Resource type: Employers

Mental Health, Migraine, and Burnout in the Workplace

What is the Connection Between Mental Health and Migraine, and How Can This Lead to Burnout in the Workplace?

 

Mental health disorders, migraine, and their connections

A mental health disorder, or mental illness, is a medical condition and affects a person’s mood, thinking, or behavior. 1 Common examples include anxiety, depression, and bipolar disorder. Migraine is a neurological disease and a primary headache disorder with symptoms such as headache, nausea, and sensitivity to light, sound, and smell. 2  

 

Migraine is not a mental health disorder. Migraine is a complex neurological disease. However, the relationship between migraine and mental health is complex and likely bidirectional. 3  

 

Migraine and mental health disorders often occur alongside one another. 

Migraine and many mental health conditions are comorbid, meaning that they occur in a higher likelihood together than they occur in the general population. 

 

There are both physiological and psychological reasons why migraine and mental illnesses occur together. 

The full connection as to why these conditions frequently occur together is still not understood. According to Dawn Buse, an associate professor in the Department of Neurology at Albert Einstein College of Medicine and the director of Behavioral Medicine at the Montefiore Headache Center,  “We think there might be some underlying reason, maybe a genetic reason, or the fact that both depression and migraine act off similar biochemicals in the brain and in the body that predisposes someone to have one, and then the second.” 4

 

Living in chronic yet unpredictable pain takes an emotional toll.

Along with the physiological connections, there is also a strong emotional component of how living with an unpredictable and disabling chronic health condition can affect your life. Chronic pain (like migraine) and mental health can mutually exacerbate each other, leading to additional physical and psychological complications. 5 People with migraine are forced to miss out on social events, job opportunities and promotions, and special occasions. This leads to social isolation, which can exacerbate mental health conditions. 6 In light of the chronic pain and poor treatment that many people living with migraine experience. It is perhaps not surprising to see higher levels of depression and anxiety among this population.  

 

Cephalalgiaphobia refers to the cycle of fear and anxiety created by unpredictable or frequent migraine attacks. 

The term cephalalgiaphobia translates to ‘fear of head pain’ and describes the anxiety of never knowing when the next migraine attack may strike. 7 Stress can trigger a migraine attack, and a migraine attack often causes additional  stress. 8 People who experience regular attacks may become trapped in a vicious cycle of worrying whether they will be able to attend an event, or complete an assignment, and this stress alone can then trigger or exacerbate the next migraine attack. 

 

Mental illness can increase the frequency of migraine attacks.

Untreated mental health conditions can exacerbate migraine and is a risk factor of chronification. Migraine becomes chronic once an individual experiences at least 15 headache days per month, 8 of which have additional migraine symptoms. 9  

 

Migraine has connections with many mental illnesses: 

 

Depression

People with migraine are 2.5 x more likely to experience depression. One study found that in patients with migraine, 41-47% of them also had depression. 10  

 

Anxiety

People with migraine are 2-5 x more likely to experience an anxiety disorder than the general population, and more than half of those with migraine will experience an anxiety disorder throughout their lifetime. 11 The most common anxiety disorders in those with migraine are generalized anxiety disorder, panic disorder, and obsessive compulsive disorder. 12

 

Post-Traumatic Stress Disorder

Also an anxiety disorder, post-traumatic stress disorder (PTSD) is also more common in those with migraine. Those with episodic migraine are 3-4 x  more likely to also experience PTSD. 13 Those living with both migraine and PTSD are more likely to lose more work days and experience greater disability compared to those with migraine and no PTSD. 14 Interestingly, both migraine and PTSD are 3x more likely in females than males. 15

 

Bipolar Disorder

People with migraine with aura are about 3 x more likely to also have bipolar disorder. In addition, of those living with bipolar disorder, about 1/3 also have migraine disease. 16 Those with comorbid migraine may have a higher risk of an unstable rapid cycling course of their bipolar disorder. 17

 

Suicide

Those with migraine have 3 x the rates of suicide than the general population. 18 The chances of suicidal ideation, suicide plans, and suicide attempts increase in those with migraine. 19

(If you are experiencing suicidal thoughts, please reach out to your doctors, loved ones, or the Suidide Hotline at 1-800-SUICIDE , 1-800-784-2433.)

 

Other Psychiatric Conditions

Migraine is more common in those who have suffered from abuse, whether the abuse was emotional, sexual, physical, or neglect. 20 Those with migraine are more likely to live with attention deficit hyperactivity disorder (ADHD). 21 In addition, there are many other psychological comorbidities of migraine. 

 

The impact of mental health in the workplace

 

Mental health can affect multiple aspects of a person’s life, including their work life. Many would argue that employers hold an obligation to ensure that their employees have the opportunity to access resources to help address both mental and physical health issues. 

 

Nearly 1 in 5 Americans live with at least one mental health disorder. 22 Americans are one of the most stressed populations worldwide, with 55% of Americans experiencing daily stress- 20% above the global average of 35%. 23

 

Stress is costing US employers billions.

This stress isn’t something employees can just leave at the door. 83% of US workers suffer from work-related stress. Stress causes 1 million Americans to miss work each day, and costs US businesses $300 billion each year. 24 The National Safety Council estimates that companies spend $15,000 a year on each employee experiencing mental health issues. 25 The CDC reports that depression alone has an annual toll of 200 million lost workdays to American businesses. 26 In addition to this, migraine is also costing employers billions of dollars annually.

 

Stigma of both migraine and mental health disorders prevent employees from seeking help.

Stigma prevents people from disclosing these conditions and requesting support. Less than 30% of employees feel comfortable disclosing a mental illness to their employer, and less than 25% feel comfortable notifying human resources. 27 The stigma of migraine also prevents employees from seeking assistance at work. 

 

Effective workplace programs for both migraine and mental health exist. 

Fortunately, there are effective management strategies for both mental health disorders and migraine in the workplace. For mental health, strategies such as Employee Assistance Programs, with free and anonymous mental health assessments and treatment options, and comprehensive health insurance plans can benefit employees. More detail about these and other strategies are discussed at the end of this article. 

 

As for migraine, there are numerous studies- including those covered in the Harvard Business Review– which highlight effective workplace programs. 28 Simple education programs, such as newsletters, webinars, or lunch conferences, can help employees identify both the diagnosis and treatment options for migraine. A literature review of multiple studies proves that these programs can increase productivity by 29-36%. 29 Accommodations for migraine in the workplace have proven effective and inexpensive. These programs can drastically reduce the cost of migraine for both employee and employer. As migraine improves, improvements in depression and anxiety may also occur, creating a virtuous cycle. Contact us today for a free survey to determine the prevalence of migraine in your office. 

 

If mental health disorders, migraine, and / or other health issues continue to go unaddressed, deteriorating health and burnout amongst employees may occur. 

 

What is employee burnout, and how can it be prevented?

According to Forbes, workplace burnout is the “​​extreme physical and emotional exhaustion that results in a lack of professional efficacy, increased cynicism, lack of engagement and depleted energy.” 30  

 

Burnout worsens employee medical conditions.

Burnout leaves employees at risk of worsening current medical conditions like migraine and mental health disorders, and potentially triggering new medical conditions such as high blood pressure, insomnia, substance abuse, heart disease, and vulnerability to contagious illnesses. 31

 

Taking steps to prioritize health and prevent burnout in your office may be easier than you think. 

 

Consider the following measures to prioritize mental wellness in your office. 

– Strive to create a supportive company culture where employees do not feel stigmatized and afraid to disclose any medical conditions such as migraine or mental illnesses. Getting support as soon as possible can help prevent burnout. Implement mandatory manager trainings on how to address mental health and migraine in the workplace.

– Lead by example. Employees seeing their managers embrace support options for mental health can pave the way for these employees to feel supported in accepting these resources. 32

– Offer accommodations like flexible scheduling and remote working. 

– Offer an Employee Assistance Program, providing mental health assessments and counseling services for a variety of stress coping mechanisms and mental health services. 33  

– Consider policies such as unlimited paid time off (PTO), so that employees are not intimidated to take advantage of mental health days. 34

– Provide comprehensive health insurance plans which will enable your employees to address these conditions before they are forced to exit the workplace. 35

– Make meaningful changes to help reduce stress in the workplace. Take preventative measures to help root out the actual causes of workplace stress like high job strain, a lack of social support, poor management, and poor recognition and compensation, instead of simply trying to ease the symptoms of workplace stress and burnout. 36  

– To learn more about how specific companies have implemented successful mental health programs in the workplace, visit the CDC’s website here.  37

 

Whether it’s for migraine, a mental health disorder, or any other type of illness or disability, by not providing employees with proper support, the company is paying for it in lost productivity, lower retention and staff satisfaction. These losses accrue to the bottom line in each business. They also play a role in the employer’s ability to attract and retain top talent. Reach out to us today for free or paid services to better support your employees with migraine or mental health issues.

 

 

1)Mayo Clinic Staff, 2019, Mental Illness, Mayo Clinic, <https://www.mayoclinic.org/diseases-conditions/mental-illness/symptoms-causes/syc-20374968>
2)2021, Migraine headaches, Cleveland Clinic, <https://my.clevelandclinic.org/health/diseases/5005-migraine-headaches>
3)Breslau, et al, 2000, Headache and major depression: is the association specific to migraine?, Neurology, <https://pubmed.ncbi.nlm.nih.gov/10668688/>
4)2018, Understanding the relationship between migraine and mental health, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/link-between-migraine-depression-anxiety/>
5)IsHak, et al, 2018, Pain and Depression: A Systematic Review, Harvard Review of Psychiatry<https://pubmed.ncbi.nlm.nih.gov/30407234/>
6)Novotney, A., 2020, The risks of social isolation, American Psychological Association, Monitor on Psychology, <http://www.apa.org/monitor/2019/05/ce-corner-isolation>
7)Giannini, et al, 2013, Cephalalgiaphobia as a feature of high-frequency migraine: a pilot study, Journal of Headache and Pain,  <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3686604/>
8)2017, Stress and Migraine, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/stress-migraine/>
9)Minen MT, Begasse De Dhaem O, Kroon Van Diest A, et al, 2016, Migraine and its psychiatric comorbidities, Journal of Neurology, Neurosurgery & Psychiatry, <https://jnnp.bmj.com/content/87/7/741>
10)Minen MT, Begasse De Dhaem O, Kroon Van Diest A, et al, 2016, Migraine and its psychiatric comorbidities, Journal of Neurology, Neurosurgery & Psychiatry, <https://jnnp.bmj.com/content/87/7/741>
11)Minen MT, Begasse De Dhaem O, Kroon Van Diest A, et al, 2016, Migraine and its psychiatric comorbidities, Journal of Neurology, Neurosurgery & Psychiatry, <https://jnnp.bmj.com/content/87/7/741>
12)Baskin, et al, 2006, Mood and anxiety disorders in chronic headache, Headache, <https://pubmed.ncbi.nlm.nih.gov/17034402/>
13)Peterlin, et al, 2014, Post-Traumatic Stress Disorder and Migraine: Epidemiology, Sex Differences, and Potential Mechanisms, Headache, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3974501/>
14)Rao AS, Scher AI, Vieira RV, et al, 2015, The impact of post-traumatic stress disorder on the burden of migraine: results from the national comorbidity survey-replication, Headache, <doi:10.1111/head.12698>
15)Peterlin, et al, 2014, Post-Traumatic Stress Disorder and Migraine: Epidemiology, Sex Differences, and Potential Mechanisms, Headache, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3974501/>
16)Fornaro & Stubbs, 2015, A meta-analysis investigating the prevalence and moderators of migraines among people with bipolar disorder, Journal of Affective Disorders, <https://pubmed.ncbi.nlm.nih.gov/25801521/>; Minen MT, Begasse De Dhaem O, Kroon Van Diest A, et al, 2016, Migraine and its psychiatric comorbidities, Journal of Neurology, Neurosurgery & Psychiatry, <https://jnnp.bmj.com/content/87/7/741>
17)Gordon-Smith K, et al, 2015, Rapid cycling as a feature of bipolar disorder and comorbid migraine. J Affect Disord;175:320–4. <doi:10.1016/j.jad.2015.01.024>
18)Fuller-Thomson E, Hodgins GA. Suicide attempts among those with migraine: findings from a nationally representative Canadian study. Arch Suicide Res. (2019) 24(Suppl. 1):360–79. doi: 10.1080/13811118.2019.1578710, <https://www.tandfonline.com/doi/abs/10.1080/13811118.2019.1578710?journalCode=usui20>
19)Minen MT, Begasse De Dhaem O, Kroon Van Diest A, et al, 2016, Migraine and its psychiatric comorbidities, Journal of Neurology, Neurosurgery & Psychiatry, <https://jnnp.bmj.com/content/87/7/741>; Berhane HY, Jamerson-Dowlen B, Friedman LE, Berhane Y. Association between migraine and suicidal behaviour among Ethiopian adults. BMC Psychiatry. (2018) 18:46. doi: 10.1186/s12888-018-1629-7
20)Gretchen E Tietjen & B Lee Peterlin, 2011, Childhood abuse and migraine: epidemiology, sex differences, and potential mechanisms, Headache, <https://pubmed.ncbi.nlm.nih.gov/21631473/>
21)Fasmer, et al, 2011, Adult attention deficit hyperactivity disorder is associated with migraine headaches, European Archives of Psychiatry and Clinical Neuroscience,<https://pubmed.ncbi.nlm.nih.gov/21394551/>
22)2019, Mental Health in the Workplace Mental Health Disorders and Stress Affect Working-Age Americans, Center of Disease Control and Prevention,  https://www.cdc.gov/workplacehealthpromotion/tools-resources/workplace-health/mental-health/index.html>
23)2019, 42 Worrying Workplace Stress Statistics, The American Institute of Stress, <https://www.stress.org/42-worrying-workplace-stress-statistics>
24)2019, 42 Worrying Workplace Stress Statistics, The American Institute of Stress, <https://www.stress.org/42-worrying-workplace-stress-statistics>
25)2021, ≥, NSC and NORC at University of Chicago, <https://www.nsc.org/newsroom/new-mental-health-cost-calculator-demonstrates-why>
26)Minor, 2021, Mental Health In The Workplace: The High Cost Of Depression, Forbes, https://www.forbes.com/sites/mariaminor/2021/01/20/mental-health-in-the-workplace-the-high-cost-of-depression/?sh=dcfb956666ff
27)Bertsos, 2020, The New Rules of Taking a Mental Health Day From Work, Thrive Global,  <https://thriveglobal.com/stories/the-new-rules-of-taking-a-mental-health-day-from-work/>; 2019, Mental Health at Work, Mind Share Partners, <https://www.mindsharepartners.org/mentalhealthatworkreport>
28)Begasse de Dhaem, 2021, Migraines Are a Serious Problem. Employers Can Help, Harvard Business Review, <https://hbr.org/2021/02/migraines-are-a-serious-problem-employers-can-help>
29)Begasse de Dhaem, et al, 2020, Identification of work accommodations and interventions associated with work productivity in adults with migraine: A scoping review, Cephalalgia, <​​https://pubmed.ncbi.nlm.nih.gov/33302697/>
30)Kurter, 2021, Employers, Here Are 4 Ways You Can Begin To Effectively Tackle Employee Burnout, Forbes, <https://www.forbes.com/sites/heidilynnekurter/2021/04/27/employers-here-are-4-ways-you-can-begin-to-effectively-tackle-employee-burnout/?sh=57c9af316009>
31)Mayo Clinic Staff, 2021, Job burnout: How to spot it and take action, Mayo Clinic, <https://www.mayoclinic.org/healthy-lifestyle/adult-health/in-depth/burnout/art-20046642>
32)Bertsos, 2020, The New Rules of Taking a Mental Health Day From Work, Thrive Global,  <https://thriveglobal.com/stories/the-new-rules-of-taking-a-mental-health-day-from-work/>
33)What is an Employee Assistance Program (EAP)?, U.S. OFFICE OF PERSONNEL MANAGEMENT

