When you’re forced to miss a family or work event due to migraine, feelings of failure and guilt can only add to the frustration of migraine pain.

Join us as we speak with migraine experts and psychologists about managing negative emotions when migraines limit your day-to-day life. You’ll hear about the range of feelings you may experience – from shame and anger to low self-esteem and depression – how to deal with them, and ways to ask for support from family and friends. You’ll also get guidance on which professionals to seek out for help managing your emotions.

As always, our expert guests answer questions from the audience.

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Now here's your host.

Rick Turner:

When you suffer from migraines, the pain in your head can be excruciating, but there is another type of pain that people with migraines often experience and rarely talk about, the pain that comes from depression and feelings of guilt, shame and anger. Hello and welcome to The Emotional Pain of Migraines: Coping with Frustration and Guilt. I'm Rick Turner. And during the next hour, we will hear how migraine sufferers can experience a wide range of emotions from guilt to anger to depression. We will get expert advice on how to deal with negative emotions and ways to get the support you need from family and friends.

Joining us on the phone from Ann Arbor, Michigan today is Dr. Barbaranne Branca. Dr. Branca is a board-certified clinical neuropsychologist and is the neuropsychology supervisor at the Michigan Headache and Neurological Institute. Dr. Branca, welcome to HealthTalk.

Dr. Barbaranne Branca:

Hi. Welcome to you too, Rick.

Rick:

Thank you. So, Dr. Branca, help us understand first of all what a migraine attack is like in terms of physical pain. It's probably covering familiar ground for most of our listeners, but describe that for us.

Dr. Branca:

Well, when you look at the paintings and drawings of people who have migraines, they draw their heads split in part. They draw daggers. They draw knives. They draw lightening bolts coming out of their head and their eyes. They draw pictures of really excruciating pain. And one of the ways to imagine what's happening to a person that has a migraine attack is to look at the four phases of a migraine. There is something called the prodrome, which is the beginning phase, and then there is the actual headache phase, and then there is the postdrome. Some people have a phase between the prodrome and headache, which is called an aura.

Rick:

Right.

Dr. Branca:

So in the prodrome phase, you might start to have food cravings. You might become very tired and yawn. All of your senses become very sensitive, and you might start to retain fluid.

After that if you have an aura, this is where you might have various visual perceptions. You might see jagged lines in front you, or you might have blind spots in front of you that last anywhere from five to 60 minutes.

You then move into the headache phase, and you can become anorexic at this time. You might not want to eat. You might become nauseous. You might become very sleepy. You might become photophobic, which means you cannot stand to be around light. You can't stand sounds. You can't stand smells. Some people become very dizzy. They have vertigo. They have trouble balancing. Later in the headache, people might throw up.

And then when the headache is over, which can last anywhere from four to 72 hours for a person, and they have this throbbing, throbbing pain usually on one side of the head or the other, they have the postdrome, and in this period they have very limited food tolerance. They are quite tired, both from the head pain itself and from having taken medications. They may feel depressed. They may feel a little bit ecstatic. And they often have sweating or excessive urination. So it's these four phases that they go through, that they experience in terms of physical pain. Is that clear to you?

Rick:

Indeed. And it sounds significantly different from what we think of as a conventional headache.

Dr. Branca:

It's very, very different. When someone has a conventional headache, that usually has a start and a stop time. And they usually know why they got it, like they mowed the lawn in the sun for three hours without sunglasses, or they had eight margaritas. They know why they got it.

Rick:

Right.

Dr. Branca:

And that's not what happens with people that have migraines. They have random attacks.

Rick:

And how common is migraine, do we know?

Dr. Branca:

Migraine is fairly common. In the United States, it's estimated that 28 million people have it and that it's present in one in four households.

Rick:

Twenty-eight million?

Dr. Branca:

Yes.

Rick:

So how about the stigma, we are talking about the emotional impact of migraines on this program, but there is also a stigma attached to that, a social stigma, how does the world generally view migraine? And is that view shaped by a lack of knowledge, by ignorance?

Dr. Branca:

It is shaped by ignorance, both on the part of people not in the medical profession at all, so there are a number of people who don't understand that migraine is a brain disorder. It's a neurological disorder. I have had people say to me that they think it's just a psychiatric disorder and it's not. There is something wrong in the brain. And they think that if the migraine person would simply pull themselves up by the bootstrap, they could get it together. The migraine person looks normal. They don't have anything that they can use to prove that they don't feel well. The diabetic person pricks their finger, they have a blood sugar rating, and they can prove it. You can't prove pain. They see the migraine sufferer as a lazy person. Migraine patients use medications, often very strong medications, and they can be seen as drug abusers. So often migraine patients withdraw from social interactions, and so they are seen as self-pitying. So those are some of the social stigma that you see with migraine.

