“Let Down” or “Weekend” Migraines

I know a “weekend migraineur” when I see one. You know the patient I am talking about. . . the one whose migraines are under control all week long while he or she works at a “stressful” job-and who spends most of the weekend in bed with a breakthrough migraine.

During my residency, I was taught to ask patients with “intermittent migraine” to set up a schedule that mimicked their weekday pattern during the weekend in hopes that they would avoid a migraine. I now see patients who only get weekend migraines, and I ask them to try this approach.

So it is with some satisfaction that the strategy I learned back when I was a resident has been confirmed by a recent study.

Lipton and colleagues¹ looked at whether level of perceived stress and reductions in levels of perceived stress might be a migraine trigger. Twenty two migraine patients in their study (mostly women in their early 40’s) were followed using an electronic “diary” and scales to exclude confounding factors such as depression and anxiety. Stress level was assessed with 2 different stress scales. Notably, the actual degree of perceived stress did not seem to predict the onset of a migraine for most time periods studied. However, the decrease in perceived stress from one night to the next was strongly correlated with the onset of a migraine. The “let down migraine” was noted the day after.

The authors offer two theories of how this “let down” migraine occurs, and thought the second was less likely.

1. Increased stress as the weekend approaches leads patient to skip meals; increased disturbed sleep and even missed medications trigger the migraine.

2. During the premonitory phase of migraine, there is increased and then decreased vulnerability to stress; subjects who reported higher stress one night and less stress the night before the migraine suggested they had already started the cycle of migraine and were in the premonitory phase.

The authors theorized that higher levels of stress during the weekdays lead to higher levels of natural glucocorticoids that fell as the stress level was perceived to drop. The drop in natural glucocorticoids may have led to “let down migraines,” similar to those that occur when we treat patients with steroids.

The exact mechanism remains a mystery. What is not a mystery is the reality of such an odd response.

Possible interventions include cognitive behavioral therapy, biofeedback therapy, mindfulness-based stress reduction, and healthy lifestyle practices (eg, exercise and good sleep hygiene). Other methods to consider include routine stress level monitoring and brief interventions that stabilize stress, such as relaxation techniques, breathing exercises, and guided visual imagery.

References:

1. Lipton R, Buse D, Hall C, et al. Reduction in perceived stress as a migraine trigger. Neurology.2014;82:1395-1401.