diagnosed, may divert attention from its underlying biological mechanisms, psychiatric comorbidities, and the optimization of pharmacological treatment.

Objective. To summarize current evidence on the relationship between migraine and stress, evaluate the evidence supporting behavioral interventions, and outline the key principles of integrated clinical management.

Materials and methods. A targeted literature review was conducted using PubMed and the official websites of scientific journals and professional societies. Clinical practice guidelines, systematic reviews, and randomized controlled trials were prioritized. The review did not include a meta-analysis, independent duplicate screening of publications, or formal risk-of-bias assessment of all included studies.

Results. The literature suggests that the relationship between migraine and stress is bidirectional and depends on individual characteristics, coexisting factors, and disease course. Emotional changes, fatigue, and irritability preceding an attack may represent prodromal symptoms rather than triggers. Headache diaries can help identify recurring patterns and assess potential triggers, changes in sleep and eating patterns, and medication use. Anxiety, depression, and sleep disorders may coexist with migraine and warrant separate clinical assessment. Evidence regarding cognitive behavioral therapy, relaxation techniques, and mindfulness-based interventions suggests potential benefits for selected headache outcomes, daily functioning, and psychological well-being. However, findings across studies are heterogeneous, and the quality of evidence remains limited for some interventions. Pharmacological treatment remains an essential component of patient management and should include effective acute treatment, assessment of indications for preventive therapy, and monitoring of the frequency of acute medication use.

Conclusions. Stress should not be regarded as a universal cause of headache, including migraine. Optimal management requires confirmation of the diagnosis, assessment of attack frequency and functional burden, identification of psychiatric comorbidities and sleep disorders, and individualized selection of pharmacological and behavioral interventions. Treatment outcomes should be evaluated in terms of headache days, medication use, daily functioning, and psychological well-being.