Rick:

Right. And is it just because we can't see the pain that we have this impression that it's all in somebody's head?

Dr. Branca:

Yes. I think that's a great deal of it, also because we have no way of proving pain. Pain is completely subjective. It's completely dependent on self-report. So we cannot prove, a patient cannot prove that they are in pain. And that's just a matter of believing what a person says. They may look pale, they may be sweating, but other people have to depend on their self-report of what they are saying, so they can't prove it.

Rick:

So that stigma obviously impacts how people view the migraine sufferer. Does it also impact funding research?

Dr. Branca:

Actually, I think that it doesn't. The research that's been done so far has shown that migraine is pretty debilitating. The World Health Organization did a study about conditions that have the highest disability severity, and they used 22 indicator conditions in their Global Burden of Disease Study, and they selected four diseases that were the most disabling. And they were acute psychosis, dementia, quadriplegia, and to my surprise the fourth one was severe migraine. So what we are seeing is that the National Institutes of Health has funding initiatives about migraines. A number of pharmaceutical companies are supporting studies on medications that will work with migraines, and a number of companies are supporting research on stimulators which can be implanted in a patient to help modulate pain.

Rick:

Well, that's all good news. And in terms of the stigma itself, it does exist in the general populace and, as you indicated, in some healthcare professionals as well. What's the best way of overcoming those preconceived notions or those attitudes, do you think? Is it just a matter of education?

Dr. Branca:

Well, I think it's a matter of the healthcare professionals becoming involved on a national level to make changes in policies on treating people who have chronic pain. I think that's very important. I think it's a matter of educating physicians on how to treat migraine. I know there are a number of programs where physicians and psychologists who are trained in treating migraine are going around the country to educate other physicians and psychologists on how to treat migraines. I think that that's very important. And I think that it's very important for each patient who has migraine disorder to get educated themselves.

Rick:

Yes.

Dr. Branca:

And that they should come in with their significant others and family members, that they should be an intermittent part of the treatment team to learn about migraines.

Rick:

Is there some sort of cohesive national education effort in this direction?

Dr. Branca:

I wouldn't say there is a cohesive national effort. I know that the association for the study of headaches has promoted a number of migraine support groups around the country, and they would be glad to put people in touch with those groups. So there are support groups around the country. And I know that a number of physicians have worked on the national level to get research money and to change national policies to get support for chronic pain and to get the government to believe that chronic pain really exists in people that don't have cancer. They do recognize that people who have terminal cancer have pain, but it's been a long time coming for the government to recognize that people who don't have terminal cancer have chronic pain, such as people with migraines.

Rick:

I was just wondering if people could search on the Web for migraine support, that sort of thing, if they could find some resources.

Dr. Branca:

Yes, they can.

Rick:

Okay. Well, let's talk about how the stigma, the attitude toward people who have migraine headaches can impact their performance at work. What are some of the obstacles people with migraine face at work?

Dr. Branca:

When a person with migraine goes to work, you have to imagine what their level of functional impairment is. When we look at how a person that has migraine reports their pain, basically they report about 40 percent impairment, and more than half the people in certain studies, 56 percent, say that their activities are impaired when they have a migraine, and they need bed rest. Thirty-nine percent say they have some impairment. And 9 percent said that they could work, so that means 91 percent said that they could not work.

So if you have that kind of pain pattern, and you have severe migraines averaging 15 to 30 pain days a month, you are not going to be a very good employee. Migraine patients that have a pretty bad chronic pain disorder often leave work early, they often come to work late because they are taking medications to control their headache. They may take medications at work, which interfere with their ability to think. The migraine patient is really in a double bind because when they have headaches, we know that headaches interfere with their ability to think. When they take a medication to control their headache, the medication interferes with their ability to think. So basically they can't think.

Rick:

Right. They are in a catch-22, as it were.

Dr. Branca:

That's right. And if they want accommodations at work, the employer often thinks they are really very inconvenient. For example, migraine patients are quite sensitive to fluorescent light. Well, it's quite costly and impractical in a situation where an employee is working in a hundred cubicles with fluorescent light to change the fluorescent light.

