Cogniphobia in Migraine: The Fear and Avoidance of Thinking
Cogniphobia is the fear and subsequent avoidance of cognitive exertion in people with migraine because it is believed to trigger migraine episodes.
Approximately 12% of people in the United States suffer from migraine; with 1 in 4 households containing a person with migraine.1-3 Characterized by episodic attacks of moderate to severe head pain with associated symptoms of nausea, vomiting, and sensitivity to light and sound, migraine is the most disabling neurologic condition worldwide.4,5 Because migraine is most prevalent during the peak years of productivity, these high rates of disability are particularly problematic in terms of occupational and household functioning.6 Migraine contributes to both missing work (absenteeism) and reduced functioning while at work (presenteeism).7
Cognitive difficulties during migraine may contribute to the high rates of burden in occupational and household functioning. Existing evidence suggests that, during a migraine episode, some people with migraine appear to experience mild transient reductions in cognitive functioning.8 This could be particularly problematic for adherence to acute migraine management strategies, as acute management of migraine is a cognitively demanding task. People with migraine must attend to a variety of sensory stimuli, sort symptoms into headache categories, track symptoms over time, and make in-the-moment decisions regarding acute migraine medication and non-pharmacologic management options to effectively manage migraines.9,10
Developing individualized decision support tools to help patients with migraine decide which acute treatment strategy to use with any given symptom profile may be particularly important when patients describe transient ictal cognitive difficulties.11 These further highlight the importance of reducing migraine frequency in people with migraine.
Some people with migraine have described difficulty thinking between migraine episodes, but evidence regarding interictal cognitive dysfunction is inconsistent.12 It is possible that migraine accounts for some persistent cognitive dysfunction in certain people with migraine; however, non-migraine phenomena likely account for some of the variation in the findings. Certain preventive migraine medications could contribute to cognitive difficulties.13 It is also possible that a cycle of fear of pain and avoidance of perceived triggers contributes to interictal cognitive difficulties in people with migraine.
This episodic symptom presentation distinguishes the patient experience of migraine from the patient experience of many other chronic diseases. A person with migraine may live most of his or her life symptom-free; however, on occasion, the person with migraine is often unexpectedly in significant pain and nauseated and/or vomiting, and routine sensory experiences are noxious. It is no surprise that people with migraine, as well as clinicians and researchers who work with migraine, expend a great deal of time and effort on identifying factors that may trigger migraine episodes. However, it is unclear to what extent triggers identified by patients reflect accurate migraine-triggering factors.14,15 Further, evidence suggests that fear (and subsequent avoidance) of triggers may be counterproductive in the management of migraine, and could contribute to migraine-related disability.16-18