References

1. Ashina M. Migraine. N Engl J Med. 2020;383(19):1866–1876. https://doi.org/10.1056/NEJMra1915327.
2. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1–211. https://doi.org/10.1177/0333102417738202.
3. Stubberud A, Buse DC, Kristoffersen ES, et al. Is there a causal relationship between stress and migraine? Current evidence and implications for management. J Headache Pain. 2021;22(1):155. https://doi.org/10.1186/s10194-021-01369-6.
4. Lipton RB, Pavlovic JM, Haut SR, et al. Methodological issues in studying trigger factors and premonitory features of migraine. Headache. 2014;54(10):1661–1669. https://doi.org/10.1111/head.12464.
5. Martinelli D, Pocora MM, De Icco R, et al. Triggers of migraine: where do we stand? Curr Opin Neurol. 2022;35(3):360–366. https://doi.org/10.1097/WCO.0000000000001065.
6. Eigenbrodt AK, Christensen RH, Ashina H, et al. Premonitory symptoms in migraine: a systematic review and meta-analysis of observational studies reporting prevalence or relative frequency. J Headache Pain. 2022;23(1):140. https://doi.org/10.1186/s10194-022-01510-z.
7. Lipton RB, Buse DC, Hall CB, et al. Reduction in perceived stress as a migraine trigger: testing the «let-down headache» hypothesis. Neurology. 2014;82(16):1395–1401. https://doi.org/10.1212/WNL.0000000000000332.
8. Ashina S, Serrano D, Lipton RB, et al. Depression and risk of transformation of episodic to chronic migraine. J Headache Pain. 2012;13(8):615–624. https://doi.org/10.1007/s10194-012-0479-9.
9. Borsook D, Maleki N, Becerra L, et al. Understanding migraine through the lens of maladaptive stress responses: a model disease of allostatic load. Neuron. 2012;73(2):219–234. https://doi.org/10.1016/j.neuron.2012.01.001.
10. Dresler T, Caratozzolo S, Guldolf K, et al. Understanding the nature of psychiatric comorbidity in migraine: a systematic review focused on interactions and treatment implications. J Headache Pain. 2019;20(1):51. https://doi.org/10.1186/s10194-019-0988-x.
11. Tiseo C, Vacca A, Felbush A, et al. Migraine and sleep disorders: a systematic review. J Headache Pain. 2020;21(1):126. https://doi.org/10.1186/s10194-020-01192-5.
12. Боженко НЛ, Боженко МІ, Боженко ОБ. Мігрень і сон. Як формується їх взаємозв’язок? Психосоматична медицина та загальна практика. 2024;9(1). https://doi.org/10.26766/pmgp.v9i1.488.
13. Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology. 2019;92(3):134–144. https://doi.org/10.1212/WNL.0000000000006697.
14. Seo JG, Park SP. Validation of the Generalized Anxiety Disorder-7 (GAD-7) and GAD-2 in patients with migraine. J Headache Pain. 2015;16:97. https://doi.org/10.1186/s10194-015-0583-8.
15. Amoozegar F, Patten SB, Becker WJ, et al. The prevalence of depression and the accuracy of depression screening tools in migraine patients. Gen Hosp Psychiatry. 2017;48:25–31. https://doi.org/10.1016/j.genhosppsych.2017.06.006.
16. Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67(6):361–370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x.
17. Moon HJ, Seo JG, Park SP. Perceived stress in patients with migraine: a case-control study. J Headache Pain. 2017;18(1):73. https://doi.org/10.1186/s10194-017-0780-8.
18. Stewart WF, Lipton RB, Dowson AJ, et al. Development and testing of the Migraine Disability Assessment (MIDAS) Questionnaire to assess headache-related disability. Neurology. 2001;56(6 Suppl 1):S20–S28. https://doi.org/10.1212/wnl.56.suppl_1.s20.
19. Kosinski M, Bayliss MS, Bjorner JB, et al. A six-item short-form survey for measuring headache impact: the HIT-6. Qual Life Res. 2003;12(8):963–974. https://doi.org/10.1023/A:1026119331193.
20. Treadwell JR, Tsou AY, Rouse B, et al. Behavioral interventions for migraine prevention: a systematic review and meta-analysis. Headache. 2025;65(4):668–694. https://doi.org/10.1111/head.14914.
21. Wells RE, O’Connell N, Pierce CR, et al. Effectiveness of mindfulness meditation vs headache education for adults with migraine: a randomized clinical trial. JAMA Intern Med. 2021;181(3):317–328. https://doi.org/10.1001/jamainternmed.2020.7090.
22. Grazzi L, D’Amico D, Guastafierro E, et al. Efficacy of mindfulness added to treatment as usual in patients with chronic migraine and medication overuse headache: a phase-III single-blind randomized-controlled trial (the MIND-CM study). J Headache Pain. 2023;24(1):86. https://doi.org/10.1186/s10194-023-01630-0.
23. Hailston A, Davies N, Ratna M, et al. The effectiveness of educational, behavioural, and cognitive self-management support interventions for chronic migraine: a systematic review. Prim Health Care Res Dev. 2025;26:e98. https://doi.org/10.1017/S1463423625100571.
24. Powers SW, Kashikar-Zuck SM, Allen JR, et al. Cognitive behavioral therapy plus amitriptyline for chronic migraine in children and adolescents: a randomized clinical trial. JAMA. 2013;310(24):2622–2630. https://doi.org/10.1001/jama.2013.282533.
25. La Touche R, Fernández Pérez JJ, Proy Acosta A, et al. Is aerobic exercise helpful in patients with migraine? A systematic review and meta-analysis. Scand J Med Sci Sports. 2020;30(6):965–982. https://doi.org/10.1111/sms.13625.
26. Puledda F, Sacco S, Diener HC, et al. International Headache Society global practice recommendations for the acute pharmacological treatment of migraine. Cephalalgia. 2024;44(8):3331024241252666. https://doi.org/10.1177/03331024241252666.
27. Боженко МІ. Роль триптанів у сучасних підходах до абортивного лікування мігрені. Міжнародний неврологічний журнал. 2025;21(6):443–449. https://doi.org/10.22141/2224-0713.21.6.2025.1211.
28. Karlsson WK, Ostinelli EG, Zhuang ZA, et al. Comparative effects of drug interventions for the acute management of migraine episodes in adults: systematic review and network meta-analysis. BMJ. 2024;386:e080107. https://doi.org/10.1136/bmj-2024-080107.
29. Різоптан^®. Інструкція для медичного застосування лікарського засобу. Реєстраційне посвідчення № UA/15160/01/01. Державний реєстр лікарських засобів України. https://drlz.moz.gov.ua/register/product/21465.
30. Puledda F, Sacco S, Diener HC, et al. International Headache Society global practice recommendations for preventive pharmacological treatment of migraine. Cephalalgia. 2024;44(9):3331024241269735. https://doi.org/10.1177/03331024241269735.
31. Potrebic S, Tanveer S, Becker WJ, et al. Pharmacologic treatment for migraine prevention in adults practice guideline recommendations: report of the AAN Guidelines Subcommittee and the American Headache Society. Headache. 2026;66(9):2173–2184. https://doi.org/10.1111/head.70199.
32. Charles AC, Digre KB, Goadsby PJ, et al. Calcitonin gene-related peptide-targeting therapies are a first-line option for the prevention of migraine: an American Headache Society position statement update. Headache. 2024;64(4):333–341. https://doi.org/10.1111/head.14692.
33. Ashina M, Buse DC, Ashina H, et al. Migraine: integrated approaches to clinical management and emerging treatments. Lancet. 2021;397(10283):1505–1518. https://doi.org/10.1016/S0140-6736(20)32342-4.