Understanding the Source of Cogniphobia
The fear-avoidance cycle is a well established phenomenon whereby the fear of an aversive experience, such as migraine, leads to the avoidance of any behavior or situation believed to be associated with its onset, such as perceived migraine triggers.19 In the context of chronic musculoskeletal pain, people sometimes develop excessive fear and avoidance of movement (“kinesiophobia”), which leads to disuse of major muscle groups, depression, and long-term disability.20 Fear and avoidance also appear to be important in explaining disability in migraine.21 Between migraine episodes, people with migraine fear the next attack, which can lead to excessive worry and avoidance of situations and behaviors believed to trigger migraine attacks. In the long-term, it is plausible that this cycle of fear and avoidance could lead to hypervigilance to perceived migraine triggers, increased depression and anxiety, and disability associated with excessive reduction in the scope of typical daily activities.
Cognitive exertion (“thinking too hard”) is perceived by some patients to trigger migraine episodes.22 Cogniphobia refers to the fear, and subsequent avoidance, of cognitive exertion in people with migraine because it is believed to trigger migraine episodes. Although initially observed in a post-traumatic headache disorder population,23 cogniphobia has also been observed in primary headache disorder populations.24,25
In 74 young adults with migraine and/or tension-type headache, greater cogniphobia was associated with greater pain catastrophizing, as well as greater anxiety and avoidance of pain.24 In 80 patients with migraine who presented at a specialty care headache center, greater cogniphobia was associated with greater levels of maladaptive headache-related beliefs and a greater number of endorsed anxiety symptoms.26 This is consistent with the broader literature on the fear-avoidance cycle: people with migraine who hold beliefs that cognitive exertion is potentially harmful, and who subsequently avoid cognitive exertion, appear to be more likely to focus on their pain, believe that their pain is uncontrollable, and experience higher rates of anxiety, particularly related to pain.
Cogniphobia is a relatively novel concept within the field of headache that bears further investigation to understand its prevalence and impact, as well as methods to mitigate cogniphobia in people with migraine. It is possible that fear and avoidance of cognitive exertion could interfere with day-to-day decision making related to migraine management, reducing the clinical outcomes of acute migraine treatments in individual patients.
More broadly, thinking is central to everyday functioning. People with migraine who exhibit cogniphobia may reduce their engagement in cognitively-demanding tasks at work, school, and at home. In time, this could lead to self-selection of career tracks that are less cognitively demanding, or even potentially self-removal from the workforce. Preliminary evidence suggests cogniphobia is associated with higher rates of disability, particularly as it relates to occupational functioning.27 Further evaluation of the real-life implications of cogniphobia in people with migraine will shed light on the impact of this phenomenon. Evidence from the chronic pain literature suggests that fear and avoidance beliefs are modifiable28; future work should extend this literature to examine interventions to reduce cogniphobia in people with migraine.
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