,<https://www.opm.gov/faqs/QA.aspx?fid=4313c618-a96e-4c8e-b078-1f76912a10d9&pid=2c2b1e5b-6ff1-4940-b478-34039a1e1174>
34)Sammer, 2020, 4 Lessons About Unlimited Vacation, Early adopters share what they’ve learned so far, SHRM, <https://www.shrm.org/resourcesandtools/hr-topics/benefits/pages/4-lessons-about-unlimited-vacation.aspx>
35)2021, Cost Effectiveness Infographic, Headache and Migraine Policy Forum, <https://static1.squarespace.com/static/5886319ba5790a66cf05d235/t/61a66c28d397313ed8ce809f/1638296617697/HMPF_CostEffectiveness_Infographic_Dec2021.pdf>
36)Stansfeld, et al, 2006, Psychosocial work environment and mental health- a meta-analytic review, Scandinavian Journal of Work, Environment & Health, <https://www.jstor.org/stable/40967597?seq=1#page_scan_tab_contents>
37)2019, Mental Health in the Workplace Mental Health Disorders and Stress Affect Working-Age Americans, Center of Disease Control and Prevention,  https://www.cdc.gov/workplacehealthpromotion/tools-resources/workplace-health/mental-health/index.html>

Migraine is Not “Just a Headache”

Migraine is a neurological disorder whereas headache is a symptom.

 

As an employer, how do you respond when an employee says they have migraine? If it’s  one of the following responses, your employees may not feel like they have your support, even if your intentions were good. 

  • – “Take an ibuprofen and get back in there!”
  • – “Have you tried drinking more water?”
  • – “Oh, I get headaches, too.” 

 

Migraine is a complex, debilitating neurological disease. 1 It’s the leading cause of disability in the US for people under 50. 2 And yet people living with this disorder are continuously belittled with the above comments and the stigma of migraine. These misconceptions are so pervasive that people feel the need to hide this disease, especially at work. 3  

 

Why is there confusion about migraine versus headache? 

1- 40% of those who have migraine haven’t been diagnosed. This is largely due to the stigma of migraine, awareness, lack of research, low funding, and under diagnosis. 

2- Migraine has a wide range of severity. While one person may have mild symptoms on rare occasions, another person may have severely disabling symptoms on a continuous basis. Those with mild symptoms may be able to ‘power through’ their attacks and may thus unjustly assume everyone else should also be able to easily manage migraine.

3- A painful headache is often mistaken for migraine. The perception that any painful headache is classified as a migraine attack undermines the fact that migraine is a genetic, neurological disease with dozens of unique symptoms. Over 70% of people will experience a tension headache at some point in their life. 4 While many headaches- including tension headache- can be quite painful, not all of these headaches are actually a sign of migraine. 

4- Migraine is not well understood. Very few people without relatively severe migraine know that it is a specific disease. Even fewer people know about more rare symptoms such as temporary paralysis or slurred speech. This misunderstanding even exists amongst medical professionals, as undergraduate medical school only provides less than four hours of headache education. 5 If an individual doctor does not seek out additional training, it is unlikely that they will understand the complexities and severity of this condition.  

5- You can’t see migraine or headache. Many of the symptoms of both migraine and headache are invisible to others, especially to those who do not know to look for them. When somebody does not have visible signs like a cast or a bruise, it is more likely that other people may discount their pain and assume they are faking or exaggerating. 6  

6- Some individuals seek attention or sympathy. Some people fake or exaggerate medical conditions to get out of certain duties or simply to be noticed. An “invisible” condition like migraine may be easier to fake. This may lead others to dismiss those truly experiencing these symptoms. It should be noted that those with migraine are far more likely to fake being well than to fake being sick. 

 

Well, if it’s not a headache, then what is migraine?

Migraine is a neurological disease which can affect the entire body 7 . It is a disease that spans a broad spectrum of severity and frequency. In some cases it can be mild and infrequent and for around 3-5% of people it can be frequent, painful and disabling. There is no cure for migraine, and it affects everyone differently.  

An acute migraine attack refers to the attack itself while the disease is referred to as migraine. 8

 

Common symptoms include:

  • – Head pain. While this one is obvious, the severity and quality of this pain can vary between individuals, and even between attacks. 9 This pain alone can completely disable a person.
  • – Nausea and vomiting 10
  • – Light/ sound/ scent/ taste/ touch sensitivity 11
  • – Intolerance to movement 12
  • – Fatigue 13
  • – Musculoskeletal Pain (Neck, jaw, shoulder, sinuses, etc.), numbness, and/ or tingling 14
  • – Tinnitus 15
  • – Dizziness and vertigo 16
  • – Gastrointestinal issues (diarrhea, constipation, etc.) 17
  • – Cognitive issues (brain fog; issues with concentration, memory, and word finding)
  • – Autonomic symptoms (chills/ hot flashes; eye redness/ tearing; sinus pressure) 18
  • – Less common symptoms include stroke-like symptoms such as paralysis; loss of vision; impaired consciousness 19  

 

Migraine can affect the way the brain interprets stimuli from every one of the senses during an attack. Lights are brighter (photophobia.) 20 Sounds are louder (phonophobia.) 21 Tastes and smells are sickening (osmophobia.) 22 Light touch may become unbearable (allodynia.) 23

 

There are multiple phases of a migraine attack

In a typical migraine attack, there are several phases called the prodrome, aura, headache/ attack phase, and postdrome or the “migraine hangover.” Not every person experiences every phase, and these phases can overlap. This infographic created by the American Migraine Foundation helps break down some of the common symptoms amongst the distinct phases of a migraine attack.

Timeline of a Migraine Attack. Prodrome: few hours to days- irritability, depression, yawning, increased need to urinate, sensitivity to light/ sound, problems in concentrating, fatigue and muscle stiffness, difficulty in speaking and reading, nausea, difficulty in sleeping. Aura: 5-60 minutes- visual disturbances, temporary loss of sight, numbness and tingling on part of the body. Headache: 4-72 hours- throbbing, drilling, icepick in the head, burning, nausea, vomiting, giddiness, insomnia, nasal congestion, anxiety, depressed mood, sensitivity to light smell and sound, neck pain and stiffness. Postdrome: 24- 48 hours- inability to concentrate, fatigue, depressed mood, euphoric mood, lack of comprehension

Migraine debilitation is a spectrum

Migraine disease also exists on a spectrum, meaning people experience it in different frequencies and levels of debilitation. 24 Episodic migraine attacks occur from 14 days per month to very seldomly. Chronic migraine attacks occur from 15 days per month and upwards, with some people never receiving relief. Symptoms range from mild to disabling, so even people also living with migraine may not be able to comprehend the true disability experienced by others.  

90% of people cannot function normally during a migraine attack. 25 Managers in your organization who lead with compassion and understanding are more likely to get the best results from their team. Discuss the needs of your staff, consider whether any simple accommodations may be helpful, and work with them to remove any barriers to achieving their full potential.

 

Other key points about migraine:

 

Learn more from real people working with migraine disorder:

 

(Alt text of the AMF infographic: Timeline of a Migraine Attack. Prodrome: few hours to days- irritability, depression, yawning, increased need to urinate, sensitivity to light/ sound, problems in concentrating, fatigue and muscle stiffness, difficulty in speaking and reading, nausea, difficulty in sleeping. Aura: 5-60 minutes- visual disturbances, temporary loss of sight, numbness and tingling on part of the body. Headache: 4-72 hours- throbbing, drilling, icepick in the head, burning, nausea, vomiting, giddiness, insomnia, nasal congestion, anxiety, depressed mood, sensitivity to light smell and sound, neck pain and stiffness. Postdrome: 24- 48 hours- inability to concentrate, fatigue, depressed mood, euphoric mood, lack of comprehension.)