Rick:

Sure. That would be tough.

Dr. Branca:

You can't ask employees not to wear perfume. Perfume triggers migraine in a lot of people.

Rick:

Sure.

Dr. Branca:

You can't ask an employer to tone down the noise. If a person has a factory job and they have migraines and they get dizzy, you have real safety concerns to deal with because they can't run certain kinds of equipment. So the employer takes a very dim view when a patient divulges that they have migraines with these associated symptoms. It's very difficult to accommodate a migraine patient.

Rick:

Right. And I'm sure it impacts the migraine sufferer's relationships with co-workers as well, right?

Dr. Branca:

It definitely does. Co-workers will tend to back away from a migraine person if they get accommodations, because then they think, “Well, that person's really obnoxiously special. Why do they get those accommodations and we don't? Why do they get extra rest periods and we don't? There is nothing wrong with her. She looks fine to me.”

Rick:

Right.

Dr. Branca:

They get special privileges.

Rick:

So there’s resentment there.

Dr. Branca:

Yes.

Rick:

And in terms of how relationships are impacted and affected at home, what sort of dynamics do you see in that area?

Dr. Branca:

It's really bad. If you look at a marriage, what happens is the person with the migraine becomes more and more dysfunctional. If they continue to work, that's about all that they do. All their energy goes to the job. They come home, they have no energy left, so there is no togetherness about making meals. That usually falls to the other spouse. Child care falls to the other spouse. Housekeeping falls to the other spouse. The spouse has to take them to the ER if they need emergent medications. The spouse has to take care of them when they don't feel well, like bring them water, bring them medications. And even though their spouse understands that they are not well, they can't help but have resentment.

Rick:

Right.

Dr. Branca:

It's a depletion of their financial resources because a lot of the financial resources are going toward medication, doctor bills. Some patients become afraid of driving because it's dangerous to drive when you have a certain level of headache or when you are taking medications, so then the spouse has to take time off work. I have a number of patients whose spouses take Family Medical Leave Act to come home and give them injections for pain management. So it disrupts the entire family.

The patient feels very guilty. They know that they are a burden on the family. They cry because their children have seldom seen them without pain, without a headache. Their children have seldom seen them not being irritable and short-tempered because of their headaches. They try, they express their guilt toward their spouse. The spouse gets irritated because they would like them to stop talking about how guilty they feel, and it's just a vicious cycle.

Rick:

Okay. And in terms of getting proper care, does that stigma, that attitude impact in that arena? When somebody, say, goes to their general practitioner, with complaints of a migraine, is it appreciated for what it is typically?

Dr. Branca:

Well, often the patient doesn't receive the proper diagnosis of migraine. When we look at studies about whether patients receive the correct diagnosis, in the past decade approximately 49 percent of women were undiagnosed, and 59 percent of males were not diagnosed that should have been diagnosed with migraines.

Rick:

Wow, 59 percent.

Dr. Branca:

Of males, 49 percent of females.

Rick:

Wow. That's a lot.

Dr. Branca:

That's a lot. And then once they do get diagnosed, the family practitioner often does not know how to treat a migraine. And they usually think of treating it only with medications, which is not the best way to treat a migraine. You should have a multidisciplinary team approach. So they don't know the kinds of medications to use to treat a migraine. And often when a medication fails, they resort to narcotics, which is absolutely not the best way to treat a migraine. Quite often the person with migraines is seen as psychosomatic, so their pain is not seen as real.

Rick:

Right.

Dr. Branca:

I had a patient who worked at a hospital. She had a very serious headache, and she went to the emergency room of the hospital to get treatment, and the second time she went there they gave her a ditto handout. They didn't talk to her about it. They just gave her a handout and said, “You have a drug problem. You need to see a social worker.” And she was absolutely stunned. And this meant that it was on her record and probably accessible to her employer. And this was not the exception. This happens to so many people, that they are told that they are drug seekers.

Rick:

Dr. Branca, we know that the primary symptom of migraine is pain, head pain, but are there other physical issues, weight gain that could arise for some migraine sufferers? Can you talk to us about some of those?

Dr. Branca:

Yes. Weight gain is one of the unfortunate side effects and sequelae to having chronic pain. Many of the medications that are used in the treatment of migraines are not weight neutral. When I look at a patient's chart from their initial visit to visits six months or a year later, I often see a 20- to 40- to even 60-pound weight gain.

Rick:

Wow.

