"When will the next attack come?" Attack anxiety in people with migraine.

"When will the next attack come?" Attack anxiety in people with migraine. 

For people with migraines, the suffering often goes beyond the actual headache. As soon as the pain fades, they start worrying when the next attack is going to hit. This anxiety can have serious consequences. In fact, it can even increase the risk of new attacks and may contribute to other health issues.

Attack anxiety: what exactly is it?

As early as the late 1980s, the American journal Psychosomatic Medicine published an article on this anxiety phenomenon in people with migraines. Researchers at the renowned Johns Hopkins University in Baltimore surveyed 10,000 individuals using a reliable, standardized questionnaire from the National Institute of Mental Health. The survey covered various aspects of participants’ well-being, including the occurrence of anxiety or panic attacks. If anxiety or panic attacks occurred, the researchers also recorded the participants’ headache burden to determine whether there were significant differences compared with people without such symptoms. They found that participants who experienced anxiety and panic attacks reported unusually frequent and especially long-lasting headaches during the study period, including migraine-type headache attacks. Male participants with anxiety and panic attacks reported having a migraine in the week before the survey seven times more often than participants in the “anxiety-free” comparison group. Other scientific studies have found that, conversely, people with migraines are up to four times more likely to develop true panic attacks than individuals without this type of headache.

Anxiety and migraine: a bidirectional relationship

Over the past decades, numerous studies have shown that the relationship between anxiety and migraine is bidirectional. This means that having one of these conditions significantly increases the risk of developing the other. Since the 1990s, researchers have increasingly proposed explanations for this interaction. Different research approaches have considered different causes, including genetic factors, neurotransmitters in the nervous system, hormonal fluctuations, and the hypothalamic-pituitary-adrenal axis (HPA axis). The HPA axis is the name given to a complex regulatory system, mediated primarily by chemical messengers, involving the hypothalamus, pituitary gland, and adrenal cortex. It influences many bodily functions, including the stress response, which plays a key role in migraine. The hypothalamic-pituitary-adrenal axis is therefore also referred to as the stress axis.

For people with migraine, the periods between attacks can be just as distressing as the attacks themselves. In one large clinical study, more than half of participants reported that the fear of the next headache was one of the hardest parts of living with migraine. Constant shifts between phases of anxiety and migraine attacks often result in nearly continuous emotional and psychological stress, creating a breeding ground for numerous accompanying mental health comorbidities.

Migraine rarely comes alone

As research efforts have intensified, it has become increasingly clear that migraine cannot be viewed as an isolated condition. States of psychological stress such as anxiety disorders, panic attacks, sleep problems, and depressive disorders are typical comorbidities (for more, read this article). The risk of these comorbidities is particularly high among patients whose migraines are accompanied by aura.

A newer study from 2025 examines how strongly migraine comorbidities impact all areas of the affected individuals’ lives. They become both objectively and subjectively less able to meet the demands of work or to enjoy their leisure time, and their overall quality of life is significantly reduced.

Sleep disturbances place a particular burden on patients. A Japanese research group examined migraine patients for various forms of sleep problems, including insomnia, sleep apnoea, and the inability to reach deep sleep phases, which are essential for restful sleep. A large share of participants (87%) reported being affected by at least one of these issues. The impact of these sleep problems was reflected in widely used assessment tools such as the MIDAS (see here for more about MIDAS and why it’s important).

All of this shows that for many people, migraine leads to a level of disease burden that goes far beyond what is commonly associated with a headache disorder.

Harmful coping strategies: medication overuse

How do patients respond to these many stressors? A research group at the University of Bologna has shown that the “specific illness phobia” associated with migraine, meaning the constant fear of the next attack, often leads patients to take pain medication preventively in an attempt to ward off future attacks. This can have serious consequences, because medication overuse can itself cause a particularly severe and difficult-to-treat type of headache known as medication-overuse headache (see here for more information). The Italian study identified a direct relationship between the intensity of attack-related anxiety and the extent of medication use, demonstrating that there is a significant need for patient education on appropriate preventive measures.

How to address anxiety

Through many years of research and clinical practice in the complex field of migraine, several non-pharmacological treatment strategies have been developed. These approaches aim to prevent attacks without the use of medication. Independent studies have repeatedly demonstrated the effectiveness of some of these methods, and they have long been used successfully in migraine treatment.

A central focus is stress reduction. Increased stress perception is a potential trigger for migraine attacks. Ongoing stress leads to a generally heightened vulnerability to headache. Significant spikes in stress, whether physical or emotional, can directly trigger attacks.

Effective non-pharmacological methods

Cognitive Behavioural Therapy (CBT) is a specific form of psychotherapy in which negative thoughts and behaviours related to the patient’s migraine condition are identified and challenged. By changing thought and behaviour patterns, patients learn to develop better coping strategies and to shift their perception of pain. Studies show that CBT helps reduce both the frequency and severity of migraine attacks.

Another method is Progressive Muscle Relaxation (PMR) developed by Jacobson. PMR has also proven effective in migraine prevention. Patients consciously focus on tensing and then relaxing different muscle groups. This reduction in overall muscle tension, and therefore in overall bodily tension, can help relieve migraine pain and prevent attacks. Instructions for PMR can be found here or in the app.

By practising these evidence-based methods, people with migraine can regain some sense of control over their condition. Feelings of helplessness and the constant fear of the next attack may lose some of their intensity, which in turn can help reduce the overall burden of the illness.

Published: November 2025