 

1)Goadsby, et al, 2018, Pathophysiology of Migraine: A Disorder of Sensory Processing, Physiological Reviews, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5539409/>
2)Steiner, et al, 2018, Migraine is first cause of disability in under 50s: will health politicians now take notice?, Journal of Headache and Pain,  <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821623/>
3)Glaser, 2021, Hidden Pain: Migraine Stigma at Work Is a Big Problem, Migraine Again, <https://www.migraineagain.com/migraine-stigma-at-work/>
4)World Health Organization. Lifting the Burden. ‘Atlas of headache disorders and resources in the world 2011.’ WHO Press. 2011.
5)Young, et al, 2007, Square One: Headache Education for the Medical Student, Headache, <https://americanheadachesociety.org/wp-content/uploads/2018/07/Medical_Student_Curriculum.HED_.March_.07.pdf>
6)Dobson, 2021, Invisible Illness and Measurability, AMA Journal of Ethics, <https://journalofethics.ama-assn.org/article/invisible-illness-and-measurability/2021-07>
7)2021, Migraine is a Whole Body Disease Infographic, Migraine and Headache Policy Forum, <https://static1.squarespace.com/static/5886319ba5790a66cf05d235/t/6036bf5eba009a5866faeea0/1614200672047/HMPF__MigraineWholeBody_Infographic_Feb2021.pdf>
8)HEADACHE & MIGRAINE DISEASE LANGUAGE & IMAGE GUIDE, CHAMP, <https://headachemigraine.org/wp-content/uploads/2021/01/Lang_Image_Guide_Handout_web.pdf>
9)Wang, et al, 2017, Headache symptoms from migraine patients with and without aura through structure-validated self-reports, BMC Neurology, <https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-017-0973-4>
10)Dunleavy, 2021,What Is Migraine? Symptoms, Causes, Diagnosis, Treatment, and Prevention, Everyday Health, <https://www.everydayhealth.com/migraine/guide/>
11)Dunleavy, 2021,What Is Migraine? Symptoms, Causes, Diagnosis, Treatment, and Prevention, Everyday Health, <https://www.everydayhealth.com/migraine/guide/>
12)Furman & Marcus, 2012, Migraine and motion sensitivity, Continuum, <https://pubmed.ncbi.nlm.nih.gov/23042062/>
13)2018, The Timeline of a Migraine Attack, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/timeline-migraine-attack/>
14)Cuadrado, et al,  2008, Migrainous corpalgia: body pain and allodynia associated with migraine attacks, Cephalagia, <https://pubmed.ncbi.nlm.nih.gov/18021265/>; Dunleavy, 2021,What Is Migraine? Symptoms, Causes, Diagnosis, Treatment, and Prevention, Everyday Health, <https://www.everydayhealth.com/migraine/guide/>
15)Doherty, 2021,, The Link Between Migraines and Tinnitus

Buzzing or ringing in your ears could be related to your episodes, Verywell Health, <https://www.verywellhealth.com/link-between-migraines-and-tinnitus-4077631>
16)Upham, 2021, What You Need to Know About Migraine and Vertigo, Everyday Health, <https://www.everydayhealth.com/migraine/what-you-need-to-know-about-migraine-and-vertigo/>
17)Upham, 2021, The Link Between Migraine Headache and Diarrhea, Everyday Health, <https://www.everydayhealth.com/migraine/the-link-between-migraine-headache-and-diarrhea/>
18)2015, Flushing, Drooping, Tearing, and Stuffiness… Autonomic Symptoms in Headache, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/autonomic-symptoms-in-headache/>
19)2017, Hemiplegic Migraine, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/hemiplegic-migraine/>
20)Wilkins, et al, Photophobia in migraine: A symptom cluster?, Cephalagia, <https://pubmed.ncbi.nlm.nih.gov/33990148/>
21)Kalita, et al, 2021,Phonophobia and brainstem excitability in migraine, European Journal of Neuroscience,  <https://pubmed.ncbi.nlm.nih.gov/33305448/>
22)Albanês Oliveira Bernardo, et al, 2020, Osmophobia and Odor-Triggered Headaches in Children and Adolescents: Prevalence, Associated Factors, and Importance in the Diagnosis of Migraine, Headache, <https://pubmed.ncbi.nlm.nih.gov/32293736/>
23)Young, 2009, Allodynia as a complication of migraine: background and management, Current Treatment Options in Neurology, <https://pubmed.ncbi.nlm.nih.gov/19094830/>
24)Aurora, 2009, Spectrum of illness: understanding biological patterns and relationships in chronic migraine, Neurology, <https://pubmed.ncbi.nlm.nih.gov/19188565/>
25)Migraine Facts, Migraine Research Foundation, <https://migraineresearchfoundation.org/about-migraine/migraine-facts/#:~:text=While%20most%20sufferers%20experience%20attacks,function%20normally%20during%20their%20migraine.>

Is Migraine a Disability?

How Can Migraine Classify as a Disability in the Workplace?

 

When Hannah first started her position as a corporate lawyer, her migraine disease was largely under control. When a migraine attack would occur, she would be completely out of commision for about three days. Luckily, this only happened a few times per year.

Now the attacks are occurring far more frequently. Even at only twice a month, she is now losing about six days of work every month. She has not spoken up about her condition as she is afraid to be perceived as weak or unreliable. Her boss is starting to ask questions and her colleagues have started to make snarky comments about whether she was going to need another sick day. Her job may be in jeopardy and Hannah needs to know her legal rights.

 

A disability is a physical or mental impairment that substantially limits one or more major life activity.

The Americans with Disability Act (ADA) provides the legal framework for disabilities including within the context of work. It is important to note that this is a legal- not medical- definition of disability. The ADA defines disability as “a physical or mental impairment that substantially limits one or more major life activity.” 1

What qualifies as a disability under the ADA may be different from what qualifies as a disability under the Social Security Administration for Social Security Disability Insurance (SSDI.) 2 This article solely focuses on the ADA requirements.

Migraine may be a disability, depending upon whether it impacts the employee’s ability to perform their job.

According to Shruti Kulkarni, JD, Principal Attorney at Sequel Legal/ Aimed Alliance, this answer is not as simple as a yes or no. “Maybe. Not everyone with migraine disease will be considered to have a disability because disability is determined on a case by case basis rather than based on a list of conditions.”

Basically, you need to prove that your condition is serious enough that your migraine attacks impact or limit your ability to complete tasks required for your job. You also need to prove that you are qualified for your position at work, and that- with or without reasonable accommodations– you will still be able to perform essential duties of your position. While the legal language of “with or without reasonable accommodations” seems confusing, it emphasizes that a worker may use accommodations, but they still must be able to complete the jobs. The tasks must still be performed, but the way the worker does it may be adjusted.

An ADA-defined disability impairs at least one major life activity. 3

Kulkarni explains, “Disability is defined as impairment that substantially limits one or more major life activities, such as the ability to work or care for oneself. Major life activities, especially as it relates to this population can be everything from seeing, hearing, eating, sleeping, walking, concentrating, thinking, communicating, working. All of these could be considered a major life activity.”

Migraine can affect multiple life activities, depending upon an individual’s symptoms.

Every activity Kulkarni listed above can be affected by migraine. However, every person experiences migraine attacks in unique ways. Unfortunately, due to the stigma of migraine, employees may need to convince their managers that their migraine disorder truly qualifies as a disability. Kulkarni states that, “Only about half of the HR professionals agreed or strongly agreed that migraine disease can be considered a disability in their organization,” in a survey of 300 HR professionals conducted by Aimed Alliance. 4

Migraine at Work can help take some of the burden off of the process of proving disability. If you are looking to prove that migraine affects these areas of your life, the list at the end of this article may help guide you to sources as scientific proof of your own lived experience.

A qualified disability provides certain legal rights, including accommodations and protections from discrimination.

You have the right to reasonable accommodations. You are legally protected from job discrimination on the basis of this disability. It cannot be used as a decision within the hiring or firing process. 5 In fact, you are never required to disclose a disability, including during the hiring process. 6

Reasonable accommodations may not cause ‘undue hardship’ on the employer.

Kulkarni explains that, “Under the ADA an accommodation must be provided to qualified individuals unless doing so would cause undue hardship. And accommodation is an undue hardship only if it would cause significant difficulty or expense to the business.” Luckily, most accommodations for migraine are inexpensive and largely effective.

If these rights are violated, an EEOC claim may be filed against the employer.

Contact the US Equal Employment Opportunity Commission (EEOC) to have them investigate your claim of discrimination. If your claim is successful, you may be entitled to backpay, re-hiring, accommodations, amongst others. Learn more about this process. 7

Resources on protecting one’s rights surrounding working with migraine are available.

These webcasts and articles may help:
Migraine at Work Webcast: Knowing Your Rights
Patients Rising: Women with Migraines: Addressing Discrimination in the Workplace
Migraine Again – Fired Thanks to Migraine? 

 

Listing specific limitations can help prove that an individual’s migraine disease is serious enough to qualify as a disability.

Kulkarni stated that you must show that your condition impacts your life in ways which may include tasks like seeing, hearing, eating, sleeping, walking, concentrating, thinking, communicating, and working. Migraine attacks can affect each of these functions. Links to patient-focused articles as well as citations from medical journals are included below to provide you with additional information to help build your case.

Use this information to add medically-relevant information to your own experience. Create a list of any factors in the workplace which may trigger or exacerbate your migraine attacks. Think of any potential accommodations which may help mitigate these factors.

 

Seeing- Migraine can affect the way the brain interprets information from all five of the senses. 8 Sight may be impacted in numerous ways. Photophobia, or sensitivity to light, is a symptom in which the brain is hyperreactive to innocuous visual stimuli. 9 Migraine aura can present with numerous visual disruptions including scintillating scotoma, flashing lights, and visual floaters. 10 A more rare symptom of migraine is temporary loss of vision 11 .

Explain the specific tasks at work which can worsen these symptoms. Computer screens, fluorescent lighting, and even seemingly benign LED lights can exacerbate the symptoms of a migraine attack, leading to increased severity.

 

Hearing- In the same regard as photophobia, phonophobia, or sensitivity to sounds, is the brain’s hyperreactivity to innocuous sonar stimuli. 12 Tinnitus, or ringing of the ears, may also occur. 13

Workplace triggers like alarms or ringing phones, coworker chatter, or loud equipment may exacerbate symptoms or trigger a migraine attack. 14

 

Eating- Eating can also be affected during a migraine attack. Osmophobia, or sensitivity to smells, is the brain’s hyperreactivity to innocuous scent stimuli. 15 The body’s sense of taste is largely dependent on the sense of smell, 16 and thus consuming food or drink may be disturbed by migraine. In addition, there are numerous gastrointestinal symptoms of migraine, including nausea, vomiting, diarrhea, and gastroparesis, where digestion is slowed. 17

It can be difficult to work when you are unable to eat or are experiencing debilitating gastrointestinal symptoms with limited bathroom breaks or privacy.

 

Sleeping- Sleep and migraine attacks have a bidirectional relationship. 18 People with migraine are more likely to have sleep issues. 19 For some with migraine, sleeping through an attack can help ease the symptoms or prevent it from progressing. 20

Poor sleep quality leads to reduced work productivity and employee satisfaction. 21 If the workplace does not have a wellness room where napping or relaxation is possible, it may be more difficult to successfully manage or avoid an incoming migraine attack and the attack itself may be more severe.

 

Walking- Interestingly, some types of migraine can affect the ability to walk. Temporary paralysis can occur in certain people, like those with hemiplegic migraine. 22 In addition, those with migraine also report that movement exacerbates their symptoms. 23

If the job requires walking or standing, this may exacerbate symptoms, leading to further debilitation.

 

Concentrating / Thinking- Migraine attacks can affect cognition, including concentrating, thinking, and memory. 24 “Brain fog” is a commonly cited symptom.

In addition, stress, like that which may come from intense concentration, problem solving, or unreasonable deadlines, can trigger or exacerbate migraine attacks.

 

Communicating- A symptom of migraine is transient aphasia, or “migraine babble.” Aphasia results in difficulty understanding or expressing language. 25 Word finding may be difficult. Dysarthria can involve slurred speech, or speech that may come out incoherent. Serene Branson brought this symptom to the public eye reporting at the 2011 Grammys. 26

Communicating is essential in the vast majority of jobs. If an employee is unable to properly communicate with other colleagues, especially during a medical event or emergency, there is the potential for danger.

 

Working- In addition to all of the examples listed above, other symptoms which may impair one’s ability to work during a migraine attack include fatigue, dizziness, pain, tinnitus, mood changes, sensory hallucinations, frequent urination, and many others.

Think of specific tasks within your job which either trigger or exacerbate your migraine attacks. 27

 

Key Takeaways

While the ADA definition of disability requires the person to prove that their condition impairs daily activity, most people struggling to work with migraine can list several unique ways in which their disabling condition impairs multiple activities required for the job.

Be sure to take the time to prepare a detailed list on how your neurological disorder affects your ability to do specific tasks required for your job. Think of specific accommodations which will be able to help ease this burden. Be sure to document every step of this process and know there are legal options if your rights are not respected.

