The Puzzle of Refractory Headaches: Part IV

As I alluded to in Part III of this conversation, many factors can contribute to the development of refractory headache. I promised to return to the matter of emotional factors affecting pain, and we will discuss that here. This is a topic that I recognized to be a critical factor years ago, and for which, I am pleased to report, there is now a much broader and more effective range of effective treatments.

I stated in the previous post that it is ‘uncommon’ for emotional factors alone to be the cause of refractory headaches. I continue to think that that statement is true, based on my experience of the response of many patients, over many years, to medical treatments including nerve decompression. I certainly agree, however, that chronic head and neck pain is often, at least in part, affected by the emotional state, and that occasionally chronic migraine is rooted in an underlying emotional condition. My clinical experience has been that it is common for refractory headaches to have both structural and emotional components.

I recently had the illuminating experience of attending a class taught by Dr. Howard Schubiner and Dr. Mark Lumley on a therapeutic technique called Emotional Awareness and Expression Therapy (EAET). I learned from these esteemed doctors about the processes by which emotional factors can create pain, and this exciting new(ish) treatment to address that pain. Dr. Schubiner is a medical doctor who completed residencies in both internal medicine and pediatrics and Dr. Lumley is a PhD psychologist. Dr. Schubiner and Dr. Lumley are delightful and erudite men, and fortune placed them together at Wayne State University in Detroit, Michigan. Their collaboration led to the development of EAET in the 2010s, with the first paper on EAET published by them in 2015. They taught me and the other approximately 120 students – about half of whom were from outside the United States – that neural circuits can be laid down in the brain in response to danger signals, and that these circuits can be activated and cause pain later in life, a condition called neuroplastic pain. Other conditions such as pelvic pain, or the diffuse body pain of fibromyalgia, or gastrointestinal symptoms is often due to neuroplastic phenomena. In order to illustrate the mechanism by which the brain can create the sensory experience of pain, Dr. Schubiner cited the highly effective analogy of the visual experience of dreaming; the visions we see in a dream are a sensory experience created by the brain, not by the ‘structural’ phenomena of light rays entering the pupil, striking the retina, traveling through a long and complex visual pathway and ultimately reaching the visual cortex. And yet, the brain-created visual experience of dreaming is just as real and profound
as that which occurs with our eyes when we are wide awake. In a similar manner, the brain can create the sensory experience of pain under a certain set of circumstances. This pain is just as real as any other triggered pain, however, it is typically less responsive to medical interventions. The diagnosis of neuroplastic pain is made based on the combination of the presenting symptoms and the exclusion of a structural abnormality.

Emotional Awareness and Expression Therapy proceeds as follows: a therapist trained in EAET techniques helps the sufferer to access the circumstances in the past that led to the generative emotional states. Through a structured conversation, the sufferer is aided to confront and process the suppressed emotions, examining the breadth and depth of the feelings experienced. The emotions then are resolved in a safe and compassionate manner. This can be accomplished in a number of ways, for instance, by safely imagining confronting the abuser and expressing the validity of the anger and hurt experienced by the sufferer as well as the wrongness of the deed acted upon him or her. If appropriate, compassion may also be expressed toward the abuser. Most importantly, the sufferer is encouraged to feel and to express compassion for himself or herself in the form of the suffering child. This is a profound experience for the sufferer, and can lead to an emotional outpouring that is cathartic and
healing. As I wrote in an essay on this topic years ago, when such powerful and sorrowful emotions are present, how can we expect botulinum toxin or a CGRP pathway-inhibitor to fix it?

The role of emotional factors in migraine is critically important, and, many years ago, I started to rely upon the collaboration of psychologists to test for the presence of any emotional factors that may contribute to the development or experience of pain. The testing has been very helpful and does provide useful and actionable information, which I have used to ensure that all factors that are relevant to a patient’s pain are addressed. The problem was…there was no good therapeutic technique available. Long-established treatments such as Cognitive Behavioral Therapy had not shown efficacy in treating chronic headache. Confronting this brick wall with a patient was a frustrating and almost scary situation – we had identified that emotional factors were present that may be contributing to pain, yet we did not have any treatment to address the condition. Learning about EAET as a treatment for chronic pain was a huge relief for me. Validating that EAET is effective in treating chronic headache, Dan Kauffman, PhD, from the University of Utah and colleagues including Dr. Mark Lumley, just published the first study of EAET in migraine (Kaufmann et al, Emotional Awareness and Expression Therapy in Migraine: a preliminary randomized controlled trial, Pain Medicine, 2026, 1-4). They demonstrated a significant reduction in Monthly Migraine Days (MMD) in subjects who were treated with EAET as opposed to a control group. A reduction of 7 MMD was seen in the treatment group compared to a reduction of 1.7 MMD in the control group. They did not break down the reductions in the population of episodic migraine versus chronic migraine, and that statistic would be very interesting to see. In my experience, it is more likely that the subjects in the chronic migraine (CM) group had a structural component compared to the episodic migraine (EM) group, and so I would expect that the CM group were less likely to respond to EAET than the EM group. Perhaps the authors of this important study can look into this particular area in future studies. It is also noteworthy that the participants in the
treatment arm of the study had a significant history of trauma, with an average Adverse Childhood Experience score of 5. It would be interesting to see if the response rate differed for people with higher levels of trauma to those with lower levels of trauma; one may expect that the greater the prior exposure to trauma, the more effective EAET will be.

It is important to recognize that other factors may result from chronic emotional stress that may play a role in the development of chronic headache. One important factor pertains to inflammation. Exposure to chronic stress may have an effect on inflammatory mechanisms. As mentioned in previous posts, it has been shown that increased inflammation is present in the occipital periosteum of individuals with nerve compression compared to people without nerve compression. In my clinical experience, it is not uncommon for nerve compression headache to begin, or significantly worsen, in the setting of acute stress, and then persist even after the stress has diminished. It would be helpful to study inflammatory processes more closely in animal studies or human studies to see if inflammation may also be a mediator of chronic stress and chronic pain.

As I stated above, in my experience it is common for both structural and emotional factors to play a role in chronic head and neck pain, along with other factors. The art of headache medicine is identifying the presence of any and all of these factors, and treating each one properly. Greater understanding of the role that emotions play in pain is a highly important step forward for the treatment of chronic head and neck pain, and this is an exciting area in which we are learning together. As always, an openness to new ideas and a critical examination of long-standing beliefs is necessary to ensure that our conversation about the causes of chronic head and neck pain are not being driven by biases and opinion, but rather evidence.