Dr. Branca:

And this is again another dreadful vicious cycle. You really don't want someone to gain weight. In fact, the research shows that obesity is implicated in people having migraines, so it can actually increase their migraines. And people that have migraines will often have depression. So we know that weight gain is implicated in depression. So now we have someone who is even more depressed, obesity is a terrible thing to have because it's implicated in other health problems, like hypertension and diabetes. So when the person goes to get migraine treatment, I think they need to be very, very assertive about what side effects they will and what side effects they won't tolerate from a medication, and weight gain is something that needs to be looked at very carefully.

Rick:

Okay.

Dr. Branca:

The other thing is that when you have chronic migraines, you don't want to move because movement hurts your head. It hurts. So that makes you more prone to weight gain. People get depressed, and they don't move around, so then they stop exercising, which also leads to weight gain.

Rick:

So it’s a vicious cycle.

Dr. Branca:

Yes.

Rick:

And in terms of other physical issues related to migraine, how about things like sleep disturbances, how common are they?

Dr. Branca:

Sleep disturbance is very common. There's this sort of unholy triad: migraine, depression and sleep disturbance. We know that when a person has disturbed sleep that that can be a trigger for migraine. Sleep disturbance is very common, and we will treat a person for sleep disturbance by teaching them behavioral changes to sleep better. It has a strange name. It's called sleep hygiene, and that teaches you how to sleep better. We will often find that many patients have obstructive sleep apnea, and we will even prescribe some medications to help people sleep because if you don't sleep well, you are going to have increased migraines. We will see that there are a lot of changes in physical appearance. If you are put on steroids, which a lot of people are, they are put on something called steroid bursts.

Rick:

For migraine?

Dr. Branca:

Yes. To break a bad cycle of migraine, you will get weight gain from that and facial bloating, body bloating.

Rick:

Sure.

Dr. Branca:

You also will begin to lose muscle tone, which doesn't improve your appearance. You will begin to become depressed, and this changes also the way that you dress. So the dress, the way that you dress becomes a form of expression of depression as well. I see people wearing the same sweatpants and sweatshirts day after day after day because they have sort of given up. They just don't groom anymore.

Rick:

Right. Well, you have just gotten to the point of talking about depression in people with migraine, and that leads me to the next topic of the emotional well-being of people. We have sort of been dancing around it, and it seems fairly obvious at this point that there has to be an emotional impact on the person's well-being. Is depression the primary consequence, do you think?

Dr. Branca:

Mood disorders in general are correlated with migraine. A number of studies have been performed about depression. You are 3.2 times more likely to have depression if you have migraines, and part of the reason for that is some of the same chemicals are missing in migraines as are missing in depression. So that's a pretty high figure. You are five or six times more likely to have anxiety and/or panic attacks if you have migraines. You are very likely to be irritable and to have anger outbursts if you have migraines. You tend to have a very short fuse. You are prone to having difficulty with your cognition. There are a number of studies that show that if you are in the middle of an attack, you cannot think. You have decrease in your verbal ability, your visual and spatial ability, planning or organization, and attention and concentration.

Rick:

I think you alluded to that earlier when you talked about the impact at work.

Dr. Branca:

Yes. But what's even more troubling, we know that over the years with repeated migraine attacks that the structure of the brain starts to change. You get like iron deposits in the brain. And some studies are showing that even in between attacks that the person will begin to have some cognitive problems. So that will affect your emotional well-being as well.

Rick:

Sure. And you mentioned earlier the feelings of guilt that a lot of people with migraine feel not only at work when they can't perform up to their usual standards, and at home when others have to sort of pick up for them when they are not up to it themselves. How about feelings beyond the guilt, I am thinking frustration, I'm thinking anger, do you see that a lot?

Dr. Branca:

I see it I think almost 100 percent…

Rick:

You do?

Dr. Branca:

…in patients that consult with me. They are extremely frustrated because their lives are so limited. They are not the people that they used to be and the people that they set out to be. In children, when they miss school, the children with severe migraines miss about 10 percent of school. They can't go horseback riding. They cannot go to the mall with their friends. The adults, they cannot do their career. They lose their jobs because they have migraines. They can't paint. They can't do a hobby that they want to do. They can't be with their friends. They become socially withdrawn. There is no point in making any plans. You can't make a deal with the higher power and say, “Okay, if I have my headache on Thursday, then I can go out to dinner with my friends on Friday.” There is no deal. The migraine is relentless, so people give up making any social plans for social activities.