 

 

 

 

1) 2021, What is the definition of disability under the ADA?, ADA National Network, <https://adata.org/faq/what-definition-disability-under-ada>
2)Benefits for People with Disabilities, Social Security Administration, <https://www.ssa.gov/disability/>
3)2021, Migraine at Work Webcast- Knowing Your Rights, Migraine at Work, <https://migraineatwork.org/webcasts_migraine/knowing-your-rights/>
4)2021, The State of Migraine Disease in the Workplace 2021, Aimed Alliance, <https://aimedalliance.org/wp-content/uploads/2021/02/MigraineDiseaseReport2021_Final.pdf>
5)Your Employment Rights as an Individual with a Disability, US Equal Employment Opportunity Commission, <https://www.eeoc.gov/laws/guidance/your-employment-rights-individual-disability>
6)Schumer, 2019, How to Disclose a Disability to Your Employer (and Whether You Should), New York Times, <https://www.nytimes.com/2019/07/10/smarter-living/disclose-disability-work-employer-rights.html>
7)2021, How to File a Complaint at the EEOC, Disability Rights North Carolina, <https://disabilityrightsnc.org/resources/how-to-file-a-complaint-at-the-eeoc>
8)Goadsby, et al, 2017, Pathophysiology of Migraine: A Disorder of Sensory Processing, Physiological Reviews, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5539409/>
9)2017, Photophobia (Light Sensitivity) and Migraine, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/photophobia-migraine/>
10)Dumas, 2020, How to Know if You Have Migraine with Aura, Migraine Again, <https://www.migraineagain.com/how-to-know-if-you-have-migraine-with-aura/>
11)2019, Retinal Migraine, National Health System, <https://www.nhs.uk/conditions/retinal-migraine/>
12)Johns Pool, 2019, Migraine.com, <https://migraine.com/migraine-symptoms/sensitivity-to-sound>
13)Doherty, 2021, The Link Between Migraines and Tinnitus, VeryWell Health, <https://www.verywellhealth.com/link-between-migraines-and-tinnitus-4077631>
14)Dumas, 2020, 7 Reasons Why You Have a Headache at Work, Migraine Again, <https://www.migraineagain.com/tension-headache-causes-work/>
15)Kuruvilla, What’s That Smell?, American Headache Society, <https://americanheadachesociety.org/news/whats-that-smell/#:~:text=Osmophobia%2C%20a%20sensitivity%20to%20smell,some%20cleaning%20products%20and%20foods.>
16)Holbrook, 2018, More Than Taste Buds: How Smell Influences Taste, Mass. Eye and Ear.,  https://focus.masseyeandear.org/more-than-taste-buds-how-smell-influences-taste/
17)2019, Dumas, An Expert Explains Why Migraine Attacks Make You Nauseous, Migraine Again, <https://www.migraineagain.com/stomach-ache-with-migraine-nausea-vomiting/>
18)Tisseo, et al, 2020, Migraine and sleep disorders: a systematic review, Journal of Headache and Pain, <https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-020-01192-5>; Rodriguez, 2021, 6 Sleep Tips for People With Migraine, Everyday Health, https://www.everydayhealth.com/hs/sleep-tips-for-people-with-migraines/;
19)Rains, 2018, Sleep and Migraine: Assessment and Treatment of Comorbid Sleep Disorders, Headache, <https://pubmed.ncbi.nlm.nih.gov/30095163/>
20)Migraine and Sleep, The Migraine Trust, <https://migrainetrust.org/live-with-migraine/self-management/migraine-and-sleep/>
21)Chamorro-Premuzic, 2020, How Much Is Bad Sleep Hurting Your Career?, Harvard Business Review, <https://hbr.org/2020/07/how-much-is-bad-sleep-hurting-your-career#:~:text=Lack%20of%20sleep%20leads%20to,absenteeism%2C%20and%20counterproductive%20work%20behaviors.&text=If%20you%20sleep%20three%20hours,a%20half%20to%20succeed%20in.%E2%80%9D>
22)2017, Hemiplegic Migraine, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/hemiplegic-migraine/>
23)2018, Timeline of a Migraine Attack, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/timeline-migraine-attack/>
24)Martins de Araújo, 2012, Cognitive Impairment in Migraine: A Systemic Review, Dementia & Neuropsychologia,<https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5619244/#:~:text=Despite%20mixed%20results%2C%20most%20studies,executive%20dysfunction%2C%20and%20attention%20deficit.>
25)2021, Dumas, The Migraine Babble: Why Your Words Get Jumbled, Migraine Again, <https://www.migraineagain.com/migraine-babble-words-get-jumbled/>
26)2018, How to Thrive in Your Career Despite Migraine, Migraine World Summit, <https://migraineworldsummit.com/talk/how-to-thrive-in-your-career-despite-migraine/>  2011, CBS2’s Serene Branson has a stroke on air?, YouTube, <https://www.youtube.com/watch?v=dwHpBwAxDIs>
27)2021, Migraine Trigger Guide, Migraine World Summit, <https://www.instagram.com/migraineworldsummit/guide/migraine-triggers/17897158031243182/?utm_source=ig_web_copy_link&utm_campaign=&utm_medium=>

Stigma & Hesitation in Migraine Care

Examine how stigma and hesitating to consult a professional are making the cost of migraine in the workplace much greater.

Questions Answered in this Webcast:

  • – Is migraine at work an issue people even need to think about?
  • – If migraine has such a huge impact,  how come no one talks about it?
  • – How many people hesitate to consult a doctor for their migraine condition?
  • – What is a headache specialist, and how may they treat migraine differently than a general practitioner or even a neurologist?
  • – If someone either chooses not to use, or does not have access to, medications, are there any other options for managing migraine?

Optimizing Brain Health in the Office

Bringing Brain Care to the Front of Migraine 

Have you ever been in a meeting when it was shared that a coworker was out for the day due to a migraine? Let’s call her Lucy. Claudia makes a remark about it just being a headache and infers that Lucy probably just didn’t have her work done or wanted the day off. Jeronimo rolls his eyes and asks when she will return. And next thing you know Kelly is dialing up Lucy for a status update on her part of the project. Lucy didn’t answer the phone. The team calls Lucy again because it is just a headache. Again, Lucy does not answer. Bill opens up his laptop and fires Lucy off an abrupt email related to when she will return to the office and complete her work. The tension in the room rises and Lucy is none the wiser.

Now this is a fictional scenario that has been pieced together from unfortunate situations I have witnessed and been a part of in the workplace. I have been Lucy and my colleagues have called, emailed, texted and so on for a laundry list of “reasons” that I’ve been given over the years when I’ve not been at work due to migraine. With more than 90% of those with migraine being unable to work or function normally during their migraine 1 , it is time to bring brain care to the forefront of the migraine conversation across all settings- including the workplace.

 

What is Brain Capital?

The Organization for Economic Co-operation and Development (OECD) recently introduced the concept of a brain capital in a growing brain economy. Sandra Bond Chapman, PhD, defines brain capital as the “economic benefit that accrues from keeping our brains powered at the highest level.” 2 Many jobs require cognitively demanding tasks, along with emotional and social skills, where innovation is a desirable “deliverable” of employee productivity. These brain-based skills and functions are driving our job market and shaping our workplaces.

There is a global need for the investment in brain health and brain skills to support the post-COVID world for economic growth. The workplace setting during the current pandemic, coupled with the shifting workplace demands, is ripe to benefit from an investment in brain health and wellness for all in the organization, including individuals with migraine disease. 

 

Understanding Brain Health


Unfortunately, there is not a universal definition of brain health that is commonly recognized across the world, or even in the United States. Broadly, brain health is conceptualized in various pillars of wellness such as the well-known “mind, body, spirit” model with associated tasks such as “thinking, moving, feeling.” The World Health Organization states that, “Good brain health is a state in which every individual can realize their own abilities and optimize their cognitive, emotional, psychological and behavioral functioning to cope with life situations.” 3

 

Migraine and Brain Health

Research suggests that brain health is 90% lifestyle and 10% genetics. 4 Furthermore, prioritizing brain health is for everyone, regardless of a brain related condition, health diagnosis, or other factors. This notion extends to individuals living with migraine disease and related headache disorders. Brain health examines lifestyle factors which impact our overall well-being across our lifetime taking into consideration that our brains are constantly changing for a variety of reasons.

SEEDS for success model, described in text below

The SEEDS model– stress, eating, exercise, drinking, and sleep- highlights some of the top ranked health concerns for brain health. 5

 

Stress: Relax the mind and avoid daily stressors.


 Eating: Eat to fuel the mind and body.


 Exercise: Engage in an ongoing exercise routine for the brain and body. Aim for 150 minutes of moderately intense exercise per week and aim for 20 minutes of cognitively stimulating exercise per day with a task that is new, novel, and challenging. 6  


 Drinking: Limit alcohol consumption and keep properly hydrated with water, an essential element to the brain’s ability to function properly.

 

Sleep: Aim for 7-9 hours of sleep per night and plan brain breaks (see examples below!) throughout the day to help unwind. 

 

Following SEEDS for brain health and migraine management emphasizes the ability individuals have to play an active role in their personal brain care. For many people living with migraine disease, the above research-informed lifestyle factors may already be top of mind. (Please note that this list is not extensive and there are more factors that can impact our brain health.)

 

Currently, the available research related to brain health and migraine is limited, but is luckily a growing area of interest. Individuals with migraine disease do not have poorer related brain health 7 , but we may tend to speak more commonly and openly with our healthcare providers about brain health related issues such as brain fog, depression, anxiety, and memory concerns. Ultimately, just like in otherwise healthy populations, the brain health of those with migraine and other headache disorders are largely individualized.

 

Navigating the Workplace with Migraine

 

Finding ways to navigate migraine at work is not always an easy path. It is estimated that of those individuals in the workforce, 14-19% of them live with migraine disease. 8 In one survey of over 11,266 individuals across 31 countries, all with more than 4 migraine attacks per month, 88% of the respondents reported migraines had a negative impact on their working life. 9   

 

Many people working with migraine are unlikely to disclose their diagnosis to their employers. Many employees with migraine are afraid of discrimination or judgement and avoid disclosing to their employer. This leads to migraine hiding in plain sight, and employers being unaware that migraine is such a burdensome issue in their office.

 

Even when employees do feel either comfortable or desperate enough to disclose, many employers will not know how to help. One study collected data from those both frequently and severely affected by migraine. Participants needed to have frequent attacks and also find preventive medications ineffective. 90% of this group disclosed their diagnosis with their employers, and less than half of those employers offered support to those employees. 10 Keep in mind that this percentage of those sharing with their employers is likely dramatically higher than in an average workplace. 

 

Modifying the Office to be Migraine-Friendly is to Make it Brain-Friendly for All Employees

 

A call to protect the brain health of all employees, including individuals with migraine disease, while producing brain skills for the organization will offer dual benefits. Many workplaces are full of migraine triggers. 11 While individuals with migraine disease may seek accommodations in the workplace related to light, sound, and smells for their personal wellness, many slight modifications could offer benefits that would extend to others to build better brains. 

 

Light: Both the brightness and color of light surrounding us affects our moods. 12 The ability to adjust our light for our personal workspace preference can lead to a boost in productivity, uplift in spirit, and a variety of health-related effects. 13

 

Sound: Our brains’ ability to filter out background noises in the workplace while attending to work-related tasks can be tiring. 14 Excessive noise has been linked to a decrease in productivity and concentration, stress, fatigue, difficulty in communication, and health related issues depending on the work environment and noise exposure. 15

 

Smell: Our sense of smell is strongly linked to our memory. Aroma is linked to our cognitive performance known as our brain-based skills in the workplace. 16 Odors both good and bad can impact our mood, behavior, and performance at work. 17

 

Touch: Ergonomic office settings can help boost productivity and employee satisfaction. 18 As every individual is unique, find what works for you. Whether it is an ergonomic keyboard or a standing desk, there are many options to improve productivity and your own physical comfort. 

 

There are many simple ways to support some of the main workplace concerns for individuals with migraine disease that can also benefit the entire workplace such as: implementing fragrance-free policies, establishing policies to minimize odors in meal areas and trash, providing desk lamps or lighting alternatives, and other modifications can help. Many brains can benefit from options purposefully designed to set them up for success. Investing in brain capital for employees makes economic sense as we align our workplace wellness values.

 

Brain Wellness, Migraine, and the Workplace

 

No two brains are alike, just like individuals’ lived migraine experiences are not alike. We have the unique ability to impact our brain and at times we can utilize our surroundings to thrive at work while minimizing environmental triggers. Employers looking to invest in the brain health and wellness of their employees, with or without migraine disease or a related headache disorder, will bode well in the future of our brain capital economy. 

 

Conclusions

 

-Now is the time for brain health in the workplace for all- both communal gathering spaces and remote settings.

 

-Prioritizing brain wellness in the workplace offers benefits for both employees and employers for minimal or no cost.

