“When will the next attack come?” Living in fear of future migraine attacks

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, Maryland, USA surveyed 10,000 individuals using a reliable, standardized questionnaire from the National Institute of Mental Health. The survey covered various areas of participants’ well-being, including the occurrence of anxiety or panic attacks. If these kinds of attacks occurred, the researchers also recorded the participants’ headache burden to determine whether there were significant differences compared to 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 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. This indicates a measurably increased risk.

Anxiety and migraine: a two-way street

Over the past decades, many surveys have shown that migraine and anxiety feed into each other. Having one significantly increases your risk of developing the other. Scientists have been searching for explanations since the 1990s, exploring causes including genetic factors, changes in neurotransmitters, hormonal fluctuations, and changes in the hypothalamic-pituitary-adrenal (HPA) axis. The HPA axis is a complex hormone-driven system involving the hypothalamus in the brain, the pituitary gland, and the renal cortex (the outer layer of the adrenal gland). It contributes to many bodily functions, including stress responses – and as many people know, stress is a major migraine trigger. In fact, the hypothalamic-pituitary-adrenal axis is also called the “stress axis”.

For people with migraine, the periods between attacks can be just as distressing as the attacks themselves. In one large research study, more than half of participants reported that the fear of the next headache was one of the hardest parts of living with migraine. The constant cycle of anxiety and pain often leads to permanent tension and emotional stress. This chronic strain can be a breeding ground for many mental health conditions.

Migraine rarely comes alone

As more research has emerged, one thing has become clear: migraine is rarely an isolated condition. Common accompanying conditions include anxiety disorders, panic attacks, insomnia and depressive disorders (for more information, read this article). The risk seems to be especially high for people with migraine who also experience aura.

A more recent study from 2025 looked at how these accompanying conditions affect everyday life. People were less able, or felt they were less able, to meet the demands of work and to enjoy their free time. Overall quality of life was impacted considerably.

Many also struggle with sleep problems. A Japanese research group studied migraine patients for insomnia, sleep apnoea (temporary breathing interruptions during sleep), and problems reaching deep sleep, which is essential for proper rest. An astonishing 87% of participants said they experienced at least one of these sleep issues. These sleep disturbances also showed up clearly in standardized tests such as the MIDAS questionnaire (for more about MIDAS and what it means, see here).

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.

A harmful coping strategy: medication overuse

How do people respond to all this pressure? A research team from the University of Bologna, Italy found that fear of the next attack often leads patients to take painkillers before symptoms start, hoping to “stay ahead” of the migraine. Unfortunately, this can backfire. Using pain medication can, paradoxically, lead to its own kind of headache: a condition called medication-overuse headache (read more about it here). The Italian study found a direct connection between anxiety and medication use: the more anxious patients were, the more medication they took. This shows a real need for better education on safe and effective preventive strategies.

How to address anxiety

Following many years of dedicated effort into understanding this complex condition, research and clinical practice have now also developed so-called non-pharmacological treatment strategies. These approaches do not rely on medication to prevent headache attacks. The effectiveness of some of these methods has been demonstrated repeatedly in independent studies. Non-pharmacological treatments have been used in migraine treatment for some time with measurable success.

A key theme across all of them is stress reduction. Stress is a potential trigger for migraine attacks. Constant stress increases general sensitivity to headaches. Sudden spikes in physical or emotional stress can directly trigger an attack.

Effective methods that don’t involve medication

Cognitive behavioural therapy, often known as CBT, is a structured therapy that helps people identify and challenge unhelpful thoughts and behaviours. By changing these patterns, patients learn healthier coping strategies and can influence how they interpret and experience pain. Rigorous studies consistently show that CBT can significantly reduce both the frequency and the intensity of migraine attacks.

Another method is progressive muscle relaxation (PMR), developed by Jacobson. PMR has an established track record in preventing migraines. In PMR, people systematically tense and relax different muscle groups. This lowers overall muscle tension, as well as tension in the body as a whole. Potential benefits include relief from migraine pain and prevention of new attacks. Instructions for PMR can be found here or in the app).

With the regular use of these proven preventive strategies, people with migraine can regain some sense of control over their condition. The feelings of helplessness decrease, and the constant fear of the next attack becomes more manageable. This, in turn, reduces the enormous burden that migraine brings to people’s lives.