Rick:

Yeah. So given that, Dr. Branca, those feelings, the physical consequences of migraine and this continuing cycle we have described, you work with people who suffer migraines on a regular basis, how do you help them overcome that relentless downward spiral?

Dr. Branca:

I think the first thing that's very important is to listen to what the person is saying because nobody really has listened to what the patient is saying. A lot of people have been told just to pull themselves up by the bootstrap, or they don't really have this pain, or they couldn't have that much pain. And one of the things that happens at our clinic is people just feel so much better by having that reality of theirs recognized and validated.

Rick:

Yes.

Dr. Branca:

And then the next thing is education. They need to know what type of headache they have, what the prognosis is for that headache, and they need to have realistic expectations. Many people are looking for a magic pill. They want the headache to go away. They want to be pain-free. And that's not realistic. They have a chronic disorder, and it's not going away. Nobody can ever promise to take your pain away or make it less. They can promise to be committed to working with you, and we want to make it better. So they need to look at what's realistic. A lot of people, they are terrified they are going to die. They don't understand the pain that they have, and generally we can reassure them that that's not the case. Then we look at what can you do.

Rick:

Yes.

Dr. Branca:

Let's focus on what you can do. And we make small changes on what we can do. We focus on lifestyle change, for example, having a regular sleep-wake cycle. This is very critical for migraine patients. And that sounds easy on paper, but it's much harder to do in real life. Our culture stays up late on the weekends and gets up late on Saturday and Sunday, and migraine patients can't do that. They have to have a very regulated sleep-wake cycle. They cannot have their circadian rhythms disrupted.

We work on exercise, which is hard. If you have pain, you really don't feel like exercising.

Rick:

Right. You don't want to move.

Dr. Branca:

And I will tap dance for that patient. I will stand on my head. I will laugh. I will nag. I will be General Branca. I mean, I will do anything to help them to exercise. Give me five minutes, walk five minutes away from your house and five minutes back. We will start on any level.

Then we go through all of the arenas of their life, their home, their job, their family, their marriage, and we look at making small changes. If this has become a totally pain-centered family, that's not healthy, and we have to change that.

Rick:

This is interesting. Listening to you describe this process, it's more than just avoiding triggers.

Dr. Branca:

Oh, yes.

Rick:

Yeah. So you're changing lives in ways that not only help to avoid triggers, obviously, but that address some of the other ancillary problems connected with this whole issue.

Dr. Branca:

Yes. You mentioned triggers. And we will work with a patient to look at what their triggers are. For example, weather is a big trigger for people, social events. So I work with handouts. I have a lot of handouts. So let's say a person is going to go to a social event. We will strategize how to go to that social event. For example, I will have them sit next to a wall, which decreases about 50 percent of the stimuli in the room. I will have them go late and leave early. There are a number of tricks for handling social events that make it more palatable for the patient.

We use headache diaries, and we keep track of things that might be triggers so that they can manage their pain situation better. We work very hard on learning how to take medication. Patients take a daily medication, and then they have abortive medications or medications they take for rescue, and they have to learn how to take those medications at the right time, like you don't take an abortive medication when your headache is at a level four. So that's kind of like putting perfume on B.O. You have waited too long. It won't work. You have to take it at the right place in your headache level. And we train people how to use their medications appropriately.

Rick:

Yes.

Dr. Branca:

So we have a very thorough program step by step.

Rick:

And if you are able to find the right treatment in addition to all that, that at least keeps the headaches under control, they are not as frequent, and maybe, hopefully not as a severe. Does that in and of itself help treat some the other problems, the emotional problems connected with that?

Dr. Branca:

Definitely. If a person's headache is less, it does help with some of the emotional reaction that the person has.

Rick:

I would think.

Dr. Branca:

But if they have unhealthy lifestyle, unhealthy family interactions, that needs to be addressed because if it isn't, it can perpetuate pain patterns, and they may not have gotten the pain relief that they should be getting if you don't look at the whole picture.

Rick:

Got it. So in terms of therapy for people with depression, do you ever take drugs for the depression to address that per se?

Dr. Branca:

Absolutely. Now, this is a complex question. Medications for migraine often serve dual or even triple purposes. As I mentioned earlier, some of the same neurotransmitters that are missing for people that have migraine are also missing in people that have clinical depression. So some of the same medications that are used in migraine will also help manage a person's depression. So if we've tried a patient on medication protocol and they still have depression, we will then look at adding a medication that's specific for depression or anxiety but not without cognitive or, shall we say, talk therapy.