 

-Many individuals living with migraine disease have likely been making choices to optimize a brain-healthy lifestyle already.

 

Three Brain Health Tips for All

 

-Brain care is self-care. Make your brain-care a priority and not an option. Start simple. Purposefully make one decision each day that is better for your body and brain. Small changes can lead to lasting habits. We have the ability to build daily habits and plans that nourish our minds, bodies, and spirits during tough times and we can try new things to support our brain-care needs as they ebb and flow.

 

-Take 5-minute brain breaks. Build-in brain breaks throughout your day to optimize your brain performance and prevent fatigue and low mood. A brain break should be purposeful engagement in a brief, meaningful exercise or activity and a “break” from other tasks that require concentration and focus.

Get up and move, do some light stretching, spend time with your pet, get outdoors, write in a gratitude journal, experience a good laugh, or read a poem aloud. Take multiple brain breaks daily and use these as a tool to prevent tiredness, frustration, lack of focus, or feelings of low mood.

 

-Ready to get brain-healthy at work? Start with this guide today!

 

 

Headshot of Dr Krystal Culler

Krystal Culler, DBH, MA. Founder & Creative Director, Virtual Brain Health Center

Dr. Culler is the Founder & Creative Director of the Virtual Brain Health Center. Krystal has spent nearly 5 years in Executive-level positions with health non-profit organizations and has over 15 years-experience working with individuals with brain health concerns, their families, and advocacy organizations. Under her leadership, the centers have received 4 international and national awards from leading organizations in the aging care sector for innovation in brain health programming and community impact including honors from the International Council on Active Aging, Mather Lifeways Institute on Aging, the American Society on Aging and the Southern Gerontological Society on Aging. Additionally, she has been recognized through the receipt of 4 personal leadership awards for her contributions to the field including the Global Brain Health Leaders Award (2019) from the Alzheimer’s Association, Alzheimer’s Society, and Global Brain Health Institute, and Crain’s Cleveland Business 40 Under Forty (2017).

 

Krystal is a Doctor of Behavioral Health with a background in the behavioral sciences (psychology of aging, gerontology, and sociology). She is a Senior Atlantic Fellow with the Global Brain Health Institute, where she was the first scholar from the United States to complete her residency training at Trinity College Dublin, Ireland on dementia prevention and the social determinants of brain health. She has an unwavering commitment to promote brain health equity to individuals of all ages and the communities she serves. 

 

1) 2020, Migraine Facts, Migraine Research Foundation, <https://migraineresearchfoundation.org/about-migraine/migraine-facts/>

2)Smith, et al, 2020, A Brain Capital Grand Strategy: toward economic reimagination, Nature, <https://www.nature.com/articles/s41380-020-00918-w>

3)World Health Organization, Brain Health, <https://www.who.int/health-topics/brain-health#tab=tab_1>

4) 2014, The National Institute for Occupational Safety and Health (NIOSH), Exposome and Exposomics, Center for Disease Control, <https://www.cdc.gov/niosh/topics/exposome/>

5)Robblee and Starling, 2019, SEEDS for success: Lifestyle management in migraine, Cleveland Clinic Journal of Medicine, <https://pubmed.ncbi.nlm.nih.gov/31710587/>

6)Livingston, et al, 2017, Dementia prevention, intervention, and care, The Lancet, <https://www.ucl.ac.uk/psychiatry/research/mental-health-older-people/projects/lancet-commission-dementia-prevention-intervention-and>; Yu, et al, Evidence-based prevention of Alzheimer’s disease: systematic review and meta-analysis of 243 observational prospective studies and 153 randomised controlled trials; Cognitive Neurology, <https://jnnp.bmj.com/content/jnnp/early/2020/06/01/jnnp-2019-321913.full.pdf>

7) Baars, et al, 2010, Migraine does not affect cognitive decline: results from the Maastricht aging study, Headache, <https://pubmed.ncbi.nlm.nih.gov/19925622/>

8)Yucel, et al, 2020, Estimating the Economic Burden of Migraine on US Employers, The American Journal of Managed Care, <https://www.ajmc.com/view/estimating-the-economic-burden-of-migraine-on-us-employers>

9)Martelletti, et al, 2018, My Migraine Voice survey: a global study of disease burden among individuals with migraine for whom preventive treatments have failed, Journal of Headache and Pain, <https://pubmed.ncbi.nlm.nih.gov/30482181/>

10) Sumelathi, et al, 2020, My Migraine Voice survey: disease impact on healthcare resource utilization, personal and working life in Finland, The Journal of Headache and Pain, <https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-020-01185-4>

11) Okifun, Migraine in the Workplace: Implications on Employee Productivity and Ways to Address it, Corporate Wellness Magazine, <https://www.corporatewellnessmagazine.com/article/migraine-in-the-workplace-implications-on-employee-productivity-and-ways-to-address-it>

12)Wilms & Oberfeld, 2018, Color and emotion: effects of hue, saturation, and brightness, Psychological Research, <https://pubmed.ncbi.nlm.nih.gov/28612080/>

13)Küller, et al, 2006,The impact of light and colour on psychological mood: a cross-cultural study of indoor work environments, Ergonomics,<https://pubmed.ncbi.nlm.nih.gov/17050390/>

14)Gorvet, 2018, Why office noise bothers some people more than others, Worklife: BBC, <https://www.bbc.com/worklife/article/20191115-office-noise-acceptable-levels-personality-type>

15) Housley, et al, Health effects of environmental noise pollution, Australian Academy of Science, <https://www.science.org.au/curious/earth-environment/health-effects-environmental-noise-pollution> ; Occupational Noise Exposure, United States Department of Labor, OSHA, <https://www.osha.gov/noise/health-effects>

16)Sowndhararajan, et al, 2016, Influence of Fragrances on Human Psychophysiological Activity: With Special Reference to Human Electroencephalographic Response, Scientia Pharmaceutica, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5198031/

17)Herz, 2002, Do scents affect people’s moods or work performance?, Scientific American, <https://www.scientificamerican.com/article/do-scents-affect-peoples/>

18)Pereira, et al, 2018, The impact of workplace ergonomics and neck-specific exercise versus ergonomics and health promotion interventions on office worker productivity: A cluster-randomized trial, Scandinavian Journal of Work, Environment, and Health, <https://pubmed.ncbi.nlm.nih.gov/30132008/>

 

What is Migraine Stigma?

“A migraine? Really? You can just take something and come in?”

“No…it’s not like that.”

“Hmmph. Well OK. We’ll talk when you’re back though.”

That was a conversation I overheard years ago when a coworker called out because of a migraine. It wasn’t too surprising, considering that I was working in retail, an industry notoriously unsympathetic of absence. But it’s a conversation that has played out for countless migraine sufferers across all sectors. And it’s one that has caused many to become fearful of their job security, and discriminated against because of their disabling condition. Let’s explore the impact of migraine stigma in the workplace.

 

So what is migraine stigma?

A stigma is an established construct in the social sciences that describes a characteristic, trait, or diagnosis that is used to discredit an individual and leads to prejudice, discrimination, and loss of status. 1 Stigmatized people often have disrupted relationships, decreased quality of life, and lower employment rates. 2 The common denominator with stigmatized conditions is that they often come with a perception that the person with them is at least somewhat at fault. Examples of stigmatized conditions include HIV/AIDS and mental illness. Fortunately, the hard work of individual advocates have helped chipped away at the stigma of these conditions, but much progress is still needed.

Migraine is an invisible- not imaginary- illness.

One of the most obvious causes for stigma about migraine is that it is an invisible illness. When someone has a broken leg or a stomach virus, the evidence is often graphically visible. Not so with migraine. With migraine, it can be hard to describe the disabling symptoms to someone who’s never had one, which can lead to the dismissive, “Just take an Ibuprofen!” response.

Migraine primarily affects women.

Around 75 percent of people affected with migraine are women. 3 This leads to another possible reason for stigma. This stigma of being a “women’s disease” prevents proper research, diagnosis, and treatment for patients of all genders. 4 According to Dr. William Young, in the 1700s, people perceived migraine as a disease of women who were overly sensitive and trying to escape from their social responsibilities. 5 Even today, women’s pain is often discounted by medical professionals and society at large. 6 However, a study of people with migraine showed that men were more likely to miss work with migraine, and were also less likely than women to mention the reason why they had to miss work. 7 This suggests yet another reason how the stigma of being a “women’s disease” harms people of all genders. 

The ‘migraine personality’ is a stigmatizing myth.

Is there such a thing as a “migraine personality”? Despite the aforementioned 1700’s view that migraine was an excuse to escape responsibilities, by the mid-20th century, that view had changed. Famed headache researcher Harold Wolff said the migraine personality consisted of individuals who were ambitious, successful, perfectionist, and efficient. Migraine patients were seen as good people who had trouble dealing with anxiety. Wolff also suggested that female migraine patients were sexually dissatisfied and uncomfortable with motherhood. Interestingly, Wolff’s study on male migraine patients found that they were by and large, sexually well-adjusted. This “migraine personality” further led to patients being discounted and yet again led society to place undue responsibility to those living with this neurological disease. 8

As science has progressed, the “migraine personality” view among medical experts has largely faded as a misconception of the past. But it’s been a relatively recent development- only in about the last 30 years has migraine been treated as a neurological brain disorder, rather than a psychosomatic condition.

Migraine research is underfunded.

Migraine research is also underfunded. In fact, it is the least funded neurological disease in regards to its economic burden. 9 The National Institute of Health estimates that funding for migraine research is only at $.50 per patient, a paltry figure. 10

It’s not difficult to see why these stigmas and history of discrimination makes it difficult for many to disclose that their migraine condition. The stigma of migraine has led to negative results for both people with migraine and their employers. Worldwide, migraine is the second most disabling condition (and the leading cause of disability in people under the age of 50). But 40% of patients most have not received an accurate diagnosis for either episodic or chronic migraine. 11 The migraine diagnosis is further complicated by the fact that around half of migraine patients report experiencing anxiety disorders and depression, creating a sort of “chicken or egg” effect. 12  

Those with migraine may be forced to work through their symptoms.

Absenteeism from work occurs more often in people with migraine, although as previously discussed, the reason for absence is not always revealed. However, a phenomenon known as “presenteeism” is common for those with migraine and could be equally damaging to workplaces. Presenteeism is when employees work while sick as a performative measure. 13 Dr. Rashmi Walker Sangh describes presenteeism as “You just kind of slug through your day because you had to be there, but you really got nothing done.” 14 Productivity obviously suffers as a result, though it can be hard to quantify.

There is hope for those living with migraine.

Migraine is a condition that affects relationships, family, and life in the workplace. There is a long history of stigma about it, but increased awareness is bringing more visibility to this “invisible illness.” In the past few years, advertising for migraine medication has grown in the United States, hopefully inspiring more people with migraine to seek help for their condition, and making it clear to those without migraine that it’s not “just a headache.” There’s still an abundance of progress that needs to be made. 

Workplaces can help eliminate migraine stigma in their offices.

Workplaces can be more accommodating to people with migraine and discuss leave options such as FMLA. They can implement simple education programs and inexpensive accommodations. Dozens of peer-reviewed studies back up the claims that these simple strategies provide vast return of investment, not to mention an increase in employee satisfaction. While migraine research has historically been underfunded, it is slowly ticking up. There is unlikely to be a definitive cure for migraine, at least in the near future, but there is much hope that changing attitudes and behavior by both individuals and workplaces can improve the quality of life for people with migraines.

Want to change the culture of dismissing migraine in your workplace? Reach out today and we will guide you through potential ways to mitigate the stigma and burden of migraine in the workplace.

Sólo quería decirles que me encanta su sitio. Lo encontré mientras buscaba sitios donde poder hablar con la gente sobre algunos temas, entre ellos la . Sé que hay muchos sitios que tienen mucho tráfico. La gente tiende a usarlos como una especie de canal de comunicación y si tuvieras algo similar pero que no recibiera mucha atención, tendrías la oportunidad de hacerlo grande. De todos modos, ¡sigue con el buen trabajo!

 

Josh Weinstein is a guest writer for Migraine at Work.

 

1)Young, 2018, The Stigma of Migraine, Practical Neurology, <https://practicalneurology.com/articles/2018-feb/the-stigma-of-migraine>

2)Hatzenbuehler, et al, 2013, Stigma as a Fundamental Cause of Population Health Inequalities, American Journal of Public Health,  <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3682466/>

3)Eisenstein, 2020, Closing the gender gap in migraine research, Nature, <https://www.nature.com/articles/d41586-020-02867-4>

4)2021, Migraine Stigma May Prevent Proper Diagnosis and Treatment in Men, American Headache Society, <https://americanheadachesociety.org/news/migraine-stigma-may-prevent-proper-diagnosis-and-treatment-in-men/>

5)Glaser, 2021, Hidden Pain: Migraine Stigma at Work Is a Big Problem, Migraine Again, <https://migraineatwork.org/news_articles/hidden-pain-migraine-stigma-at-work-is-a-big-problem/>

6) Zhang, et al, 2021, Womens’ pain not taken as seriously as mens’ pain, Science Daily, <https://www.sciencedaily.com/releases/2021/04/210406164124.htm>

7)2016, Isops, <https://www.reuters.com/brandfeatures/excedrin/employees-hide-headaches-migraines-from-supervisors>

8)Kempner, 2021, The Birth of the Dreaded “Migraine Personality”, Migraine Again, <https://www.migraineagain.com/the-birth-of-the-migraine-personality/>

9)2020, Migraine Facts, Migraine Research Foundation, <https://migraineresearchfoundation.org/about-migraine/migraine-facts/>

10)2020, Caduo, Migraine Research Is Underfunded, and Stigmas Are to Blame, Morning Consult,  <https://morningconsult.com/opinions/migraine-research-is-underfunded-and-stigmas-are-to-blame/>

11)2016, Headache Disorders, World Health Organization, <https://www.who.int/news-room/fact-sheets/detail/headache-disorders>

12)2017, Prieto Peres, et al, Anxiety and depression symptoms and migraine: a symptom-based approach research, Journal of Headache and Pain,  <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5360747/>

13)Begasse de Dhaem, 2021, Migraines Are a Serious Problem. Employers Can Help., Harvard Business Review, <https://hbr.org/2021/02/migraines-are-a-serious-problem-employers-can-help >

14)2020, The Benefits of a Company Addressing Migraine at Work, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/the-benefits-of-a-company-addressing-migraine-at-work/>

How Much Does Migraine Cost?

The Cost Of Migraine To The Employer And Employee 

 

There are numerous reasons why you need to care about migraine in the workplace. It’s the number one cause of disability for employees under fifty. 1 It’s a DEI issue. But perhaps the most compelling reason when it comes to the financials is that migraine is hiding in plain sight and is costing almost all American companies significant amounts of money. 

 

Before we begin, let’s define some terms for clarity. Direct costs are such as prescriptions and visits to the doctor’s office and emergency room. Indirect costs occur because of lost productivity, through both absenteeism (when people call off work) and presenteeism (when people continue to work through an attack at reduced productivity.)

 

How much does migraine cost the United States each year?

Migraine is the second leading cause of disability on a global basis 2 . According to the Harvard Business Review, migraine costs US companies $13 billion each year 3 , whereas the Headache and Migraine Policy Forums calculated that US companies lose $78 billion a year to migraine when combining both direct and indirect costs 4 . Needless to say, this cost is not something businesses can afford to overlook. 

 

How much does migraine cost each individual?

Migraine disease exists on a spectrum, meaning some people may experience milder symptoms rarely while others may experience severe disability on a daily basis. According to the Integrated Benefits Institute, an independent industry productivity group, the average person with migraine loses $600 in absenteeism costs each year 5 , which is frequently on the company’s tab. In additional health care costs, IBI determined that the average person with migraine spends $2,000 per year. The Harvard Business Review reports that the average worker with migraine loses 4.4 days to absenteeism and 11.4 days to presenteeism each year. 6 All together, these calculations amount to $8,600 each year. 

 

How much does migraine cost organizations?

Migraine affects one in every four US households, so your company is almost certainly affected by migraine disease.

The Integrated Benefits Institute determined that for every 1,000 employees, each U.S company spends $84,000 in direct costs and absenteeism 7 .

These costs vary between industries, increasing up to $180,000 in the finance industry. This does not include presenteeism. Using the proven guideline that presenteeism can cost ten times that of absenteeism 8 , the presenteeism calculation would be around $6,000. Therefore, this is a significant underestimate of the true costs of migraine. 

 

Other costs

The true cost of migraine continues to escalate as these calculations do not capture the many intangible aspects of chronic disease. In severe cases, when a person experiences symptoms of migraine more than 15 days per month, they are considered to have chronic migraine. 9 Chronic migraine is associated with a higher incidence of anxiety and depression. 10 If left unaddressed, it can lead to social isolation, stigma, and take a psychological toll on the individual. 11  These elements are unaccounted for in the above figures. 

According the the Headache and Migraine Policy Forum, those with chronic migraine lose about 14% of their annual productivity at work, and 20% of these workers report becoming occupationally disabled and unable to perform tasks required by their jobs 12 .

Forced early exits from the workplace are not uncommon for these employees, many of which could be prevented with the proper support. 

 

If migraine is such a common problem, why don’t we see or hear about it?

There are several reasons why HR or leaders don’t see or hear about migraine in the workplace:  

1)89% of the total of indirect costs result from presenteeism. People aren’t calling out of work because they are trying to work through their symptoms. As 90% of people cannot function normally during an attack 13 , this strategy obviously does not work well, but many people do not have other options. 

2)Migraine is stigmatized. 4 out of 5 employees saying that migraine isn’t a “serious enough” reason to miss work, and slightly less than half of employers agree 14 . People living with migraine are largely aware of this stigma and thus unlikely to speak up about their condition, especially at work. Stigma leads to concealment, isolation, and “pushing through pain.”

3)Largely due to this stigma, employees fear informing supervisors or HR. Even if employees with migraine are forced to call in sick for the day, many people will not admit that migraine attacks are the true reason for their absence. Only 42% of people will include that the real reason they must call in sick is migraine disease 15 . 

4)Misdiagnosis is common. 40% of Americans with migraine have not been diagnosed. Migraine can express a wide variety of symptoms. A study of sinusitis found that 9 out of 10 patients had migraine or probable migraine from a group of 100 sinusitis patients who had their diagnosis for 25 years and seen an average of 4 doctors 16 . 

5)Migraine doesn’t show up in claims data. Most pharmaceutical drugs used to prevent and treat migraine attacks are repurposed from medications designed to treat other conditions like blood pressure, epilepsy, and depression. Due to the high level of misdiagnosis or underdiagnosis, generic over-the-counter pain medications may be frequently used instead of more effective migraine-specific treatments. 

6)Migraine is an invisible illness. There are few obvious signs or symptoms that cannot be hidden by those who experience it. There is no cast or bandage. Others cannot see the disabling pain and nausea. When one’s job is at stake, even symptoms like vomiting can be hidden from others.  

 

Why people with migraine can be some of your best talent

Serena Williams, John F Kennedy, Dwayne Wade- who wouldn’t want these people with migraine on their team? The disabling nature of migraine can be a driving force for success. Living with an unpredictable illness forges skills such as adaptability, resourcefulness, agility, and resilience. Knowing that you may need to rely on others at the last minute enforces teamwork, empathy, and time management skills. When you identify your staff members exhibiting these desirable traits, it is possible that they developed these abilities as a response to living through struggles like migraine disease. 

 

How to reduce the costs of migraine

The good news is that the costs of migraine can be dramatically reduced with cost effective accommodations, education, and awareness within the organization. There have been dozens of medically-reviewed studies utilizing various migraine education and treatment programs throughout the world, and the return on investment is striking. Simple migraine education programs can increase overall productivity by 29-36% 17 . Distributing information on migraine prevention through a website, newsletter, or webinar can provide your employees with crucial knowledge on how to identify, prevent, and treat these disabling attacks. It can also help reduce stigma and encourage more people to get diagnosed and receive effective treatment. 

One company provided their employees with migraine access to telemedicine visits with a nurse trained in headache medicine. Their return on investment was over 490% 18 . In the Journal of Occupational and Environmental Medicine, three US companies implemented a migraine educational program involving three informational packets and six newsletters. Their results included a 25% reduction in absentee days, a 32% reduction in presentee-affected days, and an overall 15% reduction in total costs 19 . In addition, simple accommodations are frequently inexpensive and highly effective. 

These educational programs require so little effort, yet the payoff is enormous. Even more important than these costs are the improvements in quality of life for these valued employees. When companies invest in migraine management strategies, everybody wins. 

 

Where can we find out more about the programs for employers? 

Migraine at Work is a nonprofit organization that is here to help. Migraine at Work uses a scientifically proven methodology to significantly reduce the cost of migraine in your workplace and improve overall productivity. We’d be happy to discuss how we can support your unique workplace and even provide a free migraine cost assessment. Reach out today. 

 

 

 

1) Steiner, T. J., Stovner, L. J., Vos, T., Jensen, R., & Katsarava, Z. (2018). Migraine is the first cause of disability in those under 50: will health politicians now take notice?. The journal of headache and pain, 19(1), 17. doi:10.1186/s10194-018-0846-2

2) 2021, Migraine and Disability, Headache and Migraine Policy Forum, <https://static1.squarespace.com/static/5886319ba5790a66cf05d235/t/5c65958215fcc0538b9c85de/1550161282886/HMPF_Migraine+%26+Disability+Graphic_Feb+2019.pdf>

3) Begasse de Dhaem, 2021, Migraines Are a Serious Problem. Employers Can Help., Harvard Business Review, <https://hbr.org/2021/02/migraines-are-a-serious-problem-employers-can-help >

4) Gooch, et al, 2017, The burden of neurological disease in the United States: A summary report and call to action, Annals of Neurology, <https://onlinelibrary.wiley.com/doi/10.1002/ana.24897> ;2020, Women, Migraine, and the Workplace, Headache and Migraine Policy Forum, <https://static1.squarespace.com/static/5886319ba5790a66cf05d235/t/5d07a91e2d0147000161e1bc/1560783135659/HMPF_Women%2C+Migraine+%26+Workplace_Infographic_June+2019.pdf >

5)  2018, HEALTH AND PRODUCTIVITY IMPACT OF CHRONIC CONDITIONS MIGRAINE AND OTHER HEADACHES, Integrated Benefits Institute, <https://higherlogicdownload.s3.amazonaws.com/MBGH/4f7f512a-e946-4060-9575-b27c65545cb8/UploadedImages/migraine-toolkit/IBI_Report_Health_Prod_Impact.pdf>

6)  Begasse de Dhaem, 2021, Migraines Are a Serious Problem. Employers Can Help., Harvard Business Review, <https://hbr.org/2021/02/migraines-are-a-serious-problem-employers-can-help >

7) 2018, HEALTH AND PRODUCTIVITY IMPACT OF CHRONIC CONDITIONS MIGRAINE AND OTHER HEADACHES, Integrated Benefits Institute, <https://higherlogicdownload.s3.amazonaws.com/MBGH/4f7f512a-e946-4060-9575-b27c65545cb8/UploadedImages/migraine-toolkit/IBI_Report_Health_Prod_Impact.pdf>

8)Shimizu, 2021, Disability, quality of life, productivity impairment and employer costs of migraine in the workplace, Journal of Headache and Pain, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8061063/>

, 2015, CLOCKING ON AND CHECKING OUT WHY YOUR EMPLOYEES MAY NOT BE WORKING AT OPTIMAL LEVELS AND WHAT YOU CAN DO ABOUT IT, Virgin Pulse, <https://gccmarketing.blob.core.windows.net/marketing-site/marketo/resources/presenteeism/us-presenteeism-whitepaper.pdf >; 2021, Begasse de Dhaem, 2021, ​​Identification of work accommodations and interventions associated with work productivity in adults with migraine: A scoping review, Cephalagia, 

<https://pubmed.ncbi.nlm.nih.gov/33302697/ >

9) 2021, IHS Classification ICHD-3, <https://ichd-3.org/1-migraine/1-3-chronic-migraine/ >

10) Oh, et al, 2014, Combination of anxiety and depression is associated with an increased headache frequency in migraineurs: a population-based study, BMC Neurology, <https://bmcneurol.biomedcentral.com/articles/10.1186/s12883-014-0238-4 >

11) Lui, et al, 2020, Loneliness and Migraine Self-Management: A Cross-Sectional Assessment, Journal of Primary Care and Community Health, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7268119/>

12) 2021, Migraine and Disability, Headache and Migraine Policy Forum, <https://static1.squarespace.com/static/5886319ba5790a66cf05d235/t/5c65958215fcc0538b9c85de/1550161282886/HMPF_Migraine+%26+Disability+Graphic_Feb+2019.pdf>

13) 2020, Migraine Facts, Migraine Research Foundation, <https://migraineresearchfoundation.org/about-migraine/migraine-facts/>

14)  2016, Isops, <https://www.reuters.com/brandfeatures/excedrin/employees-hide-headaches-migraines-from-supervisors>

15) 2021, Glaser, Migraine Stigma at Work is a Big Problem, Migraine Again, <https://migraineatwork.org/in_the_news/hidden-pain-migraine-stigma-at-work-is-a-big-problem/>

16)  Eross, Eric, David Dodick, and Michael Eross. “The sinus, allergy and migraine study (SAMS).” Headache: The Journal of Head and Face Pain 47.2 (2007): 213-224.<https://pubmed.ncbi.nlm.nih.gov/17300361/ >

17) Begasse de Dhaem, 2021, Migraines Are a Serious Problem. Employers Can Help., Harvard Business Review, <https://hbr.org/2021/02/migraines-are-a-serious-problem-employers-can-help >

18) Shaetz,et al,  2020, Employee and Employer Benefits From a Migraine Management Program: Disease Outcomes and Cost Analysis, Headache, <https://headachejournal.onlinelibrary.wiley.com/doi/full/10.1111/head.13933>

19) Page, et al, 2009, Evaluation of Resource Utilization and Cost Burden Before and After an Employer-Based Migraine Education Program, Journal of Occupational and Environmental Medicine, <https://journals.lww.com/joem/Abstract/2009/02000/Evaluation_of_Resource_Utilization_and_Cost_Burden.11.aspx>

 

 

 

Why is Migraine a Diversity, Equity, and Inclusion (DEI) Issue?