Rick:

Yes.

Dr. Branca:

When a person is clinically depressed, you can see this in images of the brain. The front of the brain goes dark. And what studies show is the only things that makes the front of the brain light up again are two things: talk therapy and medication. And talk therapy trains you how to come out of depression so that you have gained skills. So you want to gain those skills, and the least amount of medication that you take, the better.

Rick:

I want to get to a couple other issues quickly before we go to questions from our audience for you, Dr. Branca. In terms of dealing with the issues that come up within the family, with your close friends, what do you advise the people you see in terms of how's the best way to go about working on those issues?

Dr. Branca:

Just when you look at how powerfully migraine affects the family, children, you want to look at children under the age of 12 and children over the age of 12.

Rick:

Okay.

Dr. Branca:

Under the age of 12, the child tends to keep quiet, plans are canceled, they get other child care. The child itself is very confused and quite angry. Over 12, that child tends to have to restrict any loud activities. They won't ask for any help. They cancel their plans. They avoid school, and they get really hostile. And what we have found to be quite helpful is – and often the children will be afraid, especially the child under 12, that their parent is going to die – so we want to avoid any pathological participation on the part of the child where the child is taking care of the parent.

Rick:

Right.

Dr. Branca:

We want to have the child involved in a way where they feel like they can be helpful, where they have a routine that they do, like they always go and get a glass of water for mom and give her a kiss, and that's kind of it. So they are not responsible for the parent. And usually we have the child come to the clinic, so they can see the place where mom or dad goes every month and meet with one of the behavioral psychologists. And we show them around the clinic, and we talk about what headache is or isn't. If they are under 12, we might draw pictures or they might talk to us and make a story about what happens when mom or dad has a headache, and we address their fears, and we tell them in age-appropriate language what migraine is and what it isn't, and reassure them.

When you deal with family and friends, I think that if it's a close friend, you can tell them what it is that's going on. But when people become intrusive – like every time you see them, “How are you feeling, how are you feeling, what medicine are you taking,” – it's important for you not to become a pain patient to your family and friends. And I'm going to tell you this in a very abbreviated way because this takes at least a whole session to learn. We generally encourage patients to say to the person who is asking this question, “I really appreciate you asking, but I don't want to talk about that right now. If I do feel like talking about it, I hope you will be there for me.” And then we ask the patients to change the subject.

Rick:

Right.

Dr. Branca:

Because it's important for the patient to be a person and not a pain patient.

Rick:

Okay.

Dr. Branca:

Does that make sense?

Rick:

It does, absolutely. Good advice.

Rick:

So, Dr. Branca, we have some questions coming in. Let's get to them. First one is from Tampa, Florida, and this listener writes, "I have had migraines since I was 13, hereditary on both sides. I have worked at the same place for 28 years, and I may go years without a migraine, and then I will have regular episodes, and I will miss work several times a month. I am a manager who has lost promotions due to this, and the stress of this and managing many times makes it worse. What can I do?" Big question.

Dr. Branca:

She has a very difficult problem. What I would suggest is that she get – I don't know if she has a regular headache specialist doctor – a regular headache specialist doctor. I know that there are headache doctors in Florida. Paul Winters is one physician that treats headaches. And I recommend that she get documentation that she has a headache disorder, and that would fall under the Americans with Disabilities Act. And get herself some protection in terms of her ability to be in the workplace with a disability, and see if she can use the Family Medical Leave Act to take time off work. I don't know if her employer has been informed that she has this medical condition, but I would suggest that she work along the lines of having a medical condition that will mean that there will be times when she will have to miss work. We write letters for our patients that have a medical condition that indicates that there are times when they are going to have to miss work due to the chronicity and severity of their pain.

Rick:

And that gives them some legal protection?

Dr. Branca:

Yes, it does.

Rick:

Good. From Shingle Springs, California comes this question, "Since most of my migraines are food-related, when I go out to eat or to a friend's house for a meal, I have to ask what's in the food they are serving. Does anybody else experience the embarrassment of having to ask for this information?"

Dr. Branca:

Absolutely. Food triggers are a problem for a lot of migraine patients. You can handle this by doing what you are doing now, which is calling ahead and asking what is being prepared. Patients with certain medications such as Nardil (phenelzine) have very severe dietary limitations. You might want to bring your own food. You don't have to explain anything. You don't have to get into any long explanations. Just say you are on a special diet, and you are just bringing your own food. And you do not want to trigger a headache, so that way you will have complete control of the food you are taking in, and you won't have to worry.

Rick:

From Lake City, Minnesota comes this question, "How do you get doctors and personnel to not think of you as a druggie who is just looking for drugs?"

Dr. Branca:

Oh, this is such a poignant question. One of the things that is so difficult that we have been working at our clinic is the fact that physicians are not taught, they are not given any formal training in pain management or how to really give out narcotics. So when a person goes to the ER or when they go to physicians and they are given pain management medications, they are kind of in a big, open sea. And you don't have to justify to anyone the medications that you are taking. If you have a physician that is a headache specialist and you trust him or her, you don't have to explain to anyone the medications that you are taking. It's really personal, and you do not have to disclose.

So if you have friends and family that are asking you questions about what you are taking, I would suggest that you do what I said earlier, which is say, “I appreciate you asking, but I don't want to talk about it. I hope that if I do want to talk about it, you will be there for me,” and then change the subject. It is a problem in ERs and with other doctors that you might be looked at as drug-seeking, and that is a common problem unfortunately. I just hope you have a really good headache doctor.

Rick:

From Altoona, Pennsylvania we get this question, "How do you deal with all the negativity from co-workers when you are already depressed? How do you make them understand just what that lost day due to the migraine has actually cost you?"

Dr. Branca:

This is really an excellent question. And there is no injection of understanding. I mean, I wish there was an injection that we could give to people that would make them understand. They have no idea what you are going through. They have none. I mean, I can't say it for all of them, but they don't understand what you are going through.

Rick:

And I guess in their defense if you have never had migraine, it's kind of hard to imagine, isn't it?

Dr. Branca:

It is hard to imagine, and what they don't understand is that the person with migraine is often going to the workplace with a moderate to moderately severe headache. And they don't say anything, and they don't usually miss unless they have a severe headache. So the person that's going to the workplace is going there compromised already and usually taking abortive medications. They are already hanging off the cliff. You can try to explain, but I wouldn't explain more than one time because either they get it or they don't.

Rick:

Okay. We have e-mail from Loveland, Colorado, "Along with the guilt is dealing with others who believe you are only using migraines as a way to get out of a commitment. How do I deal with this situation because it adds to the frustration and guilt, which adds to the stress, which, of course, adds to the migraines?"

Dr. Branca:

I think the answer I give to you is similar to the one that I gave to the person just preceding. There is no injection of understanding. You are not, I would presume, trying to avoid getting out of a commitment. It is well-known and documented in research that people with migraine and chronic pain begin to socially withdraw. Social interaction actually increases migraine because there is too much stimulation. It's hard for you to attend to what's going on. It actually is painful for people to engage in conversation. Your friends are either going to understand, or they will not understand. You can try explaining it to them once or twice. My understanding and my belief in my patients is they are not avoiding. They are really trying to manage their pain.

Rick:

Okay. E-mail from Tempe, Arizona is next, "Is there any link between type 1 diabetes and migraines? I started having migraines when I was diagnosed with type 1 20 years ago. Also, is there a link between emotions, anger in particular, and migraines?”

Dr. Branca:

We think there is a link between diabetes and migraine. There is a link between hormones and migraines. Before puberty, migraines are equally divided between males and females. And in the geriatric population, in the very elderly, again it becomes equal between males and females. But after puberty, it's about 80 percent female, and we think that the hormonal link in diabetes, the sugar is implicated in migraine. We know that there is a gastrointestinal component to migraines, so we think there is a link.

The second thing, anger is definitely implicated in migraine. It does not cause migraine, but it exacerbates the migraine condition. Many patients will say that when they get angry, they often immediately get a migraine. It's one of the kinds of stresses that can bring on a migraine.

Rick:

Sure. E-mail from Pasadena, California asks, "Isn't it possible, if not probable, that the feelings of depression are chemically tied to the cause of the migraines? For example, I take Imitrex (sumatriptan), the beta-blocker, but I also have been prescribed beta-blockers to combat depression. The question really is what is being done to follow this line of research?" What can you tell us about that?

Dr. Branca:

This line of research has been followed a great deal. I would refer you to Naomi Bresler in Detroit. As I said earlier, the same neurotransmitters are missing in depression as are missing in migraines.

Rick:

Right.

Dr. Branca:

And she has done some of the pioneering research on this. If you have migraine, you are 3.2 times more likely to get depression. If you have depression, you are 3.1 times more likely to get migraine.

Rick:

Is there a Web site to find out more about that?

Dr. Branca:

You can look up the author, Bresler, B-r-e-s-l-e-r, Naomi, and she's produced a lot of research on it.

Rick:

Great. E-mail from Richmond, Virginia is next, "What do you do when treatment of triptans fail and Topamax (topiramate) fails, anti-convulsants fail, anti-depressants fail, and counseling fails?"

So what's next?

Dr. Branca:

I would suggest that you go to a tertiary care clinic. I don't know if you have ever been hospitalized for headaches, but what we have found when a person has a complex and refractory condition like you where we have failed a number of treatments, is that you need a multidisciplinary team evaluation. I don't know anything about this person's background. But when we have someone who is refractory to treatment and has failed a number of different interventions, we would like a multidisciplinary team evaluation, and we generally hospitalize the person on an in-patient head pain unit. So don't give up hope. Never give up hope.

Rick:

Canyon Country, California is the source of this next e-mail, "How do I best support my boyfriend who suffers from chronic daily migraines? I am having a hard time finding the proper balance between my empathy and wanting to try to help him push beyond."

Dr. Branca:

I can understand that this must be very frustrating for you, and you do need to keep the proper distance because this is a battle he has to fight. I don't know where he is getting his treatment. If they have a behavioral medicine psychologist where he is getting his treatments, I would suggest that you have conjoint sessions together so that you can get a sense of what would be most appropriate for you so that you don't get in the position where you are trying to help him or oversuggest things to do. But at the same time, you need some support because this is very difficult to be the partner of someone who has a chronic disorder.

Rick:

Right. From New York, New York, "Sometimes I get so angry with my husband and his migraines. We always have to cancel plans due to his headaches, and I am usually left doing all the housework and taking care of the kids on my own. How do I get past my anger? Is it really fair that I have to suffer so much because of his headaches?"

Dr. Branca:

It's not fair. You are in a tough, very tough position. I would recommend for you what I recommended to the previous caller. If he will not go to a behavioral medicine psychologist together, which I think would be the best thing, you should get some support for yourself. I can understand you must be extremely frustrated because the burden of everything has fallen on you. So please get yourself some support. Ideally, you would go together.

Rick:

Those feelings of resentment we talked about earlier bubbling to the surface there clearly.

Dr. Branca:

Yes.

Rick:

San Francisco, California, "Lately, my depression has been so bad due to the pain of my migraines and the serious effect it has on my life that I sometimes feel suicidal. I just don't know where to turn." How common is that?

Dr. Branca:

That's very common. About 60 to 70 percent of the people that I see initially feel suicidal. They don't actually want too kill themselves, they just cannot tolerate the amount of pain that they are in.

This writer, please contact your local SOS crisis center and talk to someone if you are feeling like you are going to hurt yourself. You need to talk to someone, find a local therapist. Ask your family doctor to refer you to a therapist. Your feelings are very understandable. I don't want you to hurt yourself. It's hard to live with chronic pain. I know you feel alone, but you are not alone, so you need to find a therapist.

Rick:

And one last quick question from Columbia, Tennessee, "I find that when my migraines are not under control my anxiety level skyrockets. I start becoming paranoid that I have other types of diseases. Are my migraines contributing to these fears and anxiety? And if so, what can I do about that? The fear seems more debilitating than the migraines."

Dr. Branca:

Yes. You are right. As I said earlier, you are five to six times more likely to have anxiety and panic when you have migraines. If you are going to a headache doctor or if there is a pain clinic near you, you should find a behavioral pain psychologist to work with who believes in your pain, knows that your pain is real and not psychosomatic, and help you work with this anxiety that you have…

Rick:

Okay.

Dr. Branca:

…and maybe some medications for the anxiety.

Rick:

I am afraid we have to leave it there. We are just about out of time, but I wan to get a brief final thought from Dr. Barbaranne Branca. What would you like to leave our listeners with on this program?

Dr. Branca:

Please do not give up. Anyone who has chronic pain, do not give up. Seek treatment.

Rick:

Great. Dr. Barbaranne Branca from Ann Arbor, Michigan, thanks so much for being here today.

Dr. Branca:

Thank you for asking me to come.

Rick:

And I want to thank our audience for being here as well, for your great questions. And from HealthTalk, I'm Rick Turner.