Diversity, Equity, and Inclusion efforts are critical to any successful business. However, many of these efforts focus only on the hiring process, and then leave these marginalized employees to fend for themselves once the job is secured.

It’s in the best interest of employers to make resources available to help ensure the success of all employees. Fortunately, we are seeing greater implementation for workplace programs in several different disease states including mental health and heart disease. A recent survey reports that almost half of US workplaces incorporate some type of health and wellness program1. 

However, migraine has been almost entirely overlooked in these workplace programs. This may seem surprising since it’s a disorder which disproportionately affects several traditionally marginalized groups including women, people of color, people with disabilities, and veterans. 

Women

Women are three times more likely to be affected by migraine than men. According to the Migraine Research Foundation, 18% of women versus 6% of men are affected by migraine disease in the United States. Chronic migraine is when someone experiences migraine symptoms on fifteen or more days per month. 85% of those with chronic migraine are women. 92% of women with severe migraine consider themselves disabled (2).

In addition, women are most likely to be affected by migraine from the age of  33 through 55- their prime earning years. Because of this, migraine is a prominent factor in the United State’s gender wage gap. By educating employers and employees on how to better manage migraine, we can help more women reach the height of their professional aspirations without being held back by health disruptions related to migraine..

 

People of Color

People of color with migraine disease are more likely to get migraine attacks which are more severe, more frequent, and more likely to become chronic (3). These patients are also less likely to receive proper diagnoses and treatment plans for this neurological disease. Black, Indigenous, and People of Color face a variety of structural, institutional, social, and economic barriers. Limited English proficiency (LEP) , socioeconomic status, immigration status, and insurance status can all contribute to why certain groups are adversely impacted and underserved. All of these factors could have a role in the increased frequency and severity of migraine in marginalized populations.

Among patients with headache, only 46% of Black and African American patients seek help from a healthcare provider compared to 72% of white patients (4). These patients are also more likely to receive a probable migraine diagnosis compared to their White counterparts (5).

Hispanic and Latinx patients in the US with headaches are 50% less likely to receive a migraine diagnosis than white patients (6). Chronic migraine is also more prevalent in Hispanic and Latinx women compared to White females (2.26% v. 1.2%) (7).

Native Americans have migraine prevalence rates of 18%, ranking as the most affected demographic (8).

In addition, 1 in 3 Black Americans and 1 in 5 Latinx and Native Americans have reported discrimination from their healthcare providers (9).

For more information on how migraine affects BIPOC populations and what the migraine community is doing to address these disparities, see the Disparities in Headache Advisory Council (DIHAC), a committee organized by CHAMP and Jaime Sanders, the Migraine Diva. Be sure to read their DiHAC Issue Brief: Disparities in Headache. 

 

Employees with Disabilities

According to the Harvard Business Review, while 90% of workplaces say they prioritize diversity, only 4% of these companies include disability in these initiatives (10). Migraine itself can be a disability. 

Migraine also presents in a wide spectrum of severity and frequency. Some people may experience milder symptoms on rare occasions, whereas some people may experience disabling symptoms every single day. Research suggests that most employees with migraine are not chronic (11). But those with chronic migraine are likely to develop other health issues and comorbidities from migraine (12). 

People with migraine have 5x the rates of anxiety, 2-3x the rates of depression, 2.5-3x the rates of bipolar disorder, and 2.5x the rates of suicide than the general population (13). These rates increase with the frequency and severity of migraine disease (14). 

In this way, migraine that is left unaddressed may worsen over time and lead to other costly health issues. Fortunately, many of these disorders have a bidirectional relationship with migraine, and as one condition improves, so will the other (15).

 

Veterans

Veterans are much more likely to experience migraine and other headache disorders than civilians. The Veterans Administration (VA) reported that of those who have completed a one year tour in Iraq, 36% were diagnosed or showed signs of migraine symptoms. This is three times more likely than the general population. 

Veterans are also more likely to be diagnosed with chronic daily headache and/ or chronic migraine (see definition above). While the rate for either chronic daily headache or chronic migraine in the general population is around 3%, it is over 20% in the post-9/11 combat Veteran population. 

How to support employees with migraine: 

1.)Educate yourself and your employees about migraine. Education is crucial. Migraine is the second leading cause of disability in the world. It’s a genetic neurological disease with dozens of potentially debilitating symptoms- not just a headache. 

The Harvard Business Review found that “simply instituting migraine education programs was associated with an increase in productivity of 29-36%, due to fewer workdays missed because of migraine attacks, fewer days worked with migraine attacks, and increased effectiveness on days when employees did work with migraine attacks.” (16)

Another study found that three US companies providing access to a website and newsletter on migraine education reduced indirect costs of migraine by 34.5% within just three months (17).  

2.)Create an environment where employees are empowered to speak up about living with migraine disease. Even today, migraine disease still carries a significant stigma (18). 

A 2016 survey found that just 22% of employers found migraine to be a serious enough reason to call out sick, coming in behind stress, back pain, anxiety, depression, and the common cold (19). This stigma forces employees to suffer in silence, even to the point of leaving their jobs without ever disclosing their condition to their bosses. 

Carrying this secretive burden leaves employees feeling isolated, discouraged, and completely out of control of both their health and their employment. 

Don’t let your employees suffer in silence. The more supported an employee feels, the more productivity they yield (20). Learn more about how to make your office a workplace where employees don’t need to hide their medical conditions.   

3.)Make your workplace as accessible as possible. The best part of providing migraine accommodations is that what is beneficial for migraine management is often beneficial for overall brain health and performance. Optimizing brain health is beneficial for everyone. 

Accommodations that help employees with migraine are typically inexpensive, one-time costs, often ranging between free and $500. 

These simple accommodations can often improve overall employee productivity, safety, and satisfaction for everyone in your workplace. For example, fluorescent lighting can be an intense trigger for migraine attacks (21). In addition, they have proven to reduce productivity in the general population, regardless of if this person has migraine (22). If you ask around the office, few people enjoy working under flickering fluorescent lights. Ergonomic seating can also prevent migraine attack initiation and exacerbation, along with improving productivity in all employees (23).

How does Migraine at Work help to ensure your employees are supported and overall productivity is increased? 

Healthier employees are happier and more productive. Migraine at Work can provide a range of free resources as well as a proven workplace program to reduce lost productivity due to migraine. 

Start by receiving a free impact evaluation to estimate the cost of migraine in your workplace. Validate these estimates with our assessment tool to precisely quantify the cost of migraine in your workplace. Once the estimate or assessment is completed we can share various options from providing educational materials and informal training through to a turnkey proven program to reduce the cost of migraine and increase productivity.    

You will be supported in the delivery of every step with minimal effort required on your behalf. Don’t let your employees suffer in silence. Provide them with the support and information they need to improve their health, happiness and productivity. 

Start now with a risk-free consultation by contacting us today.

Thank you to Jaime Sanders, the Migraine Diva and leader of the Disparities in Headache Advisory Council (DIHAC), and CHAMP for assistance with this article.

 

1) Bottino, 2020, Workplace Health in America survey: ‘A lot of growing left to do’, Safety and Health, <https://www.safetyandhealthmagazine.com/articles/19333-workplace-health-in-america-survey-a-lot-of-growing-left-to-do >

2) 2021, Migraine is a women’s health issue., Migraine Research Foundation, <https://migraineresearchfoundation.org/about-migraine/migraine-in-women/>

3) Thorne, 2020, Racial Inequities In Migraine Treatment, Migraine World Summit, <https://migraineworldsummit.com/talk/racial-inequalities-in-migraine-treatment/ >

4) 2021, Racial Disparities in Migraine and Headache Care, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/racial-disparities-in-migraine-care/ >

5) Silberstein S, Loder E, Diamond S, Reed M, Bigal M, Lipton R. Probable migraine in the United States: results of the American Migraine Prevalence and Prevention (AMPP) study. Cephalalgia. 2007;227(3):220-229. doi:10.1111/j.1468-2982.2006.1275.x.

6)​​2021, Racial Disparities in Migraine and Headache Care, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/racial-disparities-in-migraine-care/ >

7) Loder S, Sheikh HU, Loder E. The prevalence, burden, and treatment of severe, frequent, and migraine headaches in US minority populations: statistics from national survey studies, Headache J Head Face Pain. 2015;55:214-228. doi:10.1111/head.12506 <https://pubmed.ncbi.nlm.nih.gov/25644596/>

8) Loder S, Sheikh HU, Loder E. The prevalence, burden, and treatment of severe, frequent, and migraine headaches in US minority populations: statistics from national survey studies, Headache J Head Face Pain. 2015;55:214-228. doi:10.1111/head.12506 <https://pubmed.ncbi.nlm.nih.gov/25644596/>

9)-2021, Racial Disparities in Migraine and Headache Care, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/racial-disparities-in-migraine-care/ > 10-Casey, 2020, Do Your D&I Efforts Include Disability, Harvard Business Review, <https://hbr.org/2020/03/do-your-di-efforts-include-people-with-disabilities> 11-Stewart, et al, 2010, Employment and work impact of chronic migraine and episodic migraine, Journal of Occupational Environmental Medicine, <https://pubmed.ncbi.nlm.nih.gov/20042889/> 12-Wang, 2020, Comorbidities of Migraine, Frontiers in Neurology, <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3008936/ > 13-Baskin, 2020, Understanding Migraine-Related Mood Disorders, Migraine World Summit,  <https://migraineworldsummit.com/talk/understanding-migraine-related-mood-disorders/;  https://jnnp.bmj.com/content/87/7/741 > 14-Buse, 2009, Common Comorbidities, Association of Migraine Disorders, <https://amd.ianryan.com/A%20Migraine%20Toolbox%20A%20Practical%20Approach%20to%20Diagnosis%20and%20Treatment%20-%20Storyline%20output/story_content/external_files/8%20Common%20comorbidities.pdf> 15-2018, The Link Between Migraine Depression and Anxiety, American Migraine Foundation, <https://americanmigrainefoundation.org/resource-library/link-between-migraine-depression-anxiety/> 16-Begasse de Dhaem, 2021, Migraines Are a Serious Problem. Employers Can Help., Harvard Business Review, <https://hbr.org/2021/02/migraines-are-a-serious-problem-employers-can-help > 17-Page, et al, 2009, Evaluation of resource utilization and cost burden before and after an employer-based migraine education program , Journal of Occupational Environmental Medicine, <https://pubmed.ncbi.nlm.nih.gov/19209043/ > 18-Young, 2018, The Stigma of Migraine, Practical Neurology, <https://practicalneurology.com/articles/2018-feb/the-stigma-of-migraine > 19-LaBianca, 2018, This Is the Single Best Excuse for Calling in Sick, According to Your Boss, Reader’s Digest, <https://www.rd.com/article/calling-in-sick-excuses/ > 20-Peart, 2019, Making Work Less Stressful and More Engaging for Your Employees, Harvard Business Review, <https://hbr.org/2019/11/making-work-less-stressful-and-more-engaging-for-your-employees> 21-Karanovic, et al, 2011, Detection and discrimination of flicker contrast in migraine, Cephalalgia, <https://journals.sagepub.com/doi/10.1177/0333102411398401> 22-Craig, 2018, Study: Natural Light Is the Best Medicine for the Office, Cision, <https://www.prnewswire.com/news-releases/study-natural-light-is-the-best-medicine-for-the-office-300590905.html > 23-McKeown,2018, Ergonomic workplace design for health, wellness, and productivity, Ergonomics, <https://pubmed.ncbi.nlm.nih.gov/28574748/ >

Accommodations for Migraine in the Workplace

Accommodations can not only help make working through a migraine attack more bearable, but they can also help prevent migraine attacks, which is, of course, the best option. 

Accommodations are never one-size-fits-all.

Each person has unique triggers and symptoms of migraine. To find which accommodations may work for you, create a list of both of these areas. For example, perfumes and a lack of sleep may trigger an attack. Once the attack has started, bright lights become unbearable. To mitigate these factors, we would need to think of accommodations for flexible scheduling on days where sleep is limited, as well as creating strategies to deal with scents and lighting issues. 

The Job Accommodation Network suggests brainstorming accommodations by two categories: By Limitation (Headache/ Other Pain, Light/ Noise Sensitivity, Stress Intolerance) and By Work-Related Function (Light, Noise, Stress.) (1)

Once you have your list created, crosscheck your needs with the suggestions made by Paula Dumas in her SAFER Plan for workplace accommodations for migraine. (2)

S– Scent Protection

A– Audio Protection

F– Flexibility

E– Escape Options

R– Reduced Light

Scent Protection

Osmophobia, or sensitivity to smells, is a common symptom of migraine attacks. In addition, scents can also trigger a migraine attack. 

1.) Enforce a fragrance-free workplace. Request that employees and visitors refrain from wearing any perfumes, cologne, or scented beauty products. 

2.) Swap any scented soaps or air fresheners with unscented options.

3.) Install air purifiers.

4.) Replace any cleaning products with unscented versions. 

5.) Position the employee away from kitchens, microwaves, trash receptacles, white boards, and other highly fragrant areas. 

Audio Protection

Phonophobia, or sensitivity to sounds, is also both a trigger and a symptom of migraine attacks. Understand that migraine brains are hyper-reactive to outside stimuli, so when an employee confides that any of these senses become unbearable during an attack, know they are not exaggerating. Most people avoid having a conversation about migraine because it remains highly stigmatized. If an employee is requesting an accommodation – it’s likely because it is significantly affecting them.  

1.) Provide noise-cancelling headphones.

2.) Install sound absorption wall panels.

3.) Consider thick rugs or curtains to help dampen the echoes in an office.

4.) Request that employees mute non-urgent sound notifications on email, text messages, etc.

5.)Provide a private area or an area far from high-traffic areas for the employee to work.

Flexibility

The pandemic proved that many jobs can be completed effectively from remote locations. Telework allows employees with migraine to have a much larger degree of control over their triggers and symptoms. For example, an employee can work from their bedroom with blackout curtains over the windows, noise cancelling headphones around their ears, and an ice pack around their head without embarrassment or the obligation to justify their pain to other employees. 

1.) Make telework an option, and allow this employee to work from home even if the request needs to be made at the last minute. Migraine attacks often occur without warning, so advanced permission may not be possible.

2.) Consider granting this employee permission to join in video conferencing with their video off. The energy it takes to look presentable during an attack can detract from an employee’s already reduced energy, making them less productive overall.

3.) Flexible scheduling can be incredibly empowering for an employee with chronic illness. Allow the employee to work an adjustable schedule. For example, if an attack occurs in the morning, the employee can rest to ensure they are able to make up the work in the evening. 

Escape Options

For many of us, all we want during a migraine attack is a silent, dark room- and some relief, of course. 

1.) Many offices provide wellness rooms where employees can nurse or just relax. If these are not available, a restroom may do the trick. Some employees may prefer the privacy of sitting in their own car until the worst of the attack passes. 

2.) Providing curtains or room divider panels can allow privacy for your employee to be able to work through the attack without the added pressures of feeling like they have to put on a bright face or exchange pleasantries with other employees as they walk past their desk.

3.) Allow the employee to leave the office to take off the rest of the day or to work from home. Depending on the employee’s symptoms and medications, a ride may need to be arranged via a ride-sharing app, even if they took their own car or public transportation to work that morning. 

 

Reduced Lighting

Photophobia, or sensitivity to light, is one of the most common symptoms and potential triggers for migraine attacks. Depending upon the person, different types of lighting like fluorescents, strobes, LEDs, and bright sunlight may be worse, so their input is critical to creating the most effective environment. 

1.) Allow the employee to wear sunglasses, hats, etc. in the office without having to explain themselves to their coworkers. 

2.) Provide light filters to any overhead fluorescents, or allow these to be turned off and replaced by incandescent desk or floor lamps. Even just having these lamps turned on in addition to the fluorescents can help dampen the effects of the flickering.

3.) For computer monitors, provide anti-glare filters and ensure the highest refresh rates possible. (3) Adjust the screens to the warmest options by turning on night shift (4) or downloading programs like f.lux. (5)

4.) Adjust your screen brightness. The typical recommendation is to match the screen brightness to that of the room, but your preference may vary.

5.) Provide blinds or curtains for bright windows.

 

The most important aspect of identifying effective accommodations is listening to your employee and having them consider their own individual needs. What works for one employee with migraine may do nothing for another employee with migraine. Do not assume you know better than the employee, but ensure they are comfortable enough to speak up and request what they need to do their job to the best of their abilities. 

Il miglior software per farmacie è quello che è semplice da imparare e utilizzare. Lussa è una soluzione potente ma facile da usare per voi nella pratica. Può fornirti un flusso di lavoro efficiente per ogni fase dei tuoi compiti quotidiani e aiutarti a organizzare la tua attività in farmacia in modo rapido e conveniente, rendendo il tuo lavoro più efficiente.

 

Accommodations are typically low-cost and highly effective. Learn how to request accommodations here.

 

 

1-Accommodation and Compliance: Migraines, Job Accommodation Network, <https://askjan.org/disabilities/Migraines.cfm>

2-Dumas, 2021, 19 Ways to Accommodate an Employee with Migraine, Migraine Again, <https://www.migraineagain.com/19-ways-to-accommodate-an-employee-with-migraines/ >

3- Change your display refresh rate in Windows, Microsoft, <https://support.microsoft.com/en-us/windows/change-your-display-refresh-rate-in-windows-c8ea729e-0678-015c-c415-f806f04aae5a>

4-Turn Night Shift on and off manually, Apple, <https://support.apple.com/guide/mac-help/use-night-shift-mchl97bc676d/mac#:~:text=Turn%20Night%20Shift%20on%20and%20off%20manually&text=a%20darkened%20room.-,On%20your%20Mac%2C%20choose%20Apple%20menu%20%3E%20System%20 Preferences%2C%20click,Displays%20%2C%20then%20click%20Night%20Shift.&text=Select%20Manual%20to%20turn%20on,until%20you%20turn%20it%20off.>

5- Get f.Lux, f.Lux, < https://justgetflux.com/>

Why Does Migraine Not Appear in Claims Data?

Migraine affects 1 in every 6 US adults. It’s the number two leading cause of disability in the US  working age group.(1) According to an independent industry group, The Integrated Benefits Institute, for every 1,000 employees, each U.S company spends $84,000 in direct costs and absenteeism.(2) 

If migraine has such a large cost, it’s reasonable to ask why it is not obvious. Why are there not a steady stream of migraine complaints? Why doesn’t it show up in claims data? You may begin to wonder if perhaps your organization is different from others that have this problem.

The answer is almost certainly no. Migraine is still an issue. 

There are several reasons why migraine does not prominently appear in insurance claims data.

1.) Most pharmaceutical drugs used to prevent and treat migraine attacks are repurposed from medications designed to treat other conditions like blood pressure, epilepsy, and depression. In fact, until 2018, there was not a single drug specifically designed for the prevention of migraine. While these medications will often appear in the claims data, the diagnosis of migraine may not.

2.) Migraine is largely genetic. If people grew up in families affected by migraine, they are often taught to live with it. Their relatives may have visited doctors in previous decades where effective options simply were not available. The misguided attitude  of, “Don’t bother wasting your time with doctors because they can’t help you,” gets passed down through generations. This information is entirely out of date, and things are very different now than they were even just five years ago. In these situations, employees are still being affected by migraine, but this disease and its productivity toll remains invisible to the company.

3.) 40% of people living with migraine are undiagnosed.(3) Many employees may not even realize they have migraine. They may incorrectly assume the issue lies in other areas like their sinuses or their neck.(4) Generic over-the-counter pain medications are frequently utilized. Employees are wrongly treating the myriad of symptoms, without addressing the cause. This ineffective treatment sets up these employees for worsening their disease, putting them at risk for migraine chronification.(5) It is also another reason why migraine remains hidden. 

Outside of the claims data, there’s many additional reasons why you may not have noticed migraine in your office.

1.) People aren’t calling out of work because they are trying to work through their symptoms. As 90% of people cannot function normally during an attack (6), this strategy obviously does not work well, but many people do not have other options. Especially those employees with frequent migraine attacks, calling out every time an attack occurs would simply not be possible. So employees come to work suffering, and productivity plummets. 

Many employees with migraine may need to fake being well enough to work through the day. Most of the cost of migraine in the workplace is due to presenteeism. They are present at work, but not operating at full capacity. 

2.)  Even if they are forced to call out for the day, many employees will not admit that migraine attacks are the true reason for their absence. Due largely to the stigma of migraine, only 42% of people will include that the real reason they must call in sick is migraine.(7) 

3.) Employees do not feel comfortable disclosing this disease. People incorrectly assume migraine is “just a headache,” and employees should be able to take a simple over-the-counter pill and continue on with their day. Others assume a migraine attack is a simple excuse to get out of obligations. In reality, migraine is a debilitating neurological disease with dozens of disabling symptoms. Employees with migraine want and need to keep their jobs, but without the proper support, many are forced to sacrifice their careers. 

 

The good news is that the heavy cost of migraine in the workplace can be avoided.

Even better news is that it’s surprisingly easy to help mitigate these costs. Simple education programs require little effort and money, and have an incredible return on investment, which has been proven in several case studies and published in research journals. Furthermore, accommodations for those with migraine tend to be inexpensive. Supporting your employees with migraine is great for them, and even better for the business. Get started today by contacting us today.

 

 

1- Steiner, et al, 2019, Migraine remains second among the world’s causes of disability, and first among young women: findings from GBD2019, The Journal of Headache and Pain, <https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-020-01208-0#:~:text=02%20December%202020-,Migraine%20remains%20second%20among%20the%20world's%20causes%20of%20disability%2C%20and,young%20women%3A%20findings%20from%20GBD2019&text=The%20capstone%20papers%20on%20the,in%20Lancet%20on%20October%2017th.> 

2- 2018, HEALTH AND PRODUCTIVITY IMPACT OF CHRONIC CONDITIONS MIGRAINE AND OTHER HEADACHES, Integrated Benefits Institute, <https://higherlogicdownload.s3.amazonaws.com/MBGH/4f7f512a-e946-4060-9575-b27c65545cb8/UploadedImages/migraine-toolkit/IBI_Report_Health_Prod_Impact.pdf>

3- 2016, Headache Disorders, World Health Organization, <https://www.who.int/news-room/fact-sheets/detail/headache-disorders>

4- 2021, Migraine, National Headache Foundation, <https://headaches.org/2012/10/25/migraine/#:~:text=The%20pain%20of%20migraine%20is,to%20anything%20touching%20their%20head.>

5- Torres-Ferrús, et al, 2020, From transformation to chronification of migraine: pathophysiological and clinical aspects, The Journal of Headache and Pain, <https://thejournalofheadacheandpain.biomedcentral.com/articles/10.1186/s10194-020-01111-8>

6- 2021, About Migraine- Migraine Facts, Migraine Research Foundation, <https://migraineresearchfoundation.org/about-migraine/migraine-facts/>

7- https://migraineatwork.org/in_the_news/hidden-pain-migraine-stigma-at-work-is-a